Over the past year and a half, we’ve reviewed a variety of mass-casualty incidents (MCIs). By far the majority involved transportation incidents of some type or another. Because we can’t control many factors in those types of event—location, access to the scene or where to establish a staging area—we can’t “pre-plan” for such an MCI in the same way we may pre-plan for a fire in a particular building.
This month, however, we’ll examine a unique incident that EMS providers can plan for—an MCI at a nursing home. Those who have similar facilities in their area can learn from the experience of the New Pittsburg Volunteer Fire Department (NPVFD) in Ohio.
On May 26, 2011 the NPVFD was dispatched to a local nursing home due to a power failure. To complicate matters, a lightning strike the prior day had damaged the facility’s backup generator. The greatest concern was that the facility had 15 patients on ventilators at the time of the power failure. Although ventilators have their own internal batteries, these batteries provide a limited amount of operation time.
Additionally, the facility’s oxygen generator was out of service due to the power loss. Initial arriving EMS providers were confronted with an MCI involving multiple patients in need of respiratory support, with the potential for other patients to start developing medical problems due to a non-functioning heating, ventilation and air conditioning system.
Assistant Chief Brad Stull was among the first to arrive on the scene and assess the situation. He described some of the challenges they faced and how they met those challenges.
In an MCI like this, EMS providers have to adjust their methods of triage. Algorithm-based systems, such as Simple Triage And Rapid Treatment (START) or Sort, Assess, Life-saving interventions, Treatment and/or transport (SALT), have limited application. Also, simply triaging based on standard patient assessment parameters may not work well when providers don’t know many patients’ baseline status. For example, what would be considered an altered level of consciousness for a patient at a bus crash may be a normal state of consciousness for a nursing home patient.
That being the case, NPVFD wisely used the nursing home staff to assist with triage. A paramedic worked with the head of nursing and began assessing patients. With her help, it was easier to identify patients who appeared to be in distress. NPVFD drafted a list patients who were being transported first and also wrote ventilator settings on a paper to go with patient.
Since the incident, NPVFD has purchased blank tags with string that can be affixed to patients like triage tags. Critical information about the patient, including ventilator settings, can be written on the tag, thereby reducing the chance that critical information doesn’t make it to the hospital with the patient.
Another unique aspect of triage at this event was the use of diagnostic tools. At most MCIs, EMS providers wouldn’t typically take the time to obtain vital signs during initial triage. In this situation, however, the use of pulse oximetry was an invaluable part of triage, identifying multiple patients with low oxygen saturations. This information helped determine which patients were in need of immediate assistance.
The nursing home staff was attempting to ventilate multiple patients with bag-valve masks (BVMs) because most of the ventilators weren’t adequately functioning on battery power. Patients had already been moved into groups to enable staff members to assist multiple patients. Stull requested that additional ambulances and EMS providers be dispatched to the scene. As EMS providers arrived, they were assigned to patients to assist with ventilations.
Another treatment challenge was suction. Most suction units at nursing homes need 110-volt power and don’t have backup batteries. So Stull assigned two teams of EMS providers with portable suction units to suction patients.
Both these aspects of operation are unique for an MCI. Although generally the need for ventilatory support means a poor prognosis for a patient at an MCI (and could even potentially relegate them to an “expectant” category), these nursing home patients had a good prognosis for survival provided their airways were kept clear and they were ventilated. If we find ourselves filling a command position at an MCI, we must be alert to assign limited resources (personnel and equipment) to where they can do the most good.
When managing what we may term a “normal” MCI, we must use hospital resources do the most good for the most patients. For example, it’s of little benefit to a patient needing surgery if we transport them early in the incident but send them to a hospital with no surgical capability. NPVFD faced a similar problem, but related to respiratory care capabilities.
The main question for receiving hospitals was how many ventilator patients they could accept. Although this seems like a simple question, there were complicating factors. Five hospitals committed to taking one to three patients each. However, we must remember that at any time prior to receiving patients from the nursing home, other patients in the hospital or arriving from unrelated EMS incidents could need one of the few ventilators available. This did occur, so some hospitals that initially said they could accept more than one ventilator patient later said they could accept only one.
Other complicating factors included the complex medical history of many of the patients and that one patient weighed more than 500 lbs. A bariatric ambulance from a neighboring fire department was requested for this patient. When planning for such a potential incident in our own district, we should include ambulances with bariatric transport capability in our resources list.
After nine of the 15 ventilator patients were transported, and while NPVFD was planning how to potentially transport additional patients should a full evacuation be needed, power was restored. Thanks to quick thinking and planning, all patients were successfully managed during this unique event.