Disaster Response Patient Care Guidelines

Pierce County EMS

(7/2009)

Pierce County EMS

(7/2009)

Table of Contents

Disaster Response Notification Guideline ...... 1

ICS Considerations ...... 3

Triage Process Overview ...... 4

START Guideline ...... 6

Jump START Guideline ...... 7

Burn Treatment Protocol ...... 8

Carbon Monoxide Treatment Protocol ...... 10

Blast Injuries: ...... 11

Lung Injury ...... 12

Abdominal Injury ...... 12

Extremity Injury ...... 13

Ear Injury ...... 13

Eye Injury ...... 13

Crush Injury/Crush Injury Syndrome ...... 14

Geriatric Patient Considerations ...... 15

Pediatric Patient Considerations ...... 16

Bombing: Injury Patterns and Care Pocket Guide ...... 17

WMD/All Hazards Events:

Chemical Agents ...... 19

Incapaciting Agents ...... 19

Choking Agents ...... 20

Blister Agents ...... 22

Nerve Agents ...... 27

Arsine ...... 29

Cyanide ...... 30

Ricin ...... 32

Bioterrorism Agents ...... 33

Radiological & Nuclear Illness/Injuries ...... 36

Communicable Disease Events ...... 41

Natural Disaster Considerations ...... 51

Mental Health Guidelines ...... 53

Deviation from PC Patient Care Protocols/Disaster Response Guidelines ...... 55

Disaster Worker Considerations: ...... 59

Attachment A- National EMS Core Content

Attachment B- National EMS Scope of Practice Model

Disaster Response Patient Care Guidelines

Disaster Response Notification Guideline

1. Introduction a. The Pierce County Disaster Response Patient Care Guidelines are a separate document from the Pierce County Patient Care Protocols, but use the latter as a foundation for patient care during a mass casualty disaster event (MCDE). All EMS providers must act within their scope of practice. b. The Pierce County Fire Chiefs’ Association Mass Casualty Incident Plan is the guiding document for incidents that occur in Pierce County and are considered ‘manageable’ by routine mutual aid/response activities for a multiple patient event. It is, as well, the guiding document for initial response to what will eventually be declared a disaster emergency by some entity. c. The intent of these Disaster Response Patient Care Guidelines are to provide guidance for events that are expected to overwhelm county pre-hospital and hospital entities in a short time or over an extended period of time. d. Examples of the type of disaster events that may require activation of these guidelines: Natural Hazards- avalanche, earthquake, flooding, urban/wildland interface fires, landslides, severe storms, tsunamis & seiches, and volcanic hazards. Technological Hazards- abandoned underground mines, civil disturbance, dam failure, energy emergency, epidemic, hazardous materials, pipelines, terrorism, and transportation accidents. 2. Notification and Activation of these Disaster Response Patient Care Guidelines a. EMS agencies are expected to notify Good Samaritan Hospital Emergency Department, the Disaster Medical Control Center, in the event of a potential or actual disaster. Madigan Army Medical Center Emergency Department is the back-up DMCC if Good Samaritan is non-functional. It is anticipated that in many instances related to the type of events listed in these guidelines, notification to/from the DMCC has already occurred, but it is still important for each EMS agency to notify the DMCC of the need for use of these guidelines in their jurisdiction. When contact is made with the DMCC, request “activation of the Disaster Response Patient Care Guidelines”. This will put into affect a cascade of other hospital and EOC notifications. b. When contacting the DMCC, the following information will be needed: i. Name of agency making notification ii. Name of person doing the notification iii. Call-back number for person doing the notification and/or Incident Command iv. Type of disaster (i.e. What caused it?) v. Location of the disaster as it related to your jurisdiction and beyond as necessary vi. Number of injured/ill involved (approximate)

vii. Types of injuries/illness (burns, respiratory, etc.) viii. Route of entry into the disaster area (if applicable) ix. Known hazards to responding units x. Any other pertinent information deemed necessary xi. Get the name of the person at the DMCC this information was reported to c. The Pierce County Emergency Operations Center (PCEOC) will be activated at some level in response to an event referred to in these guidelines. In the initial phase, the Pierce County Duty Officer will react to the DMCC activation and be available to EMS agency requests for assistance above dispatch center capabilities. Once the PCEOC is activated, requests for resources, equipment, supplies, and other support should be directed to the ‘EMS Liaison’ in the PCEOC. d. It is imperative that you contact the DMCC when the event has concluded for your agency, even if the event never moved out of the ‘potential’ phase. This allows the DMCC to deactivate the other hospital and EOC notifications that occurred at the outset of the event.

Incident Command System (ICS) Considerations

1. Responsibility a. The use of ICS is expected for all disaster responses, and it is anticipated to have integration of EMS into Unified Command (UC) regardless of the number of EMS response vehicles/personnel. b. The Pierce County Fire Chiefs’ Association Mass Casualty Incident Plan is the guiding document for incidents that occur in Pierce County. It contains the information regarding Incident Command/Unified Command and all other key functional roles EMS personnel may be asked to fulfill. c. The Pierce County EOC will stand up in a support role to field operations, to include an EMS Liaison for EMS resource/support requests. All requests for assistance from the field should be funneled through the on-scene Medical Group Supervisor or Operations Section Chief. d. Pierce County Medical Examiner’s office is the lead agency for activities concerning the deceased including temporary morgue, identification, and disposition of the deceased. 2. Accountability a. If the declared disaster is of a “scene response” type such as a bombing, etc access to the scene will be restricted to those individuals possessing appropriate identification. All EMS personnel should have in their possession their Washington State EMS provider certification card as well as any agency identification. b. Individuals that arrive on scene with an ambulance for the purposes of transporting patients, but which will not be staying on scene, must remain at or near their vehicle. It is important that crew members do not leave the immediate vicinity of their ambulances if they are transport units. c. Individuals that arrive at the scene as part of a non-transport asset, but was requested to report to the scene must check in with the appropriate unit leader. This may include check- in and check-out at a personnel assignment station. d. Volunteer individuals that arrive and was not requested to be at the scene should be directed to report to their own agency (if appropriate), or report to a volunteer registration/check-in area if one has been established. If a check-in area has not been established, the individual should be directed to an area outside of the perimeter until a volunteer check-in is established by Incident Command. Command should be notified that volunteers are available.

Triage Process Overview

1. Introduction a. Triage of patients during a mass casualty disaster event will be slightly different than triage during a routine MCI or other small scale multiple patient event. It is imperative to track these patients on a log as outlined in the PCFCA MCI plan and/or via electronic method. This includes both trauma and/or medical disaster events. This log (paper or electronic) must be forwarded, in an immediate and ongoing/updating manner, to the Pierce County EOC EMS Liaison to assist the DMCC, hospitals, and family members locate patients. This information is critical for reports to the State Department of Health and State Department of Emergency Management to assist them in planning efforts. b. The Pierce County Fire Chiefs’ Association Mass Casualty Incident Plan is the guiding document for initial response to what will eventually be declared a disaster emergency by some entity. 2. Priorities a. Assess the situation using the DISASTER paradigm: i. Detection: identify the event as having, or having the ability to generate, a significant number of patients. ii. Incident Command (IC): meet with or establish IC/UC. iii. Safety & Security: ensure that those on scene are not in harm’s way and discuss/implement measures to keep the scene safe. iv. Assess Hazards: look for things that can pose a danger and plan to avoid, notify about and/or mitigate the hazards. v. Support: call dispatch to notify of the situation, location of IC, to request additional support and to advise of ingress/egress routes or safety issues for incoming resources. Contact DMCC to activate these Disaster Response Patient Care Guidelines and provide them information listed in previous ‘Notification’ guideline. Contact PCEOC EMS Liaison for needed supplies, etc. vi. Triage & Treatment: establish the areas to set up Triage and Treatment, identify Triage and Treatment Unit Leaders. vii. Evacuation: establish a location or locations for the Transportation Unit Leader to set up pick-up sites, set up patient tracking/logging, and communicate with DMCC for patient destination. viii. Recovery: coordinated with Incident Command.

4 b. MASS should be used when you reach the “T” of the DISASTER paradigm: i. Move: “Everyone who can hear me and needs medical attention, please move to the area with the green flag (or other easily identifiable spot)”. Minimal. “Everyone who can hear me, please raise an arm or a leg so we can come and help you”. Delayed Identify the location of who is left. Think mobilization, not immobilization as appropriate. ii. Assess: these people assessed/triaged using the START or Jump START triage criteria and categorized into the IDME categories. iii. Sort: starting with the nonmoving patients, the patients are sorted by category and sent to the corresponding treatment area. Moving patients that were not ambulatory are sorted next and sent to the appropriate treatment areas. Ambulatory patients are next and sent to the appropriate treatment areas. iv. Send: patients are transported from the scene with priority going to the Immediate patients, then Delayed, then Minimal. Expectant patients are last with those already Dead coming under the Medical Examiner’s jurisdiction. c. IDME Categories i. Immediate: life or limb threatening. Often with respiratory, bleeding/perfusion or mental status problems. Red. ii. Delayed: need definitive medical care, but should not worsen rapidly if initial care is delayed. Yellow iii. Minimal: ambulatory patients. Green iv. Expectant: severely injured with little or no chance of survival. Blue Dead: already deceased. Black

Simple Triage and Rapid Transport (START) Guideline

ASSESS: All victims initially able RESPIRATIONS to walk to treatment area

GREEN: Minor NO YES

Under 30/min Over 30/min

Position Airway RED: Immediate NO Respirations YES Respirations

BLACK: RED: Deceased Immediate

PERFUSION

Radial Pulse Absent Radial Pulse Present OR Over 2 sec. CapillaryRefill Under 2 sec.

MENTAL STATUS Control Bleeding

CAN’T Follow CAN Follow RED: Simple Simple Immediate Commands Commands

RED: YELLOW: Immediate Delayed

JumpSTART Pediatric Guideline Patients <1 – 8 Years Old

Victim initially able YES GREEN: BLUE: to walk to treatment area? Minor Secondary Triage*

*Evaluate infants first in NO secondary triage using the entire JumpSTART algorithm

ASSESS: NO Position Upper Breathing RED: RESPIRATIONS Airway Immediate

Apneac

NO BLACK: Palpable pulse? Deceased

YES YES

Apneac BLACK: 5 Rescue breaths Deceased

Breathing

RED: Immediate

<15 or >40 RED: Respiratory Rate or irregular Immediate

15-40, regular

NO RED: Peripheral Pulse Immediate

YES

“P” (inappropriate) RED: Mental Status or “U” Immediate

“A”, “V” or “P” YELLOW: (appropriate) Delayed

Burn Treatment Protocol (From initial burn to 72°/transfer to Burn Care Center) 1. Primary Survey a. Airway Maintenance and consider cervical spine protection b. Breathing and ventilation (100% O2 via NRM, intubate PRN) c. Circulation and hemorrhage control d. Disability (assess neurological deficit, AVPU) e. Exposure (remove any sources of heat and remove any clothing that may be burned, covered with chemicals or are constricting) f. Secondary Survey to include Scene Hx, Physical exam, SAMPLE, etc 2. Initiate Fluid Resuscitation a. Estimate the burn size based on the Rule of Nines or based on patient’s palmer surface hand size (1% TBSA) to calculate the resuscitation fluid volume. b. Lactated Ringers solution at 3ml/kg/%TBSA burn = ml’s in first 24 hours; with ½ of this total given in the first 8 hours post injury and the remaining ½ given in the next 16 hours. Titrate to maintain urinary output as well. c. In children <30kg also administer D5 ½ LR solution @ maintenance rate of:

For the first 1 to 10 kg – 100ml/kg/24 hours = 4ml/kg/hour For the second 11 to 20 kg – 50ml/kg/24hours = 2ml/kg/hour For any weight 21 to 30 kg – 20ml/kg/24hours = 1ml/kg/hour Example for a 12 kg child: 100 ml/kg for first 10 kg – 10 kg x 100 ml = 1000ml 50 ml/kg for each kg between 11 and 20kg – 2 kg x 50 ml = 100ml 20 ml/kg for each kg between 21 and 30 kg –  none needed  =1100ml/24hours

Do not give dextrose solutions (except for maintenance fluids in children) - they may cause an osmotic diuresis and confuse adequacy of resuscitation assessment.

3. Pain Management and other medications a. After fluid resuscitation has been initiated, pain management must be considered. Titrate doses of analgesia and sedation based on patient’s hemodynamic stability and pain control. Adjust as necessary. b. A tetanus immunization should be given. c. Antibiotics are not indicated but can be considered PRN. 4. Insert Nasogastric Tube for every intubated or unresponsive patient a. Give an IV Proton blocker if the patient will not be transported within 12 hours.

5. Assess Urine Output a. Insert Foley catheter in patients with burns >15 percent TBSA. Adequate urine output is 30 mL/hr in adults and 1 mL/kg/hr in a child less than 30 kg. b. Observe urine for burgundy color (seen with massive injuries or electrical burns).There is a high incidence of renal failure associated with these injuries, therefore prompt and aggressive intervention is required. Fluid bolus until output levels achieved or urine color changes to a straw color. 6. Escharotomies - If transfer will be completed within 12 hours, escharotomies are rarely needed. a. Elevate burned extremities and assess distal pulses hourly. b. Assess for circumferential full thickness burns of extremities or trunk. c. Perform escharotomy as needed for decreased or absent pulses or respiratory compromise. 7. Wound Care a. Cover patient with a dry sterile sheet and tuck in to prevent hypothermia. b. Apply a thin layer of Silver Sulfadiazine to open burns if transport delayed by more than 12 hours. c. Consider debridement and application of topical antimicrobials if transfer to Burn Center is delayed beyond 24 hours. 8. Special Considerations for Chemical Burns a. Remove ALL clothing. Be careful to protect yourself. b. Brush powered chemicals off wound: then flush burns for a minimum of 30 minutes with running water. c. Irrigate burned eyes with a gentle stream of saline. Follow with an ophthalmology consult if transport is not imminent. 9. Special Considerations for Electrical Injuries a. Monitor distal pulses. Elevate burned extremities slightly. b. Cardiac monitor. c. Watch for burgundy colored urine.

Carbon Monoxide Treatment Protocol

1. Introduction a. When power outages occur during emergencies such as severe weather, energy emergencies, etc, the use of alternative sources of fuel or electricity for heating, cooling, or cooking can cause CO to build and poison the people or animals inside. b. Sources of CO poisoning: gas-powered generators, charcoal grills, propane stoves, motor vehicles, fire, boats, power washers and other gas powered tools. c. At-risk populations: infants and children; elderly; individuals with chronic heart disease, anemia or respiratory illness. 2. Signs and symptoms-variable and non-specific a. Common: headache, weakness, dizziness, nausea, vomiting, chest pain, altered mental status b. Severe: malaise, shortness of breath, irritability, ataxia, other neurologic symptoms, loss of consciousness, coma, tachycardia, tachypnea, hypotension, cognitive and sensory disturbances, metabolic acidosis, arrhythmias, myocardial ischemia or infarction, and noncardiogenic pulmonary edema. c. Red Flags: no fever associated with symptoms, history of exposure, multiple patients with similar complaints. d. An elevated COHb level of 2% for non-smokers and >9% COHb level for smokers strongly supports a diagnosis of CO poisoning. e. COHb levels do not correlate well with severity of illness, outcomes or response to therapy so it is important to assess clinical symptoms and history of exposure when determining type and intensity of treatment. 3. Management a. Administer 100% oxygen. Serial neurologic exams should be performed to assess improvement or detect the signs of developing cerebral edema. b. Consider transport to hyperbaric therapy facility, keeping in mind if multiple patients may need to be treated. Consult DMCC for transport destination. c. Cardiac injury can occur during poisoning, it is important to perform a 12 lead EKG. d. During a disaster event, EMS may be recalled to the patient’s home if the patient was discharged earlier than normal.

Blast Injuries

1. Key Concepts a. Bombs and explosions can cause unique patterns of injury seldom seen outside combat. However, with the increase of terrorism worldwide, the potential for such activities nationwide has increased our vigilance and preparation locally. b. Blast sites are dangerous; EMS personnel must be alert for secondary devices, fire, environmental exposure, and/or structural collapse. c. We should expect that all initial casualties will seek medical care over a short period of time. Most severely injured patients will arrive at care facilities after the less injured, as they bypass EMS triage and go directly to the closest medical facility. d. Predominantly injuries will involve multiple penetrating injuries and blunt trauma that will require ongoing assessments repeatedly. e. Explosions in confined spaces (buildings, large vehicles, mines) and/or structural collapse are associated with greater morbidity and mortality. Primary blast injuries in survivors are predominantly seen in confined space explosions. f. All bomb events have the potential for chemical and/or radiological contamination. Triage and life saving procedures should never be delayed because of the possibility of radioactive contamination of the victim; the risk to caregivers is small. g. Universal precautions effectively protect against radiological secondary contamination of first responders. 2. Blast injuries causes/examples: a. Primary: injury from over-pressurization force (blast wave) impacting the body surface i. TM rupture, pulmonary damage and air embolization, hollow organ injury b. Secondary: injury from projectiles (glass, nails, screws, bomb fragments, flying debris, etc) i. penetrating trauma, fragmentation injuries, blunt trauma, punctures, lacerations c. Tertiary: injuries from displacement of the victim by the blast wind (patient flying through the air and striking walls, fences, surfaces) i. blunt/penetrating trauma, fractures, and traumatic amputations d. Quaternary: injuries imposed by heat or fumes created by the explosion i. burns, inhalation injuries, asphyxia, toxic exposures, chronic illness exacerbation e. Quinary: myriad of health effects that may be caused by additives to bombs, to include fragments of human remains (e.g. pieces of bone belonging to the suicide bomber) i. secondary infections/reactions from bacteria, radiation & chemicals ii. psychological effects of having impaled human remains

3. Lung Injury- blast wave impact on the lungs results in tearing, hemorrhage, contusion and edema, which may occur without obvious external injury to the chest. a. Clinical presentation i. Dyspnea, hemoptysis, cough, chest pain. ii. Tachypnea, hypoxia, cyanosis, apnea, wheezing, decreased breath sounds. iii. Victims with skull fractures, injuries penetrating torso/head, or burns covering more than 10% body surface area are more likely to the Blast Lung Injury (BLI). iv. Hemothoraces or pneumothoraces may occur. v. Due to pulmonary or vascular tearing, air may enter the arterial circulation and result in air embolic events involving central nervous system, retinal or coronary arteries. vi. Signs/symptoms typically present at the initial assessment, however, BLI can appear 24-48 hours after a blast/explosion. b. Management i. Scene survey to assess kinematics of event. ii. High flow oxygen iii. If ventilator failure occurs, patients should be intubated, however, mechanical ventilation and positive pressure may increase the risk of alveolar rupture, pneumothorax, and air embolism. iv. If air embolism is suspected, place patient in a prone, semi-left lateral, or left lateral position. v. Chest decompression for patients presenting with tension pneumothorax. vi. Fluids should be at maintenance rates. 4. Abdominal Injury- gas-containing sections of the GI tract are most vulnerable to primary blast effect. This can cause immediate bowel perforation, hemorrhage, mesenteric shear injuries, solid organ lacerations, and testicular rupture. Underwater and closed space blasts carry a significantly greater risk of abdominal injury. Children are more prone to abdominal injuries in blast situations due to their unique anatomy. a. Clinical presentation i. Nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, unexplained hypovolemia, fever ii. Abdominal pain, rebound tenderness, guarding, absent bowel sounds iii. Lacerations, punctures, crush injuries b. Management i. Scene survey to assess kinematics of event. ii. High flow oxygen. iii. Nothing by mouth. iv. Stabilization of impaled objects.

5. Extremity Injury- soft tissue and musculoskeletal systems have the highest incidence of bodily injury in blasts/bombings. Traumatic amputation occurs in 1 – 3 % of blast victims. a. Clinical presentation i. Traumatic amputations ii. Penetrating wounds which may include wound contamination from the traumatic implantation of biologic material iii. Fractures as a result of impact against surrounding structures iv. Crush injuries and compartment syndrome b. Management i. Scene survey to assess kinematics of event. ii. High flow oxygen. iii. Wound dressings and bandaging to include pressure dressings as needed. iv. Tourniquets for traumatic amputation/exanguinating extremity hemorrhage. v. Fracture stabilization/splinting. vi. Pharmaceutical pain management. 6. Ear Injury- the first organ to sustain damage in blasts/bombings is typically the ear. Isolated tympanic membrane (TM) perforation without additional signs and symptoms, does not appear to be a marker for severe injury. Middle and inner ear damage may be missed as a result of attention drawn to more life-threatening injuries. a. Clinical presentation i. Tinnitus, earache, hearing loss, vertigo ii. Lacerations to external ear iii. Degloving of cartilage-considered to be a serious injury b. Management i. Scene survey to assess kinematics of event. ii. High flow oxygen. iii. After life-saving measures are taken, a focused evaluation of auditory function should be done. iv. Routine wound care, assure dressings are not too tight. 7. Eye Injury-ocular injuries in blasts/bombings may be extensive, and may involve blunt or penetrating injury to the tissues of the globe, lids, orbit, or ocular adnexa. Injuries are frequently bilateral, may range from minor corneal abrasions and foreign objects to extensive lacerations, open globe injuries, intraocular foreign objects or orbital fractures. a. Clinical presentation i. Minimal discomfort to severe pain or loss of vision ii. Bleeding from lacerations iii. Periorbital swelling or bruising iv. Corneal abrasions, conjunctivitis, foreign objects that may be difficult to detect

v. Open globe injuries including penetrating and perforating injuries to the cornea or sclera with vitreous hemorrhage vi. Hyphema, misshapen pupil, loss of ocular movement b. Management i. Scene survey to assess kinematics of event. ii. High flow oxygen. iii. After life-saving measures are taken, a focused evaluation of ocular function should be done: test light perception, hand motion, and count fingers. iv. Do not force the lids open to examine the eye. v. Do not put any pressure on an injured eye, always assuming a ruptured globe. vi. Stabilization of impaled objects. 8. Crush Injury/Crush Injury Syndrome- Crush Injury (CI) is defined as compression of extremities or other parts of the body that causes muscle swelling and/or neurological disturbances in the affected areas of the body. Crush Injury Syndrome (CIS) is defined as localized CI with systemic manifestations. These systemic effects are caused by a traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic muscle cell components and electrolytes into the circulatory system. Crush injury syndrome can cause local tissue injury, organ dysfunction, and metabolic abnormalities including acidosis, hyperkalemia, and hypocalcemia. It is imperative that patients be pretreated before extrication or movement as patients with CIS may not survive if treatment is not initiated before removal from the situation. a. Clinical presentation i. Hypotension- massive third spacing occurs which may lead to secondary complications as compartment syndrome, hypotension may contribute to renal failure ii. Renal failure iii. Metabolic abnormalities- calcium flow into muscle cells cause hypocalcemia, potassium release from ischemic muscle to circulation causes hyperkalemia, lactic acid release from ischemic muscle to circulation causes metabolic acidosis; all causing life-threatening cardiac arrhythmias including cardiac arrest iv. Compartment syndrome may occur, further worsening vascular compromise b. Management i. Scene survey to assess kinematics of event. ii. High flow oxygen. iii. ECG monitor. iv. Manage airway as indicated- if intubation necessary, DO NOT use succinylcholine, consider vecuronium 0.1 mg/kg IV. v. IV- 1000cc NS with 2 amps (100 mEq) sodium bicarbonate. Volume replacement and pre-alkalization should take place immediately after CIS identified. vi. If dysrhythmias, stabilize excitable tissue with 1 amp (500 μg) of Calcium Chloride IV push over 2 – 5 minutes.

vii. Albuterol 2.5 mg in 3 ml NS SVN continuously. viii. If prolonged extrication, consider 1 amp (50 ml or 25 gr) D50W. Monitor blood glucose levels and consider giving an additional amp D50W. ix. If prolonged extrication, consider Lasix 80 mg. Use Lasix only if patient is well hydrated. x. Consider MS 2 mg every 2 minutes or Fentanyl 25 μg. IV every 5 – 10 minutes to a maximum dose of 100 μg as needed for pain control. xi. Consider Versed 2 mg increments to a maximum dose of 0.1 mg/kg or 10 mg for sedation. xii. DO NOT use PASG xiii. Apply ice, if available, to injured areas and monitor for the 5 Ps: pain, pallor, parasthesias, pain with passive movement, pulselessness. xiv. Contact DMCC for direction to transport to a facility with dialysis, which may be limited in the case of disaster event. 9. Geriatric Patient Considerations- older patients are especially subject to increased risk of fractures, decreased ability of organs to withstand rapidly applied strain forces, traumatic brain injury, post-traumatic complications. Consideration should be given to co-morbid conditions such as: physiologic reserves, multiple concurrent injuries, pre-existing medical conditions/chronic diseases, and routine medication needs affected by prolonged on-scene times during disaster events. a. Clinical presentation i. Physiologic abnormalities may be difficult to assess ii. Delirium is not uncommon, and may be due to medications, infections, hypovolemia, hypoxia, electrolyte imbalances, sleep deprivation, etc. During disaster events, fecal impaction and urinary retention may be a factor. iii. Decreased hearing and visual impairment are common in older patients. Evaluation of these conditions must be done to assess if they are preexisting or due to the blast/bombing. b. Management i. Oxygen therapy –be aware of prolonged on-scene times that may affect chronic respiratory disease patients. ii. Pain management- maintain balance between optimal pain relief with optimal physiologic function. iii. Medications- be aware of need for daily /routine medication needs during prolonged on-scene times during disaster events. iv. Take measures to prevent skin breakdown during prolonged on-scene times during disaster events. v. Provide psychological support to decrease fear and distress.

10. Pediatric Patient Considerations- pediatric patients are especially able to compensate physiologically in response to trauma, however once they begin to decompensate then the situation becomes grave quickly. This clearly may become an issue by prolonged on-scene times during disaster events. a. Clinical presentation i. A traumatic brain injury may occur without the patient losing consciousness- watch for abnormal behavior, persistent vomiting, seizures, CSF leak ii. Chest injuries are a common cause of death-assess for severe thoracic injuries even without significant external evidence of injury iii. Abdominal injuries are common due to anatomical vulnerabilities-assess for internal injuries even without significant external evidence of injury iv. Orthopedic injuries may be neglected during assessment during disaster events, but may affect growth later in life-carefully assess all extremities for fractures/dislocations. Children under 8 years old are subject to spinal cord injury v. Traumatic asphyxia, resulting from sudden compression of the abdomen or chest against a closed glottis, symptoms may include: hyperemic sclera, seizures, disorientation, petechiae in upper body, respiratory failure b. Management i. Scene survey to assess kinematics of event. ii. Consider cervical spine injury immobilization in children with head injury. iii. IV fluids for suspected traumatic injuries, keep TKO unless fluid resuscitation is required then provide at 20 cc/kg. Follow burn management fluid resuscitation per Burn Treatment Protocol as necessary. iv. Temperature regulation is important-keep warm and hydrate. v. Ongoing assessments to avoid missing decompensation. vi. Provide psychological support to decrease fear and distress.

WMD/All Hazards Events

1. Introduction a. The Pierce County Disaster Response Patient Care Guidelines are a separate document from the Pierce County Patient Care Protocols, but use the latter as a foundation for patient care during a WMD disaster. b. The Washington State, Department of Health, Health Services Quality Assurance Division, Office of Emergency Medical Services & Trauma System, Mass Casualty-All Hazards Field Protocols are separate State Protocols that establish the standard for field performance. They serve as a foundation for this section of these Pierce County Disaster Response Patient Care Guidelines, but some variances may be seen based on recent nationwide research and references. 2. Chemical agents a. Incapacitating Agents-Tear Gas (CS,CA,CR),Mace (CN), Pepper Spray (OC) - These riot control type agents are intended to incapacitate individuals and are not intended to cause significant injury or fatality. Effects are immediate and symptoms resolve themselves in 10-30 minutes. 1. Signs/Symptoms 1. Eyes-intense irritation, pain, spasmodic twitching, tearing, sensitivity to light, blurred vision, corneal burns 2. Respiratory-runny nose, pain, tightness in chest, difficulty breathing, choking, burning, hoarseness, cough, sensation of suffocation; Acute- wheezing, rales, tachypnea, hypoxemia, cyanosis, noncardiogenic pulmonary edema 3. Skin-stinging, redness, occasional dermatitis, blistering may occur 4. Gastrointestinal- nausea, vomiting rare 5. Other-headache 2. Management 1. Scene safety with appropriate level PPE. 2. Remove patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. 3. Irrigation of eyes may help with pain relief, remove contact lenses immediately and do not put them back in. Wash skin with soap and water as soon as possible. 4. Oxygen and ventilatory support as necessary. 5. Bronchodilators and steroids for acute respiratory s/s. 6. Burn injury management per Burn Treatment Protocol.

19 b. Choking/Pulmonary Agents-chemicals that cause severe irritation or swelling of the respiratory tract. These dissipate rapidly in a breeze. 1. Chlorine (Cl)-usually stored as a liquid, reactive to water, but there is no contamination of objects when in gas form. 1. Signs/Symptoms a. Eyes- tearing, irritation b. Respiratory- nose and throat irritation, salivation, sneezing, dyspnea, violent cough, chest pain, decreased breath sounds, wheezing, stridor, loss of voice, runny nose, laryngeal or pulmonary edema, ulceration of respiratory tract, rales, tachypnea c. Skin- redness, chemical burns, cyanosis, dermatitis d. Central nervous system- general excitement or restlessness, lightheadedness, headache, muscle weakness e. Gastrointestinal- nausea, vomiting, abdominal pain f. Cardiovascular- tachycardia 2. Management a. Scene safety with appropriate level PPE. b. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. c. Irrigation of eyes may help with pain relief, remove contact lenses immediately and do not put them back in. d. Handle frostbitten skin and eyes with caution, place frostbitten skin in warm water (about 108°F) and if warm water is not available then wrap gently in warm sheet/blanket, allow circulation to reestablish itself naturally. e. Flush skin and hair with plain water for 3-5 minutes, then wash twice with mild soap and rinse thoroughly with water. f. Fresh air. Oxygen and ventilatory support as necessary. g. Bronchodilators for acute respiratory s/s. h. Burn injury management per Burn Treatment Protocol. 2. Ammonia (Nh3)- used in the production of methamphetamine; can cause illness through absorption, inhalation, or ingestion; the extent of illness depends on exposure, depth of inhalation, and concentration of exposure; ammonia is reactive to water, produces toxic gases and may increase toxicity when mixed with water. 1. Signs/Symptoms

a. Eyes- irritation, corneal scarring, potential blindness b. Respiratory- nose and throat irritation, cough, laryngospasm and laryngeal edema, pulmonary edema, bronchospasm c. Skin- stinging pain, inflammation, blisters, necrosis and deep penetrating burns especially in moist areas d. Central nervous system- altered mental status e. Gastrointestinal- burning, abdominal pain, difficulty swallowing, drooling, nausea, vomiting 2. Management a. Scene safety with appropriate level PPE. b. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. c. Irrigation of eyes may help with pain relief, remove contact lenses immediately and do not put them back in. d. Flush skin and hair with plain water for 5 minutes, then wash with mild soap and rinse thoroughly with water. e. Fresh air. Oxygen and ventilatory support as necessary to include intubation, and PEEP for pulmonary edema. f. Bronchodilators for acute respiratory s/s. g. Pain management. h. Burn injury management per Burn Treatment Protocol. i. IV therapy as necessary. j. Do not induce vomiting in the case of ingestion. 3. Phosgene (CG)- chemical used to make plastics and pesticides, can cause illness through absorption, inhalation, or ingestion; the extent of illness depends on route, length and concentration of exposure; phosgene gas is converted to a liquid for shipping and when released is a poisonous gas at room temperature (70°F). 1. Signs/Symptoms a. Eyes- burning, watery, blurred vision b. Respiratory- painful cough, difficulty breathing, shortness of breath, pulmonary edema within 2-6 hours c. Skin- lesions d. Gastrointestinal- nausea, vomiting e. Cardiovascular-hypotension, heart failure 2. Management a. Scene safety with appropriate level PPE.

b. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. c. Irrigation of eyes for 15 minutes may help with pain relief, remove contact lenses immediately and do not put them back in. d. Flush skin and hair with plain water, then wash with mild soap and rinse thoroughly with water. e. Fresh air. Oxygen and ventilatory support as necessary to include intubation, and PEEP for pulmonary edema. f. Treat heart failure and pulmonary edema symptomatically. g. Dress skin lesions after washing. h. IV therapy as necessary. i. Do not induce vomiting or drink fluids in the case of ingestion. c. Blister Agents- agents affect both exterior and interior parts of the body by causing tissue destruction, and upon inhalation form blisters on lung tissue. The rate of action can range from immediate to hours later. The liquid blister agents slowly vaporize, and blister agent vapors dissipate slowly. 1. Chloropicin (PS)- highly irritating agent often used during riot control, a dermally active toxin. Hazardous materials team must rescue and decontaminate these patients. 1. Signs/Symptoms a. Eyes- irritation, pain, redness, burning, watery, prolonged exposure can cause blindness b. Respiratory- irritation, cough, difficulty breathing, sore throat, bluish skin, chemical pneumonitis and pulmonary edema c. Skin- chemical burns or dermatitis manifested by red, cracked, and irritated skin, if injected > redness and irritation of surrounding tissue d. Gastrointestinal- burns to mouth, throat and esophagus; nausea, vomiting; ingestion of large quantities of PS liquid can be fatal e. Central nervous system-dizziness 2. Management a. Scene safety with appropriate level PPE. b. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process.

c. Irrigation of eyes for 15 minutes may help with pain relief, remove contact lenses immediately and do not put them back in. d. Scrub patient’s entire skin surface with mild soap and rinse thoroughly with water. e. Do not use mouth-to-mouth ventilations. Oxygen and ventilatory support as necessary to include intubation, and PEEP for pulmonary edema. f. Bronchodilators for acute respiratory s/s. g. Treat heart failure and pulmonary edema symptomatically. h. IV therapy as necessary. i. Pain management. j. Other supportive measures as needed. 2. Mustard (H)- initial first response to a scene where mustard was disseminated may not see clinical effects because there may be a latent period of 2 hours to 1 day before blisters appear on skin. Mustard causes injury mainly through skin contact because it vaporizes slowly, if inhaled the symptoms begin in 4 – 6 hours. 1. Signs/Symptoms a. Eyes- irritation, pain, redness, watery, edema of lids, sensitivity to light, spasmodic twitching, gritty feeling, corneal ulceration, possible scarring, miosis, possible blindness b. Respiratory- irritation, cough, hoarseness, sinus and pharynx burning, nosebleed, loss of taste and smell, difficulty breathing, wheezing, rales, pulmonary edema, fever, pneumonia in severe cases, later causes bronchitis, infections, lung fibrosis c. Skin- redness, small rash-like dots, itching, tissue destruction and death may be seen within minutes, burning, blisters within hours, necrosis within days, moist areas affected most d. Gastrointestinal- ingestion may cause chemical burns of the GI tract, nausea, vomiting, diarrhea e. Central nervous system-high doses cause hyperexcitability, convulsions, insomnia f. Hematopoietic-systemic absorption may induce bone marrow suppression with increased risk for fatal complicating infections, hemorrhage and anemia 2. Management a. Scene safety with appropriate level PPE. b. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over

face, avoid contamination of unaffected areas during removal process. c. Early decontamination, preferably within 1-2 minutes after exposure is the only way to reduce tissue damage. Unless carried out within 1-2 minutes, decontamination does not prevent subsequent blistering. Decontamination still should be carried out to prevent secondary contamination. d. Irrigation of eyes for 5 - 10 minutes may help with pain relief, remove contact lenses immediately and do not put them back in. e. Decontaminate exposed skin and scalp by blotting, not wiping off the agent, so the contaminant will not spread. Use military or commercially available decontamination kits i. As an alternative, use 0.5% sodium hypochlorite solution, or absorbent powders, such as flour, talcum powder or Fuller’s earth . ii. Wash off the decontamination solutions within 3-4 minutes with soap and water. f. If the patient already has skin redness, then wash the patient’s entire skin surface with mild soap and rinse thoroughly with water. g. Do not use mouth-to-mouth ventilations. Oxygen and ventilatory support as necessary to include intubation, and PEEP for pulmonary edema. h. Bronchodilators for acute respiratory s/s. i. IV therapy as necessary, follow Burn Treatment Protocol. j. Pain management to include antihistamines for itching and edema. k. Do not induce emesis. If the patient is alert and able to swallow, give 4-8 ounces of milk or water to drink. Do not administer activated charcoal. l. Treat cardiac dysrhythmias , pulmonary edema, seizures symptomatically. m. Dress affected skin areas as necessary, but do not cover the eyes with bandages. Use sunglasses if available, for light sensitivity. 3. Lewisite (L)- a powerful irritant and blistering agent that can cause damage by contact via skin/eye exposure to the liquid agent or water containing the agent, inhalation of the vapor, ingestion of water or food contaminated with the agent; the extent of illness depends on route, length and concentration of exposure. 1. Signs/Symptoms

a. Eyes- irritation, pain, swelling, redness, watery, sensitivity to light, spasmodic twitching, corneal damage, edema of eyelids b. Respiratory- runny nose, extreme immediate irritation, productive cough, hoarseness, sneezing, nosebleed, shortness of breath, pulmonary edema c. Skin- pain and irritation within seconds to minutes, redness within 15-30 minutes followed by blister formation within hours; the blister begins as a small blister in the middle of the red areas then expands to cover the entire reddened area; lesions develop with necrotic grayish skin d. Gastrointestinal- nausea, vomiting; ingestion causes severe stomach pain, diarrhea, and bloody stools; liver failure in high doses e. Hematopoietic-systemic absorption may induce bone marrow suppression with increased risk for fatal complicating infections 2. Management a. Scene safety with appropriate level PPE. b. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. c. Early decontamination, preferably within 1-2 minutes after exposure is the only way to reduce tissue damage. Unless carried out within 1-2 minutes, decontamination does not prevent subsequent blistering. Decontamination still should be carried out to prevent secondary contamination. d. Irrigation of eyes for 5 - 10 minutes may help with pain relief, remove contact lenses immediately and do not put them back in. e. Decontaminate exposed skin and scalp by blotting, not wiping off the agent, so the contaminant will not spread. Use military or commercially available decontamination kits i. As an alternative, use 0.5% sodium hypochlorite solution, or absorbent powders, such as flour, talcum powder or Fuller’s earth . ii. Wash off the decontamination solutions within 3-4 minutes with soap and water. f. If the patient already has skin redness, then wash the patient’s entire skin surface with mild soap and rinse thoroughly with water.

g. Do not use mouth-to-mouth ventilations. Oxygen and ventilatory support as necessary to include intubation, and PEEP for pulmonary edema. h. Bronchodilators for acute respiratory s/s. i. IV therapy as necessary, follow Burn Treatment Protocol. j. Pain management. k. Do not induce emesis. If the patient is alert and able to swallow, give 4-8 ounces of milk or water to drink. Do not administer activated charcoal. l. Treat cardiac dysrhythmias, pulmonary edema, seizures symptomatically. m. Dress affected skin areas as necessary, but do not cover the eyes with bandages. Use sunglasses if available, for light sensitivity. 4. Phosgene Oxime (CX)- a corrosive agent also called an urticant or nettle agent, as it does not cause blisters but it results in corrosive lesions. It can come in contact with skin/eyes or be inhaled, and can penetrate clothing faster than other chemical agents. Reactions occur immediately following exposure, and the extent of illness depends on route, length and concentration of exposure. 1. Signs/Symptoms a. Eyes- severe & unbearable pain, redness, watery, spasmodic twitching, corneal damage, edema of eyelids, possible temporary blindness b. Respiratory- immediate irritation, sore throat, hoarseness, dyspnea, chest pain, cough, runny nose, pulmonary edema including rales and wheezing, possible pulmonary thromboses with severe exposure c. Skin- unbearable pain, blanching of the skin surrounded by red rings occurring on the exposed areas within 30 seconds, hives and itching within 15-30 minutes, after 24 hours the whitened areas of skin become brown and die then a scab is formed. Itching and pain may continue. d. Gastrointestinal- possible bleeding in the GI tract e. Other-anxiety and depression 2. Management a. Scene safety with appropriate level PPE. b. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process.

c. Immediate decontamination is necessary as the agent is absorbed from the skin within seconds. Decontamination still should be carried out to prevent secondary contamination. d. Irrigation of eyes for 5 - 10 minutes may help with pain relief, remove contact lenses immediately and do not put them back in. e. Decontaminate skin with vapor exposure only soap and water or 0.5% sodium hypochlorite solution. Decontaminate liquid exposure by showering with water alone. If the patient already has skin redness, then wash the patient’s entire skin surface with mild soap and rinse thoroughly with water. i. As an alternative, use 0.5% sodium hypochlorite solution, or absorbent powders, such as flour, talcum powder or Fuller’s earth . ii. Wash off the decontamination solutions within 3-4 minutes with soap and water. f. Do not use mouth-to-mouth ventilations. Oxygen and ventilatory support as necessary to include intubation, and PEEP for pulmonary edema. g. Bronchodilators for acute respiratory s/s. h. Corticosteroids given IV may be helpful. i. IV therapy as necessary, follow Burn Treatment Protocol. j. Pain management. k. Do not induce emesis. If the patient is alert and able to swallow, give 4-8 ounces of milk or water to drink. Do not administer activated charcoal. l. Treat cardiac dysrhythmias, pulmonary edema, seizures symptomatically. m. Do not cover the eyes with bandages. Use sunglasses if available, for light sensitivity d. Nerve Agents- Tabun (GA), Sarin (GB), Soman (GD), VX - agents that have the same mechanism of action as organophosphate pesticides insecticides which are potent inhibitors of acetylcholinesterase. Thereby leading to an accumulation of acetylcholine in the central and peripheral nervous systems, which produces a predictable cholinergic syndrome. The illness will rely on the amount and type of agent, as well as the route and length of exposure to the agent. 1. Signs/Symptoms a. Eyes- miosis(pinpoint), lacrimation, blurred/dim vision, achy pain b. Respiratory- rhinorrhea, salivation, bronchial secretions, chest tightness, difficulty breathing, bronchospasm, respiratory failure

c. Skin- sweating d. Gastrointestinal/GU- nausea, emesis(vomiting), abdominal pain, diarrhea, urination e. Musculoskeletal- fasciculations(twitching), weakness f. Central Nervous System-irritability, nervousness, fatigue, insomnia, memory loss, impaired judgment, slurred speech, seizures, coma g. Cardiac- bradycardia(muscarinic effect), hypertension, tachycardia(nicotinic effect) h. DUMBELS – muscarinic symptoms mnemonic i. Diarrhea ii. Urination iii. Miosis iv. Bronchospasm, Bradycardia, Bronchorrhea v. Emesis vi. Lacrimation vii. Salivation, Secretions, Sweating i. Days of the week- nicotinic symptoms mnemonic i. Mydriasis (pupil dilation) ii. Tachycardia iii. Weakness iv. tHypertension v. Fasciculations 2. Management a. Scene safety with appropriate level PPE. b. Request MMRS nerve agent cache with consult with DMCC. c. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. d. Flush skin and hair with plain water, then wash with mild soap and rinse thoroughly with water. e. Antidote for nerve agent poisoning is atropine and pralidoxime chloride (2-PAMCl). The MARK 1 kit consists of one autoinjector containing 2mg of atropine and one autoinjector containing 600mg of 2-PAMCl. i. For mild to moderate symptoms, administer one dose of atropine IM followed by one dose of 2-PAMCl IM.

ii. If signs or symptoms are still present after 5-10 minutes (depending on severity), repeat a second set of atropine and 2-PAMCl IM. iii. If signs or symptoms are still present after 5-10 minutes (depending on severity), repeat a third set of atropine and 2- PAMCl IM. iv. For severe symptoms, administer three doses (sets) of atropine and 2-PAMCl IM in rapid succession. v. Pediatric: start with atropine, 0.5mg IV and repeat as above, not to exceed 10.0mg. The recommended dose of 2-PAMCl is 15 mg/kg. f. Oxygen and ventilatory support as necessary to include intubation, but DO NOT use succinylcholine. g. Suction of bronchial secretions is paramount. h. Seizures can be controlled by diazepam in the dose of 2.0-10.0 mg IV or IM for adults, and 0.2 mg/kg IV or IM for pediatrics. i. IV therapy as necessary. j. If ingestion exposure- do not induce emesis. If the patient is alert and able to swallow, administer activated charcoal. e. Arsine (arsenic)- Inhalation of this nonirritating toxic gas is the most likely route of exposure. Absorption into the body via the eyes/skin has not been known to occur. Depending on the intensity of exposure, symptoms may occur 2 -2 4 hours after exposure. However, exposure to high doses can be immediately fatal. 1. Signs/Symptoms a. Eyes-red staining of the conjunctiva may be an early sign of arsine poisoning b. Respiratory- difficulty breathing, garlic odor may be on breath, pulmonary edema, respiratory failure c. Skin- characteristic bronze tint of skin is induced by hemolysis and may be cause by hemoglobin deposits d. Gastrointestinal - nausea, vomiting, crampy abdominal pain, e. Renal-brown, red, orange or greenish colored urine; kidney failure f. Musculoskeletal- muscle pain and twitching g. Central Nervous System-headache h. Cardiovascular- hypotension with severe exposures, hemolysis, EKG changes and dysrhythmias associated with hypocalcemia 2. Management a. Scene safety with appropriate level PPE.

b. Gas trapped in hair/clothes are a minimal threat, but gross decontamination is recommended. c. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. d. Flush skin and hair with plain water, then wash with mild soap and rinse thoroughly with water. e. There is no specific antidote for arsine. Treatment is symptomatic and consists of measures to support respiratory, vascular, and renal function. f. Oxygen and ventilatory support as necessary to include intubation. g. Bronchodilators for patients with bronchospasm. h. IV therapy to ensure adequate hydration. Monitor fluid balance and avoid fluid overload. i. Consider use of lasix to maintain urinary flow, but consult DMCC. f. Cyanide- hydrogen cyanide (AC), cyanogen chloride (CK)- exposure could occur by breathing air, drinking water, eating food, or touching soil that contains cyanide. Inhaling cyanide gas causes the most harm, but ingesting cyanide can be toxic . Cyanide gas is most dangerous in enclosed places, but evaporates and disperses quickly in open spaces. 1. Signs/Symptoms a. Eyes-local irritation b. Respiratory-early> shortness of breath, chest tightness, tachypnea, later> bradypnea, gasping, cyanosis, pulmonary edema c. Central Nervous System-excitement, dizziness, headache, weakness; as poisoning progresses >drowsiness, titanic spasm, lockjaw, convulsions, hallucinations, coma d. Cardiovascular- early>tachycardia, hypertension; later> dysrhythmias, bradycardia, hypotension, death 2. Management a. Scene safety with appropriate level PPE. b. Speed is critical in treating symptomatic patients so decontamination should occur simultaneously. c. Gas trapped in hair/clothes are a minimal threat, but gross decontamination is recommended.

d. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. e. Flush skin and hair with plain water, then wash with mild soap and rinse thoroughly with water. f. Consult with DMCC for use of a cyanide antidote kit for patients who are symptomatic, remembering that speed is critical. The kit contains amyl nitrite perles, and IV infusions of sodium nitrite and sodium thiosulfate. i. Amyl nitrite perle should be broken onto a gauze pad and held under the nose, or over the ambu-bag valve intake, or under the lip of the oxygen face mask. The vapor should be inhaled for 30 seconds of every minute; use a new perle every 3 minutes if sodium nitrite infusion will be delayed. ii. Once IV access is obtained sodium nitrite should be infused as soon as possible. The usual adult dose is 10 ml of a 3% solution (300mg) infused over absolutely no less than 5 minutes; the average pediatric dose is 0.12 – 0.33 ml/kg up to 10ml infused as above. Monitor blood pressure during administration, and slow the rate of infusion if hypotension develops.

iii. Next, infuse the sodium thiosulfate IV. The usual adult dose is 50 ml of a 25% solution (12.5g) infused over 10-20 minutes; the average pediatric dose is 1.65 ml/kg. Repeat one-half of the initial dose 30 minutes later if there is inadequate clinical response.

g. Oxygen and ventilatory support as necessary to include intubation. h. IV therapy as necessary. i. If ingestion exposure- do not induce emesis. If the patient is alert and able to swallow, administer activated charcoal depending on length of time from ingestion to treatment. Isolate any vomitus as it may off-gas hydrogen cyanide. g. Ricin-it would take a deliberate act to make ricin as a chemical weapon. It may be dispersed as a mist or powder, used to poison water or contaminate food, or injected as a liquid into a person’s body. Significant exposure to ricin would result in a relatively rapid, progressive worsening of symptoms over approximately 4 to 36 hours. Depending on the route of exposure (injection or inhalation), as little as 500μ of ricin could kill an adult, but a greater amount would be needed to cause death via ingestion. 1. Signs/Symptoms a. Ingestion exposure i. Profuse vomiting and diarrhea, severe dehydration, hypotension, hypovolemia ii. Weakness, hallucinations, seizures b. Inhalation exposure i. Cough, bronchoconstriction, pulmonary edema, cyanosis ii. Excessive diaphoresis, fever iii. Nausea, weakness iv. Hypotension c. Injection exposure i. Pain at injection site ii. Nausea, vomiting iii. Weakness, dizziness, fatigue

iv. Hypotension 2. Management a. Scene safety with appropriate level PPE. b. If inhalation exposure, gas may be trapped in hair/clothes, so gross decontamination is recommended. c. Remove and double-bag patient’s contaminated clothing and personal belongings. Cut clothing off to avoid pulling clothing over face, avoid contamination of unaffected areas during removal process. d. Flush skin and hair with plain water, then wash with mild soap and rinse thoroughly with water. e. There is no specific antidote for ricin, but it is critical to get ricin off or out of the body as quickly as possible. Treatment is symptomatic and consists of measures to support respiratory, vascular, and renal function. f. Oxygen and ventilatory support as necessary to include intubation and PEEP. g. If ingestion exposure- do not induce emesis. Gastric lavage if ingestion is < 1 hour ago. If the patient is alert and able to swallow, administer activated charcoal. h. IV therapy to ensure adequate hydration. Monitor fluid balance and avoid fluid overload. i. Consider use of vasopressors to maintain blood pressure. 3. Bioterrorism Agents-Category A and Category B diseases/agents

“Statewide and Regional Treatment and Transport Protocols” include these Pierce County Disaster Response Patient Care Guidelines, current Pierce County Patient Care Protocols, specific Pierce County EMS Office guidelines put out during active events, and the Washington State, Department of Health, Health Services Quality Assurance Division, Office of Emergency Medical Services & Trauma System, Mass Casualty-All Hazards Field Protocols.

Recognizing bioterrorism-related illnesses: EMS providers should be alert to illness patterns and signs/symptoms that might signal an act of bioterrorism: An unusual increase in the number of EMS calls for people seeking care, especially with fever, respiratory, or gastrointestinal symptoms. An unusual increase in the number of EMS calls in the same geographic area or public event.

4. Radiological & Nuclear Illness/Injury a. Introduction

36 b. Signs/Symptoms & Management

38 c. EMS responder actions after nuclear weapon detonation :

Radiation Exposure Documentation: Submit to Pierce County EMS Office-Fax # 253-798-2200.

Communicable Disease Events

1. Introduction- a. A major biological incident (mass casualty disaster event) has the potential to significantly overwhelm the health and medical capabilities of a region. A critical and essential function during a major biological incident will be to divert the “worried well,” “stable sick,” and “urgent sick” patients away from the existing hospital medical systems by using alternate care facilities to ensure medical resources are used for maximum benefit. These alternate care facilities will be available for the public to be triaged, receive information, and obtain medical services. A four-tiered disaster medical care delivery system was developed, using existing infrastructure as much as possible: • Pre-Tier 1 – EMS Response and Health Information and Nurse Triage Lines • Tier 1 – Triage, Outpatient Care, and Referral Function • Tier 2 – Alternate Care Facilities (Acute Care Centers) • Tier 3 – Hospital care – reserved for most critically ill with favorable outcomes. i. Pre-Tier 1: EMS Response and Health Information and Nurse Triage Lines. To decrease burden on health care facilities and to lessen exposure of the “worried well” to persons with biological event illness, telephone hotlines will be established to provide advice on whether to stay home, be referred to a triage site, send EMS or a home care or hospice provider. These calls could come directly into 911 and 211 or the nurse advice lines. Criteria are developed to identify “stable patient” and the “urgent sick” patient. The “stable patient” will be advised to remain at home and will be provided educational materials on home care with access to antibiotics and antiviral medications (AVM), if available. The “urgent sick patent” will be referred to EMS or the nurse and/or general advice line. The nurse line will evaluate whether patient needs an in-person evaluation. If so, EMS may be sent or the patient will be referred to a Tier 1 Site. If EMS is sent, there are different outcomes including “no transport” and “transport” based upon condition criteria. The patient can be transported to Tiers 2 or 3, depending upon condition. Late phase in the biological event: when limited EMS are available, resources are limited, there are limited or no hospital beds, equipment or supplies available, the criteria for defining “urgent sick” remains the same; however, as resources become scarce, a new category of patient is assigned, the “too sick” patient. Chances of survival are assessed to be minimal, based upon established medical criteria. A morbidity scale will be followed. EMS transport will be determined by services available. Home health nurses or hospice will be sent, as appropriate and available. Families will be provided with home health care educational materials. ii. TIER 1: Triage, Outpatient Treatment and Referral Centers

Tier 1 sites are located in approximately 36 urgent care and medical clinics located away from, but many in proximity to, hospitals and are geographically distributed throughout the county. Staffing may include MDs, RNs, ARNPs, PAs, LPNs, behavioral health, security staff, health educators, and pharmacy technicians. The Tier 1 sites will provide physical assessments of the patient, treatment per standing protocols for antibiotics and AVM, if eligible and available, and either advise the patient to return home or arrange for transport to Tier 2 (ACC) or to Tier 3 (Hospitals), depending upon patient’s condition. Standard patient screening forms, history and physical exam forms, and admission and treatment orders forms have been developed. A patient tracking system is being developed. iii. TIER 2: Alternate Care Facilities - Acute Care Centers Tier 2 Alternate Care Facilities are in 14 proposed locations throughout the county, predominantly high schools. They are designed to function as alternate inpatient care facilities to augment hospital capacity to admit biological event patients. Local hospitals may be linked to the alternate triage and treatment centers to coordinate and direct patient care, medical logistics and information flow. Tier 2 facilities are designed to care for patients who are too sick to be cared for at home and might need a few hours to a few days of medical care. Examples of types of services available include supplemental oxygen requirement, oral hydration therapy, IV bolus, O2/NC, as appropriate, antiviral medication, IV antibiotic treatment of pneumonia, vital signs monitoring including pulse oximetry, antipyretics and analgesics, limited airway management (but no ventilators available), lab work, palliative care, and fatality management. No X-ray; no aerosolized procedures. Standard forms will accompany patient from Tier 1. iv. TIER 3: Hospital Care A Response matrix has been developed to provide guidelines for hospital personnel in determining admission of patients to critical care units. 2. Triage and Treatment Guidelines a. Pre-Tier 1 EMS Response-To decrease the burden on health care facilities and to lessen exposure of the “worried well” to persons with biological illness, Telephone Health Information and Nurse Triage lines will be established to provide advice on whether to stay home or to be referred to a Tier 1 Triage site, or to send EMS or a homecare or hospice provider. (Refer to Puget Sound Call Center Coordination Project – Conceptual Model.) Criteria is developed to assist 911 and 211 Dispatchers and Phone Triage and nurse advise lines to determine appropriate EMS response. Criteria will identify the “Stable” patient and the “Urgent sick,” patient. The “stable” patient will be advised to remain at home and will be given education for home care. The “urgent sick” patient will either be referred to a Tier 1 – Triage site, or EMS will respond. The EMS response will be driven by certain assumptions based on the biological illness phase in the community. b. Triggers: i. Category 1 – WHO Phase 6 and Federal Government Response Stage 4:First human case in N. America

• Usual Standards of Care • One to five ICU cases have been identified in Pierce County • Full resources are still available • Calls coming into phone triage lines either directly from patients or diverted from 911 dispatch • Action: o Alert and Standby Pre-Tier 1, Tier 1 and 2 Alternate Care Facilities o Activate Hospital Facility Emergency Plans o Activate and Standby Hospital surge capacity c. Criteria to identify the “Stable” patient • No fever or low grade (less than 102.5 for older than 3 months of age), with usual mobility • Slight complaint of or lack of sore throat, muscle aches, or cough • No labored breathing d. Response to the “Stable” patient • Advise to remain at home • Provide education on Home care of stable patient. • Education and Information will also be available on the TPCHD Website e. Criteria to identify “Urgent Sick” patient (driven by chief complaint flu-type symptoms) i. Single criteria - Only one criteria required to send EMS at this Phase: ␀ Difficulty breathing with fever > 102.5; difficulty breathing is assessed as rapid breathing, needing to sit up to breathe, blue color around the lips, and being unable to talk in more than 3-4 words: or: ␀ Altered mental status, which suggests hypoxia or sepsis ii. Two or more of the following criteria required to send EMS ␀ Symptoms of dehydration (check for dry mucous membranes, lack of tears in children, decreased urination in past 12 hours) ␀ Cool, clammy, sweaty skin ␀ Extremes of age: under 2 or over 64 years of age ␀ Comorbidities, such as pneumonia in the last year, COPD, etc. f. Response to the “Urgent Sick” patient The response to the identified “Urgent Sick” patient will involve either EMS being dispatched or a referral to the Nurse Advice Line/Phone Triage. (Refer to Puget Sound Call Center Coordination Project, attached). If EMS is sent, there are different possible outcomes. i. EMS Response: (Per Altered Standards of Care) (1) No transport - Transport to a Tier 2 (ACC) or Tier 3 (Hospital) not warranted ␀ Patient advised to remain at home ␀ Provide flu pack ␀ Provide education on home care and on TPCHD website ␀ Provide information about location of Triage centers, if illness worsens (2) Requires transport: (Per Altered Standards of Care) ␀ Transport to Tier 2 (ACC) if SP02 is greater than 90%

␀ Transport to Tier 3 (Hospital) if SP02 is less than 90% ii. Referral to Health Information Line or Nurse Triage Line (1) May determine that EMS needs to be sent, or they may refer the patient to a Tier 1 -Triage Center g. Criteria for Health Information Line/Nurse Triage Line or EMS to refer to Tier 1- Triage This may be determined by EMS personnel at patient’s home or by Nurse Triage Line. ␀ Fever greater than 102.5; or does not reduce with anti-pyretics ␀ Fever greater than 100.5 in infants and children under 2 years of age ␀ Fever greater than 101.0 for 5 days and not improving ␀ Symptoms for dehydration ␀ Candidate for Anti-viral medication h. EMS Treatment Protocols If EMS dispatches to the home, the following treatment protocols have been identified: ␀ Hydration ␀ Fever Reduction ␀ Pain medication, as needed ␀ Oxygen, once transport is decided ␀ No aerosol generating procedures will be done in the field, including intubation and nebulized treatments i. Triggers: Category II /III– Federal Government Response Stage 5: Spread throughout U.S. and in community • Altered Standards of Care • 50 + ICU cases in Pierce County; increased ventilator demand • Emergency Declaration • Hospital capacity and resources diminishing • Action: ␀ Activate Pre-Tier 1 Altered triage protocols ␀ Activate Tier 1 and 2 Alternate Care Facilities ␀ Activate hospital surge capacity In evaluating triage guidelines for Pre-Tier 1, Tiers 1 and 2, the criteria to identify the “Urgent Sick” patient during Categories II and III of the Pandemic will be the same as noted above in Category l. EMS and Telephone Health Information/Nurse Triage Lines’ response to the “Urgent Sick” will also be the same, but only if resources and services continue to be available. As resources become scarce, a new category of sick patient will be assigned. This category is the “Too Sick” patient. Chances for survival for this patient are assessed to be minimal. A “morbidity scale” will be followed to determine if the patient fits this category. j. Criteria to identify the “Too Sick” patient • Documented DNR (Do not resuscitate) • Unresponsive • Agonal or gasping breathing • Fever greater than 102.5 (along with any of the other criteria) • Cyanotic

• Age greater than 75 years (Age factor may decrease to 70, 65, 60, etc., as needed, per direction of Health Officer, as resources become more limited.) • Also, consider patients who may not have the flu, but are still “too sick” due to other conditions k. Response to the “Too Sick” patient • EMS transport will be determined by services available • Send Home Health Nurse or Hospice nurse, as appropriate • Place on list to be contacted for follow-up when Tier 2 or Tier 3 open up • Refer to mortuary service, if patient deceased • Advise family regarding no resources in the community to provide care • Provide education on home comfort care: o Hydration o Fever reduction o Pain medication, as needed l. Patient Typing Triage During Biological Mass Casualty Disaster Event

45 m. General precautions.

n. WAC 246-100-040 Procedures for isolation or quarantine. (1) At his or her sole discretion, a local health officer may issue an emergency detention order causing a person or group of persons to be immediately detained for purposes of isolation or quarantine in accordance with subsection (3) of this section, or may petition the superior court ex parte for an order to take the person or group of persons into involuntary detention for purposes of isolation or quarantine in accordance with subsection (4) of this section, provided that he or she: (a) Has first made reasonable efforts, which shall be documented, to obtain voluntary compliance with requests for medical examination, testing, treatment, counseling, vaccination, decontamination of persons or animals, isolation, quarantine, and inspection and closure of facilities, or has determined in his or her professional judgment that seeking voluntary compliance would create a risk of serious

harm; and (b) Has reason to believe that the person or group of persons is, or is suspected to be, infected with, exposed to, or contaminated with a communicable disease or chemical, biological, or radiological agent that could spread to or contaminate others if remedial action is not taken; and (c) Has reason to believe that the person or group of persons would pose a serious and imminent risk to the health and safety of others if not detained for purposes of isolation or quarantine. (2) A local health officer may invoke the powers of police officers, sheriffs, constables, and all other officers and employees of any political subdivisions within the jurisdiction of the health department to enforce immediately orders given to effectuate the purposes of this section in accordance with the provisions of RCW 43.20.050(4) and70.05.120 . (3) If a local health officer orders the immediate involuntary detention of a person or group of persons for purposes of isolation or quarantine: (a) The emergency detention order shall be for a period not to exceed ten days. (b) The local health officer shall issue a written emergency detention order as soon as reasonably possible and in all cases within twelve hours of detention that shall specify the following: (i) The identity of all persons or groups subject to isolation or quarantine; (ii) The premises subject to isolation or quarantine; (iii) The date and time at which isolation or quarantine commences; (iv) The suspected communicable disease or infectious agent if known; (v) The measures taken by the local health officer to seek voluntary compliance or the basis on which the local health officer determined that seeking voluntary compliance would create a risk of serious harm; and (vi) The medical basis on which isolation or quarantine is justified. (c) The local health officer shall provide copies of the written emergency detention order to the person or group of persons detained or, if the order applies to a group and it is impractical to provide individual copies, post copies in a conspicuous place in the premises where isolation or quarantine has been imposed. (d) Along with the written order, and by the same means of distribution, the local health officer shall provide the person or group of persons detained with the following written notice: NOTICE: You have the right to petition the superior court for release from isolation or quarantine in accordance with WAC 246-100-055. You have a right to legal counsel. If you are unable to afford legal counsel, then counsel will be appointed for you at government expense and you should request the appointment of counsel at this time. If you currently have legal counsel, then you have an opportunity to contact that counsel for assistance. (4) If a local health officer petitions the superior court ex parte for an order authorizing involuntary detention of a person or group of persons for purposes of isolation or quarantine pursuant to this section: (a) The petition shall specify: (i) The identity of all persons or groups to be subject to isolation or quarantine;

(ii) The premises where isolation or quarantine will take place; (iii) The date and time at which isolation or quarantine will commence; (iv) The suspected communicable disease or infectious agent if known; (v) The anticipated duration of isolation or quarantine based on the suspected communicable disease or infectious agent if known; (vi) The measures taken by the local health officer to seek voluntary compliance or the basis on which the local health officer determined that seeking voluntary compliance would create a risk of serious harm; (vii) The medical basis on which isolation or quarantine is justified. (b) The petition shall be accompanied by the declaration of the local health officer attesting to the facts asserted in the petition, together with any further information that may be relevant and material to the court's consideration. (c) Notice to the persons or groups identified in the petition shall be accomplished in accordance with the rules of civil procedure. (d) The court shall hold a hearing on a petition filed pursuant to this section within seventy-two hours of filing, exclusive of Saturdays, Sundays, and holidays. (e) The court shall issue the order if there is a reasonable basis to find that isolation or quarantine is necessary to prevent a serious and imminent risk to the health and safety of others. (f) A court order authorizing isolation or quarantine as a result of an ex parte hearing shall: (i) Specify a maximum duration for isolation or quarantine not to exceed ten days; (ii) Identify the isolated or quarantined persons or groups by name or shared or similar characteristics or circumstances; (iii) Specify factual findings warranting isolation or quarantine pursuant to this section; (iv) Include any conditions necessary to ensure that isolation or quarantine is carried out within the stated purposes and restrictions of this section; (v) Specify the premises where isolation or quarantine will take place; and (vi) Be served on all affected persons or groups in accordance with the rules of civil procedure. (5) A local health officer may petition the superior court for an order authorizing the continued isolation or quarantine of a person or group detained under subsections (3) or (4) of this section for a period up to thirty days. (a) The petition shall specify: (i) The identity of all persons or groups subject to isolation or quarantine; (ii) The premises where isolation or quarantine is taking place; (iii) The communicable disease or infectious agent if known; (iv) The anticipated duration of isolation or quarantine based on the suspected communicable disease or infectious agent if known; (v) The medical basis on which continued isolation or quarantine is justified. (b) The petition shall be accompanied by the declaration of the local health officer attesting to the facts asserted in the petition, together with any further information that may be relevant and material

to the court's consideration. (c) The petition shall be accompanied by a statement of compliance with the conditions and principles for isolation and quarantine contained in WAC 246-100-045. (d) Notice to the persons or groups identified in the petition shall be accomplished in accordance with the rules of civil procedure. (e) The court shall hold a hearing on a petition filed pursuant to this subsection within seventy-two hours of filing, exclusive of Saturdays, Sundays, and holidays. In extraordinary circumstances and for good cause shown, the local health officer may apply to continue the hearing date for up to ten days, which continuance the court may grant at its discretion giving due regard to the rights of the affected individuals, the protection of the public's health, the severity of the public health threat, and the availability of necessary witnesses and evidence. (f) The court shall grant the petition if it finds that there is clear, cogent, and convincing evidence that isolation or quarantine is necessary to prevent a serious and imminent risk to the health and safety of others. (g) A court order authorizing continued isolation or quarantine as a result of a hearing shall: (i) Specify a maximum duration for isolation or quarantine not to exceed thirty days; (ii) Identify the isolated or quarantined persons or groups by name or shared or similar characteristics or circumstances; (iii) Specify factual findings warranting isolation or quarantine pursuant to this section; (iv) Include any conditions necessary to ensure that isolation or quarantine is carried out within the stated purposes and restrictions of this section; (v) Specify the premises where isolation or quarantine will take place; and (vi) Be served on all affected persons or groups in accordance with the rules of civil procedure. (6) Prior to the expiration of a court order for continued detention issued pursuant to subsection (5) of this section, the local health officer may petition the superior court to continue isolation or quarantine provided: (a) The court finds there is a reasonable basis to require continued isolation or quarantine to prevent a serious and imminent threat to the health and safety of others. (b) The order shall be for a period not to exceed thirty days. (7) State statutes, rules, and state and federal emergency declarations governing procedures for detention, examination, counseling, testing, treatment, vaccination, isolation, or quarantine for specified health emergencies or specified communicable diseases, including, but not limited to, tuberculosis and HIV, shall supercede this section. [Statutory Authority: RCW 43.20.050 (2)(d), 70.05.050, and70.05.060 . 03-05-048, § 246-100-040, filed 2/13/03, effective 2/13/03.]

Isolation & Quarantine Patient Transport Guidelines

TPCHD investigates and assesses patient(s) status

Patient(s) ill & requires Patient(s) requires transport to hospital transport to I&Q facility

Patient(s) Patient(s) Patient(s) Police vehicle POV Taxi Pierce acutely ill & not acutely not acutely - Transit,etc requires urgent ill, but ill, but transport to requires requires involuntary hospital- CALL transport to transport to Van Bus 911 FOR LOCAL hospital- hospital-

FIRE DEPT. non- ambulant- RESPONSE ambulant- transport contact POV private ambulance

O:\EMEM\TPCHD\I&Q Transport algo.doc 8 July 2004

Natural Disaster Considerations

2. Introduction a. Natural disasters present challenges to effectively performing access, assessment, triage, treatment and transport. Limited access to large geographic area MCI scenes, multiple patients in multiple locations, and dangerous scenes with downed power lines, gas leaks, fires, and floods are some of the barriers to efficient and effective delivery of emergency medical care following a natural disaster. b. Planning for events when there is advance notification should take in consideration the need for supplies, equipment, personnel specific to the event. c. Communication that is continuous, effective, and two-way is imperative during these events. Prehospital personnel should be aware of directives/guidance/notifications that are sent out from the Pierce County EMS Office during incidents. As well, prehospital personnel should notify the Pierce County EMS/EMS Liaison in the Pierce County EOC of issues in ‘the field’ during incidents-you are the eyes directly from the scene for the EMS Office/EMS Liaison in the Pierce County EOC. This information is critical to the success of support efforts in planning during disaster events. d. Navigating through and around natural disaster incident sites will be difficult. EMS vehicle drivers need to remain up-to-date/up-to-the-minute regarding road closures and be vigilant as they maneuver through areas to avoid hazards. Continuously perform ‘windshield’ surveys and report any hazards not previously identified. e. The role of helicopter services during natural disaster MCI events can be important, and need strategic planning. There services can include victim extraction, as well as disaster access routes, victim location, structural damage visual assessments, and supplies/personnel drop-ins. 3. Specific event considerations a. Flood i. Drowning is the main cause of fatalities due to being trapped in vehicles and homes. ii. Lacerations and punctures are the most common injuries during the clean-up phase, which can pose an infection issue if not properly cared for. iii. Dehydration of victims if water system is affected, this can exacerbate preexisting medical conditions. GI illness symptoms are common. b. Volcanic eruption i. Ash causes acute eye and respiratory tract irritation, as well as exacerbation of preexisting conditions such as COPD and asthma. ii. It can impede the victim’s ability to self-care and self-evacuation, as well as the EMS provider’s ability to provide care if not wearing the properly safety equipment.

51 c. Earthquake i. Traumatic injuries include fractures, lacerations and crush injuries as a result of the initial and subsequent shockwaves. ii. Dust and fumes can cause eye and respiratory tract irritation, as well as exacerbation of preexisting conditions such as COPD and asthma.

Mental Health Guidelines

1. Introduction a. Mental health issues will be prevalent for all types of disaster events, whether it is an earthquake or biological event. Most fear and distress are normal, expected, and can be managed using good psychological patient care. EMS personnel must be knowledgeable concerning symptoms of anxiety, depression and dissociation to differentiate patients with somatic complaints from those patients suffering from acute illness. However, there may be considerable overlap between these populations as acute stress disorders may be coon among both victims and responders. All reports of physical, emotional, cognitive and behavioral reactions should be taken seriously. 2. Disaster responses a. ‘Worried well’, a majority of persons in a disaster event, may have somatic symptoms below the threshold for a diagnosable disorder b. Psychiatric disorders- anxiety disorders (acute and post traumatic stress disorders), affective disorders (major depressive or dysthymic disorders), bereavement complicated by depression c. Acute stress disorder- dissociative symptoms(sense of numbing, detachment, derealization, depersonalization, absence of emotional responsiveness), persistent re-experiencing the event, impairment of normal functioning d. Behavioral reactions- substance abuse, change in travel patterns, smoking, alcohol consumption, sleep problems, crying easily, excessive activity level, startle reactions, isolation/social withdrawal, distrust, feeling rejected/abandoned, regression of behavior e. Cognitive reactions- difficulty with concentrating/remembering things, difficulty making decisions, confusion/disorganization, recurring dreams, nightmares, preoccupation with disaster, shortened attention span, questioning spiritual beliefs f. Physical reactions-fatigue/exhaustion, gastrointestinal distress, tightening in throat/chest/stomach, headache, worsening chronic conditions, tachycardia g. Emotional reactions-sadness, irritability/anger/resentment, fear, despair/hopelessness, guilt, self-doubt, unpredictable mood swings 3. Actions a. Many mental health issues that occur as a result of a disaster will be resolved as a result of the preplanning to begin the recovery phase as soon as an event occurs. This preplanning will address normalizing activities. b. Triage to identify and refer to a behavioral health specialist victims i. with acute stress disorder or other significant symptoms ii. who are bereaved

iii. who have preexisting psychiatric disorders, including substance dependence, affective disorders, and substance-induced mood or anxiety disorders iv. who have suicidal or homicidal thoughts or plans v. psychosis: hearing voices, seeing things that are not there vi. whose exposure is particularly intense or of long duration vii. who are involved in domestic violence: child, spouse, elder, animal abuse viii. who require medical or surgical attention c. ‘Psychological First Aid’ iii. be calm, patient and professional iv. protect survivors from further harm v. reduce physiological arousal vi. get support for those who are most distressed vii. keep families together and facilitate reunions of family members ix. provide information and reassurance d. Support for EMS personnel-prevention of chronic stress disorders i. Pace yourself, rescue and recovery may take days to weeks. ii. Take frequent rest breaks; try to get away from work area for break time. iii. Watch out for each other, intense attention to the present situation may cause a responder to miss a danger to them. iv. Maintain as normal routine as possible, regular sleeping and eating are crucial. v. Drink plenty of fluids such as water and juices. vi. Try to eat a variety of foods and increase your intake of complex carbohydrates (e.g. breads, muffins, granola bars with whole grain), and eat in a clean area. vii. Recognize things you cannot change-event, waiting, etc. viii. Talk to people when you feel like it. Reach out –others really do care. ix. If provided with professional mental health assistance, use it. x. Do not make any important life decisions. xi. Give yourself permission to feel rotten- it is a difficult situation. xii. Communicate with loved ones as frequently as possible. xiii. Your family will experience the disaster along with you. You will need each other. This is a time for patience, communication, and understanding. xiv. Remember that ‘getting back to normal’ takes time. Take time getting back into your routine.

Deviation from PC Patient Care Protocols/Disaster Response Guidelines

1. Introduction a. The Pierce County Disaster Response Patient Care Guidelines are a separate document from the Pierce County Patient Care Protocols, but use the latter as a foundation for patient care during a disaster. b. The Pierce County Fire Chiefs’ Association Mass Casualty Incident Plan is the guiding document for incidents that occur in Pierce County and are considered ‘manageable’ by routine mutual aid/response activities for a multiple patient incident. It is, as well, the guiding document for initial response to what will eventually be declared a disaster emergency by some entity. c. It has been stressed many times in this document that the PC Patient Care Protocols, PCFCA MCI Plan, and WA State Mass Casualty-All Hazards Field Protocols are the foundation for care to be provided during disaster mass casualty events. It is virtually impossible to create protocols/policies/procedures/guidelines that takes into account every unique aspect, extraordinary circumstance, and possible situation during disasters. While decisions made by those closer to the event may trigger a move to altered or deviations from the standard of care, it is imperative that the Washington State Department of Health, Office of Emergency Medical Services & Trauma System support these decisions with policies to that effect. d. The goal of the EMS response to a mass casualty disaster event is to save as many lives as possible. To achieve this goal, EMS care will have to be delivered in a manner that differs from standards of care that apply under normal circumstances, and possibly different than the guidelines outlined in the sections of these guidelines. It is expected that EMS care practices that are modified during disaster mass casualty events will come with proper education (which might be via a ‘Just-In-Time’ method), medical oversight and quality assurance to reasonably protect patient safety. EMS medical care must be flexible, to permit graded responses based on changing circumstances. This will require both the field provider as well as medical oversight to remain vigilant to the ongoing needs and changes during the disaster mass casualty event. e. It is anticipated that EMS responders will respond from various states to disaster mass casualty events in our jurisdiction. While it will be optimal for every out-of-jurisdiction EMS vehicle will be issued a set of PC Patient Care Protocols, PCFCA MCI Plan, WA State Mass Casualty-All Hazards Field Protocols and a set of these PC Disaster Response Patient Care Guidelines, it is understood that responding EMS personnel will function under their state/jurisdiction’s protocols and scope of practice. As a general guide, the National EMS Core Content document (Attachment A) will specify what knowledge and skills are expected of EMS responders, and the National EMS Scope of Practice Model document (Attachment B) will specify which level of practice will perform specific skills. During mass casualty disaster events, EMS personnel may be required to function in health care settings other

than prehospital scenes or EMS vehicles. It is anticipated the WA State Department of Health will allow these EMS personnel to function in these nontraditional settings (such as EDs, shelters, vaccination clinics, free-standing medical units, urgent care facilities, etc) under the umbrella of protection offered in the WAC for EMS personnel. It is an assumption that EMS personnel will not be held liable for any civil damages, except in cases where they were found to be negligent in treating or failing to provide treatment. 2. Providing EMS care with Scarce Resources a. During a mass casualty disaster event, it may be necessary to allocate scarce resources in a manner that is different from usual circumstances, but appropriate to the situation. Requests for supplies, equipment, etc from field responders should be funneled through the on-scene Medical Command (if at a response event) or through their agency Operations Supervisor. In the event these individuals are overwhelmed or run out of supplies, equipment, etc, the request for support will be taken to the EMS Liaison in the Pierce County EOC. If multiple requests are made for scarce items, the EMS Liaison will consult with the MPD and other health directors to allocate resources. Allocating scarce resources will be conducted in a manner to save the most lives; will be conducted on a basis that is fair, open, transparent, accountable, and well understood by both EMS providers and the public; ensure to the possible extent, a safe environment for the provision of care, and placing a high priority on infection control measures, and other containment processes. b. Approaches to the allocation of scarce resources i. Maximize the availability of EMS personnel through modified or extended shifts, deployment of no more than two providers per vehicle, and use of one-person response vehicles for ‘patient evaluation’ prior to dispatch of transport vehicles. ii. Maximize the use of available EMS personnel through use of non-local responding EMS personnel in nontraditional settings such as the EDs, vaccination clinics, alternative care settings to keep those with local geographic knowledge available ‘on the streets’, use of EMS personnel under an expanded scope to provide vaccinations/medications and/or deliver nontraditional medical care at the scene or in the home. iii. Maximize transport capability by allowing on-scene decisions by paramedics to be made to use nontraditional methods of transport if available and appropriate (taxis, buses, POVs, etc). Load transport vehicles to their maximum capacity. iv. Encourage PC NET (Pierce County Neighborhood Emergency Teams) members to assist and care for individuals in their neighborhoods for extended periods of time, until EMS responders are able to access them. v. To keep those on the front lines healthy and able to continue to respond, maximize personal protection for EMS personnel. Universal precautions should be used for every patient encounter if at all possible. Protections such as

antibiotics, vaccines, or antidotes to staff and family members should be provided. In the case of chemical exposure, decontamination of EMS providers is paramount as well as decontamination of any patient entering a transport vehicle to preserve transportation assets. vi. Maximize destination choices in that alternative care facilities may be able to care for some ill/injured patients to keep from overloading EDs. It is likely that a number of disaster mass casualty event patients may end up being most appropriately managed in the home setting, either because their illness or injury is not severe enough to warrant care in an ED, hospital, alternative care facility, etc, or because the successful outcome of such inpatient treatment in the setting of scarce limited resources would be considered futile and potentially wasteful. vii. Triage efforts will need to focus on maximizing the number of lives saved; instead of treating the sickest or most injured first, triage would focus on identifying and reserving immediate treatment for those individuals who have a critical need for treatment and are likely to survive. Complicating health issues may have an impact on an individual’s ability to survive and should be taken into consideration during triage activities. viii. Equipment and supplies may be rationed and used in ways consistent with achieving the ultimate goal of saving the most lives (e.g. disposable supplies and equipment may be sanitized and reused). ix. Nontraditional methods of splinting/bandaging may be done with ‘improvised’ splinting/bandaging material. Potential spinal injury patients will be critically assessed using screening tools to minimize use of long backboards, etc on all disaster patients. x. The scarce resource of time may be rationed by relaxing current documentation standards. Providers may not have time to obtain informed consent. Minimum data points with assessment and treatment done may be the limited documentation left with patients transported by EMS vehicles. xi. How health and medical standards maybe modified in a disaster mass casualty event- by stage of disease in the population-(although this model is focused on a disease model, it can be adapted to other types of disaster mass casualty events by compressing the stages according to the magnitude of the event).

Disaster Worker Considerations

1. Introduction 4. Preplanning and care for the EMS responder is just as important, if not more vital, to the success of disaster response and recovery. Safe, healthy EMS responders provide effective and efficient patient care during disaster operations. 5. Response and recovery work in disaster areas and during major medical disaster events presents safety and health hazards that should be identified, evaluated, and controlled in a systematic manner to reduce or eliminate occupational safety and health risks to EMS personnel. This section contains guidance from historical data and experiences during disasters, however it clearly cannot cover every concern that may be encountered during a specific disaster be it natural or manmade/ illness or injury. 6. This guidance does not provide an in-depth analysis of OSHA or other Labor & Industry standards or regulations, nor take away from the responsibility of each agency to properly train, educate and equip personnel. It is every EMS responder’s responsibility to evaluate each situation and assure the ‘scene’ is safe for them to enter. It is intended as a quick reference for EMS personnel. 2. General Recommendations a. Exposure monitoring- conduct task specific exposure monitoring during the response and recovery activities: i. when required by specific standard (e.g. lead, asbestos, noise) ii. when exposure is reasonably anticipated to be greater than the ‘action level’ (50% of an established occupational exposure level), as required by an individual OSHA substance-specific standard iii. when necessary to assess and evaluate specific employee exposure or to investigate an employee concern iv. to verify the adequacy of implemented hazard control measures b. Hazard Control- mitigate hazards: i. Elimination or substitution-whenever possible, eliminate the hazard from the work area; although desirable, elimination and substitution may not be options for most airborne/chemical hazard created by a natural disaster ii. Engineering controls-take steps to reduce or eliminate exposure to a hazard iii. Work practice or administrative controls- implement work practices that reduce the probability of exposure; assure EMS personnel get adequate rest, breaks, food & water, conduct higher-hazard or new activities during daylight hours, acclimatize EMS personnel for heat and cold stress, provide fans/ventilation for cooling and heaters for warming, encourage wearing layers of clothing during cold operations that are windproof and waterproof

iv. Personal protective equipment (PPE)- if other controls are not feasible or sufficient, then select and use PPE appropriate for the hazard and level of exposure c. Work Practices- provide for basic safety, sanitation, and good housekeeping to minimize exposure to health hazards and contaminants: i. Establish and maintain evacuation routes and an alerting system to notify individuals in case an evacuation becomes necessary ii. Assure fire protection for the hazards in the work area iii. Ensure emergency care supplies are readily available iv. Drink water from sources proven to be safe for drinking v. Do not consume food or beverages that were exposed to elements of the disaster (floodwater, chemicals, debris, etc) vi. Wash hands ( to include under fingernails) before eating, drinking, or using the restroom; if potable water is not available then use hand sanitizer or commercial sanitizing wipes vii. Minimize accumulation of trash and keep garbage in closed containers viii. Use insect repellent containing DEET or Picaridin to prevent insect bites ix. Prevent creation or disturbance of dust and work upwind of dusty activities when possible x. Take care of personal cuts/scrapes/lacerations by cleaning immediately, cover with bandages, avoid contact with pollutants/contaminated water, and report to your supervisor. Seek further care at the first sign of infection xi. Ensure you have your personal information such as immunization record and blood type on you xii. Ensure personnel come to work prepared, planning to remain for a period of time; bring; 1. Weather gear appropriate to the season/disaster 2. Changes of clothing 3. Toiletries(in plastic rather than glass bottles) 4. Alcohol-based hand sanitizer 5. Flashlight with spare batteries 6. Prescription medication for expected duration of shifts (with a safety margin) 7. Over-the-counter medications for minor illnesses (pain reliever, allergy, hydrocortisone cream, antibiotic cream, etc) 8. Sunscreen 9. Lip salve/balm 10. Insect repellent 11. Hat/cap for sun/rain/weather protection

12. Extra pair of glasses or contacts (with contact lens cleaner,etc-but beware of dusty conditions in some disaster situations) 13. Sunglasses d. Personal Protective Equipment (PPE)- PPE must be properly fitted to the EMS responder, PPE must be inspected prior to each use for repair or replacement as necessary, maintain PPE in a clean manner, maintain adequate replacement supplies: i. General PPE 1. Foot protection-assure approved protective footwear for the activity being performed, give special consideration to water protection in wet or flooded areas 2. Eye protection-safety glasses with side-shields 3. Head protection-hard hats or helmets in areas where overhead or electrical hazards exist 4. Appropriate work clothing- clothing appropriate for protecting individuals from hazards in the general work environment that may cause cuts, scrapes, abrasions, irritation or overexposure to sunlight, consideration should be given to heat and cold stresses 5. Hand protection- gloves specific to job hazards (from simple latex/vinyl patient care gloves to heavy-duty leather gloves for handling debris) ii. Additional PPE as required 1. Eye and face protection-goggles, full-face shields or other suitable protection dependent on hazard 2. High-visibility apparel – safety apparel compliant with standards 3. Hand protection- specialty gloves suitable for the tasks being performed, considering the chemical, biological, physical hazards 4. Work clothing and gear- lanyards, harnesses and supports for fall protection; chemical suits as necessary 5. Leg protection- protection from flood water and hazards that may be encountered, be aware of stray or wild animals that may bite 6. Respiratory protection- In all cases, surgical and dust masks that are not NIOSH-approved are not considered suitable respiratory protective devices. mandatory use of HEPA/N95/other respirators as deemed necessary to the level of the event a. Where nuisance levels (exposure below the PEL) of dust or mold are present, use of a NIOSH-approved N, R, or P95 filtering face piece is recommended. Those with a layer of activated carbon provide and additional level of comfort for personnel by controlling nuisance odors

b. Where contaminants such as lead, asbestos, etc are present, respirators appropriate for the anticipated level of exposure are required, e.g. N,R or P 95 or 100 air-purifying respirators c. Where other contaminants exist, specific filters or cartridges appropriate to the contaminant are required 7. Protection from drowning- employees working around, near, over, on water that presents a drowning hazard must wear appropriate personal floatation devices, approved by the Coast Guard 8. Hearing protection- EMS responders should wear earmuffs and/or earplugs when working around potential noise sources (above 90 dBA), a useful rule of thumb >if you cannot hold a conversation in a normal speaking voice with a person who is standing at arm’s length, the noise level may be exceeding 90 dBA 9. Other- consider having rubbing alcohol on hand to remove resin from plants such as poison ivy; consider having sun protection lotion for every EMS responder to carry e. Removing human or animal remains-After any natural disaster that involves loss of life, EMS personnel may be forced to move or remove remains to access victims who need care, and/or as a part of the recovery phase. i. Follow universal precautions, including washing any areas of the body or clothing that become contaminated with blood, or bodily fluids ii. Do not wear PPE that has been damaged, torn or penetrated by bodily fluids iii. Wear heavy duty work gloves if potential for cuts exists iv. Follow all other hazard mitigation controls and avoid putting yourself in potentially hazardous spaces/situations that will risk your safety

Attachment A

National EMS Core Content

Attachment B

National EMS Scope of Practice Model