AARC Times Extra

When Seconds Count: Preparing Respiratory Therapists for Mass Casualty Incident Response

prepared by: Frank G. Rando, RCP, CRT, CVT, EMT-P

Introduction and Rationale

Due to the prevalence and probability of natural, technological, and terroristic disaster scenarios, the need for appropriately trained health care professionals is self-evident. It is crucial that these professionals be adequately prepared and equipped for rapid mobilization during unusual occurrences and incidents that impact heavily upon community infrastructure and health care delivery systems. Disaster or emergency preparedness and relief in this context refers to medical readiness, rapid mobilization, and operational deployment of various health care assets and resources under austere conditions ranging from local incidents to national security emergencies. The events of September 11 and the subsequent anthrax bioterrorism attacks attest to the need for medical preparedness and planning.

Disaster preparedness and mitigation can, of course, include humanitarian efforts that address basic human needs such as food, clothing and shelter; however, this report shall address medical readiness and response and the areas directly related to the support of the overall medical mission.

The Role and Responsibilities of the Respiratory Care Professional/Respiratory Therapist

The proper function of the cardiorespiratory system is essential for maintaining homeostasis and the human organism's viability. The respiratory therapist or respiratory care professional (RCP) is a vital member of the health care team and must be included in a prominent role during the overall medical response to high impact/mass casualty incidents. As a prime provider of life support skills such as airway management and ventilatory support, it is more than likely that the respiratory therapist will contribute significantly to initial resuscitative and stabilization efforts, as well as assessment, treatment and consultation throughout the entire medical response continuum.

Because airway patency and intact respiratory function must be assured as apriority during any medical response and is considered as the initial medical intervention, the respiratory therapist possesses the best overall knowledge, expertise and modalities to effectively manage cardiorespiratory compromise from a variety of etiologies, e.g. trauma, toxic inhalation, sepsis, etc. In a covert terrorist attack utilizing tactical hazardous materials such as nerve agents or biotoxins, for example, casualties would elicit neuromuscular dysfunction leading to profound, and in many instances, fatal cardiorespiratory compromise. Nerve agents such as sarin or "G-series", (which includes sarin) and certain biotoxins (botulism toxin) affect acetylcholinesterase (AchE) and acetylcholine activity by inhibition which eventually leads to respiratory muscle fatiguability, paralysis and respiratory failure. Another clinical feature would be the production of copious secretions that would contribute to impaired gas exchange and severe bronchospasm. In the case of nerve agents, rapid atropinization is required to overcome an induced cholinergic crisis.

Salvageability and decent clinical outcomes will in large part depend on the availability of prepared medical personnel and resources that can be mobilized efficiently and rapidly.

In many case scenarios, this would require extensive resuscitative and support components, the rapid administration of antidotal preparations such as atropine and the availability of large reserves of mechanical ventilatory equipment, oxygen and oxygen administration devices, intubation and other airway management equipment and adjuncts, physiological monitoring equipment (pulse oximetry, EKGs, etc.). In mass casualty management, triage becomes essential, and respiratory therapists may have to apply their expertise, especially in assessing respiratory casualties. Chemical exposures involving phosgene, cyanide, mustard gas and other agents would require similar clinical and logistical efforts.

Similarly, scenarios involving etiologic (pathogenic) organisms such as anthrax, smallpox, viral hemorrhagic fevers, plague, etc. elicit profound pulmonary and systemic involvement that would require hemodynamic and respiratory support.

Here, vectors, incubation periods and transmissibility play vital roles and are crucial factors involved in infectivity, morbidity and mortality, weaponization, dispersal and epidemiology and overall impact of a bioweapons attack. The health care provider and public health epidemiologist need to become aware of unusual disease clusters, signs and symptomatology and maintain high alert and scrupulous medical surveillance of outbreaks. The respiratory therapist, as a first-line health professional, would definitely encounter these casualties in the ED and critical care setting.

The widespread stockpiling, availability and distribution of antibiotics, antivirals, vaccines, disinfectants as well as supportive medical and public health resources and equipment must be made expeditiously available. All health care providers must practice state-of-the- art body substance isolation (BSI) and quarantine measures and must draw upon their knowledge base of microbiology, immunology, pathology, isolation procedures as well as specialized knowledge that can only be gained through chem-bio event preparation, which includes mock simulations and interfacing with a multiagency response. Initial signs and symptoms of a bioweapons attack may mimic or resemble the common cold, flu, bronchitis, pneumonia, therefore evading medical detection, appropriate treatment and public health surveillance for days or even weeks. Due to varying degrees of incubation periods, environmental and meteorological conditions, disease resistance/immunity and various other factors, bioagent casualties can appear at emergency facilities and physicians offices for weeks after an initial airborne dispersal.

The possibility of genetically-engineered micro-organisms possessing enhanced virulence and drug resistance being used in a terrorist attack is a distinct possibility based on past intelligence reports. Despite international treaties banning research, production, and deployment of chemical and biological weapons and warfare (CBW), rogue nations and terrorist cells still pose a very real and significant threat. The dissolution of the former Soviet Union's complex and widespread Biopreparat bioweapons research and development program and its extensive chemical weapons scheme has led to the export of these hazardous technologies and the technical and scientific personnel to defect to many rogue nations and most likely terrorist groups as well.

Unfortunately, scientific expertise, technical sophistication and government support, command and control are not required to create biological weapons, also known as the "poor man's atomic bomb". The instructions for cultivating and weaponizing pathogenic biological agents are readily available on the Internet and in several "underground" books and pamphlets. Similar instructions are available for toxic agents and even for designing a prototype thermonuclear device and improvised explosive devices (IEDs) and incendiary devices. Weapons of mass destruction (WMD) which should also create substantial concern and awareness among all health professionals and public health officials include nuclear devices with and without enhanced radiation capabilities, conventional, high order and improvised explosive devices, radiological dispersal devices (RDDs) and incendiary devices. The physical and psychological trauma and the long-term, chronic effects of all of these devices and destructive techniques are devastating and staggering. Medical effects run the gamut from minor to major to lethal.

The destruction of a community's social, political, economic, public safety, and health infrastructure couples with serious and grave injuries, panic and loss of order, environmental contamination, loss of sanitation, psychological/psychiatric effects and social breakdown would be a disaster of unprecedented proportions which would hamper effective search, rescue and medical capabilities as well as the provision of the most basic human needs. This entire "worst-case scenario" would be especially true in even a low yield nuclear explosion in a major metropolitan area, a massive biological agent attack or chemical agent attack as well as a massive attack with conventional explosives. The scenario would change, of course, with the use of chem-bio agents and other devices and techniques that do not cause actual physical damage, such as structural collapse. Chem-bio agents, for example, are deployed to maim and kill the enemy force while leaving physical structures intact for eventual takeover by an occupying force. They are also intended to decrease the fighting strength and will of the opposing forces.

The Oklahoma City and World Trade Center bombings attest to the devastation, mayhem, and overtaxing of existing medical facilities and capabilities created by weapons of mass destruction. The September 11 tragedies and the subsequent bioterrorizing attacks that followed in October 2001 have magnified the importance of emergency management for all health care facilities (HCFs).

The sarin nerve agent released in Japan by an apocalyptic cult, Aum Shirinkyo and the deliberate contamination of salad bars with salmonella in Oregon by another cult group, attest to the devastation created by terrorist groups or fanatical organizations that possess weapons of mass destruction. the use of multiple agents and/ or destructive devices, e.g. nerve agents followed by deployment of biological agents and multiple targets throughout a city, region or even nationally are, indeed terrifying, yet feasible, threats. Also, industrial facilities which produce, process, or store hazardous materials or nuclear facilities could be attacked by stealth utilizing a well-trained, motivated and equipped team intent on sabotage and release of contained toxic or radioactive materials. Similarly and maybe simultaneously, medical facilities can be concurrently attacked and sabotaged or destroyed by other terrorist contingents, which of course would weaken, cripple or eliminate medical response elements.

Critical systems such as cryogenic oxygen banks and electrical generation systems (including backup) can be targeted and destroyed. Communication systems can be disrupted and ventilation systems contaminated or made to malfunction. Medical providers, ancillary and nursing personnel, visitors and patients can be attacked and/ or taken hostage. Respiratory care managers and staff therapists need to be aware of these contingencies and prepare to utilize appropriate countermeasures. All RCPs must be well prepared for all contingencies that may befall their facilities and communities. During a nontactical hazardous material incident, a toxic cloud can form and permeate throughout a community. This can result in mass toxic inhalations and serious respiratory and systemic sequelae. An incident such as this can result from a stationary industrial release, transportation mishap, hazardous materials incinerator operation, fire, explosion, hazardous waste sites, or even an episode of illegal chemical disposal or clandestine drug lab operations. RCPs must be aware that toxic exposures can induce acute lung injury (AU) and ARDS, as well as chronic respiratory dysfunction such as reactive airways dysfunction syndrome (RADS) and interstitial fibrosis. Major chemical disasters such as the one that occurred in Bhopal, India in 1984 are entirely possible in the US (and abroad) despite "defense-in-depth" technologies. Communities that contain chemical munitions (chemical weapons) depots and chemical weapons demilitarization programs (chemical surety) are also at great risk for environmental contamination and adverse public health effects from accidental releases or sabotage. These agents, as aforementioned, have left a deadly legacy and are extremely hazardous substances and only minute amounts are required to induce deleterious and lethal physiological effects. Respiratory therapists must also familiarize themselves with personal and protective countermeasures (PPE) and decontamination protocols and participate in team training.

The National Institute of Medicine in its report, entitled "Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response," indicates that many facilities and health care providers are ill-prepared to manage hazardous materials exposures and weapons of mass destruction scenarios. Although, there are on-going national efforts to train health care providers to manage victims of both tactical and non-tactical hazardous materials exposures, WMD, and other disaster contingencies, respiratory therapists are significantly underrepresented in training and readiness efforts and many health care providers including RTs/RCPs are still inadequately prepared to meet these unique challenges.

The respiratory care practitioner (RCP) in many instances is either disinterested, apathetic, incredulous, or in denial ("It can't happen here") when it comes to emergency preparedness. And, this is true of many health care providers and even some emergency response personnel. This is an unfortunate situation because it can result in lack of cooperation, confusion, and poor coordination of available assets and resources during a true emergency and may lead to loss of life, limb, and community infrastructure.

All RCPs need to become aware and obtain proper training in all phases of disaster preparedness and response. We all need to interface with all segments of community preparedness and become familiar with institutional and community emergency management programs, protocols, and procedures. We need to interface effectively and professionally with emergency responders such as pre-hospital emergency medical providers, share our experiences and mutual knowledge and actively participate in training sessions, mock simulations and drills. We need to sit on committees and commissions that address disaster / emergency preparedness issues such as Local Emergency Planning Committees and contribute our thoughts and expertise during hazard analysis and contingency planning sessions. There is nothing wrong with speaking with fire department officials or other public safety / emergency management officials about our concerns and possible contributions as respiratory care professionals. We have to break down these professional barriers to achieve optimal results. In terrorist incidents, we must be aware that the incident site and victims are part of a crime scene and that there are forensic considerations, such as the preservation of evidence. Therefore, relationships with the law enforcement community become critical.

Additionally, we must carry the leadership and knowledge torches and instruct our current and future respiratory therapy students on these vital public health and safety issues. We must not forget that natural catastrophes pose their own inherent challenges among health care personnel and other responders and can be equally devastating as terrorist attacks and technological disasters. Understanding the components of the National Disaster Medical System (NDMS) and utilizing our skills on Disaster Medical Assistance Teams (DMATs) are excellent ways to become actively involved in disaster response activities.

In closing, we must all be aware and prepared for any eventuality that would compromise the health, safety and wellbeing of the human community, the institution and infrastructure and the way of life that binds us all together as a global community. Our readiness and willingness to act as compassionate human beings and skilled health care providers will do much to alleviate pain, suffering, and devastation following any calamity or catastrophic event.

Some Priority Areas

1. Hazardous materials (tactical/non-tactical) medical management
2. Personal and facility protection (PPE, decon, etc.)
3. Respiratory care implications of disaster scenarios
   1. Toxic inhalations or systemic absorption resulting in pulmonary involvement, cardiovascular compromise, neural disruption.
   2. Resuscitation/ stabilization of contaminated patients requiring respiratory care, use of RDIC and disposables, use of atropine, 2-P AM.
   3. Rapid mobilization of RT personnel and medical material readiness/availability, e.g., intubation and other airway management equipment, supplemental oxygen and administration equipment, mechanical ventilation, etc.
   4. Pathophysiology /treatment of blast injuries resulting in pulmonary barotrauma and contusions, penetrating and closed chest trauma, burns, sepsis, crush injury, etc.
   5. Transport issues, including use of automatic ventilators in austere environments.
   6. Pediatric/perinatal care
   7. Evacuation issues
4. Interagency/multiagency familiarity/cooperation
5. Multiskilling/cross-training for disaster scenarios.

Educational and Experiential Criteria for the Disaster-Prepared Respiratory Therapist

Section I-Necessary Criteria

1. Academic and Credential Requirements
   1. Graduate of an approved and accredited respiratory therapy program
   2. CRT, RRT, or registry eligible
   3. Hold course completion cards for Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS), and one of the following: Pediatric Advanced Life Support (PALS), Neonatal Resuscitation Program (NRP), plus preferably either Basic Trauma Life Support (BTLS) or Advanced Trauma Life Support (A TLS)
2. Experience
   1. Two-five years of acute care/critical care experience as a credentialed respiratory therapist.
   2. Adult, pediatric, and neonatal clinical experience as a respiratory therapist or another health care profession such as RN or paramedic.
   3. Experience with airway management situations, including management of the difficult airway in a variety of clinical settings. Intubation skills preferred.
   4. Interface with a variety of clinical situations involving trauma, burns, penetrating injuries, and mass casualties.
   5. Volunteering on fire rescue units or ambulance services, Civil Air Patrol, or urban ( or wilderness) search and rescue teams.

Section 2- Preferred Criteria (should be achieved to maximize effectiveness)

1. Academic and Credential Requirements
   1. Emergency responder certification (or equivalent), or EMT-B certification or preferably EMT -P certification or recent military corpsman/medic training or equivalent.
   2. Hazardous materials awareness/orientation course (OSHA or EPA approved). Higher levels of hazardous materials (Hazmat) training would be preferable, such as hazardous materials technician or hazardous materials specialist. This training will include the use of personal protective equipment (PPE) including level A gear such as self -contained breathing apparatus (SCBA) and encapsulating suits. Individuals must receive pre-training medical assessments and respirator fit testing PRIOR to attending training or deployment. Modified Level "B" or Level "C" is recommended for health care facility personnel.
   3. Training in management of nuclear , chemical, and biological casualties. (This could be incorporated into overall hazmat training. ) Training in administration of antidotes, such as atropine.
   4. Specialized disaster medicine oriented training to include recognition, pathophysiology, and treatment of conditions connected to disaster medical contingencies such as bum trauma, penetrating injuries, crush injuries, blunt trauma, percussion injuries/blast trauma, toxic inhalation/chemical lung injury, and radiation injury. This could incorporate EMT or ATLS training. Comprehensive training in mass casualty incident (MCI) handling, including principles of triage. Provision of assessment and treatment in an austere medical environment. Mock simulation training and field training.
   5. Familiarity with the Incident Command System (ICS), National Disaster Medical System (NDMS), and elements of federal, state, and local response. Experience with interfacing with public safety/EMS officials. Participation on Disaster Medical Assistance Team (DMAT), Metropolitan Medical Strike Force Teams (MMSFT), military medical or humanitarian missions, and joining Reserve or National Guard Units.
   6. Basic Emergency Management Course as provided by FEMA/EMI or other agency.
2. Experience
   1. Transport, flight, prior EMS or emergency/trauma experience (Prior military experience would be acceptable.)
   2. Prefer involvement with Disaster Medical Assistance Teams, Metropolitan Medical Strike Teams, military medical units, pre-hospital EMS.
   3. Multiskilled individual capable of performing various skills or able to cross-train in a variety of clinical skills such as venous access, fluid resuscitation, blood draws, EKG and rhythm interpretation, wound care and debridement, suturing, bandaging/splinting/cast application, rapid assessment using START algorithm, sedation/anesthesia, extrication/cervical spine immobilization, nasogastric intubation, pleural decompression using needle thoracotomy and assistance with chest tube insertion and drainage, cricothyroidotomy, intraosseous cannulation and infusion, administration of blood products, use of blood salvage/autotransfusion equipment, interpretation of hematologic values, administration of antidotal regimens to counteract chemical agent exposures (atropine, 2-PAM), hazmat decontamination procedures and PPE, sterile technique, X -ray technique and interpretation of radiographs.
3. Attributes
   1. All respiratory therapists who may respond to disaster scenarios must show acceptance of the fact that disasters can happen anywhere, any time, to anyone.
   2. Maintenance of an open mind is essential, because many scenarios and disaster situations present unusual and unique phenomena not usually seen in "normal" day-to-day medical operations. One must be prepared to deal with conditions such as massive structural collapse, multiple casualties with varying degrees of physical illness or injuries, patients who may present with unusual signs or symptoms. Therefore, psychological, academic and clinical preparation are essential. Compassion in the face of extreme adversity, austere or hostile conditions and utter chaos and devastation is important, as is the ability to make or be directed to make difficult triage decisions (ìDo the most good for the most people.î) The ability to make quick, effective, and appropriate decisions and to react with a calm demeanor. and display equanimity are all essential attributes of any disaster prepared professional. The ability to accept criticism and also to perceive the need for rest and personal crisis intervention and counseling are also important attributes of a disaster professional. The ability to effectively interface with other professionals and the concept of teamwork are essential factors which would also determine the inclusion of any respiratory therapist on a disaster response team.

Frank G. Rando is a licensed respiratory care practitioner in Utah and Idaho. He is a special advisor/medical planner on counterterrorism, public health preparedness, and respiratory casualty management in Salt Lake City and served as a special consultant on medical preparedness during the 2002 Olympic Winter Games. He lectures frequently on medical preparedness and management of biological, chemical, and radiological casualties and is a member of the AARC Ad Hoc Committee on Disaster Response.

ADDITIONAL READING

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Borak, J., Callan, M., & Abbott, W. (1991). Hazardous materials exposure: Emergency response and patient care. Englewood Cliffs, NJ: Brady-Prentice Hall.

CDC/Agency for Toxic Substances and Disease Registry. (1994). Managing hazardous materials incidents. Volume III: Medical management guidelines for acute chemical exposures. Atlanta, GA: Centers for Disease Control.

Cordasco, E.M. Sr., Burns, D.E., Beerel, F., et al. (1995). Noncardiac pulmonary edema, newer environmental aspects. An update. Angiology, 46(9), 759-766.

DeLorenzo, R.A., & Porter, R.S. (2000). Military and tactical emergency care: Operational out-of-hospital medicine. Upper Saddle River, NJ: Brady-Prentice Hall Health.

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U.S. Department of Justice/Federal Emergency Management Agency. (1997). Emergency response to terrorism. Washington, DC: Department of Justice.

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