**EMERGENCY PREPAREDNESS**

**FY 2008 - Denver Medical Center & NHCU / Pueblo NHCU /CBOC's**

This document will cover the action to be taken by our VA Eastern
Colorado Health Care System, Denver Medical Center, in the event of an
emergent situation or a disaster (internal or external).

**The ECHCS Emergency Preparedness Book is available on the ECHCS
Webpage as a link within the "for Employees" section, available through
the "VISN 19 Document Tree", and also on the ECHCS Webpage.**

(Upon reaching the Document Tree site click on the + at
![](media/image1.png){width="0.19791666666666666in"
height="0.20694444444444443in"}![](media/image2.png){width="0.1673611111111111in"
height="0.20694444444444443in"}Eastern Colorado HCS; click on the + at
![](media/image1.png){width="0.19791666666666666in"
height="0.20833333333333334in"}![](media/image2.png){width="0.16666666666666666in"
height="0.20833333333333334in"}ECHS Emergency Preparedness Book; select
the file you wish to review.)

***What are Emergency/Disaster situations that our hospital could
experience?***

**There are 2 types of disasters: Internal disasters and External
disasters.**

##### INTERNAL DISASTERS

> Internal disasters include such things as **fires** in our medical
> center, **bomb threats, computer systems failures, and utility
> failures.**
>
> Any internal problem/failure that would drastically reduce our ability
> to care for our veterans could be considered an internal disaster.
>
> **EXTERNAL DISASTERS**
>
> External disasters include such things as **civil disorders (riots),
> severe weather conditions, and massive accidents in our city/area of
> the country.** Any situation that would require additional support of
> our medical center in a community-wide effort could be considered an
> external disaster.
>
> In other words, our medical center might triage and treat non-veterans
> during a community-wide disaster. External disasters most likely would
> affect all area hospitals working in a combined effort to provide
> health services to the population in general.

***[If the hospital goes into an "Emergency Response" mode, the command
structure follows the Hospital Emergency Incident Command System (HEICS)
with the Facility Directors in command.]{.underline}***

**Chain of Command during regular hours**:

![](media/image3.wmf)

**Chain of Command after normal duty hours:**

![](media/image4.wmf)

The Medical Center will establish an **EMERGENCY OPERATION CENTER
(EOC).** The EOC is the command post for all communications &
coordination during a drill or an actual emergency or disaster event,
whether it is internal or external.

The primary location for the EOC will be the **DIRECTOR'S CONFERENCE
ROOM**, room 1C130. If the Director's office is unusable, the EOC will
be moved to a secondary location: room 1B135 (ambulatory care conference
room).

***[How will the hospital know to activate the Emergency Preparedness
Plan?]{.underline}***

For internal disasters, any **employee who discovers** an
emergency/disaster should report it to the operator by **calling ext.
3911** (24 hours/day -- 7 days/week). The operator will immediately
announce over the Public Address System the situation by announcing an
**ALARM** **CODE OR ALARM CODE 6** and its location three times.
**Example: CODE 6, WARD 5 SOUTH**.

The **ALARM CODE 6** announcement is a **[notification
only]{.underline}** announcement (except for individuals already
involved with the situation, EOC, or DET members). No action is required
at this time except to be aware a situation has occurred and wait for
further directions to be given on the over head paging system (EXAMPLE
following)**.**

Only on the Alarm Code 6 **[with a location]{.underline}** will the
**DISASTER EVALUATION TEAM (DET)** immediately respond directly to the
incident to evaluate. Ideally, the individual who reported the problem
should remain at the scene to provide information to the DET. If
casualties are present at the site, then the Associate Chief of Staff
(Ambulatory Care) will assume the "On-Scene Coordinator" role. If no
causalities are present, the Chief FMS will be the "On-Scene
Coordinator". The DET will then secure the area and the "On-Scene
Coordinator will establish communication with the Director or designee.

Based on the DET assessment or other information, the ECHCS Director or
designee will determine to activate the EOC and the Emergency
Preparedness Plan. The Director and the EOC may determine to implement a
specific response plan/response team(s) within the Emergency
Preparedness Plan. The announcement will be repeated (3 times),
"ATTENTION PLEASE, ACTIVATE THE \_\_\_\_\_\_\_\_\_\_\_\_\_ (type)
Response Plan/Response Team(s) at \_\_\_\_\_\_\_\_\_\_\_ (location)."

# What are the Response Plans?

# Emergency Response Plan

# Fire Plan

# Tornado Plan

# Snow Emergency Plan

# Bomb Threat Response Plan

# Computer Shutdown Contingency Plan

# Evacuation Plan

# Terrorism Response Plan

# Decontamination Plan

# 10. Others include (Critical Incidents of Violence, Telephone Outage Emergency, & Civil Disturbance) (see ECHCS Emergency Preparedness Book for all available plans)

***[Will my normal work role change during a disaster?]{.underline}***

**[YES]{.underline}**. It is entirely possible for your role to be
totally different during activation of the Emergency Preparedness Plan.
**Your "*Service Specific"* Emergency Preparedness Plan should be
reviewed to determine your role during a drill or actual disaster. YOUR
ROLE IS MOST LIKELY DIFFERENT FROM YOUR NORMAL JOB...KNOW IT!**

Hospital staff not having a specific responsibility assigned during a
disaster should report to the PERSONNEL POOL for assignment. The
personnel pool is set up so that staff can be sent to areas of need as
they arise. The personnel pool will be located in the AUDITORIUM of the
main hospital (Room BE103). If the auditorium is affected by the
disaster, the alternate location of the personnel pool will be the
CHAPEL (basement of main building (Room BB124).

*[Numerous individuals may be affected and injured by a disaster, how do
we know who to deal with first?]{.underline}*

A **TRIAGE TEAM** will be established in order to prioritize those who
require care most. This occurs both during an internal or external
disaster. Team members will report to the ER patient waiting area for
directions.

***[If there is a fire near oxygen use, who cuts the main oxygen
off?]{.underline}***

The person in charge of that area (i.e. Nurse Manager/charge person)
will shut off the zone valve to that area, isolating it from the rest of
the facility. This occurs because the charge person will need to make
arrangements for portable oxygen if oxygen use is critical in the
affected area.

***[What is the difference in a TORNADO WARNING and a TORNADO
WATCH?]{.underline}***

**Tornado Watch:** Weather conditions are favorable for the formation of
funnel

clouds. "Watch" for funnel clouds!

**Tornado Warning:** Funnel clouds have actually been spotted in the
area.

***[What does the "SNOW EMERGENCY PLAN" of our medical center
mean?]{.underline}***

The **Snow Emergency Plan** will be activated when snow accumulation is
or is anticipated to be so great that it **affects public
transportation**, which would in turn affect the delivery of hospital
supplies and the ability of hospital staff to get to work.

***[What is a CRITICAL INCIDENT OF VIOLENCE?]{.underline}***

This occurs when **any life threatening assault, shooting, taking of
hostages, or barricading** oneself to prevent law enforcement officers
from taking them into custody occurs.

***[If disasters occur, won't the news media be here to find out what is
happening?]{.underline}***

Most likely, YES! Be advised that all media should be referred to the
**Chief, Business Office or their alternate, the Administrative Officer
(AO) to the Chief of Staff**. **These persons are the designated
hospital spokesperson(s) responsible for handling all Public Affairs
issues.**

***[If a disaster affects the hospital phone system, how can I call for
help?]{.underline}***

Certain phones will work even if the phone system fails. These phones
will be identified by a **"FOR EMERGENCY ONLY"** label. In the event
that the emergency phones fail, 2-way radios or cellular phones may be
used.

***[What happens if we have to evacuate the hospital? How do we
evacuate?]{.underline}***

There are [3 types]{.underline} of Hospital Evacuation:

**HORIZONAL EVACUATION** -- Evacuation to an adjacent compartment within
the same building on the same floor. The hospital is sectioned off into
compartments which should contain small fires and smoke to that area. If
an incident is isolated to one area, persons are moved to the adjacent
non-affected area in a horizontal evacuation.

**VERTICAL EVACUATION** -- Evacuation of a floor because of increased
threat to life & property. This type of evacuation will consist of
downward movement at least 2 floors below the threat when feasible.

**TOTAL EVACUATION** -- Evacuation of an entire building because the
incident has rendered the building unsafe for occupation.

***[What am I suppose to do when notified of an Emergency Response Call
Back?]{.underline}***

Personnel arriving at the facility in the response to a personnel call
back need to report to their duty station initially and check in. If not
needed in this area, your supervisor will direct you to the personnel
pool or another team where you will be required to check in again. Do
not report to personnel pool until directed by supervisor or a designee.

**REMEMBER**...it is **YOUR** responsibility to know your **service
specific Emergency Preparedness Response Plan**.

**LOOK** at the ECHCS WEBPAGE for more information on the ECHCS
Emergency Preparedness Plan

.

**YOUR ROLE** may be different during a disaster! **KNOW IT!**

## [Weapons of Mass Destruction]{.underline}

**WEAPONS OF MASS DESTRUCTION --** Weapons with the capacity to inflict
death and destruction on such a massive scale and so indiscriminately
that its very presence in the hands of a hostile power can be considered
a grievous threat. Modern weapons of mass destruction are either
**C**hemical, **B**iological, **R**adiological / **N**uclear, or
**E**xplosive weapons ---frequently referred to collectively as
**CBRNE**.

**CHEMICAL WARFARE AGENTS** -- Chemical warfare agents are synthetic
organic chemicals designed to cause rapid debilitating and lethal
effects in humans and are classified according to the symptoms they
cause, such as blistering and nerve agents. These weapons are attractive
to terrorist groups because they are easily accessible and the parts to
make them are generally legal and cheap to obtain. As a result, many
military and terrorism experts believe there will be an increasing trend
in the use of such weapons.

Since the Second World War, the most common military chemical warfare
agents are organophosphorus (OP) nerve agents, such as Sarin, and VX and
blister (also known as vesicant) agents such as the mustard agents.

**Nerve Agents -** OP nerve agents are anticholinergic poisons. They
produce irreversible inhibition of the enzyme acetylcholine esterase
(AChE) that results in widespread over stimulation of the nervous system
and muscles. Certain commonly available pesticides, e.g., malathion and
parathion, have the same general chemistry as OP nerve agents. The main
difference is that military nerve agents are designed to be more toxic
to humans and have certain physical properties that make them more
desirable for military use. However, these same common
commercially-available pesticides possess sufficient acute toxicity to
be fatal to humans.

Treatment -- Atropine, 2-PAMCl, Diazepan or Lorazepam to prevent
seizures and ventilation support as required.

**Blister Agents -** Mustard agents are chemically reactive, and
reacting with biological molecules in skin or other tissue results in
severe irritation and eventually in tissue destruction and a chemical
burn.

Treatment -- Chemical burns are treated like conventional burns.

**Blood and Choking Agents -** Other forms of chemical agents include:
blood agents, including cyanide, arsine, cyanogens chloride and hydrogen
chloride; choking agents, including chlorine, diphosgene and phosgene.

**Harassing Agents -** such as riot control chemicals and vomiting
agents.

Chemical agents can be absorbed into the body either by inhalation of
vapors or through dermal contact with liquid agents. The best early
intervention is decontamination of the casualties by removal of clothing
followed by thorough water shower using soap and shampoo. Clothing and
casualties are a potential source of contamination to health care
providers. Universal precautions and respiratory protection may be
indicated.

Indicators of a possible chemical incident include: numerous dead
insects and animals in the area; numerous surfaces having oily droplets
or film; discolored or withered trees, shrubs, bushes, food crops or
lawns; unexplained odors ranging from fruity to flowery, to sharp or
pungent garlic or horseradish smells, bitter almond or peach odors and a
smell of hay.

**BIOLOGICAL WARFARE AGENTS** -- Attacks with biological agents remain a
concern for Emergency Management planners.

Biological weapons can be aerosolized, meaning they can be easily spread
into the air and inhaled by humans. These weapons can also be put into
food or water supplies, where they would be ingested. Many will also
cause harm if they contact human skin.

Because of the relatively long incubation period of these agents (days
to weeks), symptoms might not manifest until the initial exposed victims
have become infectious and have started transmitting the disease
throughout the community. In which case, the initial incident has
involved many more casualties, as well as the "worried well" who may
have been exposed or fear they have been exposed to the agents.

As a result, the local medical system can expect to see a patient surge
to medical facilities tying up critical medical resources that would be
better utilized on the more seriously ill patients. It is important that
health care providers have a high index of suspicion about biological
agents and be prepared to provide appropriate health care.

### Dealing with Cases of Exposure to Any Biological Infectious Agent

In dealing with cases of exposure to **[any biological infectious
agent,]{.underline}** medical personnel must be aware of this diagnostic
and treatment continuum:

1.  Clinical presentation

2.  Diagnosis

3.  Treatment

4.  Infection control

5.  Long-term effects

Key issues to consider related to this continuum are the following:

-   Mass exposures are possible

-   Etiology may or may not be known upon admission

-   Primary diagnostic work-up may not be considered initially; signs
    and symptoms may present after admission due to longer incubation
    periods of some agents

-   Some organisms may have altered toxic profiles

The U.S. Department of Health and Human Services Center for Disease
Control and Prevention (CDC) places biological agents in three
categories, A, B, and C. Category A agents are the greatest concern
because they are easily disseminated, often easily transmitted, produce
a high human mortality rate, and have a high social disruption
potential.

  -------------------- -------------------------- -----------------------
  Category A           Category B                 Category C

  Anthrax              Brucellosis                Hantavirus

  Botulism             Food borne/Waterborne      Multidrug-resistant
                       (e.g., salmonella)         Tuberculosis

  Plague               Q Fever                    Nipah Virus

  Smallpox             Staphylococcal Enterotoxin Tick-borne Hemorrhagic
                       B                          Fever

  Tularemia            Viral Encephalitis         Yellow Fever

  Viral Hemorrhagic                               
  Fever                                           
  -------------------- -------------------------- -----------------------

**Don't forget Agricultural bioterrorism, which potentially could
produce famine or widespread malnutrition. These include Foot-and-Mouth
Disease, Mad Cow Disease, Swine Fever, and Karnal Bunt of wheat.**

**RADIOLOGICAL / NUCLEAR WARFARE AGENT --** Ionizing radiation is one of
the public's greatest fears, which makes it an especially attractive
weapon for terrorists. But these are the hardest of all types of weapons
to make because the critical nuclear elements - plutonium and/or highly
enriched uranium - are hard to come by and are very expensive.
Radiological Terrorism is generally considered to be less likely than
either biological or chemical attacks. However, devices involving
radiation will have, perhaps, the greatest panic factor of all. Ionizing
radiation comes from radioactive materials, nuclear reactions, and some
types of equipment such as X-ray machines. **The 3 most important
principles for protection are the concepts of: Time, Distance and
Shielding.**

There are four types of nuclear threat scenarios:

1.  [Dispersal of radioactivity without any explosives]{.underline} --
    it is designed primarily to cause fear and panic. An example would
    be to put radioactive powder in a subway system and simply wait for
    it to be dispersed by foot traffic.

2.  [Dispersal of radioactivity with explosives (the so called "dirty
    bomb" or radiological dispersion devices RDDs)]{.underline} --
    Dispersal of large amounts of radioactivity using conventional
    explosives may result in quite a number of traumatic injuries. The
    purpose of the radioactivity is mostly to complicate the triage and
    treatment of the traumatic injuries. A major health hazard resulting
    from this type of radiological spreading is unlikely to exist for
    more than a few city blocks.

3.  [Attacks on nuclear reactors]{.underline} are felt to be less likely
    since on-site armed security are always present. In addition, U.S.
    reactor designs virtually make accidents involving the reactor core
    almost impossible. The spent fuel from reactors is a possibility,
    but usually these are well secured and watched, and there is a real
    logistical problem to the terrorist to then disperse these solid
    objects.

4.  [Use of an improvised nuclear device or weapon]{.underline} - these
    require more expertise and money than other likely terrorist
    weapons. Results could be devastating and even a so-called fizzled
    weapon can have the destructive power of the Oklahoma City bombing.

**Injuries from nuclear weapons** come as a result of intense blast and
heat as well as radiation. A portion of the radiation occurs
immediately, but there can be additional significant radiation from
fallout.

**Contamination --**radioactive material, such as gases, liquids, or
solids, which are released into the environment and get on a person's
body. If a person breathes or eats contaminated materials or has an open
wound, it can get inside the body as well.

> Patient Characterization

-   **[Irradiated]{.underline}** -- patients who are only irradiated
    pose no contamination risk and no risk to caregivers. Irradiation
    means that a patient has been exposed to a radioactive source,
    similar to an X-ray or radiation therapy treatment. Like a light
    that simply shines on a person, and is then switched off, there is
    no residual radiation on the patients or inside the patient.

-   **[Contaminated]{.underline}** -- patients possessing radioactive
    materials inside or outside their bodies poses little immediate
    health threat to caregivers. Experience has shown that healthcare
    workers have received very little radiation exposure from caring for
    even highly contaminated patients.

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-   **[Internal Contamination]{.underline}** -- It is important to
    recognize this possibility and take measures to keep the radioactive
    materials from getting to tissues where they may be localized for
    long times.

    -   Exposures routes: inhalation, skin/wounds, ingestion

    -   Treatment must be early to be very effective

    -   Mechanisms (decreased absorption, blocking, dilution,
        mobilization, chelation)

-   **[External Contamination]{.underline}** - When there is
    contamination on the body or clothing surface, the first step with
    any medically stable patient who has any possibility of
    contamination is to remove the clothing. 80-95% of any contamination
    will come off the person's clothes and then the patient can be
    washed with lukewarm soap and water.

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-   **[Psychological Issues]{.underline}** -- an actual or suspected
    release of radioactive material creates immediate and long-term
    psychological consequences that can impair effective rescue, relief,
    and recovery operations. This holds true whether the incident is a
    technological accident or a terrorist attack. A goal of terrorism is
    to undermine government decisions and actions by creating and
    maintaining fear in the general population. While all weapons of
    mass destruction can immediately incapacitate a community, incidents
    that involve, or are suspected to involve, radioactive components
    have the unique potential to debilitate for an even greater duration
    of time -- possibly generations.

**EXPLOSIVE TERRORISM WEAPONS** -- Improvised Explosive Devices (IED)
explosives are economical and the easiest weapons to obtain and are used
almost daily to injure and kill large numbers of people.

There are two basic types of explosives:

> **[LOW]{.underline}** order explosives do not cause blast wave
> formation, and include black powder and an explosive mixture, which
> under any condition cannot support a detonation wave. Confinement
> required for explosion.
>
> **[HIGH]{.underline}** order explosives generate a reaction that
> results in the creation of a blast wave. Material undergoes detonation
> without confinement. These include TNT, dynamite, and composition C4.

Injuries during an explosion result from flying debris and blast
injuries. During an explosion, gases under extremely high pressures are
produced. When these gases expand, they form a blast wave, which spreads
out in all directions and is the main culprit of primary blast injury.
The magnitude and duration of the blast wave are major determinants of
the severity of a blast injury. As a blast wave impacts the body, a
pressure wave is transmitted through the body surface, affecting the
underlying tissues. This transmitted wave may fragment tissues of
different densities, compress air-filled organs, or tear organs from
their points of fixation.

**PATIENT DECONTAMINATION AWARENESS TRAINING** -- VHA Directive 2002-033
"Steps Required to Establish a Practical Medical Center Emergency Mass
Casualty Decontamination Capability" requires all VA medical centers to
develop an appropriate plan for identified mass casualty hospital
decontamination needs. The ECHCS Decontamination Plan (Chapter 7 --
Emergency Preparedness Book) took into consideration the cities'
capability, the capabilities of adjacent medical centers, the number of
staff available, as well as the overall role this medical facility would
play in a mass casualty situation. The plan has established that our
level of response will provide a medium capacity, semi-fixed, ambulatory
only capabilities.

***Why have a Patient Decontamination Program?***

OSHA defines a Hazardous Material as "any substance to which exposure
results or may result in adverse affects on the health or safety of
employees or any chemical which is a physical hazard or health hazard.
The toxicity or the ability of a substance to cause injury or harm to
the body once contact or exposure has occurred is dependent on the
concentration and the duration of its exposure. A patient
decontamination team is established to start decontamination procedures
on the patient potentially exposed to external radiological and chemical
substances to 1) reduce the concentration and 2) shorten the duration of
exposure of the substance on the patient. The other purposes are to
eliminate potential staff, other patient and facility contamination, and
provide victims with psychological comfort.

***Why so much emphasis on patient decontamination when the odds of a
terrorist hazardous material attack at our facility is a very low
probability?***

This may be true, the probability of a terrorist attack at our facility
may be extremely low, but the odds for a medical center to conduct
decontamination are higher for internal spills, industrial activities,
or transportation incidents. The medical center needs to be prepared to
respond to any incident that may pose as a risk to patients and staff.

***Why isn't the entire staff provided with Personal Protective
Equipment (PPE)?***

The entire staff is provided with (PPE) daily. The PPE instituted in the
medical center's Standard Precautions guidance is adequate for
daily-anticipated risk levels. The PPE provided to the decontamination
team members is based on the anticipated risk level while they are
performing decontamination procedures. Once the patients have been
decon'd, there is no need to have any additional PPE than what has been
established under the Standard Precaution guidance.

***What actions need to be taken if an unannounced contaminated patient
enters the medical facility?***

-   **Recognize the hazard, stop the person from going any further, ask
    the person to go back out the way they came in, and wait for help.**

-   **Initiate actions to protect yourself, the medical facility, and
    notify your supervisor.**

-   **Activate the Decon Plan and (if other victims are possible)
    security lockdown.**

-   **Isolate any area potentially contaminated and try to identify the
    contaminate.**

-   **Set-up the Decon area and initiate decontamination procedures as
    appropriate.**

-   **Initiate recovery operations.**

***I would like to obtain more information about the Patient
Decontamination Program and what is required to become a member of the
Decon Team?***

To obtain additional decontamination information or to inquire about
volunteering for the Patient Decon Team you can contact Zane A. Shaw,
D.V.M., VISN 19, Area Emergency Manager, at ext. 7584 or via e-mail at
<zane.shaw@med.va.gov>. His office is located just north of the medical
center's Clermont entrance at 4495 Hale Parkway, Suite 300.