University Hospitals of Cleveland's Manager of EMS and Community Outreach, Laura Frost, RN continues to discuss the logistics of preparation and planning of event medicine. This includes familiarizing all of the event medical staff with how to access primary drugs and equipment as well as how to access supplemental support such as transportation and law enforcement.
Prehospital Paradigm Podcast
Event Medicine for EMS - Pre-Assessment, Execution and Lessons Learned, Part 2
(upbeat music) - That brings up kind of the next point, us, right? Is who's us? And I think that's gonna vary based on size of your event, right? Whereas something as large as the fare that we're using kind of as an example here today deserves a multi-disciplined team of doctors, nurses, medics, EMTs, the whole gamut, might not necessarily be necessary for the July parade or your fireworks or something like that. But I think if I'll make a broad brushstroke here, I think if you have an event going on and you can involve your local hospitals to some extent, they may be willing, right? And I don't want to speak for every hospital system in the world, obviously, but, and I know we are, we are on the far pendulum swing of that, where we're going out to as many of these things as we can, 'cause that's just part of our UH program and our commitment to the community. But even at that, I mean, a small local hospital may be able to give you some assets or something like that, get a few people to volunteer or get a bolster that even just for a short time. It doesn't hurt to ask. - Though they're probably gonna use as a recruiting opportunity, oh, hey. - Potentially. - Hey, you're a nurse, you wanna come work at our hospital. If we'd love to have you, there's some of the fun stuff we get to do. - They wanna be seen out in the community as well, right? So don't just immediately think that it's completely on your shoulders, yeah. - Yeah, you don't have to do it on your own, I think that's a great point. If you're gonna have some type of event, parade, festival, street fair, large fair, whatever's going on in your community, touch base with your EMS coordinator or the hospital system that has your protocol and then have that conversation. Do you have generalized numbers for how many people are gonna attend every day? You need to check the weather. There's a lot of prep work that goes into it, but you never know, you might get some free help out of it for a lack of a better word that gives you a different viewpoint on it. And I think what we have learned over the years in doing our event medicine is it's better to be over-prepared, obviously, than under-prepared because then now you can control a lot of that event. So if you have that mass casualty event or that massive heat emergency or cold emergency, you can control patients going to the hospital. You can control, maybe you only have somebody ambulances or you only have one exit point for those ambulances. You control a lot of that. You can bring a lot of calm to the chaos with that prior planning. So I think that's huge is reaching out and you might get resources from the Red Cross, the hospital, from all these different entities that might be able to come help and maybe they only come during your peak hours or something. To the lowest point, I agree 100% is it depends on what's going on at the fair is where your massive crowd's going to move. So, you know, Brantley Gilbert's coming this year, so you know that crowd is going to shift, they're all going to be in the grandstands or-- And you know what time they're going to start lining up to get in and who has VIP and all or so on. So it's pretty easy to judge it by their schedule to your point, it's a great point. I know, OK, the rest of the fair is not going to be as busy. Yeah, there's going to be people that want to go get a driver or a pizza like me, but for the most part-- I can pull my resources from my second station to my main station where everyone's at. Yeah, so you've got to have some mobile assets. That's why trailers work really well. I mean, large fairgrounds have fixed structures, which are extremely beneficial. But yeah, I think the more people you get engaged in your event have some pre-planned meetings that can help. Absolutely. And just as a courtesy, let's take the, hey, hey, can you give us assets and help and stuff, logistical support in a conversation with the hospital. They should know that there's a potential for an influx of patients, right? That same event I was recalling where the gator was having access problems, and we just pivoted to humans walking, I personally want to take a patient to the hospital when I called in. I'm bringing them from this event. And they're like, what's that? You know, the closest hospital, and you know, nothing about this. This was not well-designed by the planners of that event, right? They had no idea that in that particular case, we didn't inundate them. We brought them several, but it wasn't inundation. But they still, till we started showing up, that's not the time for staffing to see. You can't make any staffing decisions. You can't make any decisions of how many beds are available or any control they might have at that point is gone, right? And they can't help your cause at that point, right? And then you're going to be mad because, oh, we had a long turnaround time at the hospital, right? Yeah, but they didn't know about the event. But they didn't know? Yeah, that's a good point too, yeah. Involve-- and you know, and involving more partners is just-- it's going to give you more resources. You know, talk to the EMA, talk to Red Cross, talk to the hospital, and then that allows them to plan on their end, you know? So in that-- and that relates back to-- that's why I think we talk a lot about EMS and fire departments because they're so engaged in the community. You know, I know what we keep using canfield as an example, but they're a good example. I mean, how far ahead do all the meetings start? They've already started. With all the people. So like months and months ahead of time so that you keep reviewing all of these steps. So it's, oh, we forgot to tell this person, right? Let's engage them. You have months to engage them in that. It's not like you don't know the fares coming. You don't know these large events are coming. So yeah, and you've got to let the hospital know. Instead of, like, to your point, well, especially as resources and fire and EMS are so limited right now, if you do not tell that hospital and now your turnaround times are increased and you have-- you need a good flow. Gaps and coverage. You know, I kind of use Geogas fare as an example. You know, you have staffing for the fare and you have staffing for event medicine. And you know how many ambulances you have to essentially make that loop back and forth between the event medicine or your field hospital and the hospital that you're transporting them to, so you kind of placate on, OK, I got one that just dropped off. They're coming back. I'm going to start the second one. My other ambulances coming back. It's a logistics game is what it boils down to is how can I move these people safely and treat them in a controlled environment, but also not deplete myself of all of those resources. You know, are they going to get stuck in traffic? Do I have enough ambulances? All those types of things. So I think it's a huge point to involve facilities. There's two other points that kind of dovetail with that. And, you know, again, I'll use the marathon experience. At the beginning of the day, the Cleveland-- UH Cleveland Medical Center is where most of our patients from the Cleveland Marathon wind up. Along the route, there's other hospitals, right? We make it a point to call all those hospitals. Like, hey, just a reminder, Cleveland Marathon's going on today. Things might be coming in. Then we talk to our people at UH. We're the vast majority of patients are going to go. And we talk-- we have EMS traffic handler there. We affectionately call them quarterbacks. And so we'll call the EMS quarterback and say, I need priority beds today for-- this time to this time, right? I don't care what the bed is, it can just be bring four extra hall beds down, whatever you need to do, but we need quick turns. And then the other thing is breathing the crews. This isn't a regular, you know, especially in that where nothing happens, everything happens. You go from, you know, everybody's sitting around bored, half asleep, to everybody's running, system status zero, I got four-- or negative four, I've got four calls waiting, right? All over the course, because the half marathon's ending, and everybody's coming back and collapsing. There's very predictable things that happen in that, having done it for so long. But the other thing is coaching the crews. Guys, these are short turnarounds, right? This isn't going to the EMS room and get cookies and a water, and talk to your friends, flirt with the nurses, whatever you're going to do, right? Today's not today, right? Your report is going to be-- you're going to be doing the report on the way back, right? Make these short turnaround times, because especially in those high volume events, not a tremendous amount, but they're just-- it all happens at the same time. We spread that out over the entire event. It would be a very manageable thing. It never happens that way, right? And I mean, that's pretty much true. I wouldn't imagine of anything, right? There's always those peak hours. If it's your first time doing it, you don't know, then-- I mean, you could probably guess and estimate, but you're never going to know until real time. No. Another thing to, like, another resource to reach out to is, like, the paramedic programs, right? They're doing clinical times, they're doing rotation time, and having them there as extra resources, extra hands, they need that IV stick, they need all these different skills. They're going to see everything at some of these really big events, even the smaller events, if you're concerned, like, a fair route. They can be people that you can stage throughout to at least start and get things going. I know at the Canfield Fair, we've had them the last, I think, two years, and they've been very helpful on the really busy days, just with patient control and who gets a bed, who gets treated at the door, that kind of stuff. Absolutely, there was a big paramedic student cash at the marathon recently, at the start finish line, and they were the same thing, you were doing all that all. But it's not a good experience. It's a real true street medicine. No, it was, you know, it's in there, it's in mandated as part of their curriculum as mass casualty experience and training, but-- You want to teach triage, that's the way to teach it. That's it, that's it, that's it. You're doing it. And that's an excellent way to do it. Yeah, that's a great point for that and well in the paramedic programs. Get them out, get them that firsthand experience. And then, you know, what do we want? We want to give our students the most high-fidelity experience and training that you could possibly get. Well, it's real people's, is it? Well, and their working and-- Real people and experience is it. Right, and they're working in an environment where they're with UH nurses, UH paramedics, UH physicians, who are their medical control. They're working with, you know, the UH boxes, and they're seeing all of the stuff that they are probably going to see in this area in six months. And they're going to be thematic. Yeah, just better prepares them, I agree. The, you know, part of that preparation is expecting the worst of, you know, some sort of mass casualty tornado hits, active shooter, whatever nonsense the world's going to throw at you. And a lot of that now ties in with pre-planning with your local police fire, like some of the events UH that we do like the Cleveland Browns. They go so far as they have at the ready tactical medics if there is an event who are going to provide, you know, they're going to go forward and, you know, and do the care under fire, if you will, while everybody else shelters in place. So that it expands well beyond just, well, I'm here to hand out aspirin and Band-Aids and going back to our tactical medicine podcast episode, right, and I mean, that was the big takeaway from that. It can happen here. Yep, it can happen anywhere. You are, you are incredibly short-sighted if you don't think it's, that it could happen here, wherever here is. I mean, it doesn't matter what it is. It doesn't, but yeah, I mean-- It could be a street fair. It could be a high school graduation with a gym full of people or all the bleachers are full or a concert, a fair. It could be all of those types of things. All you need is a large amount of people and then one individual that wants to-- Wants to do harm, yeah. Wants to do harm, unfortunately. Yeah, it doesn't have to be a bad actor. It could just be an accident. Imagine if we have a food truck there that's frying food and then they have a leak and you have a big explosion. Yeah, right. So we've got propane in the area, you've got hot grease in the area, and you've got everyone waiting for their basket of fries. Yeah, nothing goes up. You now have a number of victims. A bomb, yeah. A bomb. You let bomb? You have an unintentional bombing. But yeah, no, that's exactly it. It doesn't have to necessarily be malicious. Correct. But it'd be responded to it in a certain way. So all of your triage, your mass kel stuff-- Tack med stuff. Tack med stuff, if you're blessed to have such resources available. But it's also planning and knowing who has kits and who has Narcan and who has stopped the bleed stuff and where is it located in the different buildings? People don't overdose at the fair. Nope. You can't feel it. [LAUGHTER] But what do the cops have on them? As you know, running our little hospital that we run there, I like to know how many officers do we have and what do they have on them? What do they have on them, right? And where are they stationed and where is our emergency exit vehicle stationed? Do you guys have turnkits? Nope. Here's a turnkits. A turnkit, you may return it in six days. [LAUGHTER] That's not a UH way. Here's a turnkit. Keep it. Put that in your pocket. Please never use it. Please never need to use this one. Here's actually-- here's two for good measure. Yeah. But yeah, the-- Well, I think it's to that point. I had an event that I was a part of in Youngstown where we literally just made up Narcan boxes. So that way, every provider there could have Narcan on them. And then after the event, we just flipped it out to the pharmacy to just have extra Narcan on an event. That is-- yeah, your spot on there. We, in my former place, we did a medicine at Macaulicium, basically, right? And a high-profile wrapper came in, and said crowd came with high-profile wrapper. And we did exactly that. We called down to the pharmacy. And we just ordered a bricks of Narcan. And we just had-- Oh, return what I don't need. And that's exactly what happened, right? Because we probably had 60, 70 doses of it, just brick effort, brick after brick. We used a fair amount, that particular one. The one that actually-- the one that-- let me tell you where I got burned in planning for a-- it was a rave. And we took-- We were attending or working. Sorry. [LAUGHTER] For clarification. It sounded like the old-- It sounded a rave. I was putting it on. [LAUGHTER] Sorry. I said my house. Make it sense. But we had, oh, we'll get all of this. And we sent all of this Narcan. Not quite as much as that other event I was talking about. But we sent additional Narcan, extra drug bug, a couple extra mini kits that had Narcan. And a bunch of bad PCP went around at that. And we needed more ketamine. So that was like a two or three day thing. It was some mega event that had several, several happenings. I wind up needing to go into work and take extra drug boxes down and restock things. Just for ketamine, because people were going nuts on the PCP. So it's short-sighted on our behalf. And hopefully maybe less than learn to know your audience. Know your audience, right? We were like, oh, you know, we-- Quite a lot of times, but all supplies, right? What if something unplanned for happens? How am I going to get more supplies? Make sure that I have enough of what I think I'm going to need and how do I get extras in a very short amount of time. If I have a three day affair, a three day thing going on, Friday, Saturday, Sunday, and I burn through all my stock on Friday and now it's a weekend, how do I get more of the sense of supply that I'm going to need for the next two days? Yeah. Ketamine. Ketamine in that particular case, though, because that was the one that burned me. We had prepared for what we thought was going to be a bunch of heroin and the usual stuff. Nope, that-- Lesson learned. I can think of, let's say, that you had a bunch of cardiac arrest that happened, you burned through all your pad pads for your-- Pad perfect, yeah. All your upbeat. I'm going to make sure that I got enough for it. Yeah, I've been there. We ran into a bunch of diabetics, and we went through leaders and leaders of Fluid, of IV Fluid. You know, now this year, I'm like, I need extra cases. Cases, right? Like any cases of that to come, not just a couple of bags. I don't want those. Yeah. Because they didn't want to go to the hospital. Right. And then we're trying to-- They want to go back to the fair. They want to go back to the fair. I want to go-- I want to go back to the fair. I want to go eat more food. Or carbohydrates, yes. And I'm going to come back. [LAUGHTER] You're going to get my sugar moderately under control. Oh, you're under 300. I haven't been there in years. I'm good. Cinnamon roll time. That's right. The other thing that I certainly have run into is, depending on who's sponsoring it and who will be in attendance, not only does local credentialing, who are going to let into these areas, please fire law enforcement. When you start talking about larger things, where now you get FBI secret service, stuff like that, I will tell you that some of our-- going back to my experience with the RNC, the night before they were changing the rules for access and credentialing. And they were like, now we need everybody's copy of everybody's birth certificate. And in that particular situation, we were talking about a staff of 200 people that we were trying to pull. Like, hey, man, I need to have your break. I don't even know where my birth is. Got to find it. You got to find it or you can't work. It was really-- so that may be something as simple as an agreement, like, hey, these are the people we're going to let in and you've got somebody just traffic handling, or you'll have some formal body that is credentialing people and giving a formal blessing and maybe even a full on background check. None of those things happen instantaneously. Again, those things can just start way ahead of time. In that particular situation, they're like, just send us the information of the people that you're going to have staffing the event. If stuff goes sideways, if stuff goes sideways, everybody's going, right? So I'm like, this doesn't work. Everybody has to be credentialed. Everybody has to be authorized. What if you're going to just magically start letting people in if a bomb goes off or somebody starts shooting? No, you're still going to hold them all up at the-- Yeah. You're going to hold them up at the warm zone and that particular event. You're not going to let them in, right? So no, they have to be credentialed to meet all access areas for where they're going to be needed. And then that's something we do in our organization when we help with the air show. So we're entering a military installation. Yeah, perfect example. It's kind of secure there, I would say. A little bit gentleman holding an M4 at the front gate. So you can't just get in. So weeks beforehand, if not-- Well, you probably get five or six steps in, but-- Not very far. They have this really cool gate that comes out of the ground. Yeah, it's pretty badass. It's not going to lie for the car right over. So it's totally cool. But months ahead of time, we'll submit all of our employees. Absolutely. You always submit more than you need, because what happens when someone calls off sick, well, now we need to replace them. So yeah, you always want to credential more people. And they have to do all of their military checks for DoD. And then you'll be issued a pass, and it's a pass for this time, these windows. This time, you know, it's very structured. And we have a great relationship with them. I love Chief Lewis out there. And they're excellent to work with. It's just there are formal parameters that you have to follow. And then to your point, now you have to think into, if I have this emergency there, now I need to get more units onto that scene that are not credentialed, that have not been through that. So those could be some hang up, some bottlenecks where you get, I think, in this sense. Yeah, that part of that planning might be if the big event happens, hey, all of us that are already in the hot zone are in the warm zone, we're just going to be bringing them out to the periphery of you, right? Everybody else stay outside because we can't get you in in a timely manner to begin with. And I gave my example of getting the people back into the RNC. They got to have the whole truck bomb sniff and stuff. It was taking an hour. And then escorted, guess what? There's not going to be an escort if there's a big event, right? So now we're stuck. Nobody can get in or out. But sometimes it's hard to even move at the fair. Sure. You have all these rows of food trucks and you have the walking path. And it's all people. Half the time, you know, canfield's trying to get a golf cart through there. And that's damn near impossible half the time. Yeah, sometimes because there's a lot of people. So all the odds and ends you got to think about. And, you know, as far as the-- so we talked about supply logistics and needing-- just needing to have that backup plan. Like Dr. Hill was talking about where we're going to get the next thing if we use a bunch of it. The Lord is an excellent job of that at the fair, you know? And that's a huge point is, you know, this is what we have the field hospital stocked with, the other field hospital stocked with. And then we have a mobile unit that has overflow, and then even the logistics of weird things. Like, where are we going to get rid of all of our linen that you, you know, fill up the bags? Well, all your sharps. All your sharps containers. That was something we learned, you know, very quickly. I think our first year was, OK, we have just bags and bags and bags of linen. And, you know, by the end of the week, the trailer was pretty full in it. Yeah, after six days and 500 and some patients, it's full. Yeah, you use a lot of pillowcases. You're like, you know, sheets, but it's all those types of things that you have to think about. I know it sounds goofy and silly, but Lord has an excellent job with that. That was-- I was bringing that back up for those points to share some experience that we came-- that developed over time, is we learned just to, on these bigger events, just to staff somebody as a runner. It's their job. We give them a vehicle. Go for it. We give them a vehicle and your job is to hang out and get things, whatever that is. Access to money in case they have to go buy things, right? Whether that's a corporate credit card or whatever the arrangement is, right? Whether that's run stuff to and from the hospital, get rid of linens, get rid of-- and that was developed out of that one year that I was telling, talking about the marathon, where we hit every single-- because we actually hit every single season. Because we had to split a team up and send people-- because we were all geared up for hyperthermia. We were not well-equipped for hypothermia, which was occurring. And then, of course, we had hyperthermia later in the day. But we had to split teams to go get more linens and things to wrap people up in and illuminate blankets and stuff like that. So I guess, plan for the unknown and just have some flexibility built in there and some backup plan to get things that you hadn't thought of, right? And I think a big part of it is, have that open communication with your storeroom or whoever your supply person is, have their cell phone number and say, hey, we're running a little on this. Can you get these ready? Especially for us, it's a holiday weekend. And a lot of these events are a holiday weekend, right? So your person, your contact, may not always be there. So you need to say, I need to have this open communication for this time period, just so that if I need something, it can come. I need to know who your staff is this weekend. So I can communicate that and get what we need. Or answer my phone call. Yeah, whichever. It's true. Or a little about it. Or the person I send there to show up, the gopher, I need you to give them the stuff. Because maybe they've never met. Well, especially drug boxes. I mean, usually at one point during the fair, we have to go exchange drug boxes. And our closest hospital is UH Portage. So making sure that we have people at the right credentials to be able to go and do that. And someone that pharmacy is going to say, oh, yes, you're good to exchange these. Exchange these, right? Right, you can't just send anybody. But when we talk about when we start bringing in that element of pharmaceuticals, now we're talking about storage, temperature management, whatever your state's rules or federal government's rules are on, as far as the regulatory commitments to having pharmaceuticals, the selection of the storage, who's going to administer them, who's going to transport them and replenish, if need be, something to keep in mind if you're-- and I'm working this from an Ohio perspective, because obviously I'm familiar with Ohio law. But if you're going to have a vehicle there for more than 24 hours, you have to give the board written notice that you're going to have a vehicle with drugs on it for greater than 24 hours, right? And you have to tell them you're posting up for this event. You can't just willy-nilly do that. And then the RNC, when we lock ambulances inside the odd zone, we had to do that ahead of time. A pharmacy board we're posting up is their legal terms that they use in Ohio. Hey, we're posting up. We've got drugs secured in these vehicles down there. And they make you just write a dissertation on how you're going to store it, how you're going to manage it, and all that. It's really not that big a deal. But again, it's one thing you don't want to be caught with your pants down. If something goes sideways, and you come under any type of scrutiny. Well, there's also the concern of who can exchange the boxes, right? So I cannot exchange drug boxes. I'm a nurse. I'm not allowed to exchange them. It has to be a paramedic, because they're paramedic boxes. But you also have the concern of we have Dr. Hill a couple of days with us on site. I can give Medicaid because based on his order. But I've never been trained on the drug box. So if you're working with somebody who isn't familiar with maybe that, drug box, like nurses at different events that you have, they're not familiar with that. The first time I saw one was at a fair. That's not fair. Yeah, like-- It's a time to be learning it. Correct. So it's just something to think about too, is if you are new to some of those equipment familiarizing yourself with it. That brings up-- that actually brings up a really good point is if you're getting other medical volunteers, let's say, an organization like-- again, I hate using the marathon, but every year I get to see it. They get nurses, doctors from podiatry, from all over all these different places in the hospital come down with their specialty. But they're using equipment they've never seen before. Right, and they're using all sorts of things. Right, and they're not in a familiar setting. Most of us are used to being in a building, in a controlled environment, and this is not that. That's not that, for sure. [MUSIC PLAYING] [MUSIC PLAYING] [MUSIC PLAYING] [MUSIC PLAYING] [MUSIC PLAYING] [BLANK_AUDIO]