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Background:
On July 15, 2009, approximately 1300 hrs the Redrock and Trailer
1 fires started 25 miles north of Reno, Nevada, in heavy grass,
moderate sage, and moderate to heavy juniper fuel types. Temperatures
were in the 95-103°F range, causing the fires to spread
rapidly with afternoon winds. Typical duration of similar incidents
in the area have been three to seven day events, with rapid
mobilization and demobilization of large quantities of local
resources.
Both fires were initially under two Type 3 command structures,
made up of local personnel. It was quickly identified that the
fires progression was going to threaten structures within the
community areas of Cold Springs, Red Rock, and Rancho Haven,
as this was the historical precedent. The capabilities of the
Type 3 command structures were going to be exceeded, and a Type
2 IMT was requested.
Great Basin IMT2 Whalen was ordered. A considerable number
of the IMT personnel were local and very familiar with the incidents
and their progression, the fire history, and local resources.
The ICP was located at Cold Springs Middle School, 15 miles
North of Reno, Nevada. The IMT took command of the incident
at 1800 hours July 16th, 2009.
Facilities for the Medical Unit were established within the
school, in a laboratory room. This room was chosen due to its
multiple sinks for hand washing, solid surface floors and countertops
for cleaning of blood or body fluids, close proximity to the
restrooms, a connected adjacent lab that could be used as a
quiet resting area for ill or injured personnel, and a separate
entrance/exit for ambulance transport. These factors proved
essential for treatment, and turn-over of the facility at incident
close.
On July 19th, during the evening hours, the medical unit started
to see an increase in nausea and diarrhea complaints. It was
a small increase (<5), but raised awareness amongst the MEDL
and MEDL(T). Many of the patients attributed their discomforts
possibly to the food that was served during breakfast that day.
July 20, 2009. The incident was progressing with demobilization
of excess resources, and reassignments. There was strong movement
to release resources do to predicted lightning and an anticipated
increase in local initial attack.
There was a noticeable increase in nausea, vomiting, and diarrhea
complaints. Several team members along with crew personnel were
having severe complaints. Safety Officer and Food Unit Leader
were notified. Food Unit Leader discussed that during routine
inspection of the catering unit the day before that some rice
used for meals may not have been stored properly. The Food Unit
Leader initiated some fact finding for food borne illness through
professional contacts. The information gathered, plus a previous
event occurring on an incident locally 10 years prior, stimulated
a meeting between the command and general staff, including the
medical unit for direction on proceeding with the issue.
During this meeting, it was identified that the only way to
know whether the issue is food borne, or other, was to take
individuals experiencing symptoms to be evaluated and stool
specimens collected for analysis. Arrangements were made to
transport several personnel with the MEDL to local facility
for evaluation. Upon arrival at the treating facility, the MEDL
held conference with the attending physician about concerns
and timeframes for sample analysis results. Possibilities outside
of food borne illness were discussed, and it was relayed that
test results could take up to 48 hours to receive.
While the three team members with symptoms were being evaluated,
six other incident personnel became ill to the point of five
of them being emergently transported for evaluation. The attending
physician, once notified of more patients, notified the Washoe
County Health Department. This notification was also being performed
by the SOF2 (T) at the incident.
Of all, three were federal employees and AD’s, four were
state or local employees, and two were contractors. All were
treated and released. Stool samples were collected and sent
to the lab for analysis.
Updates were given by the MEDL at the treating facility to
the IC. Local district COMP personnel assisted with procurement
and documentation at the treating facilities. Accommodations
for filling prescription orders for anti-emetics and anti-diarrheal
were made.
July 21st. Nausea/vomiting/diarrhea complaints quadrupled.
Personnel complained of vomiting outside of the ICP on the school
grounds, in tents while they slept, and in vehicles. Demobilization
was rapidly occurring. Information on Noro-type virus symptoms
and treatments was distributed at the morning briefing.
ISUITE Injury/Illness module reports were pulled to identify
possible source personnel, affected personnel, and home units
or reassignments. Command and General staff met again and discussed
further issues regarding noro-type virus, as this was the suspect
according to Washoe County Health Department EpiTeam.
Lists of personnel and crews affected were given to the IC2(T)
to notify home units, staging areas, and other incidents. There
was discussion of isolation and cleaning protocols for equipment,
facilities, personal belongings, and affected personnel. These
protocols are contained in the attached documentation from the
Washoe County District Health Department and CDC guidelines
for Norovirus.
Washoe County School District already had plans in place for
such an event and was going to clean the facility according
to the plan.
The IMT transitioned and closed out the incident, passing
on information to the type 3 IC. All resources were demobilized,
and notifications sent to home units, and districts of reassignment.
The following information was collected by the IMT and Washoe
County Health Department:
- 18 firefighters and six contracted staff have reported
becoming ill.
- Primary symptoms are nausea, vomiting and diarrhea.
- While some have sought medical care (e.g., through emergency
departments), none that we know of have been admitted to any
local hospitals.
- Specimens were collected and sent to the State Lab for
analysis. Norovirus has been confirmed among several of those
who reported being ill. The cause of the outbreak has not
yet been determined.
- We don't yet know the source of the outbreak and are continuing
to investigate.
- Due to the contagious nature of many illnesses that involve
vomiting and/or diarrhea, the Incident Commander indicated
that contaminated items (i.e., sleeping bags and tents) would
be discarded and owners would be reimbursed.
- In general, outdoor gatherings where food is served have
greater potential to lead to food borne illness due to less
control over items such as proper food preparation and storage
and lack of
hand washing. That said, many improvements have been made
in firefighting environments to reduce the number of food
borne illnesses occurring in those settings.
Lessons Learned from a Medical Unit perspective:
- Choosing appropriate facilities is to handle such incidents
is essential. The Medical Unit in fixed facilities should
be in close proximity/or have or have: sinks for hand washing,
solid surface floors and countertops for cleaning of blood
or body fluids, close proximity to the restrooms, adjacent
rooms of similar types that could be used as a quiet resting
area for ill or injured personnel, and a separate entrance/exit
for ambulance transport. Laboratory rooms or similar rooms
in schools are ideal. Outdoor incident medical facilities
should have hand wash stations and restrooms within close
proximity, and ambulance or vehicle access for transports.
- Hand wash stations must be located in numerous locations
early in an incident, specifically during transition. Crew
that were spiked or coyote camped should be encouraged to
clean and bath before continuing in any camp or ICP functions.
- Locate large bottles of hand sanitizer in each functional
unit, or area (Check-in, Supply desk, Briefing areas) for
use.
- Encourage bathing, hand washing, and good hygiene during
operational briefings.
- Maintain strong communication lines with the safety officer,
food unit leader, logistics staff, and medical unit staff.
All personnel need to be informed.
- Prepare an isolation protocol/plan to be quickly enacted.
Pre-established numbers of common complaints can be used as
trigger points (i.e. >5 similar complaints/100 personnel/operational
period).
- Utilize and become familiar with ISUITE Injury/Illness
module. Tracking of complaints by personnel allowed for quick
identification of affected crews, home units, and reassignments.
- Early identification, appropriate notification and fact
finding. Prepare handouts for units, trap lines, information
boards, and IAP inserts.
- Identify common vectors of transmission, and mitigate as
necessary. Common vectors: Hand rails to serving windows,
table items (salt and pepper shakers, ketchup, etc.) in eating
areas, shower facilities, hand wash facilities, ice chests,
vehicles, shared computers, door handles, etc.
- Order and provide cleaning supplies for incident vehicles,
specifically rental vehicles. Insides should be sanitized
before demobilization. Germicidal wipes and latex gloves should
be provided for this purpose and placed at vehicle inspection
areas.
- BSI stockpiles should be identified. At minimum, latex
gloves should be ordered and on hand for personnel operating
within the food unit, ground support, medical unit, facilities
and supply. Masks, eye protection, and gowns should be available
if needed.
- Identify possible quarantine areas. Incident personnel
may be utilized for this area. All must be trained on universal
precautions. This may require extended assignments or work
hours.
- Establish a pharmacy for use. 24 hour pharmacies are ideal.
Work with procurement and/or buying team for this.
- Coordinate with the local treatment facility and staff
early. Early notification can assist in improving the surge
a facility may experience to increased number of patients.
- Communicate early with the health district of jurisdiction.
The treatment facility may be able to assist with this.
- Coordinate with the rest of the management team.
- Coordinate with Finance and COMP personnel to complete
CA-1 and CA-16 for federal employees. Gather information for
state, local, and contracting personnel. Personal items, or
incident property may have to be disposed of to eliminate
risk of transmission. Approval for incident replacement items
may need to be sought.
- Increased illness numbers may have an impact on incident
prioritization. Report accurate illness and injury numbers
to the Situation Unit for 209 reporting.
- Remember patient care is the priority, and so is confidentiality.
Balancing confidentiality and situational awareness to other
personnel is difficult.
- Variations in diet, hydration, work periods and exertion,
stress factors can create similar symptoms. Do appropriate
rule outs for GI illness.
- Prioritize orders appropriately. When ordering items, be
specific about quantities, form (Liquid, pills, gel-caps,
suppositories, etc.), delivery times and locations. If need
be, get the IC to fast-track essential items on the order.
- During extended incidents, using online vendors (in coordination
with the buying team) may be the most cost effective and speediest
way to receive essential items.
- A lot of affected personnel may not even come to the medical
unit for evaluation or treatment. Keep your ears open for
complaints in idle discussion. Encourage personnel to check
in and advise the medical unit if they feel ill.
- Mass Casualty Incident plans may need to be initiated.
Work with the local emergent transport provider for information
on this.
- Work with the local emergent transport provider or treatment
facility on having the ability to get large quantities of
IV supplies, oxygen and oxygen refills, and universal precaution
supplies. They may also be utilized for biohazard disposal.
Facilities and Finance may have to do EERA’s or LUA’s.
- Coordinate with the Food Unit Leader to ensure there are
adequate supplies of water and Gatorade for hydration. Also,
bland food types may need to be requested for those suffering
from extreme nausea and vomiting.
- Get in the habit of marking names on water bottles. This
will eliminate a transmission vector. Dispose of unmarked
open water or beverage bottles.
- Control the rumors, don’t let them control you.
Chris Graves, Medical Unit Leader, IMT2 Whalen
Diana Ludwig, Medical Unit Leader (Trainee), IMT2 Whalen
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