key: cord-0780557-ftkoxzz4
authors: Grossman, Valerie Aarne
title: Catastrophe In Radiology: Considerations Beyond Common Emergencies
date: 2020-05-13
journal: J Radiol Nurs
DOI: 10.1016/j.jradnu.2020.05.002
sha: 7c2a7e6cefee455922292580314dad7ff2a93cb7
doc_id: 780557
cord_uid: ftkoxzz4

Abstract Disasters often occur without warning and have the potential to affect large numbers of people. Those in the radiology environment experience unique effects on them, their equipment, and their ability to provide quality patient care. Lessons can be learned by reviewing events and their impact on imaging departments around the world. Radiology departments need to be actively involved in the disaster planning and the management of disasters when they occur. Common themes emerge regardless of the type of disaster and these themes should be included in all planning.

Organizations around the world, increasingly prepare for the "what ifs" of our environments. Regulating and certifying agencies mandate organizational plans for threat management to include risk factor identification, threat mitigation, prevention (when possible), response to, and recovery from the event. The World Health Organization (WHO) estimates that natural disasters kill approximately 90,000 people annually and affect an additional 160 million people worldwide (WHO, 2019; WHO, 2011) . The Disaster Recovery Reform Act of 2018 developed improvements to the Federal Emergency Management Agency (FEMA) by establishing a clearer framework for disaster management in both the preparation for and response to each event; pre-staging now occurs with incident command centers, resource mobilization, and search/recovery teams on standby, ready to act (FEMA, 2018; Reynolds & Knox, 2019) . The Joint Commission continually updates their expectations for organizations, uses information obtained through their post disaster organizational debriefing, and supports organizations by providing informational resources (Joint Commission, 2018) . The Occupational Safety and Health Administration (OSHA) provides a number of resources to assist organizations in the creation of their individual disaster management plans (OSHA, 2015) . In 2011, a policy directive was developed to deal with all natural and manmade disasters, which evolved into The Hartford Consensus that addresses the loss of life and has a chief principle that no one should die from uncontrolled bleeding (Jacobs, Burns, Pons, & Gestring, 2017) . While disasters of every kind have occurred throughout history, the number and severity continue to increase. Society demands to be kept safer … demands that are at times, difficult to achieve.

Even with an ever-increasing amount of information available and regulations to comply with, radiology departments are still often excluded from a hospital's disaster management plan and drills. It often isn't until an organization experiences a catastrophic event that the Catastrophes in Radiology 4 identification of a plan for radiology's role during a disaster, comes to mind. Regardless of the event type, radiology will be affected in some manner. While no amount of preplanning can fully prepare any organization for the unpredictability of a catastrophic event, having a plan in place will provide for better response and care during any mass casualty incident (MCI), regardless of the type of catastrophe. Many radiology departments are now creating their own disaster management plan within their department: while the hospital may have an organizational plan, individual departments should be aware of the role they will need to play when a catastrophe occurs (Dargan, 2018; Haygood, 2018) .

Anecdotal reports from events around the world are valuable to consider when creating an organization's disaster response plan. Firsthand lessons learned by others should be considered when organizations create their own disaster management plan, inclusive of considerations for the imaging departments. Whether external or internal in origin, many similar considerations apply to nearly all MCI events. While catastrophic events may vary in type, length, recovery time, number of victims/relief workers, and a host of other important details, radiology departments should consider all types and create disaster plans accordingly.

Redundancy and back up plans are essential to also have in place, as established disaster plans do at times, fail (Dargan, 2018) The following chart lists types of disasters which could be catastrophic to any healthcare facility, its imaging department including some historical examples. (insert Table 1 (Schoeberl, 2018; Snair, 2018; Berger, 2016; Sen, 2013; CDC, 2018b; Flammarion, 1870 : Richmond Enquirer, 1840 Torok, 1997; Goodwin Veenema, 2019; Trevisanato, 2007; Grojec, 2018; OPCW, n.d.; Sutherland, 2019; Haygood, 2018; Aarne Grossman, 2020) Hospitals are seen as part of the solution to any catastrophic event in the community, however, hospitals can also be the problematic during mass casualty incidents (MCI) as people often flock to a local hospital to seek safety and to look for loved ones, which creates additional issues for the healthcare team. The WHO describes an MCI as any event that results in a greater number of people seeking assistance and support than what a local system can provide (WHO 2007) . MCIs are usually a sudden and dramatic event that cause a surge in patients or a change in normal business. Whether an act of violence or a natural disaster, the healthcare community must have an action plan that can be immediately implemented to provide safety and recovery to all people affected. Healthcare personnel by nature, are dedicated to responding to any event they are faced with: it is this dedication that drives them to figure out a back-up plan when the original disaster plan doesn't or can't work.

The WHO outlines guiding principles which all disaster management plans should incorporate. Clear lines of responsibility should define roles, responsibilities and assigned activities to all dealing with the event. The plan should have scalability and be flexible to meet the needs of any MCI which could occur. It should address whole health and be prepared to deal with: Injuries and death, environmental issues (water, sanitation, housing, food, transportation), disease management (communicable and non-communicable), health care delivery, and mental health services. The evidence based plans should include case reviews of historical events and consider lessons learned from past events worldwide when developing their own plan. All plans must be multisectoral in order to be successful, with the inclusion of different organizations which will need to work together in a professional manner. These will often include but not be limited to: Communication providers, transportation, law enforcement, security forces, military, water/sanitation departments, social services, health care providers, emergency service personnel, local industry/businesses, and emergency response teams (Red Cross, governmental agencies, etc.) (WHO, 2007) . It is essential for organizations and communities to drill repeatedly, looking for potential flaws in any disaster management response plan (Haygood, 2018) 

These acts can be difficult to predict or understand. The goals of these individuals who intentionally inflict harm and fear towards others are usually intended to impact the greatest number of victims possible. Sometimes, the goal is more about maximum disruption (hysteria) than maximum damage (injury, death, environmental destruction). The aggressor(s) may be a single individual, a small group of people, "homegrown" violent extremists, international terrorist groups, or transnational criminals. (Breslin, 2019; Williams, 2019) . The purpose of their destructive actions may be based on perceptions and beliefs and can be quite difficult for others to understand and explain. These could include beliefs or goals such as: unfairness in social, racial, economic or political arenas; spiritual or religious ideology; personal revenge towards another person or group; a statement in support of or against a person, group, nation, ideological; some may have a mental illness however, there is no clear proof that all people who commit aggressive acts towards others, are mentally ill. (Gotzsche-Astrup & Lindekilde, 2019).

When a violent act occurs, initial response focuses on neutralizing the threat and minimizing any additional damage. This is most successful when responding services have preplanned and carried out robust, ongoing training and practice drills. Partnerships must be formed and maintained between all agencies that may be involved. Ongoing monitoring of activity that may appear suspicious can pre-empt some attacks. It is difficult to smuggle bombs into a country or to transport them, so some terror groups are sending their bomb making recipes to home grown terrorists in locations where an attack is scheduled to occur, and the bomb can be crafted close to where the attack will occur. To help combat this, the New York City Metropolitan Transportation Authority's Security Awareness Campaign introduced "if you see something, say something" in 2002, as a method to be able to report suspicious behavior or packages. In 2010, the Department of Homeland Security expanded this to be a nationwide campaign. (DHS, n.d.) In 2016, a terrorist drove a truck into a crowd of people in Nice, France. 86 people died, 458 were injured, and 202 people received care at local hospitals. Challenges included being able to properly identify patients as many were unconscious or did not speak French. One hospital that normally performed 15 CT scans during an average night, performed 42 CT scans on 42 patients in 2 hours. (Dargan, 2018; Amoretti, 2018) Mass Shootings:

These events can occur anywhere, at any time. Mass shooting events externally to a hospital can result in a surge of injured patients coming to a hospital. Shooting events which happen inside of a hospital pose their own risks for a number of reasons. A person can plan their assault within a hospital by conducting surveillance ahead of the event, planning entrance and exits, identifying departments or offices to target, and studying the habits of security and other staff.

Hospitals are open to the public, and the aggressor optimizes the sudden chaos and fear to their own advantage. Staff may be confused between saving themselves, or someone near them.

Some key facts about shooting events and hospitals include: ♦ Active shooting events often begin spontaneously and end quickly (average is less than 19 minutes) ♦ Since 2000 over 160 healthcare facility related shootings in the US with 60% occurring inside of hospitals and 40% occurring outside of buildings on hospital property ♦ Hospitals are high stress environments where individuals may have weakened coping skills, experience fear, aggression, anger and seek retaliation ♦ There are large concentrations of potential victims ♦ 67% of healthcare facility-based shootings occur before police arrive ♦ Smaller hospitals may be more vulnerable due to easier maneuverability, less security, (Blair, 2014; Schwerin, 2019; Bjelopera, 2013; Borchers, 2017) To be best prepared in the event of a mass shooting, disaster plans must include threat assessment and frequent training and drills. Each department, including radiology, should have their own threat assessment conducted including a map of the department, location of staff, patients, and visitors. Staff should be inserviced on policies, procedures, methods of communication, and behaviors that can preserve lives during such an emergency. Staff may be trained in the following for use during an active shooter event:

♦ Run (escape route, leave belongings behind, save self not others) ♦ Hide (out of shooter's view, block/lock the door, silence electronics, turn off lights) • While waiting for help to arrive, administer first aid to those who are hurt (Jacobs, 2017) In 2017 Las Vegas, Nevada experienced a mass shooting that killed 59 people, injured 851 people (422 of them sustaining gunshot wounds). The shooter was positioned on the 32 nd floor of a nearby building, fired 1,000+ rounds in less than 15 minutes into a crowd of 22,000 concert attendees. Many victims self-transported to area hospitals, "carloads" of gunshot wound victims appeared at unsuspecting hospitals. ♦ Most victims were cared for at three of the over 10 hospitals in the area ♦ A national shortage of intravenous (IV) fluids complicated the care of the patients: it is estimated that 1000+ intravenous lines were started that night and supplies of IV fluids ran short ♦ It is estimated that ~500 units of blood components were transfused in the first 24 hours post incident. (Lozada, 2019) In 1994 at the Fairfield Air Force Base Hospital in Spokane, Washington a mass shooting event killed 5 people and wounded 23. One of those wounded was 5 months pregnant and miscarried a day after the shooting. ♦ The shooter was a former airman who was diagnosed with schizophrenia and recommended for military discharge by two psychiatrists. These two physicians were among those murdered by the shooter. After killing two psychiatrists, the gunman walked through the facility, firing randomly until he exited the building.

Theft of radiopharmaceuticals may occur for use in making "dirty bombs" (radiological dispersion device = RDD). These would typically result in "weapons of mass disruption" instead of "weapons of mass destruction". Victims of a dirty bomb may have radioactive shrapnel embedded in their bodies, respiratory injury from inhaled radioactive dust, or wounds with radioactive contamination but not likely have injury or illness directly related to the exposure to radiation. These attacks could occur inside of a hospital or in a community with the contaminated injured patients transferred to the hospital. Blast related injuries are meant to cause massive injury to a large number of people with the most common injuries including blunt, penetrating, burn, amputation, and emotional trauma. The most common injury locations include: brain, ear, eye, lung, cardiac, abdominal, limbs

In 2013, the Boston Marathon Bombing occurred when 2 pressure cookers, packed with shrapnel (nails, metal pellets, etc.), exploded, killing 3 and injuring 275+ people. 90 of the patients were treated at 3 hospitals (patients were cared for by a total of 27 hospitals).

Hospital emergency response teams were immediately alerted, outpatient schedules were cleared, and additional radiology teams were called in to work. CT scans and x-rays were able to quickly identify the scope of injuries caused by the shrapnel contained in the explosive devices (Ready.gov, 2019; Goodwin, 2019; Singh, Goralnick, Velmahos, Biddinger, Gates & Sodickson, 2014) Cyber Attacks:

Cyber-attacks can happen to individuals, businesses, governments, and hospitals.

Fraudulent access enters a computer system with goals to steal, dismantle, alter, extort, or take part in other criminal activity. These actions can be conducted by one individual or from an international criminal enterprise In 2017, a ransomware attack occurred at the Erie County Medical Center (ECMC) in Buffalo, NY. It locked down 6,000 computers by encrypting files, and severely affected the 600 bed hospital and 390 bed nursing home. ECMC did not pay the $40,000+ ransom, however, it did spend $10 million to recover from the attack. The hospital was forced to revert to paper charting for 6 weeks while they recovered from this event.

Earthquakes can occur suddenly and without warning. Those who live in earthquake prone zones, know that damage occurs quickly to infrastructure, buildings, and equipment. To minimize personal injury, it is important for people to get low to the ground, cover the head and neck, and avoid windows, doorways, falling furniture/equipment. Imaging departments in Elevators were inoperable. During the first 12 hours post initial earthquake, only portable

x-rays and ultrasound imaging were available to the ED patients. Without generator power available, radiologists relied on flashlights and headlamps for light. Nuclear medicine department received no damage, computed tomography was up after the initial 12 hours. While this hospital was built with seismic upgrades, geotechnical failures did occur and lead to widespread damage to the hospital (walls/ceilings/floors cracked, tunnels flooded, damage to the roof/boiler stack/medical equipment, etc.). (Gregan, 2016; Mitrani-Reiser, Kirsch, Jacques, Giovinazzi, McIntosh, & Wilson, 2011; Haygood, 2018) Hurricanes/Tornadoes/Flooding:

Powerful and at times, unpredictable storm systems which can include strong winds, heavy rainfall, storm surges, rip currents, flooding, and landslides. Most areas have emergency communications and alerts which should be listened to carefully and directions followed.

Emergency crews will be mobilized, emergency supplies will be on standby (ready to infiltrate the disaster area), and individuals as well as businesses will make necessary arrangements and preparations (Reynolds, 2019) . Hospitals can be best prepared by: ♦ Frequent training drills that are comprehensive ♦ Ensuring a 3-5 day supply of emergency power, water, medication, food, linen, and other essential supplies ♦ The more emergency power a hospital has available, the more successful they can be during a catastrophic event ♦ Hospitals located near known threats, should be built to expect the worst (flooding, earthquake, tornadoes, etc.). This includes: special windows that protect against flying debris (withstand up to 250 mph); underground wiring to guard against power outages with 2 different wiring pathways; a reinforced roof, safe interior rooms to protect against wind, rain, and flooding; watertight barrier storm doors; and equipment with extra battery backup (ventilators, bassinets, specialty equipment, etc.) (Lallanilla, 2013a) (Hayes, 2005) When a severe storm system attacks a hospital, care consideration and planning must occur that includes care of those within the structure (food, safe shelter, medical care) as well evacuation. Care of the equipment should be considered as loss of electrical power, flooding, or wind damage can severely damage equipment and hinder the ability to care for patients.

Tornado prone areas may have sirens that alert the community of an approaching tornado.

Other indications of an approaching tornado include: A dark or green colored sky; large, dark, low-lying cloud; large hail; or loud roar that sounds like a freight train. Not all tornadoes will present with the characteristic funnel cloud. Danger exists from extremely high winds, flying debris, falling objects, etc. People should seek protection during a tornado, including: underground shelter, interior part of a basement or the lowest floor of a building away from windows and doorways. It is never safe to stay in a mobile home, car, bus, long-span building (i.e. mall).

Regardless of the type of weather event, flooding is a potential danger. Fast flowing water or standing water, pose a dangerous risk. Flood waters commonly test positive for waterborne and/or sewage contamination including: (Haygood, 2018; Lallanilla, 2013b; Schubert & Busciolano, 2015; Grossman, 2018) Mudslide/Landslide/Avalanche: These disasters can occur without warning and create a sudden loosening of earth from a mountain side, that travels quickly down the slopes. There is great danger to structures in the path of this disaster as the moving landslide carries with it any structure in its path, which increases the danger to those below. Roads can be disrupted which increase danger to motorists, emergency vehicles, and may hinder evacuation routes (CDC, 2019). Victims suffer from crush injuries from rock, soil, mud, snow, ice and debris (trees, cars, etc.). Drowning can occur from swift moving flood waters. Many victims also sustain ocular injuries due to infiltration of mud into the eyes, and must be treated emergently to limit traumatic blindness.

In 2010 a sudden, heavy downpour resulted in a mudslide in Leh, India sending mud, rocks, and boulders cascading down the barren mountains to the communities below. The closest hospital became inoperable due to overwhelming sludge and flooding. 

This disaster occurs as a result of a series of enormous waves (known as seismic sea waves) caused by displaced water following underwater earthquakes, volcanic eruptions, landslides, or meteorite. Tsunamis are not preventable nor entirely predictable other than a few warning signs that may include: ♦ The ocean may appear to be "boiling" as large quantities of gas bubble up from far below the ocean surface ♦ The ocean water may smell of rotten eggs, be hot, and/or sting the skin ♦ A loud thunder boom may be heard, followed by a roar or whistle ♦ The ocean shoreline may recede a large distance from the coastline ♦ The horizon may appear red in color ♦ Animals often are seen running to higher ground in advance of the receding water line Tsunami damage is often catastrophic in nature as powerful waves destroy structures in its path, injure or kill living beings, destroy basic infrastructure (transportation, communication, public water/sewage, etc.), cause widespread chemical contamination and debris to be washed over land. Resulting health risks occur from contaminated water, destruction of safe housing, food supply, healthcare services, etc. There is a usually a high death toll from drowning, resulting in fewer victims seeking emergency health care.

In 2011, the Great East Japan Earthquake (magnitude 9.0) and resulting tsunami caused the evacuation of 150,000 people claimed the lives of over 15,000 people (90% of those deaths were from drowning), 4,000+ people missing, damaged over 750,000 structures, and cost over $235 billion in damages. (McCurry, 2011; Ehara, 2011; Fuse, 2012; Goodwin Veenema, 2019; Nohara, 2011; Oskin, 2017) Volcanoes:

Volcanoes are an opening in the earth that allows molten rock, gases, and debris to erupt and flow across land at up to 100 mph. Volcanic ash can travel hundreds of miles and cause respiratory difficulties, skin/eye/nose/throat irritation for all living beings. Volcanic activity can be monitored, and be somewhat predictable however, they are also quite unpredictable. Areas that would be affected by a volcanic eruption have emergency alert systems that announce instructions for those in danger. Volcanic eruptions can additionally cause flooding, mudslides, and loss of infrastructure (roads, power, communication, clean water, etc.) . Common injuries and diseases include multiple trauma, burns, infectious disease, respiratory compromise/suffocation, ocular injuries, etc.

In 1985, the Nevado Del Ruiz volcano erupted in South America. The enormous lahar of molten lava and mudslides buried the small town of Armero, killing 25,000 people (the deadliest lahar in history). The entire town was submerged in lava and mud. All buildings and infrastructure were completely destroyed, and the town was eventually declared a 'national cemetery' ♦ For those few who were able to be rescued, they suffered abrasive burns and other injuries from the caustic substances mixed in with the mud ♦ The loss from this disaster included 50 schools, 2 hospitals (including all equipment), roads, railroad tracks, bridges, water/sewer systems, pipelines, 6,000 acres of farmland and livestock. (NRC, 1991; CDC, 2019) Wildfires:

Wildfires are often fast moving and unpredictable. A raging fire can travel 6.7 mph through a forest, 14 mph in open fields, and these speeds can be higher if there is an upward slope involved (Siegel, 2017) . Those areas in the danger zone, should heed evacuation orders, ♦ Due to the high cost of repairs, the hospital was closed and 1200+ employees laid off. (Sutherland, 2019; Gabbert, 2019) 

Preparing for the "what ifs" and the "worst case scenarios" in our world can be very difficult. Disasters are difficult to anticipate and properly plan for perfectly. By listening to the experts in the field of disaster management and learning from those who have lived through catastrophes, we can better evaluate our own environment and strengthen the disaster management plan that we create.

Community services, emergency response organizations, industries, businesses, and governmental agencies must work together when responding to a crisis in a community.

Intelligence and law enforcement agencies must work together with effective communication and role delineation. During the initial event and response, competition should be set to the side and the focus placed on the safety of all members of the community. From a review of case studies looking at disasters that have occurred, there is a repeated recommendation to have a "back up plan" in case the original disaster management plan fails. (Reynolds, 2019) Each healthcare organization must have an individualized plan that is fitting of the facility, the size, the patient populations, layout, security (onsite and also municipal). In addition to the organization's plan, each imaging department should have their own disaster management plan that works in concert with the organization's overall plan. Investing large amounts of capital into resilient infrastructure can be difficult to justify when there are competing projects that need to be completed in the immediate future. Until an organization has endured great hardship and loss as the result of a catastrophe, investing money into a project that may never be needed, is often pushed to the side. (Grain, 2014; Lau, 2013) The events listed earlier, are examples of what can happen during a disastrous event.

Hospitals in earthquake zones, should invest in appropriate foundations and watertight rooms to protect their expensive equipment. Radiology reading rooms should always be on a back-up generator and remote reading capability should always be in place. Regional businesses should be included in the responsibility for disaster plans and their back up: the financial district of New York City, the oil/gas industry in Texas, or the shipping industry in Southern California are essential to the well-being of not just their local communities but also the nation as a whole.

Including key players in the preparation for catastrophic events for the entire area, should be a priority for all involved. (Lau, 2013) .

Communities and organizations that have experienced catastrophic events, can offer valuable first-hand accounts of the lessons learned and offer suggestions for others to consider when creating their own disaster management plan. Precise needs for each individual catastrophe may differ, however, there are many common considerations that should be included in all plans.

Electrical considerations: ♦ Guard against flooding of the generators, have ample fuel available to run generators ♦ If there is a loss of power to industry, water treatment stations, etc. may negatively impact the hospital ♦ The more emergency power a hospital has available, the more successful they can be during a catastrophic event

♦ Incident command centers must be deployable and not fixed ♦ Organizations must keep up-to-date phone lists (employees, local business, vendors, fuel companies, utility companies, medical equipment companies, etc.) ♦ Portable wi-fi units can be used if IT down or power outages occur ♦ Satellite telephones, wireless radios, amateur radios, and other forms of communication may be used if cellular telephones and/or landlines fail ♦ Organizational leadership must be visible around the building, calm, optimistic, and ready to respond to issues (Bluth, 2007) ◊ Communication must be honest, transparent, and frequent in order to counter the spread of inaccurate rumors and contain mounting fear among staff, patients, visitors (Jones, 2017) ♦ When calling for emergency assistance ("911") or reporting suspicious activity, essential facts should include: Gray, 2007; DOH, 2011) patient transport to/from radiology (Berger, 2016) ♦ If the disaster is an approaching storm, all studies should be dictated, rooms stocked with supplies, phone numbers updated, disaster management plan reviewed with team ◊ Extra staff should be called in ◊ Consider moving some portable equipment to essential upper floors (in case elevators fail during the storm event). (Bluth, 2007) ♦ The role of imaging in a MCI is to increase triage accuracy, identify injuries, and more precisely assign resources ◊ Whole body CT scans using an MCI protocol can increase the number of CT scans per hour and also detect indirect injuries that could otherwise be missed. A disadvantage is the large number of images generated that the technologists then need to reconstruct, and the radiologists need to read (Korner, 2011) ♦ If technology is intact, remote radiologists may be able to assist in reading exams ♦ All steps of imaging may be affected by a catastrophic event: orders from referring physicians, patient transport, images (acquisition, coding, worklist, storage, retrieval, viewing, reporting, etc.) . ◊ Communication may need to be flexible (face to face, paper notes, etc.) if telephones, computers, etc. are inoperable ♦ Some hospitals have found that having a radiologist go to the ED with the technologists to perform bedside x-rays and ultrasounds, allows for immediate reading of images ... which allows for immediate identification of injuries, streamlines communication between radiologist and emergency physician, reduces the risk of errors from high volume and miscommunication or lost information, incorrect patient ID, etc. Elevate any equipment that could be water damaged if flooding occurs such as coils, control consoles, and MRI quench duct • MRI suites should close until threat of quench passes. (Gregan, 2016) o Risk of quench if the quench pipe is damaged, loss of temperature regulation of the liquid helium, movement of the helium inside cryostat vessel, o MRI rooms should be designed to be watertight, with an additional stabilizing foundation construction. (Hayes, 2005) ♦ Staff: ◊ Staff shortages (staff can't come to work, those who can't leave will face exhaustion) ◊ Plan for 150% of normal staffing levels with enough food and water ◊ Care of the staff must include risk protection and:

• Physical needs must be met • Protection from chemical, biological, infectious, and radiologic exposure • Psychological and behavioral health should be provided for ◊ Staff coming into work should bring own supplies (water, food, medicines, etc.) and waterproof clothing for both hot/cold temperatures ◊ Staff must stay, until replacements have arrived. Consider staffing up, in case future replacements can't get into the hospital and those on duty, must work elongated shifts ◊ Maintain employees on payroll … need to have adequate staff for disaster recovery periods ◊ Staff should be encouraged to create a family emergency plan in advance, that covers all possible disasters. Plans should cover a minimum of 3 days (best if 2 week supply on hand) and should include:

• Phone numbers (family, legal, medical, community, etc) • Bottled water (1 gallon/day for each person and each pet) There is no perfect plan, when preparing for a catastrophic event. The best preparation includes an evidence based plan, consideration of past events (case reviews, lessons learned, etc), ongoing education, frequent drills, and stock piling of essential supplies. Considerations need to be designed for the individual (person, patient, staff, etc), the departments that could be affected, the organizations that could be involved, and the community as a whole.

Fast Facts for the Radiology Nurse

Massive Influx of Patients to a Radiology Department

Emergency imaging after a mass casualty incident: role of the radiology department during training for and activation of a disaster management plan

Public Mass Shootings in the United States

A Study of Active Shooter Incidents

Managing in a Catastrophe: Radiology During Hurricane Katrina

Accessed 5/23/19

The squishy definition of 'mass shooting' complicates media coverage

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Natural Disasters and Severe Weather

Preparedness and safety messaging for hurricanes, flooding, and similar disasters

Past Pandemics

Center for Disease Control and Prevention: Rabies

Natural Disasters and Severe Weather: Infectious Disease After a Disaster

Including Radiology in Emergency Plans is Critical

Nationwide Suspicious Activity Reporting (SAR) Initiative (NSI)

If You See Something, Say Something Campaign

In a Radiology Department During an Earthquake, Tsunami, and Nuclear Power Plant Accident

Raw Sewage Released by Hurricane Harvey

Disaster Recovery Reform Act

The Necrology of Aeronautics". Wonderful Balloon Ascents; or, The Conquest of the Skies

Lessons Learned from the Japan Earthquake and Tsunami

Feather River Hospital evacuated 280 patients and staff as Camp Fire approaches. Wildfire Today

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster

Disaster Nursing and Emergency Preparedness

Either or? Reconciling Findings on Mental Health and Extremism using a Dimensional Rather than Categorical Paradigm

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Radiology in the Christchurch earthquake of 22 February 2011: Challenges, interim processes and clinical priorities

Chemical Weapons: A Deadly History. Radio Free Europe

Disaster Management

Hurricanes test radiology's disaster preparedness

Including Radiology in

Discussion Paper: Health and Medical Response to Active Shooter and Bombing Events

Active-shooter events in the workplace: Findings and policy implications

Initial Steps in Training the Public about Catastrophes in Radiology 39

Bleeding Control: Surgeon Participation and Evaluation

Emergency Management Resources -General References

Rumors during a campus lockdown

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64-MDCT in Mass Casualty Incidents: Volume Image Reading Boosts Radiological Workflow

A Day Like No Other: A case study of the Las Vegas Mass Shooting. Nevada Hospital Association

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Will Climate Change Destroy New York City? Live Science

USNS Comfort: How the Hospital Ship Helps During Disasters. DoDLive

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The Las Vegas Mass Shooting: An analysis of blood component administration and blood bank donations

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Catastrophes in Radiology Response of the Regional Health Care system to the 22 nd

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The Eruption of Nevado Del Ruiz Volcano Columbia

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Active Shooter Response

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Coping in a calamity

The Terrifying Physics of how Wildfires Spread so Fast

Radiologic Features of Injuries From the Boston Marathon Bombing at Three Hospitals

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Improving Local Health Department Cybersecurity

135 Minutes. National Fire Protection Association Journal. February Catastrophes in Radiology

A Large Community Outbreak of Salmonellosis Caused by Intentional Contamination of Restaurant Salad Bars

The 'Hittite plague', an epidemic of tularemia and the first record of biological warfare

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World Health Organization (2019) Flooding and Communicable Disease Facts Sheet

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Planning for catastrophes affecting imaging departments ♦ Disaster management plans rarely include radiology ♦ 160 million people worldwide are affected by a disaster each year ♦ Lessons can be learned from those who lived through one