 Welcome. This is your host Craig Thomas on Much More on Medicine, part of Think Tech Hawaii's live stream series. And with me today is Dr. Shawn Kovant. Good morning Craig. It's nice to see you Shawn. How are you? Good, good, good, good. Beautiful Hawaii weather as always. You know, I was just talking to a friend in Seattle and asked how things were and he says, oh, it's raining. And I said, yeah, it's raining here too, but it's still 75 or 80 degrees, so come on. He can't complain. Exactly. And in fact, I've been enjoying the Kona weather. It makes for some nice glassy surfing. Life is good. So today we're going to talk a little bit about disasters and disaster responses and you're uniquely suited for this because you're fellowship trained in emergency medical services and disaster medicine. So thanks for coming. Again, you're very welcome. I thought that we might talk about sort of the history of how, I mean, disasters have been going on forever, but how organized responses to disasters have evolved over the years and kind of what constitutes the elements of an effective response, what is a little more challenging and recognizing that just because you have a disaster response plan doesn't mean you necessarily have an effective alternative, you know, effective option. So why don't we talk a little bit about where all this started? Understood. So one of the things we can do historically in the United States, it was way back in 1803, there was a big fire in Portsmouth, New Hampshire. After that time, Congress provided legislation for relief for the merchants in that city. And that was the first time that the legislator actually got involved with a response to a disaster. Since then, as you move forward in time, it's evolved to what happened in 1979, April 1st, the United States government created FEMA, which was their disaster response agency. Since 1979, we've had significant disaster events that's occurred throughout the nation, and it has subsequently evolved over time since then. That's a broad picture historically of how the United States, as an entity, became involved in disaster response. First through legislator, then through actual response to the events. So interestingly, you should mention 1979 because in 1979, I was a medical student and I was doing a rotation in Alaska. And I didn't know FEMA started that year. But the hospital decided it was going to have its first ever disaster drill. And sort of recognition of the importance placed on disaster drills at the time, they picked the most unsuitable person in the hospital, namely me, the medical student doing a pathology rotation to be the triage officer. None of the staff wanted anything to do with it. It turned out they actually only picked the second least qualified person to be involved in the disaster drill. It turned out that the driver of the bus that was bringing all the moulage marines from the supposed airplane crash was the least qualified because he succeeded in running into the hospital and getting the bus stuck in the ambulance bay so you couldn't get people on or off of it, which was my introduction to disaster drills. And sort of pointing out that disasters are named because things go wrong. Absolutely. We've been struggling as to how do you actually define a disaster because is it national scope? Is it local scope? But I think the best definition it's the paraphrase, the UN's definition of disaster. And that's something that affects the society that you're in that to such a degree that it overwhelms your local resources. And that can affect could be environmental, it can be physical, it can be economic. And I think that that's broad enough, but at the same time focus enough to get you into the disaster mindset as opposed to, well, I'm just having a really bad day. A bad day is a cup of coffee, spooning your shirt. A disaster is, you know, a large scale event such as a hurricane or tsunami. Right. Your society. And but if clearly a very broad spectrum of possible disaster disasters can occur. And it also sort of by their very nature, some kinds of disasters can be either ameliorated entirely, you probably can't prevent the disaster, but you may. But you can certainly impact its impact. Others, it's all about the response. And so I guess well, let's pursue what we think are the key elements to an effective disaster plan. I think the key elements to an effective disaster plan. Number one is early recognition and forewarning that goes hand in hand. One of the things that is done during disaster response is a creation of what's called a hazard vulnerability analysis. Fancy way of saying, in my universe, what are the things that's most likely going to affect? So that sounds key because a high probability event for which there's an intervention, that's one we should be working on, especially if we can get some warning. Correct. A low probability event for which there's either inadequate warning or no reasonable intervention, that probably should not be our focus. Correct. We probably should not be spending most of our time worrying about if we're going to be invaded by aliens from another galaxy. We should probably be spending it on hard to prepare for. The warning is a problem. That's correct. And I don't have a clue what the intervention would be. So that's probably not should not be our focus. Works for me. And probably not too far off on that is hit by a giant asteroid at the moment. Our prediction is not too good and our response is correct. Existence. So but there are events such as tsunamis that that does lend itself to preparation for and pretty clearly Hawaii surrounded by the Pacific Ring of Fire, which is of course the source of earthquakes, not only experienced multiple tsunamis, but is going to have more. Correct. And one of the cool things about all tsunamis, except the ones caused by local earthquakes come with hours of warning. Correct. So I guess on the local earthquake thing, you feel a real earthquake head for high ground. Correct. One of the things you like to say is that it if it's a local event, meaning it's the earthquake is happening. The percentage of the earthquake is happening close to where you physically are at the time. And you see the waters recede, you feel the earthquake. Don't stop and take pictures. Yeah, leave get out of the area. Don't pick up the fish flopping. It's okay. Just leave it there and just leave get the higher ground as soon as possible. We come a long way with tsunami recognition. Absolutely because tsunamis are inherently related to earthquakes. The best tsunami for warning we get is actually to improvement in our earthquake recognition systems. So for example, in Hawaii, we're able to know if there's for example, a magnitude seven earthquake in Alaska. And therefore we're able to predict with computer models that we would be inundated by waves in four to six hours or seven to eight hours, depending on the magnitude of the event. And that leads us into early recognition of tsunamis. Once we can recognize it to earthquake events, that gives us time to initiate our disaster plans and responses for them. Right. And we have the Pacific tsunami Warning Center here. And so as you say, they monitor earthquakes, of course, not all earthquakes are created equal, even if they're the same magnitude, it really depends if they're kind of an up and down earthquake or a side to side earthquakes. Yeah. So the earthquake triggers the alertness, but then monitoring the ways that develop or don't, let you fine tune the warning. So I find tsunami warnings intriguing because of the various responses of people. So there was a warning not too long ago, two, three years, actually time slipping four or five years. And at the time, I had a boat in the Alawai. Well, the thing you do with the Alawai is get on your boat and go out to sea because once you're out at sea, the wave isn't breaking. So I had to drive over the poly. There were people setting up camp on the poly turn off on the Kailua side. You're at, I don't know, eight or 900 vertical feet there. If a tsunami came that high, life almost as we know it would not be in existence. So I have to make a confession. I was one of those people really? It was October 27. I think was 2012. So it was a seven 7.7 magnitude earthquake in Alaska. We were predicted to get seven foot waves and in Oahu, we actually got two and a half foot waves. Yeah. I was actually staying near the beach about half mile from the beach in Kailua. My wife and I frantically, after being fellowship trained frantically, do some clothes in the car and drove up to the poly lookout. Oh, that's wonderful. I was one of those people. Correct. And we had the same thought process you had that if it's above, you know, if it hits the poly lookout, if it's reached that high, then there's nothing much to do. Well, here's the other piece of that. So get on the boat, take it out, look back. And there's one car in the parking lot. Mine saved the boat, lose the car, you know, what are you going to do, right? Whatever, wasn't much of a car anyway. And as you say, the wave actually never transpired. Correct. Correct. And that point out a challenge of tsunami preparedness is that we need to prepare for the worst case scenario. And whether or not you will not know, you will know that there are waves in advance. And for the average lay person, they need to institute their plan, they need to prepare, they need to evacuate as needed. They need to seek higher ground. It's better to seek higher ground and have a two and a half foot wave, then not seek higher ground and have a 40 foot wave. Correct. Although realistically, the poly is probably a little over. That is true. But that kind of segues into the other portion of an effective response is having a plan. Yes. And having an actionable plan. Actionable plan. Having an actual plan is key. So in that scenario, you know, saying I'm going to go to the beach and set up my barbecue is probably not an actionable plan. Might be a plan, but not your first, first guess, I should not be your plan. Going to an area that's equal in height to where you are initially is probably not a good plan as well. I'm seeking high high initially, in which case, state what? Exactly, exactly. Taking photos on Instagram of the tsunami waves, you know, is not not a priority, not your highest priority. Evacuating your family seeking higher ground is an actionable kind of plan. And then it's depending on the circumstances, if you're somewhere where it's easier to go vertical, then you go vertical. If you're it's downtown Honolulu and it's tons of traffic, you might say, let me stay in my office building, but go up to the highest floor to the roof, yeah, which may be better than trying to fight your way through traffic, which is going to be a ground level during the event. Even in the disastrous Fukushima event, I think a number of the larger buildings survived. And this was an enormous tsunami. Correct. So the people going up to find the people in their cars got washed away. So and that was a look course of local phenomena. They're very much warning there. Correct. Part of the action plan, which is actually has a very limited audience is if you're going to go out in a boat, and you cast off, you probably should have checked to make sure your propeller was not a ball of barnacles. Well, you did that. I was like, huh, the motor's gone. The boat is not. I wonder what the challenge is. You probably also need fuel, right? We had by by the effective propeller, we did not. So that was correct, have minor detail. Correct. So tsunamis are a great example. Generally, you're gonna have warning. There's a active plan that action plan that if everybody followed it, no one would be lost. Correct. And there's a course. It's why we have both the Pacific tsunami warning center, but also all those sirens down along the coast. Correct. And so that's a fabulous example. Detection isn't always so easy. Let's say it's an epidemic. Correct. So a case study we have is from the couple years ago, we had SARS outbreak started in China and actually went involved into an epidemic than about 37 countries. We were fortunate in the United States and in particular, Hawaii, where we weren't quarantined individuals, we didn't have that particular response. But it is something that is high up on the disaster probability because we have such a large population of visitors coming from internationally from around the world. It is difficult to surveil epidemics. Part of the difficulty is that a lot of times in epidemics, they all look the same. I have fever shows, you have a cold or you have SARS. That's right. Exactly. So you know, I think this is fascinating. We're going to pick it up after the break. So again, this is much more on medicine assisted by engineers, Rich and Ray, and my guess is Dr. Sean Kovant. This is Think Tech Hawaii, raising public awareness. Freedom. Is it a feeling? Is it a place? Is it an idea? At DiveHeart, we believe freedom is all of these and more regardless of your ability. DiveHeart wants to help you escape the bonds of this world and defy gravity. Since 2001, DiveHeart has helped children, adults and veterans of all abilities go where they have never gone before. DiveHeart has helped them transition to their new normal. Search DiveHeart.org and share our mission with others. And in the process, help people of all abilities imagine the possibilities in their lives. Aloha. My name is Mark Shclav. I'm the host of Think Tech Hawaii's Law Across the Sea. Law Across the Sea comes on every other Monday at 11am. Please join us. I like to bring in guests that talk about all types of things that come across the sea to Hawaii, not just law, love, people, ideas, history. Please join us for Law Across the Sea. Welcome back. This is your host, Craig Thomas. I'm much more about medicine. And this is my guest, Dr. Sean Covant. And before the break, we were talking about epidemics and challenges with detecting them, which is, as we say in emergency medicine, everything begins with a flu-like illness. And even the flu can be a problem. But all the flu like illness really means is you're sick. Most people who are sick are not the index case in an epidemic. Most of them will get better. Some of them will not. And occasionally, it's SARS or Ebola or the next one, whatever that is. And it's challenging. We actually have some better tools than we used to, sort of surveillance tools. But even so, pretty clearly, early detection is key. You want to kind of share what happened with SARS a little bit and also how it demonstrated air travel, how you can wear health care facilities role in spreading disease, those kinds of things. I thought it was fascinating and terrifying. So SARS, we believe, originated in China. Yeah. And one of the things, it was one of the first cases, modern epidemic, that really highlighted the problem with international air travel. We had an index case, which is, say, the first case in China. And then before we knew it, it spread throughout the world, in particular Canada. And that was spread via air travel. Yes. It also highlighted the difficulty and that individuals may have gotten on an airplane with co-like symptoms. I have a fever. I have runny nose. I have a cough. And then they get to their destination, they meet family, friends, they go back to work, and it spreads. And by the time the patient is sick enough to get to the hospital, there's a problem with recognition in the hospital. For free SARS, we were thinking, hey, there's a potential severe acute respiratory syndrome floating around that we need to be prepared for. So those patients were indexed patients or those patients who traveled arrived at their point of destination, went to their hospitals, their emergency departments, and they were treated like normal illnesses. We take precautions, such as wearing masks when appropriate, but we were not prepared for a widespread disaster or a widespread epidemic. And that really highlighted our need to be more suspicious, if you will. And that led to screening and airports, temperature screenings, questionnaires such as do you have you had a cough in the last 24 hours? Have you been in areas that may have had epidemic outbreaks? So that that was really a wake up call. It was. And SARS was particularly bad for a couple reasons. One, I don't remember what it turned out to be, but the case fatality rate was high, I think it was over 60%. So that means you got it, you had a very good chance of dying. The other was it was air transmission and a respiratory condition. So if, for example, you came in the ER with a little cough, you might get put on a nebulization treatment. That's another way of nebulizing the whole ER with SARS. The other really interesting thing about SARS is, like epidemics often do, it disappeared without a trace. And it hasn't resurfaced yet. That is correct. It was a blip on the radar. When you were reminding your own business, SARS came along and then it disappeared. We're thankful that it did. And we're, although it's tragic, it has led us to having better biosurveillance. So hopefully, we'll be better prepared for the next SARS or Yeah, and there's a really excellent book called Outbreak. And it talks about how that most of these are actually animal reservoir illnesses that cross over into humans. And because we have no resistance for whatever that pathogen is, it takes off. And this describes Ebola, for example, has animal reservoir. Correct. So the good thing about Ebola, although it's very contagious by direct contact, far as I know, it's not contagious, at least very being any kind of aerosol. So not like SARS. One thing about Ebola versus SARS is that when the patient is going through full bone Ebola crisis, it's very dramatic. I mean, you don't need to be a medical personnel to say this person is sick, stay away. Whereas, again, in the initial phases of SARS, I think I have a flu like illness. So it makes it a little bit harder to sort of quarantine a little bit harder to surveil a little bit harder to intervene early as early as we would like, because it's present so vague in the beginning. Exactly. Well, let's shift gears a little bit because we're entering the hurricane season starts early June, I think officially here, although the truth is the peak time here is late summer and fall. And that's actually a obviously very predictable disaster for Hawaii. And it's one where warning exists, although the ability of hurricanes to do surprising things is always with us. Some years ago, for Iniki, I was planning to meet my family at Mount Rainier. And Iniki had been trucking along this headed west south of the Big Island when we took off. By the time I got to Mount Rainier, my brother's like, you do know the hurricane is brushing by Honolulu as we speak. And I'm like, no, that suckers head west. No, it's not. So even with modern tools, it's still nature and it's still the world. That is that is true. And hurricanes are pretty complex neurological phenomena. It's sort of depending on wind is between rain is depending on water temperature. And then we have computer models, but you know, they only have a certain level of prediction success. We believe all things being equal, it's going to be yourself of the Hawaiian islands. And it may hit a patch of water that's a temperature off and degree. And next, you know, it's brushing Honolulu and striking Hawaii. Right. And the satellites have changed all that. So there's been an image that is being projected which shows what a hurricane looks like from space. And typically, there's there's two, two sort of hurricane nurseries, there's west of Central America, and most of those head west and then go north. And they might give us nice waves, but they generally aren't anywhere near it's rare for a hurricane to travel far enough west that it gets to the second nursery, because that's the one where most of ours come from. And I think that's on the order of, I don't know, 10 or 15 degrees north, 140 west and those ones head west for a while. And ultimately, they go north. And the question is, do they go north before us, over us, or after us? And we do get warning, it may be less than we expect. And again, it's a nice kind of disaster. It can be pretty hard on the infrastructure. But in general, people take precautions. No one should get hurt. Correct, correct. Here in the islands, I think that we're pretty well hurricane centric in the sense that most people who know have water, board up your house or your place of business, evacuate to higher ground as needed, stay away from storm surge. But I think that all plans can be improved upon, whether that's increasing the amount of water and food that you have in your household, or securing your medications in advance, or taking care of even such things as your pets, checking in on the elderly population, whereas grandma I'm going to be during the storm. Those are all things that come into play. And one of the unique challenges with hurricanes, as demonstrated by Niki, is not only do you have the initial issues of the hurricane itself and the initial dangers, but post hurricane, a lot of times the infrastructure so badly damaged, that you still have prolonged issues. Yeah, and that actually surfaces in some interesting ways. For example, if you are oxygen dependent, right? Do you have a power supply for your oxygen accumulator? Or do you have sufficient oxygen at home for an extended period? And the other issue is one island may be significantly impacted, others may not. But it's not so easy to get from one to the other after it's happened. And so I know that we staff a number of islands. And I know that you have prepared, thank you, an internal plan for our group to be able to respond, at least with medical resources. And it's hopeful. On the other hand, they are disasters, things happen. Correct, correct. I think the value in having a disaster plan whether it be tsunamis or hurricanes or epidemics is that life is going to present itself how we present itself and things are going to become overwhelmed. You will deviate off script. But I like to tell people that having a disaster plan is similar to learning the alphabet. Once you learn the alphabet, you can collect, you can make a collection of words as you see fit, as your thoughts dictate. It's the same idea. If you have a plan, then you may need to change one or two things about your plan. But you have some actionable items that you can move forward with. You're not, you're not undergoing what's called decision paralysis. I'm overwhelmed. Oh my God, this is out of my normal scope of practice or my normal way of being. Wait, let me just fall back to my disaster plan. Okay, now I have to adapt a breath, see what resources we have, see what resources we don't have, move forward. Exactly. So so far, we've been talking about disasters that are generally predictable. Pretty likely to happen. There's some warning, and there are some plans to minimize harm. There are some other disasters that are sort of in the generally predictable, not any warning. And the plan is mixed. And the next one I like to switch to is the mass casualty sort of thing. And the reason I want to switch to that is, just because you have a plan doesn't mean it's a good one. And I'm thinking specifically of last week, when a politician, Rick Santorum, said, Oh, we shouldn't be talking about school shootings, we should be talking about CPR. Now that would be a good example of a bad plan. Personally, I think that anything we can do to minimize the chance of mass casualties, including things like school shootings, is clearly desirable. I'm not sure entirely how to do that. But I'm pretty sure that CPR is useless for bullets. That is correct. And I understand that representative Santorum may have a certain point of view and have valid points on a certain scale. But I think that by the nature of disasters, we have to sort of alter our normal perception. So CPR is very important on a normal day, during normal event has its place. During things such as a mass shooting or mass casualty, we need a better frame of reference. We may have higher priorities that need to be in play. And so I think that mass casualties highlights our initial thought of what are my hazards? If there's a school shooting, you know, and bullets are flying. Yes, CPR may be needed on someone, but that's probably not your greatest hazard at that point in time. Exactly. And so we should take out energy and focus on the greatest hazards. Exactly. And how you can minimize the chance of them happening. And I guess my point was, sometimes the focus should be on prevention, whether it's correct, human induced mass casualties, whether it's war, and not be comforted by the fact, Oh, we have a plan because the plan should be focused on trying to keep it from happening. Listen, I really appreciated you sharing your time. I look forward to doing this again. There are many elements of emergency medicine and disaster planning that are fascinating. And we'll look forward to having you back. Thank you so very much for having me on the show. Thank you all. Appreciate your attention and sharing with Dr. Sean Kovant.