Disaster Management

Eric R. Frykberg

Health care providers and facilities have been confronted with an increasing number and frequency of catastrophic events in recent years, which result in large numbers of injured casualties and substantial property damage. The defining characteristics of such mass casualty disasters include a sudden and unpredictable occurrence, a disruption of societal infrastructure that gives rise to chaos, and an overwhelming of medical resources by the urgent medical needs and sudden presentation of large numbers of casualties.¹,²,³ The medical management of mass casualties requires an entirely different approach from the routine care of emergency patients who usually present one at a time. A true disaster is more than just a large emergency. Simply doing more of the same will not work, and yet this is what is often done, as most medical personnel do not understand the unique demands of mass casualty management. This is not taught in medical or nursing schools, and is not generally a requirement of residency training. Consequently, medical preparedness for mass casualty events is woefully lacking across the United States.⁴,⁵

Approximately 80% of all disasters have resulted in physical trauma to casualties. This emphasizes how important it is that surgeons, and other acute health care providers who provide surgical capability (i.e., emergency physicians, emergency department [ED], operating room [OR], trauma and intensive care unit [ICU] nurses, prehospital professionals), play prominent roles in disaster planning and management. It is surgeons who will be on the front lines of mass casualty management as the most likely first receivers of casualties. Surgeons regularly confront the challenges of trauma care and rapid decision making in their everyday practices. Likewise, trauma centers should serve as the foundation of any disaster response system, as they have the experience, personnel, resources, and linkages most essential to a successful disaster response, even in disasters that do not involve physical trauma.⁶,⁷,⁸,⁹,¹⁰

This chapter will review the basic concepts of disaster preparedness and response, emphasizing the critical contributions that surgeons must make to these processes within the context of the many nonmedical elements that a disaster response also entails. These concepts will be presented in the framework of the six Ps of disaster management: preparedness, planning, prehospital considerations, procedures for hospital care, and pathophysiology and patterns of injury, with the pitfalls of each of these elements incorporated into the discussion of each of these issues.

PREPARATION

This component of disaster management refers to the acquisition of a basic level of knowledge and skills that are necessary for a successful medical response. The medical aspects of mass casualty care are so different from the routine approaches to medical care of emergency patients that substantial education and training of medical personnel must be provided. Many principles of a disaster medical response are counterintuitive, and even morally antithetical to the precepts and ethics of patient care that are enshrined in standard medical education. Since disasters occur suddenly and unexpectedly, physicians must be trained in advance for this necessary paradigm shift in casualty care in order to optimize casualty outcomes. The longer the learning curve, the more lives lost.

There are many classification schemes for disasters that should be understood (see Table 1). The most useful of these is based on the level of resources needed to manage the property damage and casualties, which correlates closely with the overall magnitude of the event. This classification best reflects the essential characteristic of disasters, being the mismatch between the needs of a community and its victims, and the resources available to meet these needs.

TABLE 1 DISASTER CLASSIFICATION SCHEMES

Mechanism
	Natural
		Weather-related (hurricane, tornado)
		Geophysical (earthquake, tsunami)
	Man-made
		Intentional (terrorist attack)
		Unintentional (industrial accident)
Number of casualties
Nature of injuries
Geographic extent
	Closed
	Open
Duration
	Finite
	Ongoing
Level of response
	Level I: Local resources
	Level II: Regional resources
	Level III: State or national resources

An extensive literature on the experiences with past disasters serves as a valuable learning tool to understand those patterns that typically follow disasters. A massive influx of casualties, most commonly into the hospital nearest to the event, should be anticipated. Generally, 50% of all disaster casualties that will present to a hospital will do so within the first hour of the event, and 75% will arrive within 2 hours. The first wave of casualties will not be critically injured and largely not even require hospital care. However, this wave jeopardizes the hospital’s ability to care for that minority (10% to 20%) who will be critically injured and in need of immediate life-saving care, and who will arrive in later waves, unless established mechanisms are in place to lock down the hospital and screen out those casualties, bystanders, curious onlookers, and volunteers who do not belong there. A major challenge facing physicians in this setting is the need for an orderly but expeditious process to rapidly identify those who need urgent care from among the majority who do not, as treatment delays for the latter could be fatal. Another challenge is to provide appropriate treatment to all with limited and overwhelmed resources. This may require a rationing of care according to how salvageable a casualty may be and the extent of resources needed, so as not to squander the scarce resources on one casualty that could better be applied to save many other more salvageable lives. Our standard approach to medical care of providing the greatest good for each individual, must change in a mass casualty event to the greatest good for the greatest number, requiring the focus of care to change from the individual to the casualty population as a whole. It must be recognized that optimal care for all casualties is impossible in this setting. The altered standards of medical care described in the preceding text must apply in order to maximize casualty salvage.¹¹,¹² This basic principle of disaster management has been documented in the extensive experience in Israel with terrorist events, in which the hospital management of mass casualties has evolved to minimal acceptable care of all but the most severely injured, so as to be able to concentrate the limited resources where they are most needed.³ These major changes in the goals of medical care are difficult and uncomfortable for health care providers to accept, and therefore difficult to learn. Physicians in the United States are generally not familiar with these principles of disaster preparedness and response; this includes surgeons, who are the most likely medical specialists to be among the frontline providers for disaster victims.¹³

There are many challenges and barriers to disaster education in the civilian medical sector (see Table 2). The rarity of true disasters tends to dampen the urgency of learning, as most physicians may never see one in their entire careers. The new approaches to medical care that disasters entail require time-consuming study and an unlearning of some habits and practices. The command structure of a major disaster response is also new to physicians, involving much more than medical care, placing medical providers in a subservient role, and requiring new levels of cooperation and teamwork with unfamiliar entities, all of which may cause discomfort and angst among physicians who do not understand the purpose of command structure.¹⁴ The complexity of the injuries resulting from many disasters are a magnitude beyond that normally encountered by emergency care providers, and are made more difficult by the rapid decisions and treatment that are necessary to accommodate the large casualty influx.³ There are major disconnects between the military and civilian medical sectors that prevent the latter from learning the effective procedures used by the military for disaster planning and response. Similar disconnects exist between the US health care sector and the many government and nongovernmental organizations that comprise the disaster response infrastructure of this country, effectively preventing medical personnel from
engaging in the existing disaster system and becoming an integral and necessary component of a disaster response. There is a striking failure of the medical sector to learn the lessons from the mistakes of past disasters, which results in the same problems arising in every successive disaster response, with no progress being made to improve this response. Finally, there are so many educational efforts in disaster management being propagated in a disjointed manner by multiple groups, all with very different goals and target audiences, with no attempt made to coordinate and consolidate these efforts, that health care providers can easily be confused and discouraged from pursuing this necessary education. A standard curriculum in this discipline should be established in medical and nursing schools, and residency training, in order to provide all health care personnel with a basic core of knowledge and skills in disaster planning and management. All of these educational barriers must be overcome, as preparation—education and training-must be the most basic and essential component of a successful medical response to disasters, which in turn allows us to achieve the ultimate goal of any medical effort, that of saving lives.

TABLE 2 CHALLENGES IN DISASTER EDUCATION FOR US HEALTH CARE PROVIDERS

Rarity of events

Different approaches to medical care

Incident Command structure and role

Complexity of injury patterns and decision making

Civilian vs. military disconnect

Health care sector vs. government/nongovernment agencies disconnect

Apathy and complacence

Failure to learn lessons from past disasters

Multiple disaster courses

PLANNING

The Challenge

There is a misguided tendency to think that there can be no effective planning in advance to deal with major disasters, given their sudden, unpredictable, random, and rare occurrence. The word “disaster” is derived from the Latin roots for “evil star,” promoting the idea that they are acts of God or Fate, uncontrollable, and cannot be anticipated. This perception is largely untrue, but it discourages any form of preparedness, and leads to prolonged chaos when disasters strike, because people only then begin thinking about what to do.

The fact that disasters will always occur lends urgency to planning and preparation for them. There are several aspects of the modern world that increase the risk and frequency of disruptive and catastrophic events, including growing population density, an aging population, increased settlement in high-risk areas (i.e., flood plains, ocean fronts, earthquake-prone fault zones, unstable cliffs), increasing transport of hazardous materials through populated areas, increased technologic hazards (i.e., nuclear reactors, toxic chemical storage sites), the emergence of new and resistant strains of microorganisms, and the increased threat of terrorism.¹⁵

Figure 1 Graphic comparison of injury severity among survivors of the terrorist bombings of the Bologna, Italy train terminal in 1980 (BOL) and the US Marine barracks in Beirut, Lebanon in 1983 (BER), showing the consistently similar pattern of only a small minority of surviving casualties being critically injured (Injury Severity Score [ISS] >15). (From Frykberg ER, Disaster and mass casualty management. In: Britt LD, Trunkey DD, Feliciano DV, eds. Acute care surgery: Principles and practice. New York: Springer Science + Business; 2007;229-262, reprinted with permission.)

In fact, there are numerous opportunities to prepare for the unique contingencies of disasters. Many geographic areas are vulnerable to natural disasters that have occurred in the past, such as tornadoes in the American Midwest, hurricanes along the southern US coast, floods in major river valleys, and earthquakes in California. The patterns of property damage and injuries that occur in these events are well documented and easily anticipated. Many areas have known risks from industrial and environmental hazards. A Hazards Vulnerability Analysis (HVA) should be the first step in a disaster planning process by any hospital or community, analyzing all local threats, collating past experiences with these hazards, and developing a plan for responding to these potential problems that may threaten the population.¹⁶ The identified risks should be prioritized according to their probability so as to most fully prepare and allocate resources for the most likely threats.

Planning must also anticipate the need for local assets to be on their own without outside help for several days. This has been confirmed time and again in most disasters, and when ignored has led to major ongoing losses of property and life, and prolonging of recovery, as occurred in New Orleans following Hurricane Katrina in 2005.

An appropriate medical response is greatly facilitated by analyzing the documented results of past disasters to identify common patterns of injury, and casualty and responder behaviors. For instance, abundant evidence from major terrorist bombings consistently shows that most surviving casualties are not seriously injured (see Fig. 1), a pattern that in fact characterizes most forms of mass casualty disasters. This allows hospitals to anticipate the need to keep most arriving casualties out with a restrictive screening
process, so as to apply the limited hospital resources most efficiently to only those who need urgent care.³,¹⁷,¹⁸

An all-hazards approach to disaster planning recognizes that all disasters have many patterns of injury, infrastructure damage, human behaviors, and resource requirements in common, which permits a basic plan template to be developed that can apply to virtually any disaster. Then, using such tools as an HVA to identify likely disaster mechanisms, this broad plan can be adapted to the specific and unique aspects of each individual disaster once it occurs. A single flexible and all-encompassing plan is far preferable and more workable than multiple plans to cover a multitude of specific events, as every possibility can never be covered, and responders will not be able to know the details of every plan.

The most effective disaster plans include the following elements¹⁹:

Valid assumptions of injury patterns, threats, human behavior and needs
Lessons learned from the results of past disasters
Evidence-based principles of disaster response
An integrated collaborative “systems” approach of many different entities working toward a common goal
Inclusion in the planning process of those who will participate in the response
Knowledge and agreement of the plan by the response participants
Training and education of the participants in the elements of the plan
Regular hospital drills and community exercises to test the plan’s workability, and revision of the plan as necessary to address weaknesses and problems uncovered by the drills

A postevent debriefing and critique should follow all disaster drills and actual disasters, preferably within 24 hours. All key participants in the response should critically analyze its effectiveness and weaknesses, from which the lessons learned can be documented, disseminated, and used to revise the original plan.²⁰

Planning Pitfalls

One of the most common pitfalls in disaster planning is the paper plan syndrome, which is the false sense of security that can be imparted by a written plan. This can be made worse by a failure to rehearse the plan to uncover its flaws. Realistic planning and rehearsal require a major effort that includes extensive research and collaboration of all elements and stakeholders in a disaster response (see Table 3). This is usually not done because of its substantial expense and time commitment. This is confirmed by accounts of most disasters, in which the original disaster plan was uniformly discarded early on when it was found unrealistic and unworkable for the actual circumstances.²⁰ In fact, the planning process should be considered more important than the written plan, to the extent that it involves a serious multidisciplinary effort to anticipate the problems and understand everyone’s proper role in the response. This tends to encourage initiative and creativity in solving problems as they arise.¹⁶

TABLE 3 HOSPITAL AND COMMUNITY STAKEHOLDERS IN DISASTER PLANNING

Hospital Participants	Community Participants
Medical and nursing staffs	Emergency Operations Center
Administration	Public health department
Security	Prehospital emergency medical services (EMS)
Food services	Law enforcement
Hospital Incident Command (HICS)	Fire department
Volunteer pool	Search and rescue
Blood bank/laboratory	Media
Pathologist/morgue
Imaging services	Transportation/evacuation services
	Medical examiner/morgue
Operating room staff	Area blood banks/Red Cross
Intensive care unit staff	Area hospital representatives
Public information office	Mental health services
Chaplains	Local medical society
Rehabilitation assets	Structural engineers

Deviating from the all-hazards approach is another pitfall of planning. It is common for planners to concentrate on the last disaster (e.g., terrorist attacks in Washington, DC), or the most “popular” disasters regardless of their likelihood (e.g., bioterrorism), or worst-case but lowprobability scenarios (e.g., global thermonuclear war), which tend to neglect the most basic principles and on the most likely threats that all disaster plans should encompass.¹

Another planning pitfall is the application of faulty assumptions and stereotypes about human behavior in disasters to the structure of the plan, which usually arise more from the imagination of inexperienced planners than from a critical analysis of how people actually behave in this setting. There is a tendency to assume that behaviors will conform to the plan, rather than developing the plan according to likely behaviors that consistently occur. The belief that disasters result in widespread panic, or that casualties will go where directed in an orderly manner, are examples of common misperceptions that in fact rarely happen. Casualties and many uninjured people, most of whom do not need hospital care, consistently flock to the nearest hospital, and many times are sent there by first responders (i.e., the geographic effect), overwhelming the ability of these facilities to render effective care. Rather than resisting this inevitable casualty flow, plans should anticipate this, and direct that these inundated hospitals be
converted to triage hospitals, otherwise termed ground zero, or evacuation hospitals, that do not treat casualties but take over the function, which should have occurred from the scene, of distributing casualties systematically to all other hospitals in the area.³

Failure to engage trauma centers and acute care medical personnel, who regularly manage trauma, in the planning process and in the established disaster infrastructure, is among the most common pitfalls of disaster planning. Trauma systems are already established throughout the United States, which should serve as the template for local, regional, statewide, and national disaster systems, because their resources, experience, and linkages are all important assets necessary for a successful medical response to disasters.¹⁰,¹⁶,¹⁷

PREHOSPITAL CONSIDERATIONS

The initial focus of a disaster response is at the scene of the event, where the nature and extent of the damage must be assessed, further damage minimized, and plans for dealing with the destruction and injured casualties formulated and implemented. Some forms of disasters do not have a specific “scene” or prehospital phase, such as disease pandemics or bioterrorist attacks, which evolve over long periods of time without a clear beginning or end. However, most disasters do have a readily identifiable scene, although it can vary quite extensively in size. The many challenges and complexities of the prehospital component of a disaster response may best be understood in the context of the classic phases through which most responses evolve³ (see Table 4).

Phases of Response

All major disasters are characterized by an initial phase of chaos, with people dazed, frightened, and confused, running for shelter, and confronting the horrors of dead bodies and property destruction. There is no leadership or authority, and no organization of efforts. This is the period in which the geographic effect occurs, with the nearest hospital rapidly being inundated by arriving casualties, worried well, and volunteers trying to help, all usually without warning. In urban areas this chaos lasts only 30 to 60 minutes, but in more isolated locales where resources are fewer and further away, it may last several hours. The longer this phase lasts, the harder it becomes to achieve order, emphasizing the importance of a rapid prehospital response.²¹ Critically injured casualties are most vulnerable in this phase, and the longer it lasts, the more lives may be lost. The ultimate goal at this time is to establish order, for the primary purposes of maximizing casualty survival and minimizing further damage and injury.

Initial response and reorganization represents the start of the crisis management phase of a disaster response, and begins with the arrival at the scene of first responders, such as emergency medical services (EMS), law enforcement, and fire department assets, who assume responsibility for securing the disaster scene and establishing command and control. Generally, the first responders to arrive at the scene assume command and establish communications with the central command authority that is located in an Emergency Operations Center (EOC). A command post is established in an area near the scene, but located far enough to assure safety. Protection of first responders must be the first priority of prehospital efforts, to prevent them from becoming secondary casualties, and thereby depriving the disaster casualties and response of their necessary skills. Protection of casualties from further harm must be the next priority. The designated incident commander (IC) of the scene assumes authority from the interim commander upon arrival, with the responsibility to survey the damage and develop a needs assessment, which allows the EOC to mobilize the required resources. Any contamination of the scene with toxic materials must be determined at this time, and if present a decontamination process is established. A mechanism for transporting casualties must be developed. Security of the scene must also be established to restrict access to its potential dangers to all except those trained to be there with a defined role, to handle the predictable influx of onlookers and volunteers, to maintain order in the assessment and clearing process, to preserve forensic evidence if a crime is involved, and to keep traffic lanes open to ensure the flow of casualties and resources to their proper destinations.²,²²

TABLE 4 PHASES OF PREHOSPITAL/HOSPITAL DISASTER RESPONSE

Chaos
Initial response/reorganization
	Establish command post
	Needs assessment
	Security and safety procedures
	Casualty evacuation to casualty collection areas (CCAs)
Site clearing
	Search and rescue/recovery
	Casualty distribution from CCAs to hospitals
	Clearing debris
	Initial hospital medical care
Late/recovery
	Rebuilding infrastructure
	Definitive hospital medical care/secondary casualty distribution
	Provider and casualty mental health follow-up
	Postevent critique and analysis of disaster response
	Community recovery
From Stein M, Hirshberg A. Medical consequences of terrorism: The conventional weapons threat. Surg Clin North Am. 1999;79: 1537-1552.

The site-clearing phase involves the work of casualty rescue and evacuation, and addressing ongoing dangers to provide a safe environment for the rescue and clearing operations. Active fires, downed power lines, gas leaks, and toxic chemical spills are usually addressed by the fire department. Structural engineers inspect damaged buildings for stability. Specialized response teams may be required to detect and neutralize hazardous materials, and contain flow of blood and bodily fluids from casualties, as decontamination procedures are begun. Heavy equipment is brought in to clear debris. A major danger that must be addressed is the possibility of delayed second-hit events that could jeopardize first responders. Unstable buildings may collapse during rescue efforts, aftershocks may continue following earthquakes, gas leaks could explode, and terrorist bombings are often followed by a second explosion after a short period of time to allow first responders, onlookers, and volunteers to arrive and also to be killed.³,¹⁷

Search and rescue operations are carried out in the site-clearing phase. Unlike routine emergencies, casualties following major disasters may be buried beneath debris or fallen buildings, or widely scattered, and search is required to find them. This calls for highly trained and specialized personnel, including hazardous materials specialists, structural engineers, heavy equipment operators for extrication, and those who understand search and rescue principles and methodology. Caring for casualties who are entrapped in locations that are difficult to reach, and in confined spaces, also requires special training that most hospital-based providers do not have, such as treating airway and breathing problems in poorly accessible locations, hypothermia, dehydration, and crush injuries. Extrication may be prolonged and require persistence with several shifts of rescue workers. Pressure is on the rescue personnel to find casualties as quickly as possible, as survivors are rarely found after 24 hours. After this time, rescue efforts are supplanted by efforts to recover the dead, which poses another set of emotional burdens on workers.³

Human casualties are first assessed and transported for eventual care during the site-clearing phase. There should be no attempt to render care to casualties who do not require extrication. The goal must be only to determine who is alive and who is dead, and move survivors away from the dangers of the scene to safer, more distant casualty collection areas (CCAs). It is best not to send large numbers of casualties directly to hospitals before determining their need for care and decontamination. The dead should be segregated in different areas from the living to allow eventual identification and forensic analysis, and to avoid wasting resources on their evaluation. At the CCAs, prehospital personnel should quickly assess injuries and the need for hospitalization, rendering no care beyond emergent life-saving interventions that are deemed appropriate according to the available resources (i.e., pressure on active bleeding).²,²² Triage, or the sorting of casualties according to priority of treatment needs, should be simple and minimal at these sites, limited to determining only who needs hospital care and who does not. Ideally, those requiring hospitalization should be distributed among all available hospitals in a systematic manner from the scene that avoids any one facility from being overloaded, termed leap-frogging, preferably matching the needs of each casualty to each hospital’s resources.¹⁷,²³ Moving casualties through multiple sequential CCAs for repeat evaluation will tend to improve the accuracy of these triage decisions, and the efficiency of casualty care, by assuring that only those needing the limited hospital resources will finally be admitted. This further prevents hospitals from being unnecessarily overwhelmed by the geographic effect, and assures that the limited resources are applied where they are most needed. The initial phase of acute hospital care usually occurs simultaneously with these prehospital operations.

Those casualties not requiring immediate hospital care should be transported to other areas and monitored by medical personnel for any deterioration that may require an alteration of the original triage decision, and possibly sending for immediate care. This is one of the ways to mitigate the adverse consequences of initial triage errors, to ensure an error-tolerant system.

Personal protective equipment must be worn by all scene workers, and safety procedures for search, rescue, and extrication must be strictly followed. Experience from many disasters has shown that 70% of fatalities in confined-space rescue operations are the rescuers themselves, who become secondary casualties. Furthermore, 35% of these secondary casualties were the most experienced rescue supervisors. Occasionally, extrication of a casualty may require the emergent amputation of a limb, as happened following the bombing of the Murrah building in Oklahoma City in 1995, and following an expressway collapse after the 1989 San Francisco earthquake. This is only one of the indications for physicians to be at a disaster scene, yet even these medical personnel should be trained in the hazards of disaster management. It is the responsibility of a safety officer at the scene to oversee all rescue and site-clearing operations, to assure provider and casualty protection, and to report directly to the central command authority at the EOC.

The late phase of disaster response, otherwise known as the consequence management phase, involves the long-term clearing of all debris and damaged property, and the rebuilding of infrastructure in the community. It also includes the later phases of definitive hospital care after the acute casualty influx subsides, and secondary casualty distribution between hospitals to expedite care, which may involve evacuation of casualties over long distances. A post-disaster critique and analysis of the entire response should be carried out within 24 to 48 hours of its completion, to identify weaknesses and the lessons that should be learned to improve future responses. Confidential personal debriefings should be carried out among all active response participants to address emotional issues as a means of recognizing
and preventing long-term problems such as post-traumatic stress disorder (PTSD). There should be a mechanism for addressing the short- and long-term mental health needs of responders, casualties, and the community as a whole, as a part of their long-term recovery to pre-event levels.

Incident Command

The many disparate jurisdictions, agencies, organizations, and personnel who must suddenly work together in a seamless coordinated effort to achieve the common goals of management and recovery following major disasters can succeed only with a strong and organized command structure. The Incident Command System (ICS) was developed for this purpose during wildfires in California in the 1970s, and has proved effective in all forms of major emergencies and disasters because of its modular and adaptable structure around the essential functional elements of command, planning, logistics, operations, and finance/administration. The ICS encompasses the concepts of unity of command, in which all personnel have specific assigned roles contributing to the ultimate goals; chain of command, in which all personnel have specific positions in the overall command structure and know who they report to and who reports to them, with limited spans of control in which no more than five to seven people report to any one position; and unified command, in which multiple independent entities with differing experience, training, and functions are all brought together to submit to one central authority for the purpose of achieving common goals. The Incident Commander (IC) is located in the EOC to direct the entire disaster response through the other four section chiefs. The IC staff is comprised of safety, public information, and liaison officers to facilitate this function. Planning, logistics, and finance/administration sections serve to support the operations section in its management of the disaster response with search and rescue, casualty transport, scene clearance, and other such nuts and bolts functions. The operations section is the only one that interacts directly with the public. It is critical that all participants in a disaster response understand this structure and their role in it, which requires education and training, as well as involvement in the planning process.²,²⁴

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