Jonathan L. Burstein
In the past quarter century, disasters worldwide have claimed more than 3.4 million lives (1). As the world population increases and population density rises, a single catastrophic event may affect more victims simultaneously. Further, both the use of hazardous materials and population in hazardous environments (flood plains, earthquake zones, etc.) are rising. Disaster planning and response must include not only the ability to care for casualties but the ability to function in environments rendered dangerous or even actively hostile. The mission of the disaster responder is not only to render aid but also to restore society’s homeostasis (2–7).
A “disaster” may be defined as a destructive event that disrupts the normal functioning of a community; it may be natural (e.g., Hurricanes Sandy or Katrina), technologic (e.g., chemical spill), or even deliberate (e.g., the 2013 Boston Marathon bombing, the September 11, 2001 terror attacks, the Madrid and London mass-transit bombings). Combinations of events can worsen the impact of each, such as the 2011 Fukushima nuclear plant disaster after an earthquake and tsunami in the area.
A medical disaster occurs when an event results in casualties that overwhelm the healthcare resources of the community involved (8). Many disasters, such as a jumbo jet crash without survivors, may not in this sense represent a medical disaster, although many slow-evolving events, such as pandemic influenza, may very well represent medical disasters. Response to a disaster may involve all aspects and needs of a community, including restoring food, water, power, communication, and transportation networks. The role of the emergency physician in a response may not be narrowly limited to emergency medical care, as broader public health knowledge and organizational skills may be necessary, requiring emergency physicians to step outside their usual role of individual patient care and take more of a systems-management approach (9). In the largest-scale events, refugees and displaced populations can be both the result and the cause of disasters (10).
As noted, disasters are classified by origin. Natural disasters include earthquakes, floods, volcanic eruptions, hurricanes, tornadoes, winter storms, and other geologic and meteorologic phenomena; in this era of electronics, one may add the effects of solar storms disrupting pager and phone systems. Human-caused or technologic disasters include explosions, chemical spills, radiation leaks, biochemical terrorism, transportation accidents, civil disturbances, and armed conflicts. Complex humanitarian emergencies generally include features of both natural and technologic disasters, such as population displacement that results from a combination of drought, famine, and political upheaval.
In a model that is perhaps more useful for the planner, disasters also may be categorized by onset and impact. For example, earthquakes and tornadoes have a rapid onset, with a sudden impact on the community. In contrast, droughts and famines have a more gradual onset and generally have a prolonged impact. Numerous factors may modify the impact of a disaster on a community, including the nature of the event, time of day or year, health and age characteristics of the population affected, and the availability of resources. Planning for a sudden event should focus on responding with resources on hand, as opposed to the mobilization of resources that can occur in a slower-paced impact (11).
The impact of a disaster also depends on the location where it occurs. For example, an earthquake occurring in a sparsely populated area obviously injures fewer people. In contrast, a similar quake, even one of lesser magnitude, could produce extensive losses of life and property if it occurred in a densely populated region with poor construction or limited medical resources. Additionally, many may be left homeless or without essential services. Even in the acute medical response to an event, a small community hospital could be easily overwhelmed by numbers and types of casualties that might be handled routinely by a large university hospital or metropolitan medical center (12). Hospitals can be resources in a response but also may be severely affected by the impact of a disaster, and the first priority of a hospital or other essential service must be to preserve its function so that it can play its assigned or necessary role in mitigating the disaster (5).
In the United States, although health care is generally provided by private-sector institutions, governments at all levels have both the responsibility and some capability of supporting disaster medical care. Town or municipal governments often regulate mass-casualty distribution and may coordinate the roles of local hospitals. State governments often serve as providers of funding and equipment, in a support role to local or county agencies, and provide a conduit to request federal aid. The federal government’s main role is to provide funding for response, but there are also directly deployable federal assets (people, mobile hospitals, vehicles) available from the military, the Veterans Administration, and the National Disaster Medical System (NDMS). The NDMS has more than 30 specialty teams throughout the country that can deploy to provide field-hospital capability, including advanced specialty care (burns and pediatrics). These teams can be deployed within 6 to 24 hours of request by a state government. The NDMS also provides or coordinates patient evacuation and mass-fatality management (12,13).
DISASTER PLANNING
Disaster planning must address numerous types of events, ranging in scale from small mass-casualty incidents (MCIs), such as motor vehicle collisions with multiple victims, to extensive flooding or earthquake damage, to civil wars. The planning continuum includes advance preparations and provision for supplies, staff, and training and actual event management and recovery efforts. Those people and organizations responsible for disaster plans must conduct extensive risk analyses, from the sanitation needs of crowds at mass gatherings to evacuation procedures for buildings and geographic areas to the threat posed by terrorist or military action that may be directed at an institution or its personnel (5,6,12,14).
Risk analysis is an essential feature of disaster planning in which a comprehensive inventory is created for all existing and potential hazards that are sufficiently likely to be a threat. Hazards may include such items as chemicals used by local industry, transportation elements such as airports and railroad stations, or collections of large groups of people in areas with limited access, such as high-rise office buildings, nursing homes, or sports stadiums. Environmental and meteorologic hazards must also be considered, such as the presence of fault lines and seismic zones and the seasonal risks posed by tornadoes, hurricanes, and snowstorms. Certain types of disasters can even be considered as “planned events” such as mass gatherings for sports or performance events or political conventions. These events require planning of the same type, although perhaps varying in detail, as do all other disaster responses (15).
Risk analysis should attempt to identify any groups of people at particular risk of injury or death or loss of property from each hazard and groups with particular needs such as children, the elderly, or the disabled. The estimated risk and patient load may vary by time of day, season, or location within a community. Properly conducted risk analysis necessitates the cooperation of corporate, governmental, and community groups to produce a comprehensive listing of potential hazards (1,12,16). It may be possible to reduce the relative risk posed by some hazards. For example, relocating a chemical depot further away from a school would reduce the risk that children would be exposed to hazardous materials.
The other essential step to take in planning is resource identification. Resources include both human and logistic elements, such as organizations with specialized personnel and equipment (17,18). Disaster preparedness should include assembling lists of medical and paramedical groups, public works and other civic departments, and volunteer agencies, along with phone numbers and key contact personnel for each. Hospital departments should have readily available a complete record of all personnel, including home addresses and telephone numbers, accessible 24 hours a day. Local, state, or federal teams of responders may be available, and a planner must know how this aid can be activated or requested. In the realm of terrorism with weapons of mass destruction, highly trained and extensively equipped specialty teams may be an absolute need for effective disaster mitigation.
Effective disaster planning must occur at all levels, from local institutions to municipal, state, and federal governments, including private, volunteer, and international agencies (19). All groups should understand their own capabilities and limitations and those of the organizations with which interactions are anticipated or intended. The use of a hierarchical management system, such as the Incident Command System (ICS), to coordinate the information and resource management is essential for any large-scale disaster. The ICS is a command system for large-scale firefighting developed by the federal government, which has now been adopted under the name National Incident Management System as the standard system for all US public safety response agencies. Hospitals may choose to use a variant of the Hospital Emergency Incident Command System (a California-developed adaptation of ICS for hospitals) to function within the same structure as all other responding agencies (12). Disaster plans should be both structured and flexible, with provisions made for plan activation and decision making by field-level managers, if indicated.
Once a plan has been devised or a strategy outlined, it must be used and tested. Staff must be trained to carry out their roles in the plan. In general, the best plans assign to each person a role as close as possible to his or her everyday job: “Do what you always do, but faster.” A recurring problem in disaster response is “failure of communications,” but this often actually represents failure of coordination; the message may get through, but the person getting it does not know what to do about it. True communication failures also may result from several conditions, including loss of infrastructure damaged by the disaster itself, and lack of operator familiarity, excessive demands, inadequate supplies, and lack of integration with other communications providers and technologies. Back-up communications systems, such as wireless, hardwire, and cellular telephones, may reduce the impact of disrupted standard communications. However, frequently, even advanced technology has been ineffectual or overloaded during disasters, pointing out the need for personnel to be well trained in their roles so they can function with minimal outside direction.
An essential step in planning and preparedness is the evaluation of the response, both to real events and after drills and exercises. Exercises to test plans are usually “tabletop” drills in which the responders gather around a tabletop and discuss their theoretical actions. More complex drills may involve activation of communications systems or transport of supplies or staff to different location. The most complex and helpful “functional exercises” may take the form of full-scale multijurisdictional exercises, using moulaged victims and requiring vast resources of supplies and personnel. A plan also may be assessed by computer simulations or seminar sessions focusing on key personnel or limited aspects of the disaster response, but generally this will be of minimal assistance in testing a plan’s real value.
The specific goal of any drill should be clearly understood in advance. If drills are to be used as training sessions and evaluations of preparations and response plans, personnel are more likely to make the correct or most appropriate response choices during the drill if they are prepared. Consequently, they will be more likely to take appropriate actions when faced with an unexpected disaster situation in the future. The more realistic the exercise, the more likely it is that useful information about the strengths and weaknesses of both the disaster plan and the responders will be acquired. The factor common to all disasters is a local shortage of available resources; without experiencing at least some of the stress which accompanies that situation, it is unlikely that the disaster plan and response will be taxed at a level that realistically simulates the circumstances of an actual disaster.
Essential features of all effective disaster drills are the inclusion of all parties likely to be involved in the disaster response and a joint critique, with a formal debriefing of all participants after the exercise. This review should consider comments from all individuals, groups, or agencies involved in the drill. It is helpful, and essentially mandatory, to designate observers in advance to assess specific aspects of the plan, such as effectiveness of a phone tree or accuracy of medication dispensing. The observations and comments should result in modifications of the disaster plan, if necessary (20). A drill that produces no changes in plans or goals likely did not sufficiently stress the system. Any alterations in disaster plans or response procedures must be communicated to all groups involved or affected. Periodic evaluations of disaster plans are essential to ensure that personnel have adequate familiarity with their roles in disaster situations and to provide for changes in regional emergency response operations, hospital renovations and closings, and other variables. Hospitals have a requirement to conduct at least two disaster-plan exercises per year to maintain compliance with the standards of the Joint Commission on Accreditation of Healthcare Organizations (12,21).
Mass gatherings provide a unique form of “planned disaster.” In general, they will occur in a defined location such as a sports stadium, concert hall, waterfront, or field. Planning should include basic sanitation needs, hydration and environmental protection (against sun, heat, or cold exposure), and both routine medical care (acetaminophen and abrasion care) and full emergency care (cardiac resuscitation). Additionally, planning must address the medical response to a mass-casualty event at the scene, such as might be caused by a vehicle accident or terrorist attack. Staffing for a mass gathering is generally composed of a mix of provider types and levels (first aid, emergency medical service [EMS], nurses, physicians, security, fire, and rescue), a mix of venues (first aid stations, medical tents, ambulances), a mix of roles (on-scene care, evacuation, command and control), and a mix of jurisdictions (private providers, public safety, city authorities, venue staff, state or federal authorities). This complexity makes preplanning critical for success. In terms of types of patient encounters to be anticipated, the best guide is prior experience at the same event, if available (such as recurring races, sporting events, or concerts). Some data are available in the literature, but the numbers are highly variable. In general, patient volume will be higher in outdoor environments, with younger average crowd age (confounded by event type) and with the increased use of alcohol or other substances in the environment (15,22). It may be appropriate to plan for care of victims of terrorism or other causes of mass casualties at an event.
DISASTER MANAGEMENT
The philosophy of disaster management may be summed up in the phrase, “The needs of the many outweigh the needs of the few.” Resources may be so limited that stringent rationing of care or supplies is vital to the survival of the maximum number of people. Austere conditions may be alien to responders accustomed to ample quantities of medical supplies, equipment, personnel, and time, but they are commonly encountered with many large-scale disasters. In this setting, difficult triage decisions must be made to ensure that all resources are used in the most efficient and pragmatic manner (5,22).
The goal of disaster management is to provide the most appropriate intervention and assistance based on the most accurate information available in a timely manner. Disaster response includes several phases (Table 378.1) but must begin with recognition that disaster conditions exist. Some disasters, such as hurricanes, may be preceded by a period of time, called the preimpact phase, during which advance information may be gathered about the potential effects of the disaster. The data acquired during the preimpact phase may allow prepositioning of personnel and resources in a strategic location. As a result of a lack of verifiable data, it may be necessary, at times, to begin a response or asset deployment without full intelligence, with efforts made to tailor and modify the response as updated information becomes available (23).
TABLE 378.1
Components of a Disaster Response
The EMS and hospital responders must be aware that triage in a disaster is devoted to providing the greatest good for the greatest number, rather than maximal effort for each patient. Often, patients in cardiac arrest who would normally have received a great deal of care are instead triaged as “expectant” (not resuscitated) so that the personnel and supplies saved may be used to help numerous other salvageable patients. The presence of toxic substances or radioactive materials may also change triage priorities (e.g., severely injured and heavily irradiated patients may be unsalvageable in a disaster setting). There are numerous methods for rapid triage that have been devised, such as the “START” (Simple Triage and Rapid Transport) system, and planners and responders should be familiar with the system in use in their area or institution (12).
Inevitably, in the event of a disaster that produces significant morbidity and mortality, including psychological threats and fears resulting from terrorist actions, the physician on duty in the emergency department will be one of the first people called on to assume a leadership role. The existence of a hospital disaster plan provides a valuable resource but, ideally, the emergency physician should already be well versed in the administrative and logistical aspects of the plan and the purely medical functions. The response will evolve more smoothly if the emergency physician understands both the hospital plan and resources, capabilities, and disaster plans of the first responders and EMS system in the region. The physician may be required to coordinate or facilitate the hospital response and to provide direction for numerous aspects of the regional response and may be looked to as a resource for hospital administrators who want to know “What should I do?” The physician may also be consulted regarding the need for the deployment of agencies and resources from outside the affected region and will need to know where to direct these inquiries, because they are unlikely to have the knowledge to appropriately answer them. Additionally, emergency department staff should expect to be bombarded with requests for information on all aspects of the disaster and response—from family members, media, and government representatives and from the public at large—and be prepared to refer or respond to such questions. Early in a disaster, the emergency physician and staff will likely be expected to disseminate information about the disaster event, demonstrate expertise and leadership in the response and management efforts, and even make the initial determination that disaster conditions exist. Hospital administrators, social services, and public relations personnel will need to assume their proper roles to allow the ED to continue to provide medical care and should be notified as soon as a disaster is recognized.
In the case of damaged or destroyed healthcare facilities or after a large-scale disaster, the physician may also be called on to provide medical care in unconventional settings. In the situation in which field medical care stations must be established, coordinating responses with other agencies is essential. It is important to remember, during the early stage of the disaster, that information available from those at the disaster area (data regarding death, injury, or damage) may not be accurate. Problems with communications are frequently the source of delays and misapplications of disaster resources. The ability of those in a region devastated by a disaster to survey the population and infrastructure may be severely curtailed by damage, such that even initial calls for help may be impossible. It is essential, therefore, that external resources of personnel and equipment be available and accessible if anticipation of potential need for them arises (5,22). Conversely, as a result of disruption of communications and transportation, it is possible for the effects of the disaster to be overestimated. To minimize damage and disruption, expedient decisions must be made, with future consequences of such actions considered as well. Short-term benefits and costs must be weighed against their long-term counterparts. Disasters are costly events, but judicious initial expenditures may result in substantial savings, in both monetary and humanitarian terms, over the long haul. Conversely, excessive spending by individuals, agencies, or organizations may result in prolonged or delayed recovery from the disaster and may restrict the capability to prepare or respond when the next disaster strikes.
In the case of a disaster that causes substantial destruction of infrastructure, the response may be prolonged, requiring that long-term healthcare and support services be established. Issues such as nutrition evaluation and ongoing disease surveillance may require the expertise of numerous other healthcare providers and agencies. Additionally, mental health issues must also be considered for the victims and the responders during both the emergency phase and the recovery. Posttraumatic stress disorder, major depression, generalized anxiety disorder, and substance abuse are frequently reported among disaster survivors who have experienced traumatic bereavement or severe disruption of their lives. Early and voluntary access to mental health workers for evaluation and intervention may reduce the incidence and severity of such reactions (2,24).
Common Pitfalls
• Failure to prepare for a disaster by identifying potential hazards in the local environment and hazards that may be brought in, whether by nature or human action.
• Failure to develop appropriate multiagency and multijurisdictional contingency plans.
• Failure to properly exercise and update disaster plans.
• Failure to appreciate that disrupted communication and transportation systems frequently cause problems in assessing and responding to disasters and that redundancy of equipment, training in its use, and flexibility of use of communication and transportation resources are desirable.
• Failure to consider the needs of the elderly, children, and other special populations and to include such things as appropriate medical supplies, diapers, formula, medications, interpreters, and special transportation requirements in disaster planning and response.
• Failure to appreciate that disaster responders may become casualties themselves, that they may suffer psychological effects during and after the event, and that personal planning and institutional support are crucial to minimize the impact of disruptions in the personal or professional lives of disaster responders.
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