The demands of international disaster relief have changed over the past decade in the spectrum of threats, the field of operations, and scope of medical care. International disasters include large-scale disasters from natural events, such as earthquakes and tsunamis, and human-generated humanitarian crises, both intentional (war and terrorism) and unintentional. Today’s international disasters from natural events are even more devastating because of factors such as explosive population growth, poverty, and increasing economic and social disparities. Armed conflicts increasingly involve civilians, especially vulnerable populations such as children and the elderly.
Many of today’s complex international disasters occur in “austere” environments. An austere environment is a setting where access, transport, resources or other aspects of the physical, social, economic or political environments impose constraints on the adequacy of care for the population in need. All of these factors greatly increase the challenges of international disaster relief. Civilian and military medical teams are increasingly being mobilized to respond to international disasters, which are increasing both in frequency and complexity , ( Fig. 15.1 ).
Disaster medical care is not the same as conventional medical care. Disaster medical care requires a fundamental change (“crisis management care”) in the care of disaster victims to achieve the objective of providing the “greatest good for the greatest number of victims.” This is in contrast to the objective of conventional medical care, which is the “greatest good for the individual patient.” It is important to apply the principles of crisis management care to all phases of disaster management (preparedness, mitigation, response, and recovery). Demand for resources always exceeds the supply of resources in a mass casualty incident (MCI). , ,
Epidemiology of Disasters
Natural disasters may be classified as sudden-impact (acute) disasters or chronic-onset (slow) disasters. Sudden-impact natural disasters generally cause significant mortality and morbidity immediately as a direct result of the primary event (e.g., traumatic injuries, crush injuries, drowning). Chronic-onset disasters cause mortality and morbidity through prolonged secondary effects (e.g., infectious disease outbreaks, dehydration, and malnutrition). Earthquakes, tsunamis, landslides, and wildfires are examples of sudden-impact disasters. Chronic-onset disasters include famines, droughts, hurricanes, and typhoons. ,
Man-made disasters may be unintentional or intentional and range from technological disasters to MCIs involving weapons of mass destruction (radioactive, biological and chemical agents). , Disasters involving weapons of mass destruction (WMD), whether accidental or man-made, are a significant challenge for medical providers for several reasons:
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WMD have the potential to produce casualties in numbers large enough to overwhelm healthcare systems.
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WMD may produce large numbers of “expectant” victims. This denotes a category of disaster victims not expected to survive because of severity of injuries or underlying diseases and/or limited resources. This term was first used in conjunction with chemical warfare.
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WMD may produce a “contaminated” environment. Medical providers must be able to perform triage, initial stabilization, and possible definitive surgical care outside traditional healthcare facilities.
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WMD produce significant numbers of “psychogenic” casualties, greatly complicating rescue and triage efforts. Terrorists do not have to kill people to achieve their goals.
Creating a climate of fear and panic to overwhelm the medical infrastructure achieves their goals. During the sarin attack in Tokyo (1995), 5000 casualties were referred to local hospitals. Fewer than 1000 individuals were suffering from the effects of the gas. The remainder of the individuals were experiencing psychological symptoms.
PRINCIPLE 1
Medical providers cannot use traditional command structures when participating in disaster response. The Incident Command System (ICS) or Incident Management System is a modular/adaptable system for all incidents and facilities and is the accepted standard for all disaster response. Functional requirements, not titles, determine the ICS hierarchy. The organizational structure of the ICS is built around five major management activities (Incident Command, Operations, Planning, Logistics, and Finance/Administration) ( Fig. 15.2 ). Operations directs all disaster medical personnel. The Incident Commander in international disasters may be an international organization such as the United Nations (UN) or the World Health Organization (WHO), a government military or civilian organization of the affected country, or a responding organization from outside the country. ,
The structure of the ICS is the same regardless of the nature of the disaster. The difference is in the particular expertise of key personnel. Medical providers, often used to working independently, must adhere to the structure of an ICS to integrate successfully into the disaster response team and avoid many negative consequences including:
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Death of medical personnel because of lack of safety and training
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Lack of adequate medical supplies to provide care
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Staff working beyond their training.
Principle 2
Disaster response includes basic medical and public health concerns that are the same in all disasters regardless of the etiology of the disaster ( Boxes 15.1 and 15.2 ). A single emergency operations plan for many different situations is more effective than multiple separate disaster plans (“All Hazards Approach”), and most nations now adhere to this concept. , , The difference in disasters is the degree of disruption of the medical and public health infrastructures and the amount of outside assistance (regional, national, or international) that is needed to meet the needs of disaster victims. Rapid assessment by experienced personnel will determine which assets are needed in the acute phase of the disaster to augment local capacity. The complexity of today’s international humanitarian crises has increased the need for multidisciplinary medical and public health specialty teams as critical assets in international disaster relief. Flexibility and mobility are key assets required of all international disaster management teams, regardless of expertise.
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Search and rescue
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Triage
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Definitive care
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Evacuation
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Water
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Food
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Shelter
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Sanitation
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Security/safety
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Transportation
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Communication
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Endemic/epidemic diseases
Principle 3
Effective “surge capacity” is not based on well-intentioned and readily available volunteers. Disaster medical responders must understand the basic principles of disaster response (ICS, disaster triage, gross decontamination) to be effective members of the disaster team. Medical providers must be willing to care for the nondisaster-related injuries/medical conditions always seen in disaster response, in addition to disaster-related injuries/diseases. Predisaster training is an essential part of disaster preparedness.
Medical Response to Disasters
Disaster medical response includes four components: (1) search and rescue; (2) triage and initial stabilization; (3) definitive medical care; and (4) evacuation. International disaster teams are designed and trained to provide specific “functional” areas of disaster care. Clinical competencies, not titles, determine the role of disaster medical responders in international disaster relief. ,
Search and Rescue
The local population near any disaster site is the immediate search and rescue asset, but the technical equipment and expertise to facilitate extrication of victims trapped in the rubble is usually lacking. Many countries have developed specialized search and rescue teams, and acute care medical providers are part of these teams. Search and rescue teams are involved both in the rescue (extrication) and initial stabilization of victims, including field amputations and fasciotomies as necessary. , , Search and rescue teams are generally composed of specialists in the following areas:
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Acute care specialties (surgery, emergency medicine, anesthesia)
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Technical search
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Hazardous materials
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Communications and logistics
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Trained canines and their handlers.
Disaster Triage
Triage is the process of prioritizing casualties according to the level of care they require. It is the most important, and psychologically most difficult, mission of disaster medical response, both in the prehospital and hospital phases of the disaster. Disaster triage requires a fundamental change in the approach to the medical care of victims. , , , The objective of conventional civilian triage is to do the greatest good for the individual patient. Severity of injury/disease is the major determinant for medical care. The objective of disaster triage is to do the greatest good for the greatest number of patients. The determinants of triage in disasters are, however, based on three parameters:
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Severity of injury
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Likelihood of survival
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Available resources (logistics, personnel, evacuation assets).
The major objective and challenge of triage is to rapidly identify the small minority of critically injured patients who require urgent life-saving interventions, including operative interventions, from the larger majority of noncritical casualties that characterize most disasters. In a mass casualty event, the critical patients with the greatest chance of survival with the least expenditure of time and resources are prioritized to be treated first.
Triage is a dynamic decision-making process of matching victims needs with available resources. Many MCIs will have multiple different levels of triage as patients move from the disaster scene to definitive medical care. Disaster medical triage may be conducted at three different levels depending on the level of casualties (injuries) to capabilities (resources). , ,
Field Triage
Field triage, often the initial triage system used at the disaster scene in MCIs, is the rapid categorization of victims potentially needing immediate medical care where they are lying or at triage sites. Victims are designated as “acute” or “nonacute”. Simplified color coding may be used. Once the victims are transported to casualty collection centers (fixed or mobile medical facilities), medical triage according to severity of injury/disease may be performed.
Medical Triage
Medical triage is the rapid categorization of victims, at a casualty collection site or fixed or mobile medical facilities, by the most experienced medical personnel available to identify the level of medical care needed based on severity of injury. Triage personnel must have knowledge of the medical consequences of various injuries (e.g., burn, blast, or crush injuries or exposure to chemical, biological, or radioactive agents). Color coding may be used ( Fig. 15.3 ).
