No one can predict the time, location, or complexity of the next disaster. The management of the medical effects of contemporary disasters, whether natural or man-made, is one of the most significant challenges facing medical providers today. Disaster medical care, including trauma 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 in order to achieve the objective of providing the “greatest good for the greatest number of individuals.”^1,2,3,4,5 The demands of disaster medical care have changed over the past decade, both in the scope of medical care, the type of threats, and the field of operations (Fig. 8-1). Mass casualty incidents (MCI) are events causing numbers of casualties large enough to disrupt the health care services of the affected region. This is in contrast to multiple casualty events in which medical resources are strained (prehospital and/or hospital resources) but not overwhelmed. Demand for resources always exceeds the Supply of available resources in a disaster.

Natural disasters may be classified as sudden-impact (acute) disasters or chronic-onset (slow) disasters.⁶ Sudden-impact natural disasters generally cause significant mortality and morbidity immediately as a direct result of the primary event (eg, traumatic injuries, crush injuries, drowning).⁷ Chronic-onset disasters cause mortality and morbidity through prolonged secondary effects (eg, infectious disease outbreaks, dehydration, and malnutrition). Earthquakes, tsunamis, landslides, and wildfires are examples of sudden-impact disasters. Chronic-onset disasters include famines, droughts, and infectious disease epidemics.

Man-made disasters may be unintentional or intentional (terrorism).^1,8,9,10 The spectrum of agents used by terrorists is limitless and includes conventional weapons, explosives, and weapons of mass destruction (biological, chemical, and radioactive agents). Over 70% of terrorist attacks involve the use of explosive weapons. Improvised explosive devices (IEDs) are a particular concern for trauma providers (Fig. 8-2). Such incidents present a significant challenge due to the complexity of injuries (primary, secondary, tertiary, and quaternary blast injuries).^{1,7,8,9,10,11} Responders must also be aware of the potential for secondary strikes directed at harming medical personnel. Terrorists do not have to kill people to achieve their goals. They just have to create a climate of fear and panic to overwhelm the health care system (examples: sarin/anthrax attacks).

Principle 1

Medical providers cannot utilize traditional command and control structures when participating in disaster response. The Incident Command/Management System is the accepted standard for all disaster response. Functional requirements, not titles, determine the organizational structure of the Incident Command/Management System.

Principle 2

All disasters are not different. Disaster response includes basic concerns (similar to the ABCs of trauma care) that are the same in all disasters (Table 8-1). A single emergency operations plan for many different situations is more effective than multiple separate disaster plans (all hazards approach).^1,2,3,4,11 The difference in disasters is the degree of disruption of the medical and public health infrastructures and the amount of outside assistance (regional, national, international) that is needed to meet the needs of disaster victims. Rapid assessment by experienced disaster responders will determine which “functional capacities” are needed to meet the demands of the acute phase of the disasters.

Principle 3

Effective “surge capacity” is not based on well-intentioned and readily available volunteers. Disaster responders must understand the basic principles of disaster response (ICS, disaster triage, gross decontamination) to be effective members of the disaster teams.

Principle 4

Trauma care in disasters is not the same as conventional trauma care. Disaster care of traumatic injuries requires a fundamental change in the approach to the care of victims (“crisis management care”). The objective of conventional trauma care is the greatest good for the individual patient. Severity of injury/disease is the major determinant of medical care. The objective of disaster trauma care is the greatest good for the greatest number of victims. Determinants of care are severity of injuries, likelihood of survival and available resources (personnel, logistics, evacuation assets).^1,4,7,9

Medical providers cannot utilize traditional command structures when participating in disaster response. The Incident Command System (ICS) is a modular/adaptable system for all incidents and facilities and is the accepted standard for all disaster response. The Hospital Incident Command System (HICS) is an adaptation of the ICS for hospital use, allowing effective coordination in disaster preparedness and response activities with prehospital, public safety, and other response organizations. The trauma system is an important component of the ICS.

Functional requirements, not titles, determine the ICS hierarchy (Fig. 8-3). The organizational structure of the ICS is built around five major management activities—incident command, operations, planning, logistics, and finance/administration.^1,10,11 Key activities of the five categories are listed in Table 8-2.

The structure of the ICS is the same regardless of the nature of the disaster.^1,10,11,12 The difference is in the particular expertise of key personnel. An important part of disaster planning is the identification of the incident commander and other key positions before a disaster occurs (24 h/d–7 d/wk). Each person within the command structure should supervise only 3–7 persons. This is quite different from conventional prehospital/hospital command structures. All medical providers must adhere to the structure of the ICS in order to integrate successfully into the disaster response team and avoid many negative consequences including

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  Death of medical personnel due to 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 or certification

  
  
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  Lack of coordination

Search and Rescue

Many countries, including the United States, have developed specialized search and rescue teams as an integral part of their national disaster plans (Fig. 8-4).^1,13,14

Members of these teams, who receive specialized training in confined space environments, include the following:

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  A cadre of trauma specialists

  
  
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  Technical specialists knowledgeable in hazardous materials, structural engineering, heavy equipment operation, and technical search and rescue methodology

  
  
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  Trained canines and their handlers

Triage

Triage is a dynamic decision-making process of matching patients’ needs with available resources. Triage is the most important and psychologically challenging aspect of disaster medical response, both in the prehospital and hospital phases of disaster response. Disaster triage is significantly different from conventional trauma triage. The major objective and challenge of disaster triage is to identify the small minority of critically injured patients who require urgent lifesaving treatments, including damage control surgery, from the larger majority of noncritical casualties.

Critical patients having the greatest chance of survival with the least expenditure of time and resources are prioritized to be treated first. Review of the literature from major disasters estimates that 15–25% of victims are critically injured, and the remainder of victims are noncritical casualties.^1,4,7,11

Triage Errors

Triage errors, in the form of undertriage and overtriage, are always present in the chaos of mass casualty events. Undertriage is the assignment of critically injured casualties requiring immediate care to a “delayed” category. Undertriage leads to treatment delays with increased mortality and morbidity. Overtriage is the assignment of noncritical survivors with no life-threatening injuries to immediate urgent care. The higher the incidence of overtriage, the more the medical system is overwhelmed with increased mortality and morbidity. The level of acceptable over/undertriage in a MCI and the best method for evaluation of triage effectiveness in a MCI are controversial.

Levels of Triage

Three levels of disaster medical triage have been defined. The level of disaster triage utilized at any phase of the disaster will depend on the ratio of casualties to capabilities. Many mass casualty incidents will have multiple levels of triage as trauma patients move from the disaster scene to definitive medical care.^{1,2,3,4,12,15,16}

Field triage (level 1) is the rapid categorization of victims potentially needing immediate medical care “where they are lying” or at a casualty collection center. Victims are designated as “acute” or “nonacute.” Color coding may be used.

Medical triage (level 2) is the rapid categorization of victims by experienced medical providers at a casualty collection site or fixed/mobile medical facility.^15,17 Victims are classified into the following categories: