Planning

Pre-disaster planning by LMICs improves their ability to utilize international aid when a disaster occurs and decreases the time to rescue efforts being initiated to limit life loss associated with these events.⁵ Foreign medical teams, even if deployed immediately, often fail to arrive in time to provide emergency trauma interventions in the immediate aftermath of an event. This task falls to the local medical or surgical providers, who, in the chaos directly following the disaster, lack a coordinated response and are unable to access needed medical supplies, transportation, and hospitalization for the victims. The more robust the public health infrastructure (primary care, emergency care, and medical transport) prior to a disaster, the more effective the local disaster responders can be in the rescue of the initial victims.⁶ The time required to mobilize disaster medical teams and the fact that these teams can only deploy to the affected areas at the invitation of the host nation lead to prolonged delays before these teams become effective. Strategic relationships with world bodies such as the World Health Organization (WHO), United Nations, Non-Government Organizations (NGOs), and governments as well as academic or professional organizations from developed countries can limit this delay and allow disaster teams to mobilize efficaciously. Professional critical care societies in developed countries should invest in critical care education (resuscitation, evacuation, and transport of critically ill patients) and protocol development to be utilized in these LMICs in a disaster, prior to the arrival of international medical responders.

Disaster Medical Responders

Who should provide critical care services in a disaster?

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   1. Skilled and experienced adult and pediatric trained critical care providers, preferably with previous training/expertise in disaster response.⁵ Skills required to be an effective provider:

   
   
   
   
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     Leadership skills, but also a team player

     
     
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     Flexibility/self sufficiency to work in a variety of non-traditional critical care arenas

     
     
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     Experience/training in mass casualty incidents with diverse medical equipment and with specific training in the unique injury patterns that may be encountered

     
     
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     Ability to communicate and coordinate workflows across multidisciplinary and multicultural teams

     
     
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     An understanding of the political and cultural background contributing to the disaster

   
   
   
   
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   2. Providers aligned with groups who provide this type of care (Médecins Sans Frontières, Red Cross, military responders, NGOs, etc.)

Who shouldn’t provide critical care services in a disaster? Well-intentioned, but poorly prepared, inexperienced or untrained disaster responders, who may be unable to adapt their skills in austere environments and thus hinder the process rather than help.⁵

Disaster Logistics

Critical care delivery is resource intensive and is challenging when barriers such as a poor economy, lack of infrastructure, and lack of trained staff are exacerbated by crisis and disaster. Successful delivery of care in this environment depends on meticulous planning, fastidious management of resources, and having the right people on the team (local and foreign). Disaster responders should engage with the local medical staff and stakeholders, preferably giving them strategic and leadership roles in managing the disaster victims.⁷ This integration will allow teams to garner locally available resources and technologies, as well as get buy-in to facilitate care of the victims. These relationships with also allow for a smooth disengagement in the post-disaster period.⁹

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   1. Leadership and supervisory systems to support care – a critical care team leader (CCTL) is appointed to lead the unit/team. The CCTL should be a competent, disaster trained, and respected clinician, as well as an effective communicator, a flexible leader, and a consummate professional. The intensivist in this role will be responsible for patient triage in conjunction with surgical teams, resource allocation, medical direction, and oversight of the other providers. The CCTL should have final decision-making authority regarding who receives and does not receive critical care services.

   
   
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   2. Clinical staff shortages – a 1:2 nurse-to-patient ratio may not be feasible with shortages and should rather be determined by provider experience and clinical demands. To remove variability and allow less skilled providers to safely care for critically ill patients, safety checklists, nurse-driven care guidelines, and protocols can be utilized. The use of adaptive staffing models with innovative shift structures can maximize care delivery without causing staff burnout.⁴

   
   
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   3. Biomedical engineers (for repairs and to keep equipment in working order), translators and research personnel are key non-clinical team members to facilitate workflow.

   
   
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   4. Supply chain – an administrative director (this may be a role shared by the nursing and physician leader of the ICU) is helpful to take care of the supply chain while the clinical team focuses on the medical needs of the patients. Some issues that the administrator will need to address are as follows:

   
   
   
   
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      a. Security for staff in insecure environments, which will require high-level situational awareness, communication with military or other groups in the disaster area, along with contingency and evacuation plans (for staff and patients) should an unsafe environment deteriorate

      
      
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      b. Support services for staff such as food, housing, and transport

      
      
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      c. Equipment, which should be appropriate for the local environment, affordable, portable, multiuse and simple to operate. A list of essential emergency equipment can be found at: www.who.int/surgery/publications/EEEGenericListFormatted%2006, but include ICU specific additions:

      
      
      
      
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         i. Beds/stretchers

         
         
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         ii. Ventilators – both adult and pediatric with flexible electric/battery power with the ability to run on low-flow oxygen without a high-pressure gas source. These ventilators need to be easy to operate and repair

         
         
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         iii. Cardiopulmonary monitors and point-of-care (POC) testing devices for blood work, which are simple to calibrate and maintain

         
         
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         iv. Arterial and central venous lines

      
      
      
      
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      d. Essential medications (narcotics, antibiotics, inotropes, and vasopressors) to provide comfort and supportive care for critically ill patients

      
      
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      e. Intravenous fluids (crystalloids and colloids) available on hand and a stable supply chain, as the initial amount that can be transported may be limited

      
      
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      f. Oxygen (tanks or a concentrator) – tanks are robust, but transport and refilling of tanks is expensive and unreliable

      
      
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      g. Personal protective equipment for staff to maintain universal precautions for the duration of the relief effort.