Preparing to manage, to deal with the sequelae of, and to mitigate future disasters originating from natural events, industrial accidents or, of more interest recently, caused intentionally by terrorists using chemical, biologic, radiologic, nuclear, or high-yield explosive (CBRNE) agents is a high priority for the majority of governments the world over. Even large multinational corporations recognize the need for planning to assist during disasters and to decrease future risk of disasters. Two thousand such corporations, each with $5 billion or more in assets, participate in the World Economic Forum, a private not-for-profit foundation established in Switzerland. Through its Global Agenda Council on Humanitarian Assistance, partnering with the United Nations, humanitarian aid is provided throughout the world following natural disasters wherever there is a need. The resulting public–private collaboration has a distinguished track record; however, the Council recognizes the need to do more with respect to disaster risk reduction and disaster (www.weforum.org/issues/disaster-management). Money may also play a role—natural disasters that occurred in 2011 caused more than 350 billion dollars in losses (www.weforum.org/content/global-agenda-council-catastrophic-risks-2012). Whatever the reason, though, the aid provided is the only mechanism to mitigate the effects of disasters in many areas of the world where economic resources are inadequate. The United States also is cognizant of the benefits to its foreign policy by assisting in humanitarian missions. The U.S. Agency for International Development (USAID) spends a significant portion of its budget each year to provide humanitarian assistance in the wake of natural disasters such as floods, volcanic eruptions, and earthquakes but spends just as much to mitigate the effects of future catastrophes. The American Society of Anesthesiologists has recognized the importance of such activities and in the past decade has established a Committee on Emergency Preparedness and Trauma (COTEP) and a Global Health Initiative. While no one can doubt the altruistic motives for these actions, as a member-driven organization it has been driven in these endeavors from requests from members during this same time frame: After 9–11 strike, after Hurricanes Katrina and Ike, after the tornados that struck the central and southeast part of the country over the last couple years, and most recently after the earthquake that struck Haiti in 2010. ASA members who have been involved in relief efforts, members who have either been in the military or are in the military, and international members who have experienced terrorism on a more frequent basis have created a cacophony of voices calling for more education and training on how to prepare for a disaster and how to manage the victims of such disasters. Most residency program directors would agree that anesthesiologists are well prepared to manage individual patients but are lacking when it comes to education in managing the numbers of patients that might arise from a mass casualty event. Books have been written on such topics and governments have created large bureaucracies to address such events, so it would be naïve to think that a chapter in a book could adequately prepare one to cope with all contingencies. However, there are certain principles that are common to all such events, independent of their etiology, and as a group anesthesiologists are as well prepared if not better prepared to assist their communities in planning for and in caring for patients from a disaster. We must expend the energy to be better educated as the initial response to any disaster always occurs at the local level; therefore, as anesthesiologists we must be prepared to provide assistance during such emergencies. Other physicians, hospital administrators, and nongovernment organizations (NGOs) all place anesthesia providers at the top of the list of healthcare workers who are needed to manage the sequelae of natural disasters and mass casualty events. We are in such demand that the NGO, Doctors Without Borders (Medicins san Frontiers), waives its policy that clinicians commit for 9- to 18-month rotations; there is an option for anesthesia providers of 1- to 3-month assignments (www.doctorswithoutboarders.org/work/field/recruitment.cfn). Whether it is providing anesthesia so that an extremity can be amputated allowing someone trapped in the rubble of a building following an earthquake can be extracted, starting an intravenous infusion in a child or adult debilitated by diarrhea, treating the effects of a chemical agent, managing a ventilator in someone with anthrax, or providing anesthesia to a casualty from an explosion, anesthesia providers have the requisite skills to assist in all these scenarios—these are services we provide on a daily basis.

However, disasters and mass casualty events are not something in which we participate on a daily basis so therefore education and training for these situations is critically important, beginning with preparation to respond to the most likely disasters to occur in our respective geographic location, for example, hurricanes on the Atlantic Seaboard and Gulf of Mexico, earthquakes on the West Coast of North America or tornadoes in the Midwest and Southeast of the United States. Even though natural and industrial disasters have occurred for millennia, the use of CBRNE agents and devices by terrorists in recent decades has emphasized the need for increased preparedness.

However, time and time again history shows that enthusiasm for education is high after an event and then tapers off; maintaining that enthusiasm is difficult,¹ and therefore most if not all healthcare facilities² are not prepared to deal with mass casualty incidents the exception being those facilities staffed by physicians with prior military training.³ In dealing with acts of terrorism geography is not helpful in anticipating what might occur, but that is not to say that one cannot anticipate what to expect. One can learn from experience; terrorists have been successful in their minds’ eyes with improvised explosive devices (IEDs), and even in those situations in which IEDs were not used, terrorists have chosen to use certain weapons of mass destruction (WMD) more often than others. For example, if they were to choose a chemical agent, a nerve agent is most likely and amongst those sarin has been the agent of choice. Similarly amongst biologic agents, anthrax, which was used in 2001, or smallpox would be the most likely choice because of the high lethality and infectivity associated with those two agents.⁴,⁵ Twice in the past 20 years “dirty” bombs have either been planned or planted (and fortunately not used) so such devices would be the most likely source of radiation used by terrorists. However, to underscore what was stated above based on past experience a natural or industrial event would be most likely (Table 53-1).

To prepare for the kinds of scenarios described above, there are certain terms with which one must be familiar. A mass casualty incident is one that results in a number of patients that a community healthcare system has the resources to treat,
despite turmoil and confusion. A mass casualty event is one that overwhelms the hospital or the community’s healthcare system. One also must be cognizant of the fact that though she or he might never plan to participate in a humanitarian mission overseas and therefore think that there is no need to train to work in an austere environment, depending on the circumstances of the disaster in which one finds one’s self the environment may be very austere indeed. Any time a situation arises in which medical capability is significantly below standards to which we are accustomed in the United States the anesthesiologist is indeed practicing in an austere environment. This austerity might occur in a:

As described above, graduates of anesthesia training programs in North America can cope well in such situations, provided that they understand the basic requisites of disaster management, the focus of this chapter.

It is difficult to anticipate every situation in which anesthesiologists could be asked to assist in managing mass casualty situations. For example, on October 26, 2002, terrorists held 750 hostages at the Nord-Ost Theater in Moscow. Many believe that the authorities instilled nebulized or volatile carfentanil into the air ducts of the opera house, thereby immobilizing the terrorists.¹² Unfortunately, because of the incapacitating effect of carfentanil, the hostages became victims too. Patients were transported from the theater to hospitals without any treatment prior to arrival. Ideally, anesthesiologists or other healthcare providers with an opioid antagonist such as naloxone should have been readily available and present at the site to manage both hostages and the terrorists. Unfortunately, this was not the case.

Anesthesiologists’ basic understanding of physiology and pharmacology, their airway skills, their fluid resuscitation expertise, their ability to manage ventilators and to provide anesthesia in the field environment, in the emergency department, in the operating room, and in intensive care units (ICUs) will be invaluable. In these mass casualty situations, many patients suffer burns, fractures, lacerations, soft tissue trauma, and amputations that will require triage, stabilization in the emergency room or in some other facility near the emergency room, and either more definitive treatment in the operating room or in the ICU.

During a mass casualty incident an anesthesiologist may well be asked to provide anesthetic services in an area other than the operating room or ICU. One will not know where one will be working until reporting to the hospital and the command and control center established to manage the incident.¹⁴ The site of the command and control center is pre-established and outlined in the hospital’s emergency preparedness plan, but typically within the hospital’s emergency department or in close proximity. Other entrances to the hospital are typically closed during a mass casualty incident for the purposes of maintaining control of the numbers of patients that might present and to allow for decontamination of patients if necessary avoiding exposure of hospital personnel to contagious agents or transferrable substances such as nerve agents. The lack of such control and decontamination of the Tokyo subway sarin attack victims in 1995 resulted in a number of healthcare workers becoming ill by absorbing sarin from patients who had not been properly decontaminated.¹³ Not only were they unable to work but they became patients themselves, increasing the number of patients requiring care and consuming resources.