The editors and publisher would like to thank Dr. Eric Y. Lin for contributing to this chapter in the previous edition of this work. It has provided the framework for much of this chapter.
Disasters can be broadly characterized into two categories: those that happen to someone else and those that happen to you. We typically define a disaster as an event that overwhelms the usual capacity of the facility or geographic area, often requiring outside resources in management. Disasters come in many different forms. They include human-driven intentional acts of violence (e.g., terrorism, riots, and war) and natural phenomena (e.g., severe weather, seismic events, or epidemics). The range of a disaster may vary from a localized event to one covering entire regions or continents. It can result from a single event in time, like an earthquake, or be extended over months to years (i.e., droughts, pandemics). Disasters universally create a mismatch between need and available resources including medical supplies, pharmaceuticals, food and water, shelter, and skilled responders such as police officers, firefighters, and health care professionals. In recent years, an increasing number of casualties have been caused by disasters such as earthquakes (e.g., Haiti in 2010 and Japan in 2011), shootings (e.g., Paris in 2015, San Bernardino in 2015, and Orlando in 2016), and other terrorist attacks (e.g., New York City World Trade Center attacks in 2001, London bombings in 2005, and Boston bombing in 2013). Thus, it is important for anesthesia providers to be educated and trained on disaster management to help save lives. It takes disciplined individuals to sustain their education and training because traumatic events of this nature rarely happen (outside a busy urban trauma center or war zone).
Disaster Types and Nomenclature
Communities often require outside help and international assistance, depending on the severity of the disaster. Various disasters can result in mass casualty events (MCEs) ( Table 43.1 ), in which the number of victims surpasses the treatment ability and resources provided by a medical center. Even at Level I trauma centers with an activated disaster plan, it is difficult to provide care to more than seven casualties per hour.
| Category | Examples |
|---|---|
| Natural | Hurricane, tornado, flood, earthquake, fire, volcano, tsunami, drought, avalanche, extreme heat or cold, rain, ice, snow, bacterial/viral pandemics |
| Unintentional | Public transportation accident, boat accident, nuclear accident, industrial accident, building collapse |
| Intentional | Bombing, nuclear/biologic/chemical attack, environmental interference |
| Human-induced | Oil spill, fire, chemical/nuclear plant explosion, terror attack, war |
A health disaster constitutes decreased quality of public health and medical care to victims and an overall decline in the health status of a community, which is unable to adequately recover. Syria is an extreme example of such a continuous disaster. Conversely, a medical disaster refers to the suspension of providing health care to individuals because of a disaster event. Hazards are any conditions that may pose a threat to safety, well-being, or environment and can be natural, human-induced, or mixed. The probability of a negative event occurring is defined as a risk. A schematic representation of these definitions is provided in Fig. 43.1 .
Epidemiology
Various types of disasters occur frequently around the world leading to environmental and resource destruction, injury, and death of large populations. Disasters can be natural, human-induced, or mixed with contributions from nature and people. Table 43.2 shows the incidence of various disaster subgroups that occurred over the past 5 years globally and the number of people who were injured, affected, and died. Table 43.3 shows the frequency of disaster types by continents.
| Year | Disaster Subgroup | Occurrence | Total Deaths | Injured | Affected |
|---|---|---|---|---|---|
| 2011 | Biologic | 27 | 3,174 | 420 | 1,156,317 |
| 2011 | Climatologic | 23 | 10 | 5 | 30,423,594 |
| 2011 | Geophysical | 34 | 20,767 | 11,663 | 1,274,378 |
| 2011 | Hydrologic | 172 | 6,472 | 2,403 | 135,241,070 |
| 2011 | Meteorologic | 94 | 3,537 | 34,778 | 42,341,557 |
| 2011 | Technologic | 241 | 6,588 | 5,640 | 10,156 |
| 2012 | Biologic | 25 | 1,887 | 149 | 156,302 |
| 2012 | Climatologic | 25 | 21 | 422 | 23,554,769 |
| 2012 | Complex disasters | 2 | 1,482,214 | ||
| 2012 | Geophysical | 29 | 727 | 41,776 | 2,799,144 |
| 2012 | Hydrologic | 142 | 3,961 | 9,144 | 63,490,304 |
| 2012 | Meteorologic | 137 | 4,922 | 12,419 | 20,147,336 |
| 2012 | Technologic | 185 | 5,720 | 10,090 | 13,504 |
| 2013 | Biologic | 22 | 526 | 2,509 | 306,851 |
| 2013 | Climatologic | 15 | 32 | 17 | 7,949,631 |
| 2013 | Extraterrestrial | 1 | 1,491 | 300,000 | |
| 2013 | Geophysical | 31 | 1,156 | 21,566 | 7,158,348 |
| 2013 | Hydrologic | 158 | 10,071 | 6,701 | 31,777,995 |
| 2013 | Meteorologic | 116 | 10,418 | 92,133 | 48,878,386 |
| 2013 | Technologic | 191 | 6,701 | 5,032 | 10,016 |
| 2014 | Biologic | 22 | 12,923 | 69,276 | 122,941 |
| 2014 | Climatologic | 20 | 14 | 500 | 68,821,066 |
| 2014 | Geophysical | 31 | 876 | 5,973 | 3,317,439 |
| 2014 | Hydrologic | 146 | 4,428 | 5,022 | 40,237,519 |
| 2014 | Meteorologic | 111 | 2,440 | 26,493 | 26,828,377 |
| 2014 | Technologic | 205 | 6,389 | 4,233 | 284,893 |
| 2015 | Biologic | 16 | 1,089 | 44,108 | 26,952 |
| 2015 | Climatologic | 30 | 76 | 1,017 | 46,938,206 |
| 2015 | Geophysical | 30 | 9,563 | 81,865 | 7,907,683 |
| 2015 | Hydrologic | 176 | 4,455 | 23,343 | 34,685,784 |
| 2015 | Meteorologic | 118 | 8,662 | 22,072 | 11,151,582 |
| 2015 | Technologic | 202 | 9,726 | 8,643 | 71,600 |
| 2016 | Biologic | 5 | 40 | 2,160 | |
| 2016 | Climatologic | 10 | 4 | 335,107,656 | |
| 2016 | Geophysical | 13 | 1,185 | 234,952 | 1,172,679 |
| 2016 | Hydrologic | 116 | 3,655 | 8,190 | 9,068,011 |
| 2016 | Meteorologic | 50 | 1,953 | 3,062 | 5,665,433 |
| 2016 | Technologic | 118 | 3,406 | 2,855 | 12,202 |
| Disaster Type | Asia | Americas | Africa | Europe | Oceania | Total |
|---|---|---|---|---|---|---|
| Transport | 668 | 233 | 437 | 186 | 11 | 1535 |
| Floods | 362 | 216 | 207 | 153 | 25 | 963 |
| Windstorms | 322 | 283 | 49 | 71 | 58 | 783 |
| Industrial | 225 | 55 | 37 | 67 | 2 | 386 |
| Misc. accidents | 178 | 45 | 57 | 53 | 5 | 338 |
| Droughts/famines | 77 | 39 | 113 | 13 | 11 | 253 |
| Earthquakes | 112 | 48 | 10 | 37 | 8 | 215 |
| Avalanches/landslides | 101 | 40 | 12 | 25 | 5 | 183 |
| Forest fires | 18 | 55 | 11 | 39 | 9 | 132 |
| Extreme temperatures | 35 | 30 | 6 | 51 | 4 | 126 |
| Volcanic eruptions | 16 | 23 | 3 | 2 | 6 | 50 |
There has been an increased frequency of disastrous events over the past century ( Fig. 43.2 ). Improved technology, database development, and increased reporting of these casualties may contribute to the rising number of disasters, but there are additional contributing factors. The advances in technology, chemicals, weapons, and increasing use of transportation vehicles contribute to the increasing number of human-induced disasters. Additionally, the world population has significantly increased, with an increase in the number of inhabitants of desolate regions, where disaster planning, preparedness, resource availability, and response may not be as well established as in larger cities. In less developed countries, the access to resources and emergency preparedness plans may not be well established, resulting in higher death tolls compared to developed countries. International organizations such as the World Health Organization (WHO) and Pan American Health Organization (PAHO) work to help such countries implement cost-effective emergency preparedness plans to mitigate the effects of disasters. Yet, mortality statistics do not reflect the severity of the disaster. Communities can be affected by interrupting employment, education, transportation, food resources, and security. The vast damage created by disasters may also affect health care workers by preventing them from safely reporting to work. In addition, power failures or floods can damage hospital equipment and cause secondary health hazards.
Disaster Preparation and Response
Phases of a Disaster
The goals of disaster management are to reduce or prevent the potential losses from hazards, provide prompt and appropriate assistance to victims, and achieve rapid and effective recovery. Disaster responsiveness requires the coordination among responders, civilians, and government agencies to plan for and reduce the impact of disasters. Disaster management also incorporates developing public policies and plans that prevent or minimize the harmful effects of disasters on people, structures, and communities. There are four phases of a disaster, and they are described in Table 43.4 . The phases can sometimes overlap and do not necessarily proceed in order.
| Phase | Action | Example |
|---|---|---|
| Mitigation | Predisaster; preventing or minimizing the effects of the disaster | Public education, building codes and zoning |
| Preparedness | Planning how to respond | Preparedness plans, emergency drills, warning systems |
| Response | Efforts to minimize the hazards created by a disaster | Search and rescue, emergency relief |
| Recovery | Returning the community to normal, rebuilding, data collection of lessons learned | Temporary housing, medical care |
Disaster Preparedness and Mitigation
Disaster preparedness consists of actions taken to prevent or minimize the negative impacts of disasters. Previous experiences with natural disasters and mass casualties have led to the development of preparedness plans and protocols to be implemented for future events. Preparedness also entails public education, simulation drills and training, hospital and national organization coordination, and expectant management. Not all disasters can be prevented, but proper planning, education, evacuation, and preparation of necessary resources can help mitigate the consequent effects.
A community’s socioeconomic status, quality of structures (bridges, roads, buildings), hospital systems, and emergency medical services are important factors in disaster preparedness. Those communities with poor predisaster resources may not be equipped to deal with the repercussions of such disasters. This can result in increased injuries, fatality, destruction of infrastructures, and quickly exhausting resources. Such communities become reliant on assistance from other towns or countries (e.g., Haiti after the 2010 earthquake).
Personal Preparedness
A personal and family emergency preparedness plan should be in place and routinely updated. Families should also perform drills to prepare for unanticipated emergencies. There are numerous online websites of organizations such as the Federal Emergency Management Agency (FEMA), which have family plans, materials geared toward kids, communication resources, and updated information on what to do in the event of certain disasters. The American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness (ASA COTEP) has also provided a document on necessary supplies, first aid and disaster kits, clothing, utilities, and items needed to pack in the event of an emergency or evacuation ( Box 43.1 ). Families should expect that telephones or electricity may not work in certain situations and devise alternative methods of communication. Additionally, resources should be shared with neighbors, and one should provide assistance and help to neighbors and other community members.
a Make sure every member of the family knows the plan, that you post in it an accessible place, and that you practice yearly. For more details see www.ready.gov .
by ASA COTEPShelter
Supplies (at least 3 days)
- •
Medications
- •
Food and water (1 gallon per person per day)
- •
Pet care
- •
Batteries
- •
First aid and disaster kit
Communications (battery-powered radio)
Security plan
Sanitation/hygiene plan
Cash
Utilities
- •
Ability to safely shut off
- •
Establish alternative power and lighting
- •
Evacuate
Supplies (72 hours or more)
- •
Medications
- •
Food and water (1 gallon per person per day)
- •
Pet care
- •
Batteries
- •
Communications (battery-powered radio)
Clothing (weather/climate appropriate)
Transportation and fuel
- •
Preplanned routes and alternatives
- •
Utilities
- •
Shut off water and electricity if instructed
- •
“Go bags”
- •
Documents/supplies
- •
Maps/compass
- •
Flashlight
- •
First aid and disaster kit
- •
Cash
- •
Meeting place
- •
Right outside home
- •
Outside neighborhood
- •
Critical documents (in waterproof container)
- •
Identity (passport, driver’s license)
- •
Marriage license, divorce decree
- •
Birth certificates
- •
Medical license
- •
Insurance documents
- •
Financial records and deeds
- •
Irreplaceable photos
- •
ASA COTEP, American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness.
Government Plans
If a disaster or critical event has extensive impact requiring more assistance and resources than can be offered locally, national agencies often intervene. These various disaster management agencies have specific responsibilities in response to the type of crisis event as given in Table 43.5 .
| Agency | Responsibility |
|---|---|
| Federal Bureau of Investigation (FBI) | Domestic terrorism and crisis management |
| Federal Emergency Management Agency (FEMA) | Coordinates national emergency response and provides assistance to local and state governments, emergency relief to affected persons and businesses, and support for public safety |
| Department of Health and Human Services (HHS) | Provides health-related and medical services |
| Department of Defense (DOD) | Assists with biologic or chemical terrorism, bomb disposal, and decontamination |
| Centers for Disease Control and Prevention (CDC) | Coordinates response to public health threats and provides resources to local and state organizations |
In the United States, agencies such as the Centers for Disease Control and Prevention (CDC) prepare for disasters related to public health threats and have resources to provide equipment, specially trained medical personnel, and medications within 6 hours of notification. There are also national pharmaceutical stores that can be rapidly dispensed to regions affected by disasters when needed. In certain situations, such as terrorist threats or attacks and biochemical exposure, military services may be called upon to create field hospitals, isolate exposures, and provide public safety.
The National Disaster Medical System (NDMS) is a partnership between the Departments of Health and Human Services (HHS), Defense (DOD), Homeland Security (DHS), and Veterans Affairs (VA). NDMS provides medical response to a disaster area, moves patients from a disaster site to unaffected areas, and delivers medical care at participating hospitals. NDMS has formed specific disaster response teams such as the International Medical Surgical Response Team (IMSuRT), Disaster Medical Assistance Team (DMAT), Disaster Mortuary Operational Response Team (DMORT), National Veterinary Response Team (NVRT), and, most recently, Medical Specialty Enhancement Teams (MSETs). The response team descriptions and responsibilities are provided in Table 43.6 . Despite the presence of these governmental response teams, the number of teams is small and the activation and deployment of resources to a specific location can take up to 2 hours.
| Response Team | Description and Responsibilities |
|---|---|
| International Medical Surgical Response Team (IMSuRT) | Three teams that provide care to U.S. citizens injured in areas of conflict. |
| Disaster Medical Assistance Team (DMAT) | Rapidly mobilizes and sets up staff with physicians, nurses, and other support personnel, emergency facilities, and pharmaceutical dispensaries near the disaster site. Response personnel must complete 1 weekend of training each month. |
| Disaster Mortuary Operational Response Team (DMORT) | Manages mass deaths; handles bodies and performs forensic examinations. |
| National Veterinary Response Team (NVRT) | Provides veterinary services and zoonotic disease surveillance. |
| Medical Specialty Enhancement Teams (MSETs) | Team composed of 30 surgeons, 30 anesthesiologists, and pediatricians who are federally employed during deployments of at least 2 weeks. They respond to domestic/international crises and deploy either to the disaster site or specified facility. |
Risk Assessment and Management
The components of risk assessment and management include predicting the probability of adverse outcomes, identifying and monitoring risks associated with the disaster event, and implementing policies and practices aimed at mitigating these risks. Risks must be prioritized to identify those most likely to occur and have the most severe impact. There are several risk assessment scores and matrices ( Fig. 43.3 ) that help distinguish such risks, allowing organizations to focus planning and interventions in these areas. Risk modification or prevention strategies should be reviewed regularly so that implementation plans can be adapted accordingly.
Response Systems
Hospital Incident Command System
In the United States and internationally, the Hospital Incident Command System (HICS) can be used during emergencies, planned events, or in managing threats. HICS is based on the Incident Command System (ICS), a management system that was developed after analysis of catastrophic wildfires in the state of California in the 1970s. The elements of ICS include command, operations, planning, logistics, and finance/administration. HICS, like ICS, is an adaptable system that can be employed at any hospital. The principles presented in HICS apply to the mission areas of prevention, protection, mitigation, response, and recovery. Although HICS is most often considered for hazardous events, it can also be used for nonemergent purposes such as hosting large hospital events and administering annual influenza vaccinations.
HICS utilizes a standard format for responses that is both effective and recognized by other responding agencies, thus facilitating coordination among various organizations during a disaster. The principles of HICS include facilitating smooth transitions of care between hospitals and outside responding providers, assigning responsibilities to personnel and designated teams, planning and coordinating support requirements, emphasizing efficient communication, and obtaining necessary equipment or supplies from outside sources. HICS provides job action sheets that define responder roles and list the tasks to be performed. The implementation of HICS in individual hospitals requires education and training in order to provide a structured system that results in successful management of any pertinent event or disaster.
Hospital Emergency Management Plans
Hospitals should have emergency management plans in order to provide prompt medical care, justly allocate resources, and minimize deaths from disasters or MCEs. Emergency management plans should address situations in which large numbers of victims require treatment. Examples include MCEs due to terror attacks as well as incidents that affect the hospital itself, such as earthquakes and other natural disasters. The plans should educate and prepare the staff on disaster management, with the goal of appropriately allocating and using hospital resources to provide the best care possible. The main principles of hospital disaster plans are provided in Box 43.2 .
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