Human-Induced and Natural Disasters

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.

Table 43.1

Types of Disasters Resulting in Mass Casualty Events

Aitken P, Leggat P. Considerations in mass casualty and disaster management. In Blaivas M, ed. Emergency Medicine—An International Perspective . Rijeka, Croatia: InTech; 2012:143-182. Also available from ; TFQCDM/WADEM (Task Force on Quality Control of Disaster Management/World Association for Disaster and Emergency Medicine). Health disaster management: guidelines for evaluation and research in the “utstein style.” Chapter 3: overview and concepts. Prehosp Disaster Med . 2002;17(suppl 3):31-55; Dudaryk R, Pretto EA. Resuscitation in a multiple casualty event. Anesthesiol Clin . 2013;31:85-106.

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 .

Fig. 43.1

Schematic illustration of definitions.

From TFQCDM/WADEM [Task Force on Quality Control of Disaster Management/World Association for Disaster and Emergency Medicine]. Health disaster management: guidelines for evaluation and research in the “utstein style.” Chapter 3: overview and concepts. Prehosp Disaster Med. 2002;17(suppl 3):31-55.


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.

Table 43.2

International Disaster Subgroups and Mortality Data from 2011 to 2016

From Centre for Research on the Epidemiology of Disasters (CRED). Emergency Events Database (EM-DAT). . Accessed on: December 1, 2016.

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

Table 43.3

Frequency of Disaster Types by Continent

From Aitken P, Leggat P. Considerations in mass casualty and disaster management. In Blaivas M, ed. Emergency Medicine—An International Perspective . Rijeka, Croatia: InTech; 2012:143-182.

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.

Fig. 43.2

Graphic depiction of the frequency of disasters each decade.

From Centre for Research on the Epidemiology of Disasters [CRED]. Emergency Events Database [EM-DAT]. . Accessed on December 1, 2016.

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.

Table 43.4

Four Phases of Disaster

Baird ME. The phases of emergency management. 2010. Prepared for the Intermodal Freight Transportation Institute (ITFI). . Accessed December 1, 2016; Wisner B, Adams J. Environmental health in emergencies and disasters: a practical guide. World Health Organization, 2002. . Accessed December 1, 2016; Federal Emergency Management Agency (FEMA). Principles of emergency management: independent study. 2006. . Accessed December 1, 2016; American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness (ASA COTEP). Emergence Preparedness Resources. . Accessed December 1, 2016.

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.

Box 43.1

Family Emergency Preparedness Checklist a

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 .


From American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness (ASA COTEP). Emergence Preparedness Resources. . Accessed December 1, 2016.


  • 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


  • 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 .

Table 43.5

U.S. Government Agencies and Responsibilities in Mass Casualty Events

From Lin EY. Trauma, bioterrorism, and natural disasters. In Miller RD, ed. Basics of Anesthesia . 6th ed. Philadelphia: Elsevier Saunders; 2011:681-697.

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.

Table 43.6

U.S. Government Medical Response Teams: Description and Responsibilities

From Murray MJ. Emergency preparedness for and disaster management of casualties from natural disasters and chemical, biologic, radiologic, nuclear, and high-yield explosive (CBRNE) events. In Barash PG, ed. Clinical Anesthesia . 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2013:1535-1549.

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.

Fig. 43.3

Risk management using risk matrix.

From Risk Assessment. . Accessed December 1, 2016.

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 .

Oct 21, 2019 | Posted by in ANESTHESIA | Comments Off on Human-Induced and Natural Disasters

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