Key points

The roots of disaster medicine trace back as the early as the late eighteenth century, when the surgeon in chief to Napoleon created the concept of triage for military injuries. Basic concepts of disaster medicine continued to evolve in the military over time as wars continued to be waged. In the early twentieth century, Heinrich Zangger, one of the founding fathers of disaster preparedness, is credited with building the subspecialty from the study of civilian mine explosions. Much of the early phase of disaster medicine focused solely on the prehospital response due to the military history of assessing viability of soldiers on the battlefield. As modern medicine has continued to become specialized, disaster medicine has become an important subspecialty.

In the United States, it was not until 1984 that the National Medical Disaster Systems (NMDS) developed disaster response protocols at the federal level. As part of the NMDS, Disaster Medicine Assistant Teams (DMATs) were created under the Department of Health and Human Services and the Federal Emergency Management Agency. ^, The main purpose of DMATs was to receive and treat war casualties in an efficient and effective manner. Focus was placed on training and standardizing procedures. Due to the lack of war casualties, the roles of these systems evolved to respond to natural disasters and other issues affecting mass populations. The DMATs are located throughout the country and are available for immediate deployment for a variety of situations.

The purpose of the DMATs is to provide support in the early stages of a crisis to facilitate on-scene stability in the prehospital environment. The approach is standardized, allowing for efficient utilization of personnel and organization of the response. The initial actions include mobilization and distribution of resources. Mobile triage units are established on site or at the closest safe location. The goal of the DMAT is to quickly identify, stabilize, and move the affected individuals to the appropriate destination. Within the past decade, there has been a focus on improving the collaboration and communication with the health care system that ultimately receives the patients.

Philosophic approach to disaster medicine

The approach to disaster medicine presents a philosophic dilemma. By definition, a disaster is an event where the needs of the situation are greater than the resources available. In a situation where resources are a limiting factor in providing medical care, difficult decisions must be made. There are 3 main philosophies in disaster medical care: utilitarian, egalitarian, and proceduralism. Each of these philosophies has both benefits and drawbacks. Often, the cultural norms of the society, which can change depending on time and place, play a large role in the approach to utilization of resources.

The utilitarian philosophy embraces the basic tenet in trauma medicine, which is to produce the greatest happiness; in medicine, this translates to mean providing the “greatest good to the greatest number.” ^, The goal is to maximize the number of survivors with a meaningful quality of life. Mathematical metrics, such as years and number of people saved, are used to determine distribution of care. The benefit of this approach is that if employed correctly, it results in the greatest number of survivors. One of the criticisms of the utilitarian method is that some people who could be saved need to be sacrificed in order to save a greater number of people. In this way, the value is placed on the benefit to society and not the individual. In certain cultures, this is a less acceptable approach due to the importance of the individual within its structure. Utilitarian philosophy favors pediatric patients because they have the most years of life to save.

The egalitarian philosophy distributes all resources equally, with an approach of “take anyone, with anything, at anytime.” Under this philosophy, there is no rationing of goods or services, and, as a result, there is significant resource utilization on patients who do not survive, often at a cost of those who could have survived. Egalitarian philosophy is at the foundation of the Emergency Medical Treatment and Labor Act (EMTALA) of 1986 that guaranteed medical care in emergency rooms across the United States. As opposed to the utilitarian approach, egalitarianism places the value on the life of the individual. This philosophy often is viewed as the most fair or equitable.

The proceduralism philosophy utilizes predetermined criteria to distribute resources. Usually the decisions are made by inclusion or exclusion criteria. Some systems even use a lottery system to assign priority for resource access. The benefit of such a system is that it takes the human component out of the decision process. This type of system often is seen as the most easily executed because it requires minimal individual thought. Because these systems are not flexible, however, there is a potential for excess resource utilization on patients who meet criteria but are not salvageable.

Disaster medicine involves the intersection of medicine, ethics, and resources. ^, Cultural and societal attitudes play a critical role in determining which philosophic approach guides distribution of resources. Determining procedures prior to an event as well as the goal, lives saved versus life years saved, is important to ensure that streamlined procedures are executed in the immediate chaos of a disaster event.

Types of disaster events

A disaster is an event when the needs of the situation outweigh the resources available. There are 3 main categories of disaster events: natural, traumatic terror, and exposure. Each category has considerations for the anesthesiologist as well as unique pediatric considerations. Although a single disaster plan is not sufficient for the response to all events, there is considerable overlap, and the need for a systematic protocol allows for the most effective and efficient action. Understanding the needs of the different types of disasters as well as the available resources is critical to designing the correct plan.

Natural disasters include those that occur due to climate or geologic events. Examples of natural disasters include hurricanes, tornadoes, earthquakes, and similar events. These events have the potential for significant volumes of victims. The anesthesiologist has a role in the entire response, from the site of the event, to the prehospital staging area, to the hospital reception, and through to the postoperative recovery.

In both natural and terror events, geographic location dictates the expected/needed role of the anesthesiologist. For example, in rural settings, the anesthesiologist often plays a significant role in the field, often providing on-site support becuase the responding emergency medical services (EMS) may be limited. In urban areas, there is a robust EMS system and the anesthesiologist is most effective in the perioperative arena. This role can change depending on the event, as witnessed with the attack on the north and south towers of the World Trade Center in New York on September 11, 2001. Because there was a concern for significant volumes of injured patients which would overwhelm the EMS system, anesthesiologists, as part of a multidisciplinary team, were deployed to the site for immediate triage and treatment. Similarly, at the Boston Marathon bombing on April 15, 2013, there were robust medical tents that provided approximately 200 beds available for injured runners. After the bombing, medical staff, including anesthesiologists, were involved in the prehospital triage and stabilization of the victims.

Another factor for consideration in natural disasters is that often the anesthesiologist is located within the disaster red zone. For example, if a tornado hits a town, the physicians and the hospital system are at risk for personal involvement and devastation. In such situations, the ability of anesthesiologists to respond is compromised as they care for their family and possessions. If the hospital structure itself is affected, such as the 1994 Northridge earthquake in California, the safety of the environment in which the anesthesiologist provides care may be compromised. At the epicenter, Northridge Hospital Medical Center (NHMC) suffered severe structural damage, requiring treatment of patients to be moved from the emergency room to tents in the parking lots. Due its proximity to the earthquake, NHMC received many injured patients, treating approximately 200 patients in the first 2 hours and more than 1700 patients during the duration of the event. NHMC sustained significant structural damage that included interruption of electricity. This provided a significant obstacle to the anesthesiologists’ ability to provide care in the surgical suite. All disaster plans should include alternative plans for providing anesthesia for critical patients in the situation in which water and electricity are compromised.

Natural disasters also disrupt the normal channels that replenish supplies and personnel to the hospital system. The Joint Commission on Accreditation of Healthcare Organizations requires hospitals to have on-hand enough resources and the capability of providing care for 72 hours. Probably the greatest example of the impact on resources and personnel was Hurricane Katrina, which struck New Orleans in 2005. Tulane University Hospital and Memorial Medical Center were 2 hospitals that were significantly affected. The difference between these 2 hospitals highlights the benefits of a well-designed disaster preparedness plan. Tulane Hospital recognized alternative plans for patient transfer and contracted with private helicopter, bus, and ambulance companies. Memorial Medical Center relied solely on governmental resources to mobilize patients. ^, When Hurricane Katrina hit downtown New Orleans, Tulane was able to evacuate all necessary patients, with no loss of life from the storm. In contrast, Memorial Medical Center was dependent on the arrival of transportation and resources from federal and state government agencies. By day 4 of the storm, all generators had failed. There was complete loss of electricity, sanitation, running water, and heating, ventilation, and air conditioning systems. The staff waited for days for more resources and personnel to arrive from the state and federal aid sources, but none came. Overall, there were 45 patient deaths that were directly attributed to the lack of resources. ^, Anesthesia requires a steady supply chain of both medication and equipment. The basic core of medications that are utilized most frequently in anesthesia are quickly exhausted in cases where new supplies cannot be obtained. Pediatric anesthesiology requires the maintenance of a range of equipment due to the age and size ranges of children so that interruption of the supply chain can have a more dramatic effect on the ability to provide care.

Terror events pose a different challenge for the anesthesiologist. These types of events can be broken down into 2 main categories: traumatic and exposure. Although the potential for significant numbers of victims and the resultant drain on resources are similar for both types, there are differences in the considerations for the anesthesiologist. Each disaster plan should account not only for the difference in event type based on the treatment of the patient but also on the self-care of the anesthesiologist.

Traumatic events can quickly overwhelm an operating room due to the increased likelihood for surgical procedures. In the Route 91 Harvest music festival shooting in Las Vegas in October 2017, a total of 515 people were shot at an open air country music concert. Sunrise Hospital received 200 patients in rapid succession, most arriving in groups of 4 to 5 people transported in the back of pickup trucks. This was an extreme test of the hospital’s surge capacity. Staff was quickly overwhelmed while equipment and supplies became a limiting factor in patient care. The anesthesia staff was forced to mobilize both staff and resources to staff multiple operating rooms at the same time. Further compounding the chaos was that this occurred at 10:00 pm, well after normal scheduled hours. Due to the mechanism of injury caused by high-velocity guns, the injury pattern almost exclusively was hemorrhage control. Obtaining significant volumes of compatible blood in a timely fashion for multiple patients was a top priority in the anesthetic set-up. With after-hours staffing numbers, this would be a challenge at most hospitals. Contingency plans for increasing staff numbers for events that happen during times when staff is at a minimum is an important step in any disaster plan. Because a majority of operating suites around the country are coordinated by an anesthesia board runner, a system for rapid identification and assignment of available surgeons is necessary for fluid movement of patients.

In the age of the powerful electronic medical record, staff have become overwhelmingly dependent on it functioning correctly. A rapid influx of patients needing to be registered is an overwhelming task for even the most robust electronic system. Many hospitals are paralyzed by the need for complete registration to not only record an intraoperative anesthetic record but also to place orders, obtain blood products or studies, and facilitate patient movement through the system. A reliable alternative to attempting to register large volumes of patients simultaneously is a system that reverts to paper registration. The advantage of a paper system is that packets can be made with preregistered patients with coded generic names. Because the patients are already registered within the hospital system, all that needs to be completed is placing a name band that already has been printed onto the patient. This saves considerable time, effort, and manpower. Within each premade packet is a paper anesthetic record, so that if there is the need for an anesthetic procedure, all documents are located in a solitary place. The disadvantage of this system is that it requires significant effort postdischarge to merge the paper records with their real electronic medical records, and most staff, in particular anesthesia providers, are not as facile with paper records.

The ability of the physicians in the emergency room to efficiently triage and transport the most critical patients to the operating room can have a significant impact on the status of arrival to the operating room. The anesthesia disaster plan for traumatic terror events must start with an effective communication plan with the emergency room so that the reception of patients is well choreographed. The largest obstacle in most disaster events is effective communication. The failure in communication most often is due to staff attempting to utilize standard operating procedure systems. In large-scale events, lines of communication quickly become chaotic and overwhelmed. Large amounts of information are lost or incorrectly conveyed. The most critical line of communication is from the emergency room to the operating room office with the anesthesia board runner. Designing an emergency operating procedure that streamlines this communication allows for operating rooms to be appropriately prepared to receive patients in rapid succession. In pediatric anesthesia, this is even more important because there is considerable difference in the equipment set-up and medication preparation for a 2-year-old child versus a 16-year-old child, thereby requiring correct prior information.

Exposure events produce challenges that are different from traumatic terror events. Such events are abbreviated by the mnemonic, CRBNE, which stands for: chemical, radiological, biological, nuclear, and explosive. In contrast to a traumatic event, where staff often is eager to respond and report to the hospital, exposure events can be a real or perceived threat to the well-being of staff and their families, therefore reducing the amount of voluntary staff available. Exposure events are less likely to need surgical intervention and more likely to require tracheal intubation. Patients who are victims of an exposure event need decontamination prior to any medical treatment. It is imperative that decontamination is performed to prevent compromise of the staff. The benefit of decontamination is that it creates a bottleneck prior to entering the emergency room, thereby causing a pacing system that prevents rapid influx into the hospital. This patient staggering allows more time for the anesthesia team to communicate and prepare for the reception of possible patients as opposed to the uncontrolled patient volume of a traumatic event.

How to design a disaster plan for the anesthesiologist

The first step in creating a disaster plan is for the anesthesia department to be involved at a leadership level. Most disaster planning for hospital systems focuses primarily on the emergency room response. As such, emergency room physicians and trauma surgeons dominate the planning committees as well as the leadership positions. By being present at the table, perioperative planning and needs are included in the overall disaster plan, allowing for smooth transitions from the hospital entrance through the operating room complex.

The goal is to create a disaster plan that is simple and easy to follow. In any disaster event, there undoubtedly is chaos and confusion. Simplicity with clear actionable items increases the likelihood of seamless execution. The disaster plan should be easily accessible with both electronic and paper copies in multiple locations. Along with the disaster plan, there should be an extensive list of phone numbers, including numbers for all anesthesia staff, surgical staff, nursing administration, blood banks, hospital administration, command center, and security. Although most hospitals have an electronic staff directory, having a centralized location of needed numbers is invaluable if the electronic systems are slowed or fail.

The same response should be enacted for all disasters with only minor modifications depending on the needs of the situation. The 3 Cs—command, control, and communications—should be the structure used to guide the first step of the disaster plan. Command is the establishment of a command structure that clearly delineates the hierarchal plan of leadership. Control refers to the identification of the anesthesiologist in charge of the operating room schedule and flow. Anesthesiologists familiar with board running duties often are best suited for this position because they have experience with patient flow and interfacing with different aspects of the perioperative care model. Communications identifies the mode of communication that will be utilized and the personnel in charge of said communications.

The second step is to create and communicate situational awareness among the staff. This step is defined by the 4 Ws: who, what, where, and when. This step allows the staff to prepare for surgical cases based on prehospital information from the scene. Who is the patients who are expected based on the type of event. In most disaster events, patients sometimes are transported to incorrect hospitals. Adults can end up at pediatric hospitals and vice versa. What are the types of injuries most likely to be encountered: blast, penetrating, chemical, and so forth. Where describes the location of the scene of the event. This gives an indication of the magnitude of the event as well as provides a broad view of the disaster event. When refers to the time of day of the disaster, which has an impact on staffing as well as the timing of the arrival of patients.

The third step is to create an incident action plan, more commonly known as the protocol. The action plan should describe in a clear, concise, step-by-step fashion the duties that should be performed by different roles. These duties should be enumerated and divided by time periods: 1 minute to 15 minutes, 15 minutes to 30 minutes, and 30+ minutes. It is the duty of the anesthesia board runner to ensure that the plan is executed properly. The action plan includes all phases of the response. It is important to include the possibility of a prolonged event, such as a natural disaster, that could last days to weeks. All-important actionable items should be listed as well as plans for disruption of the supply chain and replenishment of resources and personnel.

The final step is called the battle rhythm. This stage refers to the execution of the incident action plan. Having a well-planned and thorough disaster plan and conducting regular drills of the disaster plan enable this step to become routine. Many institutions avoid practice of the disaster plan because disaster drills are time-consuming and resource-intensive endeavors. Exercises are the most effective way to identify areas of deficiency within a plan. If disaster drills are not practiced at regular intervals, much of the information is forgotten because disasters are low-frequency events at most hospitals.

Resiliency is the ability of a person or object to return to its original state after a state of stress. Disaster incidents are profoundly stressful for all staff involved. Often, personnel are pushing to or past the limits of their capability to care for patients. Loss of life takes a significant toll on the morale of staff. Although not a part of the response phase, the recovery phase needs to include plans to maintain the well-being of staff. This portion of the plan involves mobilizing therapists, counselors, and chaplains early on in an event to minimize psychological damage and prevent the loss of personnel postincident.

Summary

In conclusion, disaster incidents occur across the country at a frequency much greater than that appreciated by most people. Historically, anesthesiologists have not been involved at a leadership level of hospital disaster planning. As gatekeepers to the operating rooms, it is imperative that anesthesiologists take an active role in disaster planning and management to provide the most efficient and effective care of patients. It is important that every anesthesia department establish and practice the execution of a well-designed disaster plan. Such planning and preparation allow resources to be maximized and standards of care to be provided for the greater number of patients while minimizing waste.

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