Emergency medicine (EM) is optimally suited to lead the health care response in the hours following a disaster. By routinely providing the front line of hospital care for acutely ill and injured patients, regardless of the underlying characteristics of the pathology or the patient, emergency providers can adapt quickly to the changing conditions brought on by a mass casualty incident. In addition to having broad expertise in response to various types of emergencies, EM providers manage patient-volume surges routinely. Thus, when confronted with mass casualty incidents, they have less of a transition to make in their practice compared with any other specialist.
Following a disaster, physician leaders and frontline care providers will need a wide variety of skills and knowledge to deliver care and manage resources. These may differ from one disaster to another, involving an understanding of triage of mass casualties, decontamination, resuscitation, trauma, infectious disease, hypothermia, toxicology, and management of radiation poisoning. In addition, the physician leader in a disaster must know how to interface with incident-command systems, community resources, and regional assets. Most of these skills are already integral to the practice of EM. Emergency physicians thus commonly assume a leadership role in the immediate aftermath of a disaster.
Emergency departments (EDs) serve as the key interface between the community and the hospital system. The role of the ED is to triage patients on arrival to the health care facility, and then stabilize and disposition patients to their next stage of care, which may be to an inpatient setting, an outpatient setting, or another health care facility. The basic role remains unchanged in a disaster, but the methods by which it is executed change, based on the nature and extent of the disaster and the resources available to the ED.
The definition of the word disaster is highly subjective. A number of papers have tried to develop a standard nomenclature that would cover events ranging from a contained mass casualty incident to a catastrophe that knocks out most of the health care system. , For the purpose of this chapter, a disaster will be viewed as a mass casualty incident in which the health care resources are overwhelmed and outside help is required. When properly managed in this situation, the ED expands its capacity to the limit, using hospital resources for added staffing and space, thus modifying triage prioritization to ensure the highest survival rate. Once saturated, outside resources are needed to allow the ED to be bypassed, but this role is then delegated to other emergency facilities, in the field or at remote hospitals.
By processing patients with acute illness and injuries from stabilization to disposition, the performance of the ED will be a major determinant of survival; however, this is dependent on the skills of the health care providers who staff the emergency department and the design of the ED itself. To define the role of EM in disasters fully, the role of emergency providers and that of the facility must be considered. EM providers not only deliver emergency care but also oversee prehospital care, as well as engage in leadership roles in disaster preparedness and study ways to improve outcomes following a disaster. As an example, ED data can be used in disease detection and surveillance as an early warning system to an impending pandemic. Because of their unique knowledge of the prehospital world, hospital leadership, and the other medical specialties, EM providers play an integral part in communications during a disaster and in the delivery of the initial care.
Finally, in disasters, care and resources must be rationed. Under normal conditions, EM providers prioritize access to inpatient beds and diagnostic studies. This gatekeeper role is expanded in a disaster when rationing rather than prioritization is necessary.
To understand how the role of EM adapts to disaster management, it is helpful to review the development and evolution of the entire public health infrastructure, and, in particular, the specialty of EM ( Box 4-1 ).
|6 ad||The Corps of Vigiles: first professional fire service established|
|13th century||England: fire protection insurance becomes available|
|1666||Great Fire of 1666 in London; changes that took place after this disaster resulted in the model of today’s fire service|
|1798||Marine Hospital Service created (later to become the Public Health Service)|
|1931||Flood in China|
|1932||Famine in Soviet Union|
|1953||U.S. Department of Health, Education, and Welfare (cabinet level)|
|1954||Volcanic eruption in Colombia|
|1961||Alexandria Plan: first full-time emergency physicians|
|1966||Accidental Death and Disability report by the National Academy of Sciences/National Research Council|
|1968||Foundation of ACEP established|
|1973||Emergency medical services created|
|1979||Emergency medicine recognized as a medical specialty;|
|Federal Emergency Management Agency formed;|
|FIRESCOPE and Incident Command started;|
|Public Health Service is moved to Department of Health and Human Services|
|1983||Critical incident stress debriefing begins|
|1988||ACEP forms Section of Disaster Medicine|
|1991||National Fire Protection Association begins standard development|
|1993||World Trade Center attack|
|1995||Oklahoma City Bombing|
|1999||Federal Response Plan|
|2000||Disaster Mitigation Act of 2000|
|2001||Joint Commission on Accreditation of Health Care Organizations, standards for preparedness change;|
|Sept. 11 attacks at the World Trade Center, Pentagon, and in Pennsylvania;|
|2002||Passage of the Homeland Security Act|
|2003||Homeland Security Presidential Directive/HSPD-5 calls for a National Incident Management System (NIMS) and a National Response Plan (NRP);|
|Department of Homeland Security established|
|2004 (November)||States must file to qualify for predisaster hazard-mitigation funds; threat assessments completed|
|2010||Earthquake in Haiti|
|2013||Boston Marathon Bombing|
EDs grew rapidly along with hospital-based medicine after World War II. Available staffing was driven by financial incentives because of fee-for-service reimbursement. Complaints about the quality of care and threat of liability because of inadequate staffing motivated hospitals to recruit physicians with some EM experience. With improved care and financial success, these early EDs evolved rapidly from part-time coverage by physicians without specialized training to 24-hour coverage by residency-trained, board-certified emergency physicians. The highly specialized knowledge and skills these doctors came to possess allowed EDs to dramatically expand their scope of practice, to diagnose and manage a wide range of problems, and to serve as gatekeepers for inpatient care. With the growth in scope and competency, EDs became increasingly complex and versatile. A victim of this success, hospitals began allowing crowding of EDs by inpatient borders, patients who were admitted but for whom there was not an available hospital bed. This practice allowed for maximum occupancy of the inpatient services and strong operational performance without overstraining the inpatient staff. However, it resulted in growing dysfunction in the ED. The Institute of Medicine report described emergency care in 2007 as an “overburdened, under-funded and highly fragmented” system of emergency care. The strain seen routinely in many tertiary centers could pose a significant liability in preparing the ED to receive victims from a disaster.
By 1976, the American College of Emergency Physicians (ACEP) published a position paper on the role of the emergency physician in mass casualty and disaster management. This policy was later approved (1985), reaffirmed (1997), and revised and expanded (2000). (See Box 4-2 for the full policy statement.) In this policy, “ACEP believes that emergency physicians should assume a primary role in the medical aspects of disaster planning, management, and patient care.” It also called for emergency physicians to participate in “local, regional, and national disaster networks.” The University Association of Emergency Medicine echoed the call for training in disaster medicine and further called for the development of fellowship training in disaster medicine. ACEP also was an advocate for emergency physician participation in the “development of comprehensive plans developed by communities” to cope with disasters, and of the National Disaster Medical System, through disaster medical assistance team (DMAT) participation (1985, revised 1999). The ACEP Section of Disaster Medicine was formed in 1988. Through continued involvement and advocacy of disaster medicine, section members are participating on many levels: joining DMATs, researching and writing, and participating in educational conferences and hospital and community emergency management.
The American College of Emergency Physicians (ACEP) believes that emergency physicians should assume a primary role in the medical aspects of disaster planning, management, and patient care. Because the provision of effective disaster medical services requires prior training or experience, emergency physicians should pursue training that will enable them to fulfill this responsibility.
A medical disaster occurs when the destructive effects of natural or human-made forces overwhelm the ability of a given area or community to meet the demand for health care.
Disaster planning, testing, and response are multidisciplinary activities that require cooperative interaction. Each agency or individual contributes unique capabilities, perspectives, and experiences. Within this context, emergency physicians share the responsibility for ensuring an effective and well-integrated disaster response.
Emergency medical services and disaster medical services share the goal of optimal acute health care; however, in achieving that goal, the two systems use different approaches. Emergency medical services routinely direct maximal resources to a small number of individuals, while disaster medical services are designed to direct limited resources to the greatest number of individuals. Disasters involving the intentional or accidental release of biological, chemical, radiological, or nuclear agents present an extremely difficult community planning and response challenge. In addition, they may produce a far greater number of secondary casualties and deaths than conventional disasters. Because the medical control of emergency medical services is within the domain of emergency medicine, it remains the responsibility of emergency physicians to provide both direct patient care and medical control of out-of-hospital emergency medical services during disasters.
Improvement of established disaster management methods requires the integration of data from research and experience. Emergency physicians must use their skills in organization, education, and research to incorporate these improvements as new concepts and technologies emerge.
Where local, regional, and national disaster networks exist, emergency physicians should participate in strengthening them. Where they are not yet functional, emergency physicians should assist in planning and implementing them.
This policy statement was prepared by the Emergency Medical Services Committee. It was approved by the ACEP Board of Directors June 2000. It replaces one with the same title originally approved by the ACEP Board of Directors June 1985 and reaffirmed by the ACEP Board of Directors March 1997.
Role of Emergency Medicine Specialists
During a disaster, at the very least, emergency physicians will be expected to play a role in providing triage, emergency stabilization, and disposition of disaster victims. These basic responsibilities have led many academic emergency physicians to adopt disaster medicine as an area of expertise. They study these events to predict outcomes and improve future responses. They teach disaster preparedness, from the level of the medical school to international professional meetings. With this expertise, they often become leaders in preparing for regional and national disasters. At the time of a disaster, they often assume roles as incident commander or chief medical officer. Routine work in the ED puts EM providers into professional contact with the key specialties needed in disasters, as well as administration and nursing leadership. Emergency physicians are thus ideally suited to act as system integrators, allowing easy communication within the hospital and the prehospital sector.
The various roles of the emergency position are shown in Figure 4-1 . The figure identifies nine potential interactions within the system. When a disaster strikes, emergency physicians will need to assume the roles identified as two through five, even if they possess only the basic knowledge of disaster management.