10 Injury, 15, 1 O-l 2 Printed in Great Britain
The definition and classification
W. H. Rutherford and J. de Boer
Royal Vietoria Hospital, Belfast
Summary
The universe, we are told, began with a big bang, and ever
since, nature has provided a series of unexpected bangs and
calamities of one type or another. Since the advent of the
industrial revolution, man has been more or less controlling
larger and larger amounts of energy. World population has
rocketed. The interaction of crowded humanity and escalat-
ing energy has added a series of man-made disasters to the
continuing natural calamities.
INTRODUCTION
ANY disaster, either man-made or natural, can produce
very large numbers of casualties in a short period,
often at a time when the community is least fitted to
come to their aid. Disaster medicine is that part of the
art and science of medicine which studies the clinical
and organizational problems of disasters. It is a young
branch of medicine and confusion still occurs because
people use different terms in different ways. The
foundation of science is definition, .classification and
measurement, and if disaster medlcme is to grow and
progress, it also must have its definition, classification
and measurement.
Definitions of the word disaster in ordinary diction-
aries are very wide. The word is applicable to every-
thing from an event like an earthquake to occasions
when two ladies turn up for a party wearing the same
dress. We need criteria by which we may judge
whether any particular event is or is not, from a medi-
cal standpoint, to be counted as a disaster (De Boer
and Baillie, 1980).
The International Trauma Foundation established
in 1980 an international working party which pro-
duced a report suggesting a definition and a classifi-
cation for disasters from a medical standpoint
(Rutherford, 1980). The working party took as its
starting point an earlier paper given at the lnter-
national Conference on Disaster Medicine in Cape
Town in 1979 (Rutherford, 1980).
This article explains the main features of the work-
ing party’s report.
DEFINITION
The international working party made the following
definition: ‘A disaster is a destructive event which,
relative to the resources available, causes many casual-
ties, usually occurring within a short period of time,’
Let us examine this definition in detail. Disasters are
of disasters
usually caused by the release of a great amount of
energy. This release of energy is usually accompanied
by physical destruction. In some cases, for example
civil disorder, the destructive energy is to a large extent
psychological, and injury to people is out of all pro-
portion to material damage.
Secondly, the resources available; these can be
defined and assessed. The availability and stage of
development of such services are not the same in all
countries. Nevertheless, they exist in some form, and
can be represented by the list in Table I.
Thirdly, many casualties; the fundamental point is
that a disaster occurs when there is a disproportion
between the number of casualties and the resources
available. A pile-up on the motorway need not be a
disaster if there are adequate facilities for rescue and
treatment.
Fourthly, a short period of time; famines and epi-
demics are naturally occurring events which claim
their victims over a relatively long period of time,
sometimes years. Much of the organization needed is
very similar to that needed for earthquakes or rail
crashes. By stating that the casualties usually occur
within a short period of time, the door is left open
to include famine and epidemics should this seem
desirable.
Thus, despite the fact that the above definition of a
disaster is in some respects vague, it does emphasize
those features which are important in disaster
medicine.
CLASSIFICATION
The effect on the surrounding community:
A simple disaster is one in which the structure of the
community in which it occurs remains intact. A com-
pound disaster is one in which the whole structure of
the community is destroyed. In the case of a simple
disaster the integrity of the surrounding community
remains intact and the resources of the local and
regional rescue services can be easily mobilized to deal
with the occurrence. In a compound disaster roads are
impassable, hospitals may collapse, telephone cables
may be destroyed, the number of casualties is often
very large and the resources available locally and
regionally are inadequate, so that the involvement of
national and international organizations is called for
(Table Zr). A railway accident involving a passenger
train in Europe is an example of a simple disaster. An
Rutherford and de Boer: Definition and classification 11

Table I. Local and regional rescue organizations Table 11. National and international rescue organiz-
ations
Local: police
fire brigade National: Ministry of Health
ambulance services Ministry of Internal Affairs
hospitals Red Cross
doctors and nurses, independent or as Armed Forces
members of rescue teams the Media (radio, television, post- office,
industrial organizations, e.g. railways, air telephone).
and seaport authorities. In terna tional: Hopital sans frontiere
Regional. Ministry of Health (regional office) Medicins sans frontiere
Ministry of Food (regional office) Register of Engineers for Disaster Relief
social services Caritas lnternationale
technical services Action d’urgence internationale
doctors and nurses, independent or as Oxfam
members of rescue teams World Vision International
Save the Children Fund
Element Medical d’intervention rapide
(France)
Table !/I. Disasters classified according to origin
Swedish Standby Force
Corps Suisse pour I’aide en cas de
Man-Made Naturally-occurring catastophe a l’etranger
traffic earthquake Disaster Area Survey Teams (USA)
explosion flood League of Red Cross Societies
collapse hurricane United Nations Disaster Relief
fire volcanic eruption Organization
poisonous gas avalanche World Health Organization
panic meteoric collision
civil disturbance drought
& b moderate: IOO-1000 casualties alive or dead, or
nuclear accident famine 50-250 casualties requiring admission to hospital;
local wars - fugitives - epidemic c major: more than 1000 casualties alive or dead,
or more than 250 casualties requiring admission to
hospital.
earthquake in a densely populated region of North This classification by numbers is intended to be a
Africa is a compound disaster. tool for the academic study of disaster. It is not a cri-
terion to be applied in order to decide whether to use
The cause: disaster plans. At the stage when such decisions need
The main distinction is between naturally-occurring to be made, those numbers are not known. The three
and artificial (man-made) disasters. These may be divisions are arbitrary, but the minor disaster will only
further subdivided (Table ZZZ). be of interest and concern at local level, and in indi-
vidual hospitals. The moderate will often involve
The duration of development in the cause of regional organization. The major disaster is likely to
disaster: be of national and possibly international concern.
Most simple disasters occur instantaneously. Com- As defined above, a disaster occurs when there is
pound disasters, are usually characterized by a longer really a disproportion between casualties and facilities
initiation time, for example, famine, earthquakes with and it would seem incorrect to classify it merely on the
several shocks, typhoons and epidemics. Disasters are number of casualties. However, there is not yet any
therefore classified in the following way: simple way of quantifying facilities, and in practice if
a short-less than 1 hour; we are to identify some events as disasters and others
b relatively long-l-24 hours; as too small to be reckoned as such, then at this stage,
c long-more than 24 hours; classification by numbers of casualties is essential. The
casualties requiring admission to hospital form, from
a medical point of view, the most crucial group: the
The extent of the disaster area: dead and slightly injured, who do not require in
From a medical viewpoint the disaster area is that area patient treatment, are in this respect less important.
in which casualties have occurred. It is not necessarily
the area of damage to property. The radius may be any Pathology
distance but subdivisions are usually, radius less than This should be classified if possible according to the
1 kilometre, between 1 and 10 kilometres or more than following categories: those suffering from mechanical
10 kilometres. injuries, radiation injuries, emotional shock, or other
illness. Numbers should be given for those admitted to
The number of casualties: hospitals, those who did not need to be admitted and
An arbitrary division of the number of casualties is those who died. When it is not possible to supply a
made as follows: breakdown into casualties not admitted, admitted and
a minor: 25-100 casualties alive or dead, or lo-50 immediate deaths, every attempt should at least be
casualties requiring admission to hospital; made to give total figures.
12
In some countries an even more complete analysis
of pathology may sometimes be attempted; for
instance mechanical injuries, radiation injuries and ill-
nesses may be further subdivided. The analyses start
with the classification of the injuries of every patient,
and the results are then summated to give an overall
picture of the disaster.
In the case of mechanical injuries (including burns)
the injuries are classified firstly into the body regions
used for the Injury Severity Score (Baker et al., 1974),
and then within each area into the categories of the
International Classification for Disease. Injuries with
an Abbreviated Injury Score of 1 are ignored except
in cases where there is no injury more severe than
score 1. In this case a single score 1 injury is entered.
For each body area, the highest Abbreviated Injury
Score is calculated. Having calculated this score for
each patient (live or dead) it is then possible to calcu-
late the mean Injury Severity Score for the whole
disaster.
In the case of radiation injuries, the classification
should be attempted by the assessed exposure. This
might be divided into mild (1 Gy), moderate (l-5 Gy)
and severe (over 5 Gy).
In the case of illnesses, the specific illness should be
classified according to the International Classification
of Disease.
The time required by the rescue organiz-
ations
The period required for the initiation of primary treat-
ment, organization of transport facilities and evacu-
ation of the injured can be divided into the following
categories:
a-less than 6 hours;
b-24 hours;
c-more than 24 hours.
In the case of a simple disaster, the primary treat-
ment time will generally be that time required to clear
the disaster site of casualties. To this may be added the
evacuation time, which is the time required to move
casualties from the site to the surrounding hospitals.
A disaster occurring at sea or underground has its own
special problems in this respect and evacuation may
be subject to considerable delay. Even in the case of
a simple disaster occurring in a rural area, rescue oper-
ations may be hampered considerably by weather con-
ditions or natural hazards.
Requesfs for reprints should be addressed to: W. H. Rutherford, Accident and Emergency Department, Royal Victoria Hospital, Belfast.
Injury: the British Journal of Accident Surgery Vol. 1 s/No. 1
In the case of a compound disaster the primary
treatment time will be that time required for the insti-
tution of the most urgent first aid at the site, followed
by full medical treatment, possibly in a field hospital.
The time required for the establishment of such a field
hospital is difficult to assess. The three categories are
arbitrary and may require revision in the light of
experience.
CONCLUSION
The recommendations of the above-mentioned
working-party (Rutherford, 1980) will be forewarded
for consideration via the WHO, UNDRO, ICDO and
the Red Cross and to the countries affiliated with these
organizations. The publication of exact figures exposes
co-operating countries to the possibility of criticism.
For this reason there may be some initial resistance on
the part of certain countries to joining such a registry
scheme. However, this reservation will have to be
overcome if adequate and efficient rescue organization
and exact disaster registration are to be established. In
the event of general international agreement on the
definition and classification of disasters, it should be
possible to assess more accurately not only the gravity
of a given situation but also the rescue requirements
appropriate to that particular disaster.
Registration with exact rules would also allow com-
parison of disasters and perhaps also provide an
answer to the question of whether the incidence of
disasters is increasing with the growing world popu-
lation and technological advance.
Finally, this approach should provide a firm founda-
tion for the science of disaster medicine, on which
basis further development can be confidently expected.
REFERENCES
Baker S. P., O’Niel B. and Haddon W. et al (1974) The
Injury Severity Score, J. of Trauma, 14, 187.
de BoerJ. and BailleTh. W. (eds)(1980)Dimasters: Medical
Organization, Oxford, Pergamon Press.
Report of the International Working Party on Disaster
Medicine (1980)(Chairman: W. H. Rutherford). London
International Trauma Foundation.
Rutherford W. H. (1980) In: MacMahan and Jooste, (eds),
Definition and ClussiJicution of Disaster in Disaster
Medicine, Cape Town, Balhame.
Paper accepted 16 December 1982.