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Chapter 62 Critical Care of Disaster Victims
Chapter 62 Critical Care of Disaster Victims
Chapter 62 Critical Care of Disaster Victims
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Critical Care
Chapter 62: Critical Care of Disaster Victims
Carla VenegasBorsellino; Sharon Leung; Vladimir Kvetan
KEY POINTS
KEY POINTS
1. Major natural and manmade disasters have always occurred, but their increasing frequency over the past decade has elevated awareness of the
importance of planning and preparing for catastrophic events.
2. The responses of different healthcare systems to major disasters in the past have demonstrated the continued need for a more clearly identified
planning process in order to effectively respond to multihazard events.
3. The CCM physician should be prepared to provide triage, stabilization, clinical management, teamwork leadership and managing of hospital
resources.
4. The goal in mass casualty scenarios is to minimize mortality and morbidity, but an effective response during a disaster situation depends on
multiple variables: nature of the incident, number of victims, resources, and the coordination of efforts, among others.
5. Understanding the characteristics of different disasters and predicting their impact on the healthcare system, integrating the principles of the
command center, and participating in the local disaster planning process will improve the appropriate response by the critical care physician to
disaster situations.
6. Educational efforts are crucial before and after a disaster. Simulation sessions and mock outbreak/disaster exercises must be instituted on a
regular base to understand our current level of preparedness, teach personnel how to respond appropriately to these unique situations, predict
and be prepared for unexpected events.
INTRODUCTION
Major natural and manmade disasters have always occurred, but their increasing frequency over the past decade has elevated awareness of the
importance of planning and preparing for catastrophic events. Over the past 2 decades, more than 3 million lives have been lost worldwide due to
major disasters. In 2008 alone, the total number of deaths caused by disasters with a natural and/or technologic trigger was a staggering 242,662.1 As
populations grow and occupy spaces that are vulnerable to different hazards, it is expected that disasters will increase in severity and impact. The New
York City Panel on Climate Change 2013 states in its executive summary that “Climate change poses significant risks to New York City’s communities
and infrastructure.”2 Analyses of the response of different healthcare systems to major disasters in the past have demonstrated the continued need
for a more clearly identified planning process in order to effectively respond to multihazard events.3
In general, the US Critical Care Medicine System receives massive resources in terms of gross national product expenditure when compared with other
developed countries, giving it the capacity to provide care to critically ill patients resulting from these disasters. But the question is whether the US
critical care system and the intensivists are ready to handle the challenges such events present.4 The expected percentage of critically injured can vary
depending on the nature of the event, but it is estimated to be approximately 16% of the overall number of survivors (range 2.5%34%).5,6 However,
published experience has shown that in mass casualty situations, the ICU is also commonly utilized as an overflow area for primary triage, as well as
initial and overflow postoperative management.7 Therefore, the CCM physician should be prepared to provide triage, stabilization, clinical
management, teamwork leadership and managing of hospital resources.
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Chapter 62: Critical Care of Disaster Victims, Carla VenegasBorsellino; Sharon Leung; Vladimir Kvetan Page 1 / 12
The responsibility of caring for the most serious salvageable casualties in natural and manmade disasters will ultimately involve the critical care
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physician.8 To provide an appropriate response the intensivist should be part of the institutional disasterplanning effort, understand what the
resources and capabilities are for the community, hospital, and its ICU on a continual basis, and be able to plan a modular expansion of the critical care
developed countries, giving it the capacity to provide care to critically ill patients resulting from these disasters. But the question is whether the US
critical care system and the intensivists are ready to handle the challenges such events present.4 The expected percentage of critically injured can vary
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depending on the nature of the event, but it is estimated to be approximately 16% of the overall number of survivors (range 2.5%34%).5,6 However,
published experience has shown that in mass casualty situations, the ICU is also commonly utilized as an overflow area for primary triage, as well as
initial and overflow postoperative management.7 Therefore, the CCM physician should be prepared to provide triage, stabilization, clinical
management, teamwork leadership and managing of hospital resources.
The responsibility of caring for the most serious salvageable casualties in natural and manmade disasters will ultimately involve the critical care
physician.8 To provide an appropriate response the intensivist should be part of the institutional disasterplanning effort, understand what the
resources and capabilities are for the community, hospital, and its ICU on a continual basis, and be able to plan a modular expansion of the critical care
services for any successful emergency response.9
The goal in mass casualty scenarios is to minimize mortality and morbidity, but an effective response during a disaster situation depends on multiple
variables: nature of the incident, number of victims, resources, the coordination of efforts, among others. So one of the most important concepts to
guarantee a successful management of disaster victims is understanding the layers of command and control related to which organizations that are
responding to any unique event and how to participate within the disaster incident command system.
Through this chapter we want to initially review basic concepts of the nature of the disaster and expected medical complications, and then review the
most recent recommendations for critical care providers about disaster medical management and preparedness for local mass casualty situations,
based on the 2 most recent publications offering illumination on this topic: the Critical Care Collaborative Initiative’s January 2007 Mass Critical Care
Summit10 and the 2007 US Department of Homeland Security National Preparedness Guidelines.11 The former contains 5 articles which include an
executive summary10 and individual papers on current capabilities,12 a framework to optimize surge capacity,3 medical resource guidance,13 and
recommendations for allocating scarce critical care resources in a mass critical care setting.14 The latter highlights 15 national disaster scenarios, 12 of
which have the potential to produce large numbers of critically injured or ill patients.
IMPORTANT DEFINITIONS
Disaster—Currently there is no uniformly accepted definition for the word disaster as it implies individual and local perspective. From a healthcare
standpoint, the most important variable that defines a disaster is its functional impact on the healthcare facility.15
Hazard—An event with the potential to cause catastrophic damage. It may be a “naturally” or “manmade” occurring phenomena.
Emergency—A natural or manmade event that significantly disrupts the environment of patient care resulting in disrupted care and treatment.
Casualty—Any person suffering physical and/or psychologic damage by outside violence leading to death, injuries, or material losses.
Multicasualty incident—A hazardous event that regardless of its size is containable by local emergency medical services.
Mass casualty incident: A hazardous event that overwhelms local response capability. It is likely to impose a sustained demand for health
services rather than a short, intense peak typical of many smallerscale events.
NATURE OF THE DISASTER
The nature of the disaster is widely variable and can include a terrorist attack, infectious pandemic, mass transit accidents, or natural disaster and all
of them can exhaust regional or national critical care systems. As highlighted by the 2007 US Homeland Security Task Force,11 the scenarios which can
generate massive amounts of critically ill victims are broadly divided into 3 general categories: terrorist attacks, epidemic disease, and natural disaster.
Natural disasters arise from forces of nature and include earthquakes, volcanic eruptions, hurricanes, floods, fire, and tornadoes.
Infectious disasters can be classified as epidemic or pandemic.
Manmade disasters are due to identifiable human causes and may be further classified as complex emergencies (eg, wars, terrorist attacks) and
technologic disasters (eg, industrial accidents, explosions from hazardous material).
Regardless of the type of classification used to categorize disasters, certain unique features are associated with each type of disaster. It is important to
understand the common effects of different natural and manmade disasters to predict their impact and plan effectively.15
Natural Disasters
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Chapter 62: Critical Care of Disaster Victims, Carla VenegasBorsellino; Sharon Leung; Vladimir Kvetan
Earthquakes
Page 2 / 12
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Earthquakes are common and even predictably frequent especially in many earthquake prone areas of the world and result in significant mortality.11
technologic disasters (eg, industrial accidents, explosions from hazardous material). Access Provided by:
Regardless of the type of classification used to categorize disasters, certain unique features are associated with each type of disaster. It is important to
understand the common effects of different natural and manmade disasters to predict their impact and plan effectively.15
Natural Disasters
Earthquakes
Earthquakes are common and even predictably frequent especially in many earthquake prone areas of the world and result in significant mortality.11
Availability of health care providers well trained in basic and advanced trauma and life support and the architectural design and build quality of the
stricken area’s housing and public facilities are 2 major determinants of outcomes for earthquake victims. Earthquakes also commonly result in
damage to health infrastructures and water systems and create disruptions to communication and transportation networks.11
Volcanic Eruptions
Different types of eruptive events occur, including pyroclastic explosions, hot ash releases, lava flows, gas emissions, and glowing avalanches (gas and
ash releases). Although lava flows tend not to result in high casualties, the “composite” type of volcano is associated with a more violent eruption
which is associated with air shock waves, rock projectiles (some with high thermal energy), release of noxious gases, pyroclastic flows, and mud flows
(lahars). The morbidity and mortality are related to respiratoryrelated syndromes and conjunctival and corneal injury, topical irritation of skin and
other mucosal surfaces.15
Hurricanes, Cyclones, and Typhoons
These are large rotating weather systems that form seasonally over tropical oceans. They are among the most destructive natural phenomena. Many
complications are the result of widespread flooding and most hurricanerelated deaths occur from storm surgerelated drowning. The most common
injuries include lacerations, blunt trauma, and puncture wounds. Late morbidity can be due to postdisaster cleanup accidents (eg, electrocution),
dehydration, wound infection, and outbreaks of communicable disease.11
Floods
There are 3 major types of floods: flash floods (caused by heavy rain and dam failures), coastal floods, and river floods. Together, they are the most
common type of disasters and account for at least half of all disasterrelated deaths. The primary causes of death are drowning, hypothermia and
injury due to floating debris. The impact on the health infrastructures and lifeline systems can be massive and may result in food shortages.
Interruption of basic public services (eg, sanitation, drinking water, electricity) may result in outbreaks of communicable disease. Another concern is
the increase in both vectorborne diseases and displacement of wildlife.15
Landslides
They are defined as downslope transport of soil and rock resulting from natural phenomena or manmade actions and are more widespread than any
other geologic event. Landslides cause high mortality but relatively few injuries. Trauma and suffocation by entrapment are common. Pending an
assessment needs can be anticipated, such as search and rescue, mass casualty management, and emergency shelter for the homeless.15
Other Natural Disasters
Tornadoes occur most commonly in the North American Midwest. They cause widespread destruction of community infrastructure. Injuries most
commonly seen are complex contaminated softtissue injury, fractures, head injury, and blunt trauma to the chest and abdomen.
Infectious Disasters
Pandemic Respiratory Infections
Pandemic H1N1 2009 was caused by a new strain of influenza A virus that within weeks spread worldwide through humantohuman transmission.
During the first month of the emergency, the CDC’s Strategic National Stockpile released 25% of the supplies in the stockpile for the treatment and
protection from influenza.6 At the third month the World Health Organization (WHO) declared the 2009 H1N1 influenza a global pandemic, generating
the first influenza pandemic of the 21st century. The initial data show that about 8% of H1N1 patients were hospitalized (23 per 100,000 population);
6.5% to 25% of these required being in the ICU (28.7 per million inhabitants) for a median of 7 to 12 days, with a peak bed occupancy of 6.3 to 10.6 per
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million inhabitants; 65% to 97% of ICU patients required mechanical ventilation, with median ventilator duration in survivors of 7 to 15 days; 5% to 22%
Chapter 62: Critical Care of Disaster Victims, Carla VenegasBorsellino; Sharon Leung; Vladimir Kvetan Page 3 / 12
required renal replacement therapy; and 28day ICU mortality was 14% to 40%.6
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Judicious planning and adoption of protocols for surge capacity and infrastructure considerations are necessary to optimize outcomes during a
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Pandemic H1N1 2009 was caused by a new strain of influenza A virus that within weeks spread worldwide through humantohuman transmission.
During the first month of the emergency, the CDC’s Strategic National Stockpile released 25% of the supplies in the stockpile for the treatment and
protection from influenza.6 At the third month the World Health Organization (WHO) declared the 2009 H1N1 influenza a global pandemic, generating
the first influenza pandemic of the 21st century. The initial data show that about 8% of H1N1 patients were hospitalized (23 per 100,000 population);
6.5% to 25% of these required being in the ICU (28.7 per million inhabitants) for a median of 7 to 12 days, with a peak bed occupancy of 6.3 to 10.6 per
million inhabitants; 65% to 97% of ICU patients required mechanical ventilation, with median ventilator duration in survivors of 7 to 15 days; 5% to 22%
required renal replacement therapy; and 28day ICU mortality was 14% to 40%.6
Judicious planning and adoption of protocols for surge capacity and infrastructure considerations are necessary to optimize outcomes during a
pandemic.16,17 Safe practices and respiratory equipment are needed to minimize aerosol generation when caring for patients with influenza. These
measures include handwashing, gloves and gowns, and the use of N95 mask.16,17
Manmade Disasters
Transportation Disasters
Transportation accidents can produce injuries and death similar to those seen in major natural disasters. Some of the largest civilian disasters in North
America have been related to transportation of hazardous materials, but more commonly they are related to motor vehicle accidents, railway
accidents, airplane crashes, and shipwrecks. They cause a wide range of injuries including multiple trauma, fractures, burns, chemical injuries,
hypothermia, dehydration, asphyxiation, and CO inhalation.15
Weapons of Mass Destruction
Weapons of mass destructions (WMDs) are those nuclear, biological, chemical, incendiary, or conventional explosive agents that pose a potential
threat to health, safety, food supply, property, or the environment. Since the terrorist attacks in September 2001 and subsequent intentional release of
anthrax spores in the United States, there is growing concern around the world about the possible threat of chemical, biological, or nuclear weapons
used against a civilian population. In response to a WMD incident, healthcare personnel should be prepared to manage casualties in an environment of
panic, fear, and paranoia.4 Because most attacks occur without warning, the local healthcare system will be the first and most critical interface for
detection, notification, rapid diagnosis, and treatment.11
Biological Weapons
Biological weapons can be either pathogens (diseasecausing organisms such as viruses or bacteria) or toxins (poisons of biological origin). Compared
with other WMDs, biological weapons are characterized by ease of accessibility and dissemination, difficulty in detection because of their slow onset of
action, and their ability to cause widespread panic through the fear of contagion.11,18 Based on these characteristics they require special action for
public health preparedness. In the event of a suspected bioterrorist attack, the CDC has issued protocols for early notification of local and state public
health department agencies.
Chemical Weapons
Chemical incidents are events that threaten to or do expose responders and members of the public to a chemical hazard. Agents commonly used as
chemical weapons are also used in industrial processes. These agents, however, pose serious problems for emergency care providers because of their
potential to cause a large number of casualties rapidly and their potential for secondary contamination. Any emergency medical or public health
response to a major incident involving a chemical warfare agent will require coordination among local, state, and federal organizations. First
responders should be aware of access to specialized local and federal response teams, basic triage and demarcation of the contaminated area, use of
handheld devices for agent detection and identification, use of personal protective equipment, and knowledge of appropriate medical treatment and
antidotes.11
Nuclear Weapons and Radiation Accidents
A variety of terrorist applications of radiation exist that could produce varying degrees of damage to public infrastructure and operations, human
casualties and illnesses, and most importantly, fear. Approximately 50% of the energy released from a nuclear bomb is due to the blast and shock
waves, giving a majority of the survivors blastrelated injuries as well as creating extensive infrastructure damage. About 35% of the energy released is
thermal radiation (in orders of tens of millions of degrees), giving rise to highdegree skin lesions. However, the most likely terrorist threat using
radiation is the so called “dirty bomb” in which some type of radioactive material is added to a conventional explosive bomb. Among experts in this
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field it is thought such a bomb would most likely involve the use of more easily accessible but less dangerous forms of radioactive material; thus the
Chapter 62: Critical Care of Disaster Victims, Carla VenegasBorsellino; Sharon Leung; Vladimir Kvetan
11
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likelihood of mass casualties with acute radiation poisoning at this point is not high.
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Hazardous Materials Disasters
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A variety of terrorist applications of radiation exist that could produce varying degrees of damage to public infrastructure and operations, human
casualties and illnesses, and most importantly, fear. Approximately 50% of the energy released from a nuclear bomb is due to the blast and shock
waves, giving a majority of the survivors blastrelated injuries as well as creating extensive infrastructure damage. About 35% of the energy released is
thermal radiation (in orders of tens of millions of degrees), giving rise to highdegree skin lesions. However, the most likely terrorist threat using
radiation is the so called “dirty bomb” in which some type of radioactive material is added to a conventional explosive bomb. Among experts in this
field it is thought such a bomb would most likely involve the use of more easily accessible but less dangerous forms of radioactive material; thus the
likelihood of mass casualties with acute radiation poisoning at this point is not high.11
Hazardous Materials Disasters
A hazardous material is a substance potentially toxic to the environment or living organisms. Fullscale disasters from hazardous materials disasters
(HazMat) are relatively rare, but isolated incidents are among the most common in the community and are not limited to chemicals but can include
various biological and radiologic materials as well. Knowledge of the types of industries present in the community would be helpful in developing a
potential plan to deal with likely HazMat situations. Injuries secondary to release of hazardous materials can present as chemical burns, inhalational
injury, and a variety of systemic injuries.11
Armed Conflict
Armed conflict continues to be the most preventable and destructive of manmade disasters. Specific healthcare issues during these conflicts include
trauma from blast injuries and projectiles, crushrelated injuries, communicable diseases due to the breakdown of public infrastructure, mass
displacement of populations, burns, and radiationrelated injury.15
PRINCIPLES IN DISASTER PLANNING
Disaster Plan Development
Most of the logistical problems faced in disaster situations are not caused by shortages of medical resources but rather from failure to effectively
coordinate their distribution. Planning requires the participation of leaders with clear responsibilities and corresponding skill to coordinate efforts
and develop policies to contain the disease; to coordinate resource allocation and manpower; to advise and share information regarding infection
control and treatment; to share data and research endeavors; to maintain staff morale; and to provide information to various levels of government,
health care institutions, frontline workers and the public.8
Existing Preparedness Requirements
In developing disaster plans, hospitals must take into account the national and local requirements imposed by governmental agencies like the Centers
for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC). The CMS’s conditions for emergency preparedness and services establish
minimum requirements for hospitals that participate in Medicare or Medicaid programs. Similarly, TJC standards apply to a full range of hospitals
from small rural to large urban academic centers and are focused on 4 main areas: (1) emergency preparedness management plan, (2) security
management plan, (3) hazardous materials and waste management plan, and (4) emergency preparedness drills.19
Hazard Vulnerability Analysis
Any disaster plan should start with a thorough analysis of potential hazardous events that can occur in or around the healthcare facility. TJC requires a
formal documented hazard vulnerability analysis that is integrated with the emergency management plan, setting priorities among potential
emergencies and also defining the hospital’s role in the local communitywide emergency plan.19
Incident Command System
The incident command system (ICS) is designed to provide the basic response in emergency management to avoid the lack of coordination among
various public and healthcare agencies and from the lack of operational integration of various medical specialties. The ICS specifies a common
terminology and a command structure with 5 functional sections:
Command—Unified command staff responsible for overall management of the incident. This includes a designated person who will have the
authority to declare an emergency. All personnel involved in the command system should be aware of the exact predetermined location of the
command center.
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Operations—Performs the actual response work under the directives of the command center.
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Planning—Gathers relevant information and develops response strategies as the situation progresses. The plan should provide protocols that
guide notification and the sequence of mobilization of the personnel in a disaster situation.
terminology and a command structure with 5 functional sections:
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Command—Unified command staff responsible for overall management of the incident. This includes a designated person who will have the
authority to declare an emergency. All personnel involved in the command system should be aware of the exact predetermined location of the
command center.
Operations—Performs the actual response work under the directives of the command center.
Planning—Gathers relevant information and develops response strategies as the situation progresses. The plan should provide protocols that
guide notification and the sequence of mobilization of the personnel in a disaster situation.
Logistics—Responsible for facilitywide supplies, equipment, personnel, and services. The command system must have independent telephone
lines to ensure uninterrupted communication with the external world in a disaster situation.
Finance—Authorizes expenditures, maintains records, and provides documentation of the incident.
Once initiated, the ICS has a builtin chain of command that would be responsible for triage of patients and allocation of personnel and resources.19
TRIAGE
Triage is a dynamic process that includes not only the disaster site or the emergency department but is carried through several levels of the medical
response pathway in disaster response. Triaging critically ill patients in the mass casualty situation is challenging, because the medical critical care is
provided not necessarily to the sickest patient, but the one who has the best opportunity for longterm survival. Although less applicable in disasters
with a gradual onset, patient triaging is extremely important in sudden events like explosions or natural disasters. Frykberg4 established a direct linear
relationship between overtriage (delivery of immediate care to disaster victims who are not critically ill or injured) and higher critical mortality rate.
Problems commonly encountered in the triage process include the following:
Lack of medical direction at the scene—During a mass casualty event, triage is approximately 70% accurate with a tendency to underestimate
injury severity.20 The most important strategy to prevent under or over triage includes the use of an experienced triage officer, usually a senior
physician/surgeon, with outstanding leadership and communications skills, who has a clear understanding of the medical resources at hand and
the ability to recognize and, if necessary, perform immediate lifesaving measures.
Lack of interorganizational planning—Dynamic management of the triage process requires constant assessment of medical resources and
communication between the command center, the scene, and the triage site. This will allow for rational and appropriate triage based on the
availability of resources.
Regarding triaging admissions to the ICU, the triage officer will review all patients for inclusion and exclusion criteria (recommended by sequential
organ failure assessment [SOFA] scoring system)21 and facilitate discharge from critical care for patients no longer requiring it. The triage officer will
evaluate daily all patients receiving critical care, and evaluate those requested to be considered for critical care as they arise.
Another challenging issue is how to provide critical care management during a prolonged period of time if resources can be limited. In these cases it is
important to provide essential rather than limitless critical care to allow many additional community members to have access to key lifesustaining
interventions during disasters. The concept of emergency mass critical care (EMCC) involves planning and provision of essential interventions to
maximize the number of individuals who receive sufficient critical care.3 Medical resource planning recommendations for EMCC can be divided into 3
categories: treatment materials, hospital personnel, and facilities; or stuff, staff, and space. Resources include mechanical ventilators, intravenous
fluids, vasopressors, antidotes, antimicrobial for specific diseases, sedatives and analgesics, specific therapeutics, and intervention materials (such as
those needed in renal replacement therapy and parenteral nutrition). The EMCC recommendations should be used only in overwhelming events,
meaning after calls for assistance from local, regional, state, interstate, and federal authorities have been exhausted.10 The Task Force recommends
that hospitals with ICUs should be prepared to provide EMCC for at least 3 times the usual number of critically ill patients and to maintain such care for
10 days without “sufficient external assistance.” The panel also offers a progressive list of changes in resource use for coping with shortages. It starts
with substitution and runs through adaptation, conservation, reuse, and finally reallocation, the last meaning taking a resource from 1 patient and
giving it to another with a better prognosis or greater need.14
While the initial triage during a disaster focuses on the patients, the disaster critical care triage focuses on the resources (tertiary triage). Decisions to
reallocate critical care resources among patients will require a high degree of transparency and regular reviews to ensure that established processes
are being followed.14 The SOFA score, though not validated, has been proposed to determine qualification for ICU admission during mass critical
care.21 Patients who are excluded from critical care should receive palliative care.22 It is mandatory that mass disaster preparation anticipates
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palliation for large numbers of individuals.10
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The EMCC, to date, is untested, and the real benefits of implementation remain uncertain. Nonetheless, EMCC currently remains the only
23
giving it to another with a better prognosis or greater need.14 Access Provided by:
While the initial triage during a disaster focuses on the patients, the disaster critical care triage focuses on the resources (tertiary triage). Decisions to
reallocate critical care resources among patients will require a high degree of transparency and regular reviews to ensure that established processes
are being followed.14 The SOFA score, though not validated, has been proposed to determine qualification for ICU admission during mass critical
care.21 Patients who are excluded from critical care should receive palliative care.22 It is mandatory that mass disaster preparation anticipates
palliation for large numbers of individuals.10
The EMCC, to date, is untested, and the real benefits of implementation remain uncertain. Nonetheless, EMCC currently remains the only
comprehensive construct for mass critical care preparedness and response.23
SURGE CAPACITY
Critical care service and supplies should be assessed and prepared for possible expansion during a major disaster.7,8 The plan should have a current
inventory of all supplies and capabilities of the facility: number of ventilators in use and its absolute capacity, inventory of various ICU supplies; and
vendor lists should be readily available if there is sudden demand for supplies. The disaster plan should allow for at least 2 days’ worth of supplies.
Available computerbase systems can help to predict surge capacity and design the disaster plan response.24
Disaster plans should also consider the possibility of internal and external power outages and related disruptions (such as communications), loss of
utilities such as power, water, or telephones due to floods, civil disturbances, accidents, or emergencies within the organization or in its community.10
Stuff (Medical Equipment and Supplies)
The recommendations focus on the surgecapacity on ventilators because there is little guidance in the medical literature and the anticipation is that
most patients who will require mechanical ventilation in a mass critical care event will probably require several days of ventilation.
Ventilators
All predictions are that the need for ventilators in a major pandemic will far exceed the supply.25 Currently there is an estimated total of 105,000
ventilators in the United States and the US national stockpile has about 4600 ventilators, making them likely insufficient to deal with a pandemic
influenza outbreak or lung injury following a widespread terrorist attack.26,27 Most hospitals cannot afford to stockpile ventilators, and in a
catastrophic disaster, transportation and communication disruption may limit the ability to draw from regional and national stockpiles. The guidance
includes suggestions on shortterm strategies to boost ventilator capacity, such as repurposing other types of ventilators (anesthesia machines,
noninvasive devices, and transport devices), and borrowing from other hospitals that are not having critical care shortages. In a surge setting,
ventilators should be able to operate without highpressure medical gas, be able to oxygenate and ventilate pediatric and adult patients with
significant airflow obstruction, accurately deliver the prescribed minute ventilation, and have a standard alarms system. Modifying a ventilator to be
used for multiple patients is no longer acceptable.10
Oxygen Tanks
Oxygen remains the critical consumable resource in disaster management28 and may run short in a disaster situation due to consumption by large
numbers of patients in respiratory failure, or due to damage of oxygen storage and delivery systems. Strategic management of oxygen supplies in
disaster scenarios remains a priority because in the case of a shortage, the Strategic National Stockpile will not supply oxygen, and delivery by
contracted vendors can be delayed. Medical oxygen sources include bulk and portable liquid systems, compressed gas cylinders, and oxygen
concentrators. Most hospitals have sufficient stores of bulk liquid oxygen to support patient needs for the short term. Potential areas of concern
include damage to reserve systems that are contiguous with the main system and ventilator models that require a highpressure gas supply and cannot
be supported by small oxygen concentrators.29
Medications
The Task Force recommends planning how to optimize availability of medications and safe administration thereof during a disaster response.
Planning should include rules for medication substitutions, safe dose or drug frequency reduction, conversion from parenteral administration to
oral/enteral when possible, medication restriction, and guidelines for medication shelflife extension.13
Staff
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The current shortage of critical care trained personnel is well documented30 and staffing issues may be further complicated if the crisis is prolonged or
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8
affects employees personally (also possible due to staff absenteeism). Staff resources may also be reduced by illness during an influenza epidemic or
bioterrorist attack, especially in the critical care setting where the personnel have direct contact with the airway secretions and there can be significant
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The Task Force recommends planning how to optimize availability of medications and safe administration thereof during a disaster response.
Planning should include rules for medication substitutions, safe dose or drug frequency reduction, conversion from parenteral administration to
oral/enteral when possible, medication restriction, and guidelines for medication shelflife extension.13
Staff
The current shortage of critical care trained personnel is well documented30 and staffing issues may be further complicated if the crisis is prolonged or
affects employees personally (also possible due to staff absenteeism).8 Staff resources may also be reduced by illness during an influenza epidemic or
bioterrorist attack, especially in the critical care setting where the personnel have direct contact with the airway secretions and there can be significant
pathogen aerosolization. Strategies for infection control include early identification and triage of atrisk populations, and ensuring adequate supply
and strict use of personal protective equipment. Hospitals should also fittest all staff with negative pressure respirators, such as the n95 mask.31 Other
concerning issues are the exposure to critical care staff at significant risk of sleep deprivation and exhaustion, the feeling of being isolated working in
difficult and demanding conditions, and the worrisome event of them falling ill (like during the Severe Acute Respiratory Syndrome by
coronavirus[SARS] SARS epidemic).31
A complete disaster management plan should include a regimented shift schedule that balances available staff and skills with current clinical abilities,
constant moral support for the team members, a frequent feedback system that allows the personal to get congratulations for their efforts, and the
possibility to start a cases group support with help from psychiatric or the emergency response crisis team; treatment for posttraumatic stress
disorder that cause longterm disability in the healthcare providers should also be considered.23
To extend their ability to provide direct critical care to large numbers of patients, the Task Force guidelines recommend that criticalcaretrained
physicians and nurses oversee noncritical care staff supported by guidelines of standardize interventions to reduce care variability.13 The Task Force
recommends that any nonintensivist physicians willing to serve in intensivist roles could be encouraged to join critical care teams. These physicians
could be assigned to care for up to 6 critically ill patients each with intensivists overseeing 4 to 8 of these nonintensivist clinicians (up to 48 patients),
depending on their experience. Noncritical care nurses and pharmacists could become responsible for medication delivery to all of the critical care
patients; paramedics could help maintain airways of critical care patients; respiratory therapists (RT) who specialize in critical care could oversee
groups of their noncritical care colleagues (1 critical care RT and 1 noncritical care RT to care for perhaps 1214 patients); and pharmacists could help
redistribute scarce pharmaceutical resources.13
Space
Hospitals can expand critical care to other areas, but shortages of equipment and staff can limit that option due to the fact that most critical care
interventions need specialized machines and equipment which only can be performed in locations with electricity and oxygen.23 Intensive care units,
postanesthesia care units, and emergency rooms are best outfitted to provide mechanical ventilation and close monitoring; stepdown units, large
procedure suites, telemetry units, and hospital wards may be used for EMCC when capacity in these spaces is exceeded.13 Facility planning for both
backup systems and expansion of services (ie, generator availability) is essential to maximize critical care capacity.
Also because care of noncritical patient requires less infrastructure, strong consideration should be given to the transfer of stable patients to “surge
facilities” to maximize dedicated hospital space for critical care delivery in an overflow situation. Finally, another resource is evacuating critical patients
to another facility when the hospital exceeds its capacity or is directly affected by the disaster to maximize survival in a mass casualty event6; but this is
not likely to be a good immediate option while the disaster is in the early stages of its evolution.
Point of Care
There is a constant concern about the delay in identification of complex pathologies which require medical testing and their significant associated
mortality and morbidity (eg, myocardial infarctions, acute kidney injury, and sepsis). So, new recommendations are focusing on pointofcare (POC)
testing32 that allows medical testing, early patient stabilization and transfer to a critical care setting for comprehensive critical care management.
Palliative Care
During a catastrophic mass casualty event, there is an important role for palliative care services in the support of individuals not expected to survive
and their relatives. These services should be included in the state and local disaster plan to minimize the suffering of the victims, and free up resources
to optimize survival of others. In a recent publication,22 the investigators provide guidance about the role of palliative care in a mass casualty event,
stating that even in the context of scarce resources during these events, support and training for healthcare personal deciding treatment for those
“likely to die” should be in place.
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OTHER CHALLENGES IN DISASTER PLANIING
Planning
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During a catastrophic mass casualty event, there is an important role for palliative care services in the support of individuals not expected to survive
and their relatives. These services should be included in the state and local disaster plan to minimize the suffering of the victims, and free up resources
to optimize survival of others. In a recent publication,22 the investigators provide guidance about the role of palliative care in a mass casualty event,
stating that even in the context of scarce resources during these events, support and training for healthcare personal deciding treatment for those
“likely to die” should be in place.
OTHER CHALLENGES IN DISASTER PLANIING
Planning
It has even been reported that less than 10% of casualties actually require hospital admission4,5; in large scale casualty event it is known that field
triage stations are often bypassed, causing hospital nearest to the disaster site to receive the bulk of the casualties. This makes it remarkably important
to conduct a careful survey of potential sites and types of hazardous events specific to the local area while designing a disaster plan, and include
transfer agreements between hospitals and nearby ICUs to meet possible bed shortages.8
Communication Devices
The failure of communications systems in major disasters due to excessive demand or possible disruption has been well documented.10 It is
considered the responsibility of local and regional health officers to identify medical disaster communication needs and establish primary and backup
systems linking response providers, health care facilities, and emergency operations centers. The Trust for America’s Health sponsored by the Robert
Woods Johnson Foundation, include streamlined and effective communication channels as 1 of the 8 core goals of a public health emergency
response to enhance rapid and accurate transfer of information between health care workers, frontline responders, and the public.33
Legal Issues
Resource triage is arguably the most problematic issue in disaster medicine because it inevitably raises the concern of health care rationing that will
potentially impact individual survival. The ethical, legal, and social ramifications of resource triage can be quite significant, compelling us to first to
make all efforts to obtain scarce resources, transfer patients, or increase surge capacity through EMCC before considering the “rationing” of
resources.14 To ensure appropriate legal and societal support, resource triage should be done in collaboration with regional and federal public health
authorities using objective, fair, and transparent criteria for provision of care.14
In contemplation of the ethical implications of resource triage, more work is needed to develop a system that is effective, rational, and amenable to
society. Several groups, including the Task Force have favored employing the SOFA score to stratify patients with respiratory failure and/or shock with
endorgan damage in terms of shortterm survival, because it relies on objective data that are relatively easy to obtain and has been validated in a
variety of critical illnesses10,21; yet, considering finite and potentially dwindling resources consideration must be given to excluding those patients with
overall poor prognosis caused by endorgan failure such as endstage liver disease, endstage heart failure, or endstage pulmonary disease.
Education and Simulation Training
Scheduling regular training and exercises in disaster management at different scales is important to enhance preparedness. Regular drills will help
identify difficulties and provide knowledge of the absolute capacity of devices, equipment, and services in a disaster situation.34 Plans to evacuate
critically ill patients to nearby hospitals in the event of failure of backup systems should also be addressed in the process. Even though there is no
perfect educational tool which exactly replicates a disaster, educational efforts in preparedness are still useful and necessary. Simulation training
provides opportunities for teaching, observing and analyzing performance in order to find ways to improve.
Training our staff and our future ICU trainees for such eventualities through the use of simulators and mock disaster codes has become necessary to
build on our successes and learn from to avoid the problems we encountered in the past. Educational tools include table exercises, standardize
patients, and robotic patient simulators among others. A recent study showed that all critical actions took longer to perform on simulator patients
compared to actor patients (standardize patient), and the time required to perform procedures on simulators were similar to published results on
realworld patients.34
Critical Care in Unconventional Situations
There have been numerous examples in medical literature describing extended critical care through mobile ICU teams, not necessarily restricted to
disaster settings. Some of the special factors to consider in the formation of ICU teams are: (1) choosing personnel that are flexible in terms of their
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availability, (2) having flexible staffing strategies to respond appropriately to each unique situation, (3) providing special training that allows innovative
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interventions adapted to local needs, and (4) assessing if the mobile ICU team can be implemented quickly enough. The preparation of mobile ICU
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teams should include review of the overall effort and adequacy of the ICU teams, outcome of victims, operational costs, and analysis of the structure
and process of the ICU in the field.35
realworld patients.34 Access Provided by:
Critical Care in Unconventional Situations
There have been numerous examples in medical literature describing extended critical care through mobile ICU teams, not necessarily restricted to
disaster settings. Some of the special factors to consider in the formation of ICU teams are: (1) choosing personnel that are flexible in terms of their
availability, (2) having flexible staffing strategies to respond appropriately to each unique situation, (3) providing special training that allows innovative
interventions adapted to local needs, and (4) assessing if the mobile ICU team can be implemented quickly enough. The preparation of mobile ICU
teams should include review of the overall effort and adequacy of the ICU teams, outcome of victims, operational costs, and analysis of the structure
and process of the ICU in the field.35
CONCLUSIONS
Critical care is an indispensable part of the medical disaster response not only because intensivists provide care for the sickest of the salvageable
patients but also because they can share their clinical expertise in triage, resuscitation, and complex medical care. Understanding the characteristics of
different disasters and predicting their impact on the healthcare system, integrating the principles of the command center, and participating in the
local disasterplanning process will improve the appropriate response by the critical care physician to disaster situations. Also appropriate
interventions for medical syndromes that require specific therapies are critical to minimizing morbidity and mortality during disaster events and their
aftermaths.
Educational efforts are crucial before and after a disaster. Simulation sessions and mock outbreak/disaster exercises must be instituted on a regular
base to understand our current level of preparedness, teach personnel how to respond appropriately to these unique situations, predict and be
prepared for unexpected events. Learning from the successes and failures of past local and global disasters is necessary to prepare our health system
for a successful emergency response which can mitigate the inevitable suffer that a mass causally event brings to the community.
General Disaster Resources and Websites
Centers for Disease Control and Prevention, Emergency Preparedness and Response. At http://www.bt.cdc.gov/disasters/
World Health Organization, natural disaster profiles. At http://www.who.int/hac/techguidance/ems/natprofiles/en/index.html
Federal Emergency Management Agency, disaster management. At http://www.fema.gov/hazard/types.shtm
Centers for Disease Control and Prevention, radiation emergencies. At http://www.bt.cdc.gov/radiation/clinicians.asp
Centers for Disease Control and Prevention website for bioterrorism. At http://www.bt.cdc.gov/
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