Disaster Medical Services

Tintinalli Ch. 6
Ken Goodell, PGY2
 Definition of disaster
 Sudden ecologic phenomenon of sufficient
magnitude to require external assistance.
 Number of patients presenting in a given time
are such that ED cannot give even minimal care
without external assistance.
 “mass casualty incidents”
 Massive disruptive impact (small pox, anthrax)
 External and/or Internal disasters
 Difficulties in Disaster Medicine
Hospital shortcomings include …
Delayed or improper notification
Poor delineation of command structure
Overloaded/ broken communications network
Improper or incomplete identification
Lack of supplies
Lack of public relations
 Difficulties in Disaster Medicine
Factors hindering ED disaster mgmt …
Poor communications with scene and within
facility
Incidence Command System not followed
Convergence of rescuers, EMTs, and media
Convergence of doctors/ nurses with
inadequate experience with MCI/ roles
Convergence of family and friends
 Difficulties in Disaster Medicine
 Walking wounded arrive
at hospital before the
most injured.
 Within 90 min, 50-80%
of acute patients will
likely arrive at closest
medical facilities.
 Severity Predictor for Mass Casualty Events
1/3 Critical Black (dead/Expectant)
casualties Red (Immediate)
Yellow (delayed-admitted)
All acute 2/3 Non-critical Yellow (delayed-released)
casualty casualties Green (Minimal)
victims

*The following factors can change the pattern of casualties:

 Use of manufactured weapons (i.e., military ordinance)
 Explosion in a confined space
 Collapse of buildings or other structures
 Federal Response Resources
DHHS (dept health human services)
 OEP (office emergency preparedness)
 MMRS (metropolitan med response team)
Local responders - WMDs, bioterrorism
 NDMS (national disaster medical system)
Large scale natural disasters/ bioterrorism
DMATs (disaster medical assistance teams)
 Local response to federally declared disasters
 CCRF (commissioned corps readiness force)
 DMORTs (disaster mortuary operations …)
 Federal Response Resources
DHHS cont.
CDC
Rapid response teams
Laboratory response network
Rapid response and adv tech lab
National electronic disease surveillance system
Health alert network
National pharmaceutical stockpile
 Hospital Emergency Incident
Command System (HEICS)
Common language
Defined/ predictable chain of management
Flexible response
Prioritized response
Accountability of position function
Documentation guidelines for
accountability and cost recovery
 HEICS describes …
 Activation of plan
 Assessment of hospital’s capacity
 Establishment of a disaster control center
 Communications
 Supplies
 Hospital disaster administrative and treatment
areas
 Training and drills
 Security and crowd control
 Role of Disaster Control Center
Disaster Operations
Disaster site
Incident Command
(fire, EMS, police)
Center
(remote from ED)
Triage area
(patient-
recieving)

Patient care area

Outside assistance
(ED)
(other hospitals,
federal response)
 Disaster Operations
“In the field”
START (simple triage rapid treatment)
First level of triage
Transportation capacity overwhelmed
Advanced field med/surg treatment
Local hospitals overwhelmed
SAVE: 2º assessment of victim endpoint
Prolonged delay in accessing definitive care
Distribution of casualties to receiving hosp
Hospital Disaster Adm & Rx Areas
 Disaster control center
 Triage
 Patient care stations
 Major trauma and medicine
 Minor trauma and medicine
 Presurgical holding
 Surgery
 Morgue
 Decontamination
 Psychiatry
 Family waiting/ discharge area
 Initial ED response
Call to ED from disaster site …
 Disaster notification form
 Appropriate hospital administrator notified
 (now disaster control) puts plan in effect
 Additional ED staff notified
 Notify other departments (ICU, surgery, etc)
 Initial needs assessment by charge nurse/ Dr
 ED physician - on site incident commander
 Communicate c prehosp disaster com center
 Triage
 “Prioritization of patient care based on
severity injury, prognosis, and resources.”
 Triage officer
 ED physician or qualified nurse
 Performs second triage upon patient arrival
 Easily identified
1. Assigns Pts to appropriate treatment areas
2. Institutes most basic life-support measures
– Manually opening airway, control hemorrhage
 Triage Categories
Red
 Life-threatening shock, hypoxia
 Can be stabilized and survive with immediate care
Yellow
 Injuries have systemic effects, not yet life-threatening
 45-60 min wait before immediate risk
Green
 Local injuries w/o systemic effects (walking wounded)
Black
 Dead/ expectant; no spontaneous respir’n or circul’n
 Triage Categories
Red
Resuscitaiton areas, “crash rooms”

Yellow
Major trauma-medical area

Green
Minor trauma-medical area
Black
Morgue
 Patient Care in ED
Wounds
flush copiously; delayed 1º closure; Td
Consider delayed injury
Crush syndrome: arrhythmia, K, RF
Fulminant pulmonary edema/ pneumonia
Delay x-rays 24-48h (nonangulated, stable)
Consider XR alternatives (FAST)
Order labs sparingly
 References
Tintinalli Ch. 6
http://www.bt.cdc.gov/masscasualties/
preparedness.asp