Austere Environment and Disaster Preparedness

Key Points

• Mass casualty events and the practice of anesthesia in austere environments are situations for which anesthesiologists should be prepared.

• Proper triage techniques can help prevent misallocation of resources and also can help alleviate psychic trauma on healthcare professionals.

• Anesthesiologists are willing to respond to disasters but desire further education and training in preparation for them.

• A mass casualty event resulting from communicable disease, whether from SARS, influenza, or another novel viral strain, will remain a threat indefinitely.

• Patients afflicted by chemical, biological, or radiological exposures may also present with concomitant traumatic injuries.

• Airway management in a challenging environment requires creativity from airway practitioners.

• Performing a surgical airway may be the best approach to airway management in an austere environment because of combat, positional constraints, or associated craniofacial trauma.

• Infrastructure resiliency and training and maintenance of skills that may not be practiced routinely are integral to disaster preparedness planning.

Introduction

We live in an unpredictable world and uncertain times. The threat of disaster, natural or man-made, causing a mass casualty scenario is forever looming underneath the surface of our otherwise casual routines. Although there are many definitions of the word disaster, the most commonly used medical definition of a disaster is an “event that results in a number of casualties that overwhelms the existing healthcare system.” Typically, disasters also degrade the fundamental infrastructure necessary for a viable economy and civil society. This disruption magnifies the impact of the event by widening the gap between needed and available resources.

In most parts of the world, natural disasters, such as floods, major storms, earthquakes, wildfires, tsunamis, and epidemics, occur at higher frequencies than man-made disasters, such as wars or technological events. Catastrophic events can be viewed by scale (local vs regional), proximity (happens locally vs somewhere else), time scale (discrete vs continuous), degree and type of infrastructure degradation (minimal vs total; physical destruction vs loss of personnel), and casualty spectrum ( Box 33.1 ).

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Epidemiology: Natural Versus Man-Made Disasters

Disasters are not uniformly distributed in time or geographic location. According to the Center for Research on the Epidemiology of Disasters (CRED), 396 disasters related to natural hazards were reported in 2019, and one-third of all disasters reported in the database are technological and related to industrialization. These disasters culminated in the deaths of tens of thousands of individuals, hundreds of millions of dollars’ worth of damage, and countless lives affected or displaced. ^, The greatest impacts are felt in the countries with the lowest levels of technological development.

As clinicians, we are increasingly likely to encounter mass casualty situations and/or deliver care in austere environments. For instance, climate change is likely to accelerate and increase the frequency of all types of disasters, with human consequences ranging from famine, to pandemic spread of disease, to acts of terrorism and war. As a result of increased ease of world travel, recent years have witnessed the rapid spread of infectious disease resulting in potentially fatal consequences on a large scale. Diseases, such as influenza, SARS coronavirus 2 (SARS-CoV-2), and the Ebola virus, continue to threaten populations and test the containment and treatment strategies of our healthcare infrastructure. We are living in a time when terrorism, mass shooting, natural disaster, and infectious disease are always on the horizon, threatening to overcome our present healthcare resources ( Fig. 33.1 ).

Triage Techniques

By definition, a mass casualty incident is one in which the number of injured individuals exceeds the available healthcare resources. In such a scenario, it is imperative to ensure that the patients in the direst need of attention receive help first. It naturally follows that the patients with clearly unsurvivable injuries are categorized to receive comfort measures but not necessarily life-saving resources. Therein lie the art and science of disaster triage. Simply put, triage is the act of sorting patients to maximize incremental survival and most efficiently use resources. Triage is also used as a clinical decision-making tool and to minimize moral and intellectual distress among care personnel. S ort- A ssess- L ifesaving interventions-Treatment/ T ransport (SALT) and S imple- T riage- A nd- R apid- T reatment (START) are two systems commonly used in the United States ( Figs. 33.2 and 33.3 ). Most triage techniques have their origins in military practice though there is very little, if any, scientific validation to any of these techniques. Essentially, triage is conducted with the purpose of doing the greatest good for the largest number of people. All techniques are going to have some error, such as over- or under-triaging of patients. In cases where patients are over-triaged, there may be misallocation of resources, where patients with relatively minor injuries may receive higher than necessary levels of care. ^, Under-triaging of patients may lead to potentially avoidable morbidity and mortality. Regardless of the technique used for triage, it should be performed by a person or team that has received appropriate training and practice. Triage may have to be repeated when circumstances, patients’ conditions, and resource availability changes.