Disaster Management

Barriers to Effective Disaster Response

In any MCI, a small group of critically injured patients (typically, 5% to 25% of the live casualties) will be contained within the larger crowd of less severe casualties. This was well demonstrated in the 1995 Oklahoma City bombing, where of 388 victims who went to local hospitals, only 72 (18.6%) required admission and only 7 (2%) required intubation. The core mission of a hospital disaster response system is to identify these critical casualties and to provide the requisite level of trauma care that may be acceptable under the circumstances. Failure in this task may result in the misappropriation of valuable resources away from those casualties most in need. Although this task is quite manageable in daily trauma occurrences such as after motor vehicle crashes, mass-casualty events add considerable complexity to attaining this goal. A key barrier is any obstacle that threatens this core mission. This includes a lack of warning, inaccessible resources, triage errors, or even a lack of disaster training. Disaster response plans must anticipate and attempt to remove these obstacles in advance to achieve success.

A rapidly evolving event may pose a key barrier. Disasters, especially the increasingly prevalent intentional attacks, may provide no warning and little lead time for hospital preparedness. Two corporate bombings in Turkey in 2003 produced 184 casualties for evaluation by a single medical center within the first hour after the incident. An initial surge of patients may also place hospital facilities and personnel at risk for exposure to undetected nuclear, biologic, or chemical toxins. After the sarin gas attacks on the Tokyo subway system in March 1995, hospital workers became victims, falling ill before the toxin was even suspected. This resulted in contaminated hospitals and fewer caregivers available to provide treatment. Even with a well-rehearsed disaster plan, it takes time to organize a facility into an appropriate disaster response mode and to clear physical space for victim management. Once the patient load outpaces the allotment of resources, an exponentially longer amount of time is necessary to restore the balance. Communication is critical in early alerts to allow hospitals the necessary time to decompress their emergency departments and prepare for the influx.

The timing of disasters can also present significant yet variable barriers. For instance, a daytime mass-casualty situation may flood hospitals with victims while resources such as operating rooms are in use and therefore are not available for immediate reallocation. Meanwhile, a nighttime MCI may be met by an understaffed response capability until additional assets are made available.

Communication is another consistent source of difficulty during disasters. Whether this equates to cellular phones ceasing to function or emergency lines being inundated with calls, backup plans and system redundancy for communication are critical. This may include dedicated land telephone lines, computer-based systems, or satellite connections. If communication both within and between the response teams (prehospital responders, hospital providers, incident command leaders) fails, then the entire response effort suffers severely. Effective communication also encompasses the relaying of accurate information and proper instruction to the general population through the media. This can reduce panic and gridlocking. Poor interoperability and compatibility of communication platforms between response systems and agencies must always be considered as a potential barrier and reconciled in advance.

Another barrier to providing disaster care is human error. Beginning at the scene, less experienced first responders may tend to overtriage, in which case hospital systems will be overburdened with the less severely injured. With larger MCIs, undertriage may occur because the injury numbers are so vast. Once at the hospital, the initial wave of casualties will be treated while there may still be limited knowledge about the true nature and scope of the surrounding event. This will cause early errors in resource allocation. Disaster training exercises may help minimize these mistakes because these issues should be identified if the exercise is properly performed and a comprehensive AAR completed. In addition, casualties often change triage categories throughout the course of the event. For this reason, each casualty must be retriaged at each level, or echelon, of care.

The overall lack of disaster preparedness by healthcare professionals poses a formidable barrier. In any community, most physicians are not involved in disaster training and planning, which will hinder an effective disaster response. This is evidenced by several physician surveys. Seventy-two percent (118/166) of nonurban physicians in Texas reported no CBRNE training. This mirrored a national survey in which only 21% of physician respondents felt prepared to treat bioterrorism victims. Among trauma surgeons, only 60% understood the Incident Command System for disasters, and less than 50% of respondents were prepared to manage an exposure to nerve or biologic agents. The Advanced Trauma Life Support (ATLS) manual dedicates only half of a page to the basics of blast-injury management. In addition to being unable to provide exposure-specific treatments, untrained physicians can impede disaster responses by adding to the number of unnecessary people around intake areas without assigned duties or knowledge of mass-casualty triage. Now more than ever, it seems appropriate for all members of the healthcare community to become versed in the language and principles of disaster management.

Additional barriers to effective disaster response exist and are numerous. It is relatively easy for medical practitioners to respond on their own to offshore disaster situations. Spontaneous unaffiliated volunteers (SUVs) may have no food or water supplies and no housing or security arrangements. Although well intentioned, they may have no training on how to properly function in a disaster situation. Vetting these individuals on-site with respect to licensing and credentialing cannot be easily carried out, and separating the “medical tourist” from the legitimate practitioner can be extremely challenging. Many will not have proper immunizations and have not considered the consequences of sickness or injury while doing this work. Their malpractice, disability, medical, and life insurance policies may not provide coverage. In general, it is best for medical practitioners who are interested in doing this type of activity to work through one of the many legitimate, nongovernmental organizations (NGOs), which will provide reasonable umbrella coverage for training and security to avoid becoming another victim of the disaster.

The US military may become involved in a response because of its ability to provide transportation, logistics, supplies, and security. The military's position with respect to civilian volunteers is that response needs should be met by active-duty personnel, Department of Defense (DoD) civilian employees, and contractors. However, there is a specific federal statute that permits the DoD to accept voluntary medical services (10 US Code 1588). Under the statute, a medical volunteer must be “licensed, privileged and have appropriate credentials” in the same manner as comparable DoD active-duty, civil servant, or contract providers. Medical volunteers are considered “government employees” for the Federal Tort Claims Act. A medical volunteer performing authorized duty cannot be held personally liable for any potential tort. The statute also recognizes volunteers as government employees for the purposes of the Federal Employees Compensation Act. These provisions provide compensation for injuries incurred while performing authorized voluntary services, including medical care and disability compensation. However, disability payments are usually based on federal pay. Overall, this legal framework seems unlikely to provide what most volunteer surgeons would expect as adequate disability compensation to replace a lost career. For civilian volunteers, privately purchased supplementary disability insurance coverage might be prudent. Does the DoD have a credentialing process for civilian volunteers? Within the military, all medical providers are entered into a common database called the Centralized Credentials and Quality Assurance System (CCQAS). The American Academy of Orthopaedic Surgeons (AAOS) and the Orthopaedic Trauma Association (OTA) have explored with its military liaisons whether a system could be developed whereby appropriately credentialed civilian volunteers might also be placed into the CCQAS system. Unfortunately, the vetting requirements for credentialing and maintaining the database were found to be overly complex and not sustainable. These efforts were abandoned. Ultimately, an electronic system whereby identity credentials similar to the military's Common Access Cards (CACs) might be issued by states and/or “trusted” organizations and should be interoperable with federal personal identity systems.

Within the United States, there is no medical licensing reciprocity between states and no truly integrated, nationwide database of practitioners who might be considered as critical assets in the event of a catastrophic national MCI. Under the Federal National Response Framework, public health and medical services are managed under Emergency Support Function #8 (ESF-8), which is formulated to render assistance to state and local disaster efforts. This is overseen by the office of the Assistant Secretary for Preparedness and Response (ASPR) of the Department of Health and Human Services (HHS). Within this system, there are two separate, government-supported entities that compete for diminishing funding pools to carry out relatively similar precredentialing activities: the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) and the Medical Reserve Corps (MRC). Both are state-based networks of medical and nonmedical volunteers committed to improving the health, safety, and resiliency of their communities. Unfortunately, there is no formal integration of the ESAR-VHP and MRC databases. There is no standardization of training, nor is there uniformity in credentialing processes.

The Emergency Medical Treatment and Active Labor Act (EMTALA), Health Insurance Portability and Accountability Act (HIPAA), Centers for Medicare & Medicaid Services (CMS), Children's Health Insurance Program (CHIP), and other federal laws provide important protections for patients during normal day-to-day operations but may impede the ability of healthcare facilities to keep up with disaster operations and patient care during an emergency with a large victim surge. Section 1135 of the Social Security Act permits the Secretary of Health and Human Services to waive or modify certain regulatory requirements for healthcare facilities in response to emergencies. By securing a temporary 1135 Waiver from HHS for certain activities, healthcare facilities can ensure the availability of services in the emergency area without fear of incurring sanctions or penalties. The period for which the waiver is active is time-limited.

Good Samaritan laws provide basic legal protection from liability if unintended consequences result from a medical professional providing assistance. Three basic principles are applied to Good Samaritan acts: (1) immediate danger exists to bypass the general need for consent before treatment, (2) care is rendered within generally accepted standards, and (3) care delivery is within the medical professional's area of general expertise. All 50 states and the District of Columbia have some type of Good Samaritan laws, but who is protected under these laws (physicians, emergency medical technicians, and other first responders) and how these laws are implemented exhibit tremendous state-to-state variability. A 2010 study reported that 8 states provide no immunity to private individuals not meeting certain criteria, and 24 states provide immunity for physicians rendering emergency care in a hospital. Six states exclude rendering emergency care in a hospital from Good Samaritan coverage, whereas two states require a duty to assist.

Other potential barriers to an effective response include diminished funding for disaster response and management educational programs. There is a persistent lack of effective communication interoperability between civilian sectors and federal/military providers. Government interagency connectivity also remains problematic. Unions present an unassessed potential obstacle to a fluid response. In the aftermath of Hurricane Sandy in 2012, many nursing and medical professionals fanned out to unaffected facilities. They encountered conflicts between union and nonunion hospitals and nursing homes regarding working conditions, privileging, and credentialing.

Disaster Response Organization: Incident Command System

The effective response to any disaster is predicated on the coordination of many individuals, teams, and organizations. This may require concerted efforts by local agencies and medical specialists or involve added dimensions of resources dedicated from geographically distant areas. To optimize outcomes and maximize communication and efficiency during disasters, the Incident Command System (ICS) was developed ( Fig. 13.1 ). It provides a modular, scalable, and adaptable organizational hierarchy to manage mass-casualty situations. This system of organization has proven to expedite responses in many settings even when a disaster is not being experienced. For hospitals, the responses to census control, unit openings, and other events requiring an organized approach have led to the Hospital Incident Command System (HICS) .

Since its inception in the 1970s, the ICS concept has become standard practice as an organizational approach to the management of temporary situations by safety professions. In 1981, the ICS provided the basis for the National Interagency ICS Management System (NIIMS), which is the structural backbone for emergency responses by US federal agencies. This design was declared to be the best-practice standard in 2004 by the Department of Homeland Security (DHS), and compliance with the ICS structure is required to receive federal disaster relief.

The ICS structure is built on five major managerial tasks: command, operations, planning, logistics, and finance/administration. These are considered central to managing all disasters, with the size and scope of the situation dictating the number of individuals assigned to complete these tasks. Heading the ICS effort is the Incident Commander (IC) . This individual is ultimately responsible for the entirety of the disaster response. As the ranking official, this person defines objectives, oversees all operations, and delegates responsibility. Up to seven officials will report to the IC.

The safety, public information, and liaison officers are the three officials who constitute the Command Staff and report directly to the IC. The safety officer is charged with ensuring that appropriate protection is provided to first responders. With intentional terrorist activity on the rise, this officer must weigh response efforts with the risk of NBC contamination and the chances of a second hit. The public information officer (PIO) is the reference for updated knowledge to the media and public but is also responsible for internal communications to keep staff informed as the event progresses. The liaison officer is tasked with coordinating the responses of the potentially numerous agencies and organizations involved and, most importantly, acts as the single point of contact for that command section. For HICS, an event-specific fourth position known as the Medical/Technical specialist can be added to the command section. After an H1N1 threat, it was observed that the professionals with expertise in epidemiology were not present at the command level. Such an appointment could aid the decisions of the IC during that type of event.

The General Staff oversee the remaining core aspects of the ICS, including operations, planning, logistics, and finance. These areas are referred to as Sections, and the head of each is titled a Section Chief. The assignment of individuals to these positions and the number of persons within each section depend on the nature and extent of the disaster encountered. In a small-scale event, the IC may personally oversee these additional activities. However, the modularity built into the ICS becomes important in larger disasters when individual section chiefs can be assigned with direct responsibility for teams at their disposal. These chiefs also report directly to the IC (see Fig. 13.1 ).

The Planning Section Chief works in coordination with the IC to develop the designated response. It is this individual's job to conceptualize an effective strategy to approach the given disaster. Most importantly this includes maintaining foresight to anticipate evolving needs and resource depletion. Meanwhile, the Logistics Section Chief must obtain those resources and assets sufficient to perform the planned response. This would include gaining human resources, equipment, and supplies to ensure a sustainable effort. The Operations Section Chief is responsible for the deployment of tactical resources into the field. This includes rescue efforts, securing treatment areas, and the delivery of aid. This section chief is therefore responsible for the actual delivery of care directly to the casualties involved. The Finance/Administrative Section Chief should record and analyze the monetary cost of the disaster and the ongoing response. Should a declaration of disaster be issued, this role will provide the necessary structure for Federal Emergency Management Agency (FEMA) reimbursements that may be very important to economic recovery.

Although the ICS is built on well-defined leadership roles as previously described, the overall function of the ICS depends on several general principles. The more rapidly the ICS is established, the quicker an effective response is mounted. To this end, the terminology, titles, and working procedures are standardized to function in any mass-casualty situation. Furthermore, although the specifics of each disaster may dictate the size of the ICS and the expertise of those in charge, the overlying structure of the ICS is constant. The flexibility of the ICS is in its modularity and scalability, which permit expansion and contraction of the incident command structure as needed. The key concept dictating this fluctuating size of the ICS is one of a manageable span of control. This equates to no one person supervising more than three to seven individuals in order to maintain the ability to effectively oversee activities of subordinates. An additional means by which the ICS can expand when confronted with a devastating event involving significant interagency efforts is to add a Unified Command (UC). The UC would be composed of ICs from the primary organizations involved and allows them to coordinate efforts from a central location termed the Emergency Operations Center (EOC). This UC attempts to restore efficiency in situations where jurisdictional or functional roles of agencies overlap. Finally, all individuals involved in the response must perform within this structure. Efforts to operate outside the ICS may lead to confusion and detract from the overall coordination of efforts and reduce the efficient utilization of resources.

The ICS structure has also been adapted to provide a mode of operations for hospitals facing disasters. The Hospital Incident Command System was originally presented in 1991. This system follows the ICS hierarchy, principles, and structure. Ideally, this same type of organization and distributed responsibility provides the hospital with an effective paradigm to provide organized care to casualties. The only alteration to the ICS structure in the hospital is to modify operation sections into appropriate divisions such as the medical/technical specialist and surgical, medical, intensive, and ambulatory care services. Again, the adaptable nature of this system allows for expansion of those areas most needed while preserving the universal titles and terminology to allow for easy communication with other facilities and with those involved with other phases of the disaster response, such as those transporting casualties to the care facilities.

Nuclear and Radiologic Events

Nuclear or radiologic material may be dispersed by detonation of a nuclear device, sabotage or meltdown of a nuclear reactor, explosion of a dirty bomb, or a nonexplosive release of radioactive material in a public place. In approaching ionizing radiation exposure, the critical variables are time, distance, and shielding. In these situations, irradiated casualties are not radioactive themselves. Therefore emergency trauma care may commence with life- and limb-threatening injuries being addressed without delay for radiologic decontamination. Eighty-five to ninety percent of external radiologic contamination is easily removed simply by removal of clothing. Skin forms a useful protective barrier, and any decontamination technique that could traumatize the skin should be avoided. However, if open wounds are contaminated, routine débridement and delayed closure is the rule. Radioactive debris should always be removed with instruments, and the surgery may be facilitated by the use of personal dosimeters. Once radiation exposure has been verified, the radionuclide involved, amount, and physical form must be determined. It is important to be able to assess patients for exposure through the use of radiologic detection devices. Without the ability to properly scan for contamination, there is no other alternative than to carry out full decontamination procedures as if patients were contaminated.

Time to onset of systemic symptoms is the most important factor in determining whether significant radiation exposure has taken place. Initial symptoms include nausea, vomiting, diarrhea, skin tingling, and central nervous system (CNS) signs. If there are injuries requiring surgery, the procedures are best performed in the initial 48 hours, before exposure-induced bone marrow suppression occurs. If victims remain asymptomatic for 24 hours and show no aberration in complete blood count (CBC), particularly the lymphocyte count, then the patient can be safely discharged.

Biologic Events

One of the greatest challenges of biologic terrorism is the timely identification of its use. As opposed to the overt nature of explosives, biologic weaponry can be deployed covertly without immediate effects to those exposed. Instead, identification may require syndromic surveillance using local/regional health data to identify an outbreak. With the help of the Centers for Disease Control and Prevention (CDC), state and local organizations can collaborate to minimize the time needed for the detection and identification of the pathogen. Rapid biologic event recognition is critical to prevent the secondary exposure of the population at large. Monitored system-level activities include school absenteeism, 911 calls, trends in sales of over-the-counter pharmaceuticals, and voluntary reporting by medical groups of apparent trends of illnesses.

The CDC has divided biologic threats into groups A, B, and C. The categories are based on the ease of disease transmission, the potential mortality and societal health impact, the potential for inducing panic and social disruption, and the need for a specialized health response. A sample of Category A pathogens with the highest potential for being weaponized are listed in Table 13.1 .

Chemical Events

The use of sarin gas in the Tokyo subway in 1995 demonstrated the potential impact of a chemical attack. The attack, which resulted in the exposure of a number of healthcare providers to the neurotoxin, reinforces the importance of hospitals taking aggressive measures to preserve and protect their healthcare facilities and resources. The most commonly used chemical agents have traditionally been pulmonary toxins, with popularity among terrorists because of their ready availability, ease of dispersal, significant clinical effects, and proven ability to disrupt and contaminate initial caregivers.

Chemical agents are categorized by their physiologic effects. The five general classes of chemical agents are nerve, blood, pulmonary, blistering (vesicants), and riot control agents. Table 13.2 summarizes the toxicity, mechanisms, clinical signs, and exposure management of common agents.

Blast Events

Bomb detonation is the rapid chemical transformation of a solid or liquid into a gas. The gas expands radially outward as a high-pressure blast wave that exceeds the speed of sound. Air is highly compressed on the leading edge of the blast wave, creating a shock front. The body of the wave and the associated mass outward movement of ambient air (the blast wind ) follow this front ( Fig. 13.3 ).

Under ideal conditions in an open area, the overpressure that results from an explosion generally follows a well-defined pressure–time curve (Friedlander wave ). There is an initial, near-instantaneous spike in the ambient air pressure followed by a longer period of subatmospheric pressure ( Fig. 13.4 ). The pressure–time curves are variable depending on the local topography and the presence of walls/solid objects. The blast wave can reflect off and flow around solid surfaces. These reflected waves can be magnified by eight to nine times, causing significantly greater injury. Blasts that occur within buildings, vehicles, or other confined spaces are more devastating and lethal because of this increased energy and slower dissipation of the complex and reflected waves. The distance from the explosion's epicenter also is important because the pressure wave decays roughly proportionally to the inverse cube of the distance.

The velocity, duration, and magnitude of the blast wave's overpressure are dependent on several factors. These include the physical size as well as the component explosive of the charge being detonated. High-energy (HE) explosives such as TNT and nitroglycerin are much more powerful than lower-order explosives such as gunpowder. However, lower-energy explosives can produce conflagrations with a higher thermal output that cause severe burns. HE explosives tend to cause only superficial flash burns on exposed skin ( Box 13.2 ).

Blast-wave propagation varies with the medium through which it moves. The increased density of water allows for faster propagation and a longer duration of positive pressure. Therefore immersion blast injuries are typically more severe. After in-water detonation, shock waves are also reflected backward off the water–air interface at the surface and admix with the incident blast wave. The resultant overpressures are greater at the 2-foot depth and cause greater injury to the lower areas of the lung and to the abdomen in the partially submerged victim who is treading water in the vertical position. A high index of suspicion should be maintained for delayed presentations of bowel injury in those injured by underwater blasts.