Disaster Preparedness

Background

• A disaster, as defined by the Federal Emergency Management Agency, is “a natural catastrophe, technological accident, or human-caused event that has resulted in severe property damage, deaths, and/or multiple injuries.”¹
• The eleventh edition of the Advanced Trauma Life Support course manual defines a mass casualty incident as one in which the needs of the casualties exceed the resources available. This contrasts with the mass casualty event, which stretches but does not exceed available resources.²
• In a disaster or mass-casualty incident, a surge in patient volume or a decrease in resources results in a shift in the care paradigm, from maximizing good for the individual to maximizing good for the greatest number.

• Anesthesiologists are uniquely trained to be assets in any disaster response, because of their airway and vascular access skills, ability to rapidly evaluate and treat critically ill, deteriorating patients, manage teams, and many other attributes (Figure 2).³

Triage

• Triage is the systematic process of categorizing patients into groups based on the urgency of their medical needs. To maximize benefit for the greatest number, appropriate triage is essential. Patients are categorized into minor, delayed, immediate, and dead/expectant categories, and each group is color-coded analogous to traffic lights (green, yellow, red, and black/grey, respectively).

• Triage occurs multiple times during the patient’s journey – in the field, in the emergency department, and then again when the patient’s disposition is determined. Patients must be reassessed at regular intervals to monitor changes in their medical condition. Triage categories may also change as more resources become available. An expectant could become immediate, and a yellow (delayed) could become red (immediate).
• The SALT (Sort, Assess, Life-saving interventions, Transport) triage system is commonly used in the field. If many patients require medical care, first responders should loudly announce, “All who can walk, come to me.” Next, they should ask those who cannot walk to wave. Finally, they should first assess those who remain still after these two commands, as they are likely to be the most seriously ill.

• The START (Simple Triage and Rapid Treatment) system of triage is commonly employed in the hospital environment (Figure 4).

• Triage must be quick and efficient. A patient should be triaged within 1 minute without requiring advanced equipment. At the Boston marathon bombing in 2013, 264 injured people were triaged and transferred in 45 minutes.⁴
• The following life-saving interventions may be performed during triage:
  • Opening and clearing the airway
  • Hemorrhage Control: application of tourniquets
  • Chest tube placement
  • Administration of antidotes and reversal agents
• Reverse triage is another important process in disasters and mass-casualty events. This involves discharging patients and, if safe to do so, downgrading their level of care to create space and resources for the patient surge. Reverse triage is the systematic discharge or downgrading of care for stable patients during disasters or mass casualty incidents. The goal is to free up hospital beds, staff, and resources for the sudden influx of critically ill or injured patients.

Pediatric Triage

• Normal vital signs for children differ from those for adults, and respiratory failure is the most common cause of cardiac arrest in children, in contrast to adults.
• The JumpSTART triage algorithm incorporates this difference (Figure 5).

Planning and Preparation

• Planning starts at home. Every anesthesiologist should have an individual plan for themselves, their family, and their pets, in the event of a disaster. A to-go bag with essential supplies for a 3-5-day hospital stay should be prepared; the vehicle should have a fuel tank with sufficient gas; and several routes to the hospital should be known in case some are inaccessible.⁵
• Every healthcare organization should have an emergency operations plan based on its individual hazard vulnerability analysis. This is a detailed study of the most likely disasters and their impact.⁶
• The ICS is an organizational structure for command, control, and coordination during disaster response. It enables agencies to coordinate their efforts to achieve the common goal of protecting life, stabilizing the incident, protecting property and the environment, and managing recovery. ICS can be utilized for all disasters and is modular, scalable, and flexible. ICS is the National Incident Management System-compliant organizational structure to manage disasters.⁷
• The hospital ICS (HICS) is a modification of the ICS (Figure 6).

• The organizational objective is to have each person report to only one person, and every person has no more than 5-7 persons reporting to them (Figure 7). If a task requires more than seven people reporting to a single person, then another modular team with a different team leader must be created.

Anesthesia Operations During a Disaster/Mass Casualty

• It is important to maintain patient flow during disasters and mass casualty incidents. Bottlenecks should be avoided and quickly resolved if they occur. The American Society for Anesthesiologists Committee on Trauma and Emergency Preparedness has created a checklist that can be helpful.³

The key elements of that checklist are mentioned below:

When a mass casualty incident is announced:

1. Refer to your facility’s operation manual
2. Open appropriate annex
3. Activate call-in tree. Assign an individual to activate. Use clerical personnel or automatic paging system, if available.
4. Assess status of operating rooms (ORs). Determine staffing of operating rooms for the next 0-2, 2-12 and 12-24 hrs. Hold elective cases.
5. Alert ORs. Finish ongoing cases as soon as possible and prepare to receive trauma.
6. Assign staff to set up for trauma/emergency cases.
7. Anesthesia coordinator should become OR medical director and work with OR nursing manager to facilitate communication and coordination of staff and facilities.
8. Report OR status to hospital command center (HCC).
9. Ensure adequate supplies. (SSS – Staff, Space and Supplies is a helpful acronym)
10. Contact PACU. Accelerate transfer to floors, intensive care units (ICUs) and discharge as appropriate to create space for new patients.
11. Send an anesthesiologist to act as a liaison in the emergency department
12. Consider the establishment of “stat teams”. Combination of nursing, anesthesia, surgical, respiratory, and surgical technicians to different parts of the hospital to assist.
13. HAZMAT (hazardous material) /WMD (weapons of mass destruction) event: Review personal protective measures and need for decontamination and isolation. Good resources include CHEMM and REMM websites (https://chemm.hhs.gov/ and https://remm.hhs.gov/)
14. Verify blood availability with blood bank
15. Co-ordinate with other patient care areas such as ICUs, obstetrics, pediatrics, floors etc

• In addition, surgeons should be reminded to perform damage-control surgery.
• Blood banks will sometimes issue universal products for all to reduce the risk of incompatible transfusions.
• In a global survey study of 22 physicians who participated in 20 mass casualty incidents in 17 cities between 2004 and 20199, the following themes were identified:
  • Many patients arrived in private vehicles, bypassing field triage. About 20% of arriving casualties required immediate medical attention.
  • Tracking patients was difficult. The electronic record failed to keep up. Paper records were more useful. Information was written on scraps of paper and placed on the stretcher or even taped to the patient. A medical person assigned to accompany each patient through the initial phase of care till stabilization, to provide continuity of care and appropriate information transfer, was helpful.
  • Communication was suboptimal between the field and hospital and within the hospital. Cellular networks crashed.
  • Multiple specialties operating on a patient without prioritization.
  • Limited training to manage pediatric patients and military-style blast injuries in civilian populations.
  • Pediatric hospitals had to manage adult patients
  • Lack of adequate training and resistance to releasing staff for training sessions

Standards of Care During a Disaster

• The goal of planning for disaster is to prevent crisis conditions by coordinating resources at the local, state, and national levels. The levels of care are as follows:
  • Conventional: Available resources enable care to be consistent with the institution’s daily routine practices.
  • Contingency: Resources allow care provided to be functionally equivalent to conventional care
  • Crisis: Despite stretching available resources and making all attempts to secure more staff, space, and supplies, the care provided is not consistent with typical standards.
• Crises may exist within a facility without an official State declaration. It is imperative to stretch resources to the maximum and harness them at the local, state, and federal levels, rather than deny care to a patient to provide care for another. When crisis standards of care are being followed, it is important to observe a few core principles:
  • Equitable care: treat each patient the same, regardless of race, socioeconomic status, gender, ethnicity, religion, age, and other characteristics.
  • Duty: Provide the best possible care to each patient with available resources.
  • Steward Resources: Use available resources wisely to do the greatest good for the greatest number
  • Consistency: Across the facility and region
  • Proportionality: Restrict care to the minimum necessary. Do everything possible to provide conventional care.
  • Transparency: Have a shared, documented process
  • Accountability: Consult experts¹⁰

Recovery and Second Victim

• Recovery can take a long time, sometimes several years. The psychological impact on the medical practitioners cannot be underestimated.
• In the global study referenced above, some participants experienced an initial positive emotion upon completing a good job. However, a general underappreciation of the incident’s psychological impact was noted. The treating psychologists felt they were inadequately trained to provide psychological care for these circumstances.⁹