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484
C.C. Toevs
can occur with the “limited resuscitation” menu of options.
Most importantly, a DNR order does not mean “Do Not
Treat.” DNR means that we do not try to restart a heart that
has stopped. We continue to treat the patient with appropriate
medical therapies and discuss options regarding further
treatments.
Futility
Futility is a term that all understand, but few can defi ne, thus
creating much of the confl ict and ethical issues in the
ICU. One defi nition of futility is treatments successful in less
than 10 % of the patients. Futility has also been dismissed as
a term, since many treatments are physiologically benefi cial,
even if those treatments do not change outcome or restore the
patient to health. An example would be dialysis in the dying
patient in the ICU; the patient will still die, but dialysis does
what it is designed to do, which is clean toxins and fl uid from
the body.
Healthcare professionals often consider many medical
treatments in the ICU as futile, which we tend to defi ne as
“inability to survive outside of the ICU.” The new term to
describe these patients is “the hospital-dependent patient.”
For some families, the fact their loved one is alive is suffi cient. The traditional “quality of life” argument often does
not work in discussion with many families. Discussions of
goals of care and ability for their loved one to participate in
activities that are important to them are often a more benefi cial conversation and may help families defi ne the limits
of treatment in the ICU. Another term that may be more
helpful than “futile” is “non-benefi cial treatment.” We need
to help the patient and family defi ne non-benefi cial in terms
of what the patient would consider benefi cial related to the
context of their lives; again, a goal of care discussion is
indicated. Several critical care organizations have composed a consensus statement regarding futility in the ICU,
and they recommend the term “potentially inappropriate”
rather than “futile.”
Most importantly, healthcare professionals are not obligated to provide nonmedically benefi cial treatment regardless
of patient and family demands. Examples of this would
include CPR in a patient with uncontrolled bleeding and an
inability to stop the bleeding, liver transplant in stage 4 cancer, and surgical feeding tubes in advanced dementia. The
Choosing Wisely campaign by the ABIM Foundation is
meant to offer guidelines in nonmedically benefi cial tests and
treatments ( www.choosingwisely.org ). Autonomy is a nega-
tive right, not a positive right. Patients have the right to refuse
medical treatments, even if it would save their life. Patients do
not have the right to demand non-benefi cial treatments.
Advance Directives/POLST
In an ideal world, everyone would write down his or her
wishes for treatment near the end of life. These wishes would
be clear, concise, and leave no scenario undefi ned, making
ethical dilemmas rare. Regrettably, few of us ever write down
our desires, and even less likely do we ever discuss them
with our families. The lack of planning for the end of our
lives has created a huge burden on families, healthcare providers, and the healthcare system. Despite an increased effort
to encourage people to fi ll out an advance directive (AD),
few do so. (Do you have one?).
One problem with AD is they tend to be vague. “If terminal or permanent unconsciousness” is often the clinical scenario included. In the ICU, very few patients are declared
“terminal” or “permanently unconscious.” Families and
healthcare providers are then tasked with trying to defi ne
what exactly the person wanted in this particular clinical
situation. Including families in the discussion in the creation
of the advance directive is critical to its implementation.
Physicians tend to preferentially honor family requests over
what is written on the patient’s AD, therefore making it crucial for the family to be involved in the advance directive
discussion. Several states are considering legislating advance
directives over surrogate decision making, potentially resolving some of this confl ict. However, given the generic nature
of AD, discussion regarding treatment options with family is
still necessary.
One potential solution to the AD is the use of physician
orders for life-sustaining therapy (POLST, www.polst.
org ). POLST has been adopted by many states and has sev-
eral variations on the name (MOLST, POST). The goal is
the same: to defi ne goals of care in patients with a terminal
condition. POLST is generally on a bright pink card stock,
designed to be immediately visible to EMS and healthcare
providers. POLST defi nes treatment in terms of full treatment, limited treatment, or comfort care as the goal.
POSLT also includes options for antibiotic use, DNR, artifi cial nutrition and hydration. These are actual healthcare
provider orders that cross the spectrum of healthcare settings, preventing multiple DNR discussions as the patient
is, for example, transferred to the hospital from the nursing
home or from home to the hospital. If the patient signs
POLST, it cannot be overruled or changed by the surrogate
decision maker. The patient can change their mind and
void the orders. If a member of the family signs the POLST
form, the signer can change the orders. There are legal protections for healthcare providers for honoring a
POLST. The major limitation of POLST is that the patient
must be terminal (usually stage 4 cancer, advanced dementia, end-stage COPD, or CHF).
42 Ethics and the ICU
485
Artifi cial Nutrition and Hydration
Nutrition and early use of enteral feedings has made a huge
difference in the outcomes of patients in the ICU. There are
few ethical issues regarding the use of enteral feeds in the
ICU. The controversy arises in the placement of surgical
feeding tubes (PEG or gastrostomy tube) in select patient
populations. As the population ages and dementia becomes
more common, many of these patients come to the ICU for
treatment of injuries from falls, sepsis, pneumonia, etc. Their
swallowing diffi culties become quickly apparent and often
trigger a series of events resulting in a speech therapy evaluation which documents the dysphagia, then a consult for
PEG tube placement. Often this medical pathway takes on a
life of its own and occurs without a discussion of goals of
care and whether artifi cial nutrition and hydration are benefi cial in these patients in changing survival. Both the American
Academy of Hospice and Palliative Medicine (AAHPM) and
the American Geriatrics Society (AGS) have position statements on ANH in advanced dementia. Generally, the recommendation is not to offer feeding tubes to these patients.
Since this pathway often begins in the ICU, we need to be
aware of the need to start discussions early with the
families.
Dialysis
Dialysis in the ICU can be lifesaving, especially in cases of
drug overdose or rhabdomyolysis. Dialysis can be less helpful in cases of multisystem organ failure or the very elderly.
As it is a technology that we have, we often have diffi culty
limiting offering it to patients. The nephrology literature has
begun to recommend that nephrologists be involved with the
goals of care discussions with patients and their families
prior to initiating dialysis. The literature also makes specifi c
recommendations for decision making and confl ict resolution in cases of dialysis.
One strong recommendation from the ethics literature and
palliative medicine literature is to consider time-limited trials. Although the best option may be not to initiate therapies
that may not be benefi cial and with the diffi culty of stopping
treatments, one consideration is to offer a time-limited trial.
Offering a therapy to a patient for a limited period of time
(usually 72 h) to see if improvement occurs is one way to
help the patient and the family as they wrestle with options
regarding care. Time-limited trails offer an opportunity to
see if the treatment is benefi cial without the commitment of
indefi nite continuation. When the trial is over and no
improvement is seen, the treatment stops automatically.
A time trial allows more time for ongoing discussions
regarding goals of care and a plan for withdrawal of therapy
that is often easier emotionally on the family and the healthcare team.
Organ Donation
The goal of organ transplantation to save lives is an admirable goal. The ICU is often involved in the care of potential
organ donors. As the technology increases to preserve organ
function until donation can occur, ethical issues seem to be
increasing rather than decreasing. One ethical issue regarding organ donation is driver’s license assent; checking the
box “yes” (or in some states “no” is not an option, only “skip
the question”) is considered fi rst person consent for organ
donation and by federal law overrides the family wishes if
they do not want to donate. The issue of “opt-out” vs. “opt in” is currently being debated in the literature, but more and
more states are going to an “opt-out” model, meaning the
default is the patient is an organ donor unless explicitly written somewhere, usually in an AD.
Another ethical issue regarding organ donation is organ
preservation protocols. Prior to the patient being considered
for organ donation, or being declared dead by neurological
criteria (brain death), a variety of procedures and treatments
are given not for the benefi t of the patient but for the preservation of the organs. These treatments can include resuscitative thoracotomies to restore circulation for organ retrieval in
the trauma bay, hormonal therapy to preserve organ function,
placement of lines, use of vasopressors, transfusions, and
several others. In some hospitals, these protocols are the
default for all patients who are potential organ donor candidates, potentially shifting the focus from caring for the
patient to caring for his organs.
In order to increase the donor pool for solid organ transplantation, death by neurological criteria (brain death) is not
the only option. Many hospitals are performing donation by
circulatory death (DCD), where the withdrawal of LST
occurs in the operating room and organ retrieval occurs once
the patient progresses to cardiac standstill. DCD continues to
be controversial in the ICU and the ethics literature.
Ethics Consultation, Palliative Medicine,
and Confl ict Resolution
Most hospitals have an ethics consultation service that often
involves a single provider obtaining the necessary information and the ethical issue at hand and speaking to the family,
healthcare team, and patient if possible. The ethical issues
will then be presented to an ethics committee that tends to be
486
C.C. Toevs
multidisciplinary (social worker, chaplain, physician, nurse,
administration, and others). They will discuss the case, discuss the ethical principles involved, and often write a
recommendation regarding what is ethically permissible in
this particular case. Focusing on what is ethically permissible rather than providing a direct solution to the ethical issue
can be frustrating for everyone involved hoping for an
answer. Standards regarding ethic consultations have been
developed, and it is recommended that the team leader have
a master’s degree in ethics.
Given the limitations of ethics consultation, many hospitals have asked the palliative medicine service to assist with
these ethical issues. Many of the ethical dilemmas in the ICU
arise from application of medical technologies that may not
be benefi cial for the patient. In a busy ICU, it can be very diffi cult to take the time necessary to explain all options to the
family and to put these technologies into perspective regarding the patient’s wishes. These discussions are often called
“goals of care” discussions. A palliative care team consisting
of a physician, nurse practitioner, social worker, chaplain, and
potentially other members can often help the families walk
through the process of this decision-making process. Some
have suggested that including palliative medicine as part of
the ICU multidisciplinary team may improve the outcomes
and experiences for patients and the families, as well as avoiding much of the confl ict that can occur in the ICU.
Since many hospitals and ICUs have not integrated palliative medicine into the ICU team, and we tend not to be proactive in preventing confl ict, a confl ict resolution team has been
suggested as the next step for dealing with the unresolved confl ict in the ICU. The primary goal of this mediation is to actually mediate the confl ict; they do not have a vested interest in
the outcome, just that an outcome suitable to all can be
reached. There are two methods of confl ict resolution: one in
which the mediator reads the chart, talks to the healthcare providers, and gathers information before meeting with all parties
involved. The second method involves the mediator coming to
the table with the interested parties (usually family and the
ICU team) and listens to the issues at the time. The mediator
can then choose to interact with individuals or small groups of
the people involved before helping all come to a consensus.
This process tends to be very labor intensive and time consuming, not only for the mediator but also for the ICU team. Given
the extensive time commitment required for confl ict mediation
to be successful, it is often not a technique that is utilized.
However, it can be a great resource for the ICU team and families when an impasse in the ICU is reached.
Conclusion
In an ideal world, the patient will have an advance direc-
tive, POLST orders if appropriate, a family who is in
complete agreement with the wishes of their loved one,
and a clearly communicating and realistic ICU team
regarding the benefi ts and limitations of the
ICU. Communication can solve many of these ethical
dilemmas, but we also have a responsibility to recognize
that increasing use and development of technology creates new challenges and can sometimes solve existing
ones. General recommendations for prevention of ethical
dilemmas in the ICU, which usually are confl ict with the
family, are early, and frequent communication, a consistent message from the ICU team, goals of care discussions, integration of palliative medicine in the ICU, and
confl ict resolution/mediation as needed.
Suggested Reading
1. American Society for Bioethics and Humanities. 2nd ed. Core competencies for healthcare ethics consultation. Chicago, IL; 2011.
2. Aslakson RA, Curtis JR, Nelson JE. The changing role of palliative
care in the ICU. Crit Care Med. 2014;42(11):2418–28.
3. Bergman EJ. Surmounting elusive barriers: the case for bioethics
mediation. J Clin Ethics. 2013;24(1):11–24.
4. Bishop JP, Brothers KB, Perry JE, Ahmad A. Reviving the conversation around CPR/DNR. Am J Bioeth. 2010;10(1):61–7.
5. Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton
CH, Curtis JR, Ford DW, Osborne M, Misak C, Au DH, Azoulay
E, Brody B, Fahy BG, Hall JB, Kesecioglu J, Kon AA, Lindell
KO, White DB. American thoracic society ad hoc committee on
futile and potentially inappropriate treatment. An official ATS/
AACN/ACCP/ESICM/SCCM policy statement: responding to
requests for potentially inappropriate treatments in intensive
care units. Am J Respir Crit Care Med. 2015;191(11):
1318–30.
6. Brett AS, McCullough LB. Addressing requests by patients for
nonbenefi cial interventions. JAMA. 2012;307(2):149–50.
7. Feudtner C, Morrison W. The darkening veil of “do everything”.
Arch Pediatr Adolesc Med. 2012;166(8):694–5.
8. Germain MJ, Davison SN, Moss AH. When enough is enough: the
nephrologist’s responsibility in ordering dialysis treatments. Am
J Kidney Dis. 2011;58(1):135–43.
9. Halevy A. Medical futility, patient autonomy, and professional
integrity: fi nding the appropriate balance. Health Matrix Cleve.
2008;18(2):261–90.
10. Nelson JE, Curtis JR, Mulkerin C, Campbell M, Lustbader DR,
Mosenthal AC, Puntillo K, Ray DE, Bassett R, Boss RD, Brasel KJ,
Frontera JA, Hays RM, Weissman DE. Improving palliative care in
the ICU (IPAL-ICU) project advisory board. Choosing and using
screening criteria for palliative care consultation in the ICU: a
report from the improving palliative care in the ICU (IPAL-ICU)
advisory board. Crit Care Med. 2013;41(10):2318–27.
11. Neuman MD, Allen S, Schwarze ML, Uy J. Using time-limited trials to improve surgical care for frail older adults. Ann Surg.
2015;261(4):639–41.
12. Reuben DB, Tinetti ME. The hospital-dependent patient. N Engl
J Med. 2014;370(8):694–7.
13. Venneman SS, Narnor-Harris P, Perish M, Hamilton M. “Allow
natural death” versus “do not resuscitate”: three words that can
change a life. J Med Ethics. 2008;34(1):2–6.
14. Zeiler K, Furberg E, Tufveson G, Welin S. The ethics of non-heartbeating donation: how new technology can change the ethical landscape. J Med Ethics. 2008;34(7):526–9.
Disaster Management and Preparedness
Susan Miller Briggs
4 3
Introduction
Mass casualty incidents (MCI) are events causing numbers of
casualties large enough to disrupt the healthcare services of
the affected region. This is in contrast to multiple casualty
events in which medical resources are strained (prehospital
and/or hospital resources) but not overwhelmed. Demand for
resources always exceeds the supply of available resources in
a mass casualty incident. Disaster surgical care is not the same
as conventional surgical care. The objective of conventional
surgical care is the “greatest good for the individual patient.”
The objective of disaster surgical care is the “greatest good for
the greatest number of victims” [
1 – 5 ].
Epidemiology of Disasters
Disasters may be natural or man-made or a combination of
the two. Natural disasters may be classifi ed as sudden-impact
(acute) disasters or chronic-onset (slow) disasters [ 6 ].
Sudden-impact disasters include:
• Earthquakes
• Tsunamis
• Tornados
• Floods
• Tropical cyclones, hurricanes, and typhoons
• Volcanic eruptions
Chronic-onset disasters include:
• Famine
• Drought
S. M. Briggs , MD, MPH
Department of Surgery , Harvard Medical School, International
Trauma and Disaster Institute, Massachusetts General Hospital ,
Boston , MA 02114 , USA
briggs.susan@mgh.harvard.edu
e-mail:
Sudden-impact natural disasters generally cause signifi cant morbidity and mortality immediately as a direct result
of the primary event (e.g., traumatic injuries, crush injuries,
or drowning) [ 7 ], whereas chronic-onset disasters cause
mortality and morbidity through prolonged secondary
effects (e.g., infectious disease outbreaks, dehydration, or
malnutrition).
Man-made disasters may be unintentional or intentional
(terrorism) [ 1 , 8 – 10 ]. The spectrum of agents used by ter-
rorists is limitless and includes conventional weapons,
explosives, and biological, chemical, and radioactive
agents (Fig. 43.1 ). In addition to the possibility of a large
number of victims, responders must be aware of the potential for secondary strikes directed at harming emergency
personnel. More than 70 % of terrorist attacks involve the
use of explosive weapons and are a signifi cant challenge
for surgeons due to the complexity of injuries (primary,
secondary, tertiary, and quaternary blast injuries) [ 1 , 7 –
11 ]. Terrorists do not have to kill people to achieve their
goals. They just have to create a climate of fear and panic
to overwhelm the healthcare system (e.g., sarin/anthrax
attacks).
Disasters involving weapons of mass destruction (biological, chemical, or radioactive agents), whether accidental or
man-made, are a signifi cant challenge for critical care providers for three reasons:
1. Weapons of mass destruction have the greatest potential
to produce numbers of casualties large enough to over-
whelm the medical infrastructures. Such agents will
also produce a category of victims known as “expect-
ant” victims, a particular challenge for critical care pro-
viders. This denotes a category of victims not expected
to survive due to the severity of injuries or underlying
diseases and/or limited resources. This term was fi rst
used in conjunction with chemical warfare. Appropriate
triage of “expectant” victims is a particular challenge
for critical care providers given limited ICU capacities
in most mass casualty incidents. Weapons of mass
© Springer International Publishing Switzerland 2016
N.D. Martin, L.J. Kaplan (eds.), Principles of Adult Surgical Critical Care, DOI 10.1007/978-3-319-33341-0_43
487
488
S.M. Briggs
Fig. 43.1 World Trade Center bombing (2001)
destruction produce signifi cant numbers of “psychogenic” casualties, greatly complicating medical providers’ rescue efforts. During the sarin attack in Tokyo
(1995), 5,000 casualties were referred to local hospitals. Fewer than 1,000 individuals were actually suffering from the effects of the gas.
2. Weapons of mass destruction will produce “contaminated” environments. Surgeons must be able to perform triage and initial stabilization, operative care,
and critical care outside traditional hospital facilities.
The necessity for decontamination prior to surgical
care interventions further complicates resuscitative
efforts.
Biological Agents
Biological terrorism is the intentional use of microorganisms or toxins to kill or injure humans. Exposure to biological agents may be accidental or intentional (terrorism)
[ 1 , 10 ].
transmission (pneumonic plague, smallpox, and viral hemorrhagic fevers) constitute the greatest hazards. The most effective and important protection against biological agents is
physical protection. Removal of clothing will eliminate greater
than 85 % of the agents. Any dermal exposure should be treated
immediately by gross decontamination with soap and water.
Prophylaxis and Therapy
Medical defenses against some biological agents are limited.
Vaccines are available to protect against some biological
agents (anthrax, smallpox), and antibiotics may be effective
against bacterial agents such as anthrax, plague, and tularemia if given early enough. Disasters involving biological
agents have a signifi cant impact on the healthcare system for
the following reasons:
• Terror in affected populations and medical care systems
• Overwhelming casualties and signifi cant ICU/special
medication needs
• Problems with handling dead victims
Routes of Exposure
The route of exposure of most concern with biological agents
is inhalation of the agent. Oral exposure to biological agents
may occur directly or secondarily after an aerosol attack.
Agents with the highest potential for person-to-person
Chemical Agents
Chemical agent release may be unintentional (industrial
accidents) or intentional (terrorism) [
ical agents, especially warfare agents, are liquids and must
1 , 10 , 12 ]. Many chem-
43 Disaster Management and Preparedness
489
be dispersed to be maximally effective. There are three general methods of dispersion:
• Aerosolizing with an aerial sprayer
• Aerosolizing the liquid with an explosion (improvised
explosive device (IED) + chlorine tanker)
• Allowing the liquid to evaporate (Tokyo sarin attacks)
Time is of the essence in the decontamination and treat-
ment of chemical agent casualties. Treatment areas should be
upwind and uphill from the contamination site. It is important that decontamination facilities be SEPARATE from the
emergency department.
Specifi c Chemical Agents
Nerve Agents
Nerve agents are toxic relatives of organophosphate insecticides. They cause effects by disrupting the normal mechanism by which nerves communicate with muscles, glands,
and other nerves. Nerve agents enter the body either percutaneously (through the skin) or by inhalation (through the
lungs). The most important nerve agents are GA (tabun), GB
(sarin), GD (soman), GF, and VX.
Treatment of nerve agents: [ 1 , 10 , 12 ].
• Atropine – Antidote for smooth muscles and exocrine
glands.
• Pralidoxime (2-PAM) – Antidote for skeletal muscle sites.
– Atropine-sparing effect.
– Timing of 2-PAM administration is critical. Binding of
nerve agents to cholinesterase can become irreversible
with time.
Valium (diazepam) is used as an anticonvulsant as needed.
The traditional Mark 1 Kit contains two spring-loaded injectors of atropine and 2-PAM. A new product, DuoDote, contains atropine + 2-PAM in a single auto-injector. Antidotes
may be given by medical personnel in appropriate protective
gear prior to decontamination.
Vesicants
Vesicants are agents that cause erythema and vesicles on the
skin as well as injury to the eyes, airways, and other organs.
Key to treatment of these agents is thorough decontamination as soon as possible. Sulfur mustard has no specifi c antidote. BAL is the specifi c antidote for Lewisite [ 1 , 10 , 12 ].
Hydrogen Cyanide
Hydrogen cyanide has a long history as a deadly poison as it
causes death within minutes of exposure. The antidote is
hydroxocobalamin 5GM IV (preferred) or cyanide antidote kit.
Pulmonary Agents
Pulmonary agents cause pulmonary edema which can be
exacerbated by exertion. Phosgene and chlorine are the most
common agents. The pulmonary edema caused by phosgene
and chlorine causes dryland drowning to the point that the
casualty can become hypoxic and apneic.
Riot Control Agents (Tear Gases or Lacrimators)
Treatment is symptomatic with copious irrigation of eyes
and skin with water or normal saline.
Radioactive Agents
Release of radioactive material would most likely involve the
following scenarios: [ 1 ]
• Detonation of a nuclear device
• Meltdown of a nuclear reactor – melting of the nuclear
fuel within a reactor with release of radioactive materials
into the environment (Fukushima nuclear accident)
• Dispersal of material through the use of a conventional
explosive (radiological dispersal device (RDD) or “dirty
bomb”)
• Nonexplosive dispersal of radioactive material
Radiation types include nonionizing radiation (no tissue
damage) and ionizing radiation (tissue damage).
Electromagnetic radiation and particle radiation (“radiation
dust”) are the two types of ionizing radiation seen in disasters. Radiation exposure may be external irradiation (whole
body or localized) and/or contamination (radiation debris) –
internal and external contamination. Responders must
assume both external and internal contamination when
responding to disasters involving radiation agents.
Medical Effects of Ionizing Radiation
• Focal tissue damage and necrosis
• Acute radiation syndrome (result of whole body
exposure)
• Long-term effects (thyroid cancer, leukemia, etc.)
Treatment of Radiation Casualties
• Removal of clothing in victims with external contamination eliminates more than 90 % of the contamination.
• Radiation effects are delayed – trauma triage is done
according to conventional trauma protocols.
• Decontamination: Before, during, or after initial stabilization, depending on severity of injury.
490
S.M. Briggs
• Emergency surgery, as well as closure of surgical wounds,
should be performed early.
• Know the limitations of your radiation detection devices.
Protect yourself until victim is free of all radiation
contamination.
Decontamination
The basic principles in response to any hazardous-material
incident are the same regardless of agents involved. Removal
of clothing and jewelry may reduce contamination by up to
85 %. It is important for medical providers to protect themselves during decontamination with the appropriate level of
personal protective equipment (PPE).
Principles of Disaster Response
Principle #1
Medical providers cannot utilize traditional command and
control structures when participating in disaster response.
The Incident Command System (ICS) is a modular/adaptable system for all incidents and facilities and is the accepted
standard for all disaster response. The Hospital Incident
Command System (HICS) is an adaptation of the ICS for
hospital use, allowing effective coordination in disaster preparedness and response activities with prehospital, public
safety, and other response organizations. The trauma system
is an important component of the ICS.
Functional requirements, not titles, determine the ICS
hierarchy. The organizational structure of the ICS is built
around fi ve major management activities (Incident
Command, Operations, Planning, Logistics, and Finance/
Administration) [ 1 , 10 , 11 ]. The structure of the ICS is the
same regardless of the nature of the disaster [ 1 , 10 , 11 ]. The
difference is in the particular expertise of key personnel.
An important part of disaster planning is the identifi cation
of the Incident Commander and other key positions before a
disaster occurs (24 h/day–7 days/week). Each person within
the command structure should supervise only three to seven
persons. This is quite different from conventional hospital
command structures. All medical providers must adhere to
the structure of the ICS in order to integrate successfully into
the disaster response team and avoid many negative consequences including:
Principle #2
A single emergency operations plan for many different situations is more effective than multiple separate disaster plans
( ALL HAZARDS APPROACH ) [ 1 – 4 , 11 ]. The difference in
disasters is the degree of disruption of the medical and public
health infrastructures and the amount of outside assistance
(regional, national, international) that is needed to meet the
needs of disaster victims.
Principle #3
Effective “surge capacity” is not based on well-intentioned
and readily available volunteers. Disaster responders must
understand the basic principles of disaster response (ICS,
disaster triage, gross decontamination) to be effective members of the disaster teams.
Disaster Medical Response
Disaster response includes basic medical concerns that are the
same in all disasters. The difference in disasters is the degree
of disruption of medical capacity and the amount of outside
assistance needed to meet disaster needs. Rapid assessment by
experienced disaster responders will determine which func-
tional capacities , including critical care capacity , are needed
to meet the demands of the acute phase of the disaster.
Search and Rescue
Many disasters, both natural and man-made, involve large
numbers of victims trapped in collapsed structures. Many
countries, including the United States, have developed specialized search-and-rescue teams as an integral part of their
national disaster plans [
which receive specialized training in confi ned space environments, generally include the following:
• A cadre of acute care specialists, including surgeons
• Technical specialists knowledgeable in hazardous materials, structural engineering, heavy equipment operation,
and technical search-and-rescue methodology
• Trained canines and their handlers
1 , 13 , 14 ]. Members of these teams,
• Death of medical personnel due to lack of safety and
training
• Lack of adequate medical supplies to provide care
• Staff working beyond their training or certifi cation
• Lack of coordination
Disaster Triage
Triage is a dynamic decision-making process of matching
patients’ needs with available resources. Triage is the most
important and psychologically challenging aspect of disaster
43 Disaster Management and Preparedness
491
medical response, both in the prehospital and hospital phases
of disaster response. This is especially true in disasters occurring in austere environments where resources, especially
critical care capacity and evacuation assets, are limited.
Surgical disaster triage is signifi cantly different from
conventional triage. The objective of conventional surgical
triage is to do the “greatest good for the individual patient.”
Severity of injury or disease is the major determinant of triage priority as adequate resources are available for the care
of the patient. The objective of disaster triage is to do the
“greatest good for the greatest number of victims.” The
major objective and challenge of surgical triage is to identify the small minority of critically injured patients who
require urgent life-saving treatments, including damage
control surgery, from the larger majority of noncritical casualties. Review of the literature from major disasters estimates that 15–25 % of victims are critically injured. The
remainder of victims are noncritical casualties [
1 , 4 , 7 , 11 ].
In a mass casualty event, the critical patients having the
greatest chance of survival with the least expenditure of
time and resources (equipment, supplies, personnel) are prioritized to be treated fi rst.
Levels of Triage
Three levels of disaster medical triage have been defi ned.
The level of disaster triage utilized at any phase of the disaster will depend on the ratio of casualties to capabilities.
Many mass casualty incidents will have multiple levels of
triage as surgical patients move from the disaster scene to
defi nitive medical care [ 1 – 4 , 12 , 15 , 16 ].
Level 1: Field Triage
Field triage is the rapid categorization of victims who potentially need immediate medical care “where they are lying” or
at a casualty collection center. Victims are designated as
acute or nonacute . Color-coding may be used. One effective
way to begin Level 1 triage on a large number of victims is to
instruct people to get up and move to a designated location.
This will separate ambulatory (noncritical) individuals from
nonambulatory (critical) victims.
Level 2: Medical Triage
Medical triage is the rapid categorization of victims by experienced medical providers at a casualty collection site or
fi xed or mobile medical facility, including deployable fi eld
hospitals [ 15 , 17 ]. Medical personnel performing triage must
have knowledge of various disaster injuries and illnesses.
Victims are classifi ed into the following categories:
• Red (urgent) : Lifesaving interventions (airway, breathing,
circulation) are required.
• Yellow (delayed) : Immediate lifesaving interventions are
not required.
• Green (minor) : Minimal or no medical care is needed or
psychogenic casualties.
• Black : Deceased victims.
• Expectant category : Victims not expected to survive.
The “expectant” category of victims is unique to mass
casualty incidents. Victims are classifi ed as “expectant” if
they are not expected to survive due to the severity of injuries
(blast injuries, massive crush injuries or burns or exposure to
large quantities of chemical, biological, or radioactive
agents) or underlying diseases and/or limited resources. The
“expectant” category of triage was fi rst developed during
military confl icts given the threat of weapons of mass
destruction (biological, chemical, radioactive) but is now utilized in all disasters. Traditionally, this category of disaster
casualties has been classifi ed as “yellow or delayed”
category. Currently, most triage systems classify “expectant”
victims as a separate category with a different color
designation.
Classifi cation of the expectant category of disaster
victims is challenging and controversial, especially for
critical care surgeons. The challenge for critical care providers is to delineate red category victims who are expected
to live with the resources available versus expectant victims. Many models have been proposed based on severity
of injury, age, underlying diseases, and hemodynamic stability of victims at time of rescue [ 1 , 2 , 5 , 7 ]. Criteria that
are currently utilized as guidelines for the “expectant”
category are:
• Cardiac arrest on scene
• Severity of comorbid diseases
• Requirement for intubation and ventilation on scene
• Head injuries
• Age
• Massive burns (greater than 80 % total body surface
area)
Level 3: Evacuation Triage
Evacuation triage is often a neglected area of disaster preparedness. Priorities for transfer to medical facilities are
assigned to disaster victims using the same color classifi cation as medical triage. Victims are matched to available
receiving facilities. Critical care facilities are usually
overwhelmed with surviving casualties in a MCI
(Fig. 43.2 ). Often victims with minor injuries can be sent
to more distant facilities, keeping closer facilities available for higher- priority victims. Rapid evacuation of critical casualties expected to survive allows more time and
resources for caring for the larger majority of noncritical
victims.
492
S.M. Briggs
Triage Errors
Triage errors, in the form of under-triage and over-triage ,
are always present in the chaos of mass casualty events.
Under-triage is the assignment of critically injured casualties
requiring immediate care to a “delayed” category. Undertriage leads to treatment delays with increased mortality and
morbidity. Over-triage is the assignment of noncritical survivors with no life-threatening injuries to immediate urgent
care. The higher the incidence of over-triage, the more the
medical system is overwhelmed. In mass casualty incidents,
especially explosions, triage errors more commonly involve
over-triage than under-triage. Children are often over-triaged
due to the emotional impact of injured children on medical
responders. The level of acceptable over-/under-triage in a
Fig. 43.2 Crush injury to chest
mass casualty incident and the best method for evaluation of
triage effectiveness in mass casualty incidents is still controversial. Various triage systems exist, and, unfortunately,
there is no universally accepted triage system for mass casualty incidents.
D e fi nitive Medical Care
Defi nitive medical care refers to care that will improve,
rather than simply stabilize, a casualty’s condition.
Maximally acceptable care for all surgical patients is not
possible in the early stages of the disaster given the large
number of victims in a mass casualty incident. In the initial
stage of the disaster, minimally acceptable surgical care (crisis management care or altered standards of care) to provide
lifesaving interventions is necessary to provide the “greatest
good for the greatest number of victims” [ 1 , 14 – 16 ].
Damage control surgery is an important component of
crisis management care. In many disasters, local hospitals
are destroyed, transportation to medical facilities may not be
immediately feasible, or the environment may be contaminated. Mobile surgical facilities with the capacity for operative interventions and critical care can provide a graded,
fl exible response to the need for surgical care in mass casualty incidents (Fig. 43.3 ).
Damage control surgery limits trauma interventions to
control of hemorrhage and contamination. Damage control
surgery was initially developed for abdominal trauma with
uncontrolled hemorrhage but has expanded to all other trauma
specialties in disasters [ 18 – 20 ]. Spinal and regional anesthe-
sias, as well as intravenous sedation and intraosseous infusions, are important adjuvants to surgical care in disasters.
Fig. 43.3 Damage control surgery (Haiti
earthquake 2010)
43 Disaster Management and Preparedness
493
Evacuation
Evacuation may be useful in a disaster to decompress the
disaster area and provide specialized surgical care for specifi c casualties, such as those with major burns and crush
injuries. Surgeons with expertise in critical care are increasingly valuable evacuation resources in disasters. In most
disasters, the large number of victims needing evacuation,
especially in austere environments, will mandate the use of
unconventional medical transport aircraft. Special considerations during evacuation include [ 1 ]:
• A decrease in cabin pressure occurs as altitude increases.
Trapped gas in any body cavity can cause serious complications as it expands on ascent. Special attention must be
paid to trapped gas within the thorax, cranium, eye, and
the gut in the presence of an ileus. Patient care appliances,
such as endotracheal tube cuffs, are also susceptible.
• The partial pressure of oxygen in the ambient air decreases
with increasing altitude. Monitoring with pulse oximetry
is important.
• Takeoffs and landings present unique challenges, especially with head injury patients.
• Young children, burn patients, and postsurgical casualties
are particularly susceptible to temperature changes during
evacuation.
treatment phase includes objective evaluation of well-defi ned
functional capacities such as triage, operative interventions,
critical care, and evacuation [
1 , 11 , 21 ].
Summary
The mass casualty incident response is a consistent approach
to disasters based on an understanding of the common features and the response expertise they require in all phases of
the disaster response. The goal of disaster medical response is
to reduce the critical mortality associated with a disaster.
Critical mortality rate is defi ned as the percentage of critically
injured survivors who subsequently die [ 1 , 8 ]. Numerous fac-
tors infl uence the critical mortality rate, including:
• Triage accuracy, particularly the incidence of over-triage
of victims
• Rapid movement of patients to defi nitive care
• Implementation of damage control procedures
• Critical care interventions
• Coordinated regional preparedness and response
References
Disaster Management Teams
Clinical competencies, not titles, determine the roles of medical providers in disaster response. Disaster management
teams are designed and trained to provide specifi c “functional” areas of disaster care such critical care, pediatrics,
obstetrics, and acute and trauma surgery, especially when the
casualty load is unknown. The complexity of today’s disasters demands civilian and military partnerships as key to
effective disaster response. Critical care teams must be
equipped to take care of both pediatric and adult patients in a
mass casualty incident.
Disaster Drills
Disaster preparedness must include practical drills to ascertain the true magnitude of system problems, not just tabletop
exercises. Mass-casualty drills must include three phases:
preparation phase, exercise management phase, and patient
treatment phase. The preparation phase must include clear
defi nition of functional areas of responsibility that can be
evaluated objectively, not subjectively, during the disaster
drill. The exercise management phase includes objective
evaluation of all key functional roles in the ICS. The patient
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