Linda D. Norman, DSN, RN, FAAN and Elizabeth E. Weiner, PhD, RN-BC, FACMI, FAAN After studying this chapter, the reader will be able to: 1. Describe the interaction between local, state, and federal emergency response systems. 2. Examine the roles of public and private agencies in preparing for and responding to a mass casualty event. 3. Compare and contrast chemical, biologic, radiologic, nuclear, and explosive agents and treatment protocols. 4. Access resources related to disaster preparedness on the Internet. 5. Communicate effectively (using correct emergency preparedness terminology) in regard to a mass casualty incident. 6. Describe the need for personal preparedness for individuals and households. A process approach for all sectors to prepare for any emergency or disaster that may occur. Microorganisms or toxins from living organisms with infectious or noninfectious properties that produce lethal or serious effects in plants and animals. Solids, liquids, or gases with chemical properties that produce lethal or serious effects in plants and animals. Comprehensive emergency management A broad style of emergency management, encompassing prevention, preparedness, response, and recovery. Measures to protect public health and safety, restore essential government services, and provide emergency relief to governments, businesses, and individuals affected by the consequences of terrorism. Limitation of an emergency situation within a well-defined area. Situation in which the Federal Bureau of Investigation (FBI) determines that a terrorist threat is credible and confirms the involvement of a weapon of mass destruction (WMD) in the developing terrorist incident. Measures to identify, acquire, and plan the use of resources needed to anticipate, prevent, and/or resolve a threat or act of terrorism. The physical process of removing harmful substances from personnel, equipment, and supplies. A significant natural disaster or man-made event that overwhelms the affected state, necessitating both federal public health and medical care assistance. Disaster medical assistance teams (DMATs) Regionally organized teams consisting of physicians, nurses, and other health care providers that can be sent into areas outside their own regions to assist in providing care for ill or injured victims at the location of a disaster or emergency. DMATs provide triage, medical or surgical stabilization, and continued monitoring and care of patients until they can be evacuated to locations where they will receive definitive medical care. Specialty DMATs can also be deployed to address, for example, mass burn injuries, pediatric care requirements, and chemical injury or contamination. As defined in the Stafford Act, any occasion or instance for which, in the determination of the president, federal assistance is needed to supplement state and local efforts and capabilities to save lives and protect property, public health, and safety; includes emergencies other than natural disasters. Emergency Management Assistance Compact (EMAC) An organization authorized by the U.S Congress through which a state impacted by a disaster can request and receive assistance from other member states quickly and efficiently (EMAC, 2009). A multiagency operational structure that uses a model adopted by the fire and rescue community. The ICS can be used in any size or type of disaster to control response personnel, facilities, and equipment. ICS principles include use of common terminology, modular organization, integrated communications, unified command structure, action planning, manageable span-of-control, predesignated facilities, and comprehensive resource management. The basic functional modules of ICS (e.g., operations, logistics) can be expanded or contracted to meet requirements as an event progresses. As defined by the FBI, the federal department or organization assigned primary responsibility to manage and coordinate a specific function—either crisis management or consequence management. Lead agencies are designated on the basis of their having the most authority, resources, capabilities, or expertise relative to accomplishment of the specific function. Lead agencies support the overall lead federal agency during all phases of the disaster response. As defined under the Stafford Act, any natural catastrophe (including any hurricane, tornado, storm, high water, wind-driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, or drought) or, regardless of cause, any fire, flood, or explosion in any part of the United States that in the determination of the president causes damage of sufficient severity and magnitude to warrant major disaster assistance under the Stafford Act to supplement the efforts and available resources of states, local governments, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused thereby. A disaster situation that results in a large number of victims who need the response of multiple organizations. Those activities designed to alleviate the effects of a major disaster or emergency or long-term activities to minimize the potentially adverse effects of future disasters in affected areas. National disaster medical system (NDMS) A nationwide medical mutual aid network between the federal and nonfederal sectors that includes medical response, patient evacuation, and definitive medical care. At the federal level, it is a partnership among the U.S. Department of Health and Human Services (USDHHS), the Department of Defense (DOD), the Department of Veterans Affairs (VA), and the Federal Emergency Management Agency (FEMA). Weapons that release nuclear energy in an explosive manner as the result of nuclear chain reactions involving fission and/or fusion of atomic nuclei. Personal protective equipment (PPE) Equipment designed to shield or isolate individuals from chemical, physical, and biologic hazards. Activities that build capability and capacity to address potential needs identified by the threat and vulnerability study. Activities designed to return responders and the facility to full normal operational status and to restore fully the capability to respond to future emergencies and disasters; activities traditionally associated with providing federal supplemental disaster relief assistance under a presidential major disaster declaration. These activities usually begin within days after the event and continue after response activity ceases. Recovery includes individual and public assistance programs that provide temporary housing assistance, in addition to grants and loans to eligible individuals and government entities to recover from the effects of a disaster. Activities to address the immediate and short-term effects of an emergency or disaster. Response includes immediate actions to save lives, protect property, and meet basic human needs. Based on the requirements of the situation, response assistance will be provided to an affected state under the federal response plan. The act of reviewing the location of an event to look for information that might help to determine treatment options. Actions to identify, assess, dismantle, transfer, dispose of, or decontaminate personnel and property exposed to explosive ordnance or weapons of mass destruction (WMD). As defined by the FBI, a violent act or an act that is dangerous to human life, in violation of the criminal laws of the United States or of any state, and intended to intimidate or coerce a government, the civilian population, or any segment thereof in furtherance of political or social objectives. Process of prioritizing which patients are to be treated first; first action in any disaster response. Weapon of mass destruction (WMD) As defined by Title 18, US Code 2332a, (1) any destructive device as defined in section 921 of this title, [which reads] any explosive, incendiary, or poison gas, bomb, grenade, rocket having a propellant charge of more than 4 ounces, missile having an explosive or incendiary charge of more than one quarter ounce, mine or device similar to the above; (2) poison gas; (3) any weapon involving a disease organism; or (4) any weapon designed to release radiation or radioactivity at a level dangerous to human life. Additional resources are available online at: http://evolve.elsevier.com/Cherry/ VIGNETTE Questions to Consider While Reading This Chapter 1. How do we prepare for mass casualty events that will overwhelm the resources of our health facility? 2. How are response efforts coordinated so that the needs of the local area are met? 3. How do hospitals organize themselves to manage disaster situations while continuing to communicate with other external agencies? 4. How does the response differ when the hospital suffers damage and cannot function normally? 5. Where can I find current information about this ever-changing area? The purpose of this chapter is to describe the various components of our nation’s local, state, and federal National Response Framework and how these components interrelate in the event of a mass casualty incident (MCI). The problems associated with natural or terrorist disasters when the health care system is damaged or rendered ineffective because of the event are reviewed. The kinds of agents that may be used in a terrorist attack are described along with the activities and response systems related to the preimpact and impact phase of a disaster. Readers will be particularly interested to note how standard triage and patient care priorities change when care is provided during an MCI. Additionally, readers are encouraged to closely review the list of key terms to understand and be able to use emergency preparedness terminology and explore the online resources about emergency preparedness and disaster management provided at the end of the chapter. Although a great deal of attention has been targeted to preparing for an MCI related to a terrorist attack, the United States has suffered major damage from natural disasters. Hurricane Katrina has become the classic example of massive system failure in emergency response. Most of the destruction was due to storm surge, and further flooding took place in New Orleans as the levee system catastrophically failed. Although the death toll from this event was not at the level of the destruction from the World Trade Center, the damage to the health care systems in the affected areas was substantial. It became evident very quickly that the response systems in place could not be effective in dealing with the destruction of the health care infrastructure, and, in fact, the health care agencies themselves were sites of mass casualty. The extensive need for immediate and long-term shelters for large numbers of victims also highlighted the need for nurses to have knowledge and skills in how to meet the needs of victims with psychological and chronic diseases in a sheltered environment. Although the hurricane took place in 2005, today the area has not fully recovered from that event, and one of the area hospitals has never reopened. Lessons learned from Hurricane Katrina were used during the deadly tornadoes in both Joplin, Missouri, and Tuscaloosa, Alabama, in 2011. Both sites suffered the most devastating tornadoes in their history. The Institute of Medicine was called upon to convene a group of experts in 2009 and reconvened in 2011 to address the issues related to the community response to major disasters (Hanfling et al, 2012). Nurses have significant experience in dealing with natural disasters and are familiar with the work of the Red Cross in bringing disaster relief to affected areas. A disaster condition is defined as a significant natural disaster or man-made event that overwhelms the affected state and necessitates both federal public health and medical care assistance (Federal Emergency Management Agency [FEMA], 2012a). The disaster condition must be declared of significant impact to warrant federal resources. It is important for nurses to understand the stages of a disaster to be able to determine the actions that are needed during each phase. In addition, understanding the responsibilities of the multiple agencies that respond to a disaster is imperative to be able to communicate with patients, families, and other health care providers. Community disaster plans need to clearly define the care processes to be used when the needs shift from that of one patient to the needs of the populations (Hanfling et al, 2012). Nurses may also find themselves in positions in which there is a lack of necessary resources, and they will then have to come up with creative solutions. Powers (2010) describes examples of such adaptability by the Australian team in the Maldives post-tsunami 2004 with such actions as using rigid plastic drink bottles as sharps containers at each patient’s bed area and using the large, rigid containers used to transport medical supplies as privacy screens and walls between treatment areas. Busby and Witucki-Brown (2011) described such actions and decisions by nurses and other responders as developing situational awareness about MCIs. Terrorism has created the need for us to prepare against a variety of different agents. A standardized nomenclature has been developed for five categories using the acronym CBRNE, which stands for chemical, biologic, radiologic, nuclear, and explosive. Table 15-1 describes the similarities and differences related to the CBRNE agents and provides information about treatment protocols for each agent. TABLE 15-1
Emergency Preparedness and Response for Today’s World
Chapter Overview
The National Imperative for Emergency Preparedness
The Basics of Emergency Preparedness and Response
AGENTS
ACTION
ADVANTAGES
DISADVANTAGES
TREATMENT
Chemical
Agents injure or kill through variety of means: vesicant, nerve, blood, respiratory
Spread easily through air; cause immediate effects; require decontamination
Less toxic than biologic agents; need to be used in large quantities; subject to dispersion by wind; terrorists need to protect themselves; require trained HAZMAT teams
Dependent on agent used; in some cases have agent-specific medications; require decontamination; require use of personal protective equipment by personnel
Biologic
Disease-causing organisms (bacteria, viruses, toxins)
Available; small quantities can have large effect; spread through large areas; can remain in air or on surfaces; difficult to prepare against
Delayed effects; production hazardous to terrorists; difficult to develop
Dependent on agent used; most cause flulike symptoms; plague and smallpox most contagious; timing of specific treatment critical; in some cases can have vaccinations
Radiologic
Ionizing radiation able to strip electrons from atoms, causing chemical changes in molecules; expression may be delayed; radiation depends on time, distance, shielding, and quantity of radioactive material
Available; psychological effect likely to be substantial; often used in conjunction with explosive devices (“dirty bombs”)
Delayed effects of radiation materials; difficult to shield against
Dirty bomb causes immediate effects (radiation burns, acute poisoning) and long-term effects (cancer, contamination of drinking water); decontamination must occur before patient care can be safely provided by the health care worker
Nuclear
Depends on yield of nuclear weapon, but consists of blast range effects, thermal radiation, nuclear radiation, and radioactive fallout
Requires decontamination; contamination can remain for many years; psychological effect likely to be substantial
Large, heavy, and dangerous weapons; hazardous to terrorists; expensive and difficult to make weapons of this type
Symptomatic treatment of thermal burns, shrapnel injuries, and radioactive fallout; depends on distance from source and time of exposure
Explosive
Most common method for terrorists; capable of violent decomposition; pressure, temperature changes and propellants cause injury and/or death
Available materials to construct explosive device; large devices can be placed in abandoned vehicles; smaller devices can be placed on bodies of persons willing to commit suicide by igniting the device
Volatile ingredients could cause premature explosion of device, thus creating danger for terrorists; government agencies have improved training and processes for identifying incendiary devices
Symptomatic; often requires treatment for burns 
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Emergency Preparedness and Response for Today’s World
