Introduction
Mass casualty incidents (MCIs) can result from both natural disasters, such as hurricanes, and human-made disasters, such as terrorist attacks. MCIs tax medical infrastructures and require urgent responses from medical personnel from many different disciplines. Physician assistants (PAs) are being called on to respond to the urgent medical needs more frequently than in the past. Many times, PAs are first on the scene and take a leadership role in chaotic situations. In recent years, large-scale disasters such as 9/11 and Hurricane Katrina have raised concerns about our ability to respond in an effective and coordinated manner to the medical (and other) needs created by these disasters.
The World Health Organization (WHO) defines disaster as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its resources.” Natural disasters include such events as earthquakes, volcanoes, landslides, tsunamis, flooding (river or coastal), tornadoes, droughts, wildfires, sand or dust storms, blizzards, and infestations. Certain geographic locations are more prone to particular natural disasters. For example, midwestern states are prone to tornadoes, whereas western states experience more earthquakes and wildfires. Situational awareness is important to be prepared for natural disasters.
Vulnerability is the “degree to which a socioeconomic system is either susceptible or resilient to the impact of natural hazards.” Vulnerability is determined by hazard awareness, infrastructure, public policy, and the ability to implement disaster management procedures. Poverty remains one of the main causes of vulnerability. There is no better illustration than the vulnerabilities present in Haiti on January 12, 2010, when a 7.0 earthquake struck the capital of Port-au-Prince, killing hundreds of thousands of people. Haiti remains one of the poorest countries in the Western Hemisphere. The Haitian government gave much attention to other natural disasters, such as hurricanes and mudslides, even though Haiti had a documented history of devastating earthquakes dating back to the 1770s. Haiti is located on the borders of the American and Caribbean tectonic plates, making it particularly vulnerable to earthquakes. In addition, because of the deforestation of trees, lumber for buildings became expensive. Therefore buildings shifted to concrete and stone structures that could not withstand the violent shaking during the earthquake. Building codes were either not enforced or were nonexistent. Buildings collapsed, trapping many beneath the ruble. Furthermore, first aid for emergency situations was not readily available, compounding the suffering and loss of life from this disaster. All of these vulnerabilities drastically increased the death toll from this natural disaster.
The WHO defines mass casualty as “an event which generates more patients at one time than locally available resources can manage using routine procedures. It requires exceptional emergency arrangements and additional or extraordinary assistance.” The phrase mass casualty conjures up images of 150 casualties waiting at several hospitals in a metropolitan area in such cases as the Boston Marathon bombings. By definition, mass casualty would also constitute a multivehicle accident with eight casualties being transported to a critical access hospital in a rural area. MCI events can be the result of a terrorist attack, such as the events of 9/11. Another less publicized event was the train derailment in Graniteville, South Carolina in 2005 that resulted in an immediate release of 46 tons of liquid chlorine near a textile mill where 183 people were working the night shift. Each of these events had vastly different origins, but all resulted in an MCI.
The effects of an MCI or natural disaster can be mitigated with well-rehearsed emergency response teams and a prepared community. The community is deemed “recovered” when the health status of the community is restored to its pre-event state. In some instances, this can be a relatively short period of time, but other instances can take many years. The goals of emergency response are to:
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Reverse the adverse health effects caused by the event.
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Modify the hazard responsible for the event (reducing the risk of the occurrence of another event).
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Decrease the vulnerability of the society to future events.
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Improve disaster preparedness to respond to future events.
Most MCIs and natural disasters come with little to no warning; therefore it is essential that PAs have a solid foundation in disaster preparedness and emergency response. Understanding the cyclical pattern known as the disaster cycle is essential to understanding the four reactionary stages that occur after a catastrophic event. The four reactionary stages are:
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Preparedness
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Response
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Recovery
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Mitigation and prevention
Each stage varies in duration, depending on the type of MCI or natural disaster experienced.
Principles of triage
Triage comes from the French verb “trier,” which means “to sort.” Triage of patients in a mass casualty or natural disaster situation often requires medical providers to alter their thought process about treating patients. Under normal circumstances, the sickest or worst injured get immediate medical attention, and often medical providers try to save the life of a patient at all costs. When medical personnel and medical supplies are limited, however, the critically injured and ill are passed over to help care for patients with a higher likelihood of surviving. Treatment is aimed at doing the most good for the most patients. By assigning priorities for treatment through triage principles, medical personnel make the most efficient use of available resources.
There are three major reasons why triage is beneficial when responding to a natural disaster or MCIs. Triage categorizes patients who need rapid medical care to save life or limb. By separating out the minor injuries, triage reduces the urgent burden on medical facilities and organizations. On average, only 10% to 15% of disaster casualties are serious enough to require overnight hospitalization. By providing for the equitable and rational distribution of casualties among the available hospitals, triage reduces the burden on each to a manageable level, often even to “nondisaster” levels. The disaster triage system in the United States is color coded and uses red, yellow, green, and black as follows:
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Red: First priority, most urgent. Life-threatening shock or airway compromise present, but the patient is likely to survive if stabilized.
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Yellow: Second priority, urgent. Injuries have systemic implications but are not yet life threatening. If given appropriate care, the patients should survive without immediate risk.
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Green: Third priority, nonurgent. Injuries localized, unlikely to deteriorate.
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Black: Dead. Any patient with no spontaneous circulation or ventilation is classified dead in a mass casualty situation. No cardiopulmonary resuscitation (CPR) is given. You may consider the placement of catastrophically injured patients in this category (dependent) on resources. These patients are classified as “expectant.” Goals should be adequate pain management. Overzealous efforts toward these patients are likely to have a deleterious effect on other casualties.
Understanding principles of triage is essential for medical providers attending to casualties to save the most lives during an MCI or natural disaster.
Chemical, biological, radiologic, nuclear, explosives, and environmental incidents
Mass casualty incidents and natural disaster events have been the scourge of humankind since antiquity. As we have moved into the 21st century, the causes of disasters have expanded from the natural disasters and infectious disease pandemics of previous centuries to potential human-made events, such as chemical, biological, radiologic, nuclear, and explosives (CBRNE) incidents that have the ability to produce widespread carnage very quickly. As the industrial age flourished, modern manufacturing processes began to use toxic chemicals in their daily operations. These chemicals are transported near urban areas via highways and railroads, which places the general public at great risk when accidental spills occur. Furthermore, these same modern manufacturing processes have allowed people to produce chemical, biological, and nuclear weapons capable of inflicting multitudes of casualties. Combined with the rise of rogue terrorist groups, the potential for one of these weapons of mass destruction to be used against a civilian population is of grave concern. PAs, no matter their practice specialty, need to have a basic understanding in the recognition and treatment of CBRNE injuries, as well as injuries that result from natural disasters.
Chemical disasters
Ancient Greek myths spoke of the effectiveness of chemical warfare, and various agents have been used throughout the ages, culminating with the widespread use in World War I. Many of the chemical agent–related disasters in modern times are related to industrial accidents. One of the most famous chemical disasters was the December 3, 1984 Bhopal disaster in India that killed between 4000 and 20,000 people from exposure to methyl isocyanate.
Disasters from chemical exposures create numerous casualties very quickly and place first responders in danger of also being contaminated. Proper decontamination of patients at the scene by trained civilian or military personnel takes priority before rendering medical care. Contamination of medical personnel and facilities not only risks the provider’s health but also can jeopardize the ability of the hospital to receive casualties. First responders will usually be able to communicate the type of chemical agent involved to the receiving hospital, where treatment of patients should be focused on that contaminant. The injuries associated with chemical disasters depend on the class of agents involved. Some more common agents that may be encountered include:
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Choking agents that target the pulmonary system, such as chlorine and phosgene. These agents are lung irritants that cause injury to the lung–blood barrier, resulting in asphyxia.
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Blood agents, such as hydrogen cyanide, that are rapidly lethal via halting cellular respiration. Treatment is the rapid removal of the victim from the environment, application of oxygen, and administration of sodium nitrite.
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Blister agents or vesicants, such as mustard gas, which are some of the most common chemical warfare agents. These oily substances act via inhalation and contact with skin. Blister agents affect the eyes, respiratory tract, and skin, first as an irritant and then by affecting cell metabolism. Blister agents cause large and often life-threatening skin blisters that resemble severe burns. The effects of mustard agents are typically delayed. Exposure to vapors becomes evident in 4 to 6 hours, and skin exposure is seen in 2 to 48 hours. Treatment is decontamination and supportive care targeted to address life-threatening respiratory compromise.
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Nerve agents, which are perhaps the most rapidly lethal chemical agents and result in respiratory paralysis and death in a matter of minutes. Nerve agents, such as sarin and VX, enter the body through inhalation or through the skin. Symptom severity depends on the level of exposure. Classic symptoms of moderate to high doses of nerve agent result in pronounced secretion of mucus, bronchoconstriction, abdominal cramping, vomiting, involuntary urination and defecation, muscle weakness, convulsions, and death by suffocation. Treatment must be rapid to prevent death and should include decontamination and administration of high doses of atropine and 2-PAM (2-pyridine aldoxime methyl) chloride. Supportive care must be aggressive because the physiologic effects can continue long after the nerve agent is reversed.
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Riot control agents , such as tear gas, which are chemical compounds that temporarily make people unable to function by causing irritation to the eyes, mouth, throat, lungs, and skin. The effects of exposure to a riot control agent last about 15 to 30 minutes after the patient has been decontaminated. Immediate signs and symptoms of exposure to a riot control agent include excessive tearing, eye burning, blurred vision, a runny nose, difficulty swallowing, chest tightness, coughing, and nausea and vomiting. Long-lasting exposure or exposure to a large dose of a riot control agent can result in blindness, glaucoma, and sometimes death from respiratory compromise. Treatment includes the removal of the patient from the environment, copious irrigation, and symptomatic treatment.
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Toxins, which are poisons produced by living organisms. One of the most well-known toxins is botulinum toxin. Botulinum toxin is produced by the bacteria Clostridium botulinum and is extremely lethal. The lethal dose has been estimated to be about 1 microgram if ingested and even less if inhaled. The incubation period is between 1 and 3 days, at which time the patient presents with abdominal pain, diarrhea, visual changes, and muscular weakness. Paralysis ensues, compromising respiratory function, and asphyxia ensues. No specific treatment is available for botulinum toxin. Treatment is directed at supporting the cardiopulmonary system.
Biological disasters
Biological disasters are diseases conveyed by biological vectors, including exposure to pathogenic microorganisms, toxins, and bioactive substances that can cause injury, illness, social and economic disruption, and death. Biological disasters can be naturally occurring or can be human-made in the form of accidental release or bioterrorism. Naturally occurring biological disasters can be divided into epidemics and pandemics. An epidemic is a disease process affecting a disproportionately large number of individuals within a population, community, or region at the same time. A pandemic is an epidemic that spreads across a continent or worldwide, such as the 2020 COVID-19 pandemic. Epidemics are common after tropical storms, floods, earthquakes, and wars, when normal hygiene and sanitation services are disrupted. Examples of natural epidemics include the avian flu common in southeast Asia; the cholera outbreak in Haiti after the earthquake in 2010 as the result of improper sanitation protocols by Nepalese soldiers who were part of the United Nations forces; dengue fever and malaria outbreaks from mosquito-borne vectors; the Ebola outbreak in West Africa in 2015; and measles, which has once again become common in the United States as the result of low vaccination rates in certain segments of the population. Measles has a high mortality rate in developing countries.
Epidemics can also be the result of bioterrorism. Bioterrorism is a method that disseminates widespread panic in a population and produces a slow onset of mass casualties. Bioterrorism can be targeted to both a human population and an animal population, and it can produce large-scale economic losses. Many of the common bioterror weapons such as smallpox, anthrax, and plague were weaponized by the United States and the Soviet Union after World War II. Although many of these bioweapon stocks were destroyed as the result of arms agreements, some stockpiles remain in the former Soviet Union. These stockpiles, as well as the scientific ability to produce these weapons, are sought after by terrorist groups. Recognizing bioterrorism is a critical first step in decreasing the number of casualties. Incidentally, frontline medical professionals may be the first to recognize health trends that indicate a bioterrorism attack.
Biological disasters present differently from chemical disasters. The vectors are different and can include agents dispersed into the air that may drift for miles; animals, including fleas, mice, mosquitoes, and livestock; food and water supplies; and from person to person, such as smallpox. Unlike chemical agents, there is a lag time between exposure and the appearance of symptoms. This lag time gives the vector more time to expose a greater number of victims. Furthermore, it increases the time it takes before the disease is recognized, isolated, and treated. Three categories of biological agents can cause mass casualties:
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Category A (which pose the most risk to public health): These agents are easily disseminated from person to person and have a high mortality rate. These agents include smallpox, Ebola, Lassa fever, anthrax, plague, tularemia, and botulism. Special isolation precautions of contaminated patients are required. Consequently, multiple casualties can be devastating to the medical system as patients require an inordinate amount of resources.
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Category B: These agents are moderately easy to disseminate; have moderate morbidity and low mortality rates; and include alphaviruses, Brucella (brucellosis), Burkholderia mallei (glanders), Coxiella burnetii (Q fever), ricin, staphylococcus enterotoxin B, Salmonella, Vibrio cholera, and Escherichia coli O157:H7. Children, older adults, and immunocompromised individuals are more at risk for complications from these diseases. Early, aggressive treatment is critical in reducing the long-term morbidity of the diseases.
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Category C: These agents include many that have insect vectors, including Nipah, yellow fever, tick-borne hemorrhagic fever viruses, tick-borne encephalitis, and bacteria such as Mycobacterium tuberculosis. Although these diseases have the potential for morbidity and mortality, they are less likely to be widespread public health threats.
Clinicians should be aware of the diseases that lend themselves to becoming bioweapons. Anthrax, smallpox, plague, tularemia, and brucellosis are diseases that are relatively easy to produce, inexpensive, readily spread from person to person, and can be “weaponized” for distribution over a wide area. Bioweapons are considered to be a “poor man’s nuclear bomb” and can produce widespread casualties. For example, smallpox causes a one in five mortality rate. Furthermore, these bioweapons can cause associated widespread panic and economic chaos. Unlike chemical weapons, where casualties would occur quickly after an attack, victims of bioterrorism would present days after the exposure with initial “flulike” symptoms. Be aware that with modern air travel, a bioterrorism victim on another continent may present to an emergency department (ED) or medical office in the United States with the early stages of the disease. It cannot be emphasized enough that a thorough travel history must be obtained on every ill patient. Clinicians should inquire about friends and family members with similar symptoms and maintain a high index of suspicion if multiple patients present with similar symptoms. Clinicians should also become suspicious of an epidemic curve that rises and falls during a short period of time, an endemic disease rapidly emerging at an uncharacteristic time of the year, lower attack rates of people who have been indoors, clusters of patients arriving from a single location, and large numbers of rapidly fatal cases. Isolation of the patient and those exposed to the patient should take first priority, including providing personal protective equipment (PPE) for all staff. Decontamination should only be considered in cases of gross contamination, and this determination needs to be made in conjunction with local and state health departments. Basic decontamination includes the removal of clothing and bathing in soap and water. Clinicians should notify the hospital’s infection control personnel, public health officials, law enforcement, emergency medical services (EMS), and the Centers for Disease Control and Prevention (CDC) promptly. Postexposure immunization and prophylaxis measures depend on the biologic agent involved. Furthermore, the determination on proceeding with an intervention should be made in conjunction with the local and state health departments. Treatment of patients should be directed at addressing presenting symptoms because exposure to many of the bioterror agents presents with respiratory or gastrointestinal complaints. Additionally, clinicians should be ready to address the potential for respiratory failure, hemorrhagic shock, or septic shock.
Nuclear and radiologic disasters
Nuclear and radiation disasters are, fortunately, uncommon in the United States. Although the prospect for a large-scale nuclear power disaster on the scale of the Fukushima, Japan accident is remote, incidents involving radiologic dispersal devices (i.e., dirty bombs), occupational accidents, or even an explosion from an improvised nuclear device are possible events. Clinicians should be prepared for these events and be familiar with the types of nuclear and radiologic devices, methods for decontamination, and ways of recognizing radiation sickness; they should also have a basic knowledge of treatment for radiation injuries.
Improvised nuclear devices
Improvised nuclear devices are a type of nuclear weapon that generates four types of energy: a blast wave, intense light, heat, and radiation. Depending on the size of the device, victims in the initial blast zone have an extremely high mortality rate from the blast wave. Furthermore, any survivors would sustain severe burns, blindness, and rapid onset of acute radiation syndrome (ARS). ARS is caused by irradiation of the entire body by a high dose of radiation over a few minutes. The major cause of ARS is the depletion of immature parenchymal stem cells in certain tissues. The radiation dose must be greater than 70 rads, from an external source of gamma rays. Symptoms include anorexia, fever, malaise, severe diarrhea, dehydration, and electrolyte imbalances. Death usually occurs in 3 days and is the result of infection, dehydration, and electrolyte imbalances. Mortality rates depend on the radiation dose received. As a general rule, nausea and vomiting that start within 4 hours of exposure are a poor prognosticator. Victims farther from the blast zone can expect radiation sickness and may have to contend with contaminated food and water. Rapid decontamination and supportive care are critical to decreasing mortality and morbidity.
Radiologic dispersal devices (dirty bombs)
A “dirty bomb” is a device that is a more likely scenario in a radiologic terrorist attack. A dirty bomb or radiologic dispersal device (RDD) is a mix of radioactive material and a high explosive that does not create a nuclear blast but disperses the radioactive material over an area. Easy to produce, the potential radioactive material can include industrial waste or even the byproducts of common medical procedures. The danger from an RDD is from blast trauma. The radiation exposure is only a concern for people near the blast, and the potential for radiation exposure serves as a “fear weapon,” possibly slowing first responders. Basic decontamination procedures need to be followed but should not impede the rapid evaluation and treatment of trauma injuries.
Occupational accidents and radiologic exposure devices
Occupational accidents and the use of radiologic exposure devices (REDs) are both situations in which a person has been exposed to radioactive material. Occupational accidents are seen mostly in research facilities, hospitals, and some manufacturing operations. Exposure to an RED is a criminal attempt to expose victims to a radiation source, usually in a public place, such as a food court or bus. In both situations, the physiologic response of the victim depends on the type and amount of exposure, the length of exposure, and what body part was exposed. High levels of exposure can result in ARS; however, the effects of low-dose exposure could take weeks to appear. Treatment is directed toward symptoms; however, the patient will require long-term monitoring specifically evaluating for leukopenia and bone marrow suppression, with resultant infection.
Natural disasters
By far, the most common type of mass casualty event seen worldwide is a natural disaster. Depending on location, PAs should be prepared for natural disasters that are common to that location. The gulf coast and the eastern coast of the United States are prone to hurricanes, which can produce widespread devastation, resulting in not only mass casualties as the result of trauma (i.e., penetrating and crush injuries) but also infectious disease issues as the result of a loss of infrastructure and sanitation. The Midwest and the southern United States are prone to tornadoes. Tornadoes give very little warning and tend to cause injuries similar to those from hurricanes, except in a smaller geographic area. The West Coast and Alaska are prone to earthquakes and tsunamis, which give little or no warning and generate widespread destruction. In the case of earthquakes, many of the injuries are crush injuries from collapsed structures or injuries related to resulting fires or explosions. Similar to hurricanes, earthquakes involve a wide area and can result in severe impairment of local fire departments and EMS to render care. Tsunamis result in widespread inland flooding and structural damage. Many of the deaths are the result of drowning; however, exposure to sewage, industrial chemicals, and waterborne pathogens can result in a widespread public health emergency. By knowing what types of environmental events are common to an area, proper preparation can ensure a better outcome in the event of one of these disasters.
Hurricanes
Hurricanes have plagued the southeastern and eastern United States, resulting in catastrophic loss of property and life. Hurricanes have become a bigger problem over the past 50 years because more people are living in coastal regions and sea levels are rising. Hurricanes inflict damage by both wind and water. Wind damage, as the result of 150 plus–mph winds, results in the structural collapse of buildings, homes, and utilities and can expose people to wind-blown shrapnel, causing penetrating injuries. Water damage occurs as the wind pushes wave action inland, resulting in flooding and potential drowning deaths. Subsequent exposure to waterborne illnesses is a very real risk. People in poor health and older adults are susceptible to aggravation of preexisting health problems caused by a lack of medications, prolonged exposure to heat, and lack of a clean water supply. The widespread devastation to health care facilities and transportation infrastructure makes treating and evacuating large numbers of patients problematic and usually requires a state or federal response. Hurricane Katrina highlighted the problematic nature of providing medical care in an environment where electricity, water, and transportation are absent. Clinicians should be ready to treat patients in poor conditions with limited supplies. Emphasis should be on the triage of patients, with prompt evacuation to intact facilities. Many times, such disasters require the assistance of ground and air military assets. Clinicians should be mindful to take care of themselves in this type of environment, with proper hydration, nutrition, and rest–work cycles to avoid fatigue and injuries.
Tornadoes
Tornadoes strike with little or no warning, usually in the spring and summer in the midwestern and southeastern United States. Although the destruction is usually confined to a narrow area, mortality and morbidity can be high. Winds exceeding 200 mph result in structural collapse and flying debris that produce crush injuries, penetrating injuries, and lacerations. Health care facilities should be prepared to receive ambulatory patients quickly after an event. Disaster protocols should be routinely rehearsed in tornado-prone areas and recall rosters updated to allow for a quick surge of staff to the ED. In some cases, the local hospital can be at “ground zero” from a tornado strike, as happened in Joplin, Missouri. In these situations, the hospital is rendered inoperable, and the staff must deal with transferring inpatients to another facility, as well as setting up a treatment area in whatever structure is available. Mutual aid compacts established beforehand between hospitals and states are critical to mitigating suffering and death. Routine disaster drills in conjunction with local emergency medicine services, hospitals, Air National Guard CRBNE Enhanced Response Force Package (CERFP) Medical Teams, and Federal Disaster Medical Assistance Teams (DMAT) can reduce confusion and provide for a quicker response in the event of a catastrophic tornado.
Earthquakes
Similar to tornadoes, earthquakes give little or no warning yet result in large areas of property destruction, injuries, and deaths. The West Coast and Alaska are known for catastrophic earthquakes, but large fault lines in the Midwest and Mississippi River Valley make this area prone to devastating earthquakes as well. Most of the injuries and deaths are the result of crush injuries, fires, and explosions. Earthquakes that strike areas with older structures not built to withstand earthquakes will result in a large-scale mass casualty event. Similar to a hurricane, local infrastructure (including medical facilities) may be inoperable, and roads may become impassable. Again, clinicians should be ready to follow their hospital’s disaster plan and be prepared to see large numbers of patients with crush injuries, open fractures, head injuries, compartment syndrome, and lacerations. Clinicians should expect casualties to exceed their facilities’ capabilities within a matter of hours. Patients standing the best chance of survival should be treated and evacuated first. Care must be taken not to exhaust material and manpower on patients with predictably poor outcomes. In addition, public health can become an issue. Rapid deployment of state and federal civilian and military assets is critical to providing nutrition, water, medical teams, supplies, heavy lift capability, and security. Hospital disaster plans should include yearly opportunities to interface with these state and federal assets.
Tsunamis
Tsunamis are enormous waves generated by an underwater earthquake, often thousands of miles away. Because of the Pacific Rim’s earthquake activity, the West Coast of the continental United States, Alaska, and Hawaii are prone to tsunamis; however, any coastline is at risk. Tsunamis occur with little warning and are characterized by a sudden receding of the ocean and then the sudden development of waves that flood inland, sometimes for miles. The majority of deaths are from drowning. Injuries as the result of debris include crush injuries, lacerations, and fractures. Populations are affected by a lack of clean water, contaminated food, and exposure to the elements. Clinicians should be prepared not only to treat acute injuries but also to manage the aggravation of preexisting medical conditions and the procurement of lost medications in the at-risk populations.
Terrorism
Terrorism is the use of violence in the pursuit of political gains. Terrorism gained a foothold through various groups in the 1970s, culminating in the events of September 11, 2001. Terrorism can be from domestic sources, such as the Oklahoma City Federal Building bombing, or from foreign terrorist groups. PAs should be aware of potentially high-value terrorist targets in their communities and be prepared to respond to blast injuries, chemical exposures, biological exposures, radiation exposures, and penetrating injuries such as gunshot wounds. Potential targets include famous landmarks, transportation hubs, hotels, government offices, chemical factories, railcars and transfer trucks carrying sensitive materials, petroleum plants, nuclear facilities, and military installations. Clinicians should practice situational awareness and know that in a mass casualty situation, there is the potential that an armed terrorist could present to a medical facility as a patient. Clinicians should be knowledgeable in regard to decontamination procedures and PPE in the event of a CBRNE attack. Protection of hospital staff and clinicians is of the utmost importance, so as not to risk the ability of the facility to provide care.
Mass casualty incident and disaster preparedness is not a luxury in the 21st century. As threats grow from both natural and human-made sources, all PAs must be prepared to respond as frontline health care providers no matter their specialty. The threats can come from any place at any time. The best chance of mitigating suffering and death is proper training and preparation of the responding providers.
Preparing before disaster strikes
Preparation for an MCI or disaster begins with education. PAs and the lay public should educate themselves on the types of disasters likely to occur in their respective regions. Situational awareness is a cornerstone of disaster preparedness. Situational awareness is the concept of observing one’s environment to identify potential dangers. Determination of the likelihood of specific types of disasters requires an understanding of natural disaster patterns, surrounding industries and businesses that incorporate hazardous chemicals and processes, and potential terrorist targets (e.g., military bases, federal buildings, national landmarks, financial institutions, key infrastructure).
Evaluating natural disaster patterns allows individuals and disaster planners to direct the focus of their preparation as it relates to sheltering in place versus evacuation. For example, a person living in an area prone to tornadoes will need to plan for sheltering options that are accessible on short notice because evacuation time will be limited. Individuals should evaluate their homes and other locations they frequent for areas that offer maximum protection. The plan used to promote safety during a tornado is much different from the plan common in hurricane preparation. Individuals caught in the path of a tornado usually have little time to escape, whereas technology normally allows tracking of hurricanes for lengthy periods of time before landfall. This lead time allows the public to physically secure houses, commercial buildings, infrastructure, and so on. The lead time also allows for self-evacuation and assisted evacuation of special needs populations. Whether an individual is facing a quick-hitting tornado or a protracted threat from a hurricane, preplanning is key to protecting life and property.
Just as preplanning for natural disasters is required for increased survival, decreased injuries, and an appropriate post disaster medical response, preplanning is also required as it relates to human-made disasters and terrorism. Human-made MCI and disaster scenarios include but are not limited to industry-related accidents, such as nuclear power plant malfunctions with large-scale radiation release, hazardous material (HAZMAT) release and contamination, structural collapse, and airline crashes. These types of incidents are unintentional, but terrorism is an intentional act causing, in this case, the disaster. Preplanning for human-made and terrorism-related disasters vary with the mechanism and location of the attack.
An appropriate and effective medical response to an MCI or disaster requires preplanning. Preplans are designed to provide a framework for responders to follow. MCI and disaster preplans are developed by governmental agencies at the local, state, and federal levels. Preplans are also common to private entities with special needs, such as high-risk industrial processes, large numbers of employees, and special needs populations. Adherence to MCI and disaster preplans allows agencies from multiple jurisdictions, as well as agencies from different disciplines (medical, fire, law enforcement, military), to work jointly rather than duplicating efforts or possibly inhibiting each other from performing required tasks. MCI and disaster preplans vary in complexity based on specific types of events, types and numbers of agencies involved, geographic areas covered, and so on. It is common for medical providers of varying levels to self-deploy to the scenes of MCIs or disasters to assist with medical care. Well-designed preplans take into account the tendency of individuals to respond independently and set up mechanisms to account for these responders, verify credentialing, and integrate them into the overall operational plan. Although the impromptu response to the scene of an MCI or disaster may provide much-needed help for dispatched resources, medical providers interested in MCI or disaster response should explore opportunities to participate through defined roles within existing MCI and disaster response teams and preplans. Interested PAs will then be trained to function as members of the responding teams. Understanding how to practice medicine in an austere environment and how it differs in some aspects from conventional medicine will make a PA an asset on the scene rather than a liability. Trained MCI and disaster medical responders understand that medicine is a part of the operation but has to be planned and carried out in a manner that is governed by such concerns as scene safety, any ongoing law enforcement activity, and limitation of resources, including personnel and supplies. As PAs, our tendency is to focus on the medical needs of the patient and provide the highest standard of care possible. Although focusing on the medical needs of our patients is completely appropriate in our conventional medical care settings, it could easily lead to dangerous tunnel vision at the scene of an MCI or disaster. Focusing on a patient’s medical needs may cause us to miss the fact that he or she is lying in contact with a live high-voltage power line. The concept of triage medicine is important for the disaster medical responder. To make the decision to withhold CPR on a patient with no pulse in the setting of mass casualties, who could benefit from immediate medical attention, is not a decision that is easily made. Learning proper triage techniques and algorithms can assist medical responders in functioning in the MCI and disaster environment. PAs interested in local or regional response should contact their municipal or state Office of Emergency Management to discuss opportunities for service. PAs also have an opportunity in disaster medicine through military service in the National Guard. PAs are a critical component of United States Air Force Air National Guard (ANG) medical disaster teams, which are designed to augment civilian responders in a MCI event. Another option for PAs interested in MCI and disaster response is the National Disaster Medical System (NDMS).
The National Disaster Medical System (NDMS) is a federally coordinated system that augments the nation’s medical response capability. The overall purpose of the NDMS is to supplement an integrated national medical response capability for assisting state and local authorities in dealing with the medical impacts of major peacetime disasters and to provide support to the military and the Department of Veterans Affairs medical systems in caring for casualties evacuated back to the United States from overseas armed conventional conflicts.
The MCI and disaster response component of the NDMS includes NDMS Response Teams. The NDMS Response Teams include:
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DMATs
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International Medical Surgical Response Team (IMSURT)
A DMAT is a team made up of medical providers of varying levels and support members, including administrative and logistics personnel. The teams are based in various states across the nation and are designed to rapidly respond to MCI and disaster situations to augment the local and regional medical response. PAs volunteering for assignment to a DMAT are considered intermittent federal employees when the DMAT is activated. The IMSURT is a specialized NDMS team capable of providing surgical and critical care services in the aftermath of an MCI or disaster. Similar to a DMAT, the IMSURT will augment local and regional resources.
The NDMS falls under the Office of Emergency Management (OEM) within the U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response. The OEM also houses the Medical Reserve Corps (MRC).
The MRC is a national network of volunteers, organized locally to improve the health and safety of their communities. The MRC network comprises 998 community-based units and over 200,000 volunteers located throughout the United States and its territories.
PAs volunteering for the MRC are available to be used during MCI and disaster situations as well as disease outbreaks. The MRC also focuses on community health and health promotion.
PAs can learn more about volunteer options for NDMS at http://www.phe.gov and more about the MRC at https://mrc.hhs.gov/HomePage . The OEM also offers the Emergency System for Advance Registration of Volunteer Health Professionals. This is a state-based registry that health care volunteers can join to have their credentials and licensure validated. This registry allows PAs to be used on scene quicker in the case of an MCI or disaster because the credentialing of responding providers can be a time-consuming process for administrative personnel on scene. Further information about this registry can also be found at http://www.phe.gov .
Another recommended resource for PAs interested in MCI and disaster response is the website of the American Academy of Physician Assistants (AAPA), http://www.aapa.org , where PAs can access a document titled The PA in Disaster Response: Core Guidelines.
Other websites with information related to MCI and disaster preparedness include:
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Centers for Disease Control and Prevention. Natural Disasters and Severe Weather. http://emergency.cdc.gov/disasters/ .
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American College of Surgeons. Disaster Management and Emergency Preparedness. http://www.facs.org/quality-programs/trauma/education/dmep .
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Federal Emergency Management Institute. ICS Resource Center. https://training.fema.gov/emiweb/is/icsresource .
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FEMA. Community Emergency Response Teams. https://www.fema.gov/community-emergency-response-teams .
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Centers for Disease Control and Prevention. Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm .
PAs who are attached to disaster response teams or who hold positions requiring them to respond to MCI or disaster situations will likely have equipment provided to accomplish their assigned tasks. For individuals who will respond in a volunteer capacity, the following items should be considered when putting together a basic medical response load:
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PPE (gloves, eye protection, hand sanitizer)
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Tourniquets (commercial, improvised)
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Oral and nasal airways
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Advanced airways (if within scope of practice)
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Bag-valve mask
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Occlusive dressing for chest wounds (commercial, petroleum gauze, examination gloves)
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Large-bore needles for chest decompression (if within scope of practice)
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Bandages (various sizes)
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Hemostatic dressings
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Emergency or survival blankets (Mylar or other conductive material)
Just as preparation is a must for any disaster medical responder, it is equally vital for the public at large. News stories after disasters are filled with individuals lamenting a perceived lack of response to their basic needs. Individual preparedness is key to survival during and immediately after an event. The most effective mindset for individual disaster preparedness is the concept of all-hazard planning. All-hazard planning allows preparation across disaster types. The concept of all-hazard planning pushes disaster planners and individuals to focus on preparedness and response measures that would be generally effective regardless of the cause of the disaster. For instance, creating safe and effective evacuation routes from a facility would increase survival regardless of the cause of the evacuation (e.g., fire, chemical release, active assailant). The following suggestions can serve as a guide for individual disaster preparedness and are derived from the information found on the CDC’s website ( https://www.cdc.gov/ncbddd/hemophilia/documents/familyemergencykitchecklist.pdf ):
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Water (1 gallon per person per day)
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Food (nonperishable, prepackaged meals ready-to-eat)
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Fire-starting material (commercially available, improvised)
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Candles (commercially available emergency candles)
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Knife with a can opener
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Cell phone and charger (commercially available emergency charger)
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National Oceanic and Atmospheric Administration (NOAA) weather radio (battery powered, solar, hand crank)
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Flashlight
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Batteries
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Fishing line and hooks
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First aid kit
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Medications (prescription medications and desired over-the-counter medications)
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Emergency or survival blankets (Mylar or other conductive material)
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Cash
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Pet supplies (food, medications, leash)
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Maps
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Communication plans for family and friends during or immediately after event
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Preplanned meeting place for family and friends during or immediately after event
As health care providers, PAs are regularly engaged in health promotion and disease prevention efforts. Educating our patients about MCI and disaster preparedness is an area of health promotion that is of vital importance and can affect not only our patients but also our public health efforts as well.
After a crisis
PAs play a vital role in caring for those who have lived through a mass casualty or natural disaster. Not only will they care for the victims of such tragedies, but they may also have to care for the first responders. Immediate medical needs are accessed to prevent loss of life and limb. Subsequently, other issues may arise well after the actual incident, such as disease outbreaks caused by contaminated food and water. PAs need to maintain awareness of federal and state surveillance and reporting requirements regarding disease outbreaks to prevent full-blown epidemics. This information can be ascertained on individual state Department of Health websites or from the CDC’s Morbidity and Mortality Weekly Report (MMWR). MMWR reports national and international incidents and gives up-to-date information on public health issues. It can be found at http://www.cdc.gov/mmwr .
Posttraumatic stress disorder
Posttraumatic stress disorder (PTSD) develops after a terrifying ordeal that involves physical harm or the threat of physical harm. People who have PTSD continue to experience stress or are traumatized long after they are out of harm’s way. PTSD was once thought to be a mental disorder suffered only by war veterans, but it can be observed in any individual who has undergone a traumatic event such as a terrorist attack or a natural disaster. It should also be noted that PTSD can be observed in children.
Signs and symptoms of PTSD include the following three categories:
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Reexperiencing symptoms
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Flashbacks: reliving the trauma over and over, including physical symptoms such as a racing heart or sweating
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Bad dreams
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Frightening thoughts
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Avoidance symptoms
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Staying away from places, events, or objects that are reminders of the experience
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Feeling emotionally numb
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Feeling strong guilt, depression, or worry
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Losing interest in activities that were enjoyable in the past
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Having trouble remembering the dangerous event
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Hyperarousal symptoms
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Being easily startled
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Feeling tense or “on edge”
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Having difficulty sleeping or having angry outbursts
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Children with PTSD often present with bedwetting after having been previously toilet-trained, forgetting how or being unable to speak, acting out the scary event during play, or being unusually clingy. Recognizing the signs and symptoms of PTSD is imperative to diagnosing and ultimately treating those who have this debilitating condition.
Not everyone who experiences a traumatic event will go on to develop PTSD. Several risk factors and resilience factors have been identified to help determine who is at greatest risk for experiencing PTSD.
Risk factors for PTSD include:
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Living through dangerous events and traumas
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Having a history of mental illness
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Getting hurt
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Seeing people hurt or killed
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Feeling horror, helplessness, or extreme fear
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Having little or no social support after the event
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Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home
Resilience factors that may reduce the risk of PTSD include:
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Seeking out support from other people, such as friends and family
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Finding a support group after a traumatic event
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Feeling good about one’s own actions in the face of danger
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Having a coping strategy, or a way of getting through the bad event and learning from it
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Being able to act and respond effectively despite feeling fear
The diagnostic criteria for PTSD as per the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), identifies the trigger as exposure to actual or threatened death, serious injury, or sexual violation. The exposure must result in one or more of the following scenarios, in which the individual:
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Directly experiences a traumatic event
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Witnesses the traumatic event in person
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Learns that the traumatic event occurred to a close family member or close friend
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Experiences first-hand repeated or extreme exposure to aversive details of the traumatic events
The disturbance, regardless of its trigger, causes clinically significant distress or impairs the individual’s social interactions and capacity to work or perform other important areas of functioning. It is not the physiologic result of another medical condition, medication, drugs, or alcohol.
Special populations
Children, older adults, and people with mental impairments are all at higher risk for injury and illness after a disaster. Cognitive impairment and physical disability such as vision and hearing impairment make evacuating older adults and people with cognitive impairments more difficult. Older adults also have more chronic illnesses and are dependent on medication to maintain a stable state of health. Evacuation of these groups of people is often delayed to the point that it is too late, as seen during Hurricane Katrina. Furthermore, pediatric populations do not realize the gravity of a particular emergency situation and may not move to safety. In addition, they are dependent on adults to direct them, which may be difficult in places such as daycare centers where the adults are outnumbered by the children in need. Pediatric and geriatric populations are also often more susceptible to infectious diseases because of lowered immune responses.
