Planning and Triage in the Disaster Scenario and Triage in the Disaster Scenario Ciro Ugarte |...

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M O D U L E 3

Planning and Triage in the Disaster Scenario

Ciro Ugarte | Jacobo A. Tieffenberg | Lou Romig | Tien T. Vu

ADDITIONAL CONTRIBUTIONS FROMLara Rappaport MD, MPH, Jason R. Blumen BA, NREMT, and Joseph Wathen, MD

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INTRODUCTION

“Failure to plan is planning to fail.” This quote by Benjamin Franklin appro-

priately reflects the message of this module. Emergency preparedness planning is

crucial to prevent or mitigate a disaster. As defined in Module 1, disasters occur

when a natural or man-made event transforms a vulnerable human condition into

a traumatic event causing needs to exceed the local capacity for response. Without

adequate planning, the most common response to these types of incidents is con-

fined to simply rescuing victims and transferring them promptly to a hospital facil-

ity (the “Scoop and Run” approach).This results in the transfer of the problem from

the incident site to the hospital, overwhelming and disrupting the care capacity of

the health facility.

Some events occur suddenly, with little or no warning. Others, such as flood

and hurricanes, usually provide advanced warning or have a gradual onset that

allows for additional preparations before the critical stage ensues. In any case, spe-

cific planning and preparedness are especially important to reduce the suffering

caused by disasters, particularly for children. Children are among the most vulner-

able populations in disasters because they have unique physiological, psychological,

and developmental needs. Pediatricians and the local community have a special

responsibility to assess how local, regional, and national preparedness plans and

response systems will actually function to protect children. Failure to consider the

needs of children in disaster planning, preparedness, and response at all levels

Planing and triagein the disaster scenario

Ciro Ugarte, MD Jacobo A. Tieffenberg, MD, MS, MPH

Lou Romig, MD, FAAP, FACEPTien T. Vu, MD, FAAP

potentially jeopardizes this vulnerable population. Pediatricians must advocate for

the health, safety, and well-being of infants, children, adolescents, and young adults

who cannot advocate for themselves. Increasing our understanding of how children

were affected by past disasters will inform and strengthen our response.

The information provided in this module can assist in the design of an emer-

gency preparedness plan that will increase coordination among the many disciplines

involved in disaster response. Active participation of all relevant entities in plan

development is crucial. Participation in planning among involved entities breaks

down the silos that all too often isolate different disciplines, and promotes under-

standing and cooperation among them. The multidisciplinary, inclusive planning

process is actually more important than the document itself. The planning process

facilitates a collective understanding among all the key agencies and their person-

nel about the plan, which is indispensable for effective implementation of the plan

when it is needed. Planning should include both short-term and more long-term

ways of risk reduction from potential disasters, efforts to educate families and com-

munity organizations about preparedness, and methods of horizontal and vertical

coordination involving multiple local entities as well as regional, national, and inter-

national assistance networks. Local planners need to have knowledge of the region-

al and national response systems and the means to coordinate local activities with

these systems.

This module reviews the basic concepts for emergency planning and response

preparedness, and discusses the various levels of planning which include the family,

health professionals, community organizations, and health facilities. The final section

of this module reviews how to organize community emergency services capable of

responding to a mass casualty incident.

SECTION I / LOCAL EMERGENCYPLAN

During the prevention phase, the ulti-mate goal is to avoid or mitigate the disas-ter, directing efforts aimed at reducingboth the risk and the vulnerability of thepopulation. In many events, damages willoccur despite mitigation efforts, and this isdefined as the remaining risk. To face thesedamages, the capacity for response mustbe improved through preparedness. If adisaster occurs, the plan will be imple-mented in order to provide medical andhumanitarian assistance. The responsephase consists of both implementation ofpreviously derived preparedness plans, aswell as any spontaneous actions felt to beneeded even if not part of a formal plan.After the response phase, efforts will bedirected towards repairing damaged serv-ices. This is known as the recovery phase.Reconstruction and recovery consists ofrestoring the goods and services back topre-disaster levels if possible, and includesmeasures for future risk reduction.

Pediatricians initially act as risk manage-ment agents in the local emergency anddisaster system and, if a disaster occurs, asspecialists in the care of children. Theyshould be familiar with the plans that existin their county or state so that they canwork in coordination with other membersof the response system. In summary, emer-gency planning includes all the activitiesand actions done preemptively in order toprevent, mitigate, respond to, and recover

LOCAL EMERGENCY PLAN

OBJECTIVES

� Describe the components of the plan andthe pediatricians’ role.

� Identify the risk factors that warrantconsideration when planning for disasters.

� Know the basic requirements for thedesign and coordination of a local disasterplan.

Disaster management is part of the socialsystem responsible for planning, organiz-ing, directing, and controlling during all thephases of emergency management:Preparedness, Prevention, Response, andRecovery. The disaster plan should definethe objectives, strategies, and activities,including a detailed chronology and a pro-posed budget.

The emergency plan will have differentobjectives depending on the phase.Disaster preparedness includes the designof the plan, the training and coordinationof those who will execute it, and the avail-ability of needed resources. The plandesigned during this stage is genericallynamed the response plan. A plan made forvarious adverse events is called an emer-gency or disaster plan, whereas a contin-gency plan is designed for a specificadverse event (e.g., tornado, flood, pan-demic).

Disasterpreparednessincludes the design of the plan, thetraining andcordination of thosepersons that willexecute it, and theavailability of theneeded resources.

6 SECTION I / LOCAL EMERGENCY PLAN

from the damages that disasters can cause.All stages of a disaster (described inModule 1) include elements of planningthat are important for the pediatrician.These involve various social agents and areperformed at different levels: the family,local community organizations, emergencyservices, community physicians, hospitals,government, and other agencies.

If a response plan has not been devel-oped or fails to contemplate the specialneeds of children, develop a plan or sug-gest additions to the existing plan. This isnot merely desk work. It involves obtainingand analyzing data, along with field visitsand meetings with representatives fromdifferent institutions and the community.Preparation demands the active participa-tion of the health-care sector and thecommunity. These efforts should result inthe production of operative and concisedocuments that clearly define the respon-sibilities of specific participants and theagreements reached among the partici-pants. It is important to institute periodicdrills to test the functionality of the systemand the coordination among the differentparticipants.

Risk evaluationA risk evaluation involves an analysis ofthreat and vulnerability. It considers thecharacteristics of potential threats to acommunity and determines how the com-munity would be affected. Identify the pos-sible natural events that threaten a partic-ular community (e.g., earthquakes, torren-tial rains, volcanic eruptions, sliding soils,the overflow of rivers or lakes). In certainregions, the climatic events that endangerthe population have a seasonal predisposi-tion. Recognizing these climatic cycles canmaximize preparedness before and during

these periods. Do not disregard disasterscaused by human actions. These includeincidents in factories, chemical or fuelstorage plants, intentional or accidentalfires, incidents with radioactive or nuclearmaterials, armed conflicts, wars, or terror-ism. In summary, risk evaluation involvesidentifying regions and communities thatare most vulnerable to the threats underconsideration, and describe the specificcharacteristics that make these communi-ties susceptible to those threats.

The Community – LocalEmergency Plan Every community should develop its ownemergency plan with the participation ofthe local institutions and agencies. Clearlydefine the responsibilities of each institu-tion and methods of coordination and col-laboration. Analyze the risks threateningthe various sectors of the community anddevelop immediate interventions recogniz-ing both geographic and climatic condi-tions for various regions. Obtain inputfrom regional and national levels, involvingnational and regional health officers in theplanning process.

Key planning conceptsThe emergency plan should fulfill threeessential characteristics: it should beclear, concise and complete.

Clear: Make the wording simple andeasy to understand, with no margin fordoubt.

Concise: It should be quick to read.The longer the plan, the less likely it willbe read in its entirety and the more diffi-cult it will be to update regularly and dis-tribute.

If a response plan hasnot been developed orfails to contemplatethe special needs ofchildren, develop aplan or suggestadditions to theexisting plan.

Every communityshould develop itsown emergency planwith the participationof the localinstitutions andagencies.

A risk evaluationinvolves an analysisof threat andvulnerability.

7SECTION I / LOCAL EMERGENCY PLAN

Complete: include all the necessarycomponents for effective action, coordina-tion, and reassessment.

The plan describes the responsibilitiesof each participant, the risks involved, andthe range of interventions. It is imperativeto involve the organizations that will carryout the plan in the planning process itself.For a health-care agency, the emergencyplan defines the objectives, the actions, andthe organization of the hospital and its var-ious departments with respect to theresponse activities and responsibilities ofits staff members.

Additionally, the plan needs to be knownby all entities involved. These elements areessential if the plan is to be executed in thepre-established manner.

Basic components of an emer-gency plan Analysis of the situationThe analysis of the situation includes:

• a description of the threats, whethernaturally occurring or due to humanaction.

• an analysis of the structural and non-structural vulnerability of areas at risk inthe community.

• an evaluation of how agencies wouldfunction to deliver needed services(operative capacity).

• the availability of resources, infrastruc-ture, equipment, and critical supplies.

AssumptionsIdentify the type or types of phenomenathat should be addressed in the plan anddescribe the probable magnitude, theexpected intensity at the site where thecommunity is located, and the time period

during which it is likely to occur.Determine the potential damages and themaximal demand for health services byestablishing a relationship between thethreat and the vulnerability.

Objectives and goalsThe objectives and goals describe theexpected outcomes from executing theemergency plan given the human, econom-ic, and material resources that will realisti-cally be available. One of the most frequentmistakes when preparing an emergencyplan is to include nonexistent resourceswith the hope of obtaining them in thenear future. Since it is usually impossible toobtain all the desired resources, establishpriorities for the actions based on the pop-ulation and geographical area to be served.The plan should include an outcome pre-diction that describes the measurableimpact of carrying out the emergency plan.

Organization Organize the various sectors and depart-ments of the institution so that authority,lines of responsibility, and methods ofcoordination and communication for planactivation are clear and well-defined.Establish an emergency operations com-mittee to oversee and coordinate theresponse actions.

Roles and responsibilities The assignment of roles and responsibili-ties is meant to answer the following questions:

• Who does what?

• When?

• How?

• With what?

One of the mostfrequent mistakeswhen preparing anemergency plan is toinclude nonexistentresources with thehope of obtainingthem in the nearfuture.

8 SECTION I / LOCAL PLAN EMERGENCY

Communication and coordination The communication instructions describea calling or notification chain from a cen-tral point until all the necessary individualshave been contacted. Establish the meansof communication to be used, indicatingthe radio band and frequency, the tele-phone numbers, and the rendezvous loca-tions. Appendices to the plan include anupdated directory of all the participants, amap of threats, vulnerable areas, or loca-tions, as well as the population database, ahealth profile, health centers included inthe network, a directory of basic services(e.g., water, electricity, telecommunica-tions, security), assistance agencies, and aninventory of the available resources.

Training Once the emergency plan has been devel-oped, conduct training. Training shouldenable the participants to describe the sit-uation, expected damages, roles andresponsibilities, and means of coordina-tion. This training should include simulationexercises consisting of a written test basedon the presentation of scenarios. The par-ticipants will have to solve theoretical(tabletop) exercises once they have beenassigned one of the roles and responsibili-ties contemplated in the plan. This exerciseallows participants to assess their knowl-edge of the technical and organizationalaspects of the emergency plan.

At a later stage, disaster drills can beorganized and enacted. Initially, organizedisaster drills with prior notice, promotingthe participation of the staff and key mem-bers of the community. Once the partici-pants have acquired sufficient knowledgeand skills, organize unannounced disasterdrills to put the response plan to test.

Enacting unannounced simulated disasterswithout previously training participantsusually causes frustration and has unwant-ed effects.

ResourcesAnalyze the activities included in theemergency plan to determine theresources required. This listing ofresources is called the requisite analysis.Contrast the listed resources with thoseactually available and define the resourcesthat are yet to be obtained. Gather theresources needed to carry out the emer-gency plan. Remember that the emergencyplan must be based on reality. Otherwise,it will become a mere listing of wishfulideas.See Box 1 for useful planning resources.

Coordination of the localemergency planThe response mechanisms will have specif-ic characteristics depending on the size ofeach community and the particular risksthat threaten it. The coordinators in hospi-tals, rescue services, and emergency med-ical services, as well as the participantsprocessing the incoming information,should report to an incident commanderwho will direct the local emergency plan(Figure I). For incidences involving multi-ple jurisdictions and agencies, a unifiedcommand system may be established inwhich individuals designated by their juris-dictions work jointly to determine priori-ties, resource allocation, and strategiesneeded to execute the emergency plan. Acoordinated emergency responsebetween various levels of local, state, andfederal government may be needed, inaddition to non-governmental agenciesproviding humanitarian aid.

Enacting unannouncedsimulated disasterswithout previouslytraining participantsusually causesfrustration and hasunwanted effects.

9SECTION I / LOCAL PLAN EMERGENCY

BOX 1. Resources for local emergency plan development in the United States1

• Federal Emergency Management Agency (FEMA) – National IncidentManagement System (NIMS) publications at http://www.fema.gov/emergency/nims/

• Centers for Disease Control and Prevention - software planningmodel tools for governments at http://emergency.cdc.gov/cdcpreparedness/science/planningtools.asp

• Your state’s homeland security office, local government affairs office,or county government office, listings at http://www.fema.gov/about/contact/statedr.shtm.

• Colorado’s Office of Homeland Security at http://www.colorado.gov/homelandsecurityand Colorado Department of Local Affais athttp://dola.colorado.gov/dem/index.html

FIGURE 1. National incident Command System

National Incident Command System (NIMS), U.S. Department of Homeland Security, Dec 2008

PLANNING LEVELS

OBJECTIVES

� Identify the different levels of planningfor disasters.

� Help families make a familyemergency plan.

� Recognize the importance of one’sown planning, and the planning byother health-care professionals andhealth centers.

� Assist schools in developing theirown emergency plans and how theycan integrate into the localcommunity emergency plan.

� Identify the special needs that shouldbe addressed in a disaster shelter.

� Describe the role of the EmergencyMedical Services (EMS) in disasterresponse.

� Discuss state and federal emergencyresponse plans.

SECTION II / PLANNING LEVELS

Planning in the FamilyPediatricians should prepare themselvesfor a disaster as well as provide the fami-lies of their patients with informationabout creating a family emergency plan.The questions below serve as a planningguide. Families need to understand thatthey have to be prepared to evacuatebefore the area becomes inaccessible byrescue services, and if they choose to stay,they might not be helped immediately.

Important questions that family plansmust address are:

• What are the disasters most likelyto occur in your community?• Is your home, your children’sschool, and your working place locat-ed in risk areas?• How well-prepared is your home toface the most likely disaster?• Can your family be notified withsufficient anticipation or should theybe prepared in order to respond atany time?• In the event of a disaster, can youlocate and reunite your family mem-bers at a safe location?

All family members should know con-tact telephone numbers outside theaffected area and know where communi-ty shelters will be located. It is also agood idea to have a pre-establishedmeeting point outside the risk area whenpossible.• What should you do when you or oneof your family members need to leavethe family because of healthcare orother related responsibilities during adisaster situation?

When professional duties (e.g., those ofhealth-care professionals, policemen, fire-fighters, public officials) limit the ability toassist one’s own family, it is important tohave a clear written plan that has been dis-cussed and can be followed. An examplewould include having a retainer contractwith a child care provider during a pan-demic influenza outbreak.• Do any members of your family havespecial health needs that might beaffected during a disaster?

Pediatricians shouldprepare themselves fora disaster as well asprovide the families oftheir patients withinformation aboutcreating a familyemergency plan.

Provide families withinformation aboutmaking a contingencyplan that will enablefamily independencefor 3 days following adisaster.

Consider storing and periodicallyrenewing medications and supplies neededby family members with special health-careneeds for use in the event of a disaster.Consider having a small backup generatorto keep a refrigerator operational to storemedications when there is no electricity.Recognize that family members with spe-cial needs may require earlier evacuationto ensure a safe environment.

Provide families with information aboutmaking a contingency plan that will enable

family independence for 3 days following adisaster. A list of supplies needed for 3 days of self-sufficiency are shown inBox 2. A local specialist can add otheruseful supplies based on the local situa-tion. Box 3 lists online resources for families.

Planning by the medical staff In addition to having their own family planand educating the families of their patients,pediatricians should address several issues

BOX 2. Supplies needed for 3 days of self-sufficiency 2Basic supplies

Bottled drinking water (4 L/day/person)*Identity cards of all family membersWell-equipped first aid kit and first aid manualNon-perishable foodMatchesFlashlight with batteries or hand-crankExtra clothing for protection from bad weather or outdoor staysBlankets or sleeping bagsMoney, including small changeInsect repellentPersonal hygiene products and sanitizerVarious supplies for infants and small childrenPortable radio, cell phones (preferably with radio or walkie-talkies)Map of the city or regionFrequently used medications and medical prescriptions

Some complementary suppliesManual can openerGarbage bagsTwo extra sets of home and car keysElements to hold and transport pets (e.g., leashes, collars, kennels)Food and water for petsExtra glasses

* It is advisable to have enough drinking water for 1 week.

11SECTION II / PLANNING LEVELS

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for their offices and staff. These issuesinvolve ensuring the safety of staff andpatients, protecting equipment and materi-al, and securing patient records.

Consider the need to have a backup gen-erator to maintain refrigeration for vaccinesand other medications. When necessary, planfor a backup location for treating yourpatients and, if possible, a method for inform-ing callers where they can obtain care. Referto the American Academy of PediatricsOnline Tool for Disaster Preparedness forPediatric Practices (http://practice.aap.org/disasterpreptool.aspx).

Planning by schoolsPublic and private schools also need emer-gency response plans. School plans shouldconsider the most frequent accidents aswell as unusual situations (e.g., fires, schoolviolence, terrorist attacks, chemical expo-sures, community violence).

School plans should include details onhow urgent medical care can be providedwhen needed on site. Plans should includetraining for school staff in basic life sup-port, first aid, and rescue techniques.

School disaster plans should alsoaddress the identification and managementof post-traumatic stress in students andstaff members, as well as indications forreferral for professional psychologicalintervention.

Following a disaster, children often needthe security of a normal routine and sup-port of teachers and peers. Closingschools for a prolonged period negativelyimpacts the functioning of children after adisaster. Every effort should be made toopen schools as soon as possible after anevent. Use of school buildings as emer-gency shelters may hinder or complicatetheir reopening. Therefore, coordinationbetween schools and relief agencies such

BOX 3. Resources for families on the Internet

• Federal Emergency Management Agency (FEMA) athttp://www.fema.gov/areyouready/

• American Academy of Pediatrics (AAP) Family Readiness Kit:Preparing to Handle Disasters at http://www.aap.org/family/frk/frkit.htm

• American College of Emergency Physicians (ACEP) FamilyDisaster Preparedness at http://www.acep.org/pressroom.aspx?id=25994

• American Red Cross Family Disaster Education Materials athttp://www.redcross.org/


From: Romig LE. Disaster Management. In: APLS Course Manual. Jones & Bartlett Publishers, 2006.

School plans shouldconsider the mostfrequent accidents aswell as unusualsituations (e.g., fires,school violence,terrorist attacks,chemical exposures,community violence).


as the Red Cross or the local organizationfor emergency management will assist inthe transition to normal operations. Moreinformation regarding school disaster planning can be found at the AmericanAcademy of Pediatrics website:http://www.aap.org/disasters/schools.cfm.

Child care centers also need a plan toensure the safety of children, to coordi-nate with other community responseagencies, and to provide a method forreuniting children with family members.Child care centers need to educate andtrain staff members to implement theemergency plan efficiently.

Families, schools, and child care centersmust consider how to help children withspecial health-care needs in an emergencysituation. The AAP and the AmericanCollege of Emergency Physicians have pub-lished an emergency information form(EIF) for children with special needs. Thisdocument (available at http://www.aap.org/advocacy/blankform.pdf) provides impor-tant medical information about the childto any person responsible for their emer-gency medical care.

Medical Planning for SheltersShelters should have an identifiable per-son who is available, accountable, andresponsible for communicating with agen-cies or organizations for supplies andassistance. Emergency planning must con-sider the possibility of prolonged shelteruse which would require additional sup-plies and greater attention to organiza-tional details. Planning should includesources of supply and methods of trans-portation. The needs of pregnant women,infants, and young children must be con-sidered with respect to formula, diapers,

basic first aid, hygiene, and safety. Sheltersalso must consider children with specialhealth-care needs. For example, childrenwith asthma may need nebulizer treat-ments. Although their families are likely tohave brought their own nebulizers, asource of electricity is needed for thesedevices to operate. Similarly, a refrigera-tor is required to store insulin for chil-dren and adults who have diabetes.Families with very young or debilitatedchildren may move temporarily to a shel-ter to protect them from the heat, cold,sun, wind, or rain. Whenever possible,shelter staff members should have directtelephone or radio access to emergencymedical care services to obtain medicaladvice. Ideally, a shelter should have isola-tion protocols for highly contagious infec-tions such as measles and chickenpox.

Shelter life must also be organized sothat children are supervised and have theopportunity for constructive play andentertainment. Supervised activities enablethe staff to inform children and keep themsafe, while allowing them to participate inactivities and tasks. Drawing and othercreative activities can help childrenexpress themselves and reduce stress.Activities engaging adolescents reduce thepotential of adolescent violence and mis-chief.

Safety in shelters is as important as safe-ty at home. Keep drugs, medical supplies,and potentially dangerous personal itemsout of children’s reach. Reduce the risk forslips or falls in bathrooms and on all floors.Lock unoccupied rooms and monitorexits. People residing in shelters shouldknow where the emergency exits are andhow they are used. If the shelters allow thepossession of weapons, these must be keptout of children’s reach.

Safety in shelters is asimportant as safety athome. Keep drugs,medical supplies, andpotentially dangerouspersonal items out ofchildren's reach.

Emergency planningmust consider thepossibility of prolongedshelter use whichwould requireadditional supplies andgreater attention toorganizational details.

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Planning by HospitalsIf you work regularly at a hospital, reviewthe hospital disaster plan to ensure thatthe plan adequately considers the needs ofchildren. If your hospital lacks an emer-gency plan, offer to help develop a plan.Available resources are listed in Box 4.

Hospital planning for disasters shoulddeal with hospital and pre-hospital events.Hospital events include accidental or nonaccidental events such as the collapse ofhospital structures, fires, explosions, pan-demics or toxic exposures. Plans shouldinclude a detailed description of the meas-ures taken to protect staff members,patients, and visitors. In cases of infectiousdiseases or toxic exposures, protectivepersonal equipment and isolation proce-dures must be instituted immediately toprotect staff or other patients. Hospitalsmay need to coordinate with governmentagencies to access stockpiles of necessarymedicines, vaccines, or equipment. In casesof structural collapse, fire or explosions,rescue interventions attempted by hospi-tal staff who have received no previous

training can put them in serious danger.Educate staff about basic safety precau-tions, and knowing when to intervene orto wait for the arrival of trained rescueworkers. During the past 25 years, naturaldisasters have destroyed dozens of hospi-tals and hundreds of health centers, result-ing in the deaths of thousands of patients,physicians, nurses, and other people whowere trapped in the debris.

Hospitals must determine if it is neces-sary to build their surge capacity. The abil-ity to treat and manage a sudden influx ofpatients will be determined by a variety offactors including, but not limited to, thenumber of inpatient, ICU, or emergencybeds available, surgical capacity, staffingneeds for all departments, supplies, andother physical spaces available for expan-sion of treatment areas. It is important toensure that existing inpatients also receiveappropriate care and are discharged ortransferred to other facilities if necessary.The plan should include a communicationmethod to call in additional health-careprofessionals and ancillary staff. Directors


BOX 4. Resources for Hospital Disaster Planning

• Centers for Disease Control and Prevention - Planning for health-care facilities athttp://www.bt.cdc.gov/planning/#healthcare

• Occupational Safety and Health Administration athttp://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.html

• Agency for Healthcare Research and Quality (AHRQ) - PediatricHospital Surge Capacity athttp://www.ahrq.gov/prep/pedhospital/

• American Academy of Pediatrics – Children & Disasters athttp://www.aap.org/disasters/index.cfm


CASE 1.

A shelter with 130 evacuates is severely damaged by a tornado during a storm.

According to the local protocol, emergency medical services cannot reach the

place due to the intensity of the storm. Victims of the tornado, both adults and

children, begin to arrive massively to the nearest hospital emergency

department. Referrals to other hospitals are not feasible because of the storm.

� Does your hospital disaster plan take into account victims arriving

on their own, or does it only consider those transported by the

emergency medical services? � Are emergency department staff members prepared to perform a

primary triage of the victims?� Does your hospital disaster plan take into account the staffing and

resources needed to operate under highly demanding conditions

with minimal external help?

of hospitals and emergency departmentsshould have a basic knowledge of the localdisaster plans and the local command lev-els. Select one or more members of thehospital staff to serve as liaisons withother responding organizations and agen-cies to coordinate any activities undertak-en outside the hospital environment. Incertain situations, a hospital can also serveas shelter for staff members and their fam-ilies, patients with special needs, and thegeneral public.

Some U.S. hospitals have adopted amodified system for mass casualty inci-dents or disasters that mirrors the exter-nal incident command system. Originallyknown as the Hospital EmergencyIncidents Command System (HEICS), it isnow known simply as the Hospital IncidentCommand System (HICS). The system wasoriginally developed by California firefight-ers in order to establish a common com-mand structure and nomenclature. This

allows for a greater integration with theexternal response plans (Figure 2 andBox 5) and provides a working commandstructure for the hospital. It also recog-nizes the necessity of many other ancillaryservices and functions that may not be ini-tially considered a part of direct patientcare, but are nonetheless vital to emer-gency hospital operations.

Hospitals can also offer physicians whohave lost their offices a space in which toattend to patients or in turn, provideemergency credentialing to communityphysicians when additional help is need.These additional physicians can cooperatewith the regular hospital physicians in thecare of patients who have minor condi-tions, thereby allowing regular hospitalstaff to attend to more critical cases.

Hospital plans also need to address themanagement of stress. Frequent rotationof providers and staff during surge timesenables efficient performance, and mini-

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COORDINATOR

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officer

Medical officer

Safety officer

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ospit

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ergency Incide

nt Com

mand System

Update Proje

ct. Califor

nia E

mergency M

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BOX 5. HEICS

HEICS (Hospital Emergency Incident Command System) was created in 1993 inCalifornia, by the authorities of San Mateo district medical emergencies service(MES). It consists in an algorithm of positions, the holders of which have a specifictask in the event of an emergency situation (Figure 1). Each of these persons hashis/her own listing of tasks to be carried out, so that he/she can guide the implemen-tation of these tasks in the framework of an integral system if a disaster occurs.HEICS also includes listings of operations aimed at maximizing the overall efficiency,promoting the undertaking of responsibilities, and facilitating the recording of keydata. This system has a flexible structure, allowing the activation of the required posi-tions only, since activating the entire structure may take hours and even days. In thegreat majority of cases, less than the complete structure will be needed. The listedpositions are not assigned to a specific individual; several individuals can be availableto cover a position assigned by the incident coordinator; in other cases, a single indi-vidual has to undertake more than one position, according to the listing of tasks.

Additional information on HEICS and its materials can be obtained inwww.heics.com.

mizes psychological and physical exhaus-tion. Hospital plans should also take intoconsideration the care of individuals withacute stress reactions, those who feelguilty for having survived or having aban-doned their families, and those who havesuffered considerable material losses orhave other psychological sequelae duringand after the disaster. Post-traumaticstress disorder and other stress-relatedsyndromes are frequent after a disaster.

The Emergency MedicalServices and GovernmentPlanning Emergency Medical Services (EMS) are atype of emergency service dedicated toproviding out-of-hospital acute medicalcare and/or transport to definitive care topatients with acute illness and injuries. The

US has a sophisticated system of EMSagencies that include different levels ofproviders. Each type of provider is an inte-gral part of the system and the composi-tion of providers is dependent on theneeds and resources of the local area.

For pediatric care, EMS must ensurethat providers have proper training totake care of children on a daily basis, andare familiar with pediatric dosing, pedi-atric equipment use, and the needs ofchildren during a disaster. EMS personalshould participate in mass-casualty inci-dent drills and exercises involving pedi-atric patients. Understanding the regionalpediatric capabilities, such as the locationof pediatric trauma and pediatric burncenters, is necessary. Having appropriatepediatric destination protocols, equip-ment, and memory aids to respond to the

18 SECTION II / PLANNING LEVELS

needs of children are important parts ofthe EMS response.

EMS “DISASTER” Response

• D Detect• I Incident Command • S Scene Security and Safety • A Assess Hazards • S Support (determine need,

order resources early)• T Triage and Treatment• E Evacuation and Transport• R Recovery

Partnerships with federal, state, andlocal EMS agencies exist to ensure thecommon goal of protection and prepared-ness for the states and its citizens. Thelocal community and state leaders areresponsible for their own disaster manage-ment. The responsibility of the federal gov-ernment is to provide support, a frame-work for organization, and resources.

References Websiteshttp://www.childrensnational.org/EmsC/Educationtraining/web-basedtraining.aspx

http://www.fema.gov/emergency/nims/nim-strainingcourses

http://www.fema.gov/pdf/emergency/nrf/nrf-esf-intro.pdf

http://www.fema.gov/nrf

MASS CASUALTY MANAGEMENTAND MEDICAL CARE

SECTION III / MASS CASUALTY MANAGEMENT AND MEDICAL CARE

OBJECTIVES

� Learn the basic components of a masscasualty management approach.

� Differentiate the various roles of theindividuals providing assistance duringa disaster.

� Be familiar with the rescue chain fromthe incident site to the hospital.

� Understand the importance of patientdocumentation and recording.

� Understand and apply the triagealgorithms.

� Identify the differences between theadult and pediatric triage algorithms(START and JumpSTART).

� Identify the tasks of a mass casualtymanagement approach in humanitarianemergencies.

� Be familiar with the planning tasksduring the mitigation phase.

CASE 2.A school bus with primary schoolstudents and caregivers leaves for adrive into the countryside, but skidson a sinuous stretch of the road andoverturns. The vehicle is seriouslydamaged. Several children and adultsmanage to escape, and many remaintrapped inside. Children are screamingand crying.

� Are emergency medical careagencies in your districtprepared for the rescue, triage,management, and transport ofa large number of severelyinjured children?

� Which of the local hospitals isprepared to provide care toseverely injured children?

� Is the nearest trauma centerprepared to treat so manypatients?

� Will some of the local pediatricemergency departments beable to collaborate in themanagement of some of the less seriously injuredvictims?

Medical Care in a MassCasualty Incident (MCI)Mass casualty management, as may occurin a disaster situation, requires an adjust-ment of the traditional emergency careapproach. In the traditional care approach,first responders are trained to provide vic-tims with basic triage and health-carebefore evacuation to the nearest available

The mass casualty management systemis based on:• Pre-established procedures to be used

in daily emergency activities and adapted to meet demands of a majorincident

• Maximizing usage of existing resources• Multi-sector preparation and response• Strong pre-planned and tested coordi-

nationThis system is developed to:

• Accelerate and amplify daily proceduresto maximize the use of the existingresources

• Establish a coordinated multi-sectorrescue chain

• Promptly and efficiently bring disruptedemergency and health-care servicesback to routine operations.

The rescue chain, the essence of themass casualty management system,involves the health department, privatehospitals, police, fire department, non-gov-ernmental organizations (NgOs), trans-port services, and communications(Figure 3). This chain starts at the disas-

receiving health-care facility. This approachjuxtaposes two organizations that workindependently with only weak linkages: thefield (often involving non health sectorresponders), and the receiving health-careorganization that is often totally divorcedfrom the pre-hospital problem. In a masscasualty situation, this approach will quick-ly result in chaos. For this reason, a systemthat would allow an adequate response tomass casualty situations was developed.

This system, known as mass casualtymanagement, includes pre-established pro-cedures for resource mobilization, fieldmanagement, and hospital reception. It isbased on specific training of various levelsof responders and incorporates linksbetween field and health-care facilitiesthrough a command post. It acknowledgesthe need for a multi-sector response fortriage, field stabilization, and evacuation toadapted health-care facilities. The develop-ment of this approach is based on the avail-ability of large amounts of human andmaterial resources, so it should be adaptedto the available resources to maintain thesame effectiveness in its implementation.

This system,known as masscasualtymanagement,includes pre-establishedprocedures forresourcemobilization, fieldmanagement, andhospital reception.

FIGURE 3. A multi-sector rescue chain

Impact zone Commandpost

Hospital disaster response plan

Accident &EmergencyDepartment

TriageStabilizationEvacuation

SearchRescueFirst aid

Traffic control

Regulation of evacuation

PRE-HOSPITAL ORGANIZATION HOSPITAL ORGANIZATION

From: Establishing a Mass Casualty Management System, Washington D.C., 1996.

21SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

ter site (with activities such as initialassessment, command and control, searchand rescue, field care), continues withtransfer of victims to appropriate facilities(using procedures to regulate evacuationand ambulance traffic control), passesthrough hospital reception (with activationof the hospital disaster response plan), andends only when the victims have receivedall emergency care needed to stabilizethem.

The implementation of this rescue chainrequires the following components:• An efficient emergency department• A basic radio communications network• Coordination procedures among all sec-

tors involved• Skilled multi-sector rescue teams

The assignment and organization ofresources in mass casualty managementrequires careful planning.

As in any chain, the strength and reliabil-ity of the system depends on each link; ifone fails, the entire system will be compro-mised.

Activities at the site of thedisasterThese activities include the proceduresneeded to organize the disaster zone. Thealert given by any observer sets theprocess into motion. Define exactly thelocation of the disaster event, the time ofits occurrence, its type, the estimatednumber of victims, the risks, and the pop-ulation threatened by these risks.

The initial assessment will establishwhat resources will be mobilized at thesite of the disaster (Figure 3).

The initial evaluation unit identifies thezones to be set up at the incident site:• Impact zone

• Incident command post• Advanced medical post• Evacuation area• Authorities and press• Roads of access• Restricted areas(Figures 4 and 5 A and B)

Appendix B, page 39, displays a numberof function cards that define in detail thebasic activities of the professionalsinvolved in the coordination and the careof victims in a MCI.

SafetyRescue activities during a disaster shouldinclude measures to guarantee the safetyof the victims, the members of the rescueunits, and the general population.

Communication anddocumentation When a disaster occurs, both landlinetelephones and cell phones could beoverburdened. The communicationmethod of choice for emergency organi-zations utilize ultra-high frequency (UHF)and very high frequency (VHF) waves.The former are used for communicationswithin the area of the event, and the lat-ter for communications with strategiccenters for purposes of coordination ortransportation. Patient referral informa-tion should be provided from the site tothe Incident Command and from thereto intervening agencies and the nearesthospital. Essential information to be col-lected includes:• Number of victims• Number of persons who need to be

transferred to a hospital• When and how they will be transported• Relevant lesions care of victims

Patient referralinformation should beprovided from thesite to the IncidentCommand and fromthere to interveningagencies and thenearest hospital.

22 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

FIGURE 4. Organization of communications

Communications center

Firemen central station

Head

Assistant head

Staff

StaffMedicaldirector

Committeechairman

Nationalcommitteefor disastersituations

Director

Assistant chief

ChiefManager

Nursingchief

STAFFSTAFF

Police central station

Ambulance service

Hospital emergency department

National committee fordisaster situations


Care of Victims Search and rescue activities should be per-formed by individuals with specific capabil-ities including firefighters and specializedrescue units. Before allowing these individ-uals to enter the disaster area, verifywhether they need special clothing orbreathing equipment to protect themfrom environmental risks.

Once the search and rescue units havelocated the victims, they must take themto a risk-free casualty collecting point tobe assessed (field triage).

After this initial triage, the victimsreceive first aid according to their status.

When the number of victims or the dis-tance from the place of the incident pre-vents the direct transportation of all vic-tims to hospitals, an advanced medical postmay be established adjacent to, but outsideof, the impact zone.

Prior to the advanced medical post, allvictims are medically triaged (see “Triage:Rationale” below), to identify those whorequire immediate care.

Following triage classification, victims arereferred to the adjacent treatment areaswithin the advanced medical post wherethey are stabilized. Stabilization proceduresmay include advanced airway management,


FIGURE 5 A. Organization of the impact zone after a road traffic accident

IMPACT ZONE –Strictly restricted access

ACCESS CONTROL

RESTRICTED ACCESS AREA

ACCESSCONTROL

Command post

Advancedmedicalpost

AUTHORITIESAND MEDIA

RESERVED AREA

FIGURE 5 B. Organization of the impact zone after a leakage of toxic debris

IMPACT ZONEStrictly restricted access

WIND

Toxicfumes

Command post

Access control

Advancedmedical post

RESERVED AREA

AUTHORITIESANDMEDIA

RESTRICTEDACCESS AREA




fluid therapy to maintain circulation andtreat shock, control of hemorrhage, andanalgesics. Document the therapies givenin the patient’s evacuation report thataccompanies the patient to the hospital. Insummary, goals of the advanced medicalpost are to stabilize patients, reassess theircondition (retriage), and organize theirtransportation to the appropriate hospi-tals. All these tasks have been summarizedas the 3 Ts principle: typifying (classifying),treating, and transporting.

Ideally, the advanced medical post shouldbe staffed with trained emergency medi-cine physicians and nurses; additional physi-cians such as surgeons and anesthesiolo-gists can be added if available and needed.

Triage - Rationale Triage is a system that allows establishingpriorities for care and transporting inorder to save as many lives as possible. Itis performed during the rescue phase, anduses priority criteria for the care ofpatients, distinguishing those requiringimmediate stabilization and transport fromthose who can wait. In a more detailedanalysis, triage also allows for identifyingpatients who need emergency surgery. Theprimary triage in a MCI consists of a quickevaluation so that all the victims can beexamined in a short period of time anddecisions can be made regarding treat-ment priorities.

Once the victims are brought to thecollection point, the staff responsible fortriage must quickly assess each and everyvictim, and refrain from providing treat-ment other than hemorrhage control andbrief airway repositioning. Specific algo-rithms, such as the START (Simple Triageand Rapid Treatment, Figure 6) have beenused to streamline this process using a

color-coding system. START triage evalu-ates for respirations, pulse/perfusion, andmental status. All patients are triaged firstprior to initial medical interventions.During this evaluation, each victim is iden-tified with a specific color-coded tag, tapeor marker to indicate the level of medicalurgency needed. Primary triage is based onthe premise that all the victims are equallyimportant, regardless of age, gender, pro-fession, or any other factor. Decisions aremade exclusively based on the victim’sclinical condition. Patients are classifiedaccording to severity as green (uninjuredor minimally injured), yellow (moderatelyinjured or urgent), Red (severely injured oremergent), and Black (deceased). Fieldtriage is performed on three levels::

ON-SITE TRIAGE: Classifies the victims toidentify those who need to be taken

immediately to the advanced medicalpost. First aid providers or medical emer-gency technicians usually do this on-sitetriage. When the technicians do not haveextensive experience in triage, considerhaving them classify the victims in the “yel-low” and “red” groups together as one.Using this approach, the percentage ofincorrect classifications declines signifi-cantly. In addition, this simplified classifica-tion results in a reduction of the timerequired for the initial evaluation.

MEDICAL TRIAGE: Determines the requiredlevel of care. An emergency physician,anesthesiologist, or surgeon should be incharge of this type of triage.

MEDICAL TRIAGE CLASSIFICATION

Red: Immediate stabilization is required.This applies to victims who have:• Shock due to any cause

Primary triage isbased on the premisethat all the victimsare equally important,regardless of age,gender, profession, orany other factor.


• Breathing difficulty with possiblerespiratory failure

• Profuse external bleeding• Head trauma with signs of altered

consciousness, such as:– disorientation (cannot obey simple

commands)– unconsciousness (cannot respond to

verbal and/or painful stimuli)– asymmetrical pupils (sign of cerebral

hernia)

Stabilize these patients so they canreceive further care. After stabilization,reclassify.

Yellow: Delayed treatment may beappropriate. Monitor closely, insert a lineif uncertain about circulatory status, but defer care initially. This categoryincludes victims who, despite not fulfillingthe criteria for inclusion in the red group,have

FIGURE 6. Start Triage

From: Radiology Emergency Medical Management, http://www.remm.nlm.gov/StartAdultTriageAlgorithm.pdf; adapted from original: Lou Romig, MD

26

Regardless of the triagesystem used, perform acareful secondaryevaluation on all thevictims on-site and thenagain at the emergencydepartment.

SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

• Shock risk (e.g., heart attack, abdominaltrauma)

• Open fractures• Femur or pelvis fracture• Severe burns• Head trauma but responsive to verbal

or painful stimuli• Uncertain diagnoses

Green: These victims can wait or do notrequire treatment. This category includesthose who are ambulatory and have:

• Minor fractures• Minor wounds or burns

After on-site care has been completed,transport victims who have been classifiedas yellow or red to a hospital. They shouldbe re-triaged on arrival.

Black: Deceased.

EVACUATION TRIAGE: Victims are reclassifiedin terms of their priority for transporta-tion to the nearest hospital.

Red: These victims have the highest pri-ority for transport, preferably with a spe-cialized crew to a tertiary hospitalbecause they require surgery for survivalor organ-function preservation or needICU services.

Yellow: These victims have the secondhighest priority for transport, whichincludes victims who are currently stablebut may decompensate or require urgentbut not emergent surgery.

Green: These victims may be dischargedon-site, if possible, after being checked andreassured. Those with minor injuries

should be treated or sent to a primarycare facility if available.

Black:Transportation to the morgue.

Pediatric triageTThe JumpStart triage system is a modi-fied triage algorithm of START based onphysiological criteria adapted to the nor-mal range of pediatric values (Figure 7).

Unlike the adult-based triage system,this system recognizes that an apneic childcan still maintain a certain degree of perfu-sion before he/she develops an irreversiblecardiac lesion secondary to anoxia. Thesechildren can survive if their respiratoryfunction is sustained or restored, some-thing that will not be identified by applyingthe START system (Figure 6), which doesnot include pulse palpation for patientswhose apnea persists after the airway hasbeen opened. Children who are not ableto walk or are carried in arms by adultsshould always be categorized at the veryleast, as yellow.

Regardless of the triage system used,perform a careful secondary evaluation onall the victims on-site and then again at theemergency department. Triage is a dynam-ic process and continues until the patientarrives at a place where he/she is offereddefinitive evaluation and treatment.

There is a newly proposed nationalguideline for mass casualty triage calledSALT for both adults and children (seeAppendix B). SALT stands for “Sort, Assess,Life-saving interventions, and Treatment.”This guideline was developed due to themultiple triage systems, many of whichhave been inadequately validated. Thisguideline was developed by an interdisci-plinary committee of the AMA, theAmerican College of Surgeons, the


American College of EmergencyPhysicians, the National Association ofEMTs, and various other representativeorganizations.

Global sorting is the first step toaddress the “walking wounded”. Thosewho are able to walk are prioritized last;those who cannot follow a command orhave an obvious life threat are prioritizedfirst; and those who can follow a commandbut are unable to walk are prioritized sec-ond. The next step of this triage system isto make lifesaving interventions before

assigning a patient to a triage category.Lifesaving interventions include control ofmajor hemorrhage, opening the airway andproviding 2 breaths for child casualties,decompression of a tension pneumotho-rax, and use of autoinjector antidotes.Finally, triage categories are assigned to beDelayed, Immediate, or Expectant manage-ment based on breathing, peripheral puls-es, respiratory distress, and hemorrhagecontrol. This system of triage is differentfrom the other systems in that there is agrey or “Expectant” category. This catego-

FIGURE 7. JumpSTART

Ableto walk?

Breathing?

Breathing?

Respiratoryrate

Palpablepulse?

AVPU**

NO

NO

NO

“P” (INAPPROPRIATE), POSTURING, OR “U”

“A”, “V” or “P” (APPROPRIATE)

15-45

<15 or >45

YES

BREATHING

NO

YESAPNEIC

APNEIC

MINOR

POSITION UPPER AIRWAY

PALPABLE PULSE?

5 RESCUE BREATHS

IMMEDIATE

IMMEDIATE

IMMEDIATE

IMMEDIATE

IMMEDIATE

DELAYED

DECEASED

DECEASED

SECONDARY TRIAGE*

*Evaluate infantsfirst in secondarytriage using theentire JumpSTARTalgorithm

From: Romig LE. Disaster Management. In: APLS Course Manual. Jones & Bartlett Publishers, 2006.

**A: Alert, V: Responsive to voice, P: Responsive to pain, U: Unresponsive.

YES


ry means that the patient may have a life-threatening injury, but current resourcesare not available to meet the demand. The“expectant” category of patients shouldbe re-evaluated frequently as resourcesbecome available.

This system of triage does not assign“colors” to patients; therefore, it shouldnot be confused with other triage systems.The SALT triage system is an attempt totake the best features of triage systemsthat have been tested. It is a differentmethod of triage in that there is globalsorting based on the ability to follow com-mands and walk, and a triage categoryassignment based on response to life-sav-ing interventions. Children would likely beover-triaged to the “assess 1st category,”as many will not be capable to follow com-mands due to developmental stage. Thisover-triage is probably inherent in pedi-atrics and can not be avoided. This SALTsystem of triage should be tested againstthe most commonly used form of pedi-atric triage: Jump START.

Transfer organization The transfer organization includes thoseprocedures implemented to ensure thatvictims of a mass casualty incident will besafely, quickly, and efficiently transferred byappropriate vehicles to a prepared health-care facility.

Transfer is organized according to differ-ent principles such as strict control of therate and destination of evacuation to avoidoverwhelming the health-care facilities.One of the roles of on-scene mass casual-ty management is to stop spontaneousevacuation from by-standers of unstablevictims or those minimally injured. Thisunmanaged transport is unsafe, endangersthe lives of victims, circumvents field

decontamination process, and disrupts theimplementation of the mass casualty man-agement system. Victims should not beremoved from the advanced medical postto health-care facilities before:• They are in the most stable condition

possible.• They are adequately equipped for the

transfer.• The receiving health-care facility is cor-

rectly informed and ready to receive thepatient.

• The most appropriate vehicle and escortare available.

Control of Victim Flow: The Noria PrinciplePatient movement (whether by walking, bystretcher, or by vehicle) must be in a “one-way” direction and without any back-tracking. From the impact zone to the col-lecting point, from the collecting point tothe advanced medical post entrance, andsubsequently to areas of treatment, evacu-ation, and hospital care, the victims will beon a one-way “conveyor belt”, taken fromthe scene to sophisticated levels of care(Figure 8).

Organization of Hospitals The mass casualty management systemneeds specific organization at the receiv-ing hospital. This organization allows theactive mobilization and management ofavailable or needed resources, communi-cates with pre-hospital providers, andfacilitates the management of inpatientsand the flow of incoming victims. Othermanagement tasks include secondaryevacuations, and communication with vic-tims’ families and various public entities.Certain key departments, including theemergency and surgery departments,

This organization allowsthe active mobilizationand management ofavailable or neededresources,communicates with pre-hospital providers, andfacilitates themanagement ofinpatients and the flowof incoming victims.


Treatment

Impact zone

Collecting Point

ADVANCED MEDICAL

POST

Triage

TRANSFERHOSPITAL

Evacuation

Triage Treatment

Transport resource flowVictims flow

FIGURE 8. Victims flow: the Noria principle*

*This one-way progression from level to level by rotating transportation resources was labelled "Noria" in 1916 during the World War I battle of Chemin deDames in Verdun, France. "Noria" comes from the Latin word for "wheel". From: Establishing a Mass Casualty Management System, Washington D.C., 1996.

operating rooms, laboratory, radiology,and intensive care unit, have to be rein-forced. It is also important to preparesequential reinforcements and allow arapid rotation of the staff in those areaswhere the workload will be mostdemanding. This prevents overburdeningthe staff during an influx of casualties andensures the prompt return to normaloperations with an adequate staff.

As part of the coordinated efforts, hos-pital security should be reinforced withpolice officers stationed at the gates and inthe reception area. In every hospital, thereshould be a well-equipped command postfor use in emergency situations.

Reception of victims In order to accommodate the influx ofnew patients, discharge all patients thatcan be cared for on an outpatient basis.

Adding hallway beds or opening up in-hospital clinics can help with surge capac-ity. If victims bypass the on-scene medicaltriage and arrive at the hospital on theirown, they should be triaged appropriatelyas with any other arriving victim. Whenprehospital management has been effi-cient, an experienced emergency nursecan do the triage. If this is not the case,triage should be performed by an experi-enced emergency physician, anesthesiolo-gist or surgeon. All arriving victims,whether or not they’ve been previouslytriaged, should be re-triaged upon arrivalto the hospital. The on-scene commandpost, the advanced medical post, and thehospital command post should all be incommunication continuously, providingupdates on number and severity ofinjured victims, transport time, and cur-rent hospital capacity.

The on-scene commandpost, the advancedmedical post, and thehospital command postshould all be incommunicationcontinuously.


Treatment Areas Clearly establish the treatment areas inthe hospital and provide the necessarystaffing. Treatment area designationshould reflect triage levels, e.g., red treat-ment area for victims triaged in the redcategory. An emergency medicine physi-cian or an anesthesiologist should be incharge of the red treatment area andshould be prepared to treat patientswith extremely severe injuries. An addi-tional triage can determine the order of

these red patients that need operativeinterventions.

Victims triaged as yellow should bereevaluated by a physician and providedcare or observation as needed. If theircondition worsens, transfer them to thered treatment area.

Victims with no hope for survivalrequire only supportive care. Thesepatients should be kept in a separate ward.Have an area ready for deceased victims ifthe hospital morgue is overwhelmed.

31SUMMARY

SUMMARYPlanning is essential to reduce risks and minimize dangers in the event of a disaster.

It should be carried out at different levels, from the family unit to the local

community with its various entities. Each community should develop its own local

emergency or disaster plan. This local disaster plan needs to be adequately

coordinated with the regional and national-level plans. Disaster plans should

contemplate the basic needs of the affected individuals and the potential

displacement of many people which may result in public health risks. The basic

components of a disaster plan are: analysis of the situation, assumptions, goals,

objectives, site organization, roles and responsibilities, coordination, and recording of

critical information. The plan needs a realistic appraisal of available resources and

extensive training and coordination.

In responding to a mass casualty incident, a management system should be insti-

tuted which includes the command post, the advanced medical post, evacuation and

transport, and hospital care. This system must be activated in a coordinated manner,

and each component sector should be prepared to organize patient care. All lessons

learned during the immediate response to the disaster should be incorporated in

future planning.

32

SUGGESTED READING

Benson M, Koenig KL, Schultz CH. Disaster triage: START then SAVE-a new method of dynamic triage for victims of a catastrophicearthquake. Prehospital Disaster Med 1996; 11 (2): 117-124.

Committee on Pediatric Emergency Medicine. The pediatrician's rolein disaster preparedness. Pediatría I997;99(I):I3O-I33.

Farmer JC, Jiménez EJ, Rubinson L, Talmor DS (eds). Fundamentalsof Disaster Management. Society of Critical Care Medicine, 2003.

Hospital Emergency Incident Command System Update Project.California Emergency Medical Services Authority Web Site. Availableat: http://www.emsa.cahwnet.gov/dms2/heics3.htm.

Jacob J. Disaster plan can safeguard your practice, records. AmericanMedical Association Web site. Available at http://www.ama-assn.org/scipubs/amnews/pick_0 1/bica1 022.htm.

Lerner et al. Mass Casualty Triage: An evaluation of the data anddevelopment of a proposed national guideline. Disaster Medicineand Public Health Preparedness 2(1):S25-S34.

Markenson, D, Reynolds, S. The Pediatrician and DisasterPreparedness. Pediatrics 117(2) : e340-e362. Available at:

http://aappolicy.aappublications.org/cgi/reprint/pediatrics;1 17/2/ e340.pdf

Mothershead JL et al. Disaster Planning. Available at:http://www.emedicine.com/emerg/topic718.htm.

Establishing a Mass Casualty Management System, Pan AmericanHealth Organization, 1996.

Humanitarian Assistance in Disaster Situations: A Guide for DisasterAid. Pan American Health Organization, 1999.

Safe Hospitals: A Collective Responsibility. A Global Measure ofDisaster Reduction, Pan American Health Organization/World HealthOrganization, Available at:http://www.paho.org/spanish/dd/ped/SafeHospitals.htm.

Romig LE. Disaster Management. In: APLS Course Manual. Jones &Bartlett Publishers, 2006.

Romig LE. Pediatric triage: a system to JumpSTART your triage ofyoung patients at MCIs. JEMS 2002;27(7):52-63.

Savage, PE. Disasters. Hospital Planning. Oxford, Pergamon Press,1979.

SUGGESTED READING

33CASE RESOLUTION

Case resolution

Case 1.

The hospital disaster plan is activated while all victims are sent to a triage area set upin a safe location (e.g., hospital parking lot). A physician, accompanied by nurses from theemergency department, initiates triage. Patients with critical illnesses or trauma aretransported directly to the emergency department. Those most severely affected aretreated in the emergency department and receive immediate evaluation, while thosewith less severe injuries are given first aid in the parking lot or wait until they can betreated in the emergency department. The hospital disaster plan includes utilizing stafffrom other hospital departments to assist in the event of a mass casualty incident.

Case 2.

The local emergency system verifies the incident, declares a mass casualty situation, andthen activates the emergency plan, setting into motion the necessary agencies such asfire, police, and emergency medical services. A structure for the care of victims is estab-lished, and children and adults are triaged. An on-scene command post is established.Local hospitals are contacted to inquire about their respective patient care capabilities.All the children with moderate to severe lesions are referred to the nearest pediatrictrauma center, whereas adults with moderate to severe lesions are sent to an adult trau-ma center. After all the severely injured victims have been transported, those patientswith minor lesions are referred to primary care facilities.

MODULE REVIEW

SECTION I: LOCAL EMERGENCY PLAN

1. What are the pediatrician's specific functions in a disaster plan?2. What factors should be considered when designing a local plan?3. What areas should the plan cover?4. What is the desired profile for the emergency plan coordinator, and what

roles should he/she play?

SECTION II: PLANNING LEVELS

1. Planning should cover several levels. What are these levels, and what are thecomponents and the adequate methods in each case?

2. What individual and family factors should be taken into account in a disastersituation?

3. What role do community organizations play in the sequential phases of adisaster situation?

4. How should these organizations be equipped to face the problems that affectchildren which may be directly or indirectly related to the disaster?

SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

1. What are the basic components of a mass casualty management system?2. How is a command post for a MCI established? What areas should be defined

around the site of impact? 3. How is an advanced medical post organized?4. What are the roles of the individuals involved in the emergency medical care

chain? How are these roles determined?5. At which points in the rescue chain is triage performed, and what priorities

are established in each case?6. What special conditions should be considered when triaging a pediatric

victim? How are these conditions integrated in a MCI where victims are notonly children?

MODULE REVIEW34

MODULE REVIEW 35

7. What data are essential for the internal communication within the system?How are these data transmitted?

8. What elements should be considered when organizing the transportation ofvictims to hospitals and other healthcare centers?

9. What systems of hospital care can be used in the response to MCI? How dothese systems operate?

10.What planning aspects correspond to the mitigation phase?

ESF #1 – TransportationAviation/airspace management and control Transportation safety Restoration/recovery of transportation infrastructure Movement restrictions Damage and impact assessment

ESF #2 – Communications Coordination with telecommunications and information technologyindustries Restoration and repair of telecommunications infrastructure Protection, restoration, and sustainment of national cyber and informationtechnology resources Oversight of communications within the Federal incident management andresponse structures

ESF #3 – Public Works and Engineering Infrastructure protection and emergency repair Infrastructure restoration Engineering services and construction management Emergency contracting support for life-saving and life-sustaining services

ESF #4 – Firefighting Coordination of Federal firefighting activities Support to wildland, rural, and urban firefighting operations

ESF #5 – Emergency Management Coordination of incident management and response efforts Issuance of mission assignments Resource and human capital Incident action planning Financial management

ESF #6 – Mass Care, Emergency Assistance, Housing, and Human Services

Mass care Emergency assistance Disaster housing Human services

ESF #7 – Logistics Management and Resource Support Comprehensive, national incident logistics planning, management, andsustainment capability Resource support (facility space, office equipment and supplies, contractingservices, etc.)

36 APPENDIX A

APPENDIX A: ROLES AND RESPONSIBILITIES OF ESFs

37APPENDIX A

ESF #8 – Public Health and Medical Services Public health Medical Mental health services Mass fatality management

ESF #9 – Search and Rescue Life-saving assistance Search and rescue operations

ESF #10 – Oil and Hazardous Materials Response Oil and hazardous materials (chemical, biological, radiological, etc.) response Environmental short- and long-term cleanup

ESF #11 – Agriculture and Natural Resources Nutrition assistance Animal and plant disease and pest response Food safety and security Natural and cultural resources and historic properties protection andrestoration Safety and well-being of household pets

ESF #12 – Energy Energy infrastructure assessment, repair, and restoration Energy industry utilities coordination Energy forecast

ESF #13 – Public Safety and Security Facility and resource security Security planning and technical resource assistance Public safety and security support Support to access, traffic, and crowd control

ESF #14 – Long-Term Community RecoverySocial and economic community impact assessment Long-term community recovery assistance to States, local governments, andthe private sector Analysis and review of mitigation program implementation

ESF #15 – External Affairs Emergency public information and protective action guidance Media and community relations Congressional and international affairs Tribal and insular affairs

38 APPENDIX B

APPENDIX B: FUNCTION CARDS

PAHO has created a number of function cards that define indetail the basic activities of the professionals involved in thecoordination and the care of victims in a MCI.

1. Operator - dispatch center

� Receives initial call or warning messageconcerning the event

� Establishes: caller's name and telephonenumber - nature of event - exact locationof event - time of occurrence - approximatenumber of victims

� Verifies information (if an unqualifiedobserver)

� Mobilizes and sends a dispatch team to sitefor initial assessment

� Alerts potential responders (stand by)

� Receives report of initial assessment

� Dispatches necessary resources

2. Initial assessment team� Travel to site expeditiously� Identify a leader� Establishes: precise location of the event -

time of the event - type of incident� Estimates: number of casualties - added

potential risk - exposed population� Team Leader reports initial information

to dispatch center� Draws a single map of the area indicating:

main topographical features - potentialrisk areas - victims - access roads -various field areas - limits of restrictedareas - compass rose - wind direction

� Directs resources arriving in the fielduntil the arrival of a high ranking officer

� Hands over the map and briefs firstarriving officer of rank

� Reports to reassigned station

3. Fire servicesThe Fire Services will be responsible for:

� Safety

� Search and rescue

� Risk reduction

� Definition of restricted areas

� Providing a senior officer as a staff mem-

ber of the Command Post

� Providing the Advanced Medical Post

(AMP) with a Transport Officer

4. Search and rescue team� Locates victims� Removes victims from unsafe locations to

collection point if necessary� Conducts initial triage of victims (acute/

nonacute)� Provides essential first aid� Transfers victims to Advance Medical Post

5. Search and rescue officer� Coordinates search and rescue activities

by: identifying and assigning teams -supervising team functioning - establishing acollection point when necessary -coordinating the transfer of patients fromthe collection point to the Advance MedicalPost communicating with Command Postfor resource reinforcement - ensuringsafety and welfare of search and rescueteams

39APPENDIX B

8. Police officer in command post

� Ensures that radio communication isestablished and maintained

� Implements security measures to: maintainrestricted areas - provide crowd and trafficcontrol

� Manage field police resources by:continuous assessment of needs -redeployment of police officers - requestsfor backup - ensure adequate supply ofnecessary equipment

� This officer is generally the coordinator ofthe Command Post

9. Health officer in command post

� Supervises the field care of victims� Provides the link between the health/

medical backup system� Ensures the adequate supply of

manpower and equipment� Receives reports from the manager of

the Advance Medical Post (acutetreatment manager)

� Deploys and manages health staffresources

� Reports to the coordinator of theCommand Post

7. Fire officer in command post

� Coordinates activities of the FireService in the field (ensures safety, searchand rescue)

� Assists in transport organization� Manages fire staff resource needs by:

continuous assessment - requests forbackup - timely rotation of staff - withdrawal of staff no longer needed

� Reports to the coordinator of theCommand Post

6. Coordinator of the com-mand post

� Performs overall coordination of the fieldoperations

� Receives reports from the other officers inthe Command Post

� Continuously assesses the general situa-tion

� Coordinates requests between sectors inthe field

� Ensures links between sectors� Ensures the welfare of all staff involved in

field operations� Liaises with central headquarters, (e.g.,

EOCs)� Authorizes releases to the media� Acts as link between field operations and

backup system� Ensures adequate radio communication

40 APPENDIX B

10. Acute treatmentmanager (manager ofadvance medical post)

� Supervises triage and stabilization ofvictims in AMP

� Establishes the internal organization ofthe AMP

� Manages the staff of the AMP� Ensures that effective victim flow is

maintained� Ensures adequate equipment and

supplies are available in each treatmentarea

� Organizes the transfer of patients tohealth care facilities in collaboration withthe Transport Officer, the Health Officerin the Command Post and receivingHealth Care facility

� Decides on the transfer order ofvictims, the mode of transport, escortand destination

� Ensures staff welfare� Reports to the Health Officer in the

Command Post

11. Medical triage officer� Receives victims at the entrance of the

AMP� Examines and assesses the condition of

each victim� Categorizes and tags patients as follows

- Red-immediate stabilization necessary -Yellow-close monitoring, care can be delayed

-Green-minor delayed treatment or no treatment

-Black-deaths� Directs victim to appropriate treatment

area� Reports to the manager of the AMP

12. Red team leader� Receives patient from medical triage� Examines and assesses the medical

condition of the victim� Institutes measures to stabilize the

victim� Continuously monitors victim's

condition� Reassesses and transfers victims to

other treatment areas� Prioritizes victims for evacuation� Requests evacuation in accordance with

priority list� Reports to the manager of the AMP

13. Evacuation officer� Receives victims for evacuation� Assesses the victim's stability� Assesses the security of any equipment

attached to victims and corrects defi-ciencies

� Ensures that immobilization is adequate� Ensures that the tag is safely and clearly

attached� Maintains observation of victims until

transported� Supervises loading and ensure escort is

briefed� Reports to manager of AMP

41APPENDIX B

16. Administration clerkevacuation area

� Maintains a register of all victims leavingthe AMP

� Records - victim name/number - injurycategory - time of departure - mode ofdeparture (vehicle) and escort -destination

� Reports to the evacuation office

17. Ambulance driver

� Remains in the vehicle at all times� Responds promptly to directives from

Transport Officer� Ensures that vehicle is parked in designa-

ted area and is ready to move� Transports patients in accordance with

safety rules and instructions� Reports to Transport Officer

15. Administration clerk - triage area

� Maintains a register of all victimsadmitted to medical triage

� Records - name or identificationnumber - age when possible - sex - timeof arrival - injury category assigned

� Reports to Triage Officer

14. Transport officer� Coordinates and supervises the

transportation of victims� Identifies access routes and

communicates traffic flow to drivers� Supervises all available ambulance drivers

and drivers of assigned vehicles� Receives requests for transportation� Assigns appropriate vehicle tasks in

accordance with specific needs� Maintains a log of the whereabouts of all

vehicles under his control� Reports to the manager of the AMP

42 APPENDIX C

APPENDIX C: SALT DIAGRAM

EB Lerner, RB Schwartz, PL Coule, et al. Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline. Disaster Medicine and Public Health Prepardeness. 2008;2(Suppl1):S25-S34.

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