When a call is made to the hospital indicating the occurrence of a disaster or potential mass casualty–producing event, the incident must be verified by the appropriate predesignated official, who then puts the emergency operations plan into effect. In some events, the first sign of a disaster may be patients arriving at the hospital. In this case, contact the regional emergency communications center to notify the regional hospitals of the impending disaster and initiate the emergency operations plan.
This sets a series of activities into motion. The information obtained from the call is given to the charge nurse; the nursing and medical personnel in the ED are notified of the impending arrival of casualties; and the ED's plan for calling additional staff is activated. If hospital telephone communications have been completely disrupted, ED personnel may have to be reached by radio, cellular phone, e-mail, or television announcement. In many disasters, cellular phone and text messaging systems are quickly overwhelmed. Alternatively, a calling station remote from the hospital, such as at the residence of an administrator, physician, or nurse, may be able to handle this extensive calling job without taxing the hospital's phone system.
An initial needs assessment is conducted by the nurse and/or physician in charge, given the information available. They should evaluate the current status of the patients in the ED and make the appropriate disposition decisions. The ED physician or charge nurse becomes the on-site incident commander until the plan-designated incident commander arrives. Among the decisions to be made are those related to the admission, discharge, or transfer of patients, and decisions about the priority of patient care. Discharge all nonemergency patients from the ED with responsible individuals.
Based on the initial assessment, the number of patients that the department can receive is determined and communicated to the prehospital disaster communications center. The nurse and the physician in charge then assign staff to those areas in the department to be used during the disaster.
Take all available litters and wheelchairs to the ambulance entrance immediately on announcement of the disaster status. Patients from the disaster site are met at the receiving area by hospital escorts who assist the EMTs in transferring patients to wheelchairs or stretchers.
Place essential equipment, such as endotracheal tubes, IV fluids, cervical collars, splints, and bandages, near the ambulance entrance to permit convenient restocking of the ambulance (when plans call for ambulance restocking from hospitals) and rapid return to the disaster site.
Hospital security diverts nonessential vehicles and ensures a smooth, one-way flow of traffic to the ambulance entrance. Once patients, family, and media arrive, security is also responsible for protecting the treatment areas and inhibiting unplanned entry into the hospital.4
Triage establishes priorities for care and determines the clinical area of treatment. Many seeking help will arrive independent of the EMS system.3,4 Triage will need to be performed at the ED entrance even if it was done at the scene.
Triage category is identified by use of a colored band or trauma/disaster tag that is placed on the patient to document that triage has been done.
The approach to patient evaluation and treatment is quite different when dealing with disaster situations that result in high casualties.16 To accomplish the most good for the most number of patients, the triage team should evaluate all patients arriving at the ED and classify their condition with regard to severity of injury and need for treatment. Some principles of medical care must be altered to achieve the best overall result. Patient care at triage should be limited to manually opening airways and controlling external hemorrhage.
The most common triage classification in the United States still involves assigning patients to one of four color-coded categories (red, yellow, green, or black), depending on injury severity and prognosis (Table 5–8). In addition to the nature and urgency of the patient's systemic condition, triage decisions should be sensitive to factors affecting prognosis, such as age, general health, and prior physical condition of the patient, as well as the qualifications of the responders and the availability of key supplies and equipment.
Table 5–8 Triage Categories |Favorite Table|Download (.pdf)
Table 5–8 Triage Categories
Life-threatening shock or hypoxia is present or imminent, but the patient can likely be stabilized and, if given immediate care, will probably survive.
The injuries have systemic implications or effects, but patients are not yet in life-threatening shock or hypoxia; although systemic decline may ensue, given appropriate care, can likely withstand a 45- to 60-min wait without immediate risk.
Injuries are localized without immediate systemic implications; with a minimum of care, these patients generally are unlikely to deteriorate for several hours, if at all.
No distinction can be made between clinical and biological death in a mass casualty incident, and any unresponsive patient who has no spontaneous ventilation or circulation is classified as dead. Some place catastrophically injured patients who have a slim chance for survival regardless of care in this triage category.
Catastrophically injured patients who have a minimal chance for survival despite optimal medical care should be classified as "expectant" ("black": to include patients with burns involving 95% body surface area, and patients in full cardiac arrest or septic shock). Devoting time and resources to patients who are not likely to live jeopardizes other patients who are truly salvageable. The goal with these "expectant" patients should be adequate pain control and the opportunity to be with friends and family.
A team consisting of an emergency physician, an ED nurse, and medical records or admitting clerks should receive every patient. In extraordinary situations, several triage teams may be required to handle the casualty load. Acknowledge the physician performing hospital triage as being in command of the triage area (clearly identified by a specially colored vest or other garment) and understanding all triage options.
Assign one member of the triage team (admitting or medical records clerk) the job of recording the victim's name on the disaster tag along with the triage destination within the hospital. If identification of the patient is not available, ethnicity, gender, and approximate age should be noted on the tag. An initial diagnostic impression should also be registered on the tag. This information is entered into a department log or into the electronic medical record, if possible. In some patient tracking systems, a scan of the bar code on the disaster tag may allow for immediate registration by disaster tag number and open an electronic medical record. Additional care can be recorded in the electronic medical record or in a paper disaster chart and kept with the patient at all times and later scanned into the electronic medical record.
Disaster care concepts often vary from the typical ED routine. Care that is not immediately time sensitive can be provided the next day. For example, wounds may benefit from delayed closure after copious irrigation due to delayed presentations or gross contamination. In the event of prolonged extrication from rubble, assess for delayed signs and symptoms, including cardiac dysrhythmias, hyperkalemia from crush injury, renal failure, and pulmonary blast injury.
Terrorist-related or industrial explosive events may lead to medical conditions or exposure to chemicals that are not familiar to clinicians.4 Patients may require prolonged observation (e.g., exposure to phosgene or ricin) or unique testing. For infectious exposures, the Centers for Disease Control and Prevention and local/state public health agencies can guide testing, observation time, and treatment. Immediately contact the local public health agency if a biological terrorist agent or a rare and potentially fatal infectious disease is seen or suspected in the ED. In the event of a chemical agent, the Carolinas Poison Center (1-800-222-1222) can provide information and guidance on whether decontamination is necessary, as well as testing, observation time, and antidotal or supportive treatment. Fact sheets on biological, chemical, and radiologic agents are available at http://www.bt.cdc.gov.4,17
Use radiographic and laboratory studies sparingly, if at all, in a mass casualty situation, and only if the results of such tests will change treatment. For example, possible closed, nonangulated fractures can be splinted, and radiographs can be safely delayed for 24 to 48 hours. A chest radiograph may be appropriate in those patients complaining of chest pain, dyspnea, or abnormal chest wall motion, or who were potentially exposed to blast waves secondary to bombs. CT imaging may be quicker than plain radiographs in some injuries, and prioritization to CT may be required. Ultrasonography to detect free intraperitoneal fluid, pericardial fluid, and pneumothorax is time- and cost-effective, and has been used in earthquakes to triage operative care.18
With the exception of identification of biological and chemical agents, there are few indications for laboratory testing in disaster medicine. If testing will change management, use point-of-care testing to expedite care. For example, obtain a baseline hematocrit and type and cross-matching for blood in cases of hemorrhagic shock. Pulse oximetry monitors may need to be used as spot assessments, rather than continuous bedside monitoring of a single patient. Consider laboratory studies to be accessory and ordered only in specific circumstances (carboxyhemoglobin in cases of smoke inhalation).
In a disaster situation involving many casualties, the blood bank should have up to 50 units of blood available and should have access to volunteer donors who can be rapidly mobilized. Potential donors include friends and family members of patients, as well as mildly injured patients.
Acknowledgments: The authors gratefully acknowledge the contributions of Eric K. Noji, MD, and Gabor D. Kelen, MD, who were the authors of this chapter in the previous edition.