Environmental disasters can overpower local medical resources. Fortunately, such crises are rare in the U.S. This situation, however, has not always been the case. For example, in 1812, an earthquake along the New Madrid fault of the Mississippi Valley caused the Mississippi River to flow backward for 3 days.1 Today, in urbanized America, an earthquake of that magnitude would be devastating and severely overwhelm medical systems. All nations, including highly modernized nations, would need help in such disasters.2 A response system that is nimble, well-trained, scalable, and rapidly deployable can mitigate disaster sequelae. This article focuses on key aspects of effective rapid response, including speed, appropriate triage, quick-response strike teams, and disaster dynamics.
Why Speed Matters Most
Response time arguably is the most important factor in increasing survival in a disaster. In a 1996 study of earthquake disasters worldwide, Schultz and colleagues found a lower survival rate for victims who received medical care outside a 24-hour window.1 Studies of earthquakes in China have suggested that unless aid is rendered within 2 to 6 hours, fewer than half the victims will survive.3 Regarding a 1980 earthquake in Italy, de Bruycker and colleagues emphasized the importance of engaging in rescue activities within the first 48 hours.4 Safar reviewed mass disasters and reported that 25% to 50% of the injured and dead could have been saved if first aid had been provided immediately.5 In 1992 and 1994, Pretto and colleagues wrote that in earthquakes in Armenia and Costa Rica, many deaths could have been prevented had the victims received medical attention within the first 6 hours.6,7 The question is: How can responses to such crises be improved? Confederate Army Lt. Gen. Nathan Bedford Forrest’s dictum “[Get] there first with the most men” holds true in disaster medicine as well: get there fast with the right people, training, equipment, and supplies.8
Deaths in disasters can be described in a 3-phase distribution: immediate, early, and delayed. Stringent building codes and public warnings and evacuations reduce immediate deaths, but victims also die of catastrophic injury soon after an event. Early deaths are preventable with use of rapid interventions, such as tourniquets and airway adjuncts, but these must be administered within minutes or hours. Delayed deaths occur days or weeks after injury secondary to infection or organ system failure—which emphasizes the value of early wound care.
Emergency Supplies
What items are most needed? As each disaster is different, it would be presumptuous to provide a one-size-fits-all list, but some common supplies have been suggested. In 2010, Ginzberg and colleagues reported that during the first 24 hours of the Haiti earthquake of 1996, the overwhelming need was for IV hydration, narcotic analgesics, and casting supplies for the splinting of fractures.9 During the next 24 hours, IV stabilization was key, along with monitoring by Foley and suprapubic catheters. In the third 24-hour period, providers began to see sepsis-related deaths. In response to this challenge, teams began aggressive treatment with open surgical debridement of wounds, amputation of severely injured limbs, and administration of broad-spectrum IV antibiotics. Regional anesthesia with conscious sedation was mandatory because supplemental oxygen and ventilators were unavailable. By day 4, wound debridement, amputations, and fasciotomies were being provided by newly arrived anesthesiologists and orthopedic surgeons. Ginzberg and colleagues emphasized that rapid response was key in maximizing survival and by day 4, there was a greater need for surgical teams and broad-spectrum antibiotics (eg, piperacillin, tazobactam) to combat sepsis.
Pereira and colleagues reported that in a catastrophe caused by a tropical storm and landslides in Brazil, the most common injuries involved the extremities; the majority of wounds required only cleaning, debridement, and suture; and the most commonly performed operations were for orthopedic injuries.10 Incidentally, population baseline morbidity and mortality continue during disasters, and rescue personnel invariably sustain injuries, which contribute to the total medical burden. These additional injuries must be anticipated, and plans to manage them must be included in any disaster contingency planning.
U.S. Coast Guard Photo by PO3 Brandyn Hill
PO3 Cameron Croteau, USCG, in Haiti 2010
Triage
Speed and correct triage are essential building blocks of disaster response. When resources are limited, triage is crucial in providing the right treatment to the right patient. There are numerous triage methods, some more rapid and straightforward; others more effective and cumbersome.11 In 2012, Sasser and colleagues wrote that the purpose of triage is to ensure injured patients are transported to a trauma center or the hospital best equipped to manage their specific injuries in an appropriate and timely manner.12 Their report focused on prehospital emergent care, not mass-casualty or disaster situations.
Triage is sometimes performed inconsistently. In a 2013 study, Kleber and colleagues found that 24% of providers overtriage and 16% undertriage.13 In the U.S., simple triage and rapid treatment (START) is commonly used to sort traumatized patients. All these methods take a “worst gets first treatment” approach. Depending on the magnitude of an event, however, providers may take a reverse-triage approach, in which they better use resources for the least injured patients and provide palliative care to the gravely ill.
During pandemic disasters, trauma triage protocols are ineffective. Instead, these events demand assessments that are sensitive to infectious diseases. Timely, didactic, hands-on training must be conducted before the fact so responders can adapt to react appropriately to a given disaster.14
Accurate, timely triage in mass-casualty incidents was conceptually demonstrated by Mekel and colleagues who reviewed the medical management of bombing victims in metropolitan Haifa, Israel during the period 2000 to 2006.15 Providers initiated a predetermined triage system in which patients are assigned to the appropriate echelon of care. Of 342 injured patients, 9.5% had severe injuries, 2.4% had moderate-severe injuries, and 88.9% had mild injuries. Correct and timely triage directed trauma victims to the appropriate medical care. Such action prevents the highest level facility from becoming overcrowded with less severely injured patients and ensures that the more critically injured receive a level of care comparable to that given under nondisaster circumstances.
The handheld ultrasound device, which can be used to correctly diagnose fractures, is an efficient triage resource for prehospital teams. In a 2008 study, McManus and colleagues suggested that ultrasound (vs traditional radiography) could be used to identify fractures in an emergency room.16 A handheld ultrasound device could be used outside the hospital, in the field, potentially reducing the number of referrals to overwhelmed orthopedic hospitals.
In 2007, Dean and colleagues reported on using ultrasound to rapidly triage disease during an earthquake in Guatemala.17 In that disaster, 23% of injuries presented within the first 24 hours, and a handheld ultrasound device was used to assess orthopedic injuries—ruling in 12% and ruling out 42%. The handheld ultrasound device is an example of a tool that small medical teams can use to speed triage, enhance patient care, and relieve overcrowded medical centers of the unrelenting pressure.