Patient Care

Minimizing Postdisaster Fatalities

Fed Pract. 2017 February;34(2):10-13

References

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On-Site vs Hospital

Complicating disaster response is self-triage. Victims with injuries of all severity levels go to the nearest hospital and overwhelm it. In 1991, Waeckerle reported that within the first 30 minutes of a disaster, a wave of victims arrives, usually with minor injuries, and impedes care for the more severely wounded.¹⁸ Correct triage instead would have directed these patients to a hospital other than the overwhelmed level I trauma center.¹⁵ This is not to say that patients with mild or moderate injuries are unimportant—just that their care may take scarce space and resources from the more severely injured.

Mallonee and colleagues reported that of the 759 people injured in the 1996 Oklahoma City bombing, 167 (22%) were fatalities, 83 (11%) were hospitalized, and 509 (67%) were treated on an outpatient basis.¹⁹ Most of the injuries could have been managed by quick-response medical teams operating in the affected area, outside the hospitals. This action would have reduced operational pressure on hospitals and improved severely injured patients’ access to care.

Specialized Teams

In 2008, Barillo and colleagues suggested that having standardized medic bags would allow a small detachment of medical professionals to provide care nimbly—and doing so would represent a leap forward in access to care.²⁰

Because of their unique ability to understand the culture and coordinate military assets with local authorities, DoD international health specialists are crucial interfaces for any population, foreign or domestic. Seyedin and colleagues and Merin and colleagues suggested that in both the Bam earthquake in 2003 and the Nepal earthquake in 2015, understanding the culture played a vital role in health care delivery and in adhering to cultural norms in deciding when to perform surgery, making end-of-life decisions, communicating with family, establishing trust with local and regional leaders, and other matters.^21,22

Strike teams are small groups of variably trained health care providers who are dispatched to underserved, outlying, or overwhelmed areas to deliver precached basic medical care and triage significant injuries to medical centers. The handheld ultrasound device is an example of a strike team tool. During a local emergency, it is understood or assumed that response is inundated and that people are going untreated.

Crucially, strike teams must be trained, prepared, and readily dispatched ahead of larger response elements. Though quickly deployable, disaster medical assistance teams (DMATs) and National Guard Chemical, Biological, Radiological, Nuclear and High-Yield Explosive Enhanced Response Force Package units, take time to mobilize. Therefore, strike teams should consist of community citizens or local National Guard assets, the latter being particularly suited to rapid response given their training, effective command and control, and intrinsic logistics.

The efficacy of strike teams was demonstrated during the 2011 earthquake in Japan.²³ Disaster medical assistance teams were invaluable in triaging and treating patients during the first 3 days. A team left 34 minutes after the event to render aid to people caught in a roof collapse. During triage, 17% of the injuries were classified urgent, 22% intermediate, and 61% minor. On day 7, a DMAT was dispatched to assist with emergency medicine and primary care; 3% of the injuries were severe and required urgent care, 50% required intermediate care, and 47% required minor care.

The value of strike teams is 3-fold: It provides rapid, professional care at a crucial place and critical time; it correctly triages patients and thus allow hospitals to maintain resources for the more severely injured; and augments overwhelmed providers at crucial sites. The roles of strike teams were echoed in 2006 by Campos-Outcalt, who reported that DMATs deployed to austere locations had the flexibility to augment existing medical staff and to rapidly deploy, self-sustain, and treat patients until a situation was resolved.²⁴ This nimble strike team mentality could become a rapid and flexible model to save more lives, relieve significant suffering, and offload pressure from local hospitals by treating the less critically injured.