key: cord-018937-5yo4rfml authors: Bortolin, Michelangelo; Ciottone, Gregory R. title: Disaster Medicine date: 2015-04-18 journal: Trauma Team Dynamics DOI: 10.1007/978-3-319-16586-8_25 sha: doc_id: 18937 cord_uid: 5yo4rfml Millions of people every day face disasters, for example, typhoons, terrorist attacks, earthquakes, famine, civil wars, explosions, and tornadoes. Disaster is defined as every event that causes serious disruption which exceeds the ability of the affected community or society to cope using its own resources. Disasters are usually categorized as natural or man-made and are described using a series of steps called the disaster cycle, defined in four phases: mitigation and prevention, preparedness and planning, response, and recovery. Disaster medicine is an emerging specialty that integrates the medical response to disaster with the systems of disaster management. Devastating events such as natural disasters like the typhoon in the Philippines (2013) and the earthquake in Haiti (2010), intentional events like the terrorist attack in New York (2001) , and the sarin attack in Tokyo's subways (1995) demonstrate that disasters are both unpredictable and ubiquitous. Disaster is defi ned as any event that causes "a serious disruption of the functioning of a community or a society involving widespread human, material, economic or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources" [ 1 ] . Considering that any number of different events could hit a population at any time, there is no place on earth completely immune to disasters. Therefore, disaster medicine was created as a broad specialty grounded in emergency medicine, but utilizing the skill sets of other surgical and medical specialties, and only able to become operational in combination with the systems supported by disaster management. For example, during an earthquake, several specialties are involved in the response and immediate care of the victims: emergency physicians, surgeons, anesthesiologists, and orthopedics; however, other subspecialties are also required in the ongoing care of victims. These include nephrologists to treat acute renal failure related to crush syndrome, both during and following the event, and psychosocial and rehabilitation specialties for continued care. These medical and surgical specialists are only able to perform their roles under the umbrella of disaster management. Without being enabled by the logistics and operations capabilities seen in a large-scale disaster response, these specialists would not be functional. outbreaks and human immunodefi ciency virus (HIV) are just two examples of natural disasters that for several reasons can spread quickly, ravaging entire communities. The Spanish fl u in the early 1900s caused more than 50 million deaths, and severe acute respiratory syndrome, (SARS) that arose from China in 2003, resulted in thousands of death in that part of the world and concern for a global pandemic. Another virus that affl icts and kills millions of people, particularly in the poor areas of Africa and developing countries, is HIV. It is estimated that from the 1980s, HIV has caused more that 30 million deaths around the world. An estimated 97 % of natural disaster-related deaths occur in developing countries (World Bank, 2000 -2001 [ 2 ] . Man-made disaster is defi ned as any event that is caused by the activity of human beings. Explosions, building collapse, civil wars, and nuclear accidents are some examples. The collapse of the Hyatt Regency Hotel in Kansas City in 1981 is one such example. Investigations found that the cause of the collapse was due to an engineering problem. There were more than 100 deaths and more than 200 casualties from that disaster. The transportation industry is commonly involved in incidents that cause large numbers of injured and dead. In 1998 in Eschede, Germany, a high-speed train derailed causing 101 fatalities. Other industrial sectors, such as the chemical industry, have also been involved in man-made catastrophes. In December 1984 in Bhopal, India, more than half a million people were exposed to methyl isocyanate. In the immediate phase after the leak, almost 10,000 people died. The Indian Government has calculated that this event has caused over the years almost 600,000 casualties due to lingering effects of the chemical exposures [ 3 , 4 ]. The 9/11 terrorist attack in New York and the Oklahoma City bombing (1995) are also man-made disasters. It is important to recognize and underline that disasters also result from war, the conduct of repressive regimes, the use of sanctions, as well as economic and social policies, particularly in developing countries [ 5 ] . The Syrian Civil War arose in the 2011 and has caused more than 120,000 deaths and more than 2.3 million refugees since 2013 [ 6 ] . Disasters and the response to them follow a pattern called the disaster cycle, which is defi ned in four phases: mitigation and prevention, preparedness and planning, response and recovery. Mitigation and prevention involve measures designed either to prevent hazards from occurring or to lessen the effects of the disasters [ 7 ] . These measures involve multiple different agencies and commissions, for example, policymakers introducing regulations regarding the storage, transportation, and disposal of chemical substances. Another example of mitigation is to empower a public health system to monitor and conduct surveillance for infection diseases and at the same time introduce rules regarding health screening at the borders. The importance of the mitigation phase is to avoid disaster or to reduce the impact on the population. It is clear if we compare the 2010 earthquake in Haiti, with a magnitude of 7.0, and similar earthquakes in Japan where despite the same magnitude the number of dead and injured were more limited, that we see the effect of a disaster is often dependent on the underlying condition of the area affected. For decades, Japan has introduced strict building codes that follow seismic regulations. Nevertheless, it is not possible to fully mitigate against all disaster events. For instance, the 2011 earthquake in the Pacifi c Ocean produced a tsunami that hit the east coast of Japan and caused severe damage, in particular a failure of the nuclear plant in Fukushima, with release of radiation that affected the local community. The preparedness and planning phase includes all activities conducted on an ongoing basis, in advance of any potential incident. Preparedness involves an integrated combination of assessment; planning; procedures and protocols; training and exercises; personnel qualifi cations, licensure, and certifi cation; equipment certifi cation; and evaluation and revision [ 8 ] . The fi rst step of preparedness is defi ning what events are more likely to hit a community. The Hazard and Vulnerabilities Assessment (HVA) is a way to objectively risk-stratify those hazards that are more likely to strike a given community. The HVA takes into account different events: natural, man-made, and CBRN (chemical, biologic, radiological, and nuclear). The output from an HVA prioritizes the risks to which a population is most susceptible and should therefore be prepared for. After the HVA, it is possible to then establish standard operating procedures (SOP) and the emergency operations plan (EOP) for the community or hospital. It is a good rule that the EOP adopts an allhazards approach to preparedness, with annexes and appendices specifi c for every type of probable event [ 9 ] . An important part of the preparedness phase is training. In particular, every healthcare professional must be trained when to activate a disaster response and their own specifi c roles and responsibilities within the framework of the response. The typical drills commonly used are tabletop and full-scale exercises. They are important also to identify shortfalls, bottlenecks, and gaps in the EOP. The staff should take part in the training, and the EOP should be tested, reviewed, and updated at least once per year. Response is the phase in which agencies and sections with responsibility to deploy to disasters activate their emergency response plan as a result of specifi c threats or situations and can incorporate local, regional, and federal response agencies [ 10 ] . The response is conducted through the intervention of several agencies and must be fl exible and adaptable for any type of event. It is important to immediately establish a response framework with a unifi ed command structure that establishes a chain of command, control, and coordinate the resources, in terms of staff, stuff, and structure. The Incident Command System (ICS) provides a structure to enable agencies with different legal, jurisdictional, and functional responsibilities to coordinate, plan, and interact effectively on scene [ 11 ] . The medical response is provided at the scene by the emergency medical services (EMS), with triage, treatment, and transport to the hospitals. EMS plays a crucial role in the immediate phase of the response to disaster. The response must be quick and effective on the scene as well as in the determination of hospital destinations for every patient, to guarantee an appropriate standard of care and to avoid bottlenecks and congestion at hospitals. Rarely, EMS is able to triage, treat, and transport every single patient from the scene. Often some casualties reach the closest hospital on their own, giving rise to disruption in the chain of triage and to the hospital. The ability of a healthcare system to suddenly expand its capacity beyond normal services to meet the increased demand for qualifi ed medical staff and services during a large-scale event is defi ned as "surge capacity" [ 12 ] . The surge capacity depends on the features of the healthcare system, but also by an effective EOP and training of the staff. The post-impact period revolves around disaster recovery in which the goal is to eliminate impairment caused by a disaster and rebuild communities and infrastructures [ 13 ] . Also this phase involves several agencies and may be long lasting, ranging from weeks to years. People affected by a tremendous disaster must face a long recovery phase. Survivors from the September 11, 2001, terrorist attacks on the Twin Towers not only had immediate treatment in the fi eld and in the hospitals that day, but their treatment has continued for years. The majority of people exposed to disasters do well; however, some individuals develop psychiatric disorders, distress, or risky behaviors such as an increase in alcohol or tobacco use [ 14 ] . The Department of Health and Human Services spent months and years following the 9/11 attacks and has gone on to provide health care, both physical and mental, to those who were, and continue to be, affected and in need [ 15 ] . The recovery phase often also involves rescue workers as their exposure to the traumatic event has a severe impact on their mental health. Studies confi rm that rescue workers are prone to have diseases or documented behavioral health disturbances following events. For example, several articles describe how the acute and prolonged exposures were both associated with a large burden of asthma and posttraumatic stress (PTS) symptoms years after the 9/11 attack. During an incident, the response must be effective and efficient. To achieve this, and thereby ensure that the best care possible is rendered to victims, it is fundamental to have a well-prepared and organized system. The Incident Command System (ICS) is a standardized, on-scene, all-hazards incident management concept and allows its users to adopt an integrated organizational structure to match the complexities and demands of single or multiple incidents without being hindered by jurisdictional boundaries [ 16 ] . The ICS was developed in the 1970s in California to manage, command, and control fi re brigades during their operations to extinguish wild fi res. Shortly after that, it was adopted by EMS and other agencies, as well as endorsed by the U.S. Department Homeland Security as a fundamental element of incident management. The ICS is used for all events and is modifi ed depending on the size of the incident. Its goal is to manage and to resolve the incident with an effi cient use of resources while protecting all persons involved. The ICS is a modular and fl exible organizational system that can be standardized for multiple uses. The ICS is modifi ed according to the size and complexity of the incident, specifi cs of the hazard, environment effected by the incident, the incident planning process and incident objectives (ICS expansion and contraction) [ 17 ] . The ICS establishes an incident commander (IC), who is in charge of all the activities regarding the incident, a chain of command, and unifi ed command between the agencies. The priorities of the IC are three: the safety of the casualties and the rescue team, incident stabilization, and property preservation. Every incident must have an incident action plan (IAP) that establishes incident goals, operational period objectives, set activities, and the response strategy defi ned by the IC during response planning [ 18 ] . The IC manages and carries out his responsibilities with three features of command that are important for every role within the framework of the ICS: the chain of command, the unity of command, and the span of control. The chain of command is a key part of the ICS and is defi ned as a structure with a clear line of authority. The unity of command infers that every responder knows without question who his/her supervisor is. Span of control describes the typically 6-7 people a supervisor directly leads. During a disaster, it is extremely important to establish a unifi ed command, because it enables all responsible agencies to manage and coordinate an incident together by establishing a common approach and a single IAP. It permits the integration of staffi ng and shared facilities, with everyone having the same objectives and not replicating efforts [ 19 ] . The IAP describes activities, responsibilities, and the communication procedures. This system is fundamental to avoid confusion and lack of communications. Adequate and redundant communication systems are very important during the response to disaster. It is essential that the ICS use common terminology and integrated communications among agencies and establish precise ways of communications. The communication systems should be: interoperable between agencies; reliable to function in the context of any kind of emergency; portable, built on standardized radio technologies, protocols, and frequencies; scalable as the needs of the incident dictate; resilient to perform despite damaged or lost infrastructure; and redundant to enable the use of alternate communications methods when primary systems go out [ 20 ] . The ICS is supported by a command staff that includes a safety manager, a liaison offi cer, and a public information offi cer. It is organized into four sections, the general staff, which supports the ICS: operation, planning, logistics, and fi nance/administration. The operation section is in charge of managing all the tactical operations on the scene; tactical operations include fi re brigades, EMS, and every agency required for the incident. The planning section is responsible to draft the IAP; to get, receive, elaborate, and share information; and to track all the resources. The logistic section provides the supplies, needs, and the facilities and supports the personnel with food, water, and fi rst aid. The fi nance/administration section is in charge of tracking all the costs and to negotiate and supervise contracts. These sections, like the ICS, are modular organizations and can be further expanded into: units (the organizational element with functional responsibility for a specifi c incident planning, logistics, or fi nance/administration activity), divisions (only for operation section, used to divide an incident geographically), groups (only for operation section, established to divide the incident management structure into functional areas), and branches (used when the number of divisions or groups exceeds the span of control and can be either geographical or functional for major aspects of incident operations) [ 21 ] . Triage in a disaster event places casualties in four classes: black (or expectant), red (or immediate, priority 1), yellow (or delayed, priority 2), or green (or minor, priority 3) in agreement with the severity of the injuries. When sorting casualties, it is important to give immediate medical care to critical patients that have a chance of survival with prompt, advanced treatment. In minor patients and patients who are so severely injured that they have very little chance of survival treatment is delayed. The goal is to provide the greatest good for the greatest number of patients, forcing the triage offi cer to decide whether the chance of a patient surviving is so low in comparison to the burden such care would place on the medical system that the patient must be consigned to the "expectant" category (dying; little or no treatment) [ 22 ] . The concept of triage must be seen in a wider context and is composed of the following elements: rapid evaluation of all disaster victims, assessment of the nature and severity of the injuries and its consequences on the vital functions of the casualties, and categorization of the casualties, resuscitation, stabilization, and conditioning for transport, distribution, and evacuation of the casualties [ 23 ] . Triage is a quick and dynamic process. This means that it must be repeated often and at every moment in which a new healthcare professional takes control of a patient, for example, during transport, at arrival at the hospital, or if there is the suspicion that the state of the patient has changed. Triage will be discussed further in the Chap. 26 . The "second hit" is a classic tactic and pattern seen in terrorist attacks. It is defi ned as second incident caused by the terrorists, following the fi rst event, with the goal of striking the fi rst responders that are on scene. Typically, it is a second explosion close to the scene and often more powerful than the fi rst detonation. This is because the intention is to create casualties during the fi rst blast and to attract people to the scene and then striking them with a larger detonation. This achieves the goal of a terrorist attack: to cause additional chaos thereby delaying the response and causing great physical and psychological impact on the populations and on the rescuers. An example of this was the terrorist attack in 2002 in Bali. Two bombs detonated within a short period of time. The fi rst was concealed in a vest worn by a suicide bomber. The second charge was in a minivan about 15 m away when the fi rst explosion happened. The force of the car bomb was enormous [ 24 ] . Terrorist attacks are very challenging and diffi cult to manage, because they are designed to create loss of life and property damage, disruption of the agencies involved in the response, and fear and harm to the population. The Israel response system is very seasoned to terrorist attack and has specifi c guidelines and protocols in case of attacks to avoid damage from a "second hit." Traditionally, medical teams do not enter the scene of the explosion until it is deemed safe by police or army personnel. With many of the terrorist attacks in Israel, a secondary explosion or bomb is set off timed to cause additional injuries to the emergency personnel and bystanders responding to the primary event. However, because time is critical, often EMS does not wait for such security clearance and attempts to rapidly remove the casualties from the immediate vicinity of the initial event. The only medical care given before this initial evacuation is external hemorrhage control [ 25 ] . They apply the "scoop and run" approach on the scene (minimal resuscitation on the scene and immediate transportation to the trauma center) to clear the casualties from the area of the event but in the meantime minimize the risk for the rescuers. Therefore, in case of a terrorist attack, it is imperative to maintain the role of the incident commander, the coordination between the agencies, and training of the rescuers to guarantee the safety of all the workers involved in the response. The United Nations Offi ce for Disaster Risk Reduction, Terminology World Bank Seminar on the role of local governments in reducing the risk of disasters Man-made disaster and development-the case of Iraq United Nations High Commissioner for Refugees, Stories From Syrian Refugees Community emergency preparedness: a manual for managers and policy-makers Guide for allhazard emergency operations planning Public health and disasters, Chapter 2 Department of Homeland Security National Response. National Response Framework (NRF) Das Konzept von "Surge Capacity" im Katastrophenfall Notfall Rettungsmed Koenig and Schultz's disaster medicine: comprehensive principles and practices Individual and community responses to disasters Testimony before the Committee on Oversight and Government Subcommittee on Government Management, Organization and Procurement United States House of Representatives, on 9/11 Health Effects: HHS's Monitoring and Treatment of Responders Federal Emergency Management Agency "ICS-100. A: introduction to ICS EMI Course Number: IS100". Student Manual Version ICS-200: Single Resources and Initial Action Incidents" EMI Course Number: IS200 Instructor Guide Version 2 Offi ce of the Assitant Secretary for preparedness and Response. What is an incident action plan? ICS-300 Intermediate ICS for Expanding" Student Manual IS-700.A: National Incident Management System, An Introduction Federal Emergency Management Agency. Introduction to the Incident Command System (ICS 100) Student Manual Mostly dead: can science help with disaster triage? Triage Unit for Emergency Preparedness, Committee for Disaster Medicine Studies. The terror attack on Bali Medical lessons from terror attacks in Israel • Disaster is defi ned as any event that causes serious disruption of society which exceeds the ability of the affected community to cope using its own resources. • Disasters are usually categorized as natural or manmade, and response to them follows the same pattern, called the disaster cycle, defi ned in four phases: mitigation and prevention, preparedness and planning, response, and recovery. • The Incident Command System (ICS) is a standardized and modular organization, on-scene, and allhazards incident management concept and allows its users to adopt an integrated organizational structure to match the complexities and demands of single or multiple incidents. • The word triage means "to categorize, to sort." The purpose of triage in a disaster event is to catalogue the casualties in agreement with the severity of injuries. Sorting casualties is important to give immediate medical care among critical patients that have a chance of survival. The goal is to provide the greatest good for the greatest number of patients. • The "second hit" phenomenon is a classic tactic and pattern of terrorist attacks. It is defi ned as a second incident caused by the terrorists, a little bit later than the fi rst event that is geared to injure the fi rst responders that are on the scene.