Coping with mayhem
Following the Asian tsunami disaster two months ago Professor J
Christopher Farmer and colleagues comment on how better management of
hospital resources and staff could greatly improve preparedness for such
disasters at a national and local level.
medical response has historically focused on the pre-hospital and
initial treatment needs of casualties.
In particular, the critical care component of many disaster response
plans is incomplete. Equally important, routinely available critical
care resources are almost always insufficient to respond to disasters
that generate anything beyond a ‘modest’ casualty stream. Large-scale
monetary funding to effectively remedy these shortfalls is unavailable.
Education, training and improved planning are our most effective initial
steps. We suggest several areas for further development including dual
usage of resources that may specifically augment critical care disaster
medical capabilities over time.
Disasters have been a part of human existence since ancient times, and
so has disaster medicine. We define disaster medicine as a human
response to unexpected mayhem with the intent to limit death, disease,
and injury. In recent decades, disaster medical response has largely
focused on prehospital care issues such as casualty evacuation, triage
and transport, without specific emphasis on hospital management. In the
United States, this phenomenon is referred to as ‘ambulances to
nowhere’. Recent experiences with large-scale disasters have strongly
reinforced the fact that hospital capacity is the major ratelimiting
factor in the chain of medical response. This is especially true for
critical care services and intensive care unit (ICU) bed capacity. As we
continue working to build adequate disaster medical response systems we
must maintain our pre-hospital readiness efforts, and we must expand our
focus to more precisely define the hospital and the ICU as critical
links in the entire response process. The purpose of the present
commentary is to explore ways in which this expansion of focus might be
A number of recent examples illustrate the importance of the hospital
and the ICU in the medical response to disaster. Within a few hours of
the Madrid bombing explosions in March 2004, 27 critically ill patients
were admitted to the two closest hospitals which had a maximum ICU
capacity of 28 beds, most of which were already occupied. After the
terrorist bombing in Bali, the Royal Darwin Hospital in Australia, with
a capacity to care for a maximum of 12 ventilated patients, was
presented with 20 critically ill patients, 15 of whom required
mechanical ventilation. Flooding due to heavy rain in June 2001 crippled
the Texas Medical Center in Houston and resulted in a sudden loss of 75%
of the ICU bed capacity for a county of four million people.
And it is not just ICU bed capacity that is subject to being
overwhelmed. Damage to the physical and organisational structure of the
hospital may wipe out an entire critical care infrastructure. Some
disasters may harm healthcare workers, thus limiting available ICU
personnel. This was the case during the Tokyo Sarin gas subway attack in
1995, and more recently during the severe acute respiratory syndrome
outbreak in Canada and Asia.
in the context of the everyday strain on currently available resources,
the challenge is even greater. An analysis of the capacity of a
1,200-bed hospital in the United States to handle patients in the
setting of a toxic chemical exposure event revealed an ability to handle
only two chemically contaminated patients at a time.
Add to this the fact that in many countries, because of efficiency and
budgetary constraints, hospitals are shrinking in capacity. This has
resulted in hospitals working at or near maximum capacity every day with
associated logistical concerns such as overcrowding, diversion of
ambulance services, and lack of surge capacity.
Particularly important is the inability of emergency departments to move
critically ill patients to their inpatient setting due to the
unavailability of staffed critical care beds. With future projections
for a shortage of critical care physicians and critical care nurses,
these logistical barriers to ICU care will persist and will influence
the provision of disaster critical care response. Taken together, this
means that we do not need a major disaster like a terrorist attack or an
emerging infectious disease epidemic to tip the strained balance between
the supply and demand of critical care resources. Disasters of a local
scale alone can tip the balance, such as when a fire broke out at a
nightclub on Rhode Island in 2003. The local hospital immediately
received 40 critically ill patients, most requiring intensive care
Education and training are effective modalities that tangibly enhance
disaster medical response at every level. However, current disaster
medical education programmes for healthcare professionals are not
coordinated in scope and content, and may not address the most pressing
needs for critical care personnel. What are the imperatives that must be
taught? For example, it would be an error to assume that principles of
triage, recognition of smallpox, antibiotics for anthrax, proper dosing
of atropine, and so forth represent a sufficient knowledge base.
The severe acute respiratory syndrome outbreak of 2003 emphatically
demonstrated that scrupulous training and execution of infection control
practices became a survival skill for ICU personnel. Unfortunately, this
is not substantially represented in current disaster medical education
Does this mean we need to build more beds, hire additional specialised
personnel, or stockpile antibiotics, antidotes, and equipment against a
possible disaster situation? We think not; this would be unworkably
expensive and would still leave us incompletely prepared for many of the
disaster scenarios just described. So, what are the solutions? We offer
the following suggestions in order of priority. These concepts attempt
to build on existing resources. We do not pretend to offer
evidence-based guidelines. Rather, our intention is to engender
discussion and dialogue.
Education and training Pre-emptive education is the single most
effective tool we can employ to mitigate the future effects of a
disaster. In terms of impact, the education of healthcare professionals
is at the top of the list. The educational initiatives we propose to
accomplish this goal are as follows: heightened disaster response
awareness, enhanced skill sets, understanding of roles and
responsibilities, alternative communication methods, self-preservation
training and experience in how to co-operate and co-ordinate during
Medical preparedness training should not be limited to firstline
treatment, but must include targeted training that covers the entire
disaster medical spectrum. The challenge is distilling all of this into
a curriculum that fits the very limited time availability of healthcare
As one evolving example, the Society of Critical Care Medicine has
developed a standardised and highly concentrated course (Fundamentals of
Disaster Management) to equip critical care professionals with basic but
essential disaster medical knowledge. The content of this programme is
still in evolution.
Disaster response medical simulation approximating actual scenarios
enables disaster planners and responders to test procedures and
technologies, and to incorporate the lessons learned from past
disasters. This simulation has been shown to be effective. The level of
realism is much higher than in facilitybased exercises, where time and
personnel utilisation are compressed and usually do not adequately teach
disaster resource management.
Finally, there is a useful role for what is termed ‘justin- time
training’. The intent of these programmes is to make concise knowledge
available to providers at the time of an event and at the point of care.
Most of these are Web-based knowledge collections that can be queried.
This approach is less time intensive, less labour intensive, and less
cost intensive than traditional educational processes. We should point
out, however, that ‘just-intime training’ serves as an adjunct, but
alone it is not an adequate replacement for the other methods enumerated
Any ‘just-in-time training’ programme is only as effective as the skills
of the professional in accessing the training when it is needed, which
must be in place beforehand. Interfacility co-operation Experience has
shown that the burden of disaster medical response largely falls to
healthcare facilities proximate to an event. Despite the widely held
impression that ‘the government will be there’, outside help and
intervention typically does not have a large impact on the initial
phases of disaster medical response. We have already outlined some of
the obstacles, such as strained resources or lack of communication and
training, that impede co-operation. While most hospitals have plans for
response to local disasters mapped out, plans that looked good on paper
often go awry during execution.
In terms of interfacility cooperation, given that many local hospitals
financially compete with each other, teamwork in the event of a disaster
is expected to materialise where it has not been previously encouraged.
As such, the results are seldom efficient. A rational approach to tackle
this issue includes the development of flexible and scalable plans for
interchanging resources to augment the existing capacity of individual
example, many communities currently divide disaster responsibilities
according to the type and severity of injuries among the various
hospitals. Unfortunately, a significant percentage of casualties make
their own way to the hospital, irrespective of these plans. A better way
would be to build flexible surge capacity that allows hospital personnel
to move from one facility to another according to need. Such adaptation
to circumstances will not happen spontaneously, and will require
An additional example of efficient sharing is disaster medical
education. Many or all of the educational proposals outlined in the
previous section could be shared increasing availability,
cost-effectiveness and, probably, quality. Dual usage of resources As
suggested, the cost of effective disaster planning is enormous. It is
not realistic to expect budgetconstrained facilities to absorb these
additional costs and yet relief from governments will not fill the gap.
It therefore seems reasonable to seek economies of scale, such as
dual-use modalities. For example, to increase ICU surge capacity,
consider our ability to provide critical care outside of a designated
geographical location. A significant volume of critical care is provided
(nondeliberately) every day outside the geographical constraints of an
ICU, hence the growing development of medical emergency teams in
hospitals around the world.
With little additional training, these teams could provide a highly
effective adjunctive capability during disaster medical response when
critical care units are full but additional ICU services are required.
As a second example, ensuring patient safety in the hospital is also
emerging as a significant resourceconsuming, but essential, activity.
This is especially true as we move beyond compliance activities into
multi-disciplinary, tiered accident and error prevention.
From this perspective, a medical catastrophe may encompass a single
patient who receives improper medication through to mass casualty
circumstances. While these events are fundamentally different in scope,
magnitude, and cause, they share at their core a need for accurate and
complete planning and education to prevent or mitigate their
Is there sufficient overlap to merge some of the planning, education,
and practice of hospital patient safety and disaster medical response?
In summary, where we have been will not get us to where we need to go
for disaster critical care response. First, we must work around apathy,
confusion of purpose and a lack of monetary resources to widen the
spotlight of disaster medical response from the prehospital arena to
include the hospital. We must enhance our abilities and capacity across
the whole spectrum of disaster medical response.
These efforts are the responsibility of society as a whole. All involved
organisations including hospitals, emergency medical services, fire
services, police, the public health system, local municipalities,
government authorities and other healthcare institutions will need to
integrate into a well developed disaster educational system and response
team. In this article we have attempted to outline conceptual elements
that may facilitate some of this integration. For this to happen,
someone with comprehensive understanding and the necessary expertise is
required nationally, regionally, and locally to provide the leadership
imperative that drives integration of these disparate entities and
resources. The first step is ownership, and as critical care
professionals we are obliged to step forward and provide the leadership
for these processes.