Disaster preparedness: What every surgeon needs to know

Many factors—including population density, environmental degradation, advanced technology (such as large passenger airplanes), the increased presence of hazardous materials and infectious disease strains, and the very real threat of terrorist acts—make the United States increasingly vulnerable to mass casualty events. Foresight, preparation, and planning are needed to significantly reduce the potential consequences of both natural and man-made disasters.

A mass casualty event is characterized by a high number of significantly severe injuries that quickly exhausts local or regional medical resources. With ongoing casualties, the ability to give unrestricted levels of care to individual patients undergoes a paradigm shift. Instead of “the application of unlimited resources for the greatest good of each individual patient,” physicians are faced with “the allocation of limited resources for the greatest good of the greatest number of casualties.”

Surgeons and trauma centers are well positioned to assist in the management of injury following a mass casualty event. At Level One trauma centers, surgeons have technical knowledge, natural leadership skills, and management and organization abilities, as part of a coordinated response team. The challenges posed by a mass casualty event, however, differ from those of everyday practice. The knowledge and skills required to mount an appropriate response can only be learned and reinforced through proper preparation, planning, and rehearsal.

Evaluating the possibilities
Planning for a mass casualty event starts with a Hazard Vulnerability Analysis (HVA). In an HVA, risks to a hospital or a community are assessed by their order of magnitude and the framework of response available to meet that threat. Templates for completing an HVA can be found online at the Joint Commission Web site (www.jointcommission.org). Considerations might include a hospital’s proximity to a railroad line that routinely transports hazardous material or its ability to meet the demands of an event such as an airliner crash.

Evaluating measures and planning to reduce the risk of such events should take an “all-hazards approach,” which provides the flexibility and adaptability to meet the unique demands of any specific event. The best disaster preparedness plans are general but can be modulated for various contingencies. Anticipating every disaster and developing individual disaster plans for every perceived threat are both impossible and impractical.

Elements of an effective disaster plan
Every effective disaster plan has common elements. Planners can make assumptions regarding injury patterns and potential threats, human behavioral response (the injured will tend to go to the nearest hospital for care, which may overwhelm that institution), and basic needs (such as food, water, and shelter). Disaster plans should be based on lessons learned from the successes and failures of responses to prior events.

Community involvement
Many stakeholders should participate in developing a coordinated disaster response, including local hospitals, fire departments, emergency medical services, public health departments, government, police, media, and other groups. Representatives from each group should participate in the planning process and undergo regular training and education.

Regular drills and exercises should be used to test the plan’s workability so that it may be revised if necessary. Assuming that “it will never happen,” “my department has no role to play in disaster response,” or “that’s somebody else’s job” is counterproductive.

In some cases, incentives may not be fully aligned with true preparedness. For example, both the accreditation requirements mandated by the Joint Commission and the government grants for disaster preparedness may be disincentives if the emphasis is on simply developing a plan that sits (unexamined) on an administrator’s shelf. The critical focus should be on the actual process of planning, education, and training.

Establishing a plan: The Brown University example
Few departments within academic medical centers, for example, have individualized disaster plans, relying instead on the hospital’s umbrella response plan. This means that individual physicians or physician groups may respond in a haphazard fashion during a crisis.

The department of orthopaedics at Brown University is currently developing an orthopaedic disaster management response plan using the “all-hazards”approach. The flexibility in the plan may enable it to serve as a template for a comprehensive workable plan for any academic department. The plan includes the following details:

• notification and alert systems
• response actions, including delineation of the lines of authority, logistics and an establishment of an orthopaedic command center
• casualty flow and physician assignments
• recovery steps

Although not intended to supersede the hospital, local, or federal disaster plans, this document provides guidance for how an orthopaedic surgery department can respond during a disaster to provide optimal care for the affected patient population.

The AAOS and disaster preparedness
The AAOS established the Extremity War Injuries and Disaster Preparedness project team (EWIDP) in 2006 to formalize relationships among civilian and military surgeons and facilitate collaboration on research and treatment of extremity war and disaster injuries.

This collaboration has resulted in three successful symposia: The Current State and Future Directions of the Management of Extremity War Injuries (EWI I), The Development of Clinical Treatment Principles (EWI II), and The Challenges of Definitive Recon­struction (EWI III). A fourth symposium, Collaborative Efforts in Research, Host Nation Care, and Disaster Preparedness (EWI IV), will take place Jan. 21–23, 2009, in Washington, D.C. Andrew N. Pollak, MD, and COL James R. Ficke, MD, are cochairs of the event.

In addition to sessions on extremity war injury research and research collaborations, the symposium will include a session on national efforts for disaster preparedness. The session will focus on the government’s response plan to disaster management within the United States, the current status of the National Disaster Medical System (NDMS), the barriers to a coordinated civilian physician training response plan, and the education of civilian physicians and surgeons as civilian responders.

Participants hope to address several areas of concern, including the difficulty that civilian physicians have in identifying and contacting legitimate regional and national responder organizations, the training and certification process, and the possibility of developing a centralized database of NDMS agency training and participation opportunities.

An additional concern is the process for individual physicians to obtain security clearance and credentials. The lack of a central database and inconsistency in the application process makes volunteering difficult. For example, although the application and background check required to work at a Veterans Administration hospital are almost identical to those required to participate in an NDMS response team, the lack of a central database means that a physician must go through this process twice.

Finally, a well-functioning disaster preparedness system requires a healthy work force with the attendant necessary immunizations. The EWIDP is exploring ways to develop an integrated immunization database of appropriately credentialed physicians through the government.

Christopher T. Born, MD, chairs the Disaster Preparedness/Partnership Opportunities Subcommittee of the AAOS Extremity War Injuries and Disaster Preparedness Project Team. He can be reached at christopher_born@brown.edu

Disaster preparedness begins at home
Every family should have its own disaster plan, so that we can all be part of the solution and not part of the unprepared. For additional information and resources, visit www.ready.gov

All families should have some plan for communication in the event of separation. In addition, families should have the following supplies on hand and safely stored:

• a supply of nonperishable food
• one liter of water per person per day for at least 3 days
• a battery-operated or hand-cranked radio and cell phone charger
• spare batteries
• cash

References:

1. Frykberg ER, et al; Position Statement on Disaster and Mass Casualty Management. American College of Surgeons Committee on Trauma Ad Hoc Subcommittee on Disasters and Mass Casualty Management, Bulletin of the American College of Surgeons 88 (8) AUG2003 pp 14-15, reprinted in J. Am. Coll. Surg. 2003; 197; 855-856).
2. Monchik KO, Born CT, McDermott: orthopedic disaster management planning; manuscript in preparation
3. Additional information and resources can be found at www.ready.gov.