3

M O D U L E 3

Planning and Triage

in the Disaster Scenario
Ciro Ugarte | Ribka Amsalu | Jacobo Adrián Tieffenberg | Lou E. Romig | Tien T. Vu
Additional contributions from
Lara Rappaport MD, MPH, Jason R. Blumen BA, NREMT, and Joseph Wathen, MD
Planning and triage 3
in the disaster scenario
Ciro Ugarte, MD
Jacobo A. Tieffenberg, MD, MS, MPH
Ribka Amsalu, MD, MSc
Lou E. Romig, MD, FAAP, FACEP
Tien T. Vu, MD, FAAP

INTRODUCTION
“Failure to plan is planning to fail.” This quote by Benjamin Franklin appro-
priately reflects the message of this module. Emergency preparedness planning is
crucial to prevent or mitigate a disaster. As defined in Module 1, disasters occur
when a natural or man-made event transforms a vulnerable human condition into
a traumatic event causing needs to exceed the local capacity for response. Without
adequate planning, the most common response to these types of incidents is con-
fined to simply rescuing victims and transferring them promptly to a hospital facility
(the “Scoop and Run” approach).This results in the transfer of the problem from
the incident site to the hospital, overwhelming and disrupting the care capacity of
the health facility.

Some events occur suddenly, with little or no warning. Others, such as flood
and hurricanes, usually provide advanced warning or have a gradual onset that
allows for additional preparations before the critical stage ensues. In any case,
specific planning and preparedness are especially important to reduce the suffering
caused by disasters, particularly for children. Children are among the most vulner-
able populations in disasters because they have unique physiological, psychological,
and developmental needs. Pediatricians and the local community have a special
responsibility to assess how local, regional, and national preparedness plans and
response systems will actually function to protect children. Failure to consider the
needs of children in disaster planning, preparedness, and response at all levels
potentially jeopardizes this vulnerable population. Pediatricians must advocate for
the health, safety, and well-being of infants, children, adolescents, and young adults
who cannot advocate for themselves. Increasing our understanding of how children
were affected by past disasters will inform and strengthen our response.

The information provided in this module can assist in the design of an emer-
gency preparedness plan that will increase coordination among the many disciplines
involved in disaster response. Active participation of all relevant entities in plan
development is crucial. Participation in planning among involved entities breaks
down the silos that all too often isolate different disciplines, and promotes under-
standing and cooperation among them. The multidisciplinary, inclusive planning
process is actually more important than the document itself. The planning process
facilitates a collective understanding among all the key agencies and their person-
nel about the plan, which is indispensable for effective implementation of the plan
when it is needed. Planning should include both short-term and more long-term
ways of risk reduction from potential disasters, efforts to educate families and com-
munity organizations about preparedness, and methods of horizontal and v­ ertical
coordination involving multiple local entities as well as regional, national, and inter­
national assistance networks. Local planners need to have knowledge of the region-
al and national response systems and the means to coordinate local activities with
these systems.

This module reviews the basic concepts for emergency planning and response
preparedness, and discusses the various levels of planning which include the ­family,
health professionals, community organizations, and health facilities. The final section
of this module reviews how to organize community emergency services capable of
responding to a mass casualty incident.
 SECTION I / LOCAL EMERGENCY
PLAN

LOCAL EMERGENCY PLAN

designed during this stage is generically

OBJECTIVES named the response plan. A plan made for
various adverse events is called an emer-
l Describe the components of the plan and gency or disaster plan, whereas a con-
the pediatricians’ role. tingency plan is designed for a specific
Disaster
l Identify the risk factors that warrant
adverse event (e.g., tornado, flood, preparedness
consideration when planning for disasters. ­pandemic). includes the design
l Know the basic requirements for the
During the prevention phase, the ulti- of the plan, the
design and coordination of a local disaster training and
plan. mate goal is to avoid or mitigate the disas- coordination of
ter, directing efforts aimed at reducing those persons that
both the risk and the vulnerability of the will execute it, and
the availability of the
population. In many events, damages will needed resources.
The phases of disaster response include pre- occur despite mitigation efforts, and this is
paredness during which time there should defined as the remaining risk. To face these
be a risk assessment and mitigation; disaster damages, the capacity for response must
response (the rescue mission) that involves be improved through preparedness. If a
warnings, evacuations, and saving lives dur- disaster occurs, the plan will be imple-
ing the immediate post disaster p­eriod; mented in order to provide medical and
and the post disaster recovery period. humanitarian assistance. The response
Disaster management is part of the social phase consists of both implementation of
system responsible for planning, organiz- previously derived preparedness plans, as
ing, directing, and controlling during all the well as any spontaneous actions felt to be
phases of emergency management: needed even if not part of a formal plan.
Preparedness, Prevention, Response, and After the response phase, efforts will be
Recovery. The disaster plan should define directed towards repairing damaged ser-
the objectives, strategies, and activities, vices. This is known as the recovery phase.
including a detailed chronology and a pro- Reconstruction and recovery consists of
posed budget. restoring the goods and services back to
The emergency plan will have ­different pre-disaster levels if possible, and includes
objectives depending on the phase. measures for future risk reduction.
Disaster preparedness includes the design Pediatricians and other clinicians that
of the plan, the training and coordination care for children need to be involved in all
of those who will execute it, and the local committees that are considering risk
avail­ability of needed resources. The plan management, preparedness, and response.
 6 SECTION I / LOCAL EMERGENCY PLAN

They should be familiar with the plans that Risk evaluation

exist in their region so that they can work A risk evaluation involves an analysis of
in coordination with other members of threat and vulnerability. It considers the
If a response plan has
not been developed or the response system. In summary, emer- characteristics of potential threats to a
fails to contemplate gency planning includes all the activities community and determines how the com-
the special needs of and actions done preemptively in order to munity would be affected. Identify the pos-
children, develop a
prevent, mitigate, respond to, and r­ ecover sible natural events that threaten a particu-
plan or suggest
additions to the from the damages that disasters can cause. lar community (e.g., earthquakes, torren-
existing plan. All stages of a disaster (described in tial rains, volcanic eruptions, sliding soils,
Module 1) include elements of planning the overflow of rivers or lakes). In certain
that are important for the pediatrician. regions, the climatic events that endanger
These involve various social agents and are the population have a seasonal predisposi-
performed at different levels: the family, tion. Recognizing these climatic cycles can
local community organizations, emergency maximize preparedness before and during
services, community physicians, hospitals, these periods. Do not disregard disasters
government, and other agencies especially caused by human actions. These include
the local red cross and red crescent soci- incidents in factories, chemical or fuel
eties. The town or district public health storage plants, intentional or accidental
A risk evaluation
involves an analysis offices are usually the convening agents fires, incidents with radioactive or nuclear
of threat and for disaster preparedness and response materials, armed conflicts, wars, or terror-
vulnerability. planning. ism. In summary, risk evaluation involves
If a response plan has not been devel- identifying regions and communities that
oped or fails to contemplate the special are most vulnerable to the threats under
needs of children, develop a plan or sug- consideration, and describe the specific
gest additions to the existing plan. This is characteristics that make these communi-
not merely desk work. It involves o ­ btaining ties susceptible to those threats.
and analyzing data, along with field visits
and meetings with representatives from
different institutions and the community. The Community – Local
Preparation demands the active participa­ Emergency Plan
tion of the health-care sector and the Every community should develop its own
community. These efforts should result in emergency plan with the participation of
Every community
the production of operative and concise the local institutions and agencies. Clearly
should develop its define the responsibilities of each institu-
own emergency plan documents that clearly define the respon-
with the participation sibilities of specific participants and the tion and methods of coordination and col-
of the local agreements reached among the partici- laboration. Analyze the risks threatening
institutions and the various sectors of the community and
agencies. pants. It is important to institute periodic
drills to test the functionality of the system develop immediate interventions recogniz-
and the coordination among the different ing both geographic and climatic condi-
participants. tions for various regions. Obtain input
from regional and national levels, involving
national and regional health officers in the
planning process.
 SECTION I / LOCAL EMERGENCY PLAN 7

Clinic and Hospital Emergency Basic components of an

Planning Key Concepts ­emergency plan
The emergency plan should fulfill four Analysis of the situation
essential characteristics: it should be The analysis of the situation includes:
clear, concise, complete and • a description of the threats, whether
widely disseminated. naturally occurring or due to human
Clear: Make the wording simple and action.
easy to understand, with no margin for • an analysis of the structural and non-
doubt. structural vulnerability of areas at risk in
Concise: It should be quick to read. the community.
The longer the plan, the less likely it will
• an evaluation of how agencies would
be read in its entirety and the more diffi­
function to deliver needed services
cult it will be to update regularly and
(operative capacity).
distribute.
Complete: include all the necessary • the availability of resources, infrastruc- One of the most
components for effective action, coordina- ture, equipment, and critical supplies. frequent mistakes
when preparing an
tion, and reassessment. emergency plan is to
Disseminate: the plan should be Assumptions include nonexistent
widely disseminated to key stakeholders. It Identify the type or types of phenomena resources with the
that should be addressed in the plan and hope of obtaining
should also be summarized in a way that is
them in the near
visually attractive when displayed in office describe the probable magnitude, the future.
space and hospitals. expected intensity at the site where
The plan describes the responsibilities the community is located, and the time
of each participant, the risks involved, and ­period during which it is likely to occur.
the range of interventions. It is imperative Determine the potential damages and the
to involve the organizations that will carry maximal demand for health services by
out the plan in the planning process itself. establishing a relationship between the
For a health-care agency, the emergency threat and the vulnerability.
plan defines the objectives, the actions, and
the organization of the hospital and its Objectives and goals
various departments with respect to the The objectives and goals describe the
response activities and responsibilities of expected outcomes from executing the
its staff members. emergency plan given the human, econom-
Additionally, the plan needs to be known ic, and material resources that will realisti-
by all entities involved. These elements are cally be available. One of the most frequent
essential if the plan is to be executed in the mistakes when preparing an emergency
pre-established manner. plan is to include nonexistent resources
with the hope of obtaining them in the
near future. Since it is usually impossible to
obtain all the desired resources, ­establish
 8 SECTION I / LOCAL EMERGENCY PLAN

priorities for the actions based on the pop- team leader identified. Team leaders can
ulation and geographical area to be served. do household counts to determine who
The plan should include an outcome pre- might be missing and need to be res-
Enacting unannounced
simulated disasters diction that describes the measurable cued. Appendices to the plan include an
without previously impact of carrying out the emergency plan. updated directory of all the participants, a
training participants map of threats, vulnerable areas, or loca-
usually causes tions, as well as the population database, a
frustration and has Organization
Organize the various sectors and depart- health profile, health centers included in
unwanted effects.
ments of the institution so that ­authority, the network, a directory of basic services
lines of responsibility, and methods of (e.g., water, electricity, telecommunica-
coordination and communication for plan tions, security), assistance agencies, and an
activation are clear and well-defined. inventory of the available resources.
Establish an emergency operations com-
mittee to oversee and coordinate the Training
response actions. Once the emergency plan has been devel-
oped, conduct training. Training should
Roles and responsibilities enable the participants to describe the
The assignment of roles and responsibili­ situation, expected damages, roles and
ties is meant to answer the following responsibilities, and means of coordina-
questions: tion. This training should include ­simulation
exercises. The participants will have to
• Who does what? solve theoretical (tabletop) exercises once
• When? they have been assigned one of the roles
• How? and responsibili­ ties contemplated in the
• With what? plan. This ­exercise allows participants to
assess their knowledge of the technical and
It is important to have a clear command
organizational aspects of the emergency
chain for communications with backup plan.
systems to mobile cellular service such At a later stage, disaster drills can be
as radios, megaphones, and mobile sound organized and enacted. Organize disaster
systems. drills with prior notice, ­ promoting the
participation of the staff and key members
Communication and of the community. Use the experience
coordination gained in the simulation drills to update the
The communication instructions describe emergency response plan. Enacting unan-
a calling or notification chain from a cen- nounced simulated disasters without pre-
tral point until all the necessary individuals viously training participants usually causes
have been contacted. Establish the means frustration and has unwanted effects.
of communication to be used, indicat-
ing the radio band and frequency, the s Resources
telephone numbers, and the rendezvous
Analyze the activities included in the
locations. Each location should have a
­emergency plan to determine the resourc-
 SECTION I / LOCAL EMERGENCY PLAN 9

es required. This listing of resources is tals, rescue services, and emergency med­
called the requisite analysis. Contrast the ical services, as well as the participants
listed resources with those actually avail- processing the incoming information,
able and define the resources that are should report to an incident c­ommander
yet to be obtained. Gather the resources who will direct the local emergency plan
needed to carry out the emergency plan. (Figure I). For incidences involving multi­
Remember that the emergency plan must ple jurisdictions and agencies, a unified
be based on reality. Otherwise, it will command system may be established in
become a mere listing of wishful ideas. which individuals designated by their juris-
See Box 1 for useful planning resources. dictions work jointly to determine priori­
ties, resource allocation, and strategies
Coordination of the local needed to execute the emergency plan. A
emergency plan coordinated emergency response
The response mechanisms will have specif­ between various levels of local, state, and
ic characteristics depending on the size of federal government may be needed, in
each community and the particular risks addition to non-governmental agencies
that threaten it. The coordinators in hospi­ providing humanitarian aid.

1 BOX 1.
Resources for local emergency plan development in the United States

• Federal Emergency Management Agency (FEMA) – National Incident

Management System (NIMS) publications at
http://www.fema.gov/emergency/nims/
• Centers for Disease Control and Prevention - software planning
model tools for governments at
http://emergency.cdc.gov/cdcpreparedness/science/planningtools.asp
• Your state’s homeland security office, local government affairs office,
or county government office, listings at
http://www.fema.gov/about/contact/statedr.shtm.

• Colorado’s Office of Homeland Security at

http://www.colorado.gov/homelandsecurity
and Colorado Department of Local Affairs at
http://dola.colorado.gov/dem/index.html

• The International Federation of the Red Cross and Red Crescent

http://ifrc.org
10 SECTION I / LOCAL EMERGENCY PLAN

FIGURE 1. National incident Command System

National Incident Command System (NIMS), U.S. Department of Homeland Security, Dec 2008
 SECTION II / PLANNING LEVELS

P
x LANNING LEVELS
• What are the disasters most likely
OBJECTIVES to occur in your community?
• Is your home, your children’s
l Identify the different levels of planning school, and your working place
for disasters. ­located in risk areas?
l Help families make a family • How well-prepared is your home to
emergency plan. face the most likely disaster?
l Recognize the importance of one’s • Can your family be notified with
own planning, and the planning by ­sufficient anticipation or should they
be prepared in order to respond at
other health-care professionals and
any time?
health centers.
• In the event of a disaster, can you
l Assist elementary and high schools
locate and reunite your family mem-
in developing their own emergency bers at a safe location?
plans and how they can integrate into All family members should know con-
the local community emergency plan. tact telephone numbers outside the
l Identify the special needs that should
affected area and know where commu-
be addressed in a disaster shelter. nity shelters will be located. It is also a
l Describe the role of the Emergency good idea to have a pre-established
Medical Services (EMS) in disaster meeting point outside the risk area when
response. possible. Family shoud also know the
l Discuss state and federal emergency location of the command center or evac-
response plans. uation site during typhoons, floods and
other natural disasters.
• What should you do when you or one
Planning in the Family of your family members need to leave
Pediatricians should prepare themselves the family because of healthcare or
for a disaster as well as provide the fami­ other related responsibilities during a
Pediatricians should
lies of their patients with information disaster situation?
prepare themselves for
about creating a family emergency plan. When professional duties (e.g., those of a disaster as well as
The questions below serve as a planning health-care professionals, policemen, fire- provide the families of
guide. Families need to understand that fighters, public officials) limit the ability their patients with
information about
they have to be prepared to evacuate to assist one’s own family, it is important
creating a family
before the area becomes inaccessible by to have a clear written plan that has emergency plan.
rescue services, and if they choose to stay, been discussed and can be followed. An
they might not be helped immediately. example would include having a retainer
Important questions that family plans contract with a child care provider during
must address are: a p­ andemic influenza outbreak.
 12 SECTION II / PLANNING LEVELS

• Do any members of your family have cial needs may require earlier evacuation
special health needs that might be to ensure a safe environment.
affected during a disaster? Provide families with information about
Consider storing and periodically making a contingency plan that will enable
­renewing medications and supplies needed family independence for 3 days following a
Provide families with by family members with special health-care disaster. A list of supplies needed for
information about needs for use in the event of a disaster. 3 days of self-sufficiency for a high income
making a contingency Consider having a small backup generator country are shown in Box 2. This list
plan that will enable to keep a refrigerator operational to store should be modified for what is appropri-
family independence
for 3 days following a medications when there is no electricity. ate and feasible for low and middle income
disaster. Recognize that family members with spe- countries. A local specialist can add other

2 BOX 2. Supplies needed for 3 days of self-sufficiency

Basic supplies
Bottled drinking water (4 L/day/person)*
Identity cards of all family members
Well-equipped first aid kit and first aid manual
Non-perishable food
Matches
Flashlight with batteries or hand-crank
Extra clothing for protection from bad weather or outdoor stays
Blankets or sleeping bags
Money, including small change
Insect repellent
Personal hygiene products and sanitizer
Various supplies for infants and small children
Portable radio, cell phones (preferably with radio or walkie-talkies)
Map of the city or region
Frequently used medications and medical prescriptions

Some complementary supplies

Manual can opener
Garbage bags
Two extra sets of home and car keys
Elements to hold and transport pets (e.g., leashes, collars, kennels)
Food and water for pets
Extra glasses
* It is advisable to have enough drinking water for 1 week.
 SECTION II / PLANNING LEVELS 13

BOX 3. Resources for families on the Internet

• Federal Emergency Management Agency (FEMA) at

http://www.fema.gov/areyouready/

• American Academy of Pediatrics (AAP) Family Readiness Kit:

Preparing to Handle Disasters at http://www.aap.org/family/frk/frkit.htm

• American College of Emergency Physicians (ACEP) Family

Disaster Preparedness at http://www.acep.org/pressroom.aspx?id=25994

• American Red Cross Family Disaster Education Materials at

http://www.redcross.org/

From: Romig LE. Disaster Management. In: APLS Course Manual. Jones & Bartlett Publishers, 2006.

useful supplies based on the local situa- Planning by schools

tion. Box 3 lists online resources for Public and private schools also need emer-
families. gency response plans. School plans should
A local specialist can add other useful consider the most frequent accidents as
supplies based on the local situation. Box well as unusual situations (e.g., fires, school
3 lists online resources for families. violence, terrorist attacks, chemical expo-
sures, community violence). School plans should
Planning by the medical staff School plans should include details on consider the most
In addition to having their own family plan frequent accidents as
how urgent medical care can be provided well as unusual
and educating the families of their patients, when needed on site. Plans should include situations (e.g., fires,
pediatricians should address several issues training for school staff in basic life sup- school violence,
for their offices and staff. These issues port, first aid, and rescue techniques. terrorist attacks,
involve ensuring the safety of staff and chemical exposures,
School disaster plans should also community violence).
patients, protecting equipment and mate- address the identification and ­management
rial, and securing patient records. of post-traumatic stress in students and
Consider the need to have a backup gen- staff members, as well as indications for
erator to maintain refrigeration for vaccines referral for professional psychological
and other medications. When necessary, plan intervention.
for a backup location for treating your Following a disaster, children often need
patients and, if possible, a method for inform- the security of a normal routine and
ing callers where they can obtain care. Refer sup­port of teachers and peers. Closing
to the American Academy of Pediatrics schools for a prolonged period negatively
Online Tool for Disaster Preparedness for impacts the functioning of children after a
Pediatric Practices (http://practice.aap.org/ disaster. Every effort should be made to
disasterpreptool.aspx). open schools as soon as possible after an
 14 SECTION II / PLANNING LEVELS

event. Use of school buildings as emer- zational details. Planning should include
gency shelters may hinder or complicate sources of supply and methods of trans-
their reopening. Therefore, coordination portation. The needs of pregnant women,
Safety in shelters is as between schools and relief agencies such infants, and young children must be con-
important as safety at
as the Red Cross or the local organiza- sidered with respect to formula, diapers,
home. Keep drugs,
medical supplies, and tion for emergency management will assist basic first aid, hygiene, and safety. Shelters
potentially dangerous in the transition to normal operations. also must consider children with special
personal items out of More information regarding school disaster health-care needs. For example, children
children’s reach.
planning can be found at the American with asthma may need nebulizer treat-
Academy of Pediatrics website: ments. Although their families are likely
http://www.aap.org/disasters/schools.cfm. to have brought their own nebulizers, a
Child care centers also need a plan to source of electricity is needed for these
ensure the safety of children, to coor- devices to operate. Similarly, a refrig-
dinate with other community response­ erator is required to store insulin for
agencies, and to provide a method for children and adults who have diabetes.
reuniting children with family members. Families with very young or debilitated
Child care centers need to educate and children may move temporarily to a shel-
train staff members to implement the ter to protect them from the heat, cold,
emergency plan efficiently. sun, wind, or rain. Whenever possible,
Families, schools, and child care centers shelter staff members should have direct
must consider how to help children with telephone or radio access to emergency
special health-care needs in an emergency medical care services to obtain medical
situation. The AAP and the American advice. Ideally, a shelter should have isola-
College of Emergency Physicians have pub- tion protocols for highly contagious infec-
lished an emergency information form tions such as measles and chickenpox.
(EIF) for children with special needs. This Shelter life must also be organized so
document (available at http://www.aap.org/ that children are supervised and have the
advocacy/blankform.pdf) provides impor- opportunity for constructive play and
tant medical information about the child entertainment. Supervised activities enable
to any person responsible for their emer- the staff to inform children and keep them
gency medical care. safe, while allowing them to participate in
activities and tasks. Drawing and other
Medical Planning for creative activities can help children
Shelters express themselves and reduce stress.
Shelters should have an identifiable per- Activities engaging adolescents reduce the
Emergency planning son who is available, accountable, and potential of adolescent violence and mis-
must consider the ­responsible for communicating with agen- chief.
possibility of prolonged cies or organizations for supplies and Safety in shelters is as important as safe-
shelter use which
would require
assistance. Emergency planning must con- ty at home. Keep drugs, medical supplies,
additional supplies and sider the possibility of prolonged shelter and potentially dangerous personal items
greater attention to use which would require additional sup- out of children’s reach. Reduce the risk for
organizational details. plies and greater attention to organi- slips or falls in bathrooms and on all floors.
 SECTION II / PLANNING LEVELS 15

Lock unoccupied rooms and monitor • Position safe hospitals as a key

exits. People residing in shelters should component of policies and pro-
­
know where the emergency exits are and grammes for disaster risk manage-
how they are used. If the shelters allow the ment at national and local levels.
possession of weapons, these must be kept The role of a hospital goes beyond that
out of children’s reach. of a traditional provider of health-care ser-
vices. The framework builds on the role of
Planning by Hospitals hospitals within the disaster risk manage-
The WHO comprehensive safe hospital ment system and positions them as key
framework provides a guide for preparing players with the ability either to lead or to
hospitals for their role in disaster risk man- strongly support actions taken to build the
agement. The report can be accessed at overall resilience of a country or locality to
(www.who.int/about/licensing/copyright_ emergencies and disasters.
form/en/index.html). • Engage key stakeholders, including
Some guiding principles when applying communities, in Safe Hospital pro-
the framework from the report are as grammes and activities.
­follows: Building a safe hospital requires inputs
• Strengthen coordination mecha- from different sectors and partici­pants — 
nisms to build and move forward with including architects, ­ structural engineers,
a national Safe Hospital programme. water and sanitation experts, health profes-
A national Safe Hospital programme sionals and others. Partner­ships between
needs inputs from various sectors, includ- different sectors are vital to ensure that
ing those beyond the health sector. A hospitals are constructed safely and can
comprehensive approach would be best function effectively when an emergency
guided by a coordination mechanism that occurs — for instance, by ensuring water
brings together all relevant sectors to and power supplies or securing access to
address all aspects of the Safe Hospitals hospitals. It is suggested that a dedicated
programme. group of stakeholders from relevant sec-
• Build evidence and apply good prac- tors (i.e. health officials, public- and pri-
tices and risk-informed approaches vate-sector hospital managers, engineers,
to safe hospitals. architects and national disaster risk man-
The Safe Hospitals programme should agement entities) build, implement and
be implemented on the basis of lessons manage the programme together to ensure
learned from past experience and good an integrated and comprehensive approach
practices founded on strong evidence • Ensure continuous monitoring and
of what works. Lessons, evidence and evaluation of the Safe Hospital pro-
good practices will be gathered through gramme based on a set of agreed
documentation and research which is an indicators.
integral part of the programme. Specific A mechanism for regular monitoring and
approaches will also be shaped by the risks evaluation of the impact of the programme
and resources available in the location of should be built into the overall approach.
implementation.
16 SECTION II / PLANNING LEVELS

BOX 4. Resources for Hospital Disaster Planning

• Centers for Disease Control and Prevention -

Planning for health-care facilities at http://www.bt.cdc.gov/
planning/#healthcare

• Occupational Safety and Health Administration at http://www.osha.

gov/dts/osta/bestpractices/firstreceivers_hospital.html

• Agency for Healthcare Research and Quality (AHRQ) - Pediatric

Hospital Surge Capacity at
http://www.ahrq.gov/prep/pedhospital/

• American Academy of Pediatrics – Children & Disasters at http://

www.aap.org/disasters/index.cfm

If you work regularly at a hospital, training can put them in serious danger.
review the hospital disaster plan to ensure Educate staff about basic safety precau-
that the plan adequately considers the tions, and knowing when to intervene or
needs of children. If your hospital lacks to wait for the arrival of trained rescue
an emergency plan, offer to help develop workers. During the past 25 years, natural
a plan. Available resources are listed in disasters have destroyed dozens of hospi-
Box 4. tals and hundreds of health centers, result-
Hospital planning for disasters should ing in the deaths of thousands of patients,
deal with hospital and pre-hospital events. physicians, nurses, and other people who
Hospital events include accidental or non were trapped in the debris.
accidental events such as the collapse of Hospitals must determine if it is neces­sary
hospital structures, fires, explosions, pan- to build their surge capacity. The ability to
demics or toxic exposures. Plans should treat and manage a sudden influx of patients
include a detailed description of the mea- will be determined by a variety of factors
sures taken to protect staff members, including, but not limited to, the number
patients, and visitors. In cases of infectious of inpatient, ICU, or emergency beds
diseases or toxic exposures, protective available, surgical capacity, staffing needs
personal equipment and isolation proce- for all departments, supplies, and other
dures must be instituted immediately to physical spaces available for expansion of
protect staff or other patients. Hospitals treatment areas. It is important to ensure
may need to coordinate with government that existing inpatients also receive appro-
agencies to access stockpiles of necessary priate care and are discharged or trans-
medicines, vaccines, or equipment. In cases ferred to other facilities if necessary. The
of structural collapse, fire or explosions, plan should include a communication
rescue interventions attempted by hos- method to call in additional health-care
pital staff who have received no previous professionals and ancillary staff. Directors
 SECTION II / PLANNING LEVELS 17

CASE 1.
A shelter with 130 evacuates is severely damaged by a tornado during a storm.
According to the local protocol, emergency medical services cannot reach the
place due to the intensity of the storm. Victims of the tornado, both adults and
children, begin to arrive massively to the nearest hospital emergency
department. Referrals to other hospitals are not feasible because of the storm.

l Does your hospital disaster plan take into account victims arriving
on their own, or does it only consider those transported by the
emergency medical services?
l Are emergency department staff members prepared to perform a

primary triage of the victims?

l Does your hospital disaster plan take into account the staffing and

resources needed to operate under highly demanding conditions

with minimal external help?

of hospitals and emergency departments allows for a greater integration with the
should have a basic knowledge of the local external response plans (Figure 2 and
disaster plans and the local command lev- Box 5) and provides a working command
els. Select one or more members of the structure for the hospital. It also recog-
hospital staff to serve as liaisons with other nizes the necessity of many other ancillary
responding organizations and agencies to services and functions that may not be
coordinate any activities undertaken outside initially considered a part of direct patient
the hospital environment. In certain ­situations, care, but are nonetheless vital to emer-
a hospital can also serve as shelter for staff gency hospital operations.
members and their families, patients with Hospitals can also offer physicians who
special needs, and the general public. have lost their offices a space in which to
Some U.S. hospitals have adopted a attend to patients or in turn, provide
modified system for mass casualty inci-
­ emergency credentialing to community
dents or disasters that mirrors the exter- physicians when additional help is need.
nal incident command system. Originally These additional physicians can cooperate
known as the Hospital Emergency with the regular hospital physicians in the
Incidents Command System (HEICS), it is care of patients who have minor condi-
now known simply as the Hospital Incident tions, thereby allowing regular hospital
Command System (HICS). The system was staff to attend to more critical cases.
originally developed by California firefight- Hospital plans also need to address the
ers in order to establish a common com- management of stress. Frequent rotation
mand structure and nomenclature. This of providers and staff during surge times
 18

FIGURE 2. HEICS structure

INCIDENT
COORDINATOR

Public information
Medical officer
officer

Safety officer

LOGISTICS PLANNING FINANCING OPERATIONS

head head head head

Center head Situation state Time unit head Medical director Linking officer Auxiliary services Human services
unit head director director

Head, task Head, funds and supplies

Data assessment and forces unit collection unit Head, laboratory Head, personal
control officer In patient areas Treatment sector unit support unit
Head, medical Head, claims unit supervisor supervisor
Sanitary systems staff unit Head, imaging Head, psychological
officer unit support unit
Head, nursing Head, costs unit Head, patient priority
Head, surgery unit classification unit
Head, communication unit Head, pharmacy Head, mandatory life
unit unit support patients care
Head, mother-child Head, delayed
Head, transportation Patient follow-up care unit treatment unit Head, cardiopulmonary
unit officer unit
Head, intensive Head, delayed
Head, material Reporting on care unit treatment unit
supplies unit patients officer
SECTION II / PLANNING LEVELS

Head, general Head, minor lesions

Head, feeding nursing care unit treatment unit
supplies unit
Head, outpatient Head, hospital
care discharge unit

Head, morgue

From: Hospital Emergency Incident Command System Update Project. California Emergency Medical Services Authority Web Site. Available at: http://www.emsa.cahwnet.gov/dms2/heics3.htm.
 SECTION II / PLANNING LEVELS 19

BOX 5. HEICS

HEICS (Hospital Emergency Incident Command System) was created in 1993 in

California, by the authorities of San Mateo district medical emergencies service
(MES). It consists in an algorithm of positions, the holders of which have a specific
task in the event of an emergency situation (Figure 1). Each of these persons has
his/her own listing of tasks to be carried out, so that he/she can guide the implemen­
tation of these tasks in the framework of an integral system if a disaster occurs.
HEICS also includes listings of operations aimed at maximizing the overall efficiency,
promoting the undertaking of responsibilities, and facilitating the recording of key
data. This system has a flexible structure, allowing the activation of the required posi-
tions only, since activating the entire structure may take hours and even days. In the
great majority of cases, less than the complete structure will be needed. The listed
positions are not assigned to a specific individual; several individuals can be available
to cover a position assigned by the incident coordinator; in other cases, a single
indi­vidual has to undertake more than one position, according to the listing of tasks.
Additional information on HEICS and its materials can be obtained in
www.heics.com.

enables efficient performance, and mini- patients with acute illness and injuries.
mizes psychological and physical exhaus- The US has a sophisticated system of EMS
tion. Hospital plans should also take into agencies that include different levels of
­
consideration the care of individuals with ­providers. Each type of provider is an inte­
acute stress reactions, those who feel gral part of the system and the composi­
guilty for having survived or having aban- tion of providers is dependent on the
doned their families, and those who have needs and resources of the local area.
suffered considerable material losses or For pediatric care, EMS must ensure
have other psychological sequelae dur- that providers have proper training to
ing and after the disaster. Post-traumatic take care of children on a daily basis, and
stress disorder and other stress-related are familiar with pediatric dosing, pedi-
syndromes are frequent after a disaster. atric equipment use, and the needs of
children during a disaster. EMS personal
The Emergency Medical should participate in mass-casualty inci-
Services and Government dent drills and exercises involving pedi-
Planning atric patients. Understanding the regional
Emergency Medical Services (EMS) are a pediatric capabilities, such as the location
type of emergency service dedicated to of pediatric trauma and pediatric burn
providing out-of-hospital acute medical centers, is necessary. Having appropriate
care and/or transport to definitive care to pediatric destination protocols, equip-
20 SECTION II / PLANNING LEVELS

ment, and memory aids to respond to the

needs of children are important parts of
the EMS response.

EMS “DISASTER” Response

• D Detect
• I Incident Command
• S Scene Security and Safety
• A Assess Hazards
• S Support (determine need,
order resources early)
• T Triage and Treatment
• E Evacuation and Transport ernment is to provide support, a frame-
• R Recovery work for organization, and resources.

Partnerships with federal, state, and References Websites

http://www.childrensnational.org/EmsC/
local EMS agencies exist to ensure the Educationtraining/web-basedtraining.
common goal of protection and prepared- aspx
ness for the states and its citizens. The http://www.fema.gov/emergency/nims/
nimstrainingcourses
local community and state leaders are
http://www.fema.gov/pdf/emergency/nrf/
responsible for their own disaster manage- nrf-esf-intro.pdf
ment. The responsibility of the federal gov- http://www.fema.gov/nrf
 SECTION II / 21
PLANNING LEVELS SECTION III / MASS CASUALTY
MANAGEMENT AND MEDICAL CARE

MASS CASUALTY MANAGEMENT

AND MEDICAL CARE

CASE 2.
OBJECTIVES A school bus with primary school
students and caregivers leaves for a
l Learn the basic components of a mass
drive into the countryside, but skids
casualty management approach.
l Differentiate the various roles of the
on a sinuous stretch of the road and
individuals providing assistance during overturns. The vehicle is seriously
a disaster. damaged. Several children and adults
l Be familiar with the rescue chain from manage to escape, and many remain
the incident site to the hospital. trapped inside. Children are screaming
l Understand the importance of patient and crying.
documentation and recording.
l Understand and apply the triage
Are emergency medical care
l
algorithms.
l Identify the differences between the
agencies in your district
adult and pediatric triage algorithms prepared for the rescue, triage,
(START and JumpSTART). management, and transport
l Identify the tasks of a mass casualty of a large number of severely
management approach in humanitarian injured children?
emergencies. Which of the local hospitals is
l

l Be familiar with the planning tasks

prepared to provide care to
during the mitigation phase. severely injured children?
Is the nearest trauma center
l

prepared to treat so many

Medical Care in a Mass patients?
Casualty Incident (MCI) Will some of the local pediatric
l

Mass casualty management, as may occur emergency departments be

in a disaster situation, requires an adjust- able to collaborate in the
ment of the traditional emergency care management of some of
approach. In the traditional care approach, the less seriously injured
first responders are trained to provide victims?
vic­tims with basic triage and health-care
before evacuation to the nearest ­available
 22 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

receiving health-care facility. This approach The mass casualty management system
juxtaposes two organizations that work is based on:
independently with only weak linkages: the • Pre-established procedures to be used
This system,
known as mass field (often involving non health sector in daily emergency activities and
casualty responders), and the receiving health-care adapted to meet demands of a major
management,
organization that is often totally divorced incident
includes pre-
established from the pre-hospital problem. In a mass • Maximizing usage of existing resources
procedures for casualty situation, this approach will quick- • Multi-sector preparation and response
resource
ly result in chaos. For this reason, a system • Strong pre-planned and tested coordi­
mobilization, field
management, and that would allow an adequate response to nation
hospital reception. mass casualty situations was developed. This system is developed to:
This system, known as mass casualty • Accelerate and amplify daily ­procedures
management, includes pre-established pro- to maximize the use of the existing
cedures for resource mobilization, field resources
management, and hospital reception. It is • Establish a coordinated multi-sector
based on specific training of various levels ­rescue chain
of responders and incorporates links • Promptly and efficiently bring ­disrupted
between field and health-care facilities emergency and health-care services
through a command post. It acknowledges back to routine operations.
the need for a multi-sector response for
triage, field stabilization, and evacuation to The rescue chain, the essence of the
adapted health-care facilities. The devel- mass casualty management system,
opment of this approach is based on the involves the health department, private
avail­ability of large amounts of human and hospitals, police, fire department, non-
material resources, so it should be adapted governmental organizations (NgOs),
to the available resources to maintain the transport services, and communications
same effectiveness in its implementation. (Figure 3). This chain starts at the disas-

FIGURE 3. A multi-sector rescue chain

Impact zone Command

post
Hospital disaster
response plan

Traffic control
Search
Rescue Triage Regulation of Accident &
First aid Stabilization evacuation Emergency
Evacuation Department

PRE-HOSPITAL ORGANIZATION HOSPITAL ORGANIZATION

From: Establishing a Mass Casualty Management System, Washington D.C., 1996.

 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE 23

ter site (with activities such as initial • Incident command post

­assessment, command and control, search • Advanced medical post
and rescue, field care), continues with • Evacuation area
Patient referral
transfer of victims to appropriate ­facilities • Authorities and press information should be
(using procedures to regulate evacuation • Roads of access provided from the
and ambulance traffic control), passes • Restricted areas site to the Incident
through hospital reception (with activation Command and from
(Figures 4 and 5 A and B) there to intervening
of the hospital disaster response plan), and
agencies and the
ends only when the victims have received Appendix B, page 39, displays a number nearest hospital.
all emergency care needed to stabilize of function cards that define in detail the
them. basic activities of the professionals
The implementation of this rescue chain involved in the coordination and the care
requires the following components: of victims in a MCI.
• An efficient emergency department
• A basic radio communications network Safety
• Coordination procedures among all sec- Rescue activities during a disaster should
tors involved include measures to guarantee the safety
• Skilled multi-sector rescue teams of the victims, the members of the rescue
units, and the general population.
The assignment and organization of
resources in mass casualty management Communication and documentation
requires careful planning. When a disaster occurs, both l­andline
As in any chain, the strength and reliabil­ telephones and cell phones could be
ity of the system depends on each link; if overburdened. The communication
one fails, the entire system will be compro­ method of choice for emergency organi-
mised. zations utilize ultra-high frequency (UHF)
and very high frequency (VHF) waves.
Activities at the site of the The former are used for communications
disaster within the area of the event, and the lat-
These activities include the procedures ter for communications with strategic
needed to organize the disaster zone. The centers for purposes of coordination or
alert given by any observer sets the transportation. Patient referral informa-
process into motion. Define exactly the tion should be provided from the site to
location of the disaster event, the time of the Incident Command and from there
its occurrence, its type, the estimated to intervening agencies and the nearest
number of victims, the risks, and the pop­ hospital. Essential information to be col-
ulation threatened by these risks. lected includes:
The initial assessment will establish • Number of victims
what resources will be mobilized at the • Number of persons who need to be
site of the disaster (Figure 3). transferred to a hospital
The initial evaluation unit identifies the • When and how they will be transported
zones to be set up at the incident site: • Relevant lesions care of victims
• Impact zone
24 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

FIGURE 4. Organization of communications

Communications center

Firemen central National committee for

station Police central Ambulance Hospital emergency
service disaster situations
station department

Chief Director National

Manager committee Committee
Head Staff chairman
Medical for disaster
Assistant Assistant director situations
head chief
Staff Nursing
chief

STAFF STAFF

From: Establishing a Mass Casualty Management System, Washington D.C., 1996.

Care of Victims When the number of victims or the dis­

Search and rescue activities should be per- tance from the place of the incident pre-
formed by individuals with specific capabil­ vents the direct transportation of all vic-
ities including firefighters and specialized tims to hospitals, an advanced medical post
rescue units. Before allowing these individ­ may be established adjacent to, but outside
uals to enter the disaster area, verify of, the impact zone.
whether they need special clothing or Prior to the advanced medical post, all
breathing equipment to protect them from victims are medically triaged (see “Triage:
environmental risks. Rationale” below), to identify those who
Once the search and rescue units have require immediate care.
located the victims, they must take them Following triage classification, victims are
to a risk-free casualty collecting point to referred to the adjacent treatment areas
be assessed (field triage). within the advanced medical post where
After this initial triage, the victims they are stabilized. Stabilization procedures
receive first aid according to their ­status. may include advanced airway management,
 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE 25

FIGURE 5 A. Organization of the impact zone after a road traffic accident

IMPACT ZONE –
Strictly restricted access
ACCESS
CONTROL

Command post

Advanced AUTHORITIES
medical AND MEDIA
post

RESERVED AREA

RESTRICTED
ACCESS AREA
ACCESS
CONTROL

From: Establishing a Mass Casualty Management System, Washington D.C., 1996.

FIGURE 5 B. Organization of the impact zone after a leakage of toxic debris

Access control
WIND
IMPACT ZONE
Strictly restricted access

Command
post
AUTHORITIES
AND
Advanced MEDIA
medical post
Toxic
fumes

RESERVED AREA
RESTRICTED
ACCESS AREA

From: Establishing a Mass Casualty Management System, Washington D.C., 1996.

 26 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

fluid therapy to maintain circulation and color-coding system. START triage evalu-
treat shock, control of hemorrhage, and ates for respirations, pulse/perfusion, and
analgesics. Document the therapies given mental status. All patients are triaged first
Primary triage is based
on the premise that
in the patient’s evacuation report that prior to initial medical interventions.
all the victims are accompanies the patient to the hospital. In During this evaluation, each victim is iden-
equally important, summary, goals of the advanced medical tified with a specific color-coded tag, tape
regardless of age, post are to stabilize patients, reassess their or marker to indicate the level of medical
gender, profession, or
any other factor.
condition (retriage), and organize their urgency needed. Primary triage is based on
transportation to the appropriate hospi- the premise that all the victims are equally
tals. All these tasks have been summarized important, regardless of age, gender, pro-
as the 3 Ts principle: typifying (classifying), fession, or any other factor. Decisions are
treating, and transporting. made exclusively based on the victim’s
Ideally, the advanced medical post should clinical condition. Patients are classified
be staffed with trained emergency medi­cine according to severity as green (uninjured
physicians and nurses; additional physicians or minimally injured), yellow (moderately
such as surgeons and anesthesiologists injured or urgent), Red (severely injured or
can be added if available and needed. emergent), and Black (deceased). Field
­triage is performed on three levels:
Triage - Rationale
Triage is a system that allows e­ stablishing On-Site Triage: Classifies the victims to
priorities for care and transporting in identify those who need to be taken
order to save as many lives as possible. It immediately to the advanced medical post.
is performed during the rescue phase, and First aid providers or medical emergency
uses priority criteria for the care of technicians usually do this on-site tri-
patients, distinguishing those requiring age. When the technicians do not have
immediate stabilization and transport from extensive experience in triage, consider
those who can wait. In a more detailed having them classify the victims in the “yel-
analysis, triage also allows for identifying low” and “red” groups together as one.
patients who need emergency surgery. The Using this approach, the percentage of
primary triage in a MCI consists of a quick incorrect classifications declines signifi­
evaluation so that all the victims can be cantly. In addition, this simplified classifica­
examined in a short period of time and tion results in a reduction of the time
decisions can be made regarding treat­ment required for the initial evaluation.
priorities.
Once the victims are brought to the Medical Triage: Determines the required
collection point, the staff responsible for level of care. An emergency physician,
triage must quickly assess each and every anesthesiologist, or surgeon should be in
victim, and refrain from providing treat- charge of this type of triage.
ment other than hemorrhage control and
brief airway repositioning. Specific algo- Medical Triage Classification
rithms, such as the START (Simple Triage Red: Immediate stabilization is required.
and Rapid Treatment, Figure 6) have been This applies to victims who have:
used to streamline this process using a • Shock due to any cause
 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE 27

FIGURE 6. Start Triage

From: Radiology Emergency Medical Management, http://www.remm.nlm.gov/StartAdultTriageAlgorithm.pdf; adapted from original: Lou Romig, MD

• Breathing difficulty with possible Stabilize these patients so they can

respiratory failure receive further care. After stabilization,
• Profuse external bleeding reclassify.
• Head trauma with signs of altered
consciousness, such as: Yellow: Delayed treatment may be
– disorientation (cannot obey simple appropriate. Monitor closely, insert a
commands) line if uncertain about circulatory status,
– unconsciousness (cannot respond to but defer care initially. This category
verbal and/or painful stimuli) includes victims who, despite not fulfilling
– asymmetrical pupils (sign of cerebral the criteria for inclusion in the red group,
hernia) have
 28 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

• Shock risk (e.g., heart attack, abdominal should be treated or sent to a primary
trauma) care facility if available.
• Open fractures
Regardless of the triage
system used, perform a • Femur or pelvis fracture Black: Transportation to the morgue.
careful secondary • Severe burns
evaluation on all the • Head trauma but responsive to verbal Pediatric triage
victims on-site and then or painful stimuli TThe JumpStart triage system is a modi-
again at the emergency
department. • Uncertain diagnoses fied triage algorithm of START based on
­physiological criteria adapted to the nor-
Green: These victims can wait or do not mal range of pediatric values (Figure 7).
require treatment. This category includes Unlike the adult-based triage system,
those who are ambulatory and have: this system recognizes that an apneic child
can still maintain a certain degree of perfu-
• Minor fractures sion before he/she develops an irreversible
• Minor wounds or burns cardiac lesion secondary to anoxia. These
children can survive if their respiratory
After on-site care has been completed, function is sustained or restored, some-
transport victims who have been classified thing that will not be identified by applying
as yellow or red to a hospital. They should the START system (Figure 6), which does
be re-triaged on arrival. not include pulse palpation for patients
whose apnea persists after the airway has
Black: Deceased. been opened. Children who are not able
to walk or are carried in arms by adults
Evacuation Triage: Victims are reclassified should always be categorized at the very
in terms of their priority for transportation least, as yellow.
to the nearest hospital. Regardless of the triage system used,
perform a careful secondary evaluation on
Red: These victims have the highest all the victims on-site and then again at the
priority for transport, preferably with emergency department. Triage is a dynam-
a specialized crew to a tertiary hospital ic process and continues until the patient
because they require surgery for survival arrives at a place where he/she is offered
or organ-function preservation or need definitive evaluation and treatment.
ICU services. There is a newly proposed national
guideline for mass casualty triage called
­
Yellow: These victims have the second SALT for both adults and children (see
highest priority for transport, which Appendix B). SALT stands for “Sort, Assess,
­includes victims who are currently stable Life-saving interventions, and Treatment.”
but may decompensate or require urgent This guideline was developed due to the
but not emergent surgery. multiple triage systems, many of which
have been inadequately validated. This­
Green: These victims may be discharged guideline was developed by an interdisci­
on-site, if possible, after being checked plinary committee of the AMA, the
and reassured. Those with minor injuries American College of Surgeons, the
 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE 29

FIGURE 7. JumpSTART

Able YES
MINOR SECONDARY TRIAGE*
to walk?
NO
NO BREATHING
Breathing? POSITION *Evaluate infants
UPPER AIRWAY IMMEDIATE first in secondary
triage using the
APNEIC entire JumpSTART
NO algorithm
PALPABLE PULSE? DECEASED

YES YES
5 RESCUE APNEIC
DECEASED
BREATHS

Breathing?
IMMEDIATE
Respiratory
rate IMMEDIATE
<15 or >45

15-45
NO
Palpable IMMEDIATE
pulse?
“P” (INAPPROPRIATE),
POSTURING, OR “U”

AVPU** IMMEDIATE

“A”, “V” or “P” (APPROPRIATE)

DELAYED

**A: Alert, V: Responsive to voice, P: Responsive to pain, U: Unresponsive.

From: Romig LE. Disaster Management. In: APLS Course Manual. Jones & Bartlett Publishers, 2006.

American College of Emergency assigning a patient to a triage category.

Physicians, the National Association of Lifesaving interventions include control of
EMTs, and various other representative major hemorrhage, opening the airway and
organizations. providing 2 breaths for child casualties,
Global sorting is the first step to decompression of a tension pneumotho-
address the “walking wounded”. Those rax, and use of autoinjector antidotes.
who are able to walk are prioritized last; Finally, triage categories are assigned to be
those who cannot follow a command or Delayed, Immediate, or Expectant manage­
have an obvious life threat are prioritized ment based on breathing, peripheral puls-
first; and those who can follow a command es, respiratory distress, and hemorrhage
but are unable to walk are prioritized sec- control. This system of triage is different
ond. The next step of this triage system is from the other systems in that there is a
to make lifesaving interventions before grey or “Expectant” category. This catego-
 30 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

ry means that the patient may have a life- decontamination process, and disrupts the
threatening injury, but current resources implementation of the mass casualty man-
are not available to meet the demand. The agement system. Victims should not be
This organization allows
the active mobilization “expectant” category of patients should removed from the advanced medical post
and management of be re-evaluated frequently as resources to health-care facilities before:
available or needed become available. • They are in the most stable condition
resources, This system of triage does not assign possible.
communicates with
pre-hospital providers, “colors” to patients; therefore, it should • They are adequately equipped for the
and facilitates the not be confused with other triage systems. transfer.
management of The SALT triage system is an attempt to • The receiving health-care facility is cor­
inpatients and the flow take the best features of triage systems rectly informed and ready to receive the
of incoming victims.
that have been tested. It is a different patient.
method of triage in that there is global • The most appropriate vehicle and escort
sorting based on the ability to follow com­ are available.
mands and walk, and a triage c­ategory
assignment based on response to life-­ Control of Victim Flow:
saving interventions. Children would likely The Noria Principle
be over-triaged to the “assess 1st cat- Patient movement (whether by walking, by
egory,” as many will not be capable to stretcher, or by vehicle) must be in a “one-
follow commands due to developmental way” direction and without any back-­
stage. This over-triage is probably inherent tracking. From the impact zone to the col­
in pediatrics and can not be avoided. This lecting point, from the collecting point to
SALT system of triage should be tested the advanced medical post entrance, and
against the most commonly used form of subsequently to areas of treatment, evacu­
pediatric triage: Jump START. ation, and hospital care, the victims will be
on a one-way “conveyor belt”, taken from
Transfer organization the scene to sophisticated levels of care
The transfer organization includes those (Figure 8).
procedures implemented to ensure that
victims of a mass casualty incident will be Organization of Hospitals
safely, quickly, and efficiently transferred by The mass casualty management system
appropriate vehicles to a prepared health- needs specific organization at the receiv­
care facility. ing hospital. This organization allows the
Transfer is organized according to differ- active mobilization and management of
ent principles such as strict control of the available or needed resources, communi­
rate and destination of evacuation to avoid cates with pre-hospital providers, and
overwhelming the health-care facilities. facilitates the management of inpatients
One of the roles of on-scene mass casu- and the flow of incoming victims. Other
alty management is to stop spontaneous­ management tasks include secondary
evacuation from by-standers of unstable ­evacuations, and communication with vic-
victims or those minimally injured. This tims’ families and various public ­entities.
unmanaged transport is unsafe, e­ ndangers Certain key departments, including the
the lives of victims, circumvents field emergency and surgery departments,
 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE 31

FIGURE 8. Victims flow: the Noria principle*

Triage Evacuation
Treatment Triage Treatment

Impact Collecting
zone Point TRANSFER
ADVANCED HOSPITAL
MEDICAL
POST

Victims flow Transport resource flow

*This one-way progression from level to level by rotating transportation resources was labelled “Noria” in 1916 during the World War I battle of Chemin de
Dames in Verdun, France. “Noria” comes from the Latin word for “wheel”. From: Establishing a Mass Casualty Management System, Washington D.C., 1996.

­perating rooms, laboratory, radiology,

o Adding hallway beds or opening up in-
and intensive care unit, have to be rein- hospital clinics can help with surge capac­
forced. It is also important to ­ prepare ity. If victims bypass the on-scene ­medical
The on-scene command
sequential reinforcements and allow a triage and arrive at the hospital on their post, the advanced
rapid rotation of the staff in those areas own, they should be triaged appropriately medical post, and the
where the workload will be most as with any other arriving victim. When hospital command post
­demanding. This prevents overburdening prehospital management has been effi- should all be in
communication
the staff during an influx of casualties and cient, an experienced emergency nurse continuously.
ensures the prompt return to normal can do the triage. If this is not the case,
operations with an adequate staff. triage should be performed by an experi­
As part of the coordinated efforts, hos- enced emergency physician, anesthesiolo­
pital security should be reinforced with gist or surgeon. All arriving victims,
police officers stationed at the gates and in whether or not they’ve been previously
the reception area. In every hospital, there triaged, should be re-triaged upon arrival
should be a well-equipped command post to the hospital. The on-scene command
for use in emergency situations. post, the advanced medical post, and the
hospital command post should all be in
Reception of victims communication continuously, ­ providing
In order to accommodate the influx of updates on number and severity of
new patients, discharge all patients that ­injured victims, transport time, and cur­
can be cared for on an outpatient basis. rent ­hospital capacity.
32 SECTION III: MASS CASUALTY MANAGEMENT AND MEDICAL CARE

Treatment Areas these red patients that need operative

Clearly establish the treatment areas in interventions.
the hospital and provide the ­necessary Victims triaged as yellow should be
staffing. Treatment area designation reevaluated by a physician and provided
should reflect triage levels, e.g., red treat­ care or observation as needed. If their
ment area for victims triaged in the red condition worsens, transfer them to the
category. An emergency medicine physi­ red treatment area.
cian or an anesthesiologist should be in Victims with no hope for survival
charge of the red treatment area and require only supportive care. These
should be prepared to treat patients patients should be kept in a separate ward.
with extremely severe injuries. An addi- Have an area ready for deceased victims if
tional triage can determine the order of the hospital morgue is overwhelmed.
 SUMMARY 33

SUMMARY
Planning is essential to reduce risks and minimize dangers in the event of a disaster.
It should be carried out at different levels, from the family unit to the local
community with its various entities. Each community should develop its own local
emergency or disaster plan. This local disaster plan needs to be adequately
coordinated with the regional and national-level plans. Disaster plans should
contemplate the basic needs of the affected individuals and the potential
displacement of many people which may result in public health risks. The basic
components of a disaster plan are: analysis of the situation, assumptions, goals,
objectives, site organization, roles and responsibilities, coordination, and recording of
critical information. The plan needs a realistic appraisal of available resources and
extensive training and coordination.
In responding to a mass casualty incident, a management system should be insti-
tuted which includes the command post, the advanced medical post, evacuation and
transport, and hospital care. This system must be activated in a coordinated manner,
and each component sector should be prepared to organize patient care. All lessons
learned during the immediate response to the disaster should be incorporated in
future planning.
34 SUGGESTED READING

SUGGESTED READING
Benson M, Koenig KL, Schultz CH. Disaster triage: START then Mothershead JL et al. Disaster Planning. Available at:
SAVE-a new method of dynamic triage for victims of a catastrophic http://www.emedicine.com/emerg/topic718.htm.
earthquake. Prehospital Disaster Med 1996; 11 (2): 117-124.
Establishing a Mass Casualty Management System, Pan American
Committee on Pediatric Emergency Medicine. The pediatrician’s role Health Organization, 1996.
in disaster preparedness. Pediatría I997;99(I):I3O-I33.
Humanitarian Assistance in Disaster Situations: A Guide for Disaster
Farmer JC, Jiménez EJ, Rubinson L, Talmor DS (eds). Fundamentals Aid. Pan American Health Organization, 1999.
of Disaster Management. Society of Critical Care Medicine, 2003.
Safe Hospitals: A Collective Responsibility. A Global Measure of
Hospital Emergency Incident Command System Update Project. Disaster Reduction, Pan American Health Organization/World Health
California Emergency Medical Services Authority Web Site. Available Organization, Available at: http://www.paho.org/spanish/dd/ped/
at: http://www.emsa.cahwnet.gov/dms2/heics3.htm. SafeHospitals.htm.
Jacob J. Disaster plan can safeguard your practice, records. American Romig LE. Disaster Management. In: APLS Course Manual. Jones &
Medical Association Web site. Available at http://www.ama-assn.org/ Bartlett Publishers, 2006.
scipubs/amnews/pick_0 1/bica1 022.htm.
Romig LE. Pediatric triage: a system to JumpSTART your triage of
Lerner et al. Mass Casualty Triage: An evaluation of the data and young patients at MCIs. JEMS 2002;27(7):52-63.
development of a proposed national guideline. Disaster Medicine
Savage, PE. Disasters. Hospital Planning. Oxford, Pergamon Press,
and Public Health Preparedness 2(1):S25-S34.
1979.
Markenson, D, Reynolds, S. The Pediatrician and Disaster
Preparedness. Pediatrics 117(2) : e340-e362. Available at:
http://aappolicy.aappublications.org/cgi/reprint/pediatrics;
1 17/2/ e340.pdf
 CASE RESOLUTION 35

Case resolution

Case 1.

The hospital disaster plan is activated while all victims are sent to a triage area set up
in a safe location (e.g., hospital parking lot). A physician, accompanied by nurses from the
emergency department, initiates triage. Patients with critical illnesses or trauma are
transported directly to the emergency department. Those most severely affected are
treated in the emergency department and receive immediate evaluation, while those
with less severe injuries are given first aid in the parking lot or wait until they can be
treated in the emergency department. The hospital disaster plan includes utilizing staff
from other hospital departments to assist in the event of a mass casualty incident.

Case 2.

The local emergency system verifies the incident, declares a mass casualty situation, and
then activates the emergency plan, setting into motion the necessary agencies such as
fire, police, and emergency medical services. A structure for the care of victims is estab-
lished, and children and adults are triaged. An on-scene command post is established.
Local hospitals are contacted to inquire about their respective patient care capabilities.
All the children with moderate to severe lesions are referred to the nearest pediatric
trauma center, whereas adults with moderate to severe lesions are sent to an adult trau­
ma center. After all the severely injured victims have been transported, those patients
with minor lesions are referred to primary care facilities.
36 MODULE REVIEW

MODULE REVIEW

SECTION I: LOCAL EMERGENCY PLAN

1. What are the pediatrician’s specific functions in a disaster plan?

2. What factors should be considered when designing a local plan?
3. What areas should the plan cover?
4. What is the desired profile for the emergency plan coordinator, and what
roles should he/she play?

SECTION II: PLANNING LEVELS

1. Planning should cover several levels. What are these levels, and what are the
components and the adequate methods in each case?
2. What individual and family factors should be taken into account in a disaster
situation?
3. What role do community organizations play in the sequential phases of a
disaster situation?
4. How should these organizations be equipped to face the problems that affect
children which may be directly or indirectly related to the disaster?

SECTION III: MASS CASUALTY MANAGEMENT AND

MEDICAL CARE

1. What are the basic components of a mass casualty management system?

2. How is a command post for a MCI established? What areas should be defined
around the site of impact?
3. How is an advanced medical post organized?
4. What are the roles of the individuals involved in the emergency medical care
chain? How are these roles determined?
5. At which points in the rescue chain is triage performed, and what priorities
are established in each case?
6. What special conditions should be considered when triaging a pediatric
victim? How are these conditions integrated in a MCI where victims are not
only children?
 MODULE REVIEW 37

7. What data are essential for the internal communication within the system?
How are these data transmitted?
8. What elements should be considered when organizing the transportation of
victims to hospitals and other healthcare centers?
9. What systems of hospital care can be used in the response to MCI? How do
these systems operate?
10. What planning aspects correspond to the mitigation phase?
38 APPENDIX A

APPENDIX A:
ROLES AND RESPONSIBILITIES OF ESFs
ESF #1 – Transportation
Aviation/airspace management and control
Transportation safety
Restoration/recovery of transportation infrastructure
Movement restrictions
Damage and impact assessment

ESF #2 – Communications
Coordination with telecommunications and information technology
industries
Restoration and repair of telecommunications infrastructure
Protection, restoration, and sustainment of national cyber and information
technology resources
Oversight of communications within the Federal incident management and
response structures

ESF #3 – Public Works and Engineering

Infrastructure protection and emergency repair
Infrastructure restoration
Engineering services and construction management
Emergency contracting support for life-saving and life-sustaining services

ESF #4 – Firefighting
Coordination of Federal firefighting activities
Support to wildland, rural, and urban firefighting operations

ESF #5 – Emergency Management

Coordination of incident management and response efforts
Issuance of mission assignments
Resource and human capital
Incident action planning
Financial management

ESF #6 – Mass Care, Emergency Assistance, Housing,

and Human Services
Mass care
Emergency assistance
Disaster housing
Human services

ESF #7 – Logistics Management and Resource Support

Comprehensive, national incident logistics planning, management, and
sustainment capability
Resource support (facility space, office equipment and supplies, contracting
services, etc.)
 APPENDIX A 39

ESF #8 – Public Health and Medical Services

Public health
Medical
Mental health services
Mass fatality management

ESF #9 – Search and Rescue

Life-saving assistance
Search and rescue operations

ESF #10 – Oil and Hazardous Materials Response

Oil and hazardous materials (chemical, biological, radiological, etc.) response
Environmental short- and long-term cleanup

ESF #11 – Agriculture and Natural Resources

Nutrition assistance
Animal and plant disease and pest response
Food safety and security
Natural and cultural resources and historic properties protection and
restoration
Safety and well-being of household pets

ESF #12 – Energy

Energy infrastructure assessment, repair, and restoration
Energy industry utilities coordination
Energy forecast

ESF #13 – Public Safety and Security

Facility and resource security
Security planning and technical resource assistance
Public safety and security support
Support to access, traffic, and crowd control

ESF #14 – Long-Term Community Recovery

Social and economic community impact assessment
Long-term community recovery assistance to States, local governments, and
the private sector
Analysis and review of mitigation program implementation

ESF #15 – External Affairs

Emergency public information and protective action guidance
Media and community relations
Congressional and international affairs
Tribal and insular affairs
40 APPENDIX B

APPENDIX B: FUNCTION CARDS

PAHO has created a number of function cards that define in
detail the basic activities of the professionals involved in the
coordination and the care of victims in a MCI.

1. Operator - dispatch 3. Fire services

center The Fire Services will be responsible for:
l Receives initial call or warning message l Safety
concerning the event
l Search and rescue
l Establishes: caller’s name and telephone
number - nature of event - exact location
l Risk reduction
of event - time of occurrence - approximate l Definition of restricted areas
number of victims l Providing a senior officer as a staff mem-
l Verifies information (if an unqualified ber of the Command Post
observer) l Providing the Advanced Medical Post
l Mobilizes and sends a dispatch team to site (AMP) with a Transport Officer
for initial assessment
l Alerts potential responders (stand by)
l Receives report of initial assessment
4. Search and rescue team
l Dispatches necessary resources
l Locates victims
l Removes victims from unsafe locations to
collection point if necessary
l Conducts initial triage of victims (acute/
2. Initial assessment team
nonacute)
l Travel to site expeditiously l Provides essential first aid
l Identify a leader l Transfers victims to Advance Medical Post
l Establishes: precise location of the event -

time of the event - type of incident

l Estimates: number of casualties - added

potential risk - exposed population

l Team Leader reports initial information
5. Search and rescue officer
to dispatch center Coordinates search and rescue activities
l

l Draws a single map of the area indicating:

by: identifying and assigning teams -
main topographical features - potential supervising team functioning - establishing
risk areas - victims - access roads - a collection point when necessary -
various field areas - limits of restricted coordinating the transfer of patients from
areas - compass rose - wind direction
the collection point to the Advance Medical
l Directs resources arriving in the field
Post communicating with Command Post
until the arrival of a high ranking officer
l Hands over the map and briefs first
for resource reinforcement - ensuring
arriving officer of rank safety and welfare of search and rescue
l Reports to reassigned station teams
 APPENDIX B 41

8. Police officer in
6. Coordinator of the com- command post
mand post
l Performs overall coordination of the field
l Ensures that radio communication is
operations established and maintained
l Implements security measures to: maintain
l Receives reports from the other officers in

the Command Post restricted areas - provide crowd and traffic

l Continuously assesses the general control
l Manage field police resources by:
situation
l Coordinates requests between sectors in continuous assessment of needs -
the field redeployment of police officers - requests
l Ensures links between sectors for backup - ensure adequate supply of
l Ensures the welfare of all staff involved in necessary equipment
l This officer is generally the coordinator of
field operations
l Liaises with central headquarters, (e.g., the Command Post
EOCs)
l Authorizes releases to the media

l Acts as link between field operations and

backup system 9. Health officer in

l Ensures adequate radio communication
command post
l Supervises the field care of victims
l Provides the link between the health/
medical backup system
7. Fire officer in l Ensures the adequate supply of

command post manpower and equipment

l Receives reports from the manager of
l Coordinates activities of the Fire
Service in the field (ensures safety, search the Advance Medical Post (acute
and rescue) treatment manager)
l Deploys and manages health staff
l Assists in transport organization

l Manages fire staff resource needs by: resources

l Reports to the coordinator of the
continuous assessment - requests for
backup - timely rotation of staff - Command Post
withdrawal of staff no longer needed
l Reports to the coordinator of the

Command Post
42 APPENDIX B

10. Acute treatment 12. Red team leader

manager (manager of
advance medical post) l Receives patient from medical triage
l Supervises triage and stabilization of
l Examines and assesses the medical
victims in AMP condition of the victim
l Institutes measures to stabilize the
l Establishes the internal organization of

the AMP victim

l Continuously monitors victim’s
l Manages the staff of the AMP

l Ensures that effective victim flow is condition

l Reassesses and transfers victims to
maintained
l Ensures adequate equipment and other treatment areas
l Prioritizes victims for evacuation
supplies are available in each treatment
l Requests evacuation in accordance with
area
l Organizes the transfer of patients to priority list
l Reports to the manager of the AMP
health care facilities in collaboration with
the Transport Officer, the Health Officer
in the Command Post and receiving
Health Care facility
l Decides on the transfer order of 13. Evacuation officer
victims, the mode of transport, escort l Receives victims for evacuation
and destination l Assesses the victim’s stability
l Ensures staff welfare
l Assesses the security of any equipment
l Reports to the Health Officer in the
attached to victims and corrects defi-
Command Post ciencies
l Ensures that immobilization is adequate

l Ensures that the tag is safely and clearly

attached
11. Medical triage officer l Maintains observation of victims until

l Receives victims at the entrance of the transported

AMP l Supervises loading and ensure escort is

l Examines and assesses the condition of briefed

each victim l Reports to manager of AMP

l Categorizes and tags patients as follows

-­­­Red-immediate stabilization necessary

-Yellow-close monitoring, care can be
delayed
-Green-minor delayed treatment or no
treatment
-Black-deaths

l Directs victim to appropriate treatment

area
l Reports to the manager of the AMP
 APPENDIX B 43

14. Transport officer 16. Administration clerk

evacuation area
l Coordinates and supervises the
transportation of victims l Maintains a register of all victims leaving
l Identifies access routes and the AMP
l Records - victim name/number - injury
communicates traffic flow to drivers
l Supervises all available ambulance drivers category - time of departure - mode of
and drivers of assigned vehicles departure (vehicle) and escort -
l Receives requests for transportation destination
l Assigns appropriate vehicle tasks in l Reports to the evacuation office

accordance with specific needs

l Maintains a log of the whereabouts of all

vehicles under his control

l Reports to the manager of the AMP
17. Ambulance driver

l Remains in the vehicle at all times

l Responds promptly to directives from
Transport Officer
15. Administration l Ensures that vehicle is parked in designa-

clerk - triage area ted area and is ready to move

l Transports patients in accordance with
l Maintains a register of all victims
safety rules and instructions
admitted to medical triage
l Reports to Transport Officer
l Records - name or identification

number - age when possible - sex - time

of arrival - injury category assigned
l Reports to Triage Officer
44 APPENDIX C

APPENDIX C: SALT DIAGRAM

EB Lerner, RB Schwartz, PL Coule, et al. Mass Casualty Triage: An Evaluation of the Data and
Development of a Proposed National Guideline. Disaster Medicine and Public Health
Prepardeness. 2008;2(Suppl1):S25-S34.