Disaster Preparedness

1. THE OPERATIONAL PARADIGM

• The Paradigm Shift: A Mass Casualty Incident (MCI) generates casualties that overwhelm immediate responders, whereas a disaster overwhelms the entire regional resource network. The fundamental operational shift during these events is transitioning from individual, resource-heavy patient care to population-based care designed to maximize survival for the greatest number of victims.
• Epidemiological Surge Patterns: In an acute "no-notice" disaster (e.g., explosion, building collapse), expect the first wave of patients within minutes. Crucially, ~80% of patients will self-transport (via car, cab, or foot) bypassing EMS completely, with ED volumes predictably peaking at 2 to 3 hours post-event.
• The Capability Continuum: Response operations follow a strict continuum from Standard Care (normal ratios) \(\rightarrow\) Contingency Care (modified staffing, conserving supplies) \(\rightarrow\) Crisis Care (significant rationing, altered care pathways).

2. THE TRIAGE & SEVERITY CRITERIA

Disaster triage requires rapid, binary categorization using validated algorithms like START (Simple Triage and Rapid Treatment) for adults and JumpSTART for pediatrics.

• The START Algorithm (Adults):
• MINOR (Green): "Walking wounded." Able to walk.
• EXPECTANT (Black): Apneic despite manual airway repositioning. Palliative care only.
• IMMEDIATE (Red): Meets any of the RPM (Respirations, Perfusion, Mental Status) failure criteria:
• Respirations: Spontaneous breathing with RR > 30 breaths/min.
• Perfusion: Absent radial pulse or capillary refill > 2 seconds.
• Mental Status: Cannot obey simple commands.
• DELAYED (Yellow): Obeys commands, normal perfusion, RR < 30, but unable to walk.
• The JumpSTART Algorithm (Pediatrics):
• The Apnea Exception: If a child is apneic but has a palpable pulse, provide 5 rescue breaths. If they remain apneic, tag DECEASED (Black). If they start breathing, tag IMMEDIATE (Red).
• Red Criteria: RR < 15 or > 45, absent palpable pulse, or AVPU score of "P" (Inappropriate Posturing) or "U" (Unresponsive).

3. THE IMMEDIATE THREAT PROTOCOL

• Step 1: The Field Response (TECC & THREAT): Field operations must utilize Tactical Emergency Casualty Care (TECC) phases (Direct Threat, Indirect Threat, Evacuation). Employ the THREAT protocol: Threat suppression, Hemorrhage control, Rapid Extrication, Assessment by clinicians, Transport to definitive care.
• Step 2: Departmental Lockdown & Decontamination: Secure the facility. Restrict all patient entry to a single triage choke-point. All decontamination must occur strictly outside the clinical care areas to prevent secondary facility collapse.
• Step 3: Surge Capacity via Reverse Triage: Rapidly initiate reverse triage to clear inpatient beds, step-down units, and the ED to absorb the incoming shockwave of Red and Yellow patients.
• Step 4: Go Offline: Electronic medical records (EMRs) will fail or slow down triage. Immediately switch to offline, paper-based disaster logs and SALT/START-colored tags to track patient disposition for the Hospital Incident Command System (HICS).

4. THE TOXICOLOGY / PATHOLOGY MATRIX

Disaster pathology is categorized using the CBRNE/WMD framework (Chemical, Biologic, Radiologic, Nuclear, Explosive).

• Radiologic Threats: Differentiated into external contamination vs. internal exposure. The hallmark of impending Acute Radiation Syndrome (ARS) is the onset of vomiting; time to emesis must be strictly documented, alongside serial CBCs and amylase.
• Biologic Threats:
• Tularemia: Presents in 6 major clinical forms (e.g., Ulcero-glandular, Pneumonic).
• Smallpox: High-risk identification requires a febrile prodrome combined with classic lesions that are in the exact same stage of development.
• Explosive/Crush Threats: Blast victims suffer delayed, life-threatening barotrauma (pulmonary blast injury). Crush victims suffer from rhabdomyolysis, third-spacing, and potentially lethal hyperkalemia.

5. THE ANTIDOTE & THERAPEUTIC GRID

• Nerve Agents (Organophosphates): Immediate deployment of high-dose, repeatedly administered Atropine (to dry secretions), Pralidoxime (2-PAM) (to reactivate acetylcholinesterase), and Benzodiazepines (for seizures).
• Tularemia Mass Exposure: First-line systemic therapies include Streptomycin, Gentamicin, Doxycycline, or Ciprofloxacin.
• Trauma/Wound Modification: In an MCI, surgical and trauma care must be altered. Severely contaminated wounds or those with delayed presentations should receive copious irrigation but be left for delayed primary closure to conserve operative time and prevent closed-space infections.

6. THE DANGER ZONE

• The "First Wave" Trap: A critical operational error is waiting for EMS to deliver the sickest patients. The first wave consists of the "walking wounded" (Minor/Green) who self-transport and overrun the ED within minutes. Triage teams must not commit critical resources to this initial wave, anticipating the arrival of Immediate/Red patients shortly after.
• The "Hot ED" Clean-Kill: Allowing self-transporting, chemically contaminated patients into the main ED waiting room. This immediately turns the ED into a hot zone, functionally shutting down the hospital and poisoning staff.
• The Austere Paralysis: Failing to actively transition from Standard Care to Contingency or Crisis Care (e.g., modifying staffing ratios, splitting ventilators, using non-clinical spaces) because clinicians are uncomfortable operating outside of optimal day-to-day guidelines.

7. MCQ MASTERCLASS

• "5 Rescue Breaths" Buzzword: A pediatric patient in an MCI is apneic but has a pulse. The board-correct action under the JumpSTART algorithm is to give 5 rescue breaths. If apnea persists, tag Black (Deceased).
• "Secondary Assessment of Victim Endpoint (SAVE)" Distractor: If asked about triage methodology in the field for prolonged austere conditions, SAVE guidelines base triage decisions strictly on patient outcome expectations.
• The "Time to Emesis" Pairing: In a radiologic/nuclear MCI vignette, the most highly tested early prognostic indicator for the severity of Acute Radiation Syndrome (ARS) is the onset time of persistent vomiting.

8. THE COMMAND CENTER REPORT

"Incident Commander, this is the ED Medical Director. We have received an MCI shockwave from the downtown kinetic event. Facility is locked down with a single entry point established. Decontamination corridors are fully operational in the external bay; no secondary contamination within the facility. Triage is operating under the START and JumpSTART algorithms. We have processed 45 casualties: 15 Red, 10 Yellow, 18 Green, and 2 Black. We have initiated Reverse Triage to clear acute care beds and are officially operating under Contingency Care protocols with offline paper tracking. Requesting immediate logistical resupply of balanced crystalloids, rapid transport assets to clear Yellows to secondary facilities, and deployment of backup trauma surgical teams to the Red zone. End of briefing."