Disaster and Mass Casualty Response for Physicians
Anna M. Pou, MD, chair-elect Mark E. Boston, MD, member AAO-HNS Trauma Committee You are finishing a late-afternoon consult at your community hospital when a security guard rushes to the nurses’ station demanding that everyone take cover because a tornado is expected to hit near the hospital. What do you do? Are you prepared? Is your family prepared for such a disaster? Within minutes the hospital is slammed by a powerful tornado that tears off the roof, shatters the windows, knocks out the electricity, destroys the generators, rips open gas and water lines, and cuts off all communication, including cell phones. Seconds later the tornado has passed leaving the hospital dark, the floors covered by debris and two inches of water, a strong smell of gas in the air, and the shouts and cries of the injured and dying all around you. What do you do? Where do you go? What is your role in the hospital disaster plan? While this is something most of us will fortunately never have to endure, this is the exact scenario the physicians, employees, patients, and visitors of St. John’s Mercy Hospital in Joplin, MO, faced on May 22, 2011.1 The past year has seen devastating tornadoes in Joplin and Tuscaloosa, AL; an earthquake in New Zealand; an earthquake and tsunami in Japan; and floods in Thailand and Australia. And who can forget the 2010 earthquake in Haiti, Hurricane Katrina in 2005, or the terrorist attacks of 9/11? No person or place on earth is invulnerable to the consequences of natural or manmade disasters, but we are all capable of being prepared to face the chaos that follows the catastrophe. Furthermore, as physicians, we have a critical responsibility in the planning and implementation of medical response plans for disasters and mass casualty situations. The devastation of natural disasters is greater in areas and countries with limited resources, and disaster response teams must be prepared for difficult or unusual working conditions. The past decade has seen great improvements in U.S. disaster preparedness policy and investment. The federal government has increased resources and focused attention on state and local governments, community volunteers have become more involved in local disaster planning, and more medical professionals have engaged as partners in disaster preparedness planning and response.2 In addition, an increasing emphasis has been placed on individual and family readiness. This is imperative for first responders and medical professionals who will have community response obligations during any local disaster. Knowing your family is prepared is essential to your being able to respond to the needs of others. Excellent resources for individual and family readiness planning can be found at www.ready.gov. Disaster preparedness and management training programs for physicians and other healthcare professionals have also been developed during the past few years. In 2003, the American Medical Association (AMA), in conjunction with other medical groups, established the National Disaster Life Support (NDLS) program to train physicians and other healthcare professionals to safely and successfully respond to disasters. The NDLS program offers instructor-led and online disaster life support courses that introduce all-hazards disaster management and mass-casualty response concepts (www.ndls.org). The NDLS has also developed a curriculum for medical students and residents. The American College of Surgeons (ACS) offers the one-day Disaster Management and Emergency Preparedness course (www.facs.org.trauma/disaster) to better train surgeons to be able to properly respond during disasters and mass casualty events. Both the AMA and ACS courses provide a solid introduction to the language, fundamentals, and essential principles of disaster response and mass-casualty management. However, in order for the training to be meaningful, disaster drills specific to the most likely event that a population could face should be done at least annually. The benefit of drills cannot be underestimated. The most difficult challenge for most healthcare providers is the allocation of resources. Mass casualty protocols address this issue; that is, there are algorithms to follow to help decide who will get treatment and who will not at any given time depending on the resources. For example, in the pandemic flu protocols there are objective criteria that are to be followed indicating who will be placed on a ventilator, who will receive palliative care, and who will be removed from a ventilator if the condition deteriorates or does not improve. When preparing for mass casualty events, healthcare providers should discuss these ethical issues frankly and be prepared to handle them as they will occur. Everyone needs to be emotionally ready to deal with these situations. A national consensus regarding ethical guidelines should also be established to help those caring for patients during disasters. Richard G. Holt, MD, MSE, MPH, wrote on this subject in 2008.3 In addition, we should do a better job of educating the public regarding this issue, as many people do not fully realize that there may not be treatment for all during a mass casualty event or overwhelming public health emergency. Everyone reading this article is highly encouraged to develop individual and family disaster response plans, and to take one of the above-mentioned disaster and emergency response training courses to acquire a fundamental knowledge of the topics. Furthermore, it is important that all physicians understand and be ready to perform their disaster response duties within their local communities and hospitals. No one knows where he or she will be at the time of a disaster, so it is important for all to be knowledgeable regarding hospital disaster protocols and to be ready to perform any job assigned to them even if it is outside of their area of expertise. The successful evacuation of patients within 90 minutes at St. John’s Mercy Hospital was largely due to the advanced planning and disaster drills. Serious consideration should be given to the requirement of disaster education to medical students and residents around the country. It should be mandatory to healthcare workers in order to be credentialed at various hospitals. Civilian physicians have much to learn about triage from military colleagues and should not overlook this important resource. The knowledge, training, and skills you acquire by working with your local hospital or community emergency response agencies will prepare you not only to respond in your community, but also to provide emergency relief to other communities or other countries. In addition, knowledge and preparedness is likely to improve provider resilience in response to a disaster or mass casualty event. References Kikta, K. 45 Seconds: Memoirs of an ER Doctor from May 22, 2011. Accessed at http://www.mercy.net/joplin/stories-of-mercy/45-seconds. Inglesby, TV. Progress in disaster planning and preparedness since 2001. JAMA. 2011;306:1372-3. Holt, R. Making difficult ethical decisions in patient care during natural disasters and other mass casualty events. Otolaryngol Head Neck Surg. 2008;139:181-186.
Anna M. Pou, MD, chair-elect Mark E. Boston, MD, member AAO-HNS Trauma Committee

You are finishing a late-afternoon consult at your community hospital when a security guard rushes to the nurses’ station demanding that everyone take cover because a tornado is expected to hit near the hospital. What do you do? Are you prepared? Is your family prepared for such a disaster? Within minutes the hospital is slammed by a powerful tornado that tears off the roof, shatters the windows, knocks out the electricity, destroys the generators, rips open gas and water lines, and cuts off all communication, including cell phones. Seconds later the tornado has passed leaving the hospital dark, the floors covered by debris and two inches of water, a strong smell of gas in the air, and the shouts and cries of the injured and dying all around you. What do you do? Where do you go? What is your role in the hospital disaster plan? While this is something most of us will fortunately never have to endure, this is the exact scenario the physicians, employees, patients, and visitors of St. John’s Mercy Hospital in Joplin, MO, faced on May 22, 2011.1
The past year has seen devastating tornadoes in Joplin and Tuscaloosa, AL; an earthquake in New Zealand; an earthquake and tsunami in Japan; and floods in Thailand and Australia. And who can forget the 2010 earthquake in Haiti, Hurricane Katrina in 2005, or the terrorist attacks of 9/11? No person or place on earth is invulnerable to the consequences of natural or manmade disasters, but we are all capable of being prepared to face the chaos that follows the catastrophe. Furthermore, as physicians, we have a critical responsibility in the planning and implementation of medical response plans for disasters and mass casualty situations.

The devastation of natural disasters is greater in areas and countries with limited resources, and disaster response teams must be prepared for difficult or unusual working conditions. The past decade has seen great improvements in U.S. disaster preparedness policy and investment. The federal government has increased resources and focused attention on state and local governments, community volunteers have become more involved in local disaster planning, and more medical professionals have engaged as partners in disaster preparedness planning and response.2 In addition, an increasing emphasis has been placed on individual and family readiness. This is imperative for first responders and medical professionals who will have community response obligations during any local disaster. Knowing your family is prepared is essential to your being able to respond to the needs of others. Excellent resources for individual and family readiness planning can be found at www.ready.gov.
Disaster preparedness and management training programs for physicians and other healthcare professionals have also been developed during the past few years. In 2003, the American Medical Association (AMA), in conjunction with other medical groups, established the National Disaster Life Support (NDLS) program to train physicians and other healthcare professionals to safely and successfully respond to disasters. The NDLS program offers instructor-led and online disaster life support courses that introduce all-hazards disaster management and mass-casualty response concepts (www.ndls.org). The NDLS has also developed a curriculum for medical students and residents. The American College of Surgeons (ACS) offers the one-day Disaster Management and Emergency Preparedness course (www.facs.org.trauma/disaster) to better train surgeons to be able to properly respond during disasters and mass casualty events. Both the AMA and ACS courses provide a solid introduction to the language, fundamentals, and essential principles of disaster response and mass-casualty management. However, in order for the training to be meaningful, disaster drills specific to the most likely event that a population could face should be done at least annually. The benefit of drills cannot be underestimated.
The most difficult challenge for most healthcare providers is the allocation of resources. Mass casualty protocols address this issue; that is, there are algorithms to follow to help decide who will get treatment and who will not at any given time depending on the resources. For example, in the pandemic flu protocols there are objective criteria that are to be followed indicating who will be placed on a ventilator, who will receive palliative care, and who will be removed from a ventilator if the condition deteriorates or does not improve. When preparing for mass casualty events, healthcare providers should discuss these ethical issues frankly and be prepared to handle them as they will occur.
Everyone needs to be emotionally ready to deal with these situations. A national consensus regarding ethical guidelines should also be established to help those caring for patients during disasters. Richard G. Holt, MD, MSE, MPH, wrote on this subject in 2008.3 In addition, we should do a better job of educating the public regarding this issue, as many people do not fully realize that there may not be treatment for all during a mass casualty event or overwhelming public health emergency.
Everyone reading this article is highly encouraged to develop individual and family disaster response plans, and to take one of the above-mentioned disaster and emergency response training courses to acquire a fundamental knowledge of the topics. Furthermore, it is important that all physicians understand and be ready to perform their disaster response duties within their local communities and hospitals. No one knows where he or she will be at the time of a disaster, so it is important for all to be knowledgeable regarding hospital disaster protocols and to be ready to perform any job assigned to them even if it is outside of their area of expertise. The successful evacuation of patients within 90 minutes at St. John’s Mercy Hospital was largely due to the advanced planning and disaster drills.
Serious consideration should be given to the requirement of disaster education to medical students and residents around the country. It should be mandatory to healthcare workers in order to be credentialed at various hospitals. Civilian physicians have much to learn about triage from military colleagues and should not overlook this important resource. The knowledge, training, and skills you acquire by working with your local hospital or community emergency response agencies will prepare you not only to respond in your community, but also to provide emergency relief to other communities or other countries. In addition, knowledge and preparedness is likely to improve provider resilience in response to a disaster or mass casualty event.
References
- Kikta, K. 45 Seconds: Memoirs of an ER Doctor from May 22, 2011. Accessed at http://www.mercy.net/joplin/stories-of-mercy/45-seconds.
- Inglesby, TV. Progress in disaster planning and preparedness since 2001. JAMA. 2011;306:1372-3.
- Holt, R. Making difficult ethical decisions in patient care during natural disasters and other mass casualty events. Otolaryngol Head Neck Surg. 2008;139:181-186.