Mass Casualty Incidents : Organizational and Triage Management Issues

Mass casualty incidents (MCIs) are characterized by such high numbers, severity, and diversity of injuries and illnesses that they can overwhelm the ability of local medical resources to deliver comprehensive, definitive medical care to all victims (1). Recent experience with large-scale natural disasters, bombings, threats of weapons of mass destruction, and pandemics suggest that modern-day mass casualty events would compromise the ability of health systems to deliver services consistent with established standards of care while rapidly overwhelming both the medical and public health systems. Yet no one recent event revealed the dangers and opportunities posed by potential MCIs more than the severe acute respiratory syndrome (SARS) pandemic that spread from rural China to 40 countries in 10 days (2,3). SARS exposed severe international political and legal impediments that not only prevented an effective and efficient local-to-international response but also contributed to the transmission of the disease. Only when emergency actions by the World Health Assembly gave the World Health Organization (WHO) unprecedented authority to overcome national sovereignty restrictions in favor of international protection was the pandemic controlled (4,5). Though the mass critical care of Ebola virus disease patients in the West Africa outbreak of 2014–2015 captured the world’s attention, the impact on global critical care was limited and isolated, and except for specified Ebola virus disease-receiving centers which focused on preparation, training, and supportive treatment (6–8). Clearly, what happens locally, as a potential global threat, has immediate international implications. Over a prolonged period of time, local capability and capacity to optimize health services, including critical care, requires unprecedented collaboration, communication, and cooperation of state, national, and international resources (2). Victims in the developed world are not prepared for the sudden challenges posed by an MCI that limits resources. Nowhere is this more evident than in countries that can provide highly advanced and technologically dependent medical, surgical, monitoring and care to critically ill victims. Arguably, critical care is the most expensive high technology and resource-intensive area of medical care, and the pressure to respond in like-minded fashion to any MCI with unlimited resources is immense (9). MCIs, in particular, the 1995 Tokyo Subway sarin attack, the 2001 anthrax letter attacks, and the 2003 SARS outbreaks, have transformed the requirements for health care facilities (HCFs), and in the process, made the critical care community more aware of how devastating are the potential expectations and risks of their roles and responsibilities. The greatest challenge for HCFs, already overwhelmed on a daily basis with high acuity, declining bed capacity, and health care worker (HCW) shortages, will be the sudden presentation of large numbers of severely critical victims (10). HCFs are expected to increase their capacity (staffing, equipment, and prioritization of care) by 110% to 120% to cope with a major MCI (11). Depending on the cause of the MCI, the patient mix may range from primarily “walking wounded” or those with minimal illnesses (e.g., influenza pandemic), to the vast majority of those requiring hospital admission for critical care (e.g., inhalational plague, anthrax, mutational avian influenza). Novel, highly virulent diseases such as Ebola virus disease can similarly have a negative impact on critical care capacity and capabilities due to the medical training and logistical demands these patients require (12,13). Research in the area of organization science challenges communities to continuously maintain effective, high-quality, and competent working conditions despite disasters that “fluctuate widely and are extremely hazardous and unpredictable” (14). New organizational systems that achieve flexibility and a degree of reliability under turbulent conditions have in common: standardization, specialization, formalization, and hierarchical authority. One community level system is the National Incident Management System (NIMS) and its Incident Command System (ICS), designed and used by many public safety professions. The NIMS has shown consistent capacity and reliability in conventional disaster conditions along with the ability to structure and restructure on a moment-to-moment basis to respond to unforeseen complications provoked by large, complex, and dynamic emergencies and disasters (14). This chapter will focus first on the description of established disaster management schemes under the NIMS that address the integration of multidisciplinary local, national, regional, and international assets required for effective management of MCIs, including issues of critical care decision making and communications. Knowledge of these schemes will allow the critical care community to be a more effective player at the emergency response table (10). Second, this chapter will address critical care decision making, capacity surge, and triage management of limited resources (2,15).