Medicine of major emergencies and disasters: strategies, logistics, tools, triage
Medicine for major emergencies and catastrophes (“disaster medicine”) is the medical area that analyzes and includes all the medical and first aid procedures that are implemented in the event of a major emergency or catastrophe, i.e. all those situations in which an event occurs that puts the health or life of a large number of people at risk, such as in the case of explosions, train accidents, plane crashes, earthquakes
Disaster Medicine: what does it consist of?
By virtue of the international agreements concerning Civil Protection, emergency interventions and other areas of Disaster Medicine, it can be assumed that in Western countries the terms are equivalent, and also the protocols are substantially superimposable.
Naturally, there are territorial differences, but they are often minimal and not worthy of great attention: rescue in maxi emergencies takes place in a rather uniform way, also for better coordination in cases of collaboration.
Disaster Medicine: the difference between a major emergency and a catastrophe is in the functioning or otherwise of the rescue systems:
- maxi-emergency: rescue systems, such as hospitals, sanitary facilities, ambulances, are intact and functioning. Help is guaranteed.
- catastrophe (or disaster): rescue systems are damaged and/or unable to function because for example they were destroyed by the disaster itself. The catastrophe is more serious than the maxi-emergency, because the rescue is NOT guaranteed.
Disaster medicine aims to provide the correct medical response when resources are insufficient compared to the needs of the event, and is based on the integration of the various components of the rescue (medical and logistic).
In disaster medicine, two basic aspects must always be considered:
- integration between relief institutions, i.e. the condition for reaching an operational synergy aimed at a common goal;
- concept of victim extended in its entirety, i.e. not only dead and wounded, but all those who have been affected in their affections and psyche.
Dynamic damage rule (Bernini Carri equation)
As an indicative reference, Bernini Carri’s equation called the “Dynamic Damage Rule” is used, which states:
“the intensity of a phenomenon (called Damage) (Q) is directly proportional to its intensity (n) and indirectly proportional to the existing resources to manage it (f) for the time in which it develops (t)”
Q = n/f x t
In this equation (n) represents the number of people involved in the catastrophe (injured, deceased or survivors in need of assistance) and (f) represents the number of rescuers or the means used for the rescue.
In this equation, the “Resilience Factor (R)” of the population (Q = n/f x t / R) can be subsequently considered, understood as the ability of a certain population to react positively and actively to the reduction of the Damage; therefore the higher the Resilience Factor (R) is considered, the more the effect of the Damage is mitigated (this is especially important for the phases following a catastrophic event).
Instruments in Catastrophe (or Disaster) Medicine
Disaster medicine actually represents the set of various types of disciplines aimed at achieving common objectives, i.e. the limitation of sequelae and loss of human lives.
The hostile environment where the operations take place requires an ability to adapt typical of field medicine; the identification of priorities characterizes emergency medicine, the healthcare management of a large number of victims must take into account mass medicine, and the concept of the victim understood as a whole is peculiar to global medicine.
It is necessary to start from a preventive planning applicable in the field typical of doctrinal medicine, maintaining a hierarchy of tasks and an essentiality of the treatments characteristic of war medicine.
The peculiar aspect of each scientific discipline is the use of operational tools.
There are three that characterize disaster medicine:
- strategy: the art of devising contingency plans;
- logistics: the set of personnel, means and materials aimed at the realization of the plans;
- the tactic: the application of the plans with the unfolding of the rescue chain.
Strategy
Strategy is the art of devising contingency plans, and three cornerstones represent its cornerstone:
- top management: emergency plans must be prepared by the most expert operators, devising realistically possible situations;
- emergency plans: the drafting of emergency plans has as its starting point the analysis of the risks present in the territorial context; it should be emphasized that the realization of a response must be based on the prediction of the events relative to their consequences;
- operator preparation: operator training is an essential requirement.
Logistics
Logistics is all that will allow the system to survive and function; it can literally be defined as the art of providing and allowing for a fair and rational deployment of men, materials and means in the field.
Certain evaluation criteria must be established in advance:
- the type of event: for example, the collapse of a residential structure in an urban environment will lead to a different response than a railway derailment.
- the operating environment: the environmental conditions heavily influence the response of the system. The action that takes place in inaccessible places, the presence of possible additional risks, the difficulties associated with accessing the victims, the climatic conditions and the possibility of effectively channeling resources to the scene of the event, represent binding aspects that must be considered in the management of the intervention.
- the duration of the operations: the autonomy of the rescuers and/or their rotation is an important variable for logistical purposes.
Tactics
The tactic is the application of rescue plans through consequential operating procedures, aimed at creating the rescue chain.
This sequence is applicable in any event, regardless of the type of catastrophe, and should be considered the basic operating model to refer to.
The specific aspects of the rescue chain must meet certain requirements:
- The centrality of a single institution that receives the alarm, scales the event and promptly provides a coordinated response.
- Medicalization is at the heart of disaster medicine; although the problems encountered in ordinary emergencies are amplified, the most common mistake is the thought of tackling them by disorderly increasing the deployment of forces in the field. The most correct approach will instead be to establish the priority of evacuation towards the definitive places of care for the victims. The medicalization will be conducted at different levels, and specifically within the Advanced Medical Post (PMA) and the Evacuation Medical Center (CME), i.e. the first and second level emergency operating structures interposed between the event site ( “Construction Site”, or “Crash”) and hospitals; in them the victims are transported from the construction site (“Piccola Noria”), evaluated there (Triage) and stabilized, to thus be put in a position to face the subsequent evacuation to the hospitals (“Grande Noria”).
- Evacuation is the uninterrupted circuit of emergency vehicles from the PMA to the definitive places of care. The evacuation can take place with the aid of means used in everyday life or special means.
- Hospitalization is the last link in the chain of relief; hospitals will have to prepare contingency plans for a large number of victims (the so-called Massive Injury Affluence Plans, PMAF).
The time phases foreseen in the tactic are:
- Alarm phase: the body in charge of receiving the alarm pertaining to health is the Operations Center (C.O.). It is the duty of the CO. drawing up operating procedures known to all those who will be sent to the field, dimensioning the event through a targeted collection of information, and modulating and coordinating the response (also of other rescue bodies/groups) on the basis of needs.
- Sanitary aid area: the aid area must be set up near the affected area, possibly sheltered from “evolutionary risks”. In the early stages of the event, stress and confusion can reach high levels. The first rescue crew to intervene must be adequately trained, because they will have the task of confirming and transmitting the information necessary to provide an adequate response to the event.
Aspects and tasks of the rescue area:
- Improvisation: the first phase observable on the affected area; it is characterized by emotional tensions and psychic responses of various kinds. The solution that can be proposed remains health education which, through information, involvement and active participation in exercises and simulated training moments, must identify its first target in the population.
- Preliminary survey: provides the elements to modulate an adequate response to the event; it can also be carried out from above by plane, or by the first land vehicle that arrives on site. It is a set of important operations that must be carried out by trained personnel, since the objective is not immediate assistance to the victims but the transmission of a description of the scene to the operational response coordination groups, and in particular information on the type of accident, the presumed number of victims, and the prevailing pathologies. The reconnaissance is also aimed at evaluating the extent of the accident, noting its topographical limits, the persistence of areas at risk and the presence of current or latent dangers (“evolutionary risks”), the consequences of the disaster on the environment with relative evaluation of damage to structures, identification of landing areas, assessment of the site where to install the PMA and the parking areas for arriving vehicles.
- Sectorisation: means the division into functional areas of work in order to rationalize the available resources. This phase, which must be carried out with the police force and the fire brigade, assumes a technical approach that is rarely possessed by health teams. Knowledge of the security perimeters and the correct distribution of teams is required. Each area must be divided up locally, in order to channel the relief resources equally, and there will be respectively zones which are in turn divided into “work sites”.
- Integration: it is the condition aimed at the execution of the institutional tasks of the rescue components. This concept, absolutely simple on a theoretical level, is sometimes very difficult to implement even in ordinary emergencies. In the absence of a common language and shared procedures, health teams, firefighters, law enforcement agencies and volunteer staff risk finding themselves operating in difficult conditions, each pursuing its own objective, or its own operational logic.
Recovery and Collection of Casualties (Search and Rescue):
- Rescue, i.e. the set of operations aimed at moving the victim to a safe place; can be performed by technical personnel.
- Rescue, in some cases, the recovery of a victim must be preceded by the execution of rapid life-saving maneuvers. The long duration of the recovery operations, the evolutionary potential of the lesions, and the need for bloody maneuvers for a complicated release (e.g., amputation of limbs blocked by metal sheets or rubble) are situations that frequently require medical intervention on the point of finding the victim.
- Front line intervention, i.e. in the “Worksite”, where a few essential therapeutic actions will be carried out, with the sole purpose of making the injured survive until access to the Advanced Medical Post.
- Intervention at the Advanced Medical Post (P.M.A.): all the victims recovered from the construction sites will be conveyed to this structure (“little Noria”), and here subjected to a new Triage. The Advanced Medical Post is an emergency health facility where the victims will be stabilized and evacuated (“grand Noria”) to the definitive places of care (hospitals), according to orders of priority (codes of clinical severity) established by the triage.
- Transportation of victims (Evacuation): the evacuation, i.e. the transfer to the hospital facilities, is coordinated by the Operations Centre. It usually takes place by land (normal ambulances or those equipped for resuscitation) or by helicopter. In some cases, however, the use of buses previously equipped for protected transport, or special vehicles for major disasters, should not be excluded. The uninterrupted circuit between the Advanced Medical Post and the hospitalization facilities, as already explained above, takes the name of Noria.
Advanced Medical Post (AMP)
The AMP is defined in many western countries as a functional device for the selection and medical treatment of the victims, located at the external margins of the safety area or in a central area with respect to the front of the event which can be both a structure and an area functional where to gather the victims, concentrate resources for initial treatment, carry out triage and organize the medical evacuation of the wounded to the most suitable hospital centres.
The appropriate site of installation will be decided by the director (or coordinator) of the medical emergency services (DSS) in consultation with the technical director of the emergency services (DTS).
Pre-existing masonry structures are to be preferred, such as hangars, warehouses, gyms, schools; or alternatively inflatable waiting forms, sent by the relevant operations centre.
The advanced medical post must meet some requirements:
- placement in a safe area, away from evolutionary risks
- easy location with respect to communication routes
- adequate signaling with separate access and outflow
optimal characteristics of temperature, brightness and air conditioning.
Doctors and nurses work within the AMP, but non-medical rescuers who will carry out logistical functions can also find a place.
Triage in Disaster Medicine (or Catastrophes)
Triage is a clinical decision-making process, aimed at establishing a priority scale of patients with respect to the others; in the non-hospital context it will be applied in two stages:
- directly on the scenario (Worksite), with the aim of establishing a priority of access to the advanced Medical Post.
- to the AMP, with the aim of establishing the evacuation order towards hospitals or alternative clinical structures.
We remind the reader that hospital triage is divided as follows:
- code red or “emergency”: life-threatening patient who has immediate access to medical intervention;
- yellow code or “urgency”: urgent patient with access to treatment within 10-15 minutes;
- green code or “deferrable urgency” or “minor urgency”: patient with no signs of imminent danger to life, with access within 120 minutes (2 hours);
- white code or “non-emergency”: patient who can contact his general practitioner.
Other colors used in triage are:
- black code: indicates the death of the patient (the patient cannot be resuscitated);
- orange code: indicates that the patient is contaminated;
- blue code or “deferrable urgency”: it is a patient with intermediate severity between the yellow code and the green code, with access within 60 minutes (1 hour);
- blue code: indicates that the patient has compromised vital functions in an out-of-hospital environment generally activated in the absence of the doctor.
THE RADIO FOR RESCUERS IN THE WORLD? VISIT THE EMS RADIO BOOTH AT THE EMERGENCY EXPO
Command and coordination in Disaster Medicine
The legislation in force in the majority of countries provides that on the scene of the event the head of the Operations Center or the head of the DEA (Emergency and Acceptance Department), or a Doctor delegated by the medical head of the Number d performs the role of Director of Medical Aid ( DSS), liaising with similar representatives of other institutions responsible for emergency management.
He will assume responsibility for every medical intervention device in the area of operations, maintaining a constant link with the Operations Centre.
A Forward Command Post (PCA) is foreseen on the site, in which the Technical Director of Rescue and the DSS operate. With reference to the US role of the Incident Commander, the Italian Association of Disaster Medicine has proposed a new name for the Director of Medical Aid, i.e. the Medical Disaster Manager; identifying him as the person who, from a health point of view, is able to coordinate all the sequential phases of the event. From an educational point of view, the educational objective of the Medical Disaster Manager courses is the creation of a chain of command where figures linked by a functional hierarchy will operate independently, each in their own sector of competence.
The Relief Management will be entrusted to a super-coordinator, who will have the task of establishing an advanced command point, optimizing the resources available, guaranteeing communications and supplies connections to the functional work areas and last but not least, verifying that the safety conditions exist for the operators.
Emergency management team
The philosophy proposed in the MDM system is certainly innovative because it undermines the figure of command who centralizes the burdens that the role entails on himself.
A management of this type is destined to fail due to the enormous workload and requests that will arrive in a short time.
The proposed solution is to entrust the coordination to a team of expert figures deployed in the decision-making areas of the rescue chain.
Each leader is linked to the coordinator by a functional hierarchy, i.e. maintains almost absolute autonomy within his or her area of responsibility.
Role identification
One of the crucial aspects of coordination is the identification of roles in the field.
Medical assistance also encounters this problem in the daily life of routine emergency interventions, but it is essential to use colored jackets to highlight the tasks of the coordinators.
Hospital emergency plans
In the event of a limited disaster medical chain, the transport terminates at one or more hospitals in the area, which will need to prepare plans for a mass influx of injuries as per current regulations.
The discussion of problems related to the management of maxi hospital emergencies goes beyond the contents of this text, however we want to specify that the concept of the chain of command remains valid also in the hospital environment; to this end, the Italian Association of Disaster Medicine has developed the figure of the Hospital Disaster Manager (H.D.M.) who, while moving in a different operating context, maintains the proposed philosophy unchanged.
Hospitals represent the last link in the Rescue Chain, which began with the activation of the alarm at the Operations Centre.
As mentioned, although there are territorial differences, in fact Europe and many other countries propose this scheme of intervention by rescuers in major emergencies.
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