I

n the days following the tragic earthquake in Haiti, media reports

focused on the time that was required to mobilize assistance for
the people of Haiti, as well as on the huge death toll. The reports
led many individuals to conclude that aid was being delayed due to
bureaucracy and red tape. Most injuries and deaths in the immedi-
ate post-disaster phase are due to physical force trauma. Trauma is
a surgical disease, and, as a result, surgeons are often called upon
to serve as information sources for patients, friends, and colleagues.
The authors believe that a short review of some of the fundamental
principles of disaster response would be helpful for surgeons seeking to
understand and interpret media reports related to the situation in Haiti,
as well as other disasters.

by Eric Frykberg, MD, FACS; Leonard Weireter, MD, FACS;

and Lewis Flint, MD, FACS
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VOLUME 95, NUMBER 3, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

1 Why did it take so long for the disaster relief response to start working in Haiti?
Successful management of a disaster re- This absence of a prevailing authority to
quires that local authorities have some level coordinate all aspects of the response resulted
of preparedness. The resources to make cer- in many rescue and medical teams operat-
tain that preparedness training was done ing independently and disjointedly, without
were not available in Haiti. The authority knowledge of the “big picture,” although they
to provide effective early command and no doubt have been rendering excellent care
control was eliminated by the damage to to the victims they have encountered.
government buildings and infrastructure The airport in Port-au-Prince was not func-
with resultant loss of communication capa- tioning for an interval after the earthquake
bility. Roads were destroyed, so rescue and because air traffic control capability had been
triage of casualties could not occur. destroyed. After U.S. military personnel estab-
The first rescuers in all disaster events lished air traffic control, the ability of incom-
are always the people in the disaster area ing flights to arrive and depart was hampered
who were not hurt or killed. They can res- by the availability of only one runway, and by
cue some of the injured. However, without a lack of fuelling facilities. The arrival of help
some response from government and health by sea was hampered by virtue of the fact that
care agencies, evacuation and care of the the only docks available to receive ships had
injured will be delayed. This was clearly the been destroyed by the earthquake.
case in Port-au-Prince. Help from adjoining Under the best of circumstances, for disas-
geographic areas, such as other Haitian ters that have occurred in the U.S., organized
cities and the Dominican Republic, was response and delivery of necessary supplies
not possible because passable roads were does not occur for a minimum of 96 hours after
not available. the disaster event occurs. Given the circum-
Medical facilities were damaged. Destruc- stances in Port-au-Prince—which included the
tion of infrastructure and widespread com- loss of communication, damage to government
munications failure rendered the Haitian organizations, damage to medical facilities,
government unable to exert effective lead- and lack of transport capability—the fact that
ership to coordinate the relief operation. many of the initial challenges have been met
The capacity to render care was impeded within one week of the disaster is impressive.
by the lack of capacity and materials neces- Thoughtful considerations of the situation
sary to treat the large number of wounded that unfolded in Haiti should raise a number
generated by the disaster. Ideally, triage is of questions about how well we are prepared
done at one or more points outside of the for a similar event. These questions are in-
medical facilities and safely away from tended to clarify what a disaster is and how
danger. When transport is done by “first we should think about preparation if we are
rescuers” (as described in the opening to minimize the short and long-term conse-
paragraph), a large number of patients quences of any such event.
arrive at the nearest medical care facility.
The first are typically the least severely
injured, and if they are allowed inside the
facility, the resources are quickly over-
whelmed. Because there was no authority
to enforce a plan to keep the least severely
injured from entering the facilities, the
facilities were overwhelmed.

MARCH 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

 2 What is a disaster? 3 What makes a disaster different?
A disaster is a catastrophic event that The most common feature of disasters,
disrupts the infrastructure of a commu- especially in terms of the medical man-
nity or society, to such a degree that they agement of casualties, is that the demand
cannot cope with the consequences using for resources outstrips the supply. This
routine methods or resources. In many is a situation rarely, if ever, encountered
ways, nothing will ever be the same, as in medical care in developed countries.
disasters are typically associated with the The most common reason for this relative
tragedies of great loss of life and property, scarcity of resources is related to the large
and a relatively long period of recovery. number of casualties that present all at
Disasters have been described as many once, which impedes the ability of medical
people trying to do quickly what they do providers to fully evaluate and treat each
not normally do, working with people casualty and allocate available resources to
with whom they do not normally work, those most in need, as we normally do. This
in an environment with which they are situation is the most fundamental charac-
not familiar, and at a time and place that teristic of a true “mass casualty event.”
is completely unexpected. It should be distinguished from the more
However, the response to a disaster common “multiple casualty event,” other-
should not merely involve a mobilization wise termed “limited mass casualty event,”
of more personnel, supplies, and other in which larger than normal numbers of
resources. In fact, disaster management injured victims present to a medical care
requires a new and different approach facility, but are able to be handled with the
from our routine daily management resources at hand.
of emergencies, because disasters pose Successful management of the patients
unique problems and challenges rarely occurs even though it does involve extra
faced under normal conditions. The work, some local mobilization, and strain-
management response to a disaster must ing of resources (for example, a busy week-
encompass many disparate elements that end night in a major trauma center). A true
normally do not work together, and the mass casualty disaster must involve some
people involved must suddenly cooperate level of rationing of resources to most ac-
with each other and foster a close working curately and effectively match needs with
relationship in order to reach the common supplies, and must involve some mecha-
goal of establishing order out of chaos, nism for evacuation or redistribution of
and to minimize mortality and morbidity casualties to other facilities for full care,
among the surviving victims. Because all because by definition, all casualties cannot
disasters are sudden, unexpected, unpre- be handled locally. This requires a funda-
dictable, and random events, and because mental change in approach to the care of
they are rare, they cannot be managed injured victims. A shift must occur from
without established plans in place that an orientation where there is a provision
are regularly rehearsed. of the greatest good for each individual to
the greatest good for the greatest number.
The population, rather than the individual,
must become the focus of medical care. It is
not “business as usual, just busier.”
There may be casualties so severe that
time and resource needs and requirements

VOLUME 95, NUMBER 3, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

 4 Why should we be concerned about
disasters?
may jeopardize the lives of many who are
more salvageable. Unlike the normal ap- Disasters are relatively rare events,
proach to medical care, in which the most even though modern global communica-
severely injured take first priority, the most tion makes us more aware of them. Ac-
severely injured of mass casualties may have cording to the Federal Emergency Man-
to be set aside and treated last, so as to more agement Agency, events with more than
efficiently apply the limited resources to 1,000 casualties occur only a few times
many more. Evaluation of casualties must each century, and only 10–15 events each
be rapid, decisions must be accurate in the year result in more than 40 casualties.
context of the special requirements of mass So, why should medical providers be at all
casualty care, and traffic flow must be con- concerned about these events? In fact, the
stantly moved forward in order to accom- idea that “it will never happen to me” is
modate the influx of casualties and treat as a major barrier to learning and training
many as possible. “Minimal acceptable care” in the unique challenges of mass casualty
is the standard in this setting, as optimal management.
care for every casualty will lose many lives The following factors have the potential
unnecessarily. to result in large-scale natural and man-
This, of course, is antithetical to the made disasters:
moral standards of health care providers, • Increasing population density, with its
and therefore a circumstance that we never associated increased settlement in high-
confront in our education, training, or rou- risk areas
tine medical practice. However, the longer • Increasing environmental degradation
it takes to learn this concept in an actual • Increasing special needs populations
disaster, the more lives may be lost un- • Increase in the amount and transport
necessarily. The successful evaluation and of hazardous materials
management of mass casualties cannot be • The emergence of new infectious dis-
accomplished with our usual individualized eases
approach to injured patients. • The increasing threat of terrorism
The health care sector is thus chal-
lenged with an increased likelihood of
confronting mass casualty disasters in
future years.

MARCH 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

 5 How may disasters be classified?
Table: Classification schemes for disasters
Classification

Number Extent Level of

of casualties Mechanism Nature of injuries and duration response required

Advantages Allows facilities Permits Allows accurate Allows planning Allows for accurate
to prepare individualized triage for supply and planning
plans personnel
recruitment

Disadvantages Number often Casualty types Nature of injuries Duration is No real

not known are usually may not be frequently not disadvantages
until days after similar in most important. Physical known until after
event disasters force trauma event
predominates.

Disasters come in all shapes and sizes, state, while “closed disasters” are those in a dis-
and even similar types of disasters may crete location with an easily defined scene, such
involve very different variables, ones that as an urban building collapse.
can influence casualty outcomes. Therefore, Disasters can also be classified in terms of
the comparison of one disaster to another time. “Finite disasters” are those occurring at
can be problematic. The Table on this page one point in time, such as a building collapse,
lists several methods of classifying disasters from which all consequences follow, while “on-
in order to gauge their magnitude. going disasters” involve continuing damage
The number of casualties is not very and dangers, such as a leaking gas main that
useful information in this context, due to explodes and causes a fire, the aftershocks fol-
the fact that the amount of casualties that lowing an earthquake that continue for days or
overwhelm resources is relative. For ex- weeks, or armed conflicts. The most useful cat-
ample, five victims of a motor vehicle crash egorization scheme classifies disaster events
could be easily handled in an urban trauma according to the level of response needed to
center, but this number of casualties, pre- cope effectively with the event. This classi-
senting all at once, would overwhelm a fication system works because the mismatch
rural hospital. between needs and resources is the element
Injury patterns tend to be similar in the vari- that most fundamentally defines a disaster.
ous natural and man-made mechanisms (for
example, the earthquake in Haiti or the attack
on the World Trade Center), as well as in spe-
cific types of injuries within each mechanism.
Geographic and time elements pose distinct
challenges and implications for the medical
response to disasters. “Open disasters” are
those occurring over a wide geographic area,
such as a tornado that goes across an entire

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6 What is disaster preparedness? 7 What are the elements of a disaster
response?
Active involvement in the process of
planning for a disaster, such as engaging Effective disaster response begins with
in hospital drills and community exer- planning. Without local and regional
cises, and learning fundamental disaster plans based on sound analyses of all likely
principles and putting them into practice hazards, no organized response can occur.
—and educating and engaging others in One “all-hazards” plan that encompasses
these activities—are the fundamental a generic approach to the common chal-
elements of disaster preparedness. This lenges of all disasters is more effective
includes not only readying one’s hospital, than multiple plans addressing individual
community, and region for potential di- types of disasters. Plans should include
saster events, but also preparing oneself inventories of local resources, arrange-
and one’s own family for the many chal- ments for redundant communications
lenges that disasters pose. Preparedness systems (telephones, internet, and cell
should not only be directed at the man- phones immediately fail during a disas-
agement of the acute phases of a disaster ter), and designation of roles for each of
response, but also for the very difficult the following: government, health care,
long-term management phases of recov- police, emergency medical services, food
ery, rebuilding, and return to normal. and water suppliers, and heavy equip-
ment operators, to name only a few.
After planning comes education and
training. These efforts involve work-
ing through scenarios (also known as
rehearsals) of various hazardous events
until everyone is familiar with their re-
spective role, and lines of communication
are established. Planning, education and
training, and rehearsals are expensive.
This fact probably explains why poor
countries have little in the way of pre-
paredness for disasters.

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 8 How should health care facilities prepare for disaster response?
Success or failure is determined by how a medical control officer in the emergency
well the institution can deal with the rapidly reception area. This individual works with
changing disaster situation. The command a representative of the hospital emergency
structure is an essential element that must response management group to coordinate
be designated, and must be recognized by all communications, supply, and personnel.
participants of the response team. The many Choke points in hospitals include laboratory
independent and disparate entities involved and radiology. Protocols for injury assessment
in a disaster response cannot function ef- and management that do not require lab or
fectively without being willing to answer radiology are important. Clinical assessments
to one authority. The Incident Command conducted during a mass casualty event are
System (ICS) has been used for this purpose not perfect, and provision is made for repeat
in the U.S., as it has proven to fulfill the assessments. Intensive care areas rapidly
major command and control requirements fill, so other areas where monitored beds are
in numerous disasters. All participants of available should be identified. Some potential
any disaster response should have training areas are endovascular surgery, endoscopy,
in this system. and day surgery facilities. Patients who will
The ICS, with its core functions of plan- survive if an airway is obtained and/or bleed-
ning, operations, logistics, and finance, ing is stopped go immediately to the operating
allows the health care facility to organize suite. Patients who need observation can be
the response and utilize workers and mate- watched by nonsurgeon medical personnel.
rials in the most efficient manner possible. Personnel who are going to transport patients
The additional key functions of acting as need to know where they are going, and this
the liaison to other responding agencies, knowledge is developed during rehearsals.
provision of victim and caregiver safety, Dining areas should be reserved for feeding
and dissemination of public information, staff, and should not be converted into patient
round out the essence of the ICS. This is a care areas.
system that requires training, and it should A sad fact of mass casualty events is that
not be operated de novo or by novices. For most patients go to the nearest hospital. A
a fuller discussion of this topic and a list of perfect plan would include provision for “leap-
comprehensive educational materials, go frogging” to facilities that are more distant.
to this Web site: http://training.fema.gov/ Even if such a plan is in place, it almost never
IS/crslist.asp. functions effectively in the early phase follow-
Disaster plans for health care facilities ing a disaster event. As a substitute, health
include plans for maintenance of forward- care facilities should have communication
flow of casualties from triage to emergency and transfer agreements with nearby facili-
assessment, and from there to the operating ties. Hospital supply inventories are kept at
room, intensive observation area, routine minimal levels for financial reasons. Caches
observation area, and transfer to another of emergency supplies are important compo-
facility or discharge. Ideally, the hospital nents of each emergency plan.
should “lock down” on notification of the
disaster event. Triage and decontamination
stations are located away from the emer-
gency treatment areas.
Teams of caregivers organized to per-
form initial assessment and care report to

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9 What is the role of health care pro-
Dr. Frykberg is profes-
sor of surgery, Univer-
viders in a disaster response? sity of Florida College
of Medicine, and chief,
Physicians and surgeons should partici- division of general
pate fully in planning, education, and re- surgery, Shands Medi-
hearsals, as they will be the first receivers cal Center, Jacksonville,
of most disaster casualties and, therefore, FL.
must function as an integral part of the
overall disaster response. Specific roles
for nonsurgeon providers will need to be
developed. Medical staff members need
to stay in the hospital and away from the
scene of the disaster event.

Dr. Weireter is Arthur

and Marie Kirk Fam-
ily Professor of Surgery
and chief, division of
10 How can I become involved in disaster trauma and critical care,
response? Eastern Virginia Medi-
cal School, Norfolk, VA.
He is Chair of the ACS
Consult the disaster management com-
Committee on Trauma
munity on the American College of Sur- ad hoc Disaster and
geons Web portal at http://www.efacs.org. Mass Casualty Manage-
Involvement in a disaster response is ment Committee.
best accomplished through a long-term
commitment to a variety of relief orga-
nizations, medical teams, or the military.
These entities provide extensive training
in the concepts and procedures of disaster
planning and management, safety, com-
mand and control, and disaster casualty Dr. Flint is Editor-in-
care, and they provide abundant experi- Chief of the College’s
ence with the collection and dispersal of Selected Readings in
needed resources. General Surgery.
Running into a disaster setting with
noble intentions of helping, but without
this education, training, and experience,
tends to fail, is potentially dangerous,
and adds a further burden to an already
overwhelmed setting. Those without this
experience can best help through support
of relief organizations and by remaining
in their hospitals to help care for victims
who are transported to the U.S. 

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MARCH 2010 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS