Disaster
Disaster
A disaster is a serious problem occurring over a period of time that causes widespread human, material, economic or environmental loss which exceeds the ability of the affected community or society to cope using its own resources.[1][2] Disasters are routinely divided into either "natural disasters" caused by natural hazards or "human-instigated disasters" caused from anthropogenic hazards. However, in modern times, the divide between natural, human-made and human-accelerated disasters is difficult to draw.[3][4][5]
Examples of natural hazards include avalanches, flooding, cold waves and heat waves, droughts, earthquakes, cyclones, landslides, lightning, tsunamis, volcanic activity, wildfires, and winter precipitation.[6] Examples of anthropogenic hazards include criminality, civil disorder, terrorism, war, industrial hazards, engineering hazards, power outages, fire, hazards caused by transportation, and environmental hazards.
Developing countries suffer the greatest costs when a disaster hits – more than 95% of all deaths caused by hazards occur in developing countries, and losses due to natural hazards are 20 times greater (as a percentage of gross domestic product) in developing countries than in industrialized countries.[7][8]
Etymology[edit]
The word disaster is derived from Middle French désastre and that from Old Italian disastro, which in turn comes from the Ancient Greek pejorative prefix δυσ- (dus-) "bad"[9] and ἀστήρ (aster), "star".[10] The root of the word disaster ("bad star" in Greek) comes from an astrological sense of a calamity blamed on the position of planets.[11]
Classification[edit]
Disasters are routinely divided into natural or human-made. However, in modern times, the divide between natural, man-made and man-accelerated disasters is quite difficult to draw.[3][4][5]
Complex disasters, where there is no single root cause, are more common in developing countries. A specific disaster may spawn a secondary disaster that increases the impact. A classic example is an earthquake that causes a tsunami, resulting in coastal flooding, resulting in damage to a nuclear power plant (such as the Fukushima nuclear disaster). Some manufactured disasters have been wrongly ascribed to nature, such as smog and acid rain.[12]
Some researchers also differentiate between recurring events, such as seasonal flooding, and those considered unpredictable.[13]
With links to natural hazards[edit]
Disasters that have links to natural hazards are commonly called natural disasters although this term has been called a misnomer for a long time.[14]
| Example | Profile |
|---|---|
| Avalanche | The sudden, drastic flow of snow down a slope, occurring when either natural triggers, such as loading from new snow or rain, or artificial triggers, such as explosives or backcountry skiers. |
| Blizzard | A severe snowstorm characterized by very strong winds and low temperatures |
| Earthquake | The shaking of the earth's crust, caused by underground volcanic forces of breaking and shifting rock beneath the earth's surface |
| Fire (wild) | Fires that originate in uninhabited areas and which pose the risk to spread to inhabited areas (see also Wildfire § Climate change effects) |
| Flood | Flash flooding: Small creeks, gullies, dry streambeds, ravines, culverts or even low-lying areas flood quickly (see also Effects of climate change) |
| Freezing rain | Rain occurring when outside surface temperature is below freezing |
| Heat wave | A prolonged period of excessively hot weather relative to the usual weather pattern of an area and relative to normal temperatures for the season (see also Effects of climate change § Heat waves and temperature extremes). |
| Landslide | Geological phenomenon which includes a range of ground movement, such as rock falls, deep failure of slopes and shallow debris flows |
| Lightning strike | An electrical discharge caused by lightning, typically during thunderstorms |
| Limnic eruption | The sudden eruption of carbon dioxide from deep lake water |
| Tropical cyclone | Rapidly rotating storm system characterized by a low-pressure center, a closed low-level atmospheric circulation, strong winds, and a spiral arrangement of thunderstorms that produce heavy rain and squalls (see also Tropical cyclones and climate change) |
| Tsunami | A series of waves hitting shores strongly, mainly caused by the displacement of a large volume of a body of water, typically an ocean or a large lake, usually caused by earthquakes, volcanic eruptions, underwater explosions, landslides, glacier calvings, meteorite impacts and other disturbances above or below water |
| Volcanic eruption | The release of hot magma, volcanic ash and/or gases from a volcano |
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A natural disaster is the highly harmful impact on a society or community following a natural hazard event. Some examples of natural hazard events include: flooding, drought, earthquake, tropical cyclone, lightning, tsunami, volcanic activity, wildfire.[15] A natural disaster can cause loss of life or damage property, and typically leaves economic damage in its wake. The severity of the damage depends on the affected population's resilience and on the infrastructure available.[16] Scholars have been saying that the term natural disaster is unsuitable and should be abandoned. Instead, the simpler term disaster could be used, while also specifying the category (or type) of hazard.[17][18][19] A disaster is a result of a natural or human-made hazard impacting a vulnerable community. It is the combination of the hazard along with exposure of a vulnerable society that results in a disaster.
In modern times, the divide between natural, human-made and human-accelerated disasters is quite difficult to draw.[20][21][22] Human choices and activities like architecture,[23] fire,[24][25] resource management[25][26] and climate change[27] potentially play a role in causing natural disasters. In fact, the term natural disaster has been called a misnomer already in 1976.[19]
Natural disasters can be aggravated by inadequate building norms, marginalization of people, inequities, overexploitation of resources, extreme urban sprawl and climate change.[20] The rapid growth of the world's population and its increased concentration often in hazardous environments has escalated both the frequency and severity of disasters. Extreme climates (such as those in the Tropics) and unstable landforms, coupled with deforestation, unplanned growth proliferation and non-engineered constructions create more vulnerable interfaces of populated areas with disaster-prone natural spaces. Developing countries which suffer from chronic natural disasters, often have ineffective communication systems combined with insufficient support for disaster prevention and management.[28]Without links to natural hazards[edit]
Human-instigated disasters are the consequence of technological or human hazards. Examples include war, social unrest, stampedes, fires, transport accidents, industrial accidents, conflicts, oil spills, terrorist attacks, and nuclear explosions/nuclear radiation.[29]
Other types of induced disasters include the more cosmic scenarios of catastrophic climate change, nuclear war, and bioterrorism.[citation needed]
One opinion argues that all disasters can be seen as human-made, due to human failure to introduce appropriate emergency management measures.[30]
Famines may be caused locally by drought, flood, fire, or pestilence, but in modern times there is plenty of food globally, and sustained localized shortages are generally due to government mismanagement, violent conflict, or an economic system that does not distribute food where needed. Earthquakes are mainly hazardous because of human-created buildings and dams; avoiding earthquake-generated tsunamis and landslides is largely a matter of location.[citation needed]
| Disaster | Profile |
| Bioterrorism | The intentional release or dissemination of biological agents as a means of coercion |
| Civil unrest | A disturbance caused by a group of people that may include sit-ins and other forms of obstructions, riots, sabotage and other forms of crime, and which is intended to be a demonstration to the public and the government, but can escalate into general chaos |
| Fire (urban) | Even with strict building fire codes, people still perish in fires |
| Hazardous material spills | The escape of solids, liquids, or gases that can harm people, other living organisms, property or the environment, from their intended controlled environment such as a container. |
| Nuclear and radiation accidents | An event involving the significant release of radioactivity to the environment or a reactor core meltdown and which leads to major undesirable consequences to people, the environment, or the facility |
| Power failure | Caused by summer or winter storms, lightning or construction equipment digging in the wrong location |
Emergency is sometimes used interchangeably with the term disaster, as, for example, in the context of biological and technological hazards or health emergencies, which, however, can also relate to hazardous events that do not result in the serious disruption of the functioning of a community or society.
Disaster damage occurs during and immediately after the disaster. This is usually measured in physical units (e.g., square meters of housing, kilometres of roads, etc.), and describes the total or partial destruction of physical assets, the disruption of basic services and damages to sources of livelihood in the affected area.
Disaster impact is the total effect, including negative effects (e.g., economic losses) and positive effects (e.g., economic gains), of a hazardous event or a disaster. The term includes economic, human and environmental impacts, and may include death, injuries, disease and other negative effects on human physical, mental and social well-being.
For the purpose of the scope of the Sendai Framework for Disaster Risk Reduction 2015-2030 (para. 15), the following terms are also considered:
- Small-scale disaster: a type of disaster only affecting local communities which require assistance beyond the affected community.
- Large-scale disaster: a type of disaster affecting a society which requires national or international assistance.
- Frequent and infrequent disasters: depend on the probability of occurrence and the return period of a given hazard and its impacts. The impact of frequent disasters could be cumulative, or become chronic for a community or a society.
- A slow-onset disaster is defined as one that emerges gradually over time. Slow-onset disasters could be associated with, e.g., drought, desertification, sea-level rise, epidemic disease.
- A sudden-onset disaster is one triggered by a hazardous event that emerges quickly or unexpectedly. Sudden-onset disasters could be associated with, e.g., earthquake, volcanic eruption, flash flood, chemical explosion, critical infrastructure failure, transport accident.
Human and material losses caused by such disasters are a major obstacle to sustainable development. By issuing accurate forecasts and warnings in a form that is readily understood and by educating people on how to prepare against such hazards, before they become disasters, lives and property can be protected. Emphasis is on disaster risk reduction: one dollar invested in disaster preparedness can prevent seven dollars’ worth of disaster-related economic losses – a considerable return on investment.
As signatories to the Sendai Framework for Disaster Risk Reduction 2015–2030, WMO Members have undertaken to prevent new and reduce existing disaster risk through the implementation of a range of integrated and inclusive measures that prevent and reduce hazard exposure and vulnerability to disaster, increase preparedness for response and recovery and thus strengthen resilience. To support the assessment of global progress in achieving the outcomes and goals of the Sendai Framework, seven global targets have been agreed, most of which have direct implications for WMO and its Members.
WMO Disaster Risk Reduction activities are integrated and coordinated with other international, regional and national organizations. WMO coordinates the efforts of National Meteorological and Hydrological Services to mitigate human and property losses through improved forecast services and early warnings, as well as risk assessments, and to raise public awareness.
Natural hazards occur across different time and area scales and each is in some way unique. Tornadoes and flash floods are short-lived, violent events, affecting a relatively small area. Others, such as droughts, develop slowly, but can affect most of a continent and entire countries for months or even years. An extreme weather event can involve multiple hazards at the same time or in quick succession. In addition to high winds and heavy rain, a tropical storm can result in flooding and mudslides. In temperate latitudes, severe thunderstorms can be accompanied by a combination of large, damaging hail stones, tornadoes, strong winds or heavy rain resulting in flash floods. Winter storms with high winds and heavy snow or freezing rain can also contribute to avalanches on some mountain slopes and to high runoff or flooding later on in the melt season.
Some National Meteorological and Hydrological Services and specialized centres have responsibility for investigating geophysical hazards including volcanic explosions (airborne ash) and tsunamis, and hazardous airborne matter (radionuclides, biological and chemical substances) and acute urban pollution.
Natural hazards
Drought
Drought is a prolonged dry period in the natural climate cylce that can occur anywhere in the world. It is a slow on-set phenomenon caused by a lack of rainfall. Compounding factors, such as poverty and inappropriate land use, increase vulnerability to drought. When drought causes water and food shortages, there can be many impacts on the health of the population, which may increase morbidity and result in death. In recent years, most drought-related mortality has occurred in countries also experiencing political and civil unrest. In the period from 1970 to 2012, drought caused almost 680 000 deaths, due to the severe African droughts of 1975, 1983 and 1984 (Atlas of Mortality and Economic Losses from Weather, Climate and Water Extremes, WMO, 2014).
Disaster Risk Knowledge
Types of Disasters
Body
Learn about the different types of natural and human-caused disasters and their impact on behavioral health.
Natural and human-caused disasters affect thousands of people each year. Major adverse events such as these have the potential to cause catastrophic loss of life and physical destruction. They are often unexpected and can leave whole communities in shock.
People who live through a disaster can experience emotional distress. Feelings of anxiety, constant worrying, trouble sleeping, and other depression-like symptoms are common responses to disasters before, during, and after the event. Many people are able to “bounce back” from disasters with help from family and the community, but others may need additional support to cope and move forward on the path of recovery. Anyone can be at risk, including survivors living in the impacted areas and first responders and recovery workers.
Natural Disasters
Natural disasters are large-scale geological or meteorological events that have the potential to cause loss of life or property. These types of disasters include:
Severe storms and floods are the most common types of natural disasters reported in the United States. These meteorological events are occasionally preceded by presidential “emergency declarations” requiring state and local planning prior to the event, such as evacuations and protection of public assets. Disaster Distress Helpline staff are available to speak to those who call or text before, during, and after a natural disaster.
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Human-Caused Disasters
Examples include industrial accidents, shootings, acts of terrorism, and incidents of mass violence. As with natural disasters, these types of traumatic events may also cause loss of life and property. They may also prompt evacuations from certain areas and overwhelm behavioral health resources in the affected communities.
In the aftermath of the tragic loss of life that occurred on September 11, 2001, the feelings of loss of security and well-being—arguably the most crucial ingredients for leading a happy, healthy life—dramatically affected the citizens of the United States. Disaster Distress Helpline staff are also trained to respond to calls or texts related to these types of disasters.
Table
US peacetime disasters with deaths exceeding 1000
Year Disaster Deaths 1865 Explosion of the steamship Sultana in Memphis, Tennessee 1547 1871 Forest fire in Peshtigo, Wisconsin 1182 1889 Flood in Johnstown, Pennsylvania >2200 1900 Hurricane in Galveston, Texas >6000 1904 Fire on the steamship General Slocum in New York's East River 1021 1928 Hurricane in Lake Okeechobee, Florida 2000
US peacetime disasters with deaths exceeding 1000
| Year | Disaster | Deaths |
| 1865 | Explosion of the steamship Sultana in Memphis, Tennessee | 1547 |
| 1871 | Forest fire in Peshtigo, Wisconsin | 1182 |
| 1889 | Flood in Johnstown, Pennsylvania | >2200 |
| 1900 | Hurricane in Galveston, Texas | >6000 |
| 1904 | Fire on the steamship General Slocum in New York's East River | 1021 |
| 1928 | Hurricane in Lake Okeechobee, Florida | 2000 |
Disasters do more than cause unexpected deaths, injuries, and illnesses. Among their effects are the destruction of local health infrastructures—hospitals, doctor's offices, clinics, dialysis centers, pharmacies, and the like; the environmental impact, such as increased risk of communicable diseases, premature death, and decreased quality of life; psychological effects, including anxiety, neuroses, and depression; food shortages and nutritional consequences; and, in some places, large population movements.
In the sections that follow, I provide an overview of some natural and man-made disasters, specific clinical entities related to disasters, disaster planning, and the future of disaster medicine.
Disasters do more than cause unexpected deaths, injuries, and illnesses. Among their effects are the destruction of local health infrastructures—hospitals, doctor's offices, clinics, dialysis centers, pharmacies, and the like; the environmental impact, such as increased risk of communicable diseases, premature death, and decreased quality of life; psychological effects, including anxiety, neuroses, and depression; food shortages and nutritional consequences; and, in some places, large population movements.
In the sections that follow, I provide an overview of some natural and man-made disasters, specific clinical entities related to disasters, disaster planning, and the future of disaster medicine.
NATURAL DISASTERS
Floods
Floods account for 50% of disasters and deaths related to disasters. The worst natural disaster in recorded history was the flood of the Yellow River in China in 1887: 900,000 people died, and 2 million were left homeless. The Johnstown flood, which killed 2200 people, was the worst flood in the USA. Not surprisingly, 70% of all floods occur in India and Bangladesh, which have miles of low-lying coastal areas and poor infrastructures.
Causes of mortality and morbidity from floods include drowning, hypothermia, and trauma. People tend to underestimate the power of a flood; they think that if they can stand in the water, they will be fine. However, fast-flowing water can easily knock people off their feet; at that point, they can drown or be struck by debris. Automobiles, even large sport utility vehicles, are no protection in fast-moving water.
Although floods can be extensive, only 0.2% to 2% of people involved in a flood require medical care. Most injuries are minor, consisting of cuts, scrapes, and broken bones; however, without proper wound care, many skin wounds become infected. Other related problems include fires from broken gas lines and oil tanks; toxic waste from overflow of waste treatment plants; and even snake bites, particularly in India and the Philippines. Infections, such as shigellosis, salmonellosis, hepatitis A, typhoid, and diarrhea due to Escherichia coli can also spread through dirty water and sanitation runoff.
Floods account for 50% of disasters and deaths related to disasters. The worst natural disaster in recorded history was the flood of the Yellow River in China in 1887: 900,000 people died, and 2 million were left homeless. The Johnstown flood, which killed 2200 people, was the worst flood in the USA. Not surprisingly, 70% of all floods occur in India and Bangladesh, which have miles of low-lying coastal areas and poor infrastructures.
Causes of mortality and morbidity from floods include drowning, hypothermia, and trauma. People tend to underestimate the power of a flood; they think that if they can stand in the water, they will be fine. However, fast-flowing water can easily knock people off their feet; at that point, they can drown or be struck by debris. Automobiles, even large sport utility vehicles, are no protection in fast-moving water.
Although floods can be extensive, only 0.2% to 2% of people involved in a flood require medical care. Most injuries are minor, consisting of cuts, scrapes, and broken bones; however, without proper wound care, many skin wounds become infected. Other related problems include fires from broken gas lines and oil tanks; toxic waste from overflow of waste treatment plants; and even snake bites, particularly in India and the Philippines. Infections, such as shigellosis, salmonellosis, hepatitis A, typhoid, and diarrhea due to Escherichia coli can also spread through dirty water and sanitation runoff.
Cyclones
In the Caribbean and Western Atlantic, cyclones are called hurricanes; in the Western Pacific, they are called typhoons. A cyclone is a wind system that rotates counterclockwise (in the Northern Hemisphere) and has sustained winds >74 mph. The Galveston hurricane that occurred on September 8, 1900, and killed >6000 people was the worst disaster in US history.
People are injured in hurricanes in a number of ways. Storm surges, in which the ocean is literally picked up and dropped on a coastal area, are responsible for 90% of all cyclone-related fatalities. People are also injured by broken glass or debris caught up in the winds, by collapse of houses, and by mud slides. After the disaster, electrocutions can occur. The risk of electrocution is particularly high in mobile homes, where the wiring is not as well grounded. Another injury, which has been called “the cyclone syndrome,” occurs when people hold on to trees in the midst of the rising water and wind; they tend to get abrasions on their chest and medial arms and thighs. Overall, mortality and morbidity rates related to cyclones remain low unless there is a storm surge or a flash flood. As with floods, most injuries consist of cuts and scrapes, which are often contaminated, as well as fractures.
In the Caribbean and Western Atlantic, cyclones are called hurricanes; in the Western Pacific, they are called typhoons. A cyclone is a wind system that rotates counterclockwise (in the Northern Hemisphere) and has sustained winds >74 mph. The Galveston hurricane that occurred on September 8, 1900, and killed >6000 people was the worst disaster in US history.
People are injured in hurricanes in a number of ways. Storm surges, in which the ocean is literally picked up and dropped on a coastal area, are responsible for 90% of all cyclone-related fatalities. People are also injured by broken glass or debris caught up in the winds, by collapse of houses, and by mud slides. After the disaster, electrocutions can occur. The risk of electrocution is particularly high in mobile homes, where the wiring is not as well grounded. Another injury, which has been called “the cyclone syndrome,” occurs when people hold on to trees in the midst of the rising water and wind; they tend to get abrasions on their chest and medial arms and thighs. Overall, mortality and morbidity rates related to cyclones remain low unless there is a storm surge or a flash flood. As with floods, most injuries consist of cuts and scrapes, which are often contaminated, as well as fractures.
Tornadoes
Tornadoes are the most lethal atmospheric condition; they have caused 9000 deaths over the past 50 years in the USA. Tornadoes can be up to a half-mile wide, travel up to 185 miles, and have winds up to 310 mph. About 700 tornadoes touch down in the USA each year, but only 3% cause casualties. Fortunately, most tornadoes touch down in uninhabited areas. The Midwest is one of the few parts of the world where a cold air mass can meet a warm, humid air mass and cause a tornado. In most other parts of the world where the 2 air masses could meet, there is an obstruction, such as a small mountain range or a large body of water.
Tornado-related causes of death include craniocerebral trauma and crush injuries of the chest and trunk. Fractures are the most common nonfatal injury. Wind speeds cause debris to be deeply impaled in the body, which frequently causes infections. Those who live in mobile homes are 40 times more likely and those in cars are 5 times more likely to be killed or injured than those in fixed structures.
Tornadoes are the most lethal atmospheric condition; they have caused 9000 deaths over the past 50 years in the USA. Tornadoes can be up to a half-mile wide, travel up to 185 miles, and have winds up to 310 mph. About 700 tornadoes touch down in the USA each year, but only 3% cause casualties. Fortunately, most tornadoes touch down in uninhabited areas. The Midwest is one of the few parts of the world where a cold air mass can meet a warm, humid air mass and cause a tornado. In most other parts of the world where the 2 air masses could meet, there is an obstruction, such as a small mountain range or a large body of water.
Tornado-related causes of death include craniocerebral trauma and crush injuries of the chest and trunk. Fractures are the most common nonfatal injury. Wind speeds cause debris to be deeply impaled in the body, which frequently causes infections. Those who live in mobile homes are 40 times more likely and those in cars are 5 times more likely to be killed or injured than those in fixed structures.
Volcanoes
Volcanoes have caused 266,000 deaths in the past 400 years. The most lethal volcanoes in history have been Krakatoa in Indonesia, which caused 36,000 deaths; Mount Pelee in Martinique, which caused 28,000 deaths; and Nevada del Ruiz in Columbia, which caused 25,000 deaths. Fortunately, when Mount St. Helens erupted in the USA, few people lived at the base or downwind. In addition, Mount St. Helens was the most studied volcano in history; researchers knew that it was going to erupt, so people were prepared for it. Mount Rainier, which is just north of Mount St. Helens, is expected to erupt sometime in the next 50 years. Should the winds take the ash and debris north and west, the city of Seattle could be severely affected.
The principal cause of death from volcanoes is asphyxia from ash inhalation. Eighteen of the 23 immediate deaths from Mount St. Helens were caused by asphyxia. Other mechanisms of morbidity include scalding from the superheated steam, the release of toxic gases, explosions, lava flows, and earthquakes.
Volcanoes have caused 266,000 deaths in the past 400 years. The most lethal volcanoes in history have been Krakatoa in Indonesia, which caused 36,000 deaths; Mount Pelee in Martinique, which caused 28,000 deaths; and Nevada del Ruiz in Columbia, which caused 25,000 deaths. Fortunately, when Mount St. Helens erupted in the USA, few people lived at the base or downwind. In addition, Mount St. Helens was the most studied volcano in history; researchers knew that it was going to erupt, so people were prepared for it. Mount Rainier, which is just north of Mount St. Helens, is expected to erupt sometime in the next 50 years. Should the winds take the ash and debris north and west, the city of Seattle could be severely affected.
The principal cause of death from volcanoes is asphyxia from ash inhalation. Eighteen of the 23 immediate deaths from Mount St. Helens were caused by asphyxia. Other mechanisms of morbidity include scalding from the superheated steam, the release of toxic gases, explosions, lava flows, and earthquakes.
Earthquakes
Earthquakes have caused more than 1 million deaths worldwide in the past 20 years. In the USA, the 1906 San Francisco earthquake caused 700 deaths; the 1971 San Fernando earthquake, 64; and the 1989 Loma Prieta that flattened the Nimmitz Freeway, 67. The decreasing number of deaths despite increasing population densities is a testament to our improved engineering safety.
The principal cause of earthquake-related deaths is collapse of buildings, which causes crush injuries, hemorrhage and shock, drownings if the earthquake is near a coast, asphyxia from the crush or from heavy dust, hypothermia from being left homeless, and sepsis from wounds. Rescue efforts are most effective in the first 24 to 48 hours after the earthquake.
Most morbidity from earthquakes does not require hospital admission. As with other disasters, the injuries are usually cuts, scrapes, minor fractures, and minor head injuries. Chronic illnesses could also be exacerbated because of the lack of medical or hospital facilities.
Earthquakes have caused more than 1 million deaths worldwide in the past 20 years. In the USA, the 1906 San Francisco earthquake caused 700 deaths; the 1971 San Fernando earthquake, 64; and the 1989 Loma Prieta that flattened the Nimmitz Freeway, 67. The decreasing number of deaths despite increasing population densities is a testament to our improved engineering safety.
The principal cause of earthquake-related deaths is collapse of buildings, which causes crush injuries, hemorrhage and shock, drownings if the earthquake is near a coast, asphyxia from the crush or from heavy dust, hypothermia from being left homeless, and sepsis from wounds. Rescue efforts are most effective in the first 24 to 48 hours after the earthquake.
Most morbidity from earthquakes does not require hospital admission. As with other disasters, the injuries are usually cuts, scrapes, minor fractures, and minor head injuries. Chronic illnesses could also be exacerbated because of the lack of medical or hospital facilities.
MAN-MADE DISASTERS
There are many types of man-made disasters. On an individual basis, planes, trains, and automobiles are principal sources. Engineering disasters, such as the collapse of the Hyatt Regency skywalk in Kansas City, can kill and injure groups of people. When large numbers of people gather for a concert or a sporting event, mass casualty incidents can occur—when people are crushed, for example. Many papers have been written outlining medical needs for these large events, including the numbers of doctors and nurses needed and the amount of water needed to keep people from becoming hyperthermic or dehydrated in the heat. I will focus on 2 man-made disasters: hazardous materials and radiation.
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There are many types of man-made disasters. On an individual basis, planes, trains, and automobiles are principal sources. Engineering disasters, such as the collapse of the Hyatt Regency skywalk in Kansas City, can kill and injure groups of people. When large numbers of people gather for a concert or a sporting event, mass casualty incidents can occur—when people are crushed, for example. Many papers have been written outlining medical needs for these large events, including the numbers of doctors and nurses needed and the amount of water needed to keep people from becoming hyperthermic or dehydrated in the heat. I will focus on 2 man-made disasters: hazardous materials and radiation.
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Hazardous materials
There are approximately 53,000 “dangerous” chemicals in the workplace; toxicity information is available for only half of them. Health care personnel may see 5 or 6 workers who were exposed to organophosphates in their workplace or large numbers of people exposed because of a release into the community. Recently, a tanker that was carrying thousands of tons of solvents to make plastics sank in the North Atlantic near England. The sinking of the ship did not affect the community but polluted the water; if the ship was instead a train going through downtown Dallas, the situation would have been much different. In Texas, 3.5 hazardous materials releases occur each day. In essence, the Oklahoma City bombing was a problem with 2 hazardous materials: ammonium nitrate and diesel oil.
Unfortunately, most emergency departments are poorly prepared for hazardous materials disasters. Baylor University Medical Center's level 1 trauma center has one decontamination room—a negative pressure room, which has tile floors, a hose for rinsing people off, and a tank underneath the floor to trap contaminated water. Baylor can certainly treat a handful of workers exposed to pesticides but would be hard-pressed to quickly treat a large group exposed in a major industrial accident. Very few institutions have the extra personal protective clothing needed, including respirator suits, and very few have significant experience with hazardous materials. In my 12 years' experience in emergency medicine, I have seen 2 hazardous materials incidents, neither of which was very serious.
Hazardous materials can reach people through inhalation, skin absorption, or ingestion. Among the inhaled toxins are the asphyxiants, such as carbon dioxide, nitrogen, and methane, which displace oxygen. Those who inhale them are unaware of a problem, since these agents cause no irritation and no physical damage. Respiratory irritants, such as ammonia, phosgene, and chlorine, are more obvious; they cause edema, secretions, and laryngospasms. Systemic toxins, such as carbon monoxide, and hydrocarbons, such as benzene, toluene, and methylchloride, can also be inhaled.
Pesticides are the classic example of toxins absorbed through the skin. However, chemical burns are another mechanism of skin absorption. These burns require extensive irrigation. Alkaline burns are more severe than acid burns: when acid burns skin or eyes, it sets up a layer of scar tissue in front of the burn, which prevents the acid from penetrating too deeply into the tissues. Alkaline burns, however, actually liquefy the tissues; thus, no layer of scar tissue forms, and the burn can progress much deeper, causing more extensive damage. Getting splashed in the eye with drain cleaner, then, is much worse than getting splashed in the eye with battery acid.
There are approximately 53,000 “dangerous” chemicals in the workplace; toxicity information is available for only half of them. Health care personnel may see 5 or 6 workers who were exposed to organophosphates in their workplace or large numbers of people exposed because of a release into the community. Recently, a tanker that was carrying thousands of tons of solvents to make plastics sank in the North Atlantic near England. The sinking of the ship did not affect the community but polluted the water; if the ship was instead a train going through downtown Dallas, the situation would have been much different. In Texas, 3.5 hazardous materials releases occur each day. In essence, the Oklahoma City bombing was a problem with 2 hazardous materials: ammonium nitrate and diesel oil.
Unfortunately, most emergency departments are poorly prepared for hazardous materials disasters. Baylor University Medical Center's level 1 trauma center has one decontamination room—a negative pressure room, which has tile floors, a hose for rinsing people off, and a tank underneath the floor to trap contaminated water. Baylor can certainly treat a handful of workers exposed to pesticides but would be hard-pressed to quickly treat a large group exposed in a major industrial accident. Very few institutions have the extra personal protective clothing needed, including respirator suits, and very few have significant experience with hazardous materials. In my 12 years' experience in emergency medicine, I have seen 2 hazardous materials incidents, neither of which was very serious.
Hazardous materials can reach people through inhalation, skin absorption, or ingestion. Among the inhaled toxins are the asphyxiants, such as carbon dioxide, nitrogen, and methane, which displace oxygen. Those who inhale them are unaware of a problem, since these agents cause no irritation and no physical damage. Respiratory irritants, such as ammonia, phosgene, and chlorine, are more obvious; they cause edema, secretions, and laryngospasms. Systemic toxins, such as carbon monoxide, and hydrocarbons, such as benzene, toluene, and methylchloride, can also be inhaled.
Pesticides are the classic example of toxins absorbed through the skin. However, chemical burns are another mechanism of skin absorption. These burns require extensive irrigation. Alkaline burns are more severe than acid burns: when acid burns skin or eyes, it sets up a layer of scar tissue in front of the burn, which prevents the acid from penetrating too deeply into the tissues. Alkaline burns, however, actually liquefy the tissues; thus, no layer of scar tissue forms, and the burn can progress much deeper, causing more extensive damage. Getting splashed in the eye with drain cleaner, then, is much worse than getting splashed in the eye with battery acid.
Radioactive disasters
Radioactive disasters are probably the most feared by the public, although historically there have been relatively few victims.
Only 5 events worldwide have prompted disaster responses. Nevertheless, a radioactive disaster can have far-reaching consequences. The explosion at Chernobyl left a radioactive cloud that covered half of the earth. The biggest risks come from nuclear reactors and from transportation of radioactive material. Cancer therapy agents, for example, are transported all over the country. If a truck or train carrying this material were involved in a collision, large numbers of people could be exposed to radiation.
Radiation consists of alpha, beta, and gamma particles. Alpha particles are the least penetrating, while beta particles can penetrate skin and gamma particles can easily pass through the human body and be absorbed by the tissues. All radiation damage is caused by penetration into the body. Geiger counters can detect beta and gamma particles; a special counter is needed for alpha particles.
Three types of contamination with radiation are possible. With external radiation exposure, the person is not radioactive. An example would be receiving an accidentally high dose of radiation through a computed tomography scanner. With contamination, gas, liquids, or solids are deposited on the body, and decontamination is required before the patient can enter the hospital. The most severe form of contamination is incorporation, in which radioactive atoms are taken up within cells or body structures and cause damage. Generally, radium and strontium are deposited in the bones and radioactive iodine within the thyroid.
Absorption of radiation is measured with the unit Grey: 1 Gy causes nausea and vomiting in 6 to 12 hours; 2 to 3 Gy, nausea and vomiting in a couple of hours. Patients who absorb 5 Gy have a 50% rate of mortality from bone marrow depression. The absolute lymphocyte count is a good indicator of toxicity, with <100/mL usually portending a fatal outcome. Absorption of 10 Gy leads to gastrointestinal syndrome with massive bloody diarrhea, which is also usually fatal.
Chernobyl was an example of contamination. The explosion caused radioactive substances to be deposited on people. In addition, the environment was contaminated, leading to contamination of the food chain. Fish died in the lakes, and people died for weeks and months to come. Other large-scale episodes of contamination occurred in Goiania, Brazil, and Juarez, Mexico, where people found cobalt cancer therapy units lying around after the destruction of hospitals and took home the green, glowing balls of cobalt for their children to play with. Hundreds of people were contaminated, and it took the health care system some time to identify the cause of the multiple cases of nausea, vomiting, and diarrhea being reported.
Radioactive disasters are probably the most feared by the public, although historically there have been relatively few victims.
Only 5 events worldwide have prompted disaster responses. Nevertheless, a radioactive disaster can have far-reaching consequences. The explosion at Chernobyl left a radioactive cloud that covered half of the earth. The biggest risks come from nuclear reactors and from transportation of radioactive material. Cancer therapy agents, for example, are transported all over the country. If a truck or train carrying this material were involved in a collision, large numbers of people could be exposed to radiation.
Radiation consists of alpha, beta, and gamma particles. Alpha particles are the least penetrating, while beta particles can penetrate skin and gamma particles can easily pass through the human body and be absorbed by the tissues. All radiation damage is caused by penetration into the body. Geiger counters can detect beta and gamma particles; a special counter is needed for alpha particles.
Three types of contamination with radiation are possible. With external radiation exposure, the person is not radioactive. An example would be receiving an accidentally high dose of radiation through a computed tomography scanner. With contamination, gas, liquids, or solids are deposited on the body, and decontamination is required before the patient can enter the hospital. The most severe form of contamination is incorporation, in which radioactive atoms are taken up within cells or body structures and cause damage. Generally, radium and strontium are deposited in the bones and radioactive iodine within the thyroid.
Absorption of radiation is measured with the unit Grey: 1 Gy causes nausea and vomiting in 6 to 12 hours; 2 to 3 Gy, nausea and vomiting in a couple of hours. Patients who absorb 5 Gy have a 50% rate of mortality from bone marrow depression. The absolute lymphocyte count is a good indicator of toxicity, with <100/mL usually portending a fatal outcome. Absorption of 10 Gy leads to gastrointestinal syndrome with massive bloody diarrhea, which is also usually fatal.
Chernobyl was an example of contamination. The explosion caused radioactive substances to be deposited on people. In addition, the environment was contaminated, leading to contamination of the food chain. Fish died in the lakes, and people died for weeks and months to come. Other large-scale episodes of contamination occurred in Goiania, Brazil, and Juarez, Mexico, where people found cobalt cancer therapy units lying around after the destruction of hospitals and took home the green, glowing balls of cobalt for their children to play with. Hundreds of people were contaminated, and it took the health care system some time to identify the cause of the multiple cases of nausea, vomiting, and diarrhea being reported.
UNIQUE CLINICAL ENTITIES IN DISASTERS
Blast injuries and crush injuries are common in disasters, and I will address those. In addition, I will address the incidence of infectious diseases following a disaster.
Blast injuries and crush injuries are common in disasters, and I will address those. In addition, I will address the incidence of infectious diseases following a disaster.
Blast injuries
Blast injuries are caused by high-energy explosives—TNT and plastic explosives like those used on the USS Cole—plus any of the nuts, bolts, nails, and other materials sometimes added to bombs. High-energy explosives explode rapidly, in contrast to gun powder, which fizzles. They cause brisance, the shattering of objects. The initial pressure wave of a high-energy explosion travels at 800 m/sec; the intensity depends on the size of the explosion, the distance from it, and the surrounding medium. The pressure wave travels faster and harder through water than through air. Following the pressure wave is a negative pressure phase—a longer period of suction formed by the vacuum of the initial wave. If the initial pressure wave didn't break some windows, the negative pressure wave will.
A number of different injuries are caused by the blast wave. The lungs, ears, and gastrointestinal tract are most susceptible. Injuries are caused by 4 mechanisms. The first, spalling or brisance, involves the movement of particles from more to less dense areas, as when liquid in the lungs moves into the gas area of the alveoli and causes pulmonary hemorrhage. Implosion, which is compression and decompression of gaseous compartments with rupture, can cause rupture of tympanic membranes. With inertia, the human body is thrown against a stationary object. Finally, with pressure differentials, the blast wave drives fluids from their spaces. This is another cause of delayed pulmonary hemorrhage, which can cause death hours or even days after the explosion. Among secondary injuries are cuts caused by flying glass, shrapnel, and debris that can imbed deeply into tissues. Tertiary injuries occur as people are thrown against hard surfaces. Burns and smoke inhalation are additional related problems.
Most blast fatalities are from brain injuries, skull fractures, diffuse lung contusions, and liver lacerations. Tympanic membrane rupture is a sign of being close to the blast and thus a marker for more serious injuries. Only about 15% of those who come to the emergency department for blast injuries are admitted to the hospital; others are either well enough to go home or do not survive the initial blast.
Blast injuries are caused by high-energy explosives—TNT and plastic explosives like those used on the USS Cole—plus any of the nuts, bolts, nails, and other materials sometimes added to bombs. High-energy explosives explode rapidly, in contrast to gun powder, which fizzles. They cause brisance, the shattering of objects. The initial pressure wave of a high-energy explosion travels at 800 m/sec; the intensity depends on the size of the explosion, the distance from it, and the surrounding medium. The pressure wave travels faster and harder through water than through air. Following the pressure wave is a negative pressure phase—a longer period of suction formed by the vacuum of the initial wave. If the initial pressure wave didn't break some windows, the negative pressure wave will.
A number of different injuries are caused by the blast wave. The lungs, ears, and gastrointestinal tract are most susceptible. Injuries are caused by 4 mechanisms. The first, spalling or brisance, involves the movement of particles from more to less dense areas, as when liquid in the lungs moves into the gas area of the alveoli and causes pulmonary hemorrhage. Implosion, which is compression and decompression of gaseous compartments with rupture, can cause rupture of tympanic membranes. With inertia, the human body is thrown against a stationary object. Finally, with pressure differentials, the blast wave drives fluids from their spaces. This is another cause of delayed pulmonary hemorrhage, which can cause death hours or even days after the explosion. Among secondary injuries are cuts caused by flying glass, shrapnel, and debris that can imbed deeply into tissues. Tertiary injuries occur as people are thrown against hard surfaces. Burns and smoke inhalation are additional related problems.
Most blast fatalities are from brain injuries, skull fractures, diffuse lung contusions, and liver lacerations. Tympanic membrane rupture is a sign of being close to the blast and thus a marker for more serious injuries. Only about 15% of those who come to the emergency department for blast injuries are admitted to the hospital; others are either well enough to go home or do not survive the initial blast.
Crush injuries
Crush injuries occur as people are trapped under collapsed buildings. A major problem of crush injuries is rhabdomyolysis, i.e., muscle crush and subsequent breakdown. Half of those with severe rhabdomyolysis will go into renal failure, since myoglobin is toxic to the kidneys. The risk of kidney failure increases with delays in fluid therapy. Once renal failure has developed, the mortality rate is 20% to 40%, even with dialysis. Most people who survive crush injuries in earthquakes are rescued early; the longer they lie under buildings, the bigger risk they have of dying from rhabdomyolysis.
Compartment syndrome is seen with crush injuries as well. A forearm, for instance, has 2 compartments, dorsal and volar. If one of the compartments is crushed and becomes filled with blood, the pressure inside it increases, neurologic and vascular flow to the distal extremity is lost, and eventually that area will undergo necrosis and require amputation. Treatment for compartment syndrome is an early fasciotomy to release the pressure.
Traumatic asphyxia results from chest compression, which interferes with respiration and increases intrathoracic pressure. Blood is forced up into the head, and blood flow back to the heart is decreased. The injured get cyanosis, petechiae in the head and neck, and subconjunctival hemorrhages.
Crush injuries occur as people are trapped under collapsed buildings. A major problem of crush injuries is rhabdomyolysis, i.e., muscle crush and subsequent breakdown. Half of those with severe rhabdomyolysis will go into renal failure, since myoglobin is toxic to the kidneys. The risk of kidney failure increases with delays in fluid therapy. Once renal failure has developed, the mortality rate is 20% to 40%, even with dialysis. Most people who survive crush injuries in earthquakes are rescued early; the longer they lie under buildings, the bigger risk they have of dying from rhabdomyolysis.
Compartment syndrome is seen with crush injuries as well. A forearm, for instance, has 2 compartments, dorsal and volar. If one of the compartments is crushed and becomes filled with blood, the pressure inside it increases, neurologic and vascular flow to the distal extremity is lost, and eventually that area will undergo necrosis and require amputation. Treatment for compartment syndrome is an early fasciotomy to release the pressure.
Traumatic asphyxia results from chest compression, which interferes with respiration and increases intrathoracic pressure. Blood is forced up into the head, and blood flow back to the heart is decreased. The injured get cyanosis, petechiae in the head and neck, and subconjunctival hemorrhages.
Infectious diseases
Disasters cause a breakdown of the usual mechanisms of infection control: safe nutrition, potable water, access to health care, and vector control. Such problems are worse in the developing world than in the industrialized world, but much can also depend on climate. In cold weather, people crowd together and spread diseases; in warm weather, vectors such as mosquitoes can become a problem. Disasters do not introduce new pathogens. Instead, infectious diseases are caused by pathogens endemic to the area or brought in by refugees. Because of this, mass vaccines are rarely useful, except for the measles vaccine, which has proven useful in past disasters.
An example of an infectious disease following a disaster is pulmonary coccidioidomycosis, which was seen after the 1994 Northridge earthquake because of increased dust levels. In Southern California, coccidioidomycosis increases every time construction work begins and the dry dirt in which it lives is disrupted and turned into dust, allowing it to be carried with the wind. Another example is the increased incidence of giardiasis in Montana in 1980 after the eruption of Mount St. Helens. The ashfall caused heavy water runoff secondary to obstructed creeks and streams and thus an increase in the pathogen in that area.
Some increases in the incidence of infection are due to host factors. People may not tend a wound carefully after a disaster. They may be malnourished and dehydrated, and the psychological stress from the disaster also takes its toll on their immune systems.
Disasters cause a breakdown of the usual mechanisms of infection control: safe nutrition, potable water, access to health care, and vector control. Such problems are worse in the developing world than in the industrialized world, but much can also depend on climate. In cold weather, people crowd together and spread diseases; in warm weather, vectors such as mosquitoes can become a problem. Disasters do not introduce new pathogens. Instead, infectious diseases are caused by pathogens endemic to the area or brought in by refugees. Because of this, mass vaccines are rarely useful, except for the measles vaccine, which has proven useful in past disasters.
An example of an infectious disease following a disaster is pulmonary coccidioidomycosis, which was seen after the 1994 Northridge earthquake because of increased dust levels. In Southern California, coccidioidomycosis increases every time construction work begins and the dry dirt in which it lives is disrupted and turned into dust, allowing it to be carried with the wind. Another example is the increased incidence of giardiasis in Montana in 1980 after the eruption of Mount St. Helens. The ashfall caused heavy water runoff secondary to obstructed creeks and streams and thus an increase in the pathogen in that area.
Some increases in the incidence of infection are due to host factors. People may not tend a wound carefully after a disaster. They may be malnourished and dehydrated, and the psychological stress from the disaster also takes its toll on their immune systems.
DISASTER RESPONSE
There existed no well-organized studies of disasters from an epidemiologic point of view until the 1976 Guatemalan earthquake. The group of investigators who studied this disaster identified 3 myths of disaster response. The first myth was that foreign medical volunteers with any kind of medical background were needed in a disaster. In reality, most of the immediate needs in a Third World disaster are met by the local population. The second myth was that any kind of international assistance was needed and was needed quickly. Again, most needs are met by the local governments, and time is required to assess that need. The third myth was that epidemics and plagues were inevitable after a disaster. Researchers found that except for measles, this is not true. Contrary to what most people thought before 1976, dead bodies from a disaster do not spread disease, so burying dead bodies becomes less of an immediate priority.
The media dubbed the response of the industrialized world to the Guatemalan disaster as the “second disaster.” No initial field assessment was conducted. No needs assessment was done. The industrialized world, namely the USA, sent 100 tons of materials, including vaccines and drugs, many of which were outdated; 90% of what was sent was not used. The antibiotics and pain medicines that were needed were not sent. In 1988, the USA sent 5000 tons of equipment and materials to Armenia in response to another devastating earthquake, and most of this was not needed either. It took 6 months for a large group of people just to catalog everything that arrived. After years of research, the World Health Organization developed an emergency health kit that contains the essential materials needed after a disaster— including antibiotics and supplies for wound care and surgical care.
Overall, disaster response should consist of 3 phases: activation, implementation, and recovery.
There existed no well-organized studies of disasters from an epidemiologic point of view until the 1976 Guatemalan earthquake. The group of investigators who studied this disaster identified 3 myths of disaster response. The first myth was that foreign medical volunteers with any kind of medical background were needed in a disaster. In reality, most of the immediate needs in a Third World disaster are met by the local population. The second myth was that any kind of international assistance was needed and was needed quickly. Again, most needs are met by the local governments, and time is required to assess that need. The third myth was that epidemics and plagues were inevitable after a disaster. Researchers found that except for measles, this is not true. Contrary to what most people thought before 1976, dead bodies from a disaster do not spread disease, so burying dead bodies becomes less of an immediate priority.
The media dubbed the response of the industrialized world to the Guatemalan disaster as the “second disaster.” No initial field assessment was conducted. No needs assessment was done. The industrialized world, namely the USA, sent 100 tons of materials, including vaccines and drugs, many of which were outdated; 90% of what was sent was not used. The antibiotics and pain medicines that were needed were not sent. In 1988, the USA sent 5000 tons of equipment and materials to Armenia in response to another devastating earthquake, and most of this was not needed either. It took 6 months for a large group of people just to catalog everything that arrived. After years of research, the World Health Organization developed an emergency health kit that contains the essential materials needed after a disaster— including antibiotics and supplies for wound care and surgical care.
Overall, disaster response should consist of 3 phases: activation, implementation, and recovery.
Activation phase
The first element in the activation phase is a 2-to 4-day survey to assess the geographical extent of damage; the number of people involved; the number of casualties; the integrity of the health care delivery system; the specific health care needs of survivors; the disruption of power, water, and sanitation; and the extent of the local response. Interestingly, most disasters in the Third World and in the USA are fairly similar from a public health point of view.
The activation phase continues with the establishment of communication and information relays. Research has shown that the most significant problems in a disaster recovery effort are in communication—particularly as 20 or 30 different agencies work in the area. In the 1970s, the Federal Emergency Management Agency (FEMA) developed the Incident Command System, a military-type command center that is set up at or near a disaster site. The senior official of the first responder team assumes the lead role, and actions follow a formalized chain of command.
The first element in the activation phase is a 2-to 4-day survey to assess the geographical extent of damage; the number of people involved; the number of casualties; the integrity of the health care delivery system; the specific health care needs of survivors; the disruption of power, water, and sanitation; and the extent of the local response. Interestingly, most disasters in the Third World and in the USA are fairly similar from a public health point of view.
The activation phase continues with the establishment of communication and information relays. Research has shown that the most significant problems in a disaster recovery effort are in communication—particularly as 20 or 30 different agencies work in the area. In the 1970s, the Federal Emergency Management Agency (FEMA) developed the Incident Command System, a military-type command center that is set up at or near a disaster site. The senior official of the first responder team assumes the lead role, and actions follow a formalized chain of command.
Implementation phase
The first stage of the implementation phase is search and rescue. Initially, survivors among the local population do this work, dispelling another myth called the “disaster syndrome”; it was believed that, after disasters, the survivors walked around dazed and apathetic. In reality, even those who are somewhat injured pull together and quickly become involved in looking for survivors. Most lives are saved in the first day or two; however, many times the rescuers themselves can become victims.
When victims are found, they are triaged. Triage in a disaster is harsh. The goal is the greatest good for the greatest number. Whereas in our emergency departments, we will spend thousands of dollars and devote up to 10 staff members to saving the life of a person in extremis with a heart attack, on a disaster scene that person could be pushed to the side and left to die in order to better utilize available resources on more salvageable patients. Color-coded tagging systems are frequently used to identify those who have minor injuries, moderate injuries, or severe injuries. The black tag is reserved for persons who have died. Assessing status is a dynamic process, and initial assessments are accurate only 70% of the time. Medical personnel on site need to have some experience with this type of triage. It is a difficult task, especially for those of us who are used to saving everyone at all costs.
Once the patients are triaged, they are taken to various collection points. The first is a clearing and staging area a safe distance from the disaster. Patients receive basic medical interventions—intravenous lines, wound care, oxygen, pain medications, and splints. From there, they receive secondary assessment and further field treatment at a casualty collection point. Treatment at this stage may include needle thoracentesis, chest tubes, and preoperative antibiotics. The Medical Command System, a branch of the Incident Command System, determines which hospitals the patients will go to for definitive care and arranges for medically supported transport. There usually are not enough backboards and cervical spine collars for all the trauma patients, so the team members transport the victims as best they can.
In disasters, health care providers should do what they are good at. Paramedics should perform the initial assessment, triage, stabilization, and transport; they are poorly prepared to replace nurses in the hospital setting. Only physicians and nurses with special field training should be in the field, and physicians should not go to the field unless there is a surplus of physicians in the hospitals.
The first stage of the implementation phase is search and rescue. Initially, survivors among the local population do this work, dispelling another myth called the “disaster syndrome”; it was believed that, after disasters, the survivors walked around dazed and apathetic. In reality, even those who are somewhat injured pull together and quickly become involved in looking for survivors. Most lives are saved in the first day or two; however, many times the rescuers themselves can become victims.
When victims are found, they are triaged. Triage in a disaster is harsh. The goal is the greatest good for the greatest number. Whereas in our emergency departments, we will spend thousands of dollars and devote up to 10 staff members to saving the life of a person in extremis with a heart attack, on a disaster scene that person could be pushed to the side and left to die in order to better utilize available resources on more salvageable patients. Color-coded tagging systems are frequently used to identify those who have minor injuries, moderate injuries, or severe injuries. The black tag is reserved for persons who have died. Assessing status is a dynamic process, and initial assessments are accurate only 70% of the time. Medical personnel on site need to have some experience with this type of triage. It is a difficult task, especially for those of us who are used to saving everyone at all costs.
Once the patients are triaged, they are taken to various collection points. The first is a clearing and staging area a safe distance from the disaster. Patients receive basic medical interventions—intravenous lines, wound care, oxygen, pain medications, and splints. From there, they receive secondary assessment and further field treatment at a casualty collection point. Treatment at this stage may include needle thoracentesis, chest tubes, and preoperative antibiotics. The Medical Command System, a branch of the Incident Command System, determines which hospitals the patients will go to for definitive care and arranges for medically supported transport. There usually are not enough backboards and cervical spine collars for all the trauma patients, so the team members transport the victims as best they can.
In disasters, health care providers should do what they are good at. Paramedics should perform the initial assessment, triage, stabilization, and transport; they are poorly prepared to replace nurses in the hospital setting. Only physicians and nurses with special field training should be in the field, and physicians should not go to the field unless there is a surplus of physicians in the hospitals.
Recovery phase
The recovery phase consists of reassessing the scene for missed victims, withdrawing prehospital services, and debriefing those involved. Debriefing involves critical incident stress management. Health care workers assisting disaster victims often become stressed and depressed. Professionals within FEMA help the workers to vent and resolve their feelings.
The recovery phase consists of reassessing the scene for missed victims, withdrawing prehospital services, and debriefing those involved. Debriefing involves critical incident stress management. Health care workers assisting disaster victims often become stressed and depressed. Professionals within FEMA help the workers to vent and resolve their feelings.
Hospitals during disasters
The disaster system is set up to triage patients and distribute them to hospitals. However, as many as 50% of the victims bypass this system and arrive at the hospital in private cars, police cars, taxis, or buses. This causes a maldistribution of patients: some hospitals are overwhelmed while others are left vacant. I experienced this during the 1992 Los Angeles riots. In the emergency department at the University of California at Los Angeles, we were expecting the worst but had a very quiet night. In the meantime, Daniel Freeman Hospital, situated closer to the riots, received 25 patients with gunshot wounds in a 3-hour period. The emergency management system was taking patients to the nearest hospitals, but because of the overwhelming number of patients, the city's system for distributing them fell apart completely.
Even after disasters are over, the emergency department will have higher patient volumes than normal. Some people will be injured in the cleanup process. The loss of doctor's offices and clinics will bring more people to the hospital for care of chronic diseases. Heat-and cold-related problems may appear, as well as somatic symptoms from psychological trauma.
The disaster system is set up to triage patients and distribute them to hospitals. However, as many as 50% of the victims bypass this system and arrive at the hospital in private cars, police cars, taxis, or buses. This causes a maldistribution of patients: some hospitals are overwhelmed while others are left vacant. I experienced this during the 1992 Los Angeles riots. In the emergency department at the University of California at Los Angeles, we were expecting the worst but had a very quiet night. In the meantime, Daniel Freeman Hospital, situated closer to the riots, received 25 patients with gunshot wounds in a 3-hour period. The emergency management system was taking patients to the nearest hospitals, but because of the overwhelming number of patients, the city's system for distributing them fell apart completely.
Even after disasters are over, the emergency department will have higher patient volumes than normal. Some people will be injured in the cleanup process. The loss of doctor's offices and clinics will bring more people to the hospital for care of chronic diseases. Heat-and cold-related problems may appear, as well as somatic symptoms from psychological trauma.
Disaster plans
The Joint Commission on Accreditation of Healthcare Organizations mandates the creation and testing of hospital disaster plans. At Baylor, we conduct a disaster drill twice a year. Nevertheless, we probably experience the “paper plan syndrome.” Although the plans are written down on paper, holes become evident as they are put into action. We have found problems during our drills and have addressed those problems, but more holes may surface under different circumstances.
In 1994, the emergency department experienced an internal disaster: a flood. The basement of Roberts Hospital had a foot of water in it. It was about 9 PM on a Friday, and we were able to move the 10 or 12 patients in the department to the recovery room. We discharged those who could be discharged, admitted those we could admit, and closed by 3 AM. The emergency department remained closed for a week, until the damage could be repaired. Other possibilities for internal disasters are power failures, chemical or radiation accidents, fires and explosions, bomb threats, and elevator problems.
Baylor University Medical Center's disaster plan addresses a plan of activation, a command center (which is the emergency department), traffic flow, triage, decontamination, treatment areas, special areas (such as family areas and a morgue), and evacuation.
The Joint Commission on Accreditation of Healthcare Organizations mandates the creation and testing of hospital disaster plans. At Baylor, we conduct a disaster drill twice a year. Nevertheless, we probably experience the “paper plan syndrome.” Although the plans are written down on paper, holes become evident as they are put into action. We have found problems during our drills and have addressed those problems, but more holes may surface under different circumstances.
In 1994, the emergency department experienced an internal disaster: a flood. The basement of Roberts Hospital had a foot of water in it. It was about 9 PM on a Friday, and we were able to move the 10 or 12 patients in the department to the recovery room. We discharged those who could be discharged, admitted those we could admit, and closed by 3 AM. The emergency department remained closed for a week, until the damage could be repaired. Other possibilities for internal disasters are power failures, chemical or radiation accidents, fires and explosions, bomb threats, and elevator problems.
Baylor University Medical Center's disaster plan addresses a plan of activation, a command center (which is the emergency department), traffic flow, triage, decontamination, treatment areas, special areas (such as family areas and a morgue), and evacuation.
The role of the federal government in disasters
President Carter established FEMA in 1979. It includes under its auspices the National Fire Administration, Civil Defense, and insurance programs, and it can call upon other federal agencies as needed, including the Department of Transportation, the US Army Corps of Engineers, the Environmental Protection Agency, and the Department of Agriculture. FEMA does not respond to disasters on its own accord but only at the invitation of a governor. FEMA had management problems in the 1980s but since that time has become much more efficient and responsive to the needs of disaster victims. One improvement made in 1992 was the development of the Federal Response Plan, in which the American Red Cross joined resources with the 26 federal agencies under FEMA.
The National Disaster Medical System is another disaster-relief program; it was initiated in 1981 and consists of volunteer disaster teams (presently 61 of them) that can be rapidly assembled and taken to a disaster site. Each team is self-sufficient, with about 35 medical and support personnel. Teams can be deployed for up to 2 weeks.
An example of how the government should not work occurred in the 1970s, when a state bank building in Crested Butte, Colorado, exploded, killing or injuring a number of people. Because it was a bank building, the Federal Bureau of Investigation became involved. Because it was an explosion, the Bureau of Alcohol, Tobacco, and Firearms became involved. Initially it was thought that the explosion resulted from coal gas from an underground mine, so the US Mine Safety Commission joined in the investigation, which also brought in the US Geological Survey because of the mine. That idea was discounted, but then it was thought that the explosion could have resulted from a propane leak, so the National Transportation Safety Board became involved, and because it was a hazardous substance, the Occupational Safety and Health Administration became involved. For the explosion of one isolated building, then, 6 or 7 different federal agencies were involved—all overlapping, all redundant, all looking at the situation from their own point of view, without anyone coordinating the efforts. That type of redundancy and lack of communication should have been eliminated by the coordination of federal programs under the auspices of FEMA.
President Carter established FEMA in 1979. It includes under its auspices the National Fire Administration, Civil Defense, and insurance programs, and it can call upon other federal agencies as needed, including the Department of Transportation, the US Army Corps of Engineers, the Environmental Protection Agency, and the Department of Agriculture. FEMA does not respond to disasters on its own accord but only at the invitation of a governor. FEMA had management problems in the 1980s but since that time has become much more efficient and responsive to the needs of disaster victims. One improvement made in 1992 was the development of the Federal Response Plan, in which the American Red Cross joined resources with the 26 federal agencies under FEMA.
The National Disaster Medical System is another disaster-relief program; it was initiated in 1981 and consists of volunteer disaster teams (presently 61 of them) that can be rapidly assembled and taken to a disaster site. Each team is self-sufficient, with about 35 medical and support personnel. Teams can be deployed for up to 2 weeks.
An example of how the government should not work occurred in the 1970s, when a state bank building in Crested Butte, Colorado, exploded, killing or injuring a number of people. Because it was a bank building, the Federal Bureau of Investigation became involved. Because it was an explosion, the Bureau of Alcohol, Tobacco, and Firearms became involved. Initially it was thought that the explosion resulted from coal gas from an underground mine, so the US Mine Safety Commission joined in the investigation, which also brought in the US Geological Survey because of the mine. That idea was discounted, but then it was thought that the explosion could have resulted from a propane leak, so the National Transportation Safety Board became involved, and because it was a hazardous substance, the Occupational Safety and Health Administration became involved. For the explosion of one isolated building, then, 6 or 7 different federal agencies were involved—all overlapping, all redundant, all looking at the situation from their own point of view, without anyone coordinating the efforts. That type of redundancy and lack of communication should have been eliminated by the coordination of federal programs under the auspices of FEMA.
FUTURE OF DISASTER MEDICINE: BIOTERRORISM
All disasters are low-probability events. Even when they do happen, at least in the USA, there are few casualties. Because of this, people tend to become apathetic: “What's going to happen will happen. What control do I have over it?” This is a major obstacle in dealing with the future threat of bioterrorism. President Clinton has said that we are going to have a biological terrorist attack sometime in the next 20 or 30 years. Interest in bioterrorism has been piqued somewhat because of the Oklahoma City bombing, the sarin attack in Tokyo, and the gas attacks in the Iran-Iraq War.
A number of studies are reporting that emergency departments are poorly prepared for bioterrorism. First, it might be difficult even to know if an attack has occurred. Symptoms from some biological weapons are mild and nonspecific, such as nausea and vomiting. It is difficult enough for us to detect common causes of these symptoms, such as infectious diseases or food poisoning, since there is no national data bank or reporting system for such diseases. In one night, 30 or 40 people in this city could show up at various emergency departments with the exact same gastrointestinal symptoms. We wouldn't call each other and say, “Do you have somebody with nausea and vomiting in your emergency department?” Physicians have to have a high degree of suspicion, but when a patient presents with nausea and vomiting, bioterrorism is not the first thing that comes to mind.
We also have a limited ability to treat victims. In the sarin attack, 74% of the patients seen had no injuries; that is part of the mass hysteria effect. One hospital served 641 patients in a single day. (We see 250 patients on a busy day in our emergency department.) In addition, 20% of the hospital staff treating the sarin victims were themselves contaminated. Federal plans do not take into account individual hospital capabilities, and some hospitals are not very well prepared to take care of disaster victims. Unfortunately, that puts the burden on those hospitals that are better prepared to care for contaminated patients. As a level 1 trauma center in a major metropolitan area, Baylor will need to play a leading role in the preparation for bioterrorism and in the care of citizens who fall victim to such attacks. Hopefully, this article and the articles on bioterrorism to appear in the July 2001 issue will help increase awareness of the problems we face as a major medical center and so help to improve our response to such disasters, saving lives in the process.
All disasters are low-probability events. Even when they do happen, at least in the USA, there are few casualties. Because of this, people tend to become apathetic: “What's going to happen will happen. What control do I have over it?” This is a major obstacle in dealing with the future threat of bioterrorism. President Clinton has said that we are going to have a biological terrorist attack sometime in the next 20 or 30 years. Interest in bioterrorism has been piqued somewhat because of the Oklahoma City bombing, the sarin attack in Tokyo, and the gas attacks in the Iran-Iraq War.
A number of studies are reporting that emergency departments are poorly prepared for bioterrorism. First, it might be difficult even to know if an attack has occurred. Symptoms from some biological weapons are mild and nonspecific, such as nausea and vomiting. It is difficult enough for us to detect common causes of these symptoms, such as infectious diseases or food poisoning, since there is no national data bank or reporting system for such diseases. In one night, 30 or 40 people in this city could show up at various emergency departments with the exact same gastrointestinal symptoms. We wouldn't call each other and say, “Do you have somebody with nausea and vomiting in your emergency department?” Physicians have to have a high degree of suspicion, but when a patient presents with nausea and vomiting, bioterrorism is not the first thing that comes to mind.
We also have a limited ability to treat victims. In the sarin attack, 74% of the patients seen had no injuries; that is part of the mass hysteria effect. One hospital served 641 patients in a single day. (We see 250 patients on a busy day in our emergency department.) In addition, 20% of the hospital staff treating the sarin victims were themselves contaminated. Federal plans do not take into account individual hospital capabilities, and some hospitals are not very well prepared to take care of disaster victims. Unfortunately, that puts the burden on those hospitals that are better prepared to care for contaminated patients. As a level 1 trauma center in a major metropolitan area, Baylor will need to play a leading role in the preparation for bioterrorism and in the care of citizens who fall victim to such attacks. Hopefully, this article and the articles on bioterrorism to appear in the July 2001 issue will help increase awareness of the problems we face as a major medical center and so help to improve our response to such disasters, saving lives in the process.
References
- ^ "What is a disaster?". www.ifrc.org. International Federation of Red Cross and Red Crescent Societies. Retrieved 21 June 2017.
- ^ "Disasters & Emergencies: Definitions" (PDF). Addis Ababa: Emergency Humanitarian Action. March 2002. Archived (PDF) from the original on 6 November 2015. Retrieved 26 November 2017 – via World Health Organization International.
- ^ a b "Why natural disasters aren't all that natural". openDemocracy. 26 November 2020. Archived from the original on 29 November 2020. Retrieved 29 December 2020.
- ^ a b Gould, Kevin A.; Garcia, M. Magdalena; Remes, Jacob A.C. (1 December 2016). "Beyond 'natural-disasters-are-not-natural': the work of state and nature after the 2010 earthquake in Chile". Journal of Political Ecology. 23 (1): 93. doi:10.2458/v23i1.20181.
- ^ a b Smith, Neil (11 June 2006). "There's No Such Thing as a Natural Disaster". Items. Archived from the original on 22 January 2021. Retrieved 29 December 2020.
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