Ebook: Handbook for Pandemic and Mass-Casualty Planning and Response

The past two decades have evidenced that natural and political forces challenge us to prepare our medical and public health capabilities to respond to a spectrum of horrific events. Wars, tsunamis, terrorist attacks, pandemics, and ecological changes are but some of the events that have and will continue to place our populations at risk and our responders in harm's way. This text, the Handbook for Pandemic and Mass-Casualty Planning and Response, has captured the lectures and teachings of an extraordinary 12-day NATO Advanced Study Institute held in Slavonski Brod, Croatia, in late 2011, the purpose of which was to address the medical and public health response to disasters. The intent of this handbook is to offer the disaster medicine professional community writ large the information and tools to better prepare, individually and collaboratively, to mitigate mortality and morbidity when catastrophe occurs.

The book is divided into three sections. Section One, The Context of Catastrophic Health Planning, begins with chapters and case studies on curriculum and methods of preparing the disaster response. It introduces MRMI—Medical Response to Major Incidents—an interactive and standardized postgraduate course developed by an international group of experts within the European Society for Trauma and Emergency Surgery. This and subsequent chapters provide a context that emphasizes both rigorous and standardized cross-disciplinary training, which is critical as global disasters necessitate a surge in response from multiple regions and countries and require swift, efficient, and aggregate capabilities as catastrophes unfold. Moreover, despite the disruption associated with mass-casualty events, we are reminded that governments and health professionals must ensure that medical and humanitarian efforts are guided by ethical principles and that risk communication and trustworthy information can result in an empowered and resilient population in the period after the disaster.

Section Two, Principles of Response to Catastrophes with Mass Casualties, offers chapters addressing specific treatment guidelines as well as medical and surgical practices. It presents information on amputation and on burn and blast injuries; it provides triage guidelines, treatment algorithms, and principles of mass-casualty planning. Charts and images are effective adjuncts to the textual material in these chapters.

Section Three, Communication and Information Sharing, provides both practical and theoretical treatises on the issue of communication. Aggregating an effective response requires more than real-time data streaming. More essential is the need to identify and correctly position—in advance—the networks and collaborative structures that must work together and share capabilities. This important teaching effectively loops us back to the beginning section: for us to be effective we must work together seamlessly.

It is in this spirit of the NATO Science for Peace and Security Programme that we offer this book, the Handbook for Pandemic and Mass-Casualty Planning and Response.

Medical Response to Major Incidents (MRMI) is a standardized postgraduate course developed by an international group of experts within the European Society for Trauma and Emergency Surgery. It is entirely interactive, with all participants training in their routine positions. It covers the whole chain of management—scene, transport, hospitals, command and communication, management of individual patients—and thereby permits training in the important coordinating between different units, which often is the weak point in real incidents. The scenarios are based on real injuries from terrorist incidents. The training is done in real time using actual simulated resources, thereby providing a measurable result of the response as a base for further development and training.

When the scale of an emergency overwhelms national response capacities, a disaster-stricken country can benefit from civil protection means or teams in other EU countries. However, there is no common, standardized approach for all relief workers. There are two major incident training systems being used across Europe: The British Major Incident Medical Management and Support (MIMMS) system and the European-based and Swedish-led Medical Response to Major Incidents and Disasters (MRMI) course. The DITAC Project proposes to develop a holistic training curriculum for first responders and managers dealing strategically with international crises.

There is a real potential for highly pathogenic and novel strains of pandemic influenza. In this chapter, new data on influenza and on the clinical and epidemiological characteristics of subtypes of viruses (H1N1)pdm09 and HPAI H5N1 are presented. Modern standards of organizing epidemiological surveillance on influenza, corresponding to International Health Regulations (2005) requirements across the pre-pandemic period, phases of pandemics, and post-pandemic period, are shown.

Slovenia is a country of 2 million residents at the tip of the Adriatic Sea. Until the 1990s it was part of Yugoslavia, which declared itself socialist but was never part of the Warsaw Pact. As a country between the eastern and western blocs, it cherished the idea of people's resistance. The ideal was that the whole society would act as a defensive force, the prevalent part being involved in civil defense. The concept also called for regular training. After Slovenia's secession from Yugoslavia, the principle of profit precluded most of the training. Industrial policy of maintaining minimum stocks of supplies at hospitals resulted in reduced reserves for response to any mass-casualty disaster. Only recently, thanks to effortless popularization of preparedness for Medical Response to Major Incidents (MRMI), was the European Society for Trauma and Emergency Surgery prompted to urge local medical societies to introduce necessary planning and training. Slovenia started (after 20 years) again to prepare courses for training a swift and correct response in case a of mass-casualty disaster. The introductory symposium was in March 2009, and in February 2010 the first true MRMI course was organized. To reduce costs, give instructors more training, and yield as much as possible from the available equipment, we renewed contacts with the Croatian medical society and worked together in organizing national MRMI courses.

Education and training for major incidents and disasters started in Croatia 20 years ago during the Homeland War, 1991-1995. In the beginning of the war in Croatia, all medical institutions were receiving orders and instructions for crisis preparation from the Crisis Headquarters of the Ministry of Health. The integrated health system had been established in which civilian and military systems were mutual. Proper planning and preparedness resulted in excellent medical care performed by civilian and military organizations; 20 years later we started education and training in Croatia based on Medical Response to Major Incidents courses.

Unfortunately, the response to humanitarian crises and large-scale natural disasters worldwide has shown consistent failures in coordination, intervention, and documentation of impact outcomes. The response to the Haitian earthquake of 2010 prompted the international community to address these shortcomings and requirements for greater accountability, stringent quality performance oversights, documentation and reporting, and a recognized process leading to professionalization of the humanitarian community. Evidenced-based studies indicate the need to use a cross- or multi-disciplinary approach to developing competencies leading to curricula and course development and to eventual certification and registry of providers. This chapter discusses the current processes by which these issues are being addressed.

Globalization, migration of the population, climate change, and war and other conflicts throughout the world have created an increasingly complex environment for humanitarian aid and international response and relations. In the past two decades, wars and other conflicts have increasingly become an internal problem for fragile nation-states, and these disrupted states often suffer from inequalities in social, economic, and political development, exacerbated by long-term ethnic, religious, and minority conflicts and by the fierce competition for existing resources. In the meantime, these animosities become an international problem to solve. The humanitarian response to war-related crises and disasters has gradually evolved from charitable but uncoordinated efforts into more systematized interventions. Large, multinational organizations have developed significant technical and logistical capacity in responding to the public health needs of large vulnerable populations. The authors analyze the current controversies and future prospects in complex humanitarian emergencies management.

The hospital is part of the chain of first responders in case of a disaster. The vulnerability of the modern hospital is growing despite scientific and technological advancement. Throughout disaster management, health professionals with broad surgical knowledge are needed, despite the existing range of subspecialists.

Modern hospitals act without having enough available operating rooms, medical teams in reserve, supply reserves, etc., in case of a disaster. Every day, the hospital management is forced into permanent cost-reduction activities involving logistical supply.

The dual-wave phenomenon threatens to overburden hospital capabilities, with the lightly injured patients arriving first and the more heavily injured coming in later. Volunteers, “freelancers,” relatives, and friends can overcrowd the hospital and compromise the health providers' safety. Hazardous materials and radiological, chemical, and biological pollution, along with hostile activity by terrorists, represent an additional safety threat.

Triage in mass-casualty incidents must be based on the principle of maximum benefit for the majority of victims. To accomplish this ethically requires people who are wise and courageous, but also cautious, just, resourceful, compassionate, willing to make sacrifices, and, last but not least, communicative.

Information sharing in disasters and emergencies is a challenge in conditions where a rapid alert system does not exist. The role of institutes of public health must be emphasized. The major institute in Croatia is the national one, and it coordinates the work of the second-level (county) institutes. In our paper we will closely describe the organization scheme.

Emerging from a quasi-socialist economy and civil war, Croatia has demonstrated a community resilience that, along with Croatia's membership in the European Union, bodes well for the future of its public health system.

One of society's biggest challenges is to prevent terrorist attacks. Good intelligence will assist with identifying the risks, the terrorist capabilities, and current trends, but it is inevitable that some attacks will succeed. This considered, the need for planning has never been greater—in fact it is essential. Based on this, those involved have a responsibility to plan for numerous potential situations; the planning should include preparedness, response, and recovery activities. After a terrorist attack where there are casualties or mass casualties, in almost all situations we have to deal with the victims. Dealing with mass-casualty incidents is not a daily occurrence for those who would be involved in the chain of survival, and therefore it requires specific organization and protocols. Terror medicine includes medical management from the scene to post-hospital care, as well as a multiagency approach.

Mass-casualty incidents will always pose challenges to those involved. Every organization has the same goal, and that is to save lives. Research has shown that good preparation and training and an understanding of and respect for the role of all participants in the chain of survival will result in lives being saved. Targeting the avoidable deaths requires well-trained staff to triage patients effectively. Part of that triage is to get the patients to the most appropriate hospital with the most appropriate facilities and medical staff without unnecessary delay. Systems for dealing with mass casualties within the UK have been developed over many years of experience. Can this experience be used by other countries? Most systems around the world have been developed from each country's historical multiagency links; some countries have no multiagency forum and therefore it is questionable how effective they really are. What does the future hold with developing technologies and transport systems giving easy access to worldwide personal travel on a scale never seen before? What about the political, social, and economic impact of natural and manmade disasters? Advanced training such as the Medical Response to Major Incidents (MRMI) course was designed to assist with understanding local capabilities and response. It was also designed to assist and develop networks between emergency responders to maximize cooperation and ultimately to save lives.

Differences among nations in cultures, languages, doctrines, procedures, and materials pose specific requirements for NATO forces for current operations and for the future. The quality of service today especially depends upon how the differing elements can operate together. Optimized interoperability leads to increased mission effectiveness through improved cohesion, performance, and speed, and it radically lowers the expenditures. This applies to the military medical sphere too; the proper interoperability level results in increases in both capability and capacity. Within the NATO military medical community, the Committee of the Chiefs of Military Medical Services in NATO (COMEDS) is the coordinating body for the NATO Military Committee (MC) regarding military medical policies, doctrines, concepts, procedures, techniques, programs, and initiatives. To meet the new requirements with the available resources, multinational solutions are increasingly applied in the whole spectrum of expeditionary military medical support. International cooperation in primary and secondary care, in medical evacuation, in preventive medical care, and in medical staff functions is common today.

The personal protection of battlefield combatants espouses the fundamental aim of keeping the soldier alive and in the fight. Historically, some semblance of clothing that blended into the environment and rudimentary head protection were considered the necessary ingredients in modern pre–20th century conflicts for supporting this aim. During the 20th century, however, huge steps were taken to improve the personal protection given to soldiers on the battlefield—the principles, philosophy, and policy of which now underpin today's doctrine. However, warfare is a constantly evolving process, and now our serving combatants are provided with cutting-edge technology, advanced materials, and first-class training that aim to ensure their survival in a multilayered and diverse theater of operations; historical threats are seamlessly entwined with hybrid threats where an enemy employs a potent mix of conventional weapons, irregular tactics, criminal behavior, and terrorism to achieve political aims while exploiting the vulnerabilities of the regular forces[1].

The history of medicine is inextricably linked to conflict. Man has waged and continues to wage war, but besides the destruction and human tragedy, war often brings clinical advances, innovative practices, and patient treatment protocols that are often cascaded into civilian practice. Both civilian and military planners should be cognizant of the bloody lessons learned from the battlefield and ensure that this hard-won experience is harnessed, understood, and translated into advantageous outcomes for future casualties.

The medical and healthcare needs of a community during disaster conditions could be drastically changed. Hospital capacities, especially the number of intensive-care unit beds and ventilators, are usually constant, so careful planning and great efforts should be made to adapt to altered circumstances. Triage for critical care patients is tertiary triage and is provided according to the hospital disaster plan, which defines triage protocols, the triage officer, and the triage support team. The triage protocols are based on inclusion and exclusion criteria combined with prioritization tools and stratifies patients into priority categories. The most recommended prioritization tool is the SOFA scoring system. The triage process is dynamic, and patients' medical conditions should be periodically reassessed and their priority category amended if necessary. When a major incident is declared, it may be necessary to triage non-disaster patients in the intensive-care unit to free beds and respirators for expected disaster casualties. Triage protocols should be objective, ethical, transparent, and publicly disclosed to avoid a collision between individual rights and community needs.

Over the last 25 years, many advances have resulted in improved survival of severely injured patients in multiple-casualty incidents. Some of the most important are the development of trauma centers and trauma systems and improved proficiency of surgeons with severe injury management. The cornerstone of surgical practice remains the care of the patient with a surgical emergency and the provision of an emergency operation where appropriate. The ideal resuscitation strategy for multiply injured patients remains a topic of ongoing debate.

This is a brief overview of the existing resuscitation protocols for multiply injured patients, including Advanced Trauma Life Support and damage control, and it will address evolving controversies in the field. A damage control approach was developed to improve survival in severely injured trauma patients. The role of damage control in the acute surgery of polytraumatized patients progressing to sepsis or overwhelming hemorrhage continues to be debated. These patients are best managed by a multidisciplinary team, which includes trauma surgeons, orthopedic surgeons, and interventional radiologists. Such an approach represents the challenge in multiple-casualty incidents, necessitating the development of standardized algorithms.

Triage is defined as medical screening of patients to determine their relative priority for treatment. When preparing for triage of patients in a mass disaster, physicians must be aware of the many unique situations and patient conditions. The most frequently used triage methods are sieve and sort—they are the simplest and are mostly used in the field. In hospital conditions, physicians also use more complicated scales: the Glasgow Coma Scale, Injury Severity Score, New Injury Severity Score, Revised Trauma Score, and Trauma Injury Severity Score. All of these scales are used to define the severity of injury as well as to predict patient mortality rates. Besides triage, hospitals in mass disaster settings face resource deficiencies and the lack of highly trained manpower—another important issue when making disaster treatment plans.

Treatment of a mangled lower extremity represents a major challenge in mass-casualty incidents. The decision whether to amputate or attempt reconstruction is currently based upon surgical evaluation. The aim of this chapter is to propose a new approach to surgical evaluation based on scoring systems and local clinical status of the patient, as well as comorbidities, mechanism of trauma, and hospital resources.

Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision making in these situations.

Despite a borderline Mangled Extremity Severity Score (see Table II in K. Johansen et al.[1]), in some cases reconstruction can be attempted considering the overall health status of the patient and local clinical status, with preserved plantar sensitivity and satisfactory capillary perfusion.

In conclusion, management of mangled extremity treatment should refer to evidence-based literature in correlation with clinical evaluation of every individual patient. Scores are helpful but should not be taken as a sole indication for amputation.

Burn injuries are usually treated according to Advanced Burn Life Support guidelines. In mass-casualty incidents, we recognize four phases of burns treatment according to International Society for Burn Injuries guidelines:

1. First triage

2. Initial wound care and fluid resuscitation, including secondary triage

3. Burn wound care with excision, grafting, and infection control

4. Rehabilitation with reconstructive surgery

The International Society for Burn Injuries proposes guidelines based on proper planning for burns treatment in mass-casualty incidents and the need to clarify levels of care and the transport of patients between these levels. Every country needs to have plans for fire incident management. Emergency medical and rescue personnel need to know basic principles of burn treatment and the locations of burn centers.

An increasing number of mass disasters involve explosions. Their principal effect is the creation of tremendous kinetic energy over a short period. The main cause of blast injuries is explosives, and there are five injury types. When approaching an explosion site, medical personnel must coordinate their actions with the police and fire-rescue services to ensure their own safety. Patient care can then be performed using standard the ABCDE principle and trauma algorithms. All vital organ systems can be affected by the blast, so a medical rescuer in the field can expect a variety of injuries.