Ebook: Integrated Emergency Management for Mass Casualty Emergencies

Towards a More Integrated Response to Emergencies and Disasters

The process of responding to emergency situations involves matching urgent needs with available resources in the most rapid and efficient way possible. Timely mobilisation and quick action can reduce the toll of lives lost, injuries sustained and damage experienced in disasters. It follows that professionalisation of response and management is the key to improvements in these processes [1]. In fact, in recent decades, advances in planning, training, technical competence, information management and the specifications of equipment have greatly improved the average level of performance of professional emergency responders and the managers who direct their efforts. At the same time, their work has become more broadly based, complex and challenging [2].

In recent decades there has been much discussion of ‘complex emergencies’. By common consensus, the term is now applied to particular situations in which governance, security, and the normal socio-economics of society have broken down under the duress of military instability. However, some commentators have argued that, rather than being a special category of disaster or crisis, by their very nature all emergencies are complex [3]. As a result they require a sophisticated response. Moreover, as the available tools become more powerful, particularly in telecommunications and information management, there is a further impetus to make the response to crisis a complex one. Complexity is inherent in the number and size of organisations that respond to disaster. Commonly, a major internationally-declared emergency may induce more than 70 nations to send personnel, expertise, equipment and donations: in the case of the January 2010 earthquake in Haiti, 129 countries participated [4].

In the modern world, responses to major disasters tend to be complex, not merely because of the size and scale of operations, nor only because of the number of countries and agencies that take part, but also because of the range of functions represented by these organisations. Full-scale emergency response involves people trained in at least 35 different disciplines and professions: from architecture to seismology, from psychology to civil engineering, from cartography to emergency medicine, the specialists must all work together [5]. One can liken emergency response to a symphony orchestra. The player of each different instrument has a particular sheet of music to read. Only the conductor has the full score, but the overall effect of playing different instruments is harmonious. Likewise, emergency managers must coordinate people from different organisations and specialities who are carrying out different tasks, and they must ensure maximum possible harmony and minimum discord.

The term ‘integrated emergency response’ implies a variety of different things. First, it signifies interoperability [6]. During the international response to the Haitian earthquake, under the aegis of European Union coordination, French and German field hospitals were set up in Port au Prince to treat injuries and provide the local population with basic health care. Personnel rapidly discovered that the procedures and equipment used were not interchangeable, which made it difficult for the field hospitals to give each other mutual support. Moreover, many of the NGOs present in Haiti lacked adequate roles, self-sufficiency and useful skills [7]. As international disasters are likely to become ever more common, imposing and complex, there is a need for compatibility beyond national borders. Concomitantly, there is a need for local and regional harmonisation of equipment, procedures, plans, protocols, training and exercising [8].

In reality, the processes of integrating emergency response go far beyond matters of interoperability. There is a need to provide a common language and culture to organisations that are likely to be highly diverse in their modus operandi and ways of approaching the problems that need to be faced during an emergency. In disasters, the ability to work together effectively and efficiently is paramount. This requires members of organisations to understand something about the work of other agencies. Indeed, in disasters it is almost as important to understand what other people are doing as to understand one’s own role, as this is the only means of successfully acting in concert. It is also necessary for emergency managers to acquire enough knowledge of the language and procedures used by specialists to be able to direct their work. To do this, they must interact effectively with the specialists and hence must appreciate their roles and potentials.

The increasing sophistication of modern emergency response makes the process of coordination a particularly challenging one [2]. The challenge is increasing in relation to the possibilities offered by the current growth in information and communications technology. Information technology tends to favour collaboration over command, cooperation over control [9]. Thus, it helps to flatten the chain of command. The transmission of digital images, maps, video clips, data-sets, situation reports, voice-over-Internet protocol messages and other information facilitates collaborative solutions to problems. It also ushers in a new age in which the comprehensive management of information is emphasised in order to provide problems with more holistic solutions than would have been possible in earlier times.

Traditional emergency management is a hierarchical process of command and control, of giving, receiving and acting upon orders. This is explained by its military origin [10]. One of the main deficiencies of this approach is its rigidity in the face of problems that can change with extreme rapidity and which require highly flexible solutions. Information and communications technology is one factor that enables this approach to be changed to one that is structured much more closely around the problems that need to be solved in emergency situations. If all participants act in good faith, and in concert, there is no reason why responding to emergencies need not be a collaborative effort, in which expertise is brought to bear collectively in order to solve multi-faceted problems (such as evacuation, the provision of shelter, public safety and the stabilisation of hazardous environments) which need the simultaneous input of different disciplines and professions [11]. The quality of interaction between the protagonists becomes much more significant than the quality of command, not least because, although professional emergency responders may be grateful to receive direction, they are often less happy to be commanded. The difference is subtle but it is one of culture and attitude: collaboration fosters creativity and autonomy in decision-making [12].

Emergency response consists of a mixture of planning and action. Plans need to be made in advance of crises in order to ensure that the most rational use is made of available resources. Failure to foresee needs and cater for them when they can be identified in advance is tantamount to negligence. However, the planning process needs to be present throughout the strategic, tactical and operational roles in an emergency situation, as it must ensure that actions are adapted to circumstances which may be changing rapidly or abruptly from day to day, or even hour to hour.

In a full-scale major emergency, it may be necessary to activate various different plans. Diverse organisations need planning instruments if they are to cope well with a crisis. Hence, there is a need to integrate plans in the following ways:

• hierarchically, with respect to different levels of government (typically local, regional and national)

• organisationally, with respect to different emergency services and categories of responder

• geographically, with respect to neighbouring jurisdictions and other territories

• functionally, with respect to sectors of public administration (health, employment, education, public works and infrastructure, public security, etc.).

If, for example, a major incident occurs at a municipal airport, it may require the activation of the emergency plans for the airport as a separate facility, as well as the plans of local and regional authorities, health services and perhaps other sectors or bodies.

Integration is, as they say, “not rocket science”: in other words, it is far from being an abstruse issue that only highly specialised experts can understand. Indeed, much emergency planning is little more than “systematic, codified common sense”. A comparative reading of plans and procedures should ensure that there are no evident barriers to interoperability, no glaring incompatibilities and no great contradictions in the provisions of the documents. The result should be a ‘nested hierarchy’ of plans, in which the overall scheme apportions tasks and responsibilities according to the roles and capabilities of the participating organisations. However, it is one thing to share out the work: it is another thing to ensure that harmony prevails when a crisis occurs. That requires considerable sensitivity to the modus operandi of the various participating organisations.

A further form of integration is that which should occur between the emergency phase and the other parts of the ‘disaster cycle’. Of course, not all disasters are cyclical, and some are not even recurrent [13]. However, the model has proved robust, as there is commonly a progression through mitigation, preparation, emergency response, recovery and reconstruction—with the proviso that the phases may overlap rather than be entirely sequential.

It is a well-known axiom that shifting resources from reacting to disasters to preventing them should reduce the need for emergency response and should reduce their impact in relation to the strength of prior preparedness. It is striking how seldom this policy has been pursued since its effectiveness was first clearly demonstrated decades ago [14]. Many researchers, politicians, public administrators and other commentators have talked about preparedness, mitigation and the need to create resilience [15]. However, most obdurately, the lion's share of resources still goes into reaction, not preventative action. In part this is because one cannot avoid responding to disaster when it occurs. In part it is because the problem of mitigation is enormous and very complex. Moreover, increases in population, pressure on land in hazardous areas, poverty and marginalisation, and forms of speculation and exploitation all conspire to ensure that vulnerability remains unacceptably high. However, it is sad to reflect that political kudos still comes more easily from response, which has an air of charity about it, than from preparedness. Electorates are seldom very impressed by prudence, yet they always demand a prompt response to disaster when it occurs.

As a result of this, there are many more opportunities to integrate preparedness with response than examples of such initiatives. One reason for this is that it is seldom fully appreciated that the starting point for disaster risk reduction is at the community level. All disasters are essentially local affairs, for the theatre of operations, like the scene of damage, is always local, no matter how large the event [16]. Careful analysis of local needs in disaster should also indicate where local coping capacity can be strengthened in order to reduce the response needs [17]. This is therefore one way of demonstrating the need for integration between emergency response and various other aspects of resilience. Moreover, it underlines the fact that emergencies are best tackled in times of “peace” not merely during the crisis itself. Indeed, devising a reaction during the disaster implies that the response is improvised. Whereas each disaster contains some final and irreducible elements of uniqueness, such that improvisation cannot be completely eliminated, a response that is heavily improvised suggests that many elements which could have been sorted out beforehand were overlooked. Improvisation in place of prior planning represents inefficiency, and that can signify avoidable damage and casualties.

In synthesis, there is a demonstrable need for greater integration in the response to emergencies and the processes of disaster risk reduction. Integration must take account of the technological challenges of a world in which society is more interconnected than ever before. It must more successfully link up agencies, organisations, services and institutions that participate in disaster risk reduction. It must bridge the gap between academic studies and practical action [18]. It must more firmly integrate the response phase of the ‘disaster cycle’ with the preparedness, recovery and mitigation phases. Finally, it must integrate training and professional qualification with response activities, and do so in such a way as to encourage multi-disciplinary, holistic, problem-based approaches.

This chapter examines the broad picture regarding the prospects for integration in response to crises and civil contingencies. It evaluates the complexity of emergency situations, using so-called ‘complex emergencies’ as a yardstick. It considers the various forms of potential to develop interoperability in emergency planning, management and response. Next, it probes the different forms of organisation that have been created in order to tackle disasters and emergencies and weighs up their potential for a more integrated approach. It extends this analysis into the humanitarian response field. Lastly the ways in which organisations learn and adapt are considered in relation to the potential for more integrated responses. It is concluded that integration is a fundamental need in emergency management, but it should be achieved by creating functional links rather than ever larger organisational structures.

A disaster is a serious disruption of the functioning of a community or system in a given spatial area causing widespread losses which exceed the ability of the affected system or community to cope with it, using its own resources. In this context, the operational continuity of hospital systems is essential for medical response during disasters and it depends on both structural and non-structural aspects. Although many models and studies already exist in the field of risk reduction, the complexity of the system makes the hospital application really difficult. In the following chapter is reported the development of a new integrated methodology and the application to several case studies (seismic risk assessment for both Italian and US medical facilities, and flooding risk assessment for the Italian hospital). A large part of the study was carried out under the aegis of the European Commission's Framework Program 7 project “MOVE – Methods for the Improvement of Vulnerability Assessment in Europe.”

Since the end of the Cold War, Foreign Field Hospitals (FFHs) have been considered as a feasible solution to cope with the lack of prompt emergency aid in low-income countries, especially after sudden-onset events. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) have developed guidelines regarding the dispatch of FFHs in areas after being hit by natural disasters. It has been demonstrated that the first hours after a catastrophic event are crucial in order to save lives. Therefore, coordination among organizations providing aid and high-level staff qualification must be guaranteed for the purpose of assuring the most cost effective management.

Administration of intravenous fluid is considered a standard of care in pre-hospital settings. Despite this, the debate about the use of crystalloids or colloids is still open. Hypertonic saline solutions can be useful in case of man-made or natural disaster because of their low costs, ease of storage and because they make it possible to expand plasma volume rapidly.

In a “ Disaster” local health services can be overwhelmed, and damage to clinics and hospitals can render them useless. Damage to the health care infrastructure will further compromise the delivery of health services. Many countries maintain mobile field hospitals in order to react in case of disaster. Lessons from past complex disasters such as civil conflicts, wars and humanitarian emergencies showed that Field Hospitals (FH) – as temporary civilian or military hospitals - play a significant response role in disasters and Mass Casualty Incidents (MCI) management. The authors describe an Italian Model of Mobile Field Hospital of ANA- Italian Association of Alpini as “a mobile- flexible hospital structure, self –contained, self –sufficient health care of rapid deployment and expansion or contraction, which has worked, works and will be engaged in case of disasters, in humanitarian emergencies, during mass casualty incidents (MCI) or during major medical incidents”. This Field Hospital supports the activities of civil protection in national and international context, implements local emergency services and hospital bed surge capacity and treatment of mass-casualties in disasters for a specific period of time, especially during international long term missions, but also during peacetime in mass gatherings events and training programs in emergency preparedness. The authors would like to suggest the dual use of a Field Hospital in supporting counties' and populations' needs during disaster time, during wars and conflicts, but also during peacetime.

This paper deals with the necessity of a qualified emergency plan in CBRN mass-casualty incidents and enumerates the basic and standard criteria to be followed in case an event of this kind occurs. Its focus also encompasses the integrated response to chemical mass-casualty events and on the key role of Poison Control Centres in this type of emergency.

Associated European Health Services cannot afford the etiologic treatment of nuclear mass casualty in emergency; however medical doctors have to be informed about nuclear events and geopolitical scenarios connected to World Nuclear Power. A Nuclear Warheads Classification is proposed to improve specific knowledge. Then Peaceful Nuclear Plants Accidents are historically reported up to 2012. Nuclear Safety statements are shared, while statistic conclusions come from criticized analysis of numbers in Mass Casualty, crossing with Chemical Plants Accidents.

Hospitals have a symbolic, social and political value which contributes to build a community's sense of security and well-being. Despite this key role, many hospitals all over the world are located in moderate to high-risk areas and are vulnerable in case a disaster takes place. Hospital evacuation is a major concern and requires a large number of qualified personnel to intervene in a short time to transfer critical patients to safe areas. Medical students can provide an efficient solution to the problem. A group of medical students was trained through a dedicated disaster medicine course composed of three sessions (a medical, a psycho-social and a technical session). Students developed remarkable skills and became capable of cooperating with hospital personnel by applying basic rescue maneuvers during a hospital evacuation. Moreover, a mobile phone application was created in order to contact students quickly and provide them with information about the scenario in case an emergency occurs. A few drills were performed, too.

The terrorist train bombings in Madrid, Spain, on 11 March 2004 triggered a swift and massive medical response. This paper analyses the pre-hospital response to the attacks in order to gain insight into current trends in disaster management among Madrid's Emergency Medical Services (EMSs). Thus, the existing emergency planning framework is described, as well as the basic structures of the different EMSs. The attacks are briefly depicted before consideration is given to pre-hospital management. The issues encountered are attributable mainly to inappropriate planning rather than to mistakes in field-level decision-making. By contrast, many of the successes are attributable to individual initiatives by frontline medics who compensated for the lack of clear command by senior managers.

On 7^th July 2005 terrorists attacked the transportation system in London detonating four improvised explosive devices. 56 persons died and over 700 were injured, 45 of them critically. These bombings were unexpected and besides causing major injury and loss of life, longer term health effects were reported. A full major incident command structure was put in place led by the London UK Metropolitan Police, and involved other emergency services, the health system and central government. The transportation system of the capital was severely affected with major disruption of the city transportation system for 24 hours. Road traffic became completely gridlocked in the central area with all transport inside the M25 beltway suspended. Communications failures included the breakdown of the mobile phone system due to overload. Despite previous experience with the management of bombing incidents in the UK, the scale of the attacks was significant and caused considerable strains on the emergency response system and public health as well as on the infrastructure of the city.

Civil Protection didactic tools and training activities are of basic importance to spread knowledge and foster the resilience of communities. By promoting the culture of peace and solidarity, one can lay the foundations of communal life that will allow people to face individual and social challenges. The University of Florence has proposed to reappraise didactic peace games as a modern way to train Civil Protection Operators by creating a prototype peace-based electronic game entitled “Auxilium!” which was designed as the conclusion of the First Level “Coordination of Civil Protection Activities” Master's Course and developed by Giunti Press. “Auxilium!” is a dynamic peace game where participants compare their capabilities to manage human resources while facing disasters by cooperating, thus reversing the traditional parameters of adult and youth games. “Auxilium!” represents a powerful and effective tool to spread the knowledge of Civil Protection and of the culture of peace by highlighting the role of dialogue and teaching how to cooperate and share goals in order to overcome problems.