EMS Catastrophic Events

Issues of Concern

Earthquakes

Earthquakes strike without warning, and the timing can significantly influence the number of casualties. An earthquake occurring at night while people sleep at home tends to cause more devastation than one during the day when individuals are awake and able to escape. Aftershocks pose additional risks, potentially leading to further injuries. Initial trauma includes fractures, lacerations, and crush injuries. Many individuals with crush injuries develop crush syndrome, which can involve rhabdomyolysis and renal failure. A significant proportion of these patients require dialysis, and some undergo fasciotomy. Secondary risks include infectious disease outbreaks.[2]

Hurricanes and Floods

Although hurricanes and floods allow some time for preparation and evacuation, damage to medical infrastructure remains a major challenge. Injuries resemble those seen in earthquakes. Exposure to contaminated floodwater increases the risk of bacterial infections, including Vibrio vulnificus and Leptospira.[3]

Radiation Emergencies

Radiation emergencies may result from accidents in healthcare facilities or nuclear sites, terrorist attacks, or acts of war. A terrorist attack could involve the detonation of a radiological dispersal device (RDD), commonly known as a dirty bomb. The initial blast and resulting fires can cause significant casualties. Radiation exposure can lead to bone marrow failure and gastrointestinal damage, with higher doses proving fatal. Beyond direct health effects, the release of radioactive material would likely incite mass panic, potentially overwhelming the healthcare system.

Infectious Disease

Infectious disease disasters may be primary, such as the Ebola epidemic from 2013 to 2016, or secondary, such as the cholera outbreak following the 2010 earthquake in Haiti. For diseases spread by contact, infection control measures, including hand hygiene, personal protective equipment (PPE) use, and proper patient isolation, are essential and must be implemented among healthcare providers. As demonstrated during the COVID-19 pandemic, personal protective equipment shortages can become a critical challenge in managing infectious disease emergencies.

Terrorist Attacks

Although terrorist attacks often result in a multi-casualty incident, they rarely escalate into a catastrophic event like the September 11 attacks. In a terrorist bombing, deaths result from the 4 stages of blast injury: the blast wave, shrapnel, bodily displacement, and secondary hazards such as fires or building collapse. On 9/11, these effects were magnified by the massive explosions from airplanes crashing into the Twin Towers and the subsequent collapse of 2 of the world's tallest buildings.[4][5]

Complex Humanitarian Emergencies

CHEs arise from political instability or armed conflict, leading to violent deaths, malnutrition, and disease. Recent examples include conflicts in Syria, Afghanistan, Bosnia, Rwanda, Kosovo, the Democratic Republic of Congo, and East Timor. Over time, these crises have caused more deaths than all natural disasters combined. Violent deaths result from shootings, shrapnel, and landmines, while infectious diseases remain the leading causes of morbidity and mortality in CHE across Asia and Africa. Common diseases include diarrheal infections, acute respiratory tract infections, measles, meningitis, and malaria. Malnutrition, mental health disorders, and sexual violence are also prevalent.[6]

Clinical Significance

Role of Emergency Medical Services

The emergency medical system (EMS) plays a critical role in disaster response, relying on established infrastructure, trained personnel, and integrated communication networks. However, disasters can severely impact these resources. The dispatch center may be destroyed, the call system may fail, and coordination with other agencies may be disrupted. Ambulances and stations may sustain damage, while personnel may be injured or killed. Survivors may be unable to respond due to vehicle damage or impassable roads. Personal losses, such as injured family members or destroyed property, may also take priority over duty. EMS must establish casualty collection points and conduct mass casualty triage.

Emergency Medical System Issues

Significant modifications to the conventional EMS structure become necessary during a disaster. Dispatch must be reserved for life-threatening emergencies, basic life support ambulances may need to handle advanced calls, and patients may require transport in nonambulance vehicles. Resuscitation efforts should not even be initiated in a true disaster scenario.

Field triage systems, such as Simple Triage and Rapid Treatment (START), Sort, Assess, Life-Saving Interventions, Treatment, and Transport (SALT), Triage Sieve and Sort, or CareFlight Triage must be implemented. These systems assess patients based on factors such as the ability to follow commands, respiratory rate, radial pulse, capillary refill, and heart rate.[7][8] START and SALT have become the most commonly used triage methods in the United States.

Fundamental Treatment Issues

In a disaster, patients who cannot breathe spontaneously are classified as expectant and placed in a separate area with the deceased. At the other end of the spectrum, lightly injured individuals and the walking wounded, who would typically be transported to a medical facility, are treated on-site and discharged. Simple fractures may be splinted. Wounds should be thoroughly irrigated. Patients with moderate-to-severe injuries require stabilization. Individuals who can breathe spontaneously with minimal assistance, such as a jaw thrust, are transported to the hospital. Clinically identified tension pneumothorax should be treated with needle decompression or chest tube insertion. Active external bleeding must be controlled with bandages or tourniquets.

Patients may also experience acute exacerbations of chronic conditions such as asthma, congestive heart failure, or diabetes. In prolonged disasters or situations where water and electricity are compromised, emergency responders must plan for treating patients who rely on dialysis or other life-sustaining treatments that may become inaccessible.

Transport of Victims

Various approaches exist for transporting patients from a disaster site to local hospitals. In the conventional method, ambulances take patients directly from the disaster site to area hospitals, with rescue, triage, and initial emergency care occurring at the scene.

In the sequential or conveyance method, rescue and emergency care take place at the disaster site, but patients are then transported to a mobile emergency medical center (MEMC). At the MEMC, minor injuries can be treated and discharged, while severely injured patients receive stabilization before being transported to a hospital. This system involves 2 ambulance lines: one moving patients from the disaster zone to the MEMC and another transporting stabilized patients from the MEMC to the hospital. This structured approach mirrors the rural model of stabilizing a patient at a level 3 emergency department before transferring to a level 1 trauma center.

The MEMC location can be determined using Google Maps, which employs artificial intelligence to identify optimal routes. However, a major limitation is that many roads may be impassable during a catastrophe. Another challenge is that while MEMC sites are ideally predesignated, the disaster itself may render the chosen location unusable. A key advantage of the conventional transport method is that physicians determine hospital destinations, which may help reduce overcrowding.

Simultaneously, hospital emergency departments will organize and activate their disaster response systems to prepare for the influx of patients. The incident command system will be initiated, and all disaster response team members will be called in. To expand surge capacity, the emergency department will discharge stable patients and admit those requiring continued treatment or further evaluation. Additional areas, such as lounges and waiting rooms, may be repurposed as treatment zones to accommodate more patients.

Field Hospitals

Field hospitals may be required to provide definitive treatment for large numbers of casualties. The World Health Organization (WHO) has taken the lead in certifying emergency medical teams (EMTs) for disaster response. These teams may be domestic, classified as National Teams (N-EMTs), or international, classified as International Teams (I-EMTs). All EMTs must adhere to hygiene standards, ensure official worker registration, carry malpractice insurance, and maintain proper medical records.

EMTs are categorized into 3 levels based on the complexity of care provided. EMT-1 functions similarly to a medical clinic. EMT-2 offers inpatient surgical care. EMT-3 includes inpatient referral care. An EMT-3 field hospital can accommodate 2 operating suites, up to 5 intensive care unit beds, and 40 inpatient beds. An EMT-3 emergency department can manage up to 200 patients daily, with laboratory and x-ray services available. During a disaster, EMS providers may transport patients directly to these facilities or facilitate transfers from lower-level to higher-level field hospitals.[9]

Mortality and Morbidity of Rescuers

Rescuers often become victims during catastrophes. Beyond the firefighters and emergency medical technicians who perished in the World Trade Center disaster in 2001, thousands more developed long-term medical and psychological conditions, including pulmonary illness from toxic dust exposure. Periodic health assessments for these responders include chest x-rays, pulmonary function tests, blood work, urinalysis, and mental health screenings. More than 20% of the general responder cohort continues to experience physical and mental health issues directly linked to 9/11.

Following the Chornobyl nuclear power plant disaster in 1986, up to 600,000 "liquidators"—civilian and military personnel involved in the cleanup—experienced elevated rates of leukemia, thyroid cancer, and other malignancies. Japan has implemented a health monitoring program for individuals exposed to the Fukushima disaster, which includes annual eye examinations for cataracts, cancer screenings, and thyroid evaluations.

Ethical Issues

In a catastrophe, most ethicists agree that the primary goal is to save as many lives as possible, prioritizing the needs of the majority over the individual. Under normal circumstances, the sickest patients receive priority care. However, in a disaster, individuals with minimal chances of survival who require extensive resources may not be treated, as doing so would divert critical care from a greater number of patients.[10]