After a major disaster, the need for search, rescue, and first aid is likely to be so great that organized relief services will be unable to meet more than a small fraction of the demand. Most immediate help will come from uninjured survivors, and they will have to provide whatever first aid they can. Any improvement in the quality of immediate first aid services must depend on increased instruction in them, as through relevant training courses.

Medical treatment and emergency care for large numbers of casualties are likely to be needed only after certain types of disasters. Most injuries are sustained in the initial impact, and thus the greatest need for emergency care occurs in the first two days. The burden of organizing and delivering transport, first aid, medical care, and supplies, therefore, falls on the affected country. Little effective help from international agencies is likely during the period of greatest need because of the response time required.

The management of mass casualties is divided into three main areas: search, rescue, and first aid; transport to health facilities and treatment; and redistribution of patients between hospitals when necessary.

Transport to health facilities and treatment

Casualties should be treated near their own homes whenever possible to avoid social dislocation and the added drain on resources of transporting them to central facilities. If there are significant medical reasons for such evacuation, the relief authority should make provisions to return the patient to his or her home.

Most casualties reasonably near a health facility will generally converge on it regardless of its operating status, using whatever transport is available, but some may avoid or be unable to seek medical care, which makes active case finding an important part of any casualty relief. This is a sufficient reason for creating mobile healthcare teams in addition to fixed first aid stations located near existing health facilities.

Providing proper treatment to casualties requires that health service resources be redirected to this new priority. Bed capacity and surgical services must be expanded by selectively discharging routine inpatients, rescheduling nonpriority admissions and surgery, and using available space and personnel fully.

Normal physician responsibilities will have to be delegated extensively to non-physicians. A center, manned 24 hours a day to respond to inquiries from patients' relatives and friends, should be established and could be staffed by able lay people. The Red Cross may be well equipped to direct this centralizing role.

If necessary, provision should be made for food and quarters for health personnel. Adequate mortuary space and services must be provided.

Triage

The mere number of casualties requiring varying degrees of medical attention on the first day after a severe disaster requires that the medical profession adopt an approach to treatment different from that they normally use.

In his Disaster Management: Comprehensive Guidelines for Disaster Relief (Bern, Hans Huber, 1979), Edwin H. Spirgi has clearly defined triage, or the sorting of patients noting that "the principle of first come, first treated' applied in routine medical care is inadequate in mass emergencies. " He continues that triage consists of rapidly classifying the injured on the basis of the benefit they can expect from medical care and not according to the severity of their injuries.

Higher priority is granted whenever some simple intensive care may modify dramatically the immediate or long-term prognosis. Moribund patients who require much attention for a questionable benefit have the lowest priority. Triage is the only approach able to provide maximum benefit to most of the injured in a disaster situation.

He also notes that some physicians may consider it ethically questionable to treat patients who can be saved before the very seriously injured but dying, but that such a strategy is the only one valid for the good of the many after a disaster.

Although different triage systems have been adopted and are still in use in some countries, the most common classification consists of three categories of patients: those who cannot benefit from the treatment available under emergency conditions; the seriously injured, who should be attended first; and patients who are ambulatory or whose injuries are less severe. After initial first aid, the last category can wait for medical attention until the seriously injured have been dealt with.

Triage should be carried out at two stages: at the disaster site in order to decide on transportation priority, and on admission to the hospital or treatment centre in order to reassess the patient's needs and priority for medical attention. Ideally, local health workers should be taught the principles of triage beforehand to expedite the process when a disaster occurs. In the absence of adequate training of field health personnel, a triage officer and first aid workers must accompany all relief teams to the disaster site to make these assessments. At the hospital, triage should be the responsibility of a highly experienced clinician as it may mean life or death for the patient and will determine the activities of the whole staff.

Tagging

All patients must be identified with tags stating their name, age, sex, place of origin, triage category, diagnosis, and initial treatment. Standardized tags must be chosen or designed in advance as part of the national disaster plan. Health personnel should be thoroughly familiar with their proper use.

Organizational Structure

As Spirgi notes, effective management of mass casualties demands an organization of services quite different from that found in ordinary times. “A hospital disaster plan designates the command structure to be adopted in case of disaster," he comments. " A command team ( consisting of senior officers in the medical, nursing, and administrative fields), . . . will direct people where to work according to the plan and mobilize additional staff and additional resources as required. The officer in charge . . . should have control as close to military authority as is ever seen in medical practice. "

Standardized Simple Therapeutic Procedures

Treatment procedures should be economical in both human and material resources. First-line medical treatment should be simplified and aim at saving lives and preventing major secondary complications or problems. Preparation and dissemination of standardized procedures, such as extensive debridement, delayed primary wound closure, or the use of splints instead of circular casts, can produce a marked decrease in mortality and long-term impairment. According to Spirgi,

Such steps can be carried out quickly, in many instances by individuals with limited training. On the other hand, certain more sophisticated techniques requiring highly trained individuals and complex equipment and many supplies (e.g., as for the treatment of severe burns) are not a wise investment of resources in mass casualty management. This shift in thinking and action from ordinary practice to mass medical care is not easy to achieve for many physicians.

Redistribution of patients between hospitals when necessary

While healthcare facilities within a disaster area may be damaged and under the pressure of mass casualties, those outside may be able to cope with a much larger workload or provide specialized medical services such as neurosurgery. The decision to redistribute patients to hospitals outside the disaster area should be carefully considered since unplanned and possibly unnecessary evacuation may create more problems than it solves. Good administrative control must be maintained over any redistribution in order to restrict it to a limited number of patients in need of specialized care not available in the disaster area.

The Health Relief Coordinator should be particularly aware of the social, administrative, and legal implications of international evacuation. Medical relief teams from other countries are often unaware of existing backup facilities in the disaster-affected country and may propose transferring excess casualties or those requiring special attention to the health services of their homelands. Guidelines and policies must be clear in this regard and communicated to each relief team.

Hospitals are listed according to their geographic location, starting with those closest to the impact area. A visual display of the number of beds available, medical or nursing personnel required for full round-the-clock services, and essential medical items to direct external assistance to areas where needs and expected benefits are greatest. Patterns for redistributing resources or patients will emerge from the analysis of the data. Such monitoring of hospital resources will be most useful when medical care is likely to be needed for an extended period.

If the Health Relief Coordinator finds that his country's total health care capacity is insufficient to meet disaster-related needs, several alternatives must be considered.

The best is rapid expansion of the country's own permanent facilities and staff, which has the advantage of fulfilling immediate needs and leaving behind permanent benefits.

If this is not feasible, a second alternative may be staffed, self-sufficient, mobile emergency hospitals available from governmental, military, Red Cross, or private sources. If such a hospital is necessary, one from the country itself or a neighboring country with the same language and culture should be considered first, and those from more geographically, culturally, or technologically distant countries should be considered second.

Foreign mobile hospitals may have several limitations. First, the time needed to establish a fully operational mobile hospital may be several days, though most casualties will occur as a result of the immediate impact and require treatment in the first 24 hours. Second, the cost of such a hospital, especially when airlifted, can be prohibitive and is often deducted from the total aid package given by the governmental or private relief source providing it. Third, such hospitals are often quite advanced technologically, which raises the expectations of the people they serve in a way that will be difficult if not impossible for local authorities to fulfill during the recovery period. Finally, it must be recognized that such hospitals are of great public relations value to the donor agency, which may thus press their use unsuitably.

A third alternative, the packaged disaster hospital (PDH), may be offered by several sources, but its use in the emergency phase should be considered with caution for several reasons. First, the training required to install and operate PDHs is extensive and buildings suitable for housing them must be located. It may take several weeks for such a hospital to become operational. Second, part of the material in the hospital may be obsolete, in poor condition, or unsuited to the needs of the recipient country since most such hospitals were designed in the early 1950s for use after nuclear disasters in developed nations. And third, the cost of airlifting such hospitals to a recipient country is prohibitive in relation to their benefit in relief operations.

Some of this equipment may be useful for long-term reconstruction, however. Careful study of this possibility and, ideally, on-site inspection of the equipment by the recipient agency should precede any shipment. Unless cooperating private airlines absorb its shipping cost, the equipment should be delivered by surface rather than air transportation.