Surge Capacity

The concept of surge capacity has emerged as a way to manage an event that produces a sudden influx of casualties with medical and health needs that exceed current hospital resources.⁶ This can be due to either the volume or types of victims. The three basic components of the surge capacity system are commonly referred to as the three s‘s of staff (hospital personnel), stuff (supplies and pharmaceuticals), and structure (physical location and management infrastructure). A complete discussion of surge capacity is beyond the scope of this chapter but has been published elsewhere.⁷

Within the context of surge capacity, new protocols are being developed that address allocation of resources when the medical and health needs of a population exceed current inventory. The issues involve creation of an equitable system for scarce resource allocation strategies, including assignment to an intensive care unit. Although no universally accepted approach currently exits, a system to optimize patient outcomes in a resource-constrained environment is clearly needed.

Definitions

One of the challenges facing those responsible for disaster preparation is that no standard definition of disaster exists. Some events that have been routinely classified as disasters clearly are not. For example, many would consider a plane crash a disaster, yet it may not even approach overwhelming of the resources of the local responders. Because disaster medicine is multidisciplinary and depends on the integration of multiple levels of responders, the use of a common, precise terminology is essential.

In general terms, an event can be considered a disaster when it overwhelms response capabilities. These response capabilities can change in diverse environments or even in the same location at different times of the day or days of the week. For example, a multiple-vehicle collision with 6 critically injured patients and 12 patients with minor injuries could overwhelm both the emergency medical services system and the hospital in a small rural community. In an urban area with multiple hospitals that participate in a trauma system, however, this same event could be managed with routine resources. Thus it is the functional impact on the specific entity that is the key concept in determining whether a disaster exists.

Hazard Vulnerability Analysis

An important consideration in disaster planning is an awareness of the types of events for which the hospital or community is vulnerable. The classic example is the monumental risk from earthquakes in the central United States resulting from the combination of the New Madrid fault and the limited seismic safety requirements for buildings in that area. The planner must learn what types of support are available from outside agencies (e.g., hazardous materials decontamination from fire departments and information from poison control centers). Although awareness of such resources is critical, contingency plans must be available when such assistance is not accessible.

After performing a hazard vulnerability analysis (www.emsa.ca.gov/disaster/files/kaiser_model.xls), emergency planners should consider the most probable events and prepare for them. There should also be planning for events that are rare but catastrophic.¹² The major peacetime threat to life and limb in the United States is probably a large earthquake in a densely populated area or a terrorist attack. The disaster planner should proactively identify all such hazards and prepare contingency plans for each.

Routine Multiple-Casualty Triage

To assist in understanding of triage techniques, it is useful to consider a routine out-of-hospital event with multiple casualties (e.g., a multivehicle collision). In such situations, rescue personnel often use a Simple Triage and Rapid Treatment (START) technique that depends on a quick assessment of respiration, perfusion, and mental status.¹⁷ These three assessments can be remembered by the mnemonic RPM (respirations, perfusion, and mental status). Initially, all victims who are able to walk are asked to move away from the immediate incident area. These patients are classified as green, or “walking wounded,” and are reassessed after the more immediately critical patients are triaged.

The Pediatric Triage Tape (PTT) and JumpSTART have been proposed for the triage of children. JumpSTART is a modification of the START triage protocol that includes an additional step of five rescue ventilations for children presenting apneic and modification of criteria for hypoventilation and tachypnea as well as for a decrease in mental status. The PTT uses criteria that change in proportion to increasing victim size. The parameters for a child 50 to 80 cm in length are illustrated in Figure 193-3. In a comparison of sensitivity and specificity between the PTT and JumpSTART in pediatric trauma patients, the PTT demonstrated superior outcomes.¹⁸ Both START and the PTT appear to be useful tools, but only START has been evaluated in an actual disaster situation.^19–21

As illustrated in Figure 193-4, a rescuer can assess each patient in seconds, quickly checking respiratory rate, pulse, and ability to follow commands (mental status), and divide the patients into the remaining three categories: red (immediate), yellow (delayed), and black (deceased). The only patient care interventions provided during this process are the opening of an obstructed airway and direct pressure on obvious external hemorrhage. At this point, patients are generally transported to a hospital for definitive care. Most often, patients arrive with a color-coded triage tag and are reassessed and retriaged by the hospital staff (Fig. 193-5). An outcomes-based evaluation of the performance of START triage in an actual disaster (2002 Placentia Linda train crash) demonstrated acceptable levels of undertriage (100% sensitivity of the red category and 90% specificity of the green category).²¹ However, significant amounts of overtriage occurred. Use of START also appropriately prioritized the transport of victims, with patients triaged as red arriving at hospitals earlier than patients triaged as yellow or green.

Recently, a multidisciplinary group was formed to propose a potential national triage system for the United States. The result, derived by consensus of opinions, was referred to as SALT (sort, assess, lifesaving interventions, and treatment or transport).²² It differs from START mainly in the assessment of respirations (relies on a qualitative evaluation of respiratory distress rather than a number), the requirement for performance of certain emergent interventions (chest decompression), and an unstructured estimate of survivability. The algorithm is more complicated than START, and no current data exist evaluating its sensitivity, specificity, or other performance characteristics in a disaster. As such, it is not currently possible to make recommendations for its use.

Catastrophic Casualty Management

Triage during a widespread, catastrophic disaster differs from triage performed in routine out-of-hospital and hospital settings. The number of victims is vastly increased, and medical resources are severely limited or even initially absent. Patients may remain on scene for an extended period and should be frequently reassessed. If hospitals remain accessible, patients tend to seek care at the closest one, a phenomenon known as convergence. Hospitals close to the disaster scene are overwhelmed, whereas hospitals located only a few miles away may receive few if any patients. More likely, the hospitals will be rendered nonfunctional. The triage process will then be decentralized, occurring at multiple sites, or compartments, simultaneously throughout the disaster zone. Rather than a single scene or localized disaster, this can be thought of as a compartmentalized disaster.

To address this situation, researchers developed the Secondary Assessment of Victim Endpoint (SAVE) system of triage.²³ The SAVE triage system is designed to identify patients who are most likely to benefit from care available under austere field conditions in a resource-poor environment. When it is combined with the START protocol, SAVE triage is useful for any scenario in which multiple patients experience a prolonged delay in accessing definitive care.

The SAVE methodology is designed for use by health care providers under two conditions: (1) for those working within the disaster zone that begin caring for patients immediately but may not be able to transport patients to a definitive care facility for days and (2) for those caring for patients within hospitals where demand for resources exceeds supply. This second situation can occur as hospitals attempt to increase surge capacity. It is immediate and dynamic rather than delayed and static. Although there are many elements in common with other triage systems, rapid transport to a functional medical center within the “golden hour” may not be possible.

The SAVE triage methodology divides patients into three categories: (1) those who will die regardless of how much care they receive, (2) those who will survive whether or not they receive care, and (3) those who will benefit significantly from austere field interventions. Only those patients expected to improve receive care beyond basic and comfort measures. With use of SAVE, patients are separated into these three categories so resources can be focused appropriately. The decision to place patients in a particular group is based on field outcome expectations derived from existing survival and morbidity statistics.²³ An example is a situation in which three victims require chest tubes (two victims require one tube each and one victim requires two tubes), but only two chest tubes are available. The SAVE principles guide providers to place their last two chest tubes into the two victims who need it rather than into the single victim requiring two tubes.

During the triage process, individuals who would most benefit from early transport should be marked as “first out,” in case an evacuation opportunity occurs. These would be victims with medical problems readily treatable at a hospital or facility with equivalent capabilities but untreatable and fatal in the field. A patient requiring surgery for intra-abdominal hemorrhage is a common example.

Since nuclear, biologic, and chemical terrorism has become a threat, new triage systems are under development.13,24 These systems attempt to incorporate the added threats from exposure and contamination into the triage process. One such method for biologic casualties triages many individuals to home observation rather than hospitalization to optimize resource use and to minimize the spread of the infectious agent.²⁴ In addition, responders must be protected from secondary contamination or exposure; therefore, part of the triage algorithm should include a risk assessment and determination of whether and what type of personal protective equipment should be donned before patients are assessed. A quick determination is critical to prevent patient deaths from traumatic injuries while awaiting medical care from responders concerned about their own health and safety. This is particularly true in a “combined event” scenario, such as an event involving a radiologic dispersion device. Also associated with terrorism incidents are large numbers of psychogenic casualties, those who believe they were exposed but actually were not and those at risk for post-traumatic stress disorder. The emergency plan should include a mechanism to assess and to sort these individuals so as not to overwhelm the emergency department and also provide mental health care. While performing triage, the emergency physician should also consider the effects of extremes of age, underlying disease, and multiple injuries when assessing the potential prognosis for a given patient. Fortunately, the treatment of many nontraumatic emergencies can be accomplished with field interventions that do not consume extensive resources. Therefore, patients with such illnesses should usually be triaged to the treatment area.

Vulnerable Triage Populations

Certain groups of patients, such as children, the elderly, and disabled persons, may have special needs that present challenges to routine triage. For example, if a person is too young to follow commands or is deaf, the individual would not be able to respond to a command to walk away from an incident site for reasons that may not indicate severe injury. Triage schemes should accommodate language and cultural barriers as well as physical and psychological limitations that result in social or medical vulnerabilities.

Special Triage Categories

To maximize personnel resources, disaster victims who would normally be triaged to the observation area can be triaged to the treatment area if they possess special skills valuable to the medical team (e.g., medical expertise and translation skills). By the increase in the number of functional team members, the effectiveness of the overall response will improve. The guiding principle supports the disaster triage goal of maximizing benefit to the most people.

Emergency Medical Services System Protocols

To prepare adequately, hospitals must be familiar with and involved in the development of county or regional plans. For example, some emergency medical services systems use automatic systems such that each hospital may be expected to accept a fixed number of critically ill or injured and minor patients without previous notification.

Physicians working at hospitals should be familiar with community disaster management operations, including the function of the emergency operations center.¹¹ Mutual aid agreements with other hospitals or regions should be considered for situations in which current hospital capacity is exceeded or evacuation is necessary.

Incident Command System

Some form of an incident management system is now a standard component of emergency command and control throughout the United States. It provides a flexible management structure on which to organize a response.²⁷ The federal version, known as the National Incident Management System, is incorporated into the National Response Framework and provides strategic guidance on the U.S. government’s involvement in disaster response. All states must use an incident management system, and it must be compliant with the National Incident Management System.²⁸ By standardizing an organizational structure and using common terminology, an incident command system provides a management configuration that is adaptable to events involving a multiagency or multijurisdictional response. At the most basic level, there are five functional elements in the organizational structure: incident command, operations, planning, logistics, and finance. The principles of an incident command system can also be applied to the hospital setting through implementation of a Hospital Incident Command System. With this type of organizational infrastructure and the flexibility to expand and to collapse functions as needed, an orderly and efficient response to any incident can be accomplished. Because hospitals cannot anticipate every contingency, a system such as the Hospital Incident Command System assists with planned improvisation. The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations) standards require use of an incident management system in health care facilities.

Organization of the Out-of-Hospital Disaster Scene

The disaster site is organized into several distinct areas. The command post is the nerve center of the operation and contains the incident commander and section chiefs. A staging area for incoming personnel and equipment should be established on the outer perimeter. If air evacuation is needed, a safe landing zone must be identified. A casualty collection point and morgue should be designated. In conjunction with an incident command system, this structure brings order to the response.

Comprehensive Emergency Management

The comprehensive emergency management all-hazard approach to disaster preparedness has been a Joint Commission requirement since January 2001. Comprehensive emergency management consists of four phases: mitigation, preparedness, response, and recovery.29,30 Mitigation involves taking actions to reduce the impact of identified hazards. Training, drills, and cataloging of resources are examples of preparedness activities. Response includes assessment of the situation and coordination of resources. Finally, recovery consists of a return to normal operations and debriefing to critique the response and to provide long-term psychological support to the victims and rescuers.

As required by the Joint Commission, a hospital’s disaster or “emergency management” plan must address events that occur both inside (internal) and outside (external) the institution.³⁰ Because some incidents affect both internal and external operations, a hospital emergency management program should contain plans that address all circumstances.

Hospital Disaster Response Plan

A disaster event can disrupt daily, routine hospital functions. This can represent an infrastructure failure (e.g., loss of electric power and water) or a threat to the safety of patients and hospital personnel (e.g., labor dispute or approaching hurricane). Because the response varies from postponement of elective surgery to facility evacuation, every hospital department must participate in the planning process. At a minimum, the disaster plan should clearly delineate the circumstances in which the plan is activated; identify the command structure with defined lines of authority and responsibility; describe a response strategy for each anticipated incident; estimate an incident’s impact on safety and hospital function, providing for evacuation if necessary; and list essential information, such as critical telephone numbers (e.g., elevators, key personnel, and pay telephones), community agencies (emergency medical services, police, and public health), and sources of vital supplies (water, oxygen, and drugs).²⁹

After plan activation, the primary role of the emergency department is to assess and to treat individuals with illness or injury. In the absence of casualties, other hospital departments primarily manage disasters that disrupt hospital operations. Nevertheless, the medical director of the emergency department should continuously monitor the response process.

In the unlikely event that evacuation of the emergency department is necessary, evacuation routes and relocation destinations that have been planned in advance maximize safety and efficiency. When resources are plentiful, emergency department patients in critical condition are assigned the highest priority for evacuation and transport. Less ill patients receive a lower priority.³¹ When resources are limited (e.g., in the event of a large-magnitude earthquake), the reverse strategy applies. The least critically ill patients receive the highest priority for evacuation.

Another scenario would be an event occurring in the community that results in a sudden influx of patients requiring emergency care at hospitals. This type of incident has no direct impact on hospital capacity or function. However, the need to rapidly increase surge capacity may require implementation of different patient management strategies (i.e., temporary creation of alternate care sites on hospital grounds). Participation in the planning and execution of the hospital disaster response is an important administrative responsibility.¹⁶ Available data guiding development of disaster strategies are incomplete, but an effective disaster response can be created by reviewing the essential components of disaster plans and the previous experience of hospitals.^16,29,31,32 A member of the emergency department must have a leadership role in the planning and implementation of the disaster plans.

Basic Components of a Hospital Comprehensive Disaster Response Planning Process

Focal Disasters

Most disasters experienced by hospitals are focal in nature. Hospital function is typically unimpaired. The majority of problems encountered are related to a sudden increase in patient volume and acuity or arrival of patients with illnesses not usually treated at that facility (e.g., burns, radiation exposure, and severe acute respiratory syndrome).

Hospitals frequently experience difficulty in effectively using and interfacing with community resources. Field triage should allocate patients rationally, and transfer agreements must be in place to facilitate interhospital movement of patients and evacuation of patients to alternate care sites.

Media access must be controlled. During the Loma Prieta earthquake in 1989, a news helicopter occupied a nearby community hospital’s only landing zone, preventing the possibility of landing a medical helicopter.

Redundant communication systems must be in place. Typical backup systems to the telephone are radios and cellular phones, but the frequencies can be overloaded in both systems. Use of cellular phones for text communication may offer another solution. Two-way radios are reliable and should be part of the communications network. Satellite phones are also an option.

Catastrophic Disasters

In a large-scale disaster, paramedics may be unavailable to assist in patient transfers or hospital evacuations. Disaster medical assistance teams and urban search and rescue teams will deploy, but their time to arrival on scene may be variable. Each individual hospital may have to remain self-sufficient for 48 to 72 hours or longer.⁴² Generator problems are frequent; they either fail altogether (as they did during the Loma Prieta earthquake) or supply insufficient power to meet emergency needs (as during the Northridge earthquake). Evacuation plans must not require elevators for this reason. Telephone service will cease as lines are disrupted or deliberately restricted by the phone company. Cellular phones may function within a local area, but failure is likely if more distant sites within the city are dialed. Hospital radios designated for disaster use should have the hardware secured to prevent earthquake damage.

Under catastrophic conditions, mobilization of personnel is more difficult. Because telephone communication is unreliable, at least one additional system to contact personnel at home should be in place. An alternative is to institute an automatic response system, in which personnel report to the hospital or another location when communications are impaired.

After earthquakes or explosions, immediate access to structural engineers is important. In the Northridge earthquake, eight hospitals in the Los Angeles area sustained enough damage to force evacuation of at least one patient. Four institutions completely evacuated their facilities in the first 24 hours, including two hospitals that met the most current structural earthquake standards. Further structural damage was subsequently identified, and two additional hospitals were forced to evacuate completely in the next 2 weeks. Ultimately, four of these hospitals were permanently closed and demolished.³¹

Hospitals are also vulnerable to hurricanes. In a study of hurricane Rita’s (2005) impact on regional hospitals in Texas and Louisiana, seven hospitals were forced to evacuate patients.³² Significant problems included prolonged loss of power, potable water, and staff. It was also difficult to obtain vehicles for transportation of patients to other facilities. Nonmedical vehicles were sometimes used to evacuate stable patients.

Catastrophic earthquakes can cause extensive casualties, including large numbers of patients with crush syndrome and lacerations. Up to 90% of victims with serious but survivable injuries are rescued by local responders and volunteer citizens in the first 24 to 48 hours. Therefore, special medical teams, such as disaster medical assistance teams and urban search and rescue teams, may not significantly affect survival from acute injuries if they arrive after more than 48 to 72 hours. If hospitals are not functional and no backup plan exists, immediate advanced medical care will not be available, and many people will die. Therefore, planners should include a backup system to provide medical care at alternate nonhospital care sites.

Toxic Disasters (Hazardous Material)

Hospitals in the vicinity of major chemical industries, transportation corridors, or probable terrorist targets (e.g., major theme parks or nationally symbolic buildings) should be aware of potential hazards from incidents involving chemical and radioactive substances and be prepared to decontaminate large numbers of individuals exposed to these hazardous substances. Effective decontamination of victims and the need for safety measures on the part of rescue personnel to prevent secondary contamination are critical.⁴⁴ Decontamination equipment should be stored near the emergency department, and the staff must be trained in its use. This location must be known to personnel.⁴⁵ When such an emergency occurs, there is little time to search the hospital for the necessary supplies.

Ideally, patients contaminated with hazardous chemicals should first be brought to a designated decontamination area containing a warm-water shower with a container to hold drainage water. Victims should remove all clothing. Clothing and valuables are bagged, tagged, and stored. Contaminated patients must never be brought into regular patient care areas because of the danger of contaminating other patients, hospital staff, and equipment. In 1994, paramedics unsuspectingly transported a patient contaminated with a degradation product of dimethyl sulfoxide to an emergency department in Riverside, California. Before the presence of the hazardous material was detected, six health care workers were exposed, including an emergency physician. The emergency physician experienced a near-fatal exposure and required intubation and an extensive stay in the hospital’s intensive care unit. Uncontrolled spread of the toxin resulted in evacuation and temporary closure of the emergency department.⁴⁶

The emergency department must close off the air intake vents in rooms containing contaminated patients so toxic products do not enter the ventilation system and circulate to other areas of the hospital. Rescue personnel and hospital staff should be protected by gowns, gloves, and masks and, if necessary, supplied air respirators. The goals are to reduce the initial level of external contamination, to contain the contamination that remains, and to prevent further spread of these potentially dangerous substances to other patients and staff members (secondary contamination).

Department of Homeland Security

The Department of Homeland Security (DHS), a cabinet-level department formed after the terrorist attacks of September 11, 2001, is the federal government’s lead organization for emergency management activities in the United States. The Federal Emergency Management Agency (FEMA) was incorporated into DHS and retained its name. DHS has a coordinating responsibility for the entire spectrum of disasters irrespective of their size or etiology. DHS assists state and local organizations to mitigate, to prepare for, to respond to, and to recover from emergencies and is a source of funding for these endeavors. In 2003, the President directed that the DHS develop a National Incident Management System and a National Response Plan. Existing federal plans, including the National Response Plan, were then incorporated into the National Response Framework. The National Response Framework includes 15 Emergency Support Functions (ESFs.) Each has a primary (lead) federal agency and many supporting agencies. ESF #8 is entitled Public Health and Medical Services and is of key importance to the health care community. The primary agency is the Department of Health and Human Services (DHHS). Examples of functions within ESF #8 include coordination of health care personnel, supplies, pharmaceuticals, surveillance and reporting, and mass fatality management.

Urban Search and Rescue (ESF #9 of the National Response Framework)

When a building collapses because of an earthquake, terrorist bombing, structural failure, or other reason, various challenges confront rescue and medical personnel.⁴⁹ Some victims require field amputations to facilitate extrication,⁴⁹ and use of urban search and rescue teams and effective emergency medical care may improve the outcomes of such lifesaving efforts. This national system of multidisciplinary task forces is designed for rapid deployment to the sites of collapsed structures.⁵⁰ The medical team’s responsibilities include caring for task force members, victims recovered by search and rescue activities, and the search team’s dogs. There are also WMD urban search and rescue teams trained by FEMA to respond to nuclear, biologic, and chemical terrorist attacks.

Department of Health and Human Services

On December 19, 2006, the President signed the Pandemic and All-Hazards Preparedness Act (S. 3678) into law and created a new position, the Assistant Secretary for Preparedness and Response (ASPR), within the DHHS. The office of the ASPR oversees the department’s responsibilities for emergency preparedness and response activities, including the National Disaster Medical System (NDMS) and the Hospital Preparedness Cooperative Agreement Program, the coordination of the Medical Reserve Corps, the ESAR-VHP, the Strategic National Stockpile, and the Cities Readiness Initiative.

National Disaster Medical System

The NDMS is a federally coordinated initiative designed to augment the emergency medical response capability of the United States in the event of a catastrophic disaster. This system is a cooperative program of four agencies in the federal government: the Department of Defense, the DHHS, the DHS, and the Department of Veterans Affairs (VA). Although oversight of the NDMS has moved between federal departments, the DHHS currently has the lead for the NDMS. The NDMS provides an interstate medical mutual aid system linking the federal government, state and local agencies, and private sector institutions to address the medical needs of victims of catastrophic disasters. Its medical response element includes dozens of volunteer civilian disaster medical assistance teams that supplement the local medical infrastructure.

In a disaster, the NDMS is activated when state resources are overwhelmed and the governor makes a request for federal assistance. The disaster medical assistance teams must meet specific NDMS standards. Throughout the NDMS, emergency physicians are taking key roles in defining training standards, the deployment of clinical services, and the administration of field operations and in developing the concept of a civilian-federal disaster response capacity during national emergencies.

Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC), based in Atlanta, is a U.S. federal agency under the DHHS. Its major responsibilities include preparing for and responding to public health emergencies (e.g., disasters) and conducting investigations into the health effects and medical consequences of these events. The major aims of CDC researchers are to assess the risks of death and injury and to develop strategies to prevent or to mitigate the impact of future disasters. Other responsibilities of CDC staff in the area of emergency preparedness and response include rapid assessment of the health and medical needs of disaster victims in the immediate postdisaster period; development and maintenance of national systems for acute environmental hazard surveillance; and provision of epidemiologic, sanitary, laboratory, and other relevant scientific support services to agencies involved in disaster planning and response.

Metropolitan Medical Response System

Metropolitan Medical Strike Teams (MMSTs) are highly trained, readily deployable, and fully equipped groups of medical, fire, and rescue professionals. As a component of the larger Metropolitan Medical Response System (MMRS), they support other local personnel in treating the victims of a chemical, biologic, or nuclear attack. In 2008 the MMRS expanded to include 124 participating jurisdictions. Although composed of local personnel, MMSTs are under the direction of the DHS. Their goal is to enhance local planning and response capability. However, hospital and community planners must still create an independent response because MMSTs require 90 minutes or longer to deploy.⁵¹ MMSTs are equipped with chemical agent monitoring devices, protective equipment, and pharmaceutical supplies.

Department of Veterans Affairs

The VA has not traditionally been regarded as a disaster response entity. However, one of the VA’s four legally mandated missions is emergency management. A unique feature of the VA is that its facilities and personnel are situated nationwide, and these are used to support federal health and medical assistance to state and local governments during disasters. The VA has highly trained specialty personnel who can support disaster medical activities. In addition to the vast pool of human resources, the VA provides large amounts of the pharmaceuticals and expendable supplies for on-site disaster support. For example, the VA purchases the contents of the CDC’s Strategic National Stockpile. VA support is coordinated through the DHS and DHHS, as the lead federal agency for health and medical response. In addition to the VA’s role in the federal response to disasters, as the largest integrated health care system in the nation, it has a well-developed hospital emergency management program. The VA Emergency Management Program Guidebook is an open-source reference that provides up-to-date information on emergency management concepts and various templates for emergency operations plans and hazard vulnerability assessment tools for hospitals.⁵²

Department of Defense

On April 17, 2002, Secretary of Defense Donald Rumsfeld announced the formation of the Northern Command, or NorthCom, to assume responsibility over all military forces that operate within the United States in response to external threats and in support of civil authorities. The stated purpose of NorthCom is to assist the Department of Defense to better deal with natural disasters, attacks on U.S. soil, or other civil difficulties. It will provide for a more coordinated military support to civil authorities, such as the Federal Bureau of Investigation (FBI), FEMA, and state and local governments. Another important asset at the state level is the National Guard. The governor has authority to activate the National Guard for its disaster response and recovery missions.

1. Waeckerle, JF, et al. Executive summary: Developing objectives, content, and competencies for the training of emergency medical technicians, emergency physicians, and emergency nurses to care for casualties resulting from nuclear, biological, or chemical (NBC) incidents. Ann Emerg Med. 2001;37:587.

2. American College of Emergency Physicians. Clinical Policies: Disaster Medical Services. www.acep.org/disaster, October 2006.

3. Kaji, AH, Koenig, KL, Lewis, RJ. Current hospital disaster preparedness. JAMA. 2007;298:2188.

4. Kaji, A, Koenig, KL, Bey, T. Surge capacity for healthcare systems: A conceptual framework. Acad Emerg Med. 2006;13:1157.

5. Barbisch, D, Koenig, KL. Understanding surge capacity: Essential elements. Acad Emerg Med. 2006;13:1098.

6. California Department of Public Health. Standards and Guidelines for Healthcare Surge During Emergencies. www.bepreparedcalifornia.ca.gov.

7. Barbisch, D, Haik, J, Tessone, A, Hanfling, D. Surge capacity. In: Koenig KL, Schultz CH, eds. Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices. New York: Cambridge University Press, 2010.

8. Koenig, KL, Dinerman, N, Kuehl, AE. Disaster nomenclature: A functional impact approach: The PICE system. Acad Emerg Med. 1996;3:723.

9. Nocera, A. Australian major incident nomenclature: It may be a “disaster” but in an “emergency” it is just a mess. Aust N Z J Surg. 2001;71:162.

10. Burkle, FM. Integrating international responses to complex emergencies, unconventional war, and terrorism. Crit Care Med. 2005;33:S7.

11. Auf der Heide, E, Resource management, Disaster Response: Principles of Preparation and Coordination. Mosby: St. Louis, 1989. http://orgmail2.coe-dmha.org/dr/DisasterResponse.nsf/section/31219255A624812F0A25691A00671909?opendocument&home=flash.

12. Department of Health and Human Services. Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large Scale Emergencies. Washington, DC: Department of Health and Human Services; 2004.

13. Cone, DC, Koenig, KL. Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emerg Med. 2003;12:287.

14. Garner, A, Lee, A, Harrison, K, Schultz, CH. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001;38:541.

15. Kahn, CA, Lerner, EB, Cone, DC. Triage. In: Koenig KL, Schultz CH, eds. Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices. New York: Cambridge University Press, 2010.

16. Waeckerle, JF. Disaster planning and response. N Engl J Med. 1991;324:815.

17. Critical Illness and Trauma Foundation, START: Simple Triage and Rapid Treatment. Newport Beach, Calif:Critical Illness and Trauma Foundation, Newport Beach Fire Department; 2001. www.citmt.org/start/default.htm.

18. Wallis, LA, Carley, S. Comparison of pediatric major incident primary triage tools. Emerg Med J. 2006;23:475–478.

19. Romig, LE. The JumpSTART Pediatric MCI Triage Tool. www.jumpstarttriage.com.

20. Sanddal, TL, Loyacono, T, Sanddal, ND. Effect of JumpSTART training on immediate and short-term pediatric triage. Pediatr Emerg Care. 2004;20:749.

21. Kahn, CA, Schultz, CH, Miller, KT, Anderson, CL. Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med. 2009;54:424–430.

22. Lerner, EB, et al. Mass casualty triage: An evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(Suppl 1):S25–S34.

23. Benson, M, Koenig, KL, Schultz, CH. Disaster triage: START then SAVE—a new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med. 1996;11:117.

24. Burkle, FM. Population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster. Acad Emerg Med. 2006;13:1118.

25. Phillips, BD. Special needs populations. In: Koenig KL, Schultz CH, eds. Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices. New York: Cambridge University Press, 2010.

26. National Commission on Children and Disasters. 2010 Report to the President and Congress. Rockville, Md: Agency for Healthcare Research and Quality; October 2010.

27. Emergency Management Institute, IS-100.b: Introduction to Incident Command System, ICS-100. Emmitsburg, Md:Emergency Management Institute, Federal Emergency Management Agency; 2010. http://training.fema.gov/EMIWeb/IS/IS100b.asp.

28. U.S. Department of Homeland Security, National Response Framework. Washington, DC:Department of Homeland Security; 2008. www.fema.gov/pdf/emergency/nrf/nrf-core.pdf.

29. Schultz, CH, Mothershead, JL, Field, M. Bioterrorism preparedness I: The emergency department and hospital. Emerg Med Clin North Am. 2002;20:437.

30. Joint Commission. Comprehensive Accreditation Manual for Hospitals. Oak Brook Terrace, Ill: Joint Commission; 2007.

31. Schultz, CH, Koenig, KL, Lewis, RJ. Implications of hospital evacuation after the Northridge, California, earthquake. N Engl J Med. 2003;348:1349.

32. Andress, K, Downey, E, Schultz, CH. Implications of hospital evacuation after hurricane Rita [abstract]. Acad Emerg Med. 2007;14(Suppl 1):S190.

33. Hoyle, JD. Healthcare facility disaster management. In: Koenig KL, Schultz CH, eds. Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices. New York: Cambridge University Press, 2010.

34. California Emergency Medical Services Authority, Hospital Incident Command System. Sacramento, Calif:Emergency Medical Services Authority; 2006. www.emsa.ca.gov/hics.

35. Schultz, CH, Koenig, KL. State of research in high-consequence hospital surge capacity. Acad Emerg Med. 2006;13:1153.

36. Superfund Amendments and Reauthorization Act of 1986 (SARA), Title III, Section 305(a), Emergency Training; Homeland Security Act of 2002, Codified in 6 U.S. Code, Public Law 107-296. www.fema.gov/government/grant/sara.shtm.

37. Reynolds, BS, Shenhar, G. Crisis and emergency risk communication. In: Koenig KL, Schultz CH, eds. Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices. New York: Cambridge University Press, 2010.

38. Keim, ME, Noji, E. Emergent use of social media: A new age of opportunity for disaster resilience. Am J Disaster Med. 2011;6:47–54.

39. Cone, DC, Weir, SD, Bogucki, S. Convergent volunteerism. Ann Emerg Med. 2003;41:457.

40. Schultz, CH, Stratton, SJ. Improving hospital surge capacity: A new concept for emergency credentialing of volunteers. Ann Emerg Med. 2007;49:602.

41. Kaji, AH, Langford, V, Lewis, RJ. Assessing hospital disaster preparedness: A comparison of an on-site survey, directly observed drill performance, and video analysis of teamwork. Ann Emerg Med. 2008;52:195–201.

42. Schultz, CH, Koenig, KL, Noji, EK. A medical disaster response to reduce immediate mortality following an earthquake. N Engl J Med. 1996;334:438.

43. Kazzi, AA, et al. Earthquake epidemiology: The 1994 Los Angeles earthquake emergency department experience at a community hospital. Prehosp Disaster Med. 2000;15:12.

44. Koenig, KL, et al. Healthcare facility–based decontamination of victims exposed to chemical, biological, and radiological material. Am J Emerg Med. 2008;26:71.

45. Koenig, KL, et al. Health care facilities’ “war on terrorism”: A deliberate process for recommending personal protective equipment. Am J Emerg Med. 2007;25:185.

46. Koenig, KL. Strip and shower: The duck and cover for the 21st century. Ann Emerg Med. 2003;42:391.

47. Oster, NS, Doyle, CJ. Critical incident stress. In: Hogan DE, Burstein JL, eds. Disaster Medicine. Philadelphia: Lippincott Williams & Wilkins; 2007:30–37.

48. Schreiber, M, et al. PsySTART Rapid Disaster Mental Health Triage System: Performance during a full scale terrorism exercise in Los Angeles County hospitals [abstract]. Acad Emerg Med. 2011;18:S26.

49. Schultz, CH, Koenig, KL. Preventing crush syndrome: Assisting with field amputation and fasciotomy. J Emerg Med Services. 1997;22:30.

50. Better, OS, Stein, JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med. 1990;322:825.

51. Institute of Medicine and National Research Council. Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response. Washington, DC: National Academy Press; 1999.

52. U.S. Department of Veterans Affairs, Emergency Management Strategic Health Care Group. 2008 Emergency Management Program Guidebook. www1.va.gov/emshg/page.cfm?pg=114.

53. European Master in Disaster Medicine. http://www.dismedmaster.com.