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Traditionally disasters are divided
into “natural” and “man made”.
However the pressures on the
poor to live in earthquake and
flood prone areas and the power
of the rich to protect themselves
suggests to many that all disasters
are ultimately man made. In 1988
an earthquake in Armenia killed
more than 25000 people. One
year later an earthquake of similar
magnitude struck California USA
and killed 300 and this number
only because building regulations
had been illegally ignored.

The vulnerability of the affected
population can contribute as much
to the disaster as the triggering
event and poverty constitutes the
greatest vulnerability. This also
compounds the other
vulnerabilities associated with
poverty - environmental
degradation, poor land use and
rapid population growth. The
death rate from disaster is six
times higher in richer than in
poorer countries and not
surprisingly therefore more than
90% of victims of “natural” disaster
in the latter part of this century
lived in Asia and Africa.

A disaster may be referred to as
“simple” where the infrastructure
remains intact and “complex”
where resources have been
compromised. In some countries
of course resources are always
compromised and any disaster is
complex. Events may also be
described as “compound” which is
another term for “complex”. Of
more obvious meaning and
therefore of more use is the use of
the terms “compensated” and
“uncompensated”. These
descriptions may describe the
whole of the event or more
commonly a phase within the
event. It is important to recognize
that whilst many disasters are
characterized by an initial
overloading of the local services
some events may be
compensated for in the short term
but a system decompensate later,
and often when wider attention for
the incident has moved on.

Key points

• It may be that all
disasters are ultimately
man made

• A disaster may be
referred to as “simple”
where the infrastructure
remains intact and
“complex” where
resources have been

The overwhelming of local
resources will trigger the need for
triage. Three or four multiply
injured patients presenting to a
small rural emergency department
may overwhelm available
resources, at least for a while. A
single critically ill or injured patient
will overwhelm an under prepared
department. A very large number
of patients with relatively minor
conditions will overwhelm the best

Whether an incident tips over into
a disaster rests in the balance
between the size of the event
measured in the number and/or
complexity of casualties and the
ability of the
doctor/institution/region/nation to
respond adequately. The latter will
be determined by their training,
preparedness and pre-existing
and residual resources. It is the
failure to respond adequately and
to be overwhelmed that
characterizes a disaster.

Major incidents
This term is generally used for
those events that could potentially
threaten an institution but are
compensated for without
collapsing into a disaster.

A number of definitions are in use.
A major incident is any emergency
that requires the implementation
of special arrangements by one or
more of the emergency services
health service or local authority. It
may also be defined as an
incident where the number,
severity or type of live casualties
or its location, requires
extraordinary resources. However
even events involving large
numbers of dead and especially
when there are no survivors at all
can still represent a very special
and often very difficult major
incident and in the public's mind
may be the very worst kind. It may
also be defined as any occurrence
that presents a serious threat to
the health of the community,
disruption to the service or causes
such numbers or types of
causalities as to require special
arrangements to be implemented
by hospitals, ambulance services
or health authorities. Common to
all definitions is the concept of a
very unusual event that requires
an extraordinary response. Not all
major incidents involve trauma.
Chemical and nuclear accidents
create major incidents of often
huge proportions but do not
usually require the input of a
surgeon. Some involve the
services of specialist surgeons for
example when there are a large
number of burns.

Key points

• Major incident - this term
is generally used for
those events that could
potentially threaten an
institution but are
compensated for without
collapsing into a disaster.

Prepare practice and have a plan

The response to a single critically
injured patient probably
represents an institution’s best
response to a stressful event.
Major incidents can be seen as
progressively larger versions of
this scenario. As performance is
unlikely to get better in a major
incident, an institution has a daily
reminder of its best response to a
major incident in its response to a
major trauma. The range of
injuries and problems that occur
simultaneously in a severely
injured patient require the co-
ordinated response of a multi
disciplinary team who have been
trained and appropriately
equipped. So it is for a major
incident, albeit in a more complex
setting. As the number of
casualties grows, so must the
response, expanding to involve
the whole of the hospital and at
times neighbouring institutions. In
the largest of catastrophes
national and even international
assistance may be required. The
principles throughout remain the
same however with senior staff
supervizing the work of others,
agencies continuously
communicating with each other
and casualties being repeatedly
triaged as the evolving incident
changes their priority for treatment
within the overall scheme of
things. To have any chance of
getting a major incident right you
must first get a major trauma right.

In planning for major incidents
many authors and institutions plan
their response on the number of
“minor” and "major" casualties
they could cope with. However a
word of caution. Until a patient has
been assessed and examined the
severity of their injury may not be
fully appreciated and a large
number of patients of any severity
all arriving at once will place
considerable strain on even the
best of emergency departments.
In fact a hospital’s capacity for
treating severe casualties will be
limited by the number of ICU beds
available at that time or that can
be vacated or staffed within a very
short time.

Planning must prepare doctors
and institutions to co-operate and
not compete. A realistic
appreciation of the capacity to
cope will allow early and safe
onward transfer of casualties and
as wide a distribution as possible.
Critically, if inappropriate over
triage of patients to one institution
has occurred, staff at that
institution must recognize the
need to transfer on whenever

A trauma system that usually
directs severely injured patients
past smaller hospitals towards a
specialist trauma centre must not
be misused to direct all patients to
the centre in a major incident. All
the hospitals within the system
must share the burden of the
response but with the trauma
centre taking special responsibility
for those with the most complex

Key points

• The response to a single
critically injured patient
probably represents an
institution’s best
response to a stressful

• Until a patient has been
assessed and examined
the severity of their injury
may not be fully
appreciated and a large
number of patients of any
severity all arriving at
once will place
considerable strain on
even the best of
emergency departments.

Plans must be discussed and
agreed within the emergency
department then outwards from
there. Each department in the
hospital must sign up to them with
staff understanding their
responsibility to be familiar with
and up to date with plans for a
major incident. Procedures should
be discussed and agreed with all
relevant external agencies with
the ambulance service playing an
integral part at every stage .

Plans must be based on the
familiar. Plans that involve staff
moving their activities to another
location, however nearby, will
inevitably create unnecessary
tensions and confusion or be
ignored – adding further to the

Staff should work in areas and
roles with which they are most
familiar. When distressed we all
gain comfort from the familiar and
a major incident is not the time to
learn new skills.

A comprehensive major incident
plan should be available to all
departments and staff required to
read it before taking up their
appointment and at least yearly
thereafter. The plan should identify
roles not individual personalities
who may be unavailable on the
day of the incident. Who might fill
these roles can of course be
indicated but the most important
function of the plan is to identify
the key roles that must be filled by
those available. As people more
appropriate to a specific role
become available they can take-
over and the plan must illustrate
and emphasise the need for

Each member of staff should be
given action card for their role in a
major incident and a full file of
action cards be available in the
A&E department at all times.

Training for major incidents can
take several forms but should
involve all staff at least at some

The simplest and most repeated
exercise should be a
communications exercise whereby
staff are called unannounced to
establish the likely strength of the
immediate response on any given
occasion. If carried out about once
a year it will remind staff to stay in
touch with the hospital when on

Key members of staff can engage
in a table top exercise with
members of the emergency
services and other potentially
receiving hospitals. This helps
establish how patients might be
distributed across a region.

Individual departments can run
through their procedures and
“walk through” patients to
familiarize themselves with the
dynamics of patient through put
and where they will be working
come the event..

Every five years or so an
institution should look to holding a
full scale practice. If carried out
not too frequently but involving all
staff it can quickly highlight the
strengths and weaknesses of
current arrangements and remove
some of the mystery that often
surrounds these events.
Those who may potentially be
involved in on site care should
look to exercising regularly with
the emergency services to ensure
they have some experience of the
realities of working out of doors
and in difficult circumstances.
In the UK there is a major incident
medical management and support
course (MIMMS) which all doctors
who might be involved in a major
incident at a senior level should

It is important that such
extraordinary events are
concluded with an occasion for all
those involved to have an
opportunity to relate their
contribution and learn from the
contributions of others. In this way
the collective knowledge of the
institution grows and individuals
are made to feel a part of the
overall effort. All staff should be
thanked by those in charge. It is
also an opportunity to identify
those who may have been
psychologically traumatized by the

Psychological support should be
offered confidentially to all those
involved but in practice
psychological sequelae will be
minimized if staff are adequately
trained and equipped, put to work
in areas appropriate to their skills
and tasked to a level appropriate
to their training and qualifications.
The alert procedure

This is usually activated by the
ambulance service but may be
instigated by the police. At times
the unheralded flood of patients
into the emergency department
causes the hospital itself to
declare a major incident. It is
important that an incident is
formally declared as failure to so
do even in the face of the obvious
will lead to confusion and
unnecessary delay in mobilizing
further resources. It is better to
declare an incident and stand
down than to begin mobilizing
resources too late.
In the UK the standard format is
as follows –

Major incident standby.
Major incident declared - activate
Major incident cancelled – stand
Major incident – casualty
evacuation complete.

Pre hospital

Hospitals must be prepared to
provide support to the emergency
services at the scene of an
incident. Those likely to be
required must be adequately
trained and equipped for the
event. The delivery of safe and
appropriate medical care in the
pre hospital setting is increasingly
recognized as a speciality in its
own right. Training courses are
available in the UK with specialist
examinations in immediate
medical care held by the Royal
College of Surgeons of Edinburgh
(DipIMC RCSEd) and a diploma in
the medical care of catastrophes
from the Society of Apothecaries
of London (DMCC).

An essential component of safe
and effective pre hospital medical
care is a recognition of the place
of doctors in the overall scheme of
things. In large-scale disasters,
safety, shelter food and water will
take priority over medicine. In
lesser events safety and rescue
will still take priority. Doctors must
truly appreciate that they are part
of a team and a team of which
they are unlikely to be the overall

There are recognized tiers of
command during a major incident.

Bronze is operational and
describes the medical teams
involved with the on site care of
casualties or the hands on care of
patients in the hospital.

Silver is tactical and refers to the
on site incident officers who
control activity at the scene and
the triage officers at the hospital.

Gold is strategic and describes
medical directors of the
ambulance service and hospitals.
The emergency services will
establish inner and outer cordons
at the scene. The outer will
exclude all but official personnel
and the inner circumscribe the
rescue area itself

Medical Incident Officer (MIO)

The most senior doctor at the
scene will be designated the
Medical Incident Officer. Their task
is to carry out triage of the
casualties in association with the
most senior ambulance officer –
the Ambulance Incident Officer. At
the scene the police and
sometimes the army will be in
overall charge. On arrival the MIO
will locate the command and
control centre and report to the
police officer in charge. The MIO
needs to wear highly visible and
fire resistant clothing including a
helmet. He/she will be clearly
labelled as a doctor and at all
times carry and show on demand
a recognized official ID.

In the UK, the Ambulance service
are in charge of the on scene
medical response. The MIO must
quickly report to and stick with the
Ambulance incident officer and as
a team they will supervise and
direct the despatch of casualties.
They will decide in which order
they will leave the incident and to
which hospital they will be taken.
This latter function is as important
as the former. It is imperative that
a balance is struck between
despatching the patient to the
most appropriate hospital for their
needs and not dangerously
overloading one or more
institutions. These decisions are
made jointly between the
ambulance and medical incident

It is the duty of the ambulance
service in the UK to provide
communications facilities for the
medical team but an appropriately
equipped and trained team will
already have their own.

The ambulance service will
establish a casualty clearing
station where the medical team
will be based and carry out triage.

The Fire service is in charge of the
rescue. In addition it is their
responsibility to establish
decontamination facilities. Medical
staff must only enter buildings etc
after receiving clear and recent
permission from the fire service to
so do. Equally the fire service will
decide who is contaminated and
when they are decontaminated.

In addition to performing triage the
MIO will supervise the mobile
medical team(s) and communicate
regularly with all the receiving
Fig. 3.2 Equipment

Protective clothing inc. hard hat, gloves and eye

protection (a, b, c)

Tabards (d)
Notepaper and/or pocket Dictaphone (e)

Radio (f)

Triage labels (g)

Medical bag (h)


The mobile medical team

Ideally this will be drawn from supporting and not receiving hospitals.
The members of these teams should be identified beforehand to allow
for appropriate training. They should be familiar with the equipment they
will be carrying and wear full safety clothing including a helmet.

Key points

• Ideally this will be drawn from supporting and not receiving

The hospital response

In overall medical control of the incident will be a senior doctor, not
themselves involved in treatment or triage. This will usually be the
medical director of the institution or their deputy. Someone must
assume this role until a designated person arrives. Alongside the chief
executive of the institution and the director of nursing they will take their
place in the designated control room. They will liase closely with the
police and triage officers. A member of the administrative staff must be
tasked very early on to deal with the media who should be kept
informed by regular and punctual briefing sessions and well away form
the treatment areas.

The immediate response to a major incident will involve those staff
already in the building and rostered to be on call. The calling in of
additional staff should be controlled and the plan should clearly indicate
where they rendezvous. To avoid crowding out the emergency
department this should be a designated place near to but separate from
where the casualties arrive. Arriving staff should be registered and
provided with a tabard that identifies their grade and speciality and
given special documentation packs. These should contain a unique set
of pre numbered notes and pathology request forms. This will allow for
a rapid register of the patients even without names. Included in the
pack is a property bag again pre numbered.

When preparing staff for a major incident it should be emphasised that
staff all ready on duty or on call are likely to cope initially and that
additional help will be required some hours later and certainly by the
next day. The excitement of wishing to be involved at the start should
be tempered by a sense of responsibility to supporting the longer term
needs of the victims.

The hospital switchboard is the most important area in a major incident
and staff must protect it. If an incident has occurred and you are off the
premises don’t ring in to the switch board. Ideally wait by the number
you have already given to the switchboard for such an emergency. Staff
already in the building should by pass the switchboard whenever
possible by using direct dial facilities or commandeering pay phones –
which can be converted to direct dial in an emergency by prior
arrangement with the phone company.
Individual departments can assist by arranging their own cascade
system for call out. An initial call from the department initiates a further
cascade of calls from the recipient and so in. The use of pagers can
further relieve the burden on the telephone switchboard. Internal
communication can be greatly facilitated by the use of “runners” and is
a good use of non qualified volunteers.

Mobile phones are potentially of great use but the local cell can quickly
become blocked with the weight of traffic. The media in particular
dominate their use and will ring their news desk then keep the line open
for as long as possible to protect their own access to the cell. This
problem can be overcome by initiating “access overload”. Recognized
agencies can gain prior approval from the government and confidential
access code words to limit access to the local cell(s) to certain
approved mobile numbers.
All routine work must stop as soon as an incident is declared. Urgent
consideration should be given to the transfer of patients to other
institutions to make room for the reception of casualties. With modern
transport facilities one's imagination must stretch to considering
securing the assistance of institutions far away from ones own. At all
costs one must resist the temptation to see the event as special only to
you and one in which you’ll cope at all costs. In developed countries
there is often little need to compromise the care of patients in this way,
even in the face of a major incident, if one involves all the resources in
an area and sometimes in a country. Furthermore whilst the initial
reception of casualties may last a few hours their ongoing surgical
management may consume the human and physical resources of a
hospital for months.

Co-incidental emergencies unrelated to the major incident may still
present to the hospital usually unannounced. These have to be
absorbed into the triage process regulating the wider incident and take
their place in the overall priorities identified by the triage officers.

Key points

• All routine work must stop as soon as an incident is declared

Chief triage officer

This will usually be the consultant/specialist in charge of the Emergency
department or the most senior doctor in the department until he/she
arrives. A guiding principle throughout disaster management is to avoid
precious commodities such as senior experienced personal being
captured by and therefore lost to a single patient. Rather such people
should stand back a little and prioritize the casualties and supervise and
direct the work of the less experienced. The chief triage officer places
themselves at the door of the emergency department and all casualties
will pass before them. By applying a quick triage sieve casualties will be
divided into categories 1,2,and 3. Category 3 will be directed away from
the main treatment areas to a designated minor area. Category 1 will go
into the resuscitation bay and category 2 into the major treatment
areas. The senior doctor in each of these areas will perform further
triage to identify further priorities within patient groups or within
treatment needs for an individual patient.

Staff will be organized into teams assigned to individual patients and
given clear instructions by a designated team leader.

All staff should wear large clear tabards that identify their grade and
speciality. In the confusion of a major incident it is important that senior
doctors know at first glance the resources available to them and do not
over task the less experienced. It also acts as an extra protection
against the unwelcome intrusion of the media.

Surgical triage officer

Once patients that might require surgery have been identified by the
emergency department staff they will be referred to the surgical triage
officer. Again this should be a designated senior member of staff.
Rather than operate themselves the surgical triage officer will identify
the type and limitations of surgery to be carried out and the order in
which patients are to be treated.


• To do the most for the most

• A job for the most senior person available

• Is to be done quickly but repeated continuously

It will be done first where the casualty is found, repeated on scene at
the casualty clearing station, repeated when the casualties are
despatched, carried out on arrival at the receiving hospital, repeated
prior to surgery or other treatment and continuously updated until the
patient is removed, discharged or dies.

From the French verb trier meaning to sort, the word is used to describe
the process whereby casualties are sorted into priorities. This process
is an extension of the triage process whereby a severely injured patient
is surveyed to identify those conditions that require treatment before
others. An individual’s injuries are triaged and priority given first to
Airway problems then Breathing problems and Circulation. Some
injuries may be so minor that treatment can be delayed or so severe
that no treatment can be offered. Just as in a multiply injured patient
you can’t treat every injury first so triage is performed when the number
of those requiring treatment exceeds the number of those available to
Any discussion of triage is not complete without mention of Baron
Dominique Jean Larrey, Surgeon Marshall of Napoleon’s Imperial
Guard. It is he who is credited with recognizing the importance of
prioritizing patients for surgery, sorting through the chaotic jumble of
patients left in the aftermath of battle to rescue first those most likely to
benefit from early treatment and it has to be said be most likely to be fit
to return to the battle. His belief in the power of early surgery led him to
break with battlefield tradition and rescue patients directly from the field
of battle rather than wait till darkness brought a break in hostilities and
cover for the rescue. The theatre of war still provides us with the basic
models, and unfortunately repeated practical demonstrations, for
developing and improving triage systems. Perhaps the greatest lesson
from these experiences has been that priorities for the individual patient
change as the condition and number of other casualties changes.
Triage is dynamic and continuous.

Triage involves rapid, repeated and authoritative decision making. It is
therefore a job for the most experienced. When resources of skill are
limited the greatest good for the greatest number may best be achieved
by tasking your most experienced worker to identify those most in need
of treatment and identify to the less skilled those procedures (and no
more) they should perform.

Unfortunately there are two triage “systems” in widespread use in the
UK although they are really different names for more or less the same
thing. The “P” system refers to priorities. P1 is immediate priority; P2
urgent priority and P3 delayed priority. The “T” system refers to
treatment and describes T1 – immediate treatment, T2 urgent treatment
and T3 delayed treatment. The T system also includes a T4 category –
expectant. These patients would receive immediate treatment in normal
circumstance but the severity of their condition is such that the
likelihood of survival is so small that the greatest good for the greatest
number dictates that resources are nor “wasted” on their care and they
are out to one side in favour of those who will clearly benefit from
immediate care. Such decisions require great experience and maturity.
Whoever makes such decisions will have to live with its consequences
– unlike the patient. These decisions must be constantly revisited. The
first triage scan might very well reveal few patients in need of
immediate life saving care and a T4 patient move up the scale to T1. It
takes maturity to accept the consequences of what appears to have
been a now avoidable delay and greater maturity to act appropriately
when a more “deserving” case appears. In fact the need for T4
decisions in civilian practice is rare but not uncommon in war,
particularly with regard to gunshot wounds to the head. However large
scale disasters in remote and poor areas of the world will pose similar
triage challenges to members of rescue teams.

Triage Categories

<!--[if !supportLists]-->1- <!--[endif]-->Life

threatening, immediate care required.

<!--[if !supportLists]-->2- <!--[endif]-->urgent

care within 6 hours

<!--[if !supportLists]-->3- <!--[endif]-->delayed

<!--[if !supportLists]-->4- <!--[endif]-->dead

<!--[if !supportLists]-->5- <!--[endif]--



Conventionally triage category 1 is colour coded red, triage category 2
coded yellow, category 3 green. The dead are coded white and
expectant blue.
Determining the triage category is achieved by applying the “ABC’s” of
resuscitation, common-sense and experience.

For example, patients with airway obstruction tension pneumothorax or
similar airway emergency are category 1 as are patients with very
severe haemorrhage. Common-sense applies. Patients who can walk
and talk are not 1 and are unlikely to be 2. Respiratory rate and
capillary refill require no special equipment and can be done quickly, in
the field and in the dark. On first pass a patient who makes no
respiratory effort in spite of a basic airway manoeuvre is dead and put
to one side. These rapid assessments of walking, talking, respiratory
effort and appearance constitute the initial triage sieve.
Attempts have been made to standardize triage methods by putting
numbers on decisions to make a triage scoring system. The
advantages of such development lie in consistency between operators
and more meaningful audit. However the fundamental nature of a
disaster or major emergency lies in it being unusual and the greatest
defence against the threat of the unusual is flexibility. The Triage
Revised Trauma Score, adapted from the established hospital trauma
score, has been used by paramedics in the USA to help standardize the
direction of patients to specialist trauma centres. It may have a place in
larger incidents but is generally untried in this area. However having
completed all the components a drop of 1 point in any of the three final
categories is significant and although the score runs from 1-12 the three
major triage categories are represented only be the final three scores
i.e. triage category 1 = TRTS 1-10, triage category 2 = RTS 11 and
triage category 3 = RTS 12.
Triage revised trauma score
Measurement Score
Respiratory rate 10-29 4

(breaths/min) >29 3

6-9 2

1-5 1

0 0
Systolic BP >90 4

(mmHg) 76-89 3

  50-75 2  

1-49 1

0 0
Glasgow Coma 13-15 4

Score (GCS) 9-12 3

6-8 2

4-5 1

3 0
  The triage category should be recorded on a card that is appropriately  
coloured clearly visible and capable of being updated. The most
practical is probably the Cruciform (Cambridge) card.

Chemical and radiation
These incidents may not involve the surgeon but if there is coincidental
injury the surgeon must be familiar with the protocols in force at such
times. Ideally decontamination is completed at the scene under the
supervision of the fire service. Casualties are decontaminated in a
“warm zone “ and proceed to “clean zone” prior to transport.

Nevertheless contaminated patients may still arrive at hospital. As part
of their major incident preparedness institutions should either have a
portable decontamination unit comprising a shower from which
washings can be gathered or have arrangements already in place to
secure a special unit from the fire brigade. Copious water is usually
appropriate with the exception of certain chemicals such as
phosphorus. If decontamination has to be carried out in hospital do not
allow the water to drain into the mains but keep the washings for later
safe disposal.

Potentially contaminated casualties must be directed along isolated and
clearly demarcated “contaminated” to “clean” pathways. There must be
protective clothing and airways protection for staff. Staff in these areas
are lost to the rest of the unit and will themselves need to be
decontaminated after they’ve finished. It is a difficult but important triage
decision to calculate the number of staff that can be “sacrificed” in this
way. Whether resuscitation can ever precede decontamination is a
triage decision for the moment and to be taken by the most senior of
doctors. The needs of one individual are clearly being matched against
the needs of another and in effect the needs of those others who may
be denied treatment if the contaminated helper is taken out of action.

Incidents involving radiation follow similar guidelines. Certain hospitals
with medical physics departments on site will be designated to receive
these casualties and have special arrangements already in place.
However radiation contaminated casualties can appear at any
department and all should be familiar with the National Arrangements
for Incidents involving Radiation (NAIR) or their own national
There is no definitive cut off point between a major incident and a
disaster and sometimes the terms are interposed. However in general a
disaster describes an incident where the authorities are failing to cope
and look unable to cope for the foreseeable future. This failure may be
as a result of the scale of the incident, a lack of preparedness and an
increased vulnerability. Many of the worst disasters occur as a result of
all three. The difference between the size of the disaster and the scale
of the response determines the impact of the disaster.

There is no generally agreed definition of a disaster but authorities
would recognize it as the result of a vast ecological break down in the
relationship between humans and their environment, a serious and
sudden event (or slow, as in drought) on such a scale that the stricken
community needs extraordinary efforts to cope wit it, often with outside
help or international aid.
The top ten killers in terms of “natural disasters” are illustrated in Table

Many of the worst disasters involve the mass migration of people and
require the skills of public health and primary care doctors. Certain
disasters involve large-scale injury and so involve surgeons. Before
offering aid to a stricken country only respond to a specific request from
a recognized and authoritative body and ensure you will be self-
sufficient. This will ensure your skills are quickly matched to the needs
of the victims, compliment the work of others and do not divert precious
resources to meeting your needs rather than those of the victims.

Key points

• Disaster is the result of a vast ecological break down in the
relationship between humans and their environment, a serious
and sudden event (or slow, as in drought) on such a scale that
the stricken community needs extraordinary efforts to cope wit
it, often with outside help or international aid.

The threat of an earthquake lies in its power to collapse structures. The
death toll is therefore higher at night when most people are in their
homes. The combination of entrapment and injury limits the severity of
injury that can be survived until rescue and evacuation to adequate
surgical services can be achieved. The victims of severe injuries to the
head and chest usually die before rescue and evacuation. Most rescue
is carried out within two to three hours of the ‘quake and accomplished
by those in the earthquake area. However it can be sometime before
further rescue and evacuation as the response is invariably hampered
by damage to roads, buildings and communications and sadly survival
from entrapment is rare beyond two days. The surgeon is therefore
most likely to be dealing with skeletal trauma, severe soft tissue injury
and occasionally abdominal injury. It comes largely within the province
of orthopaedic and plastic surgeons with the support of intensivists to
manage the metabolic problems that accompany prolonged crush. In
practice the bulk of injured survivors have had peripheral limb injuries.
Three times as many people are likely to be injured in an earthquake
than killed by it. These events therefore place an enormous burden on
a region’s and often a nation’s surgical services. Furthermore those
treating the victims of an earthquake are removed for treating co
incidental injury and disease. The impact of an earthquake on a
vulnerable country can be immense and surgeons should look to what
help can be offered across regions and at times across nations.

For those not too familiar with the effects of earthquake it should be
pointed out that contrary to repeated media concern the unburied dead
rarely pose a threat to health. The evidence to date is that threats to
public health most often come from the mass migration of people,
usually into temporary camps – a factor shared with the majority of
disasters including the greatest of them all, war.

Trauma surgery may also be required in the aftermath of tsunami and
floods as they destroy buildings and produce injury. Deforestation in
poorer areas has increased the risk of landslides and corresponding
injury. It should also be noted that structural damage, rock falls and
frantic attempts to escape mean that erupting volcanoes pose a greater
threat of injury than burns. However if called upon to treat those injured
in a volcano consideration should be given to the potential for
respiratory problems, including ARDS in the peri operative period if
there has been a significant exposure to volcanic ash.

Complex emergencies
When a disaster occurs in an area already involved in civil conflict the
UN refers to it as a “complex emergency”. The commonest combination
is the mass migration of people into refugee camps occurring in an area
of and as a consequence of civil war.

Armed conflict
This remains a major source of death and injury and like disasters of all
kinds affects the poor more than the rich. Once again the poor of Africa
and Asia bear the greatest burden.

Department of peace and conflict research Uppsala University
Sweden – battle related deaths in major conflicts 1990-1995
1990 1991 1992 1993 1994 1995
Europe 74 6- 11.2- 14.2- 1.5K 1-33K

10K 21.4K 42K
Middle >3.4K >16K 3.3- 3-4K 4.8- 3.25-

East 4.0K 12K 5.5K
Asia >15K >16K 14- 23.5- 6.3- >6.2K
60K 35K 15K
Africa 33.5K 37K 14- 25K 25- 15K

40K 35K
Americas 6- 3.2- >5.4K >3.4K >1.4 >1.7K

7.5K 6.2K


Land mines

The World Health Organization has estimated that the conflict in the
former Yugoslavia alone had already caused more than 5000 mine
related amputations by 1995 and the toll is rising still. It is estimated
that 110 million land mines are scattered across 64 countries and the
ICRC estimates they kill or maim 2000 people each and every month.

Battlefield injuries

Military surgeons (Fig. 3.1) are trained in recognizing and managing the
special and difficult features of injuries incurred on the field of battle.
Civilian surgeons may still face these injuries when acts of terrorism
bring battlefield injuries to city streets or when they are called upon or
volunteer to practice in a war torn area. The following must be firmly
born in mind.
• wounds are inevitably and significantly contaminated

• damage is widespread with involvement often distant to the
site of wounding

• mortality is inversely related to the time from wounding to

• the overwhelming priority is early thorough wound excision

• the risk of wound infection will be reduced by delayed primary

• abdominal contamination and sepsis may be controlled by the
judicious use of colostomy

• vascular repairs are best doe early

• internal fixation of bone is best avoided

The greatest threats posed by battlefield injuries relate to their
inevitable contamination and the delay to surgery.

When faced with battlefield injuries, early antibiotic cover should be
commenced with penicillin (5 mega units I/M 6 hourly) remaining the
mainstay of early therapy. However serious infection will only be
controlled and/or prevented by surgery and in particular by early and
adequate excision. Meticulous attention should be paid to tetanus
prevention with tetanus toxoid given routinely. Gas gangrene has been
a scourge of war since ancient Greece and pathogenic spore bearing
organisms continue to contaminate wounds and threaten the lives of
soldiers. Clostridium welchii is the commonest organism but wounds
are usually contaminated with a mixture that also includes C.
oedematiens, C. septicum, C. histolyticum, and C. sporogenes. Delay in
treatment is the most significant factor in its development. Its presence
is usually heralded by the sudden onset of severe pain. Oedema and
serosanguinous exudate develop with the extent of deep tissue
involvement not always reflected in the appearance of the overlying
skin. Early and extensive debridement up to amputation is required.

Battlefield analgesia is best achieved with morphine. Diluting 10mg of
morphine in 10mls of saline allows the surgeon to repeatedly administer
small amounts to ease the pain and distress without compromising the
The role of intravenous fluid replacement in such circumstance can be
unclear. If evacuation of the casualty will be rapid, safe and guaranteed
then fluid resuscitation can proceed along standard “ATLS” guidelines.
However increasing the blood pressure before haemostasis has been
secured can dislodge fragile clot and increase haemorrhage – a source
of concern when I/V fluid replacement was introduced in the First World
War. If the casualty and yourself are entrapped then fluid replacement
will have to be reduced to a level that maintains a radial pulse and if a
more prolonged entrapment is envisaged then later renal dialysis may
have to be traded for an early but short lived elevation of the blood

Gun shot wounds

Bullets damage tissues with the energy they liberate, directly injuring
the tissues they strike and indirectly injuring surrounding and
sometimes distant tissues if the energy release is great enough. The
energy transferred in this way is proportional to the movement of the
bullet through the tissues as it tumbles (rolls forwards) and yaws (spins
about its long axis). The mass, shape and type of bullet or indeed any
missile, all contribute to its energy potential although the most important
factor is likely to be its velocity.

In low energy transfer injuries the energy available for release is all
absorbed by the tissues it strikes. Its threat to the victim lies therefore in
the importance of the structures it hits. This threat is obviously
increased when the bullet fragments on impact, either by accident or
design. Low velocity (up to 300m/s) missiles are most likely to produce
this effect.

High energy transfer injuries are most likely to occur when high velocity
missiles generate so much energy that on impact its release will spread
its effects away from and sometimes far away from the point of
wounding. The local effect of this massive release of energy on impact
is a cavitation of tissues at the point of wounding creating a hole 10-15
times the size of the missile. The speed of the missile is such that this
cavitation will occur after the bullet has moved on (and often out of the
body) leaving a hole that expands rapidly to tear and stretch tissue then
collapses inwards with further destructive effect. All this takes place in
less than a second. The external evidence may be deceptive when all
the energy has been contained within, but the formation of the cavity
will have sucked in large amounts of contaminated debris including
clothing, soiled skin and earth, creating a massive injury behind a small

The treating doctor is unlikely to know the type or indeed the speed of
the missile. Furthermore, relatively slow moving missiles may be
designed to give up large amounts of energy on impact and high
velocity bullets may act as low velocity missiles when they lose energy
in flight or ricochet before or after entry. The safest option is to assume
the missile was high velocity and investigate accordingly.

Blast injuries

Explosions from shells, grenades, mortars and bombs produce
devastating injuries on the battlefield but increasingly in the high street.
Injuries are the result of the direct effect of penetration by the fragments
of the exploding device and the often more damaging effect of the
rapidly expanding explosive gas and air. Most explosive devices have a
hard, usually metal casing which fragments to produce very many high
velocity and high energy transfer penetrating injuries. The explosive
itself converts rapidly to an expanding gas. The first effect of this is to
produce a positive expansive phase where a blast shock wave
travelling at 3000m/s spreads outwards. If in a confined space the wave
will be reflected back on itself increasing its potential for harm. The
speed of expansion falls off quite quickly, reducing the area of harm
around blasts in the open air. Those likely to be exposed to these
incidents should be aware that a blast shock wave moves like a sound
wave and will go round walls. It also travels better and further water.
This is followed by a short negative phase where debris may be sucked
in, after which there is a mass movement of air producing the so-called
blast wind. This is produced as the expanding gases of the explosive
device displace an equal volume of air. It is the blast wind that causes
most tissue damage including evisceration and amputation. The
explosion will accelerate any materials within the device itself (nails ,ball
bearings) producing high energy transfer missiles and produce further
devastating injury by accelerating fragments of furniture and masonry.
The human body is generally more vulnerable to injury from fragments
accelerated by the blast than the blast itself. Where the body is
particularly vulnerable is at the interface between tissue and air. The
tympanic membrane is the most vulnerable in this regard and will
rupture under forces of about 0.5kg/cm2. Of more concern is
haemorrhage and oedema into pulmonary alveoli (blast lung) and at
higher pressures injury to the gas containing gut. The likelihood of
pressure damage to the lung and abdomen is reduced when the blast
occurs outside. Treating surgeons should be aware that blast lung may
not become manifest until 12 hours after injury. Confusion may precede
overt hypoxia and haemoptysis with ultimately the development of an
ARDS like syndrome. Finally the explosion is exothermic and will
produce burns, directly if the victim is near enough, and indirectly from
secondary fires.

Cold injuries

The field of battle is an inhospitable place even when the guns are
silent. Hypothermia can occur but more commonly prolonged exposure
to the cold, wet and wind, particularly when relatively immobile, will
produce localized injuries to the limbs, most commonly the feet
(immersion foot). Such injuries were a familiar feature of the trenches of
WWI and hence their other name of “trench foot”. When cold injury
progresses to freezing it produces “frostbite”. In general the best
treatment for cold injury to a limb is rapid rewarming by immersion in
warm water (40-42). If there is coincidental hypothermia then temporary
cooling of the limb may be required to delay thawing until it can take
place at normal body temperature.

Cold injury to limbs provokes numbness, pallor or blue discoloration
with induration, swelling and decreased movement. Avoid a potentially
more damaging cycle of thawing/freezing/thawing by rewarming the
limb in an environment where further cold injury will be avoided.

Rewarming limbs is painful and adequate analgesia (often morphine)
will be required. Aspirin can be added for its analgesic but also anti
platelet activities. The vasodilatory effects of alcohol are a useful
excuse for its administration.

Finally avoid early amputation. The power of a limb to recover from cold
injury is much greater than might be suggested by its early appearance.
Providing there is no infection any decision about amputation can be
delayed until its need is obvious.

The hidden casualties of war

Women and their children suffer dreadful consequences of war. Violent
rape and mutilation may bring the woman to the care of a surgeon and
a child’s height makes him particularly vulnerable to the effects of a land
mine. Moreover the breakdown in the usual medical care means that
conditions that were easily treated in peacetime become life threatening
and disabling with the neglect and isolation of war. Curable cancers
become fatal without early medication and diabetes claims a mortality
not seen for generations in the west. When there is a break in hostilities
or civilians escape the war zone the surgeon may very well be faced
with hip and other fractures unreduced and untreated and cancers at a
late stage in their development. Sadly when the war is over the work of
the surgeon may only be beginning.