Disaster preparation and management for the intensive
care unit
J. David Roccaforte, MD,*‡ and James G. Cushman, MD, FACS†‡
The purpose of this report is to provide information regarding
preparation for disaster management from the perspective of
ICU physicians. Both a framework toward ICU preparation for
disaster management and a guide to the relevant literature are
presented. Our objective is to show that the understanding of
disaster preparedness on multiple levels, including
government, hospital, ICU, and clinician, may lead to optimal
management in a disaster. Curr Opin Crit Care 2002, 8:607–615 © 2002
Lippincott Williams & Wilkins, Inc.
Departments of *Anesthesiology and †Surgery, New York University School of
Medicine, and ‡Co-Director, Surgical Intensive Care Unit, Bellevue Hospital, New
York, New York, USA.
Correspondence to J. David Roccaforte, MD, Bellevue Hospital, Department of
Anesthesia, 11N34, 1st Ave. at 27th St., New York, NY 10016, USA; e-mail:
JDavidR@mail.com
Current Opinion in Critical Care 2002, 8:607–615
ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc.
Since September 11th, 2001, the lay media [1,2••,3–6]
and the medical literature [7–12] have increasingly fo-
cused on the discussion of issues pertaining to disaster
preparedness. Previously published medical reports and
think tank analyses are being reread and interpreted in a
new light [13–21]. This report is written from the per-
spective of ICU clinicians and offers contemporary ways
of assessing the literature, considering both preparation
as well as actual disaster management. How well one
prepares for managing a disaster does make a difference
[22•]. Another important concept may be intuitive: how
a city department [23] or an individual first responder
[24] needs to prepare for disaster management will be
distinct from how a hospital administrator [25] needs to
prepare, and, in turn, it will be distinct from how inten-
sivists need to prepare [18]. It is essential for intensivists,
as for all physicians, to understand the overall organiza-
tion of disaster response from the field to the bedside.
Successful interaction among government organizations
(at the federal, state, and local levels), the community at
large, institutional organizers, and individual clinicians
will likely define the successful management of any di-
saster response [26,27].
Examples of reviews concerning issues of disaster
preparation and management can be found in both the
emergency medicine and the surgical literature [17,28,
29,30••,31–36]. However, based on our literature review,
there has been little published about disaster manage-
ment specific to the ICU [9,18]. Thus, from the perspec-
tive of ICU clinicians, more questions are asked in this
report than answered. Although it may seem intuitive
that the clinicians’ role in a disaster is simply an ex-
panded version of their usual function as high-
complexity medical caregivers, some authors do not
agree with this assessment [27]. Even defining the term
disaster is not straightforward [27,37]. Simplistic defini-
tions of what constitutes a disaster that are based either
on the number of patients involved [38] or on the result-
ing strain on or overwhelming of local systems and re-
sources [29] are not adequate. Many of us work on a daily
basis in institutions where resources are increasingly
strained. Auf der Heide [27] recognizes disasters as truly
cultural phenomena that affect the human condition, and
this broad definition is most appropriate. To understand
the definition of a disaster for a particular institution and
ICU is a first step toward adequate preparation and even-
tually successful management. Thus, this report is di-
vided into three main sections: “Typical disasters and
607
608 Ethical, legal, and organizational issues in the intensive care unit
responses,” in which we provide a classification scheme
of disaster types and identify common themes from re-
cent disaster reports; “Preparation outside of the inten-
sive care unit domain,” in which we summarize disaster
preparation occurring outside of the ICU domain, in gov-
ernmental and hospital administration; and “Preparation
and management within the intensive care unit,” in
which we identify specific questions for preparation and
strategies for management within the ICU.
Typical disasters and responses
Although most disasters share common elements, there
are a variety of disaster scenarios, which may be broadly
categorized as internal or external. External disasters are
further divided into natural or nonnatural according to
their causes (Table 1). By definition, most internal di-
sasters (eg, fire, loss of electrical power) will occur with
very little forewarning for the hospital and ICU physi-
cian. Preparation for these disasters requires an emphasis
on ultra-rapid response.
Although most external disasters will occur with some
degree of warning, biologic agent exposure is an excep-
tion. This weapon of mass destruction is unique in that
a diagnosis will likely be made within a hospital, perhaps
some days after the environmental release. Asha M.
George, of the Nunn-Turner Initiative in Washington,
DC, stated: “We are not going to have a bomb fly out of
the sky and land on somebody so that we can say, ‘Look,
there’s a bomb, and we are all dying of anthrax.’ It is
most likely going to be a covert release, and people will
get sick and go to their hospitals, and the public health
system will have to pick up on this” [39].
Each ICU must prepare for events that have a higher
probability of occurring locally. Disasters categorized as
external–natural are more often related to geographic lo-
cation. Other categories of disasters know no boundaries,
and certainly acts of terrorism, which include nuclear,
biologic, chemical, and explosive mechanisms, can occur
anywhere. It is appropriate for ICU physicians to con-
sider their hospital’s location and the community’s re-
sources in anticipating a likely disaster scenario.
Table 1. Classification of disasters
External
Internal Natural Nonnatural
Bomb threat Fire Fire/explosion
Fire Flood Vehicular crash
Flood Earthquake Building collapse
Loss of electrical power Hurricane Firearms
Loss of communications Tornado Biologic agent exposure
Chemical spill Avalanche Chemical agent exposure
Infectious agent release Mud/landslide Radiation exposure
Violence/firearms Other Other
Other
Mere speculation regarding system function during a di-
saster is being replaced, sadly, by actual experiences.
From the 1995 Aum Shinrikyo sarin attack in Tokyo,
Japan [40], to the Houston, Texas, floods in 2001 [41], to
the September 11th, 2001, attacks [42], to the anthrax
letters [43], to the suicide bombings in the Middle East
[44], coordinated disaster responses have been imple-
mented with increasing frequency. Auf der Heide [27]
describes in detail examples of the common pitfalls of
disaster response. From case reports, analyses, and the
authors’ own experiences, a number of common disaster
observations are highlighted:
• Communications will be impaired [2••,5,7,8,45].
• Transportation will be difficult [46].
• Information obtained will likely be unreliable [17].
• The nearest hospital will receive the most patients
[9,47•].
• Most patients may not immediately require advanced
medical treatment [34,48].
• Transport from the scene may not be to the proper
designated hospital [49].
• In the absence of a remote staging area, hospital staff
will assemble in the emergency department [50] or at
the scene [51] if not otherwise directed.
• Up to 72 hours may pass before outside help arrives
[52].
• Widespread panic is not likely to occur [27].
• Volunteers will be numerous; emergency credential-
ing may be an issue [53].
• Hospital security may need assistance from municipal
police [54–56].
• Requests for information by the public and the media
will require more resources than anticipated [27,47•].
• Many lives can be saved by properly planning and
rehearsing disaster drills (McLoughlin, Personal com-
munication, December 2001).
Preparation outside of the intensive care
unit domain
Government and community disaster response
Critical care physicians should have an understanding of
the capabilities, plans, resources, and limitations of the
various governmental and nongovernmental disaster-
related agencies. Several publications describe [16,43,57]
and critique [2••,5,13,15] the government’s preparation
and response to terrorism. Table 2 provides an overview
of some of the agencies that may be interfacing with
hospitals in a disaster. Verifying that the hospital admin-
istration has an established relationship with each of
these organizations, as appropriate, is essential. Estab-
lishing personal contacts in some of these organizations
directly between the ICU leadership and the agency may
be advantageous.

Table 2. Agencies that may interface with hospitals in a disaster
Governmental
Federal Emergency
Management Agency
(FEMA)
Office of Emergency
Management (OEM)
Centers for Disease
Control and Prevention
(CDC)
Public Health Departments
Federal Bureau of
Investigation (FBI)
Military, National Guard
Department of Health
and Human Services
Office of Emergency
Preparedness (DHHS
OEP)
National Diaster Medicine
System (NDMS)
Diaster Medical
Assistance Team
(DMAT)
Office of Homeland
Security (OHS)
Nongovernmental
Red Cross/Red Crescent
Salvation Army
World Health
Organization Dept. of
Emergency and
Humanitarian Action
(WHO)
*All URLs accessed August 1, 2002.
Disaster preparation and management for the ICU Roccaforte and Cushman 609
Type of Purpose, resources,
disaster expertise Contact*
All Comprehensive preparation for, http://www.fema.gov/regions/
prevention of, response to, and
recovery from disasters; terrorism
consequence management
Region specific Local coordination, liaison between City, county, regional, or state
federal programs and community offices
needs
Infectious diseases, Epidemiology, laboratory testing, CDC Emergency Response
bioterrorism vaccinations, antibiotics, and Hotline (24 hours):
chemical antidotes via push pack 770-488-7100
available in 12 hours http://www.bt.cdc.gov/
EmContact
Infectious diseases, Surveillance, vaccinations City, county, regional, or state
bioterrorism offices
http://www.statepublichealth.org/
emergency_phones.php
Terrorism, weapons Criminal investigation; terrorism crisis http://www.fbi.gov/contact/fo/
of mass management lead federal agency territory.htm
destruction
Any Search and rescue, civil order, logistic http://www.arng.army.mil/tools/
support, decontamination; Unit.asp
quarantine enforcement?
Natural disasters, Managing and coordinating federal http://ndms.dhhs.gov/Contacts/
technological health, medical, and health-related contacts.html
disasters, major social services and recovery to
transportation major emergencies and federally
accidents, declared disasters; lead federal
terrorism agency for health and medical
services within the federal response
plan; manages NDMS
Any National medical response capability http://ndms.dhhs.gov/Contacts/
for assisting state and local contacts.html
authorities in dealing with the
medical and health effects of major
peacetime disasters; deploys
DMATs
Any Triage patients, provide austere http://ndms.dhhs.gov/NDMS/
medical care, and prepare patients About_Teams/about_teams.html
for evacuation; provide primary
health care and/or serve to augment
overloaded local healthcare staffs
Terrorism Prevent terrorist attacks within the http://www.whitehouse.gov/
United States; reduce America’s homeland/contactmap.html
vulnerability to terrorism; minimize
the damage and recovery from
attacks that do occur
Any Provide shelter, water, food, and basic http://www.ifrc.org/contact/
health care; provide blood products, http://www.redcross.org/
infrastructure, generators where/where.html
Any Provides food, shelter, counseling, and http://www.salvationarmy.org/
other services; also involved in
coordinating long-term relief efforts
for communities
Natural, public Provide technical guidance, timely and http://www.who.int/disasters/
health, infectious relevant health information, define http://www.pano.org/diasters/
disease public health priorities and plans of
action, assess and evaluate health
interventions, as well ensure that
field offices and health partners are
able to provide basic public health
services; when needed, may
implement projects together with
partners
610 Ethical, legal, and organizational issues in the intensive care unit

Hospital disaster planning
Risk assessment
As mentioned, an early step in disaster preparation is to
take into account geographic and institution-specific
considerations. This process is formally known as hazard
vulnerability analysis [47•]. The Joint Commission on Ac-
creditation of Healthcare Organizations requires hospi-
tals to perform and document a formal hazard vulnerabil-
ity analysis [58]. This process first identifies the disasters
most likely to strike a particular institution. Next, an
assessment is made regarding preparedness. In perform-
ing a hazard vulnerability analysis, the analysis should
include the institution’s ability to accommodate a higher
than normal volume of patients (surge capacity) and con-
tingency plans, should that volume be exceeded. The
same exercise performed for the entire institution should
be repeated for individual ICUs. Full preparation re-
quires an inventory of currently available resources, a
working knowledge of what additional resources are
likely to be needed for any given disaster, and that pro-
visions exist for obtaining those resources.
Table 3 lists particular disaster types and matches them
with recent literature. The information in these reports
may assist clinicians in various locations in performing a
hazard vulnerability analysis and an assessment of antic-
ipated needs.

Table 3. Summary of recent disaster reports

Event Reference Findings

Evacuation [59] 1995 Hanshin-Awaji earthquake

5611 patients were admitted to local hospitals
352 ICU patients and 2290 noncritical patients transported within the first 4 days
Victims treated for crush syndrome and other trauma had worse chance of survival if
they remained at affected hospitals
Small aircraft crash [60] Vertebral column injuries are described as common findings in survivors
Train crashes [46,61,62] Extrication of casualties and communication were identified as problems [46]
Reports describe the casualties received and the disaster plan activation [61]
Crash involved a high-speed passenger train–truck collision in a rural area [61,62]
Earthquake [31,63] 1999 Turkish earthquake at Adapazari [63]
Supplying and staffing mobile field hospitals described
Experience reviewed with specific recommendations
Japanese Hanshin-Awaji urban earthquake [31]
Rapid transport to undamaged hospitals with ICU capacity would have improved
survival rates
Documented the demographics of patients, type and severity of injuries, and
outcomes
Tropical Storm [41] Increases in illnesses in people returning to flooded homes
Hurricane [64•] Maintaining staffing levels may be difficult as nurses’ and other workers’ primary
concerns are their own families
Tornado [65–67] F5 tornado in Alabama [65]
224 patients evaluated
The regional trauma system facilitated appropriate and efficient triage
Analysis of tornado casualties in Georgia [66]
Injuries were more severe in survivors who were thrown rather than struck
Gram-negative bacilli often infect soil-contaminated wounds
147 patients admitted after an Oklahoma City tornado [67]
Majority of soft tissue wounds
Higher than expected rate of head injuries (17.6% of 148 total injuries)
Bombing [68] A computer simulation exercise
Major bottlenecks in the flow of casualties are in the resuscitation rooms and the CT
scanner
Hospital fire [69] 375-bed Toronto children’s hospital
Review of sequence of events, communications, and evacuation
Suggestions:
Ensure that portable radios are able to communicate on the same frequency
Foster strong partnerships with vendors to replace damaged supplies quickly
Chemical release [70] Thorough review of mass casualty chemical incidents and responses
Lack of access to relevant information in the initial few hours is a consistent occurrence
Radiation release [71] Analysis of the Chernobyl accident
Stress can have a negative effect on crisis decision-making
September 11th [34,45,47,48,72,73] Descriptive essays of healthcare providers’ experiences [72,73]
Reviews of the injuries [34,48]
Medical capacity far exceeding casualties [34,47,48]
Effective triage was difficult [45]
Head trauma, burns, and crush syndrome resulted in extended ICU stays
Anthrax [74••] Intentional release via contaminated mail in late 2001
The presentations, time sequences, ICU courses, and outcomes are described
Survival rate much higher than that reported historically
May be a benefit from advances in ICU supportive care and early diagnosis
 Disaster preparation and management for the ICU Roccaforte and Cushman 611
Administrative organization
Hospitals are required to have a disaster plan, to maintain
a disaster manual [58], and have been encouraged to use
the Incident Command System. An organizational template
with generic job descriptions, the Incident Command
System was originally designed in the context of fire-
fighting and has evolved into a crisis management sys-
tem. A version has been adapted for health care [75].
According to a survey conducted in 2000, 90% of New
York City area hospitals use the Hospital Emergency
Incident Command System [76].
The Hospital Emergency Incident Command System
was developed “to assist the operation of a medical fa-
cility in a time of crisis” [75] and, as such, is a tool in-
tended for hospital administrators rather than for bedside
clinicians. In the event of a disaster, ICU physicians
should have no doubts as to their clinical responsibilities.
What may not be as clear, however, is the chain of com-
mand in their institution’s organizational structure and
how necessary assistance will be obtained to treat or
evacuate patients. In the Hospital Emergency Incident
Command System organizational chart, the Liaison Of-
ficer holds a crucial position and functions as the contact
person interfacing with representatives from outside
agencies and other hospitals. For the system to work
well, each staff member needs to know in advance: (1)
what is my job, (2) what are the other jobs relevant to
mine, and (3) who is going to be doing those jobs.
Patient care organization
Klein and Weigelt [14] emphasize the advantages in
separating the medical and administrative command
posts (Fig. 1). This concept raises some important con-
siderations for ICU physicians: how is the medical com-
mand structure for their ICUs organized, and who will be
making triage decisions?
In planning, the hospital disaster committee will try to
anticipate the needs specific to each ICU. Thus, it is
imperative that intensivists participate in at least this
aspect of the hospital’s preparation, and that ICU-based
considerations are integrated into the hospital-wide plan.
For several reasons, ICU clinicians should be leaders in
disaster preparation planning. First, intensivists are ex-
perienced in caring for the hospital’s sickest patients. In
the event of a disaster, as with trauma in general, oppor-
tunities to reduce preventable mortality will occur in the
resuscitative, operative, and critical care phases [77]. Sec-
ond, the most serious casualties of conventional disasters,
and presumably of nuclear, biologic, or chemical disas-
ters, will be managed within ICUs, which, in most hos-
pitals, have limited resources to increase capacity. Third,
intensivists bring a multidisciplinary perspective to plan-
ning and can often anticipate bottlenecks and pitfalls
that others may not appreciate [18].
Figure 1. Separation of the medical and administrative
command posts
Disaster
Entry
Administrative Medical
command post command post
Beds Media OR ICU Radiology ED Ward
Supplies
Personnel
At entry, patient information is provided to both the administrative and the
medical command posts. Each post is responsible for defined areas. Information
about patient status is tracked by the medical command post and updated to the
administrative command post when possible. The administrative command post
provides the medical command post with information regarding resource
availability. Media and family information is handled through the administrative
command post. Published with permission [14].
Preparation and management within the
intensive care unit
Intensive care unit physician
One of the first decisions the ICU physician will have to
make in the event of a disaster is the assignment of beds
for the most critically ill patients, including those already
in the ICU plus new disaster victims. Second, nurses and
physicians will have to be assigned to care for these pa-
tients. Thus, an immediate concern is that triage, now at
a tertiary or higher level, matches needs with resources.
In lessons learned from analyses of conventional explo-
sive-type disasters, Frykberg and Tepas [35] stress the
importance of the critical mortality rate. This rate is de-
fined as all deaths, early and late, among the most criti-
cally injured survivors—those with Injury Severity
Scores [78] of 15 or greater. Frykberg and Tepas [35]
point out that the mortality rate of those critically ill
patients will increase to the extent that overtriage occurs.
If, as these authors suggest, explosive-type disasters
yield low numbers of critically injured patients, then
overtriage is likely to be a problem. In a related and
parallel fashion, ICU physicians will be required to use
exceptional judgment in how to use their limited re-
sources (beds, ventilators, nurses, physicians) in a variety
of disaster situations to maximize survival and to mini-
mize preventable deaths. The damage control philoso-
phy is advocated and accepted for the field triage, resus-
citative, and operative phases of mass casualty incidents
[79••]. In a disaster, the application of damage control to
an overburdened ICU is less obvious. The ICU is a
phase of definitive care; thus, in a disaster, the emphasis
should be on expanding the ICU bed capacity by acti-
612 Ethical, legal, and organizational issues in the intensive care unit
vating transfer agreements with nearby ICUs rather than
curtailing ICU care. The following are examples of the
many questions that intensivists need to ask of their ICU
and hospital.
• Is the ICU represented on the hospital disaster
committee?
• What types of disasters are likely to affect our par-
ticular institution?
• What backup communication systems do we have for
when telephones and pagers stop working?
• How many ICU beds are available in this unit and in
the entire hospital?
• What alternative beds are available if overflow
occurs?
• Do we have transfer agreements with other nearby
ICUs?
• Do we have vendor lists readily available if there are
sudden demands for supplies?
• What is our absolute limit in terms of numbers of ICU
beds, nurses, and physicians?
• How are we prepared to accommodate patient fami-
lies and the media?
• Where is our disaster plan?
• Are we adequately rehearsed in the likely disaster
scenarios that we might face?
• Who will serve as the acting Liaison Officer?
• Who is the ICU physician and nursing leader?
• What is our inventory of ventilators and oxygen
tanks?
• How do we increase staffing, including nurses, respi-
ratory therapists, pharmacists, and laboratory person-
nel? What if we cannot increase staffing?
Table 4. Resources for the management of casualties
Recent reviews: conventional mechanisms
Triage
Explosive/blast injury
Blunt and penetrating injury
Crush injury
Burns
Recent reviews: nuclear, biologic, or chemical disasters
General overviews
Nuclear/radiation
Biologic
Chemical
Other educational resources
Planning strategies
Online disaster data sheets (guides)
• What if we require total ICU isolation?
• What and where are decontamination facilities?
• Do we have functioning access to the Internet, radio,
cable television, and so forth?
• Where is the staging area for staff, volunteers, and
student helpers?
• How do we transport patients without working
elevators?
• Who will notify our backup community hospitals if
we need help?
• How many supplies and doses of key medications do
we have?
• Do we have an updated phone list?
Resources for intensive care unit staff on
disaster-related issues
Other than reviewing the systems and organizational is-
sues outlined in the previous sections, successful prepa-
ration of the ICU physician to manage disaster victims
begins with self-education on a wide variety of topics
(Table 4). Beyond the standard critical care textbooks
and the usual curriculum for board certification, the ICU
physician will be required to read extensively on topics
that in the pre–September 11th, 2001, era were consid-
ered the domain of subspecialists.
Vaccinations
The debate regarding plans for smallpox vaccinations for
first responders and healthcare workers is ongoing [99].
Using historical data, and excluding high-risk individu-
als, a systematic smallpox immunization program is pre-
dicted to cause as many as 4600 serious adverse events
and 285 deaths in the United States [100]. The anthrax
Reference Areas reviewed/main findings
[30••,35,36,79••] Overtriage is common in disasters
Overtriage impairs appropriate treatment of critical casualties
Dual-command concept
Minimal acceptable care concept
Damage control philosophy in civilian disasters
[80••] Terrorist bombings
Pathophysiology of blast injury
Triage and ICU management
[81–83] Recent trauma care developments
Injury diagnosis and management
Organizational and systems issues
[84–86] Resuscitation, operative, and supportive concepts [84]
Outcomes after 1995 Kobe, Japan, earthquake [85]
1999 Turkish earthquake data [86]
[87] Comprehensive burn care issues
[13,88,89•] Biologic [88], chemical, radiation [89•]
Terrorist (covert) attacks [13]
[13,90••] Comprehensive management [90••]
Terrorist use of dirty bombs, nuclear weapons [13]
[91,92••—95••] Recognition and treatment
[20,21] Recognition and treatment
[57,96,97•] Biologic, chemical, food borne
[98] Management of biologic, chemical, and radiation exposure
 Disaster preparation and management for the ICU Roccaforte and Cushman 613
vaccination program, because of its association with Gulf
War illnesses, has also generated significant controversy
[101]. Containment and quarantine following a wide-
spread bioterrorist attack will certainly put public health
concerns at odds with civil liberties [102].
Afterword
Not a matter of if, but when . . .
Tim Russert of NBC’s “Meet the Press” interviewing
Vice President Dick Cheney on May 19, 2002
Disasters, by definition, are not predictable. However,
trends suggest that both the number and the impact of
disasters will continue to increase. First, as the world
population continues to grow, land is being developed in
locations that subject communities to increased risks of
floods, landslides, earthquakes, wind damage, and so
forth [22•]. Second, migration to cities continues, and
the industrial and energy infrastructure needed to sup-
port those cities grows and ages, increasing the probabil-
ity and impact of accidents [103]. Third, the resources
needed to deploy weapons of mass destruction remain
easily accessible as political and economic instability
continues, especially in the former Soviet Union and in
the Middle East [15]. Finally, one can speculate that as
society continues to polarize socially, politically, and eco-
nomically, discontent will likely increase the motivation
to incite terror.
Through foresight, preparation, and practice, disaster
victims’ outcomes can be improved. Optimization of di-
saster preparation depends on coordination at multiple
levels and interdisciplinary and interagency organization.
ICU clinicians’ thorough understanding of the entire sys-
tem will enable them not only to take a leadership role in
disaster planning and management but also to provide
the support needed to treat critically ill patients in the
event of a disaster.
References and recommended reading
Papers of particular interest, published within the annual period of review,
have been highlighted as:
• Of special interest
•• Of outstanding interest
1 Levine S: After attacks, preparing for the worst; hospitals coordinate emer-
gency procedures. Washington Post. April 25, 2002:T14.
2 Dwyer J, Flynn JK, Fessenden F: 9/11 exposed deadly flaws in rescue plan.
•• New York Times. July 7, 2002:1.
A critical analysis of the consequences of previously identified communication de-
ficiencies that had been left uncorrected. The report is based on multiple interviews
with first responders.
3 Firestone D: Traces of terror: the reorganization plan; congressional panels
recast homeland security dept. New York Times. July 11, 2002;sect A:20.
4 Elliott M, Cooper M, Dickerson J, et al.: ‘A clear and present danger’: as
Americans worry about truck bombs, germ warfare and worse, they wonder:
can our government do anything to stop the next terror attack? Time 2001,
158:26.
5 Dwyer J, Flynn JK: Fire dept. lapses on 9/11 are cited. New York Times.
August 3, 2002:1.
6 Stix G, Yam P: NewsScan: facing a new menace. Sci Am 2001, 285:14–15.
7 Asaeda G: The day that the START triage system came to a STOP: obser-
vations from the World Trade Center disaster. Acad Emerg Med 2002,
9:255–256.
8 Mack D, Heightman AJ: Staying on the air: the importance of maintaining
communication at mass casualty incidents. J Emerg Med Serv JEMS 2002,
27:42–49.
9 Simon R, Teperman S: The World Trade Center attack. Lessons for disaster
management. Crit Care 2001, 5:318–320.
10 Greene J: Readying bioterrorism defenses. Preparations continue despite in-
adequate funds. Mater Manag Health Care 2002, 11:32, 34.
11 Poe BM: Expanding disaster preparedness to include bioterrorism. Am J
Health Syst Pharm 2002, 59:926–927.
12 Dawes BS: Disaster management requires planning, improvising, and evalu-
ating. AORN J 2002, 75:730, 732.
13 Falkenrath RA, Newman RD, Thayer BA: America’s Achilles’ Heel: Nuclear,
Biological and Chemical Terrorism and Covert Attack. Cambridge, MA: Mas-
sachusetts Institute of Technology Press; 1998.
14 Klein JS, Weigelt JA: Disaster management: lessons learned. Surg Clin North
Am 1991, 71:257–266.
15 Smithson A, Levy LA: Ataxia: The Chemical and Biological Terrorism Threat
and the US Response. Report No. 35. Washington, DC: Henry L. Stimson
Center; 2000.
16 Federal Emergency Management Agency, Federal Bureau of Investigation:
United States government interagency domestic terrorism concept of opera-
tions plan (CONPLAN). January 2001. Available at: http://www.fema.
gov/rrr/conplan/ or http://www.fbi.gov/publications.htm. Accessed August 1,
2002.
17 Johnson GA, Calkins A: Prehospital triage and communication performance
in small mass casualty incidents: a gauge for disaster preparedness. Am J
Emerg Med 1999, 17:148–150.
18 Angus DC, Kvetan V: Organization and management of critical care systems
in unconventional situations. Crit Care Clin 1993, 9:521–542.
19 Ryan J, Gavalas M: What goes wrong at a disaster or major incident? Hosp
Med 1998, 59:944–946.
20 National Research Council: Chemical and Biological Terrorism: Research
and Development to Improve Civilian Medical Response. Washington, DC:
National Academy Press; 1999.
21 Burke R: Counter-Terrorism for Emergency Responders. New York: Lewis
Publishers; 2000.
22 International Federation of Red Crescent and Red Cross Societies: World
• Disasters Report 2002: Focus on Reducing Risk. Geneva, Switzerland: In-
ternational Federation of Red Crescent and Red Cross Societies; 2002.
This annual publication provides a global perspective on disasters and documents
improved outcomes with proper preparation.
23 New York City Department of Health response to terrorist attack, September
11, 2001. MMWR Morb Mortal Wkly Rep 2001, 50:821–822.
24 Crippen D: The World Trade Center attack. Similarities to the 1988 earth-
quake in Armenia: time to teach the public life-supporting first aid? Crit Care
2001, 5:312–314.
25 Benjamin GC: Chemical and biologic terrorism: planning for the worst. Phy-
sician Exec 2000, 26:80–82.
26 Collaboration and coordination in mass casualty disaster plans. Healthc Haz-
ard Manage Monit 2002 15:1–7.
27 Auf der Heide E: Disaster Response, Principles of Preparation and Coordi-
nation. St. Louis, MO: Mosby; 1989.
28 Streger MR: Prehospital triage. Emerg Med Serv 1998, 27:21, 23–27.
29 New York State Department of Health Bureau of Emergency Medical Ser-
vices: EMS Mutual Aid Planning Guidelines. Policy Statement No. 89–2.
March 1989. Available at: http://www.health.state.ny.us/nysdoh/ems/89-
02.htm. Accessed August 1, 2002.
30 Hirshberg A, Holcomb JB, Mattox KL: Hospital trauma care in multiple-
•• casualty incidents: a critical view. Ann Emerg Med 2001, 37:647–652.
The authors provide direction to the emerging philosophy of disaster management
in which the initial hospital triage is simplified to “critical” (surgical) or “not critical,”
and subsequent treatment is focused on critical patients, with all others receiving
“minimal acceptable care,” thereby conserving critical resources by avoiding over-
triage.
614 Ethical, legal, and organizational issues in the intensive care unit
31 Kuwagata Y, Oda J, Tanaka H, et al.: Analysis of 2,702 traumatized patients in
the 1995 Hanshin-Awaji earthquake. J Trauma 1997, 43:427–432.
32 May AK, McGwin G Jr, Lancaster LJ, et al.: The April 8, 1998 tornado: as-
sessment of the trauma system response and the resulting injuries. J Trauma
2000, 48:666–672.
33 Millie M, Senkowski C, Stuart L, et al.: Tornado disaster in rural Georgia:
triage response, injury patterns, lessons learned. Am Surg 2000, 66:223–
228.
34 Cushman JG, Pachter HL, Beaton H: Two NYC hospitals’ response to the
September 11th, 2001, terrorist attack in NYC. J Trauma 2002, 53:186.
35 Frykberg ER, Tepas JJ III: Terrorist bombings: lessons learned from Belfast to
Beirut. Ann Surg 1988, 208:569–576.
36 Feliciano D, Anderson G, Rozycki G: Management of casualties from the
bombing at the centennial Olympics. Am J Surg 1998, 176:538–543.
37 Nocera A: Australian major incident nomenclature: it may be a ‘disaster’ but in
an ‘emergency’ it is just a mess. ANZ J Surg 2001, 71:162–166.
38 Regional Emergency Medical Advisory Committee of New York City: Prehos-
pital Basic Life Support Protocols. Protocol 401-B. August 1996. Available
at: http://www.nycremsco.org/protocols/CHAP400/400b.htm. Accessed
August 1, 2002.
39 Stolberg SG: A nation challenged: the biological threat; some experts say
U.S. is vulnerable to a germ attack. New York Times. September 30,
2001;sect 1A:1.
40 Okumura T, Suzuki K, Fukuda A, et al.: The Tokyo subway sarin attack: disas-
ter management, Part 2: hospital response. Acad Emerg Med 1998, 5:618–
624.
41 Tropical Storm Allison rapid needs assessment–Houston, Texas, June 2001.
MMWR Morb Mortal Wkly Rep 2002, 51:365–369.
42 Tamber P, Vincent JL: The World Trade Center attack. Lessons for all aspects
of health care. Crit Care 2001, 5:299–300.
43 Update: Investigation of bioterrorism-related anthrax and interim guidelines
for exposure management and antimicrobial therapy, October 2001. MMWR
Morb Mortal Wkly Rep 2001, 50:909–919.
44 Ripley A: Why suicide bombing … is now all the rage. Time 2002,
159:32–39.
45 Cook L: The World Trade Center attack. The paramedic response: an insid-
er’s view. Crit Care 2001, 5:301–303.
46 Cordell R: The Eschede rail crash, Germany, 3 June 1998: a British observ-
er’s report. Prehosp Immediate Care 2000, 4:196–200.
47 Joint Commission on Accreditation of Healthcare Organizations: Special is-
• sue: emergency management in the new millennium. Joint Commission Per-
spectives, vol 21, no 12. December 2001. Available at: http://www.jcrinc.
com/perspectivesspecialissue. Accessed August 1, 2002.
This issue of the Joint Commission on Accreditation of Healthcare Organizations
newsletter reviews and summarizes practical aspects of disaster preparedness,
including Web sites for online resources. The interviews with hospital staff involved
in recent disasters are especially insightful.
48 Rapid assessment of injuries among survivors of the terrorist attack on the
World Trade Center–New York City, September 2001. MMWR Morb Mortal
Wkly Rep 2002, 51:1–5.
49 Leslie CL, Cushman M, McDonald GS, et al.: Management of multiple burn
casualties in a high volume ED without a verified burn unit. Am J Emerg Med
2001, 19:469–473.
50 Roccaforte JD: The World Trade Center attack. Observations from New
York’s Bellevue Hospital. Crit Care 2001, 5:307–309.
51 Martinez C, Gonzalez D: The World Trade Center attack. Doctors in the fire
and police services. Crit Care 2001, 5:304–306.
52 Gillem T (moderator): Disaster planning: how healthcare prepares for crisis.
HealthLeaders Roundtable Supplement. May 2002:R2–R15.
53 Rozovsky F: Emergency credentialing helps disaster response. Hosp Peer
Rev 2002, 27:63–64.
54 Arterburn T: What hospital security should be doing now to better prepare for
future terrorist activity. J Healthc Prot Manage 2002, 18:6–14.
55 White DE: A terrorism response plan for hospital security and safety officers.
J Healthc Prot Manage 2002, 18:15–23.
56 Roll FG: Is healthcare security prepared for terrorism? J Healthc Prot Manage
2002, 18:1–5.
57 Biological and chemical terrorism: strategic plan for preparedness and re-
sponse. Recommendations of the CDC Strategic Planning Workgroup.
MMWR Recomm Rep 2000, 49:1–14.
58 Joint Commission on Accreditation of Healthcare Organizations: Revised En-
vironment of Care Standards for the Comprehensive Accreditation Manual for
Hospitals (CAMH). Standards EC.1.4, EC.2.4, EC.2.9.1, EC.2.9.2 [special
insert]. Joint Commission Perspectives, vol 21, no 12. December 2001.
59 Tanaka H, Iwai A, Oda J, et al.: Overview of evacuation and transport of pa-
tients following the 1995 Hanshin-Awaji earthquake. J Emerg Med 1998,
16:439–444.
60 Friedman A, Floman Y, Sabatto S, et al.: Light aircraft crash–a case analysis
of injuries. Isr Med Assoc J 2002, 4:337–339.
61 Kankakee, IL: two hospitals; a middle-of-the-night train crash; 114 injured-
–how their disaster plans played out. Hosp Secur Saf Manage 1999, 20:5–8.
62 Nordberg M: Train vs. truck: rescuers respond to Amtrak crash in Illinois.
Emerg Med Serv 1999, 28:69–72.
63 Finestone AS, Bar-Dayan Y, Wolf Y, et al.: Diagnostic medical auxiliary equip-
ment in a field hospital: experience from the Israeli delegation to the site of the
Turkish earthquake at Adapazari. Mil Med 2001, 166:637–640.
64 French ED, Sole ML, Byers JF: A comparison of nurses’ needs/concerns and
• hospital disaster plans following Florida’s Hurricane Floyd. J Emerg Nurs
2002, 28:111–117.
This report highlights staffing issues during a disaster. Speculation exists as to how
many staff members would report to work in the event of a communicable bioter-
rorism attack or epidemic.
65 May AK, McGwin G Jr, Lancaster LJ, et al.: The April 8, 1998 tornado: as-
sessment of the trauma system response and the resulting injuries. J Trauma
2000, 48:666–672.
66 Millie M, Senkowski C, Stuart L, et al.: Tornado disaster in rural Georgia:
triage response, injury patterns, lessons learned. Am Surg 2000, 66:223–
228.
67 May BM, Hogan DE, Feighner KR: Impact of a tornado on a community hos-
pital. J Am Osteopath Assoc 2002, 102:225–228.
68 Hirshberg A, Stein M, Walden R: Surgical resource utilization in urban terror-
ist bombing: a computer simulation. J Trauma 1999, 47:545–550.
69 Hogan C: Responding to a fire at a pediatric hospital. AORN J 2002,
75:793–800.
70 Murray V, Goodfellow F: Mass casualty chemical incidents–towards guid-
ance for public health management. Public Health 2002, 116:2–14.
71 Weisaeth L, Knudsen O, Tonnessen A: Technological disasters, crisis man-
agement and leadership stress. J Hazard Mater 2002, 93:33–45.
72 Lipkin M: Medical ground zero: an early experience of the world trade center
disaster. Ann Intern Med 2002, 136:704–707.
73 Chalfin DB: The World Trade Center attack. Eye witness: observations of a
physician on the outside looking in. Crit Care 2001, 5:310–311.
74 Jernigan JA, Stephens DS, Ashford DA, et al.: Bioterrorism-related inhala-
•• tional anthrax: the first 10 cases reported in the United States. Emerg Infect
Dis 2001, 7:933–944.
An invaluable resource providing insight into the management of anthrax in the era
of modern medicine.
75 San Mateo County Health Services Agency, Emergency Medical Services:
The Hospital Emergency Incident Command System, edn 3. June 1998.
Available at http://www.emsa.ca.gov/Dms2/heics3.htm. Accessed August 1,
2002.
76 Silber SH, Oster N, Simmons B, et al.: Y2K medical disaster preparedness in
New York City: confidence of emergency department directors in their ability
to respond. Prehosp Disast Med 2001, 16:88–95.
77 Davis JW, Hoyt DB, McArdle M, et al.: The significance of critical care errors
in causing preventable death in trauma patients in a trauma system. J Trauma
1991, 31:813–818.
78 Baker SP, O’Neill B, Haddon W, et al.: The injury severity score: a method for
describing patients with multiple injuries and evaluating emergency care. J
Trauma 1974, 14:187–196.
79 Holcomb JB, Helling TS, Hirshberg A: Military, civilian, and rural application of
the damage control philosophy. Mil Med 2001, 166:490–493.
••
This paper outlines the military philosophy of damage control and its applicability to
civilian situations. ICU physicians must be familiar with the concepts of minimally
acceptable care and damage control, both of which are applicable to disaster
management.
80 Stein M, Hirshberg A: Medical consequences of terrorism. The conventional
•• weapon threat. Surg Clin North Am 1999, 79:1537–1552.
 Disaster preparation and management for the ICU Roccaforte and Cushman 615
A comprehensive review of the pathophysiology of blast injuries and their treat-
ment. Given the increasing frequency of terrorist bombings in the Middle East, it is
not inconceivable that other urban areas should prepare for the same. This article
bears review.
81 Fabian TC: What’s new in trauma and critical care. J Am Coll Surg 2001,
192:276–286.
82 Pepe PE: Current issues in resuscitative trauma management: an overview.
Curr Opin Crit Care 2001, 7:409–412.
83 Eckstein M: Termination of resuscitative efforts: medical futility for the trauma
patient. Curr Opin Crit Care 2001, 7:450–454.
84 Better OS: Rescue and salvage of casualties suffering from the crush syn-
drome after mass disasters. Mil Med 1999, 164:366–369.
85 Oda Y, Shindoh M, Yukioka H, et al.: Crush syndrome sustained in the 1995
Kobe, Japan, earthquake; treatment and outcome. Ann Emerg Med 1997,
30:507–512.
86 Sever MS, Erek E, Vanholder R, et al.: The Marmara earthquake: admission
laboratory features of patients with nephrological problems. Nephrol Dial
Transplant 2002, 17:1025–1031.
87 Cioffi WG: What’s new in burns and metabolism. J Am Coll Surg 2001,
192:241–254.
88 World Health Organization, Communicable Disease Surveillance and Re-
sponse: Preparedness for the Deliberate Use of Biological Agents, A Rational
Approach to the Unthinkable. Geneva, Switzerland: World Health Organiza-
tion;2002:1–16. Available online at: http://www.who.int/emc/deliberate_
epi.html. Accessed August 1, 2002.
89 Anesthesia Patient Safety Foundation: APSF Newsletter. Spring 2002,
• 17(1):1–20. Available at: http://www.gasnet.org/societies/apsf/newsletter/
newsletter.html. Accessed August 1, 2002.
A simply written, yet complete overview of the medical issues surrounding the
acute treatment of victims of biologic, nuclear, and chemical terrorism.
90 American College of Radiology: Radiation disasters: preparedness and re-
•• sponse for radiology. Available at http://www.acr.org/departments/
educ/disaster_planning.html. Accessed August 1, 2002.
This is an invaluable resource for both hospital disaster planning and clinical patient
treatment. A copy should be printed and filed in every ICU.
91 Dixon TC, Meselson M, Guillemin J, et al.: Anthrax. N Engl J Med 1999,
341:815–826.
92 Franz DR, Jahrling PB, McClain DJ, et al.: Clinical recognition and manage-
•• ment of patients exposed to biologic warfare agents. Clin Lab Med 2001,
21:435–473.
This comprehensive and well-referenced report is an update to a 1997 Journal of
the American Medical Association article. The authors review the history, signifi-
cance, clinical features, diagnosis, and management of all biologic warfare agents.
93 Martin GJ, Marty AM: Clinicopathologic aspects of bacterial agents. Clin Lab
•• Med 2001, 21:513–548.
A detailed reference with photographs and histology of bacterial agents. For each
agent, the etiology, host range, history, geographic distribution, transmission,
pathogenesis, incubation period, clinical manifestations, sample handling precau-
tions, and diagnostic tests are reviewed.
94 Burgess TH, Steele KE, Schoneboom BA, et al.: Clinicopathologic features of
•• viral agents of potential use by bioterrorists. Clin Lab Med 2001, 21:475–
493.
In this review, the authors discuss the immune and inflammatory responses, as well
as the pathophysiology, diagnosis, and therapy, of viral agents.
95 Borio L, Inglesby T, Peters CJ, et al.: Hemorrhagic fever viruses as biologic
•• weapons: medical and public health management. JAMA 2002, 287:2391–
2405.
Consensus-based recommendations regarding what measures are to be taken by
medical and public health professionals in the event of a hemorrhagic fever virus
outbreak are outlined in this paper.
96 English JF: Overview of bioterrorism readiness plan: a template for health care
facilities. Am J Infect Control 1999, 27:468–469.
97 Sobel J, Khan AS, Swerdlow DL: Threat of a biologic terrorist attack on the
• US food supply: the CDC perspective. Lancet 2002, 359:874–880.
A report reviewing the risks, response, probable agents, and treatment of various
food-borne agents. Also reviewed are the roles of the various governmental agen-
cies that would be involved in the event of an outbreak.
98 Veteran’s Administration and Department of Defense: Biologic induced ill-
ness, radiation induced illness, and chemical induced illness pocket cards.
October 2001. Available for download at: http://www.oqp.med.va.
gov/cpg/BCR/BCR_Base.htm. Accessed August 1, 2002.
99 Broad WJ: U.S. to vaccinate 500,000 workers against smallpox. New York
Times. July 7, 2002:1.
100 Kemper AR, Davis MM, Freed GL: Expected adverse events in a mass small-
pox vaccination campaign. Eff Clin Pract 2002, 5:84–90.
101 Nass M: The Anthrax Vaccine Program: an analysis of the CDC’s recommen-
dations for vaccine use. Am J Public Health 2002, 92:715–721.
102 Annas GJ: Bioterrorism, public health, and civil liberties. N Engl J Med 2002,
346:1337–1342.
103 Münchener Rück Munich Re Group: Topics 2000: natural catastrophes,
the current position. December 1999, pp. 70–82. Available for down-
load at: http://www.munichre.com/customer_relations_e/pdf/
TopicsSH2000engGESAMT.pdf. Accessed August 1, 2002.