Mass Medical Care with Scarce Resources: A Community Planning Guide (continued)

Chapter 1. Introduction

The Context: A Mass Casualty Event

In the event of a catastrophic public health or terrorism-related event, such as an influenza pandemic or the detonation of improvised nuclear devices, the result is likely to be tens of thousands of victims whose needs will overwhelm the resources of a community's health care system. Indeed, if the event incapacitates health care workers, damages facilities, or destroys supplies, the capacity of the health care system to respond to the tremendous surge in demand for its services already may be severely compromised. If other communities are faced with similar demands (as would be the case in an influenza pandemic or a nuclear detonation, for example), the arrival of additional health care resources, including assistance from the Federal Government, likely would be significantly delayed. Additional resources may not arrive at all.

In this dire scenario, which we refer to as a mass casualty event (MCE), it will be necessary to allocate scarce resources in a manner that is different from normal circumstances but appropriate for the situation if the health care system is to remain functioning and save as many lives as possible. Making optimal decisions concerning the allocation of scarce resources in an MCE could make a big difference in the degree to which health care systems continue to function; ultimately it could save many thousands of lives.

Types of MCEs

In general, MCEs can be organized into two categories:

  1. Those that result in an immediate or sudden impact.
  2. Those that result in a developing or sustained impact.

A schematic representation of the two types of MCE is shown in Figures 1 and 2; this is for illustrative purposes only, as the duration and magnitude of the two events would vary.

The first category of MCE includes events such as the detonation of a bomb or a series of dirty bombs, airplane or train crashes as a result of bombings, and earthquakes. This immediate impact category is characterized by large numbers of casualties at the outset of the event that generally taper off. In some cases there may be a second wave of casualties due to depleted resources or such factors as secondary exposure to natural elements, unclean water, and contagious diseases.

The second MCE category features events such as a massive exposure to anthrax or smallpox. Another example of this second type of MCE, and one that we discuss in detail in Chapter 8 of this guide, is the potential case of an influenza pandemic, in which there would be a gradual increase in the number of people affected, rising to a catastrophic number of patients. In this type of MCE, the number of cases may decline due to treatment and prophylactic efforts, for example, only to increase due to reinfection with a different strain or as a result of an additional wave or waves of the disease. This second type of MCE would necessitate a more sustained response, as the impact would be felt over a much longer period than the immediate-impact MCE.

Planners also need to consider situations in which the event destroys essential infrastructure (such as a nuclear detonation or natural disasters such as Hurricane Katrina), resulting in a crisis requiring a mass migration of survivors. In such circumstances, the delivery of basic care should be contingent on the recognition that all victims of a disaster should be accorded basic humanitarian rights, including "the right to life with dignity." In the international disaster response arena, the Sphere Project has developed "minimum standards" in six critical areas—water supply, water sanitation, nutrition, access to food, shelter, and health care services—required for all victims of disaster. It would be useful to consider these minimum standards in the context of MCE response planning.

The Sphere Handbook is available on the Web at

It is also important for planners to consider relaxation of standards for emergency medical services (EMS), for instance, when and if these resources are scarce or unavailable. This approach would facilitate evacuation of survivors, which may be the primary life-saving intervention. Such relaxation of standards might include reducing the number of personnel required per vehicle, using nonstandard vehicles, and using nonprofessionals as volunteer drivers, for example.

Planners also need to consider relieving pressure on EMS systems during an MCE by using call centers (e.g., poison centers, nurse advice lines, public health hotlines, etc.) to answer the public's questions and address their concerns. These issues are discussed further in Chapters 4 and 5 of this guide.

Planners should recognize an important distinction in the level of preparedness between the two types of MCEs. The sudden impact MCE—explosions and train bombings, for example—is unpredictable and requires an immediate response in terms of the need to triage and temporize until the necessary resources arrive. In the case of a developing MCE, the rising numbers of victims poses significant resource problems if the MCE is nationwide. The impact of an influenza pandemic, for example, could be considered predictable, and preparedness planning efforts could be made to mitigate its impact through prevention and public education.

Thus, planners need to be aware of the important distinctions between the two types of MCEs, as well as the implications of these distinctions in terms of the demands on the health care system and the type of response required. Regardless of the type of MCE for which planners are preparing, however, planning must occur prior to the event.

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Advance Planning—Guiding Principles

Regardless of the type of MCE, advance planning is critical Thus, the purpose of this guide is to provide State and community planners with information, recommendations, and resources that can encourage and support MCE planning efforts.

To inform the development of this guide, the authors referred to the recommendations of a 2004 expert panel,1 which articulated five principles that should steer the development of MCE response plans.

Guiding Principles

Principle #1: In planning for an MCE, the aim should be to keep the health care system functioning and to deliver acceptable quality of care to preserve as many lives as possible.

Principle #2: Planning a public health and medical response to an MCE must be comprehensive, community based, and coordinated at the regional level.

Principle #3: There must be an adequate legal framework for providing health and medical care in an MCE.

Principle #4: The rights of individuals must be protected to the extent possible and reasonable under the circumstances.

Principle #5: Clear communication with the public is essential before, during, and after an MCE.

These guiding principles have served as the framework for the development of this planning guide. They have helped formulate the topics of specific chapters and also are applied across all chapters.

Principle #1 has set the foundation for each chapter's discussions within the context of the fundamental tenets of maximizing good outcomes for the greatest number of people while having agencies, organizations, and individuals act in good faith to meet their duties and obligations in the face of an MCE. This first principle provides the underpinnings for the ethical, legal, and practical planning considerations relating to the allocation of scarce resources in a catastrophic situation. Discussions regarding this principle have included the question of what becomes of those individuals who cannot be saved or are not expected to survive as a result of the MCE episode itself or because of the lack of resources. Thus, the issue of providing palliative care to the individuals who cannot be saved has been integrated into planning considerations throughout this guide and also constitutes a separate chapter (Chapter 7).

Principle #2 touches on an underlying reality of disaster management, which is that catastrophic events need to be handled at the lowest possible geographic, community, and jurisdictional levels with clear advance plans for the local and regional coordination of available services, staff, and resources. The themes of comprehensive incident management, coordination, and regionalization are central for MCE planning, and they are discussed throughout the chapters of this planning guide.

Principle #3 addresses legal issues associated with providing care in an MCE and the resulting decisions regarding the allocation of scarce resources. These issues are the focus of Chapter 3.

The rights of individuals, which are addressed in Principle #4, constitute the basis of Chapter 2. That chapter looks at the ethical issues involved in planning and responding to MCEs.

The importance of Principle #5, communicating with the public, is recognized throughout numerous considerations and recommendations related to managing the "worried well," sharing reliable information and instructions with the public, and emphasizing the role of home care and individuals in supporting the health care demands of an MCE. In addition, the issue of developing and testing communication mechanisms to link MCE responders, health systems and institutions, public health, and local authorities also constitutes an area of focus throughout this guide.1

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Advance Planning—Overarching Themes and Recommendations

In the event of a catastrophic MCE, whether an immediate or a developing one, community planners will face the challenge of allocating scarce resources quickly enough to prevent undue illness and death. As the following chapters of this guide indicate, to prepare for such an eventuality planners need to take several steps.

Be Proactive. Good planning must be undertaken ahead of time. Planners should anticipate to the degree possible the types of health care needs and resource shortfalls that will occur, and they must identify policy and operational adjustments that will need to take place in response. Many useful planning lessons can be learned and applied from real case responses to natural and manmade events in the United States and abroad (e.g., Hurricanes Rita and Katrina in the United States, the London public transport bombings, the Madrid train bombing, the 2004 tsunami in southern Asia).

Build and Maintain Relationships. It is important to unite and forge partnerships, memoranda of understanding, interhospital agreements, and other relationships with key stakeholders from the health care system, emergency management system, State and local public health systems, local emergency responders, emergency medical services, home health care, and other medical providers; volunteer agencies; public safety agencies; and other public and private partners at all levels (State, local, regional, and Federal).

Establish Regional and Local Multiagency Coordination. Public and private health agencies, facilities, and responders must have a common vision within their cooperative regional area for how they will function during a disaster. Regional coordination may involve regions within or between States, particularly when a metropolitan area is situated in more than one State. Multiagency coordination may take the form of a planning committee, an extension of a Metropolitan Medical Response System, or something else. The key is that it provides a mechanism for cooperative coordination of activities, resources, and policy across multiple agencies and jurisdictions.

Devise, Model, and Exercise MCE Response Plans. Plans must include ways to increase surge capacity in anticipation of large numbers of patients needing care in the face of scarce resources. Stakeholders should understand and practice the processes that responders and health facilities will use to request resources from each other, from supply vendors, from special stockpiles, and from emergency management contacts. Opportunities such as special events (e.g., major sporting events, political conventions) can be used to test disaster planning. Plans should be modified and refined continually based on input and lessons from response partners, exercises, and changing conditions.

Establish Clear Channels of Communication to link the public health community, diverse health care entities, and emergency response systems. A process must be in place for sharing accurate, real-time situational information with involved stakeholders across multiple jurisdictions.

Establish Clear Messages and Communications Strategies to inform the public about the status of the event and what actions they should take. It is important to work with the media, 9-1-1 dispatchers, special information lines, and other communications mechanisms to share clear and accurate messages such as the status of the MCE, how individuals should protect themselves and others, when it is safer to stay home, how to provide the best possible care at home, where to go for particular services, and when to go or not to go to the emergency room.

Emphasize Prevention. Planners should recognize the preeminent value of prevention. This is particularly true in MCEs such as an influenza pandemic, where a focus on prevention of transmission is critical to minimize the burden of disease.

Clarify the Process for Leadership and Coordination. It is critical to identify leaders, alternates, and the decisionmaking process for resource allocation and policy guidance.

Identify Existing National and State Tools, Protocols, and Processes for each phase of the MCE. Many products and resources have been developed to help plan for catastrophic events. Numerous examples of these are presented in the chapters of this guide.

Consider the Legal and Ethical Issues Related to Planning and Responding to an MCE. Planners must be familiar with State and local emergency powers and have a solid understanding of what types of events or circumstances would trigger their implementation.

Integrate Palliative Care Strategies Across the Planning Process. Plans should be made for how to care for individuals who are not expected to survive the MCE and how to support the family members and others who are caring for them.

Consider the Financial Implications of Responding to an MCE and the potential need to enact administrative or policy changes to facilitate reimbursement and recordkeeping obligations. Take into account any funding from the Centers for Disease Control and Prevention's Public Health Emergency Preparedness Program and Health Resources and Services Administration National Bioterrorism Hospital Preparedness Program.

Consider Vulnerable Populations. Explicit planning must occur at all levels for vulnerable populations including infants, children, the frail elderly, pregnant women, the disabled and the mentally ill, and those with chronic medical conditions (e.g., cardiac, dialysis, HIV, and oncology patients). Experience has demonstrated that without explicit planning, the needs of these populations will not be adequately met. For example, planners must consider pediatric issues, such as differences in physiology, anatomy, development, and emotions, that require appropriate planning and equipment. Planners must ensure that appropriate expertise is included for vulnerable populations and recognize the value of specialty caregivers.

Develop Robust Security Plans. Security is especially important in the case of a large-scale MCE due to the chaos and confusion such an event engenders. Having a uniformed presence (e.g., hospital security personnel, off-duty police officers, National Guard members, volunteers) helps maintain order as do clear identification tags; visiting rules; and procedures for accessing supplies, service sites, and patients.

Clearly, the optimal allocation of scarce resources in response to an MCE is unlikely to occur without proper advance planning at the institutional, community, State, and Federal levels. Simply put, the goal of this document is to promote and assist in those planning efforts.

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Organization of the Guide

This planning guide is organized as follows:

It is hoped that the information and material presented in this guide will enable community planners to prepare effective MCE response plans.

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