Mass-Casualty/Medical-Surge Capabilities: Closing the Gap


In mass-casualty situations, U.S. emergency managers almost always look to HHS (the Department of Health and Human Services) and its Atlanta-based Centers for Disease Control and Prevention (CDC) to provide leadership, management, and guidance in planning for and building up the medical-surge capabilities needed to cope with particularly hazardous events and incidents. Meeting that difficult challenge, though, requires strong interdisciplinary partnerships involving a long list of public- and private-sector agencies and organizations – including but not limited to emergency medical services as well as fire-service, emergency-management, law-enforcement, public-health, and emergency-medicine agencies. Also, depending on the nature and scope of the incident, blood banks and a broad spectrum of medical units specializing in trauma surgery, burn surgery and care, pediatrics, otolaryngology, intensive-care medicine, hospital medicine, radiology, pharmacology, nursing, hospital administration, and laboratory medicine.

The CDC itself relies primarily on three agencies – the National Center for Injury Prevention and Control, the Coordinating Center for Environmental Health and Injury Prevention, and the Division for Injury Response – to lead the national effort to build up the nation’s overall mass-casualty and medical-surge capabilities. Working in close cooperation with one another, and with outside specialists, those three agencies recently published a number of specific guidelines for building up surge capacity. Those guidelines – spelled out in the publication “In a Moment’s Notice: Surge Capacity for Terrorist Bombings” – represent a major step forward, but also suggest the depth and scope of the capabilities/surge problems still to be resolved.

A Deadly Toll, Plus Continuing Problems Following the Madrid train bombings of 11 March 2004 (which killed 192 and injured an estimated 1,800 other victims) and the London subway attacks of 7 July 2005 (56 dead, 700 injured), as well as other terrorist attacks in recent years – in Iraq, Egypt, India, and Israel, to mention only a few – neweas in enhanced planning and intensive training courses were developed and delivered. Meanwhile, the broad devastation from the detonation of explosive devices in areas of high-density population became ever more clear – and immensely challenging.

In 2005, according to the most recently available worldwide statistical report, more than 8,000 persons were injured by explosive devices of various types, which also caused 3,049 deaths. The consequence-management situations involved in the terrorist incidents and events covered by such grim statistics are extraordinarily complex – and the injuries suffered were, and are, not only technically and medically challenging but also different in certain important particulars from those related to deaths and injuries caused by natural disasters.

One of the most significant differences between injuries caused by terrorist attacks and those resulting from natural disasters is that, after a terrorist attack: (a) most victims leave the scene as soon as possible, and by any means available; and (b) their pre-hospital care is considerably different from that provided after a natural disaster – and very difficult, sometimes impossible, to coordinate.

Another major problem is that hospitals relatively close to the scene of an attack receive scores of potential patients seeking care, often within just a few minutes after the attack has taken place. For example, a hospital relatively close to the Madrid train station at the time of the 2004 bombings received 272 patients in the first couple of hours after the explosions. There was a second wave of victims later, though, because many of those involved in the response and/or who had stayed at the scene to help other victims also needed serious medical attention.

Encouraging Progress, But Numerous Difficulties Remain EMS (emergency medical services) units confront many difficult issues in mass-casualty and medical-surge situations to which emergency managers need to be sensitive. Following are brief summaries of some, but by no means all, of the more difficult problems that have yet to be resolved.

  • The need for personal protection of the responders themselves, the need to establish scene safety, and the potential use of secondary explosive devices – all of which matters were faced in varying degrees in the 1993 bombing of the World Trade Center in New York City – are still being studied but full and final solutions have not yet been found.
  • Decontamination of the incident scene may be necessary – but policies and protocols have not yet been standardized from one jurisdiction to another and/or between one agency and another.
  • Incident-command and interoperability guidelines are more difficult to follow in these situations, partly because the technical problems related to radio interoperability, as well as the overall interdisciplinary aspects of stakeholder communications, have not yet been fully integrated into overall U.S. healthcare and EMS practices.
  • The guidelines for and carrying out of field triage is different from place to place, and no standard “best practices” methodology has yet been determined.
  • “Destination” decisions remain uncertain, particularly if there has been no (or insufficient) advance planning – or if the initial evaluation of the incident scene has not been carried out correctly (or, in some situations – due to fast-breaking events, perhaps – is no longer valid).
  • Hospital evacuations by EMS personnel – usually to free up acute-care beds for the more critically injured victims – is a major hardship for patients, administrators, medical staff, and those moved in as well as those moved out.
  • The sustainability of operations while also maintaining facilities, operations, equipment, supplies, and other crucial resources becomes increasingly difficult as the length of the operational phase of a mass-casualty event extends into the night and the next day, and in many cases much longer.

The most important point to remember from the preceding is not that so many problems remain, but that those problems are now being addressed both more directly and more fully. It also is now abundantly clear that: (1) all disciplines must continue to work together even more closely; (2) considerable progress has in fact been made in recent years, particularly since the 9/11 terrorist attacks against the United States itself; and (3) there is still a very long way to go before, if ever, any nation, or any community, can consider itself to be “fully prepared.”

Kay Goss
Kay C. Goss

Kay Goss has been the president of World Disaster Management since 2012. She is the former senior assistant to two state governors, coordinating fire service, emergency management, emergency medical services, public safety, and law enforcement for 12 years. She then served as the Associate Federal Emergency Management Agency (FEMA) Director for National Preparedness, Training, Higher Education, Exercises, and International Partnerships (presidential appointee, U.S. Senate confirmed unanimously). She was a private sector government contractor for 12 years at the Texas firm Electronic Data Systems as a senior emergency manager and homeland security advisor and SRA International’s director of emergency management services. She is a senior fellow at the National Academy for Public Administration and serves as a nonprofit leader on the Board of Advisors for DRONERESPONDERS International and for the Institute for Diversity and Inclusion in Emergency Management. She has also been a graduate professor of Emergency Management at the University of Nevada at Las Vegas for 16 years, İstanbul Technical University for 12 years, the MPA Programs Metropolitan College of New York for five years, and George Mason University. She has been a Certified Emergency Manager (CEM) for 25 years and a Featured International Association of Emergency Managers (IAEM) CEM Mentor for five years, and chair of the Training and Education Committee for six years, 2004-2010.



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