Chapter 1: HOSPITAL DISASTER MEDICAL SUPPORT AN INTRODUCTION

A civil emergency or disaster is, at most times, an unforeseen event. To ensure optimal operations and
minimize chaos and allow flexibility in response planning and practice is crucial. This also holds true for
hospitals when having to manage casualties from a disaster site or when having to deal with an internal
disaster.

In many communities, staff of hospitals are liable to be called back to provide various forms of
assistance outside their assigned work hours in the event of a civil emergency. This is part of the
expectations they are held to, and, in some places, part of an Essential Services Act that has been
enacted by the communitys leaders. Basically, any hospitals should be able to manage an influx of more
casualties than the usual daily load, regardless of time of day, nature or duration of the emergency.

Hospital staff need guidance in their response to a civil emergency. Such guidance can only be provided
in the context of a considered hospital response plan for disasters and civil emergencies. All
departments in a hospital need to be committed to managing the casualties brought in the event of an
emergency. There is, thus, a need for hospitals to have disaster plans. These plans should be reviewed
at regular intervals to ensure that they stay current and relevant to the needs of the community. All
hospital staff need to be regularly briefed on their roles in the event of a disaster and participate in
disaster exercises so that they better appreciate the need for their involvement in the disaster
management at the hospital.

Types of Disasters

A hospital can expect to be activated as part of the communitys response to a civil disaster to provide
medical support at the disaster site and even at the hospital. The nature of disasters for which a hospital
may be asked to provide support could vary. Some of these disasters include:

1. Aircrash at the local airport or in the vicinity

2. Major fire incidents
3. Bomb-blast incidents
4. Building collapse
5. Earthquakes
6. Floods
7. Volcanic eruptions
8. Typhoons.
9. Infectious disease outbreak
10. Chemical agent release

NEED FOR LIAISONS AND COORDINATION

Medical treatment of casualties in the event of any of these disasters will be carried out at two main
areas, viz. at the disaster site and at the hospitals / community health clinics. The arrangements for
provision of medical care at the disaster site would usually be overseen the communitys Health Services
Coordinator. Hospitals may be involved in this and may be tasked to send teams to report to a Disaster
Medical Commander at or near the disaster site. The coordination of casualty evacuation from the
disaster site to the hospital may also be undertaken by a local agency best working closely with the
Health Services coordinator and the local hospitals. Other health care agencies in the community may
have special roles in the event of a disaster, such as the Blood Transfusion Service or the Palang Merah
for blood collection, processing and distribution. Therefore a hospital would, in the event of disaster,
need to work with many agencies, some of which are as follows:

1. Ambulance services in the community

2. The rescue services (BaSARNas)
3. The various sites of potential disaster (e.g. airport authority and port authority)
4. The Armed Forces and their various agencies
5. The Police
6. The community blood collection services, such as Palang Merah Indonesia
7. Forensic Services
8. Other hospitals in the community

Such a working relationship is not just to receive calls from them or being notified by them about an
emergency. It has to do with sharing of critical information with them and working arrangements for
prompt care of casualties.

Mission of a Hospital during Civil Emergency / Disaster

The mission of the hospital would be to provide medical support for civil emergency management as
one of the responses of the communitys civil emergency plan. Such support can include care provision
at the disaster site and the hospital.

Concept of Operations

1. The hospital should provide medical teams to the disaster site as and when required
2. The Unit Gawat Darurat and the various departments in the hospital should be prepared to
receive and manage casualties evacuated from the disaster-site, immediately on activation and
should initiate the procedures for these.
3. The hospital should continue to provide medical and nursing care to existing inpatients during a
disaster situation
4. If necessary, the hospital should curtail elective operative procedures and elective specialist
outpatient visits in part or in full immediately on activation of the hospitals civil disaster plan to
ensure that available manpower and logistics resources are channeled to the care of the disaster
casualties.
5. The Hospital should set up its own casualty Information Service to provide needed information
to relatives and other loved ones.
6. For the duration of the disaster, the hospital may choose to adjust their work schedules to cope
with the disaster situation.
Definitions and Terms Used in Hospital Disaster Operations

1. Severity of Disaster and Levels of Disaster Plans

a. Many hospitals identify three levels of severity of a disaster. These are:
i. Minor Disaster: when a mix of no more than 20 casualties are expected from the
disaster site. This may also be referred to a mini-mass incident. Hospitals may
call for activation of their Disaster Plan 20. In this plan, only the Emergency
Department (UGD) and specific departments such as General Surgery and
Orthopaedic Surgery may be required to have additional staff at the UGD .
ii. Moderate Disaster: when a mix of between 20 and 50 casualties are expected
from the disaster site. This would require the mobilization of significant
resources by the hospital. Hospital may call for activation of their Plan 50. The
entire hospital organization may be activated. The hospital will need to decide
on what proportion of their staff would need to be mobilized within the first
hour.
iii. Major Disaster: when a mix of more than 50 casualties would be expected to be
brought to the hospital from the disaster-site. This is a disaster of major
proportions. Hospitals may wish to activate their Plan 100. There should then be
total mobilization and re-allocation of all hospital staff to serve the needs of
disaster casualties arriving at the hospital.

2. Levels of Activation
a. Sometimes hospitals may be activated when information of the disaster may just be
coming in. At that time it may not be clear whether any casualties may be received. It
may however occur that the casualty load may be high. Considering that mobilization of
resources by the hospital would take time and effort, three levels of activation are
usually used. These are:
i. Activate Standby: on this mode only key personnel of the hospital are informed
of the disaster so that the hospital makes initial efforts to get ready their
mobilization resources, get ready to send teams to the disaster site and to
ensure that enough staff will be ready if the activation is activated at short
notice. If the initial information is a hoax or if noted that the number of
casualties are extremely small, then disaster plans may not need to be activated
and the hospital could be stood down with little interference to the lives of
most staff in the institution.
ii. Activate Full Emergency: The Emergency plans are to be activated. The level of
disaster plan to be activated can vary as described earlier. All persons activated
should report to the hospital immediately at designated areas or within one
hour of activation.
iii. Activate Stand Down: This signifies that Disaster Operations are at an end. There
would be no further need for the disaster teams to continue working for the day.
They can complete what they are doing, ensure that all materials being used are
 cleaned and stored appropriately, complete area cleaning, if required, conduct
any immediate debriefs required and be prepared to either return home after
approval of their Head of department, or return to the hospital after approval of
their Disaster Medical Commander.

3. Severity of Casualty

This is used to describe the status of the casualty. This is also known as the triage category. In
disasters three categories of live casualties are used, viz.:
a. Priority 1: These care casualties who are severely injured or seriously Ill and are in
danger of imminent collapse if not attended to immediately on arrival at the UGD. All
these casualties are to be placed on trolleys. The Red colour is usually used for this
group of patients.
b. Priority 2: These casualties have major injuries but are not in danger of imminent
collapse. They will need to be attended to at the UGD within 15 minutes of arrival. They
are also trolley patients. These patients may also be referred to as Yellow casualties.
c. Priority 3: These casualties are ambulant and generally suffer from minor injuries. These
casualties are either walking on their own or may require wheelchairs. It would be
important that a separate area be catered for the initial assessment and management of
the Priority 3 casualties. They are often referred to as Green casualties.
d. Priority 0: In hospitals, this priority is only given to dead casualties. If recognized at
triage, such casualties are not taken to any of the treatment areas in the UGD but
directly to the temporary mortuary or to the Brought-in-dead room at the UGD.

4. Casualty Planning Norms

For planning purposes, the proportion of casualties in a casualty mix is as follows:
a. Priority 1 Casualties 20%
b. Priority 2 Casualties 30%
c. Priority 3 Casualties 50%

When planning for distribution of casualties in a community, it would be prudent to understand

the capabilities of the various hospitals there and allocate the proportion of casualties that each
hospital would be likely to manage. This would be useful for the individual hospitals when they
jointly participate in disaster management, especially from a preparedness perspective. For a
community of 5 million people, it is reasonable to plan for a total casualty load of 1,500 persons.
The communitys Health Service Coordinator would then allocate the number of casualties form
this pool likely to be evacuated to each hospital for further management. Hospitals can then use
the allocated number as a reasonable estimate of the casualty load that they should strive to
manage well. If the hospital wishes to have additional resources for a larger casualty load, then
the level of manpower and logistic resources it will require would need to be coordinated with
the health services coordinator.