Casualty Considerations, Tactics, Techniques, and Procedures
The delivery of public health and medical support falls under emergency support function (ESF) #8 of the National Response Plan (NRP). The Department of Health and Human Services (DHHS) serves as the primary agency for these functions; nevertheless, this ESF is one in which the military is likely to be involved. When required, the Joint Regional Medical Planner Office (JRMPO) of Northern Command (NORTHCOM) and the defense coordinating officer (DCO) coordinate these services. The joint task forces (JTF) medical planning staff must be in close contact with these offices as they develop their operational plans. However, there are several acute situations that the JTF will likely encounter before it has the opportunity to coordinate with these offices. These include mass casualty operations, contaminated casualties, and mental health casualties. Also, JTF planners should be aware of National Disaster Medical System (NDMS), a Federal Emergency Management Agency (FEMA) organization responsible for supporting and coordinating the federal medical response to disasters.
Mass Casualty (MASCAL) Operations
Disaster situations, whether the result of natural or man-made incidents, can quickly produce a large number of casualties across a widespread geographic area. This may, in turn, overwhelm the existing health care system and produce either a local or area-wide MASCAL situation. MASCALs are inherently difficult to control, especially across large areas, and contain several major obstacles to the delivery of health care which the JTF must plan for and overcome. These obstacles include:
Techniques and procedures to overcome obstacles to care
The key to managing MASCAL situations is triage. Triage is the process of sorting casualties based on the severity of injury and assigning priorities of care and evacuation in a situation with limited resources. The goal is to provide the greatest good for the greatest number of casualties. Medical providers, at all levels of care, must institute a uniformed system to classify casualties and assign treatment priorities..
Triage categories. Triage categories were originally developed for MASCAL management in combat environments. Most military medical personnel are familiar with this system. The same principles apply to the civilian disaster setting, with the major differences being primarily terminology and priority assignment. Table A1-1 depicts triage categories used in combat and natural disasters.
Table A2-1. Triage categories, combat vs. civilian casualties
Assigning triage categories. Medical personnel must rapidly assess casualties and assign triage categories. A systematic process should be in place to ensure proper identification occurs. A simple algorithm is suggested in Figure A1-1 to assist with this process.
Figure AB-1: Assigning triage categories
Treatment priorities. When assigning treatment priorities, the first to receive care are those in most critical need (where there is an expectation that an intervention will prevent loss of life, limb, and/or eyesight) with minimal expenditure of time, personnel, and/or other resources.
In the combat setting, triage principles dictate treating casualties in the expectant category after all other wounded; thus expectant casualties have a high likelihood of dying. Civilian medical personnel, especially in the United States, view this as an unreasonable approach. It is unlikely that resources would be so constrained such that the seriously wounded should have care delayed for any significant amount of time. It is unreasonable to expect rescuers to condemn expectant casualties when not in a tactical combat environment.
Table A2-2 outlines treatment priorities for the different triage categories in the combat and civilian settings.
Table AB-2. Treatment priorities in a combat vs. civilian MASCAL setting
Management and treatment
Every medical unit or facility that responds to a disaster situation requires a MASCAL plan appropriate to their unique operational needs and situation. However, there are several characteristics that are consistent for all MASCAL operations:
Techniques and procedures for MASCAL and triage
For further, more detailed information on triage and MASCAL, see:
During disaster events, casualties may become contaminated by either a chemical, biological, radiological, nuclear, high-yield-explosive (CBRNE) attack or from exposure to hazardous industrial waste (e.g., sewage, oil spills). In these instances, casualties must be decontaminated before entering any treatment facility; otherwise the treatment facility itself will become contaminated. First responders will decontaminate and treat the majority of these casualties in the initial hours after the event.. However, if recovery operations continue in a contaminated area, there will be an ongoing need to decontaminate and treat casualties. The joint task force's (JTF) medical assets will become involved in these situations.
Radiological (i.e., a dirty bomb) and biological weapons generally only impact the individual casualty, and this type of contamination is unlikely to spread to others. Biological and radiological contamination is usually eliminated with soap and water, and is of little tactical significance to casualty care. Likewise, industrial toxins and wastes are also easily cleaned by simple washing procedures. These types of contamination can be handled by routing casualties through washing and monitoring stations prior to them entering a treatment facility. Chemical casualties, with their potential to contaminate other personnel and facilities, require detailed decontamination plans.
Casualty decontamination is labor-intensive and requires augmentation personnel and additional, or specialized, equipment. It slows the process of casualty evaluation and treatment and is physically demanding of medical and rescue personnel. These negative impacts can be minimized with proactive planning.
Due to the abrupt, immediate nature of a CBRNE event, the initial responders will be local hazardous material (HAZMAT) units and state National Guard units. The National Guard has established weapons of mass destruction (WMD) civil support teams (WMD-CST), and chemical, biological, radiological, nuclear, or high-yield-explosive enhanced response force packages (CERFP). The WMD-CST mission is to support local and state authorities at domestic CBRNE events, identify agents and assess consequences, and advise local authorities on response measures and requests for military assistance. The primary missions of the CERFPs are casualty decontamination and triage and SAR in contaminated environments. In all likelihood these units will be in place and operational by the time federal military units arrive on the scene of a CBRNE attack. Therefore, these units act as an advance party for other military units.
The specific technical aspects of casualty decontamination exceed the scope of this handbook, but the following general concepts apply to all operations:
Key Elements of Casualty Decontamination
The management of contaminated casualties is complicated in that they must be evaluated and, possibly treated and evacuated, while still contaminated.
Techniques and procedures for contaminated casualty care
For further information on the specific details of casualty decontamination, see:
Mental Health Casualties
Disaster incidents produce strong and unpleasant emotional and physical responses in both victims and rescuers. Leaders must proactively institute preventative measures, and apply appropriate psychological first aid when indicated. The symptoms of psychological stress that rescuers and victims may experience include: confusion; fear and anxiety; hopelessness, helplessness, or sleeplessness; anger; grief, guilt, or shock; aggressiveness or mistrustfulness; loss of confidence; physical pain; or over-dedication to ones task.
One particularly stressful activity is the handling of human remains. Working around human remains may produce feelings of horror, disgust, anger, or guilt, to name a few. Many feel very strong emotions when confronted with the remains of children or when the victims remind them of loved ones.
The goal of psychological first aid is to mollify the range of emotions and physical responses experienced by personnel exposed to a disaster. The main tenets of care are to create and sustain an environment of safety, calm, connectedness to others; self-efficacy; and hope.
Techniques and procedures for psychological first aid:
Techniques and procedures for psychological first aid during the handling of human remains:
National Disaster Medical System (NDMS)
The NDMS is a federally coordinated system that augments the nations medical response capability. The overall purpose of the NDMS is to establish a single integrated national medical response capability for assisting state and local authorities in dealing with the medical effects of major peacetime disasters. The NDMS may be activated for:
Its mission is to design, develop, and maintain a national capability to deliver medical care to the victims and responders of a domestic disaster. NDMS provides medical care at a disaster site, in transit from the impacted area, and at participating definitive care facilities.
Regional offices for NDMS
Under the NDMS are several unique medical teams:
FCCs recruit hospitals; maintain local hospital participation in the NDMS; and, during system activation, coordinate the reception and distribution of patients being evacuated from the disaster area.
In most cases, patients are evacuated out of the disaster area by the Department of Defense (DOD) Aeromedical Evacuation System (AES), which is operated by the Global Patient Movement Requirements Center (GPMRC), of the U.S. Transportation Command. In the event of a disaster, the GPMRC is tasked to deploy the Immediate Response Assessment Team (IRAT). The IRAT determines the need for patient evacuation. If there is a need, a mission tasking order is issued to DOD, and FCCs are activated. GPMRC then issues instructions to the FCCs for the reporting of available beds. Simultaneously, patient information is gathered at the disaster site and forwarded to GPMRC through the IRAT. GPMRC determines to which FCCs the patients will be moved based on the victims needs, beds available, and transportation availability. GPMRC coordinates with the IRAT and other deployed DOD transportation elements at the disaster site to ensure smooth air operations.
The NDMS provides victim identification and mortuary services. These responsibilities include:
DMORTs are responsible for this mission. DMORTs are composed of private citizens, each with a particular field of expertise related to mortuary affairs (e.g., funeral directors, medical examiners, forensic scientists, etc.). During an emergency response, DMORTs work under the guidance of local authorities by providing technical assistance and personnel to recover, identify, and process deceased victims.
In support of the DMORT program, FEMA maintains two Disaster Portable Morgue Units (DPMUs). Both DPMUs are staged at FEMA Logistics Centers, one in Rockville, MD and the other in San Jose, CA. The DPMU is a depository of equipment and supplies for deployment to a disaster site. It contains a complete morgue with designated workstations for each processing element and prepackaged equipment and supplies.
Specific contact information for specific region team leaders can be obtained at the following Website: http://oep-ndms.dhhs.gov/dmort.html
A DMAT is a group of professional and para-professional medical personnel (supported by logistical and administrative staff) designed to provide medical care during a disaster or other event. Each team has a sponsoring organization, such as a major medical center, which assembles and coordinates the team. DMATs are designed to be a rapid-response element to supplement local medical care until other federal or contract resources can be mobilized, or the situation is resolved.
DMATs are principally a community resource available to support local, regional, and state requirements. However, as a national resource they can be federalized to provide interstate aid.
DMATs deploy to disaster sites with sufficient supplies and equipment to sustain themselves for up to 72 hours of operations. In mass casualty incidents, their responsibilities include triaging patients, providing medical care at the disaster site, and preparing patients for evacuation. In other types of situations, DMATs provide primary medical care and serve to augment overloaded local health care staffs. In the circumstance where disaster victims are evacuated to a different locale to receive definitive medical care, DMATs may be activated to support patient reception and disposition to hospitals..
To supplement the standard DMATs, there are highly specialized DMATs that deal with specific medical conditions such as crush injuries, burns, and mental health emergencies.
The NDMS is directed to provide assistance in assessing the extent of disruption and need for veterinary services following major disasters or emergencies. These responsibilities include:
In order to accomplish this mission, veterinary medical assistance teams (VMATs) were developed and are composed of clinical veterinarians, veterinary pathologists, animal health technicians (veterinary technicians), microbiologist/virologists, epidemiologists, toxicologists, and various scientific and support personnel. During an emergency response, VMATs work under the guidance of local authorities by providing technical assistance and veterinary services.
NPRTs represent hundreds of pharmacy, pharmacy technicians, and pharmacy students located in each of the ten DHS regions who can be activated to assist in the chemoprophylaxis or the vaccination of hundreds of thousands or even millions of Americans.
The National Nurse Response Team is a specialty DMAT that will be used in any scenario requiring hundreds of nurses to assist in chemoprophylaxis, a mass vaccination program, or a scenario that overwhelms the nations supply of nurses in responding to a weapon of mass destruction event.