The delivery of public health and medical support falls under emergency support function (ESF) #8 of the National Response Framework (NRF). The Department of Health and Human Services (HHS) serves as the primary agency and ESF coordinator for these functions. ESF # 8, however, is one in which the military is likely to be involved. When required, the joint regional medical planner office (JRMPO) of U.S. Northern Command and the defense coordinating officer (DCO) coordinate these services. The joint task force's (JTF) medical planning staff must be in close contact with JRMPO and the DCO as they develop operational plans. There are, however, several acute situations the JTF will likely encounter before it has the opportunity to coordinate with JRMPO and the DCO. These include mass casualty operations, contaminated casualties, and mental health casualties. JTF planners should also be aware of National Disaster Medical System (NDMS). The NRF deploys the NDMS as part of the HHS, Office of Preparedness and Response, under ESF #8 to support federal agencies in the management and coordination of the federal medical response to major emergencies and federally declared disasters.
Mass Casualty Operations
Disaster situations, whether resulting from natural or man-made incidents, can quickly produce large numbers of casualties across a wide geographic area. Large disasters may overwhelm the existing health care systems and produce either a local or area-wide mass casualty (MASCAL) situation. MASCALs are inherently difficult to control, especially across large areas, and contain several major obstacles to the delivery of health care that 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 injuries 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 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 B-1 depicts triage categories used in combat and natural disasters.
Table B-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 B-1 to assist with this process.
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, or eyesight) with minimal expenditure of time, personnel, 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 U.S., 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 B-2 outlines treatment priorities for the different triage categories in the combat and civilian settings.
Table B-2. Treatment priorities in a combat versus 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 (such as sewage or 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.
California, Colorado, Florida, Georgia, Hawaii, Iowa, Illinois, Massachusetts, Minnesota, Missouri, Nebraska, New York, Ohio, Oregon, Pennsylvania, Texas, Virginia, and West Virginia National Guard units have CBRNE-enhanced response force packages (CERFPs) that will be useful in decontaminating civilians. The JTF's medical assets may become involved in these situations.
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-CSTs), and 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. These units will be in place and operational by the time federal military units arrive on the scene of a CBRNE attack.
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
Management of contaminated casualties is complicated. The casualties must be evaluated, and possibly treated and evacuated, while still contaminated. Management of contaminated casualties may include:
Techniques and procedures for contaminated casualty care:
Mental Health Casualties
Disaster incidents produce strong and unpleasant emotional and physical responses in both victims and rescuers. Leaders must proactively institute preventive 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 overdedication to one's task.
One particularly stressful activity is the handling of human remains. Working around human remains may produce feelings of horror, disgust, anger, or guilt. 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
The National Disaster Medical System (NDMS) is a federally coordinated system that augments the nation's medical response capability. The overall purpose of the NDMS is to supplement an integrated national medical response capability for assisting state and local authorities in dealing with the medical impacts of major peacetime disasters and to provide support to the military and the Department of Veterans Affairs medical systems in caring for casualties evacuated back to the U.S. from overseas armed conventional conflicts.
The NRF makes use of the NDMS as part of the HHS Office of Preparedness and Response under ESF #8 to support federal agencies in the management and coordination of the federal medical response to major emergencies and federally declared disasters including:
Components of the NDMS
NDMS is composed of three major teams: disaster medical assistance team (DMAT), disaster mortuary operational response team (DMORT), and national veterinary response team (NVRT).
Disaster medical assistance team
A DMAT is a group of professional and paraprofessional medical personnel (supported by a cadre of logistical and administrative staff) designed to provide medical care during a disaster or other event. NDMS recruits personnel for specific vacancies, plans for training opportunities, and coordinates deployment of the team. To supplement the standard DMATs, highly specialized DMATs are deployed to deal with specific medical conditions such as crushing injuries, burns, and mental health emergencies.
DMATs are designed to be rapid-response elements that supplement local medical care until other federal or contract resources can be mobilized or until the situation is resolved. DMATs deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site. The personnel are activated for a period of two weeks.
In MASCAL incidents, DMAT responsibilities may include triaging patients, providing high-quality medical care despite adverse and austere conditions, providing patient reception at staging facilities, and preparing patients for evacuation.
Under the rare circumstance that 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. DMATs provide community resource available to support local, regional, and state requirements. However, as a national resource they can be federalized.
NDMS/DMAT personnel are required to maintain appropriate certifications and licensures within their disciplines. When personnel are activated as federal employees, licensure and certification are recognized by all states. Additionally, DMAT personnel are paid while serving as part-time federal employees and have the protection of the Federal Tort Claims Act in which the federal government becomes the defendant in the event of a malpractice claim.
Disaster mortuary operational response teams
DMORTs are responsible for:
DMORTs are composed of private citizens, each with a particular field of expertise, who are activated in the event of a disaster. NDMS/DMORT personnel are required to maintain appropriate certifications and licensure within their discipline. When personnel are activated, licensure and certification is recognized by all states, and the personnel are compensated for their duty time by the federal government as a temporary federal employee. During an emergency response, DMORTs work under the guidance of local authorities by providing technical assistance and personnel to identify and process deceased victims.
The DMORTs are directed by the assistant secretary for preparedness and response (ASPR), Office of Preparedness and Emergency Operations (OPEO). Teams are composed of funeral directors, medical examiners, coroners, pathologists, forensic anthropologists, medical records technicians and transcribers, fingerprint specialists, forensic odontologists, dental assistants, X-ray technicians, mental health specialists, computer professionals, administrative support staff, and security and investigative personnel.
The HHS ASPR, in support of the NDMS DMORT program, maintains three disaster portable morgue units (DPMUs). These DPMUs are staged at locations on the East and West coasts for immediate deployment in support of DMORT operations. 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.
National veterinary response team
The NRF utilizes the NDMS, a part of the HHS ASPR, OPEO. Under the NRF, NDMS serves as a component of ESF #8. The NVRT is a cadre of individuals within the NDMS system who have professional expertise in areas of veterinary medicine, public health, and research. In addition to supporting the NRF mission requirements of NDMS under ESF #8, operational support may also be rendered by the NVRT to other federal partners such as the U.S. Department of Agriculture (USDA) under ESF #11, Agriculture, and the Federal Emergency Management Agency under ESF #6, Mass Care, in the support of the Pets Evacuation and Transportation Standards Act, or PETS Act. The NVRT provides assistance in identifying the need for veterinary services following major disasters, emergencies, public health or other events requiring federal support and in assessing the extent of disruption to animal and public health infrastructures. The NVRT is a fully supported federal program. These responsibilities include:
NVRT personnel are private citizens who have been approved as intermittent federal employees and activated in the event of a disaster. The personnel are comprised of individuals with diverse expertise and include veterinarians, animal health technicians, pharmacists, epidemiologists, safety officers, logisticians, communications specialists, and other support personnel. These individuals are assigned to designated teams that train in preparation for a response. They are enabled by a regional cache of equipment, supplies and pharmaceuticals. Personnel are required to maintain appropriate and current professional certifications and licensures for their disciplines. As intermittent federal employees, their licensure is recognized by the states requesting assistance. Deployed personnel are compensated for their duty time by the federal government. In an emergency or disaster response, the NVRTs work using the Incident Command System. Teams provide assessments, technical assistance, public health, and veterinary services under the guidance of state and/or local authorities.