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Handbook 11-07
December 2010

Appendix B


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:

  • Inappropriate care distribution. Often the first casualties to present for care are the least injured, who then consume all available resources, leaving the most injured without access to lifesaving care. To ensure that medical resources are appropriately allocated across the affected area, care delivery must be prioritized at both the local level and area-wide.
  • Unequal distribution of casualties. Casualties tend to concentrate locally and then present to the nearest health facility. This may overwhelm local facilities, while other facilities in the area are underused. A variation of this pattern is when casualties take themselves to the "preferred" or "better" hospitals, while avoiding all other, closer facilities.
  • Non-emergency medical system responders. The emergency medical system (EMS) is the usual route of entry into the health care system for casualties. In MASCALs, casualties access the system through non-EMS entry points (for example: private means, police transport, and search and rescue [SAR]). This results in multiple, uncontrolled demands for health care and concentrates the demands at nontypical locations (at the SAR delivery point instead of the hospital, for instance). Also, nonlocal responders arrive to help but are not familiar with the local health system, adding to the overall confusion.
  • Lack of interorganizational planning. During major disasters, multiple organizations are involved from both within and outside the local area. They may include local, state, and military personnel; public health organizations, nongovernmental organizations, and charitable organizations; and private citizens. The actions of these groups tend to be uncoordinated, with little or no interorganizational communication.
  • Lack of proper needs assessment. The acute demand for care often results in a rapid deployment of resources to the most critical and closest casualties, without an overall assessment of need. This "ready, fire, aim" approach leads to "wrong help, at the wrong time, to the wrong people" situation. Some areas will receive an overabundance of aid, while others may be completely neglected.

Techniques and Procedures to Overcome Obstacles to Care

  • Coordinate all missions through the JRMPO, coordinate with HHS, and coordinate all other medical assets in the area.
  • Centralize command and control of all military health assets that enter the area.
  • Institute a systematic plan for allocation of medical care at ground zero and across the area.
  • Ensure coordinated and controlled delivery of casualties located by SAR into the established triage system.
  • Coordinate with law enforcement to maintain crowd and traffic control.
  • Communicate with local hospitals to determine capacities and capabilities so that casualty flow from ground zero to higher levels of care can be properly directed.


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

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.

Triage Category:
Combat Setting

Triage Category:
Civilian Setting

Category Description



This group includes those who require lifesaving surgery. The surgical procedures in this category should not be time consuming and should concern only those patients with high chances of survival.



This group includes casualties who are badly in need of time-consuming surgery, but whose general condition permits delay in surgical treatment without unduly endangering life. Sustaining treatment will be required.



These casualties have relatively minor injuries and can effectively care for themselves or helped by nonmedical personnel. Care can be delayed for hours to days.



Casualties in this category have wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resource application, their survival would be unlikely.

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.

Graphic showing  \the assignment of triage categories

Figure B-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, 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.


Combat Casualties

Civilian Casualties













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:

  • Triage area: All casualties should flow through a single triage area. This area should be close to the receiving area (landing zone, ground routes, and decontamination site), have one-way flow, and have clearly marked routes to the treatment areas.
  • Triage officer (TO): Ideally the TO is a surgeon, but must be a person with clinical experience in evaluating casualties. The TO performs a rapid evaluation of every casualty, assigns them an appropriate category, and directs them to the proper treatment area. The TO is assisted by personnel dedicated to identifying, tagging, and recording triage assignments and disposition.
  • Immediate treatment area: This area is set up close to and with direct access to the triage area and is composed of the staff and supplies necessary to administer immediate, lifesaving aid.
  • Non-immediate treatment area: All minor and delayed injuries are directed here. This area is staffed and supplied to treat all non-immediate injuries and to hold casualties awaiting evacuation to a higher level of care (i.e., a hospital).
  • Morgue: This area must be set aside, climate controlled (if possible), and secured from view and interference.

Techniques and procedures for MASCAL and triage

  • Ensure traffic flow is well marked so all casualties enter the triage area at one location.
  • No significant treatment should occur in the triage area. Casualties are sent to the appropriate treatment area for interventions.
  • An administrative recorder should walk with the TO to properly document all casualties in a log and use an indelible marker on the casualty's forehead to mark his triage category.
  • Post an administrative person at the entry of the treatment areas to document and regulate casualty flow.
  • Dedicate someone to re-triage casualties as they enter each treatment area.
  • Have as many nonmedical augmenters as possible available to assist with casualty transport (litter bearers, for example).
  • Shift resources from the triage and emergent area to the nonemergent areas as the casualty flow lessens.
  • Ensure proper rest cycles for personnel, especially if operations continue beyond 24 hours.
  • Be prepared to divert casualties to another facility as resources are exhausted or overwhelmed.

For further, more detailed information on triage and MASCAL, see:

  • Emergency War Surgery, 3rd U.S. revision, 2004, at "".
  • Auf der Heide, Erik; Disaster Response: Principles of Preparation and Coordination; 1989, at "".

Contaminated Casualties

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:

  • Establishing the decontamination site: The casualty decontamination site should be as near to the medical facilities as safety allows, but must not contaminate the facility. When establishing the decontamination site, planners must consider:
    • Wind direction and speed: While the patient decontamination site will be established in a "clean" location, the arrival of casualties and the initiation of decontamination procedures will create chemical vapor and liquid hazards. Wind direction and speed must be constantly monitored to ensure that all clean areas are not contaminated. If the wind direction shifts more than 30 degrees, the decontamination site may need to be moved.
    • Access and movement control: Access to the site must be controlled; otherwise there is the possibility that "dirty" casualties and equipment will contaminate the "clean" areas. There should be one entry point and controlled and limited areas of intersection between the clean and dirty zones. All personnel and equipment must remain in a "dirty" zone until decontaminated.
    • Personnel and equipment: Once personnel and equipment become contaminated, they remain "dirty" until decontaminated. Personnel can and should continue to treat patients and use equipment in the contaminated area for as long as possible. However, operating in this environment is physically demanding and will require additional personnel and the institution of strict work-rest cycles.

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:

  • Dirty triage: Casualties must be triaged upon arrival to the treatment facility while still contaminated. The determination made at this point is not only the immediacy of treatment based on injury but whether the casualty needs to be treated before or after decontamination.
  • Dirty treatment: Some casualties may require immediate treatment before decontamination. A treatment area with supplies and personnel must be established within the dirty area of the decontamination site.
  • Dirty evacuation: Casualties may need to be evacuated while still contaminated. This may be because the patient is minimally injured and does not need decontamination or treatment at the local treatment facility. This could also be because the patient has been stabilized while contaminated, needs further treatment, and it is a better use of resources to evacuate to another facility for decontamination and further treatment. In these cases, there must be dedicated evacuation lanes and equipment that will remain contaminated until the end of operations.

Techniques and procedures for contaminated casualty care:

  • All deploying medical units must prepare to operate in a contaminated environment.
  • Medical units should establish contact with WMD-CSTs and CERFPs prior to entering the area. This will allow for a smooth handoff of responsibilities and ongoing support.
  • Clean versus contaminated areas should be clearly designated in the area of operations.
  • Clean and dirty triage and treatment sites and evacuation lanes must be created.
  • Only casualties requiring treatment at the medical facility should be decontaminated at the facility. All others should be evacuated to other decontamination facilities.
  • The number of personnel at the treatment site may need to be increased because of increased personnel demands in the "dirty" areas.
  • Traffic control points and guards should be pre-positioned to maintain access control to the treatment site.
  • Wind direction should be carefully monitored (stakes with streamers can be used to accomplish this), and plans should be in place to shift the decontamination and treatment sites, if necessary.

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

  • Provide basic needs for food, shelter, and health care.
  • Listen to people's stories.
  • Keep families together.
  • Provide frequent, clear, updated information to victims concerning the disaster itself, the status of relief efforts, and where and how to acquire assistance.
  • Help maintain connection with friends and family. Provide responders with regular communication with family members back home.
  • Be aware of the stress levels of those around you.
  • Provide responders with a rest area for sleep, hygiene, and food that is separate from the public and media.
  • Insist on proper sleep, nutrition, and exercise among responders.
  • Do not force people to share stories.
  • Do not give simple, generalized reassurances (e.g., "everything will be OK.").
  • Do not tell people how they should feel, or "why" things happened to them.
  • Do not make promises you cannot keep.
  • Do not criticize current relief efforts in front of those needing help.

Techniques and procedures for psychological first aid during the handling of human remains

  • Remember the greater purpose of your work.
  • Wear protective clothing, take frequent breaks, and maintain hygiene, hydration, and rest when not working.
  • Talk with others around you and listen as well.
  • Humor relieves stress as long as it is not too personal or inappropriate.
  • Limit exposure to bodies as much as possible.
  • Breath through your mouth to avoid smells.
  • Do not focus on individual victims.
  • Get teams together for mutual support and encouragement.
  • Provide opportunities for voluntary, formal debriefings.

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:

  • Natural disasters.
  • Major transportation accidents.
  • Technological disasters.
  • Acts of terrorism including WMD events.

Components of the NDMS

  • Medical response to a disaster area in the form of personnel, teams and individuals, supplies, and equipment.
  • Patient movement from a disaster site to unaffected areas of the nation.
  • Definitive medical care at participating hospitals in unaffected areas.

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:

  • Temporary morgue facilities.
  • Victim identification.
  • Forensic dental pathology.
  • Forensic anthropology methods.
  • Processing.
  • Preparation.
  • Disposition of remains.

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:

  • Assessing the veterinary medical needs of the community.
  • Medical treatment and stabilization of animals.
  • Animal disease surveillance.
  • Zoonotic disease surveillance and public health assessments.
  • Technical assistance to assure food safety and water quality hazard mitigation.
  • Care and support of animals certified as official responders to a disaster or emergency.

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.



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