Natural disasters are catastrophic events that occur worldwide. They cause both physical and property damage and overlap disruption of the communication, transportation, and healthcare infrastructure on which humans have come to rely. Disasters often occur when climate hazards and population vulnerability converge, such as coastal dwellers subject to tsunami. During the last 20 years, natural disasters have caused the deaths of more than 3 million people and the destruction of more than $50 billion in property damage. ⁵ In addition, higher concentrations of the population have relocated near risk zones (floodplains, coasts, earthquake faults), exposing them to both the hazard and the resulting overlap infrastructure failure.

Natural disasters are atmospheric, hydrologic, or geologic and may be classified into five types: earthquake, hurricane, tornado, flood, and fire. Almost every state in the United States can expect one or more of these potential hazards at some time in the future. Health impacts of these natural disasters may include: moderate to severe injury, poor nutritional status, respiratory and gastrointestinal (GI) disease from exposure and overcrowding, impacts to mental health that may be permanent, and water-borne illness from the release of chemicals and sewage into drinking water supplies and waterways. ⁹ All have the potential for death, irreversible mental or physical injury, disruption of critical services, and slow recovery back to the predisaster state. In addition, drought, extreme temperature, windstorm, avalanche, and landslide are less frequent but still lethal natural disasters that occur worldwide. The critical stage in a disaster is the immediate phase; the ability of an institution or community to adequately respond with appropriate resources. For example, drought may have long-term effects for decades and cause crop damage, land deforestation and destruction, and the inability to provide food and water for a significant part of the population. However, the onset and duration of a drought are far more insidious than the immediate destruction caused by a tornado. Drought and tornados both cause injury and property damage, yet the initial severity and long-term consequences may differ. Both pose unique challenges to the community and to the responders charged with disaster management.

The transport team has the potential to provide assistance in a natural disaster; however, early response during a severe storm or fire may be impractical because of poor flying or driving conditions. In addition, social unrest after disaster has the potential for unsafe conditions, whether in the air or on the ground. Rioting, looting, and gunfire that occurred during Hurricane Katrina exposed rescue workers to additional harm (Figure 7-1). Both air medical and National Guard helicopters were fired on during early rescue efforts, compromising crew and victim safety and causing some to suspend operations all together. ⁷ The abrupt termination of relief efforts added additional strain to an already tenuous situation, with the removal of assets when they were most needed by the population.

Communicable disease is often catastrophic and accounts for the deaths of millions of people annually. The Centers for Disease Control estimate that in the last 100 years, four pandemics alone have occurred: in 1889, 1918, 1957, and 1968, with the last 3 years virus-containing gene segments closely related to avian influenza. ³ Disease may be further classified into naturally occurring outbreaks, such as measles, mumps, and meningococcal disease; emerging diseases, such as severe acute respiratory syndrome (SARS) and avian flu; and bioterrorism. ³ The circumstances of infection may vary to include type of disease, scale of exposure, transmission method (droplet or contact), and whether the spread is intentional. Identification, response, containment, and prevention of further spread of any disease is critical, especially if it creates a disaster-like scenario with large numbers of victims. The recommendation for any rescue personnel is to identify endemic and epidemic diseases common to the area and review the living conditions of the population to include numbers and the availability of safe water, sanitation, food, shelter, and healthcare.

The Department of Public Health and the Centers for Disease Control have the duty to educate healthcare providers on disease recognition and early reporting to public health agencies, especially if large numbers of victims with similar symptoms are seen in emergency departments. In addition, containment and quarantine with mass prophylaxis may be necessary to keep the exposure controlled. This situation may present in either a healthcare facility or a community-wide outbreak. Separate Infectious Disease Emergency Response plans and teams are available to either contain the outbreak or be integrated into established systems to provide expert help and guidance. ³

Critical care transport teams are an excellent resource during a widespread epidemic. Before any response or contact with patients, the crew must confirm that decontamination and isolation of the patient has occurred to protect the transport team from spread of infection. Furthermore, personal protective equipment (PPE) should be manageable and appropriate for the crew. For example, a self-contained breathing apparatus (SCBA) plus gear is not practical or safe in an aircraft; therefore, patients who need this form of isolation should not be flown. Ideally, respiratory or contact isolation is the most manageable form of PPE for a flight or ground crew and should not interfere with patient, crew, or pilot safety and the ability to work in a small enclosed space, such as a helicopter or ambulance.

Transport programs should create and follow decontamination policies and procedures that support crew, pilot, and patient safety. A predeparture discussion that is oriented to potential unusual situations should be focused on safety. In addition, a general consensus made by transport team members and the pilot or driver of whether to take a request with unusual circumstances should be part of the predeparture discussion and supported by the crew and their administration. Any identified issues made by a team member should not be discounted, even if the opinion is a minority one.

Manmade disasters have similar potential for injury, especially if terrorism is the root cause of the disaster. Engineered intentional chaos and destruction is often successful, especially if the weapon is designed to maim or cause widespread panic or is placed in an area of high population density.

Manmade disasters may be classified as biologic (anthrax, plague); chemical, blood, and nerve agent–related (blister agents, cyanide, and sarin), or nuclear. ⁵ Biologic agents are further classified by the Centers for Disease Control into three categories on the basis of virulence and ability to spread from person to person. Category A agents are of highest concern; they pose risks to national security and safety because of high mortality rates and ease of dissemination. Anthrax, plague, and botulism are among Category A agents. Category B agents are moderately easy to disseminate, are less lethal, and tend to tie up healthcare resources in efforts to identify and treat the disease. Brucellosis and ricin are classified as Category B agents. Category C agents are emerging pathogens that are easily available and have the potential for high mortality rates and major health impacts; hantavirus and lethal influenzas are examples of Category C agents. ⁵

Chemical, blood, and nerve agents are difficult to acquire, are often military in origin, and should indicate to first responders and air or ground medical crews that a terrorist-related event has occurred. Hazardous materials (HAZMAT) incidents are not considered intentional unless the method of delivery or exposure is engineered. First responders should be aware that incidents such as these have issues with scene safety and crowd control. Concise information regarding the agent used should be released to the first responders and air or ground crews by the Incident Commander on scene. Preparation that includes drugs and equipment needed should be made on the basis of the agent, the symptoms, and the number of victims at the scene.

Finally, nuclear disasters may be intentional, such as the deliberate use of nuclear or hospital waste materials in a bomb, or unintentional, such as a reactor incident. Both types of nuclear incidents cause complex injuries that may present immediately or have delayed symptoms and onset. Acute radiation syndrome (ARS) is the technical term for an acute illness that often takes hours to weeks to run its course. Survivability is determined by the victim’s exposure in rads; any exposure of less than 100 rads is survivable, doses of more than 200 rads are possibly survivable, and doses of more than 800 rads are improbable. ⁵ Immediate consideration for the first responder or air or ground medical crew is critical if contamination has occurred. Clothing or radioactive material should be removed immediately as it poses some risk to rescue personnel. However, an irradiated victim who has been decontaminated poses no risk to first responders, so the initiation of airway, breathing, and circulation (ABC) measures should be done without delay. ⁵

The challenge for the first responder is always to decipher whether the incident is accidental or intentional and, if a disease agent is used, whether the outbreak is natural or intentional in nature. For example, a large salmonella outbreak may be a simple food-borne illness from improperly cooked food at a restaurant. However, salmonella was used in the 1990s to deliberately contaminate and sicken a small community in Oregon to engineer the outcome of an election. ⁵ At the other end of the disease spectrum, a smallpox outbreak should be a red flag to first responders; it would signify a deliberate act of terrorism because the last known case occurred in 1978 and stockpiles of the virus only exist in secure laboratories worldwide. ³ First responders and air or ground transport teams should have a general working knowledge of disease and biologic, chemical, and radiologic agents to better understand the hazards and dynamics of the incident before arrival. Written charts should be created and made available to each air or ground crew member to describe the type of exposure, the symptoms, and any PPE or decontamination procedures necessary.

Other manmade disasters, either intentional or unintentional, include failures of bridges, cranes, elevated or tunneled roadways, and power plants, including nuclear accidents. The 2007 failure of the I-35 bridge in Minneapolis is an excellent example of an unintentional manmade disaster. Thirty-one people were caught during rush hour traffic on a bridge that collapsed, resulting in a high fatality rate. Air and ground transport teams were used on the scene to triage and airlift patients to local hospitals.

The air or ground transport team is an excellent resource in such incidents; however, careful attention should be paid to team and pilot or driver safety before arrival. Any exposure-related situation should not affect the rescuer; the patients involved must be decontaminated, and appropriate PPE for the air or ground environment should be issued before patient contact.

The initial confusion present at a disaster can produce additional risk for air medical crews. The convergence of multiple units and the involvement of multiple agencies can lead to communication breakdown and potential hazards. The crew should remember that the presence of multiple casualties and debris may overwhelm other responders and scene safety may be compromised.

Air medical communication centers should attempt to establish contact with the Mass Casualty Incident (MCI) command center and respond in an appropriate manner. They should not respond without being specifically requested.

Effective command and control of the MCI may take some time to establish. During the initial response, in particular, the air medical transport team should take extra precautions to ensure that safety is not compromised. Pilots should make certain that ground personnel select, prepare, and control the landing zone (LZ) in accordance with normal procedures. The need for thorough aerial and even ground reconnaissance should be considered to avoid conflict with disaster operations.

Air medical teams can and should offer and advise the MCI commanders about the full capabilities of their aircraft. Aircraft, especially helicopters, may be used for many roles, including: 1, transport of equipment and personnel to the MCI site; 2, transport of patients to or between hospitals; and 3, provision of aerial surveillance for the MCI coordinators.