Role of Bystanders in Disasters

Disasters occur with or without warning, and they can be “sudden” or “sustained.” With respect to disaster response, the terms volunteer and bystander are often used together, though they are seldom synonymous. When a “sudden disaster” occurs, bystanders witness the event and are among the first to respond. The word bystander is appropriate here referring to a person who happens to pass by or be in the proximity of an event when it occurs and often would have been a victim him- or herself but for chance. They are usually members of the general public, not part of the formal response, and have little to no formal training in disaster management, search and rescue, or advanced first aid. Volunteers , however, may be trained professionals in the first responder or health care communities. Their underlying knowledge and skills in medical care make them useful in disaster response and recovery. They may be associated with a disaster-response organization and be familiar with the “Incident Command System (ICS),” but they often have varied levels of experience and training in disaster response. Unlike “bystanders,” volunteers are usually not the very first to arrive. Other “volunteers” may be entirely untrained in disaster response, but they may have other skills that can assist with disaster recovery. They may also spontaneously present themselves to a disaster site after the event has occurred.

According to the U.S. Federal Emergency Management Agency (FEMA), 95% of all emergencies result in the victim or a bystander providing immediate assistance first. In his testimony discussing government disaster response after Hurricane Katrina, FEMA Administrator Craig Fugate was quoted as saying, “Neighbors are almost always the most effective and most immediate first responders.” All evidence and discussions suggest that emergency managers should reexamine the role of the “bystander” in disaster response and include these very important assets in the planning, response and training for disaster response. It is clear that health, safety, and security are everyone’s responsibility and should not be left to professionals alone.

Historical perspective

Historically, bystanders have been the first providers during disaster incidents worldwide. They have been thought to be effective in disaster response. For obvious reasons, it is very difficult to obtain data for such incidents. There are clear data, however, with respect to everyday life-threatening events, and these data demonstrate bystander effectiveness. “Bystander CPR” has become a part of many communities and has been scientifically proven to be effective. The data clearly show that survival rates are much higher when a bystander immediately initiates CPR after an individual sustains cardiac arrest, compared with survival rates when no bystander CPR was initiated. These conclusions have been repeated in numerous studies throughout many different communities. In addition, there are data with respect to automated external defibrillators (AEDs), which have become part of our culture and can be found in most airports, gyms, sports arenas, police cars, and many public areas. The placement of AEDs throughout these high-traffic areas has provided bystanders with an effective tool capable of assessing for “shockable” arrhythmias and treating them. Studies have demonstrated that this intervention increased survival with intact neurological function from 14.3% to 49.6%. The Heimlich maneuver, taught as a module in CPR training programs, has been performed by many bystanders throughout the world and has alleviated airway obstructions that could otherwise result in death.

Throughout history, bystanders have been recognized for completing the majority of rescues following documented disasters, and they have been credited with increased survival rates. There are numerous documented examples:

1.

June 17, 1978: The showboat Whippoorwill was struck by a tornado in Kansas, causing the boat to capsize. Out of the 58 passengers and crew, 16 people perished from drowning. Nearby recreational boaters acted as “search and rescue” and were responsible for all of the lives saved.
2.

July 16, 1979: Following a tornado in Cheyenne, Wyoming, an estimated 29% of the total search-and-rescue effort was completed by individuals not affiliated with any emergency organization.
3.

July 7, 2005: Following the London bombings, bystanders performed most of the triage at the Edgeware Road site, one of the four main triage sites, as overwhelmed emergency responders were busy at the other major triage sites.
4.

April 22, 1992: A series of 10 gasoline vapor explosions occurred in the sewers in Guadalajara, Mexico, killing 252 people and injuring nearly 500 more. Bystanders (with no formal training) formed search-and-rescue teams, using car jacks to lift rubble and garden hoses to siphon air to their entrapped neighbors.
5.

March 20, 1995: following the sarin gas attacks in the underground system in Tokyo, numerous accounts of bystanders and mildly injured passengers assisting more seriously poisoned passengers to hospitals were documented.
6.

September 11, 2001: New York City was one of a number of sites attacked by terrorists. As buildings burned and rubble fell, many bystanders helped others evacuate the World Trade Center areas before the buildings collapsed. Some perished as a result of their heroic efforts, as was the case with equity trader Welles Crowther. As with many of the other bystanders who saved thousands of lives that day, he was credited with saving the lives of at least 18 people. Throughout the world that day, more than 250 international flights inbound to the United States were ordered to be grounded. As a result, more than 43,000 passengers and crew were diverted and forced to land at 15 Canadian airports. In each of these cities, armies of bystanders and volunteers assisted the stranded passengers and crews with food and shelter.
7.

January 12, 2010: Haiti was struck by a devastating major earthquake. A survey of people who were victims of the earthquake showed that more than 90% were either “self-rescued” or rescued by bystanders.
8.

April 15, 2013: Lone terrorists used homemade bombs at two different sites close to the finish line of the Boston Marathon. Bystanders used shirts and belts as tourniquets and applied direct pressure to staunch bleeding. They assisted victims to the first aid tents and comforted those around them. Those with medical training began triaging victims. They are credited with saving many lives that day.

These and other accounts highlight the importance of bystanders with respect to disaster response and decreased mortality. The roles are endless and can successfully include critical search and rescue, extrication, water rescue, immediate lifesaving first aid, hemorrhage control, splinting of suspected fractures, triage and transportation of victims to definitive care centers, comforting victims and their relatives, and the provision of food and shelter.

Current practice

Disaster response usually begins after bystanders, witnesses, or victims alert the response agencies. In the United States, Canada, and the Cayman Islands, response agencies are notified via the 911 system. Throughout the European Union, Russia, Ukraine, and Switzerland, activation is by the 112 system. In some Caribbean countries and countries with British influence, 999 is used for activation. In Mexico, separate numbers are used for Police (#066), Fire (#068), and emergency medical services (EMS) emergencies (#065). Immediate disaster response is initiated at the local level. When needs exceed resources, official requests can be made to adjacent local communities or jurisdictions for mutual aid response. As the size of a disaster and needs increase, assistance can be requested from city, county, regional, state, and, ultimately, federal resources. If the initial disaster occurs on federal property, such as the Murrah Federal Building Bombing in Oklahoma City, federal officials would be more directly and immediately involved.

Sudden onset disasters (earthquakes, building collapses, and explosions) usually result in uninjured or minimally injured bystanders stepping forward and initiating evacuation, scene control, hemorrhage control, search and rescue, CPR, and many other roles. It is usually not possible to predict the timing of an event, its location, or the presence of bystanders. This makes planning for bystander action difficult, and therefore a confusing issue, with reliance on bystanders as a part of the formal response. For disaster incidents occurring in remote locations, however, the response time of professional rescuers is likely to be delayed, often by hours, and bystander action is critical for survival. For example, a towboat outside of Mobile, Alabama, in 1993 struck the Big Bayou Canot Bridge, displacing it and the attached rails. The oncoming Amtrak train, the Sunset Limited , struck the deformed rails, derailed, fell into the swamp, and caught fire. Because of the remote location and heavy fog, it took the Coast Guard 1 hour and 40 minutes to arrive, and the first rescue helicopter arrived an hour after that. By then, 28 individuals were rescued by the crews of the towboat and a second boat.

By all historical accounts, bystanders have various levels of training in first aid, CPR, and disaster response. It is thought that those who are trained can contribute more effectively. It is therefore in the best interest of the public that individuals are trained in such basic skills. This seems like a daunting task, but it is not without precedent. In 2009, 40% of cardiac arrest patients received bystander CPR, up from 28% in 2005. Programs teaching Basic Life Support (BLS) and CPR are common, so that people who witness a cardiac arrest can initiate assistance quickly, prior to the arrival of first responders. Public access defibrillation enhances survival as well. Using CPR training of the lay public as a model demonstrates that other skills training of the public could benefit victims injured in disasters. In the setting of disasters, it is unlikely that first responders will be able to respond to all 911 calls associated with a major disaster, and response times in remote locations will be long. Individuals can initiate search and rescue, hemorrhage control, and advanced first aid in their absence. This realization formed the basis for the development of such programs as the Community Emergency Response Teams (CERTs) in earthquake-prone Southern California. The training conducted as part of CERT also promotes safety in earthquake zones, to prevent further injury. The use of simple shoring techniques for urban search and rescue and victim extrication, hard hats, and instruction in triage principles have been found to be effective. It is important to note that not all experts see the importance of utilizing laypersons in disaster response, and some continue to separate these people from incidents. Experts have presented data and descriptions of many actual disaster situations and have discussed the pros and cons to both management styles. As the debate ensues, one thing is apparent: the usually large number of people immediately available for rescue at many scenes is an untapped resource. Any efficient and organized use of this immediate workforce is clearly beneficial.

Internationally, disasters are frequent, whether natural or human-made. Hurricanes, earthquakes, tsunamis, tornadoes, and other weather-related catastrophes seem more prevalent, and there is an expectation of the growing public for a proper response. There is also an interest and thirst for knowledge with respect to disaster management. We have entered a worrisome new world of human-made disasters over the last few decades. With the current “War on Terror,” attacks must be on everyone’s mind and not just the planners of such events as mass gatherings. The 2013 Boston Marathon Bombing clearly showed this. In addition to the well-drilled EMS and police agencies attending such incidents, the importance of bystander actions were never more apparent. The blast and ballistic injuries resulted in significant life-threatening hemorrhage, and the swift use of tourniquets (proven by the military to drastically reduce the number of preventable deaths from battlefield gunshot and blast injuries) by bystanders was lifesaving. Despite multiple explosions, many bystanders also assisted injured runners and observers to the medical tents, thereby saving lives. Another example of layperson training can be found in Ghana. This country does not have an EMS system, so the ever-present taxi cab and truck drivers were trained in initial first aid, splinting, airway management, and hemorrhage control. They now account for the transportation of many, if not most, trauma victims to hospitals in that country.

According to FEMA, the National Response Framework utilized in the United States provides context for how the entire community works together after a catastrophic event. The response effort cannot be from the government alone, and it is the residents of the affected communities that come together to help in the most-expedient way. The National Response Framework is organized into five disaster-preparedness mission areas: prevention, protection, mitigation, response, and recovery. Bystanders and people of the community need to be a part of each of these phases and must be prepared through training and discussion. In the United States, it is recognized that bystanders often assume the role of the true first responders. Thus there are efforts to improve their capabilities with the hope that this would lead to better response to any catastrophic event. On local levels, however, bystanders are often forgotten in many emergency-management plans and drills. It is well documented and understood that disaster situations often overwhelm Fire, Police, and EMS personnel. Despite this, few emergency plans include the use of bystanders as initial assets in a disaster. They also fail to recognize bystanders in the roles as already discussed. Disaster response has a few goals including decreasing morbidity and mortality, minimizing loss of property, and promoting recovery. Achieving these goals often requires efficient use of all available resources, including bystanders and volunteers. Coordination of bystanders, often accompanied by spontaneous volunteers, will have an effect on the efficiency of this response. Involvement of the community in their own disaster response also promotes the resiliency of the community. In one interview survey, volunteers and nongovernmental organizations (NGOs) were described as adhesives for connecting people together or connecting various activities together, and as catalysts for reconnecting the affected area with the rest of the world. The article also stated, “As various people and activities became connected, new relationships came into being. Relationships thus formed while dealing with a disaster together may have commercial and cultural significance and might help the affected area recover.”

Bystanders are usually present, and they play some part in disaster response, regardless of any invitation. Their presence at the scene can have positive or negative effects, depending on how they are utilized. Bystanders and volunteers at the site of an incident often remain unused and idle, despite their motivation to help. Upon arrival of Police and EMS to any incident, the usual protocol is to set up a perimeter with yellow tape. Although designed to keep the public out, this may effectively block further assistance of willing bystanders or highly trained volunteers at a scene. Valid reasons for this include: decreased risk of injury to bystanders, decreased legal and forensic ramifications, inability to verify credentials, risk of looting of victim personal property if the scene is not controlled, and prevention of imposters who can harm the victims. This last point includes prevention of secondary devices on a scene intent to harm rescue workers. Realistically, bystanders and volunteers will initiate their own missions, which are often parallel, redundant, and obtrusive to public safety responders if they are not properly utilized. In some instances, collective behavior emerges, with victims forming their own spontaneous work groups, with rules, guidelines, and spontaneous leadership. In Oklahoma City following the federal building bombing, multiple triage sites were initially set up, on different sides of the building, each unaware of the others’ existence.

Realistically, any government response will be limited and delayed for many individuals. This is usually a matter of resource allocation, access to the incident, and the scale of the event. First responders are therefore family, friends, neighbors, and “Good Samaritans.” In any incident, the greatest opportunity to save lives is in the first couple of minutes or hours, usually prior to the arrival of the organized local response. It is important to remember that a federal response usually takes up to 72 hours to fully organize and to access the affected area. Therefore bystanders play a major role in limiting avoidable and unnecessary deaths. Avoidable deaths are moderate injuries that, without treatment, cause death within hours, such as continuous bleeding from an open wound. Saving the lives of these victims is possible through early detection, first aid, and rapid evacuation to a medical facility. Statistically, most of these injured patients are saved from the rubble by themselves, family members, neighbors, and other bystanders. Few are saved by professional search-and-rescue forces. “Unnecessary” deaths are victims who become trapped in a confined space under rubble, suffering from minimal injuries or no injuries. If not detected in time, these victims can die from dehydration, heatstroke, frostbite, inhalation of smoke, earthquake aftershocks, and dust or hazardous materials, or they become trampled and crushed while attempts to remove rubble by bulldozers and heavy equipment machines are used. Thus, in the aftermath of an earthquake, many trapped victims may not be pulled out of the rubble and thus gradually die an “unnecessary” death, according to Angus et al. and Ashkenazi. Their findings indicate that the main reason is the sluggish arrival of search-and-rescue teams with domestic and international rescue forces reaching the disaster area too late. In earthquakes, this is the largest population that can be saved if there were sufficient manpower to locate and remove these victims from the rubble. Advocacy for bystander incorporation into response plans for disasters requires that we ask if bystanders will be reliable partners in such a situation. Can their lack of formal training be overcome? Will their involvement in disaster response expose the public and bystanders to unnecessary risk and injury and create increased liability to bystanders? Last, is there consensus in the government and the first responder community on the use of volunteers in disaster response? Through research, change in legislative policy, public education, and proper coordination with officials involved in local disaster planning, the integration of bystanders in disaster response can lead to improved outcomes in disaster response, resulting in decreased morbidity and mortality associated with any catastrophic event. We must not only educate the public to become active partners in a disaster response but also train first responders to organize, manage, and harness the talents of bystanders ( Box 47-1 ).

Box 47-1

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