Disaster and Mass Casualty Critical Care: Preparedness, Response, and Lessons Learned

Dr Neeraj Manikath , claude.ai

Abstract

Background: Disasters and mass casualty events pose unprecedented challenges to healthcare systems, particularly intensive care units (ICUs). The COVID-19 pandemic, natural disasters, and armed conflicts have highlighted critical gaps in surge capacity planning and disaster preparedness.

Objective: To provide a comprehensive review of disaster and mass casualty critical care, focusing on ICU surge capacity planning, the role of triage officers, and lessons learned from recent pandemics and conflicts.

Methods: We reviewed current literature, international guidelines, and real-world experiences from major disasters and conflicts between 2010-2024.

Results: Effective disaster critical care requires systematic surge capacity planning, well-defined triage protocols, trained personnel, and adaptive resource allocation. Key success factors include pre-disaster planning, staff training, equipment stockpiling, and robust communication systems.

Conclusions: Healthcare systems must develop comprehensive disaster preparedness plans that integrate surge capacity planning, effective triage systems, and lessons learned from recent global events to optimize patient outcomes during mass casualty situations.

Keywords: Disaster medicine, mass casualty, surge capacity, triage, pandemic preparedness, critical care

Introduction

Mass casualty events and disasters represent some of the most challenging scenarios in modern healthcare. These events, whether natural disasters, pandemics, terrorist attacks, or armed conflicts, can rapidly overwhelm healthcare systems and critically strain intensive care unit (ICU) resources. The COVID-19 pandemic starkly illustrated the vulnerability of even well-resourced healthcare systems when faced with sustained surge demands.

Critical care medicine sits at the nexus of disaster response, as the sickest patients require intensive monitoring, mechanical ventilation, and complex interventions that cannot be easily scaled or replicated outside traditional ICU settings. Understanding the principles of disaster critical care is essential for all intensivists, as they may find themselves at the forefront of institutional and regional disaster responses.

This review examines three critical domains of disaster critical care: ICU surge capacity planning, the evolving role of triage officers in disasters, and lessons learned from recent pandemics and conflicts that have shaped contemporary approaches to mass casualty critical care.

ICU Surge Capacity Planning

Conceptual Framework

Surge capacity represents the healthcare system's ability to expand care capabilities in response to sudden increases in patient demand. For critical care, this involves a complex interplay of space, staff, supplies, and systems—the "4 S" model that has become the foundation of surge planning.

The Institute of Medicine defines surge capacity across three levels: conventional (using standard protocols and resources), contingency (functionally equivalent care with some adaptations), and crisis (insufficient resources requiring significant care modifications). Understanding these levels is crucial for ICU leaders who must make difficult resource allocation decisions during disasters.

Space Considerations

Physical Infrastructure Adaptations

Traditional ICU space can be rapidly expanded through several mechanisms:

Horizontal expansion: Converting step-down units, post-anesthesia care units, and emergency department observation areas
Vertical expansion: Utilizing operating rooms, cardiac catheterization labs, and endoscopy suites
Alternative care sites: Establishing field hospitals, utilizing convention centers, or converting non-medical facilities

Pearl: The most successful space conversions maintain existing medical gas infrastructure and electrical capacity. Pre-identify spaces with oxygen and suction capabilities during non-disaster periods.

Engineering Considerations

Modern ICUs require significant electrical capacity (15-20 electrical outlets per bed), medical gas systems, and robust data infrastructure. During the COVID-19 pandemic, many facilities discovered that converting general ward spaces to ICU-level care was limited by electrical capacity rather than available space.

Staffing Models

Tiered Staffing Approaches

Surge staffing requires creative approaches to maintain care quality while expanding capacity:

Extensivist model: ICU physicians supervise larger patient volumes with enhanced mid-level provider support
Consultative model: ICU physicians provide oversight to non-ICU physicians managing ventilated patients
Telemedicine support: Remote intensivist oversight of multiple sites simultaneously

Staff Ratios and Competency

Normal ICU nurse-to-patient ratios (1:1 or 1:2) become unsustainable during surge conditions. Evidence suggests ratios up to 1:4 can be managed safely with appropriate support systems, including:

Enhanced respiratory therapist coverage
Increased nursing assistant support
Simplified monitoring protocols
Family member assistance with non-medical care

Oyster Alert: Be cautious of the "heroic phase" phenomenon where staff work unsustainable hours early in a disaster, leading to burnout and errors as the event progresses. Plan for marathon rather than sprint responses.

Supply Chain Management

Ventilator Allocation and Management

The COVID-19 pandemic highlighted ventilator shortages as a critical bottleneck. Effective ventilator surge strategies include:

Inventory management systems with real-time tracking
Regional sharing agreements between facilities
Alternative ventilation strategies (transport ventilators, anesthesia machines)
Protocols for ventilator liberation and weaning acceleration

Pharmaceutical Considerations

Critical care medications face unique supply challenges during disasters:

Sedation and paralytic agents require significant stockpiling
Alternative drug protocols to preserve supply (e.g., ketamine-based sedation)
Regional pharmaceutical coordination to prevent competition between facilities

Hack: Develop "surge sedation protocols" using longer-acting, less resource-intensive regimens that can maintain patient comfort while conserving supplies.

Systems and Communication

Command Structure

Effective surge response requires clear command structures that can make rapid decisions about resource allocation, patient placement, and care modifications. The Hospital Incident Command System (HICS) provides a framework for organizing disaster response within healthcare facilities.

Information Systems

Real-time data on bed availability, equipment status, and staffing levels enables informed decision-making. Many successful surge responses utilized simple dashboard systems that provided key metrics to leadership teams.

Role of Triage Officers in Disasters

Evolution of Triage Concepts

Traditional triage focuses on identifying the most critical patients who require immediate intervention. In mass casualty events, triage must balance individual patient needs against resource availability and the potential to save the greatest number of lives.

Conventional vs. Crisis Triage

Conventional triage: Standard emergency department triage focused on urgency
Contingency triage: Modified protocols accounting for increased patient volumes
Crisis triage: Resource allocation decisions that may withhold or withdraw life-sustaining treatments

Triage Officer Qualifications and Training

Professional Requirements

Triage officers in mass casualty events require specific competencies beyond standard clinical training:

Understanding of population health principles
Familiarity with ethical frameworks for resource allocation
Experience in high-stress decision-making environments
Knowledge of institutional resources and capabilities

Training Programs

Several organizations have developed specialized triage officer training:

Society of Critical Care Medicine (SCCM) surge capacity guidelines
American College of Chest Physicians (CHEST) disaster preparedness curricula
Military medical training programs adapted for civilian use

Pearl: The most effective triage officers are senior clinicians who combine clinical expertise with systems thinking and can make difficult decisions under pressure while communicating clearly with families and staff.

Triage Protocols and Decision-Making

Sequential Organ Failure Assessment (SOFA) Based Systems

Many institutions have adopted SOFA score-based triage protocols that provide objective criteria for resource allocation decisions. These systems typically establish:

Inclusion criteria for ICU-level care
Exclusion criteria based on futility assessments
Reassessment intervals for ongoing care decisions

Multi-disciplinary Team Approaches

Effective triage programs utilize teams rather than individual decision-makers:

Primary triage officer (senior intensivist)
Secondary triage officer for appeals/review
Ethics consultant for complex cases
Social work/chaplain support for family communication

Ethical Considerations

Utilitarian vs. Individual Justice

Disaster triage inherently involves utilitarian calculations—maximizing benefit for the greatest number—which may conflict with traditional medical ethics focused on individual patient advocacy.

Procedural Justice

Fair triage systems must ensure:

Consistent application of criteria across all patients
Transparent decision-making processes
Appeal mechanisms for contested decisions
Clear communication with families about resource limitations

Oyster Alert: Avoid the "first come, first served" trap in resource allocation. This approach, while seemingly fair, may not optimize overall outcomes and can disadvantage patients who arrive later despite having better prognosis.

Lessons from Pandemics and Conflicts

COVID-19 Pandemic Insights

The COVID-19 pandemic provided unprecedented insights into sustained surge operations and revealed both strengths and vulnerabilities in healthcare systems worldwide.

Surge Capacity Revelations

Staff burnout: Sustained operations over months rather than days created new challenges
Supply chain fragility: Just-in-time inventory systems proved inadequate for prolonged surges
Communication challenges: Rapidly changing protocols and guidelines created confusion
Psychological impacts: Both providers and patients experienced significant mental health consequences

Innovative Responses

Several innovations emerged from the pandemic that have broader applicability:

Prone positioning teams: Specialized teams for complex positioning procedures
Family communication systems: Video calling and remote family involvement protocols
Decentralized monitoring: Remote patient monitoring and telemedicine applications
Simplified protocols: Streamlined care pathways that maintained quality while reducing complexity

Hack: Implement "COVID protocols" even in non-pandemic disasters—simplified, high-impact interventions that can be delivered by less specialized staff while maintaining care quality.

Armed Conflict Lessons

Modern conflicts have provided valuable insights into trauma and critical care under resource-constrained conditions.

Ukraine Conflict (2022-2024)

The ongoing conflict in Ukraine has demonstrated:

Civilian hospital preparedness: Rapid conversion of civilian facilities to trauma centers
Supply line protection: Maintaining medical supply chains under attack
Staff evacuation protocols: Procedures for patient and staff evacuation under fire
International cooperation: Coordinated international medical assistance

Middle East Conflicts

Operations in Iraq and Afghanistan contributed significant knowledge:

Damage control resuscitation: Permissive hypotension and massive transfusion protocols
Early surgical intervention: Abbreviated procedures with planned returns to OR
Evacuation medicine: Critical care during transport over long distances

Natural Disaster Experiences

Hurricane Katrina (2005) and subsequent storms

Major hurricanes have consistently challenged healthcare systems:

Evacuation planning: Procedures for moving ICU patients during mandatory evacuations
Generator failures: Backup power systems proved inadequate in many facilities
Communication breakdown: Loss of traditional communication systems hampered coordination

Earthquake Responses

Major earthquakes (Haiti 2010, Nepal 2015, Turkey-Syria 2023) revealed:

Rapid response teams: International deployment of critical care capabilities
Field hospital design: Portable ICU capabilities for resource-poor environments
Local capacity building: Training local providers in disaster critical care

Pearl: The most resilient healthcare systems are those that regularly exercise their disaster plans, maintain strong community partnerships, and invest in both infrastructure hardening and staff training.

Synthesis of Lessons Learned

Common Success Factors

Across diverse disaster types, several factors consistently predict better outcomes:

Pre-disaster planning: Regular exercises and plan updates
Clear command structures: Established leadership roles and communication pathways
Flexible protocols: Adaptable care standards that can scale with resource availability
Staff support: Programs to maintain provider wellbeing during extended operations
Community integration: Partnerships with emergency management and other healthcare facilities

Persistent Challenges

Despite advances, several challenges remain consistent across disaster types:

Resource competition: Facilities competing for limited supplies and personnel
Ethical dilemmas: Difficult decisions about resource allocation and care limitations
Communication breakdowns: Information sharing failures during high-stress situations
Recovery planning: Inadequate attention to long-term recovery and system restoration

Contemporary Best Practices

Planning and Preparedness

Institutional Requirements

Modern healthcare facilities should maintain:

Hazard vulnerability analyses: Regular assessment of local disaster risks
Surge capacity assessments: Understanding of maximum sustainable census increases
Supply stockpiles: Strategic reserves of critical medications and equipment
Staffing plans: Cross-training programs and mutual aid agreements
Communication systems: Redundant communication pathways that function during disasters

Training and Education

Multidisciplinary Approaches

Effective disaster preparedness requires training across disciplines:

Medical staff: Clinical protocols and triage decision-making
Nursing: Modified care protocols and expanded patient ratios
Administration: Resource allocation and operational decisions
Support services: Maintenance, security, and ancillary staff roles

Simulation-Based Learning

High-fidelity simulations provide safe environments for practicing disaster responses:

Full-scale exercises: Institution-wide disaster drills
Tabletop exercises: Scenario-based planning discussions
Skills stations: Specific technical skill development

Hack: Use "disaster protocols" during routine high-census periods to maintain familiarity and identify workflow issues before they become critical during actual emergencies.

Technology Integration

Health Information Systems

Modern disaster response benefits from robust information systems:

Real-time dashboards: Bed availability, equipment status, staffing levels
Resource tracking: Inventory management and supply chain visibility
Patient tracking: Maintaining patient identification and care continuity
Communication platforms: Secure messaging and video conferencing capabilities

Telemedicine Applications

Remote consultation capabilities extend specialist expertise:

Remote intensivist coverage: Supervision of multiple sites simultaneously
Specialist consultations: Access to subspecialty expertise during disasters
Family communication: Remote family involvement in care decisions

Future Directions and Emerging Challenges

Climate Change Implications

Climate change is increasing the frequency and severity of natural disasters, requiring healthcare systems to prepare for:

More frequent events: Less recovery time between disasters
Compound disasters: Multiple simultaneous events (hurricanes with flooding, wildfires with power outages)
Infrastructure stress: Aging infrastructure under increasing environmental pressure

Technological Innovations

Emerging technologies offer new capabilities for disaster response:

Artificial intelligence: Predictive analytics for surge planning and resource allocation
Portable technology: Advanced monitoring and therapeutic devices suitable for field deployment
3D printing: On-demand production of medical devices and equipment
Drone technology: Supply delivery and patient evacuation capabilities

Oyster Alert: Don't become overly dependent on complex technologies that may fail during disasters. Maintain simple, robust backup systems that can function without advanced infrastructure.

Policy and Regulatory Considerations

Disaster preparedness increasingly involves regulatory and policy frameworks:

Regional coordination: Multi-facility planning and resource sharing agreements
Legal frameworks: Liability protection for crisis care standards
Funding mechanisms: Sustainable financing for preparedness activities
International cooperation: Standardized approaches for cross-border assistance

Recommendations for Practice

Institutional Level

Healthcare facilities should implement comprehensive disaster preparedness programs including:

Risk assessment: Regular evaluation of local disaster risks and facility vulnerabilities
Surge planning: Detailed plans for expanding critical care capacity using the 4-S framework
Training programs: Regular education for all staff on disaster response protocols
Supply management: Strategic stockpiling and supply chain redundancy planning
Partnership development: Mutual aid agreements with other healthcare facilities

Individual Practitioner Level

Critical care physicians should:

Seek training: Complete formal disaster medicine and mass casualty education
Understand protocols: Familiarize themselves with institutional disaster response plans
Practice skills: Participate in simulation exercises and disaster drills
Stay informed: Keep current with evolving best practices in disaster critical care
Advocate: Support institutional and regional preparedness investments

Systems Level

Healthcare systems and regions should:

Coordinate planning: Develop regional disaster response capabilities
Share resources: Create mechanisms for equipment and personnel sharing
Standardize protocols: Adopt common triage and care protocols across facilities
Invest in infrastructure: Maintain robust communication and transportation systems
Foster research: Support studies of disaster response effectiveness and innovation

Conclusion

Disaster and mass casualty critical care represents one of the most challenging aspects of intensive care medicine. Effective response requires comprehensive planning that addresses surge capacity across space, staff, supplies, and systems. The role of triage officers has evolved from simple patient prioritization to complex resource allocation decision-making that balances individual patient needs against population health considerations.

Recent experiences with the COVID-19 pandemic, armed conflicts, and natural disasters have provided valuable lessons that inform contemporary best practices. These events have highlighted both the resilience and vulnerability of healthcare systems, demonstrating that effective disaster response requires sustained investment in preparedness, training, and infrastructure.

As climate change and global instability increase the frequency and severity of mass casualty events, the critical care community must continue to evolve its approaches to disaster preparedness. This includes embracing new technologies, fostering regional cooperation, and maintaining a commitment to both individual patient care and population health outcomes.

The future of disaster critical care lies in systems that are simultaneously robust enough to maintain high-quality care under normal conditions and flexible enough to adapt to extraordinary circumstances. Achieving this balance requires ongoing commitment from individual practitioners, healthcare institutions, and healthcare systems to prioritize preparedness as an essential component of critical care excellence.

The lessons learned from recent disasters provide a foundation for improving future responses, but the dynamic nature of both disasters and healthcare technology means that preparedness must be an ongoing process of learning, adaptation, and improvement. Critical care physicians have a professional obligation to be prepared for these challenging scenarios and to contribute to the development of systems that can provide the best possible care for the greatest number of patients during society's most difficult moments.

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Conflicts of Interest: None declared.

Funding: No specific funding was received for this work.

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Sunday, September 28, 2025