The Role of the Intensivist in Disaster Medicine and Mass Casualty Incidents

Dr Neeraj Manikath , claude.ai

Abstract

Mass casualty incidents (MCIs) and disasters present unique challenges that extend far beyond the traditional boundaries of intensive care medicine. Intensivists play a pivotal role in these scenarios, not merely as bedside clinicians but as strategic leaders in resource allocation, triage decision-making, and crisis management. This comprehensive review examines the multifaceted responsibilities of critical care physicians during disasters, with emphasis on practical applications, evidence-based approaches, and lessons learned from recent global events. Understanding these principles is essential for the modern intensivist, as climate change, geopolitical instability, and emerging pandemics continue to increase the frequency and complexity of mass casualty situations.

Introduction

The modern intensivist's role has evolved dramatically from managing individual critically ill patients to serving as a crucial leader during mass casualty incidents and disasters. Whether facing natural catastrophes, terrorist attacks, industrial accidents, or pandemics, critical care specialists must rapidly transition from standard care protocols to crisis standards of care (CSC). This paradigm shift requires not only clinical expertise but also skills in ethical decision-making, resource management, and organizational leadership under extreme pressure.

Recent events—including the COVID-19 pandemic, the Beirut port explosion, and numerous natural disasters—have underscored the critical importance of intensivist preparedness for MCIs. Studies demonstrate that hospitals with well-trained critical care leadership experience significantly better outcomes during disasters, with mortality rates up to 30% lower compared to facilities without structured disaster response protocols.[1,2]

Triage Principles in Mass Casualty Events

The Paradigm Shift: From Individual to Population Medicine

Traditional intensive care operates under the principle of doing "the most for each patient." However, MCIs necessitate a fundamental ethical and operational shift toward doing "the most for the most patients."[3] This transition represents one of the most challenging aspects of disaster medicine for intensivists trained in patient-centered care.

The START System (Simple Triage and Rapid Treatment) remains the most widely utilized initial triage method. Patients are categorized within 60 seconds using the RPM mnemonic: Respirations, Perfusion, and Mental status. However, intensivists must understand that START is designed for field triage, and a secondary triage system is essential when victims reach the hospital.

Secondary Triage: The Intensivist's Domain

The SORT (Sort, Assess, Life-saving interventions, Treatment/Transport) protocol provides a more sophisticated approach suitable for hospital-based triage.[4] Intensivists should lead secondary triage, which reassesses patients upon hospital arrival and periodically thereafter, as clinical conditions evolve rapidly.

Pearl: Implement dynamic retriage every 30-60 minutes during the first 4 hours of an MCI. Patient conditions change, and someone initially triaged as "expectant" may become salvageable as resources become available.

Oyster Alert: The "expectant" category is ethically problematic. Never use visible markers (like black tags) that signal abandonment. Instead, use euphemistic coding systems and ensure expectant patients receive comfort care with periodic reassessment.

The SALT Triage System

The SALT (Sort, Assess, Life-saving interventions, Treatment/Transport) mass casualty triage algorithm, endorsed by the American College of Surgeons, offers advantages in complex scenarios.[5] It prioritizes patients who can follow commands (walking wounded) for rapid clearance, then systematically assesses others based on:

Life-threatening hemorrhage (immediate tourniquet application)
Airway positioning
Respiratory rate and effort
Palpable pulse
Neurological status

Hack: Pre-position triage kits throughout your hospital, not just in the ED. Include START/SALT cards, colored tape, permanent markers, and quick-reference dosing charts. In true MCIs, triage occurs in parking lots, hallways, and makeshift spaces.

Special Considerations for Intensivists

Unlike emergency physicians who perform initial triage, intensivists must make ongoing triage decisions about ICU bed allocation, ventilator assignment, and resource-intensive interventions. The Sequential Organ Failure Assessment (SOFA) score, while controversial, has been incorporated into some triage protocols for critical care resources during pandemics.[6]

Critical Teaching Point: The SOFA score for triage is fundamentally different from SOFA for prognosis. Time-limited trials (48-72 hours) with predetermined reassessment points are ethically superior to categorical exclusion criteria based on age or comorbidities.[7]

Allocation of Scarce Resources in a Crisis

The Ethical Framework

Resource allocation during disasters requires intensivists to navigate complex ethical terrain. The principles of distributive justice become paramount, guided by:[8]

Duty to steward resources – Obligation to society to maximize lives saved
Duty to care – Professional obligation to patients
Distributive justice – Fair allocation based on medical utility and need
Transparency and accountability – Open processes with review mechanisms

Pearl: Ethics committees must be activated immediately when transitioning to crisis standards of care. Decisions should never rest solely on bedside clinicians, who face moral injury from these choices.[9]

The Tiered Approach to Resource Scarcity

The Institute of Medicine framework describes three operational tiers:[10]

Conventional capacity: Standard care with usual resources
Contingency capacity: Functionally equivalent care using adapted resources
Crisis capacity: Care significantly different from usual standards, focused on key interventions

Hack: Develop your hospital's "flex-up" protocol before disaster strikes. Map out how you transition from 20 ICU beds to 40 to 80, with specific triggers and action items for each tier. Include equipment, staffing ratios, and documentation shortcuts.

Ventilator Allocation Protocols

The COVID-19 pandemic forced many jurisdictions to develop explicit ventilator allocation guidelines. The University of Pittsburgh Medical Center (UPMC) protocol and New York State Task Force guidelines represent well-considered approaches, though both generated controversy.[11]

Key principles include:

Prognosis-based allocation using objective scores (modified SOFA, comorbidity-adjusted)
First-come, first-served only in conventional capacity
Periodic reassessment with resource reallocation if prognosis worsens
Lottery mechanisms when patients have equivalent prognosis
Categorical exclusion criteria (highly controversial and generally discouraged)

Oyster Alert: Be cautious with "life-years" calculations that disadvantage older patients. Age-neutral, prognosis-based criteria are more ethically defensible and legally safer in most jurisdictions.[12]

Practical Resource Management Strategies

Oxygen conservation: In disasters where oxygen supply is compromised, accept SpO₂ targets of 88-92% for most patients (permissive hypoxemia). This can extend supply by 40-60%.[13]

ICU bed expansion: Convert PACUs, intermediate care units, and even ORs into ICU spaces. The limiting factor is typically trained personnel, not physical space.

Personnel multiplication: Implement the one intensivist supervising multiple ICU teams model used successfully in Italy during COVID-19. Use protocols, decision trees, and telecommunication for oversight.[14]

Hack: Create "skill-matched tasking" where each healthcare worker performs the highest-level skill they're trained for, with others supporting. A respiratory therapist can manage ventilators for 6-8 patients with nursing support, while physicians focus on complex decisions and procedures.

Management of Blast Injuries and Chemical/Radiological Exposures

Blast Injury Pathophysiology

Blast injuries present unique challenges requiring specialized knowledge. The Quaternary Classification System categorizes injuries as:[15]

Primary blast injuries: Result from overpressure waves affecting gas-filled organs:

Blast lung – Most lethal primary injury; presents as respiratory distress with bilateral infiltrates despite initially normal chest X-ray
Tympanic membrane rupture – Occurs in 50% exposed to >5 PSI
Hollow viscus perforation – Delayed presentation up to 48 hours
Ocular injuries – Globe rupture, vitreous hemorrhage

Secondary blast injuries: Penetrating trauma from projectiles and shrapnel

Tertiary blast injuries: Blunt trauma from being thrown by blast wind

Quaternary blast injuries: Burns, toxic inhalations, crush injuries, and psychological trauma

Critical Care Management of Blast Lung

Pearl: Blast lung is a clinical diagnosis—bilateral pulmonary infiltrates, hypoxemia, and history of blast exposure. Don't wait for radiographic confirmation, which may lag by hours.

Management principles:[16]

Lung-protective ventilation (tidal volumes 4-6 mL/kg, plateau pressures <30 cmH₂O)
Avoid PPV if possible – Use high-flow nasal cannula or CPAP initially when feasible; PPV increases air embolism risk
Aggressive fluid restriction – Limit to 500-1000 mL in first 24 hours unless shock present
ECMO consideration – Lower threshold than ARDS due to air embolism risk with high ventilator pressures
Early bronchoscopy – If hemoptysis present, to control bleeding and remove clots

Oyster Alert: Air embolism is the unique killer in blast injury. Monitor for sudden cardiovascular collapse, focal neurological deficits, or cardiac ischemia. Position patient in left lateral decubitus Trendelenburg position and consider hyperbaric oxygen if available.[17]

Chemical Exposure Management

Intensivists must recognize and manage exposure to chemical warfare agents or industrial toxins:

Nerve agents (organophosphates):

Recognition: SLUDGE syndrome (Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis) plus "killer Bs" (Bronchospasm, Bronchorrhea, Bradycardia)
Management: Mark I autoinjectors (atropine 2 mg + pralidoxime 600 mg); may require 20+ doses of atropine for severe exposures
ICU considerations: Prolonged ventilation required; atropine infusions (0.5-1 mg/hour); seizure management with benzodiazepines

Hack: Pre-calculate massive atropine dosing: "Atropinize until secretions dry" may require 100-200 mg in first 24 hours. Don't be timid—there's essentially no upper limit in nerve agent poisoning.

Vesicants (mustard gas, lewisite):

Delayed effects (2-24 hours)
Airway management for laryngeal edema
Supportive care for skin burns and bone marrow suppression
British Anti-Lewisite (BAL) for lewisite specifically

Pearl: The "rule of threes" for chemical exposure: If three or more patients present simultaneously with similar unusual symptoms, think chemical exposure—even in peacetime.

Radiological and Nuclear Events

Acute Radiation Syndrome (ARS) presents in phases:[18]

Prodromal phase (0-2 days): Nausea, vomiting, diarrhea
Latent phase (may last weeks): Apparent recovery
Manifest illness (weeks): Bone marrow suppression, GI syndrome, or neurovascular syndrome depending on dose
Recovery or death

Critical care priorities:

Decontamination: Remove clothing (eliminates 90% of contamination), soap-and-water wash
Supportive care: Transfusion support, infection control, G-CSF administration
Internal contamination: Prussian blue (cesium/thallium), DTPA (plutonium/americium), potassium iodide (radioiodine)

Hack: Healthcare workers fear radiation disproportionately. The mantra: "You cannot become radioactive from treating a contaminated patient." Standard PPE protects against particulate contamination. Focus on lifesaving interventions first, decontamination second.

Setting Up and Managing a Field ICU

Site Selection and Infrastructure

Establishing a field ICU requires systematic assessment of:[19]

Physical requirements:

Minimum 100 square feet per patient (vs. 200-250 in permanent ICUs)
Access to electrical power (minimum 20 amps per bed)
Oxygen supply (wall, concentrators, or cylinder manifolds)
Water and sanitation
Climate control (especially in extreme environments)

Pearl: The "Rule of Three" for ICU expansion: One intensivist can oversee 3 ICU teams, each team manages 3 patients, using 3-hour rounds. This 1:9 ratio maintains quality during surge.[20]

Equipment Prioritization

When establishing a field ICU with limited resources, prioritize in this order:

Airway and breathing: Ventilators, oxygen, suction, airway equipment
Circulation: Infusion pumps, vasopressors, IV fluids
Monitoring: Portable monitors, point-of-care testing
Procedures: Central line kits, chest tubes, ultrasound
Documentation: Simplified charting systems

Hack: Use the "ICU in a box" concept. Pre-pack standardized kits containing everything needed for one ICU bed for 48 hours. Include not just clinical equipment but communication devices, reference materials, and comfort supplies for staff.

Logistical and Communication Systems

Operational structure:

Establish clear command structure using Hospital Incident Command System (HICS)
Designate intensivist as ICU Section Chief reporting to Medical Operations
Create documentation shortcuts – use standardized templates and flowsheets
Implement buddy system for staff safety and support

Communication plan:

Primary, secondary, and tertiary communication methods
Regular huddles (minimum q6h)
Situation reports to command center
Family communication strategy

Pearl: Use visual management boards showing real-time bed status, resource availability, and pending admissions. Color-coding and simple graphics work when electronic systems fail.

Clinical Protocols and Simplified Care

Field ICUs require streamlined protocols focusing on high-yield interventions:[21]

Limited formulary – 30-40 essential medications
Protocolized ventilation – Simplified ARDSnet-type approach
Goal-directed resuscitation – Clear endpoints (MAP >65, UOP >0.5 mL/kg/hr, lactate clearance)
Minimal lab testing – Focus on point-of-care glucose, electrolytes, lactate, and blood gas

Oyster Alert: Resist "bringing the entire hospital" to the field. Complexity kills in disaster settings. The field ICU that tries to provide definitive care for everything will fail. Know your evacuation triggers and timelines.

Psychological First Aid and Staff Support in Prolonged Disasters

Understanding Disaster-Related Psychological Trauma

Healthcare workers in disasters face compounded stressors:[22]

Professional demands: Overwhelming workload, resource scarcity, ethical dilemmas
Personal impact: May be victims themselves; worry about family safety
Moral injury: Making allocation decisions, providing substandard care, witnessing preventable deaths
Prolonged exposure: Unlike typical ICU stress, disasters may persist weeks to months

Studies from COVID-19 demonstrate that 40-50% of ICU staff experienced significant symptoms of PTSD, depression, or anxiety, with intensivists at particularly high risk.[23]

Psychological First Aid: The RAPID Model

The RAPID model provides a framework for immediate psychological support:[24]

R – Reflective listening: Acknowledge emotions without judgment A – Assessment: Identify high-risk individuals needing specialized intervention P – Prioritization: Ensure basic needs met (food, rest, safety) I – Intervention: Simple, evidence-based techniques (grounding, breathing exercises) D – Disposition: Connect to ongoing support or specialized care

Pearl: Psychological First Aid is NOT debriefing. Avoid forcing people to "talk it out" immediately. Many people cope better with action-oriented tasks followed by voluntary peer support.

Organizational Strategies for Staff Support

Operational approaches:[25]

Predictable scheduling: Even in chaos, create 12-hour shifts with guaranteed off-time
Rest spaces: Designate quiet areas away from clinical zones for breaks
Basic needs support: Provide meals, transportation, childcare assistance, and lodging if needed
Rotating assignments: Limit consecutive disaster deployment days (7-10 day maximum)
Buddy system: Pair staff for mutual support and safety monitoring

Hack: Implement the "traffic light system" where staff self-assess daily as green (coping well), yellow (struggling but functional), or red (need immediate support). This destigmatizes help-seeking and allows rapid intervention.

Peer Support Programs

Psychological debriefing has mixed evidence, but peer support programs demonstrate clear benefit:[26]

Train selected staff in Mental Health First Aid
Create "respite teams" who provide temporary relief
Establish confidential peer support hotlines
Facilitate informal support groups (emphasis on voluntary participation)

Pearl: The most effective support often comes from those who've "been there." Consider bringing in intensivists from previous disasters (COVID-19 veterans, combat medical corps) to provide both practical advice and psychological validation.

Recognizing and Managing Moral Injury

Moral injury – psychological distress from perpetrating, witnessing, or failing to prevent actions that violate deeply held moral beliefs – may be more significant than PTSD in disaster scenarios.[27]

Signs of moral injury:

Persistent guilt or shame ("I should have done more")
Loss of meaning or purpose
Spiritual crisis
Self-destructive behaviors
Difficulty returning to normal clinical practice

Management approaches:

Validation: Acknowledge the impossible nature of choices made
Reframing: Help staff understand they maximized good within constraints
Ethics support: Provide post-event ethics debriefing
Longitudinal care: Moral injury often emerges weeks to months post-disaster

Oyster Alert: Leaders must model self-care and vulnerability. The "strong leader who never breaks" paradigm causes harm. Share your own struggles appropriately and demonstrate that seeking support is strength, not weakness.

Post-Disaster Organizational Recovery

The disaster doesn't end when the event ends:[28]

Immediate post-disaster (1-2 weeks):

Formal operational debriefing (what worked, what didn't)
Recognition events (thank staff publicly and meaningfully)
Provide information on accessing mental health resources
Allow flexible return to normal duties

Medium-term (1-6 months):

Monitor staff wellness through structured check-ins
Offer voluntary group processing sessions
Provide continuing education on disaster experiences
Adjust workloads for affected staff

Long-term (6+ months):

Longitudinal wellness screening
Organizational culture changes based on lessons learned
Memorial services or recognition of sacrifices
System improvements to prevent recurrence

Hack: Create a "lessons learned, lessons applied" document within 30 days. While fresh, capture what you'd do differently, then actually change protocols before the next event. Most hospitals excellently document lessons learned, then file them away unused.

Conclusion

The role of the intensivist in disaster medicine extends far beyond clinical expertise in managing critically ill patients. Today's intensivist must be triagist, ethicist, resource manager, field organizer, and psychological supporter. The capacity to rapidly transition from individualized patient care to population-based crisis management, while maintaining composure and compassion under extreme stress, defines the disaster-ready intensivist.

Preparation is paramount. Disasters are not "if" but "when" scenarios for modern healthcare systems. Intensivists should pursue formal disaster medicine training, participate in regular simulation exercises, and understand their institution's emergency operations plans. The ethical frameworks for resource allocation should be considered in calm times, not during crisis.

Most importantly, we must recognize that disaster response is a marathon, not a sprint. Systems that support the psychological wellbeing of responders, prevent moral injury, and build resilient teams will ultimately save more lives than any clinical protocol. The intensivist who emerges from a disaster psychologically intact, professionally fulfilled, and ready to serve again represents the ultimate success metric.

As climate change, global instability, and emerging infectious diseases increase disaster frequency, the intensivist's role in disaster preparedness and response will only grow in importance. Our specialty must rise to this challenge, ensuring that critical care expertise translates into optimal outcomes when society needs us most.

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Author Disclosure Statement: No competing financial interests exist.

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Our role in Disaster Medicine and Mass Casualty Incidents