oxford american handbook of disaster medicine

Oxford American Handbook of
Disaster Medicine
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1
Oxford American Handbook of
Disaster Medicine
Edited by
Robert A. Partridge, MD,
MPH, FACEP
Department of Emergency
Medicine, Emerson Hospital
Concord, Massachusetts and
Department of Emergency
Medicine, Rhode Island
Hospital
Adjunct Associate Professor of
Emergency Medicine
Warren Alpert Medical School of
Brown University
Providence, Rhode Island
Lawrence Proano, MD,
DTMH, FACEP
Department of Emergency
Medicine, Rhode Island Hospital
Clinical Associate Professor of
Emergency Medicine
Warren Alpert Medical School of
Brown University
Providence, Rhode Island
David Marcozzi, MD,
MHS-CL, FACEP
Offi ce of the Assistant Secretary
of Preparedness and Response

Department of Health and Human
Services
Washington, DC
With
Alexander G. Garza, MD, MPH
Director of Military Programs,
Department of Emergency
Medicine
Washington Hospital Center
Georgetown University School of
Medicine
Washington, DC
Ira Nemeth, MD, FACEP
Assistant Professor and Director
of EMS and Disaster Medicine
Section of Emergency Medicine,
Department of Medicine
Baylor College of Medicine
Houston, Texas
Kathryn Brinsfi eld, MD
Department of Homeland Security
Washington, DC and
Associate Professor of Emergency
Medicine, Boston University
Associate Medical Director,
Boston EMS
Boston, Massachusetts
Eric S. Weinstein, MD
Attending Physician, Carolinas
Hospital System

Emergency Department
Florence, South Carolina
3
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All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
Materials appearing in this book prepared by United States government
employees were not prepared in the individuals’ offi cial capacity as
U.S. government employees. Therefore, any views expressed therein do not
represent the views of the United States government and such individuals’
participation in the Work is not meant to serve as an offi cial endorsement
by the United States government. Dr. Kathryn Brinsfi eld was not an
employee of the US government while serving as co-editor of this book.

Library of Congress Cataloging in Publication Data
Oxford American handbook of disaster medicine / edited by Robert A. Partridge
[et al.].
p. ; cm. — (Oxford American handbooks in medicine)
Handbook of disaster medicine
Includes bibliographical references and index.
ISBN 978–0–19–537906–8
I. Partridge, Robert A. II. Title: Handbook of disaster medicine. III. Series: Oxford
American handbooks.
[DNLM: 1. Disaster Planning—Handbooks. 2. Disaster Medicine—Handbooks. WA 39]
363.348—dc23
2011039724
10 9 8 7 6 5 4 3 2 1
Printed in China
on acid-free paper
This material is not intended to be, and should not be considered, a sub-
stitute for medical or other professional advice. Treatment for the con-
ditions described in this material is highly dependent on the individual
circumstances. Although this material is designed to offer accurate infor-
mation with respect to the subject matter covered and to be current as of
the time it was written, research and knowledge about medical and health
issues is constantly evolving, and dose schedules for medications are being
revised continually, with new side effects recognized and accounted for
regularly. Readers must, therefore, always check the product informa-
tion and clinical procedures with the most up-to-date published prod-
uct information and data sheets provided by the manufacturers and the
most recent codes of conduct and safety regulation. Oxford University
Press and the authors make no representations or warranties to readers,
express or implied, about the accuracy or completeness of this material,
including without limitation that they make no representation or warran-

ties about the accuracy or effi cacy of the drug dosages mentioned in the
material. The authors and the publishers do not accept, and expressly
disclaim, any responsibility for any liability, loss, or risk that may be claimed
or incurred as a consequence of the use and/or application of any of the
contents of this material.
This page intentionally left blank
Dedicated to my parents, Raymond and Alison, and my beloved wife and
children, Karen, Rachel, Sarah, and Alexander. You have all given me endless
support, encouragement, and love.
Robert Partridge
This book is dedicated to the mentors who have been role models in my
professional career, and to all those who selfl essly respond to help others
when disaster strikes.
Lawrence Proano
To those who have helped me along the way—my wife, my parents, my
brother and sister, Dr. Robert Kadlec, Dr. Kevin Yeskey, Mrs. Heidi Avery,
Mr. Richard Reed, Dr. Kathleen Clem, Dr. Michael Hocker, Dr. Selim
Suner, and all my colleagues and friends—I dedicate this text to your love,
mentorship, and unwavering support. Thank you.
David Marcozzi
This page intentionally left blank
ix
Foreword
With the incidence of natural and intentional disasters–and the number
of people affected by such events–on the increase, the importance of
disasters as a public-health problem has captured the attention of the
world. This situation represents an unprecedented challenge to the medi-
cal and public-health community. Ten years have now passed since the
catastrophic events of September 11, 2001. Since then, periodic reviews
of the medical and public-health impact of disasters have appeared in a

number of publications, with updates on the “state of the art” of disaster
science. As a result, a considerable body of knowledge and experience
related to the adverse health effects of disasters is now accumulating that
requires regular updating so that we can apply the lessons learned during
one disaster to the management of the next. These historical lessons will
not be implemented, however, unless they are supported by adequate
preparedness planning, coordination, communications, logistics, personnel
management, and training of physicians and other health-care providers.
By blending the comprehensiveness of a weighty full-length text with
the convenience of a fi eld guide, the Oxford American Handbook of Disaster
Medicine skilfully addresses these challenges and more. With years of
experience, editors Robert Partridge and Lawrence Proano, along with a
distinguished list of co-authors, give the reader ample technical descrip-
tions of each kind of disaster, pertinent summaries of previous disasters,
and copious information useful for health-care providers in the fi eld, the
classroom, or the ward. Unique chapters address topics such as the politi-
cal and ethical issues in disaster response; urban versus rural approaches;
effective media relations; interfaces between disaster medicine and mili-
tary, operational, and wilderness medicine; and the evolving priorities of
the Department of Homeland Security (example, the NRP and an NIMS).
In view of recent catastrophic events and newly recognized threats, spe-
cifi c elements such as tsunamis and pandemic infl uenza that are usually
included as part of other chapters (for example, earthquakes and com-
municable diseases) are now covered in their own chapters. Deserving of
special attention are crosscutting chapters in the handbook that integrate
information across hazards, such as communications, lessons learned,
exercises and drills, and disaster informatics.
In addition, while always emphasizing the use of proven and evidence-
based medical methods and practices, Drs. Partridge and Proano challenge
health professionals with questions that must still be answered for them

to respond effectively in emergency situations. Approached from a real-
world perspective, designed and written by clinical and public-health pro-
viders with disaster experience, this handbook provides realistic, hands-on
experiences that challenge the reader to apply information provided in
every chapter. The inclusion of “key messages” and “essential concepts”
that introduce each chapter, plus practical information such as protocols,
clinical tools, and unique case studies, has resulted in the creation of a
major resource that will serve as a timely and comprehensive text for
x
FOREWORD
health providers. It will be an important resource in the education of hos-
pital, community, state, and national health and emergency managers, as
well as medical students and residents who will assume mass emergency
preparedness responsibilities soon, if not immediately after graduation.
All disasters are unique because each affected community has differ-
ent social, economic, cultural, and baseline health conditions. The Oxford
American Handbook of Disaster Medicine will serve as the most up-to-date
fi eld manual and course textbook available not only for medical profes-
sionals responsible for preparing their hospitals to respond effectively to
disasters, pandemics, and other public health crises, but also for emer-
gency managers and other decision makers charged with ensuring that
disasters are well managed.
Eric K. Noji, MD
Washington, DC
xi
Preface
Disasters happen—anywhere, anytime, and frequently. In the United
States, in response to numerous recent man-made and natural catastro-
phes, disaster preparation efforts have become widespread. Over time,
they have also become more complex and broader in scope.

Added layers of complexity make it more diffi cult to stay on top of
best practices, but it is essential to do so. The public expects a rapid,
well-coordinated and effective response when disaster strikes. The media
will cover the disaster and the response with extensive detail and analysis.
After a disaster, recovery and mitigation of future disasters are critical ele-
ments of the disaster cycle that will be an ongoing challenge for disaster
planners and providers.
Preparation for disasters has occurred at the federal, state, and regional
levels, with active involvement of health professionals, law enforcement,
rescue and recovery personnel, and relief organizations, as well as ordi-
nary citizens. However, even with the most careful preparation and plan-
ning, a disaster will overwhelm all standard resources. Responders have an
opportunity to save lives, limit damage and maintain public confi dence by
doing their jobs well. To manage a disaster effectively, health practitioners
must be ready to think on the fl y, make rapid and unfamiliar decisions and
know where to obtain key knowledge and resources.
This handbook is intended to be one such resource. It can be pulled
out of a pocket, off a desktop, or out of the glove compartment of a
rescue vehicle, to provide immediate, accessible information on a wide
range of topics. By covering critical areas of disaster preparation, planning,
and response for the types of disasters that are most likely to occur in the
United States and around the world, this book gives health-care respond-
ers a fi rst-line tool for ensuring their own preparedness. It is designed to
assist involved health practitioners on any aspect of disaster management
at any point along the disaster timeline.
Although this handbook is thorough, it is not comprehensive. Readers
are encouraged to consult other texts, peer-reviewed literature, web sites
and suggested readings at the end of each chapter for additional informa-
tion and detail. It is our hope that this handbook will be an essential part of
a larger library of information to help health practitioners limit the impact

of disasters through effective preparation and response.
Robert Partridge
Lawrence Proano
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xiii
Acknowledgments
The authors are grateful for the efforts of many people who worked very
hard to make this book possible. Foremost, we would like to thank all of
our co-authors. The depth and quality of this book are a testament to their
dedication and interest in the study of disaster medicine.
Thanks also go out to our co-editors, David Marcozzi, Alex Garza,
Kathy Brinsfi eld, Ira Nemeth, and Eric Weinstein, whose vision guided the
development of this project.
In addition, we are indebted to the team at Oxford University Press,
particularly Andrea Seils and Staci Hou, who have worked diligently to
bring this book to fruition.
Finally, we would like to acknowledge disaster responders everywhere,
whom we all rely on but often don’t have the opportunity to thank. Their
work has not only informed and inspired us but also left us better pre-
pared to respond to the next disaster.
Robert Partridge
Lawrence Proano
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xv
Contents
Contributors xxi
Part 1: Introduction
1 Defi nition of a disaster
3
2 All-hazards approach

10
3 The disaster cycle: an overview
of disaster phases
20
4 Mitigation phase of disasters
25
5 Preparedness phase of disaster
33
6 Response phase of disaster
39
7 Recovery phase of disasters
43
Part 2: General Concepts
Components of Disaster Response
8 Local-level disaster response
53
9 State-level disaster response
62
10 Federal disaster response
69
11 Military disaster response
74
12 Emergency management in disasters
85
13 Emergency medical services
92
14 Public health in disasters
103
15 International disaster response
112

16 Complex humanitarian emergencies
118
Hospital Components of Disaster Response
17 Hospital administration disaster response
131
18 Hospital ancillary services disaster response
141
xvi
CONTENTS
19 Hospital medical staff disaster response
146
20 Hospital nursing disaster response
152
Part 3: Pre-disaster Considerations
21 Disaster length: an overview
163
22 Short-term events 170
23 Long-term events 174
24 Extended events 179
25 Hazard vulnerability analysis 182
26 Drills and evaluation 191
Part 4: Fundamental Principles of
Disaster Management
27 Communications
201
28 Decontamination 211
29 Evacuation 227
30 Force health protection 238
31 Incident command system 251
32 Mass sheltering 260

33 The national response framework 269
34 Pediatric concerns 283
35 Personal protective equipment 299
36 Regional mass care 308
37 Provider mental health 325
38 Disaster triage 330
39 Vulnerable populations 337
Part 5: Special Considerations in
Disaster Management
40 Research in disaster and triage settings
347
41 Disaster training and education 357
xvii
CONTENTS
42 Medical ethics in disasters 364
43 Politics and disasters 368
44 Rural approaches 375
45 Urban approaches 379
46 Terrorism 387
47 Public media relations
394
48 Ultrasound in disaster medicine 405
49 Disaster informatics 415
50 Palliative care in disaster medicine 422
51 Seasonal risks and variations of an
aerosolized bioterror attack
432
52 Legal aspects of disaster medicine 438
Part 6: Specifi c Hazards in Disasters
Human Caused Disasters

53 Man-made threats: an overview
455
Biological Disasters
54 Anthrax
465
55 Botulism 476
56 Plague 482
57 Smallpox 492
58 Tularemia 496
59 Viral hemorrhagic fevers 502
60 Other biological agents 514
Chemical Disasters
61 Asphyxiants
521
62 Blistering agents 530
63 Organophosphates/nerve gases 535
xviii
CONTENTS
64 Cyanide and other chemical agents 540
65 Pulmonary agents 548
66 Riot control agents 559
67 Explosives 566
68 Mass shootings 573
69 Nuclear terrorism and disasters 577
70 Radiological terrorism 585
Mechanical and Structural Disasters
Land
71 Automobile disasters
601
72 Bus disasters 607

73 Fires 613
74 Rail disasters 620
75 Subway disasters 628
Air and Sea
76 Aviation disasters
637
77 Helicopter disasters 641
78 Ship disasters 647
Natural Disasters
79 Natural disasters: an overview
655
80 Avalanche 664
81 Cold weather 673
82 Earthquakes 678
83 Flooding 684
84 Heat wave 690
85 Hurricane disasters 697
86 Landslides and mudslides 703
xix
CONTENTS
87 Lightning strikes 706
88 Infl uenza pandemic 713
89 Tornadoes 723
90 Tsunami 729
91 Volcanic eruption 741
Part 7: Post-disaster Considerations
92 Survivor mental health
751
93 Displaced populations 765
94 Lessons learned 774

95 International disaster response organizations 785
96 Future humanitarian crises 793
Index 803
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xxi
Contributors
D. Adam Algren, MD
Assistant Professor of Emergency
Medicine and Pediatrics
Truman Medical Center/Children’s
Mercy Hospital
University of Missouri-Kansas City
School of Medicine
Kansas City, MO
and
Medical Director
University of Kansas Hospital
Poison Control Center
Kansas City, KS
Evan Avraham Alpert, MD
Attending Physician
Emergency Department
Sheba Medical Center, Israel
Michael Sean Antonis, DO,
RDMS, FACEP
Assistant Professor of Clinical
Emergency Medicine
Department of Emergency
Medicine
Georgetown University Medical

School
MedStar Health: Washington
Hospital Center and Georgetown
University
Washington, DC
Christian Arbelaez, MD,
MPH
Assistant Residency Director,
Department of Emergency
Medicine
Associate Director, Offi ce for
Multicultural Faculty Careers
Brigham and Women’s Hospital
Assistant Professor of Medicine
Harvard Medical School
Boston, MA
James J. Augustine, MD
Director of Clinical Operations,
EMP Management
Canton, OH
and
Assistant Clinical Professor
Department of Emergency
Medicine
Wright State University
Dayton, OH
Kavita Babu, MD
Assistant Professor
Division of Medical Toxicology
Department of Emergency

Medicine
Warren Alpert Medical School of
Brown University
Providence, RI
Jennifer Bahr, MD
Medical College of Wisconsin
Milwaukee, WI
Cindy Baseluos, MD
Staff Physician
Richmond University Medical
Center
Staten Island, NY
Jeff Beeson, DO, FACEP
Medical Director
Emergency Physicians Advisory
Board
Fort Worth, TX
and
Clinical Assistant Professor
Emergency Medicine
University of Texas Southwestern
Medical
Dallas, TX
CONTRIBUTORS
xxii
Jason Bellows, MD, FACEP
Lutheran Medical Center
Denver, CO
Gerald W. Beltran, DO
Department of Emergency

Medicine
Carilion Clinic
Roanoke, VA
Matthew Bitner, MD
Director, Prehospital Education
and Research
Associate Director, Prehospital
Medicine
Section of Prehospital and
Disaster Medicine
Division of Emergency Medicine
Duke University Health System
Durham, NC
Leila Blonski, RN
Madigan Army Medical Center
Department of Emergency
Medicine
Tacoma, WA
David Bouslough, MD, MPH,
DTM&H
Clinical Assistant Professor
Division of International
Emergency Medicine
Department of Emergency
Medicine
Warren Alpert Medical School of
Brown University
Providence, RI
Susan Miller Briggs, MD,
MPH, FACS

Associate Professor of Surgery
Harvard Medical School
Co-Director, Offi ce of Disaster
Response, Center for Global
Health
Massachusetts General Hospital
Boston, MA
John Broach, MD, MPH
Assistant Professor, Emergency
Medicine
Division of Disaster Medicine &
Emergency Management
Department of Emergency
Medicine
University of Massachusetts
Medical School
UMass Memorial Medical Center
Worcester, MA
Tracy Buchman, DHA
Madison, WI
Frederick M. Burkle, Jr.,
MD, MPH, DTM
Senior Fellow & Scientist
Harvard Humanitarian Initiative
Harvard School of Public Health
Cambridge, MA
John D. Cahill, MD
Assistant Professor of Clinical
Medicine
Columbia University College of

Physicians & Surgeons
and
Adjunct Assistant Professor of
Emergency Medicine
Warren Alpert Medical School of
Brown University
and
Director, Global Health
Fellowship
Senior Attending in Infectious
Disease & Emergency Medicine
Saint Luke’s Roosevelt Hospital
Center
New York, NY
Dinah Cannefax
Cannefax Consulting
Emergency Management in
Healthcare
Dallas, TX
CONTRIBUTORS
xxiii
John T. Carlo, MD, MS
Program Director
Chemical and Biological Early
Detection (BioWatch) Program
Center for Infectious Disease
Research and Policy (CIDRAP)
The University of Minnesota
Minneapolis, MN
Jimmy Cooper, MD, FACEP

San Antonio, TX
Peter John Cuenca, MD
Lieutenant Colonel, Medical
Corps
United States Army
Assistant Professor of Military/
Emergency Medicine
Uniformed Services University of
the Health Sciences
Department of Emergency
Medicine
Brooke Army Medical Center
Fort Sam Houston, TX
Michelle Daniel, MD,
FACEP
Assistant Professor (Clinical),
Department of Emergency
Medicine
Warren Alpert Medical School of
Brown University
Attending Physician Rhode Island
The Miriam and Hasbro Children’s
Hospitals
Providence, RI
Christopher Daniel, MA
Safer Institute
Providence, RI
Michelle M. Darcy, BSN,
RN, CEN
Madigan Army Medical Center

Department of Emergency
Medicine
Tacoma, WA
Siri Daulaire, MD
Department of Emergency
Medicine
Warren Alpert Medical School of
Brown University
Rhode Island Hospital
Providence, RI
Diane DeVita, MD, FACEP
Assistant Chief, Administration
and Operations
Department of Emergency
Medicine
Madigan Healthcare System
Tacoma, WA
Constance J. Doyle, MD,
FACEP
Core Faculty
University of Michigan/St. Joseph
Mercy Emergency
Medicine Residency
Deputy Medical Director
Washtenaw/ Livingston Medical
Control
Authority Attending Emergency
Physician
St. Joseph Mercy Hospital
Ann Arbor, MI

Brenda O’Connell Driggers,
RN, BSN
Trauma/Chest Pain Center
Coordinator
Carolinas Hospital System
Florence, SC
Mazen El Sayed, MD
Instructor of Emergency
Medicine
Department of Emergency
Medicine
Boston University School of
Medicine
Boston MA
CONTRIBUTORS
xxiv
Daniel B. Fagbuyi, MD,
FAAP
Medical Director, Disaster
Preparedness and Emergency
Management
Children’s National Medical
Center
Assistant Professor, Pediatrics and
Emergency Medicine
The George Washington
University School of Medicine
Washington, DC
Michelle A. Fischer, MD,
MPH, FACEP

Assistant Professor
Department of Emergency
Medicine
Penn State Hershey Medical
Center
Hershey, PA
Bryan Fisk, MD, MSc
Assistant Chief, Critical Care
Medicine
Walter Reed Army Medical
Center
Washington, DC
John L. Foggle, MD, MBA
Assistant Professor, Department
of Emergency Medicine
Warren Alpert Medical School of
Brown University
Providence, RI
Rachel L. Fowler, MD, MPH
Assistant Professor
Department of Emergency
Medicine
Warren Alpert Medical School of
Brown University
Providence, RI
Ray Fowler, MD, FACEP
Professor of Emergency Medicine,
Surgery, Health Professions, and
Emergency Medical Education
Chief of EMS Operations

Co-Chief in the Section on EMS,
Disaster Medicine, and Homeland
Security
The University of Texas
Southwestern Medical Center
and
Attending Emergency Medicine
Faculty
Parkland Memorial Hospital
Dallas, TX
Tyeese Gaines Reid, DO,
MA
Attending Physician
Raritan Bay Medical Center
Perth Amboy, NJ
Justin S. Gatewood, MD
Assistant Professor of Emergency
Medicine
Department of Emergency
Medicine
Georgetown University School of
Medicine
Washington Hospital Center
Washington, DC
James Geiling, MD
Professor of Medicine
Dartmouth Medical School
Hanover, NH
and
Chief, Medical Service

VA Medical Center
White River Junction, VT