According to the World Health Organization, a disaster is a sudden ecological phenomenon of sufficient magnitude to require external assistance. 9 From the perspective of the emergency department, however, a disaster exists when the number of patients and/or the severity of illness or injury are such that normal daily emergency department operations are no longer possible. In other words, the number of patients presenting in a given time period are such that the emergency department cannot provide care for them without external assistance.10 Disasters that cause large numbers of deaths and injuries are referred to as mass-casualty incidents.11 However, disasters cannot be defined simply by a given number of victims. Large university hospitals with house staff may not have the facilities to manage even two chemically contaminated patients.1 I3 The arrival of one important political person or celebrity with severe injuries (e.g., the President of the United States, the Pope, or a rock star) completely disrupts the normal operations of even the most efficient emergency department.14
Regardless how a disaster is defined numerically or situationally for a given institution, it is imperative that the hospital and, more specifically, the emergency department institute preestablished protocols for effectively dealing with such extraordinary situations. These protocols (e.g., for chemically contaminated patients or for the mobilization of appropriate outside assistance) must be instituted rapidly in order to prevent death or severe complications.
In many hospitals in the United States, disasters are often divided into external and internal events. External disasters are events that occur physically outside the hospital (e.g., transportation accidents, terrorist actions, etc.). As a result of such an external event, patients are brought to the hospital from the outside, usually to the emergency department. Unless the outside disaster is a chemical accident with contaminated patients, the hospital and its staff, patients, and visitors are in no immediate physical danger.
Internal disasters are events that occur within the physical plant of the hospital itself (e.g., a fire or laboratory accident involving radioactive material) that severely compromise the ability of the hospital to function.15 A disaster may be both internal and external, for example, an earthquake that severely damages the hospital.16 Such an event may damage the structural integrity of the hospital, cause dangerous equipment or supplies to fall over, and injure or kill hospital staff, patients, and visitors.
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