Extensive social and organizational research on the management of mass-casualty events has shown that emergency departments experience great difficulty coping with even moderate numbers of patients following a disaster.17 The reasons for this difficulty include confusion, lack of planning, and lack of training in the principles of disaster management. Hospitals are often not well integrated into the surrounding community's disaster planning efforts. 18 Hospital disaster plans often exist only on paper and are rarely referred to, let alone carried out, during a real disaster. Shortcomings of hospital disaster plans include (1) delayed or improper notification of hospital staff, (2) poor delineation of the command structure, (3) overloaded or broken communications networks, (4) improper or incomplete identification of patients and the dead, (5) lack of supplies, and (6) lack of public relations. 19
When a disaster occurs, transportation of patients to emergency departments is usually uncoordinated, with no thought given to equitable distribution of patients among potential receiving medical facilities.20 As a result, nearby hospitals are usually overwhelmed with the majority of severely injured patients, while those farther away see very few patients.21 Most casualties are transported to a hospital over a relatively short period of time, with most patients arriving at an emergency 1
department within 12 h after the disaster has occurred. Most patients presenting to an emergency department in a disaster have minor injuries and do not require advanced trauma services.21
Victims of mass-casualty events may arrive at hospitals by a variety of means, including ambulances, private automobiles, police vehicles, taxis, and on foot. 23 Since hospitals may receive patients in all sorts of unplanned ways, the flow of patients is not under the control of the official or formal emergency medical services (EMS) system.22 In addition, ambulatory patients and those with relatively minor injuries may arrive at the emergency department before patients with more serious injuries because they are able to leave the disaster site by their own devices, using taxis, buses, private cars, vans, and police vehicles. The more severely injured, who often need extrication (e.g., from collapsed buildings following earthquakes), arrive at a later stage. The result is that less severely injured patients often tend to be treated before the more seriously injured. The early arrival of a large number of ambulatory patients can create serious problems because the emergency department may become badly overcrowded early, resulting in confusion in the efforts to provide treatment. 24 Similarly, when attention is being paid to early arrivals at a hospital, it is easy for the more seriously injured patients brought in later not to be noticed immediately or to be given delayed treatment.
Rescuers, emergency medical technicians, and representatives of the media may rapidly converge on the emergency department and contribute to chaos.
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