isasters are natural or manmade events where the casualty numbers overwhelm the available medical and organizational resources. Media coverage has brought these events to public attention on a regular basis. Terrorist attacks in urban areas involving explosive devices and toxic agent release have emphasized that disaster outside warfare can be deliberately produced. The management of both physical and toxic trauma is an expert domain where anesthesiologists have invaluable skills in both prehospital and hospital management. In many parts of the world, anesthesiologists are leaders of prehospital emergency and disaster care.¹ They assume leadership roles of international organizations such as the World Association for Disaster and Emergency Medicine and the International Trauma Anesthesia and Critical Care Society.^{2, 3}

Worldwide Leaders in Preparedness and Response
Anesthesiologists around the world have been in the forefront of disaster preparedness and response. In France, anesthesiologists lead the prehospital emergency care with the Service d’Aide Médicale Urgente and have an integral role in the operation of prehospital disaster plans.⁴ Anesthesiologists worked in the Helicopter Emergency Medical Service rapid-response units during the July 2005 London subway bombings and were among the first to deal with casualties, particularly those requiring field amputation.⁵ In addition, in London, anesthesiologists work inside the Chemical Hazards and Poisons Division and are closely involved with the management of casualties following a toxic agent release.⁶

It is not difficult to see why anesthesiologists fit well into these roles. We are trained to manage a broad spectrum of patients, from pediatrics to geriatrics, from the healthy patient to the medically complex patient and from the difficult elective case to the hemodynamically unstable emergency case. The special training of anesthesiologists provides an in-depth understanding of pharmacology and applied physiology together with essential life-support skills, including line placement, volume resuscitation and airway management. In daily practice, we ventilate most of our patients and thus we are adept at handling challenging respiratory and ventilation cases. No other specialty has such depth and breadth of education and daily practice in hemodynamic monitoring, volume resuscitation, medical management and airway management of a diverse patient population.

From a historical perspective, it is clear that anesthesiologists have tremendous experience and skill to share with our colleagues in the management of trauma and disaster situations both here in the United States and globally. Anesthesiologists utilize triage skills in the day-to-day management of the flow of patients in our operating rooms (O.R.s), postanesthesia care units and intensive care units. Anesthesiologists must be adept at multitasking in the aftermath of an attack with weapons of mass destruction (WMD), offering care for several patients simultaneously, often under adverse and austere conditions. Nevertheless, with advance planning and training, treatment can be delivered while minimizing the harm of WMD — both to patients and responders. Reliable and accurate information is necessary for rational health policy. The recent weaponization of biological agents such as anthrax has turned what was once an unimaginable event into an actual public health threat. In a WMD attack, medical personnel will be in short supply. The ability of anesthesiologists to participate effectively in emergency medical care outside the O.R. is enhanced by the acquisition of competency in advanced trauma life support (ATLS) and basic principles of mass casualty and disaster management. Coincident with shortages of health care workers, there will be a limited need for O.R. care and increased need for respiratory therapy and intensive care. General anesthesiologists can fulfill a variety of roles outside the O.R. In cases of WMD attack, we can function as team members in field medical teams, in the emergency room or in the management of intensive care patients.

Obstacles to Overcome
Despite the obvious role for the anesthesiologist in disaster care, there are many difficulties in setting up models for practice. The first challenge is to define clearly for both our medical colleagues and the public alike the extended role of the anesthesiologist beyond the daily work as a perioperative life support physician. The second challenge is finding time to plan and work outside of our traditional work areas. The third challenge is the lack of regularly scheduled administrative and out-of-O.R. clinical time for training and field experience, particularly overseas training experiences.

There also are concerns over the provision of malpractice insurance coverage in the event of a disaster requiring deployment. Should we allow economic and legal concerns to keep us from proactive involvement in our hospitals and community disaster preparedness and response? If we do, are we neglecting the obvious important contribution to patient care in the arenas of trauma, chemical, biological and nuclear disaster management?

These concerns have led to a lack of integration of many anesthesiologists’ perspective into trauma and disaster preparedness programs. We lack the understanding of our hospital administrations as to the significant contribution we anesthesiologists can and should make to this endeavor.

Anesthesiology was the first medical specialty to identify patient safety as a specific focus. In 1984, ASA established the Anesthesia Patient Safety Foundation (APSF).7 This approach has relevance for the wider implications of prehospital and disaster care. We should utilize the bridges previously built among anesthesiologists, nurse anesthetists, manufacturers of equipment, pharmaceutical companies, government regulators, risk management attorneys and engineers and build new bridges to our colleagues in the American College of Emergency Physicians, the American College of Surgeons and the American Medical Association. Development of liaisons between ASA, APSF, the Federal Emergency Management Agency and the Department of Homeland Security will provide a way forward for establishing an essential role of the anesthesiologist in disaster management. Natural and manmade disasters are a reality, and our profession must adapt and develop to meet the necessary challenge.

What Can You Do Immediately?
Start at home with preparedness <www.ready.gov/america/index.html>. In a safe place in your home, have a disaster kit equipped for both the most common events in our area and for the predicted influenza pandemic. Every family member should know where it is. Make sure your family knows how to contact you, as well as each other, in the event of a disaster. This communication should include a family member outside the state. We cannot function as anesthesiologists if we are worried about our own families.

Become certified in ATLS, national disaster life support, Hospital Emergency Incident Command Structure and personal protective equipment. These courses are all available within the Brigham and Women’s Hospital.

Get involved: Volunteer locally, at the state level or regionally.

Develop a “disaster kit” for the main O.R.s.

Be proactive! This is the only proven way to avert an inadequate response to any disaster, whether natural or manmade.


Please note that further articles on disaster preparedness and volunteerism will appear in future NEWSLETTERS.


References:
1. Grande CM, Baskett PJ, Donchin Y, et al. Trauma anesthesia for disaster: Anything, anytime, anywhere. Crit Care Clin. 1991; 7:339-361.
2. Baskett P, Fisher J. T. Michael Moles: A life to be celebrated. Prehosp Disast Med. 2001; 16(2):73-74.
3. Trauma Care International. The International Trauma Anesthesia and Critical Care Society Home Page. Available at <www.itaccs.com>.
4. Carli PA, Riou B, Barriot P. Trauma anesthesia practices throughout the world: France. In: Grande CM, ed. Textbook of Trauma Anesthesia and Critical Care. St. Louis: Mosby Year Book Inc; 1993:199-204.
5. Lockey DJ, MacKenzie R, Redhead J, et al. London bombings July 2005: The immediate pre-hospital response. Resuscitation. 2005; 66: ix-xii.
6. Baker DJ, Personal communication, February 2006.
7. Anesthesia Patient Safety Foundation. APSF History Overview. Available at <www.apsf.org/about/brief_history.mspx>. Accessed on July 14, 2006.

Jill A. Antoine, M.D., is Associate Clinical Professor of Anesthesiology, University of California-San Francisco, San Francisco, California.