Overview Of The Basic

Principles
in the Management of
Disaster/Mass-Casualty
Incidents
Dr Nik Ahmad Shaiffudin Bin Nik Him
Emergency Physician
Hospital Sultanah Nur Zahirah
Presentation Outlines
1. Definitions
2. Our Experiences
3. The guidance
4. Emergency Medical Response
5. Summary/Conclusions

Definitions
When the destructive effects of natural or man-made forces
overwhelm the ability of a given area or community to meet the
demand for health care.
~American College of Emergency Physicians~
A sudden ecologic phenomenon of sufficient magnitude to
require external assistance.
~World Health Organization~
An Interface between an extreme physical event & vulnerable
human population
~ Susman et al ~
Generally defined by the effect on people and infrastructure resulting in the
loss of the ability to respond independently
Disaster.....
Definitions cont.
MCI: Large number of victims.enough to
overextend/disrupt the normal course of emergency and
health care services not overwhelm your facilitys
capabilities.
Mass Casualty Event The number of casualties overwhelms
hospital capabilities (usually >20 patients).
MCM: management of victims of a mass casualty event,
aimed at minimizing loss of life and disabilities.

The magnitude
1 - 99 casualties: Mild
100 - 999 casualties: Moderate
=>1000 casualties: Major


~American College of Emergency Physicians~

TYPE OF DISASTER/MCI
1. NATURAL DISASTERS
eg. Earthquakes, hurricane, volcano eruption etc.
2. TECHNOLOGY & HUMAN RELATED
eg. Collapsed building, war, air crash, transport accidents.
3. HYBRID CIVIL EMERGENCIES
e.g. When both components are involved eg. Flood with
collapsed building.

People killed and affected by type of disaster in the world
(Period 1994-2003)

Source: ADRC, Japan based on CRED EM-DAT database, 2003
Summary of Natural Disasters
(1975-2002)
Number of
Disasters
Number of
Killed
Number of Totally
Affected People
Amount of Damage
(1,000 US$)
World 7,104 2,063,633 4,797,950,112 982,894,232
Asia 2,676 (38%) 1,182,637 (57%) 4,269,422,754 (89%) 480,536,348 (49%)
Malaysian Experience
Date Disaster/Major Incident/MCI Dead Injured
19 Oct 1968 Collapse of 4 storey building, KL 7 11
Jan 1971 Monsoon flood spilled over to West
Coast of W. Malaysia
24 National
Emergency
Declared
31 July 1988 Collapse of Sultan Abdul Halim
Jetty, Butterworth, Penang
32 1674
22 Sept 1989 Fire at Sek. Agama Rakyat
Taufiqiah Khairiah Al Halimiah, Yan,
Kedah
27 6
7 May 1991 Fire & Explosion of Bright Sparkles
Fireworks Factory, Sg Buluh
Selangor
22 103
Date Disaster/Major Incident/MCI Dead Injured
5 April 1992 Fire at SAAS International Airport,
Subang, Selangor
3
20 Jun 1992 Choon Hong III Ship, Explosion and
Fire, Port Klang, Selangor
10
11 Dec 1993 Collapse of Highland Tower
Condominium Hulu Klang, Selangor.
48
4 7 Dec
1994
Landslides In Cameron Highlands 7
30 Jun 1995 Landslides off Genting Highlands
Road, Pahang
20 22
Malaysian Experience
Date Disaster/Major Incident/MCI Dea
d
Injured
15 July 1996 Tourist Bus Accident,
Landslides at KM 15, Genting
Highlands, Pahang
20 23 injured
29 Aug 1996 Mudslides at the Aborigines;
Village in Pos Dipang,
Kampar, Perak.
50 12 injured
250 homeless
26 Dec 1996 Tropical Storm GREG
(Typhoon) Keningau West
Coast Of Sabah.
270 26 injured
3,000 homeless
1,150 affected
1 30 Apr
1997
Enteroviral Outbreak Sibu
Sarawak
25 Many affected
Malaysian Experience
Date Disaster/Major Incident/MCI Dead Injured
July Oct
1997
Country wide haze in Malaysia
and haza emergency in
Sarawak
Enviroment Damage,
Health Problems &
Economic Losses.
24 Dec 1997 Fire and Explosion Shell SMDS
Bintulu Sarawak.
12
Feb May
1998
Forest and peat fires
throughtout the country
3000 hectares of
forest burnt
Mac Sept
1998
Water supply crisis in Klang
Valley
1.8 Million residents
affected
4 Feb 1999 Kg Gelam Landslides 17
Malaysian Experience
Date Disaster/Major Incident/MCI Dead Injured
Oct 98
June 99
Japanese Encephalitis (JE) Outbreak
In Perak, Negeri Sembilan and
Melaka.
101
28 Jan 2002 Ruan Changkul Simunjan, Sarawak
Landslide
16
2003 SARS
Anthrax Scare
2004 Avian Flu
26 Dis 2004 Tsunami 64 69
28 Mac
2005
Earthquake Nil
Malaysian Experience
POS DIPANG 30 AUGUST 1996
HIGHLAND TOWERS 11 December 1993
GREG TYPHOON 26 DECEMBER 1996
PENANG FERRY BRIDGE
31 DECEMBER 1988
Powders, Powders Everywhere
Anthrax Scare Threatens Malaysia
Yearly monsoon reminder in the
East Coast of Malaysia
Kg. Sungai Muda, Kedah
Pictures from KEDAH & LANGKAWI
Kuala Chenang, Langkawi
Kuala Muda Kedah
Chenang Beach, Langkawi
Bagan Jermal, Penang
Pictures from Penang..
Gurney Drive, Penang
Pictures from Perak & Penang
Tg. Piandang, Pt. Buntar, Perak
Jalan Tg. Tokong, Penang
Tg. Bungah, Penang
Terengganu Experience ???
Flood at Setiu, Terengganu on 18 December 2005.
Source: NST
Date Disaster/Major Incident/MCI Dead Injured
2002 5 kereta MVA Sg Ular 15
2003 Bas sekolah Vs Lori , Sg Ular 5 16
2003 Bas sekolah terbalik di Jln Air Putih 20
2003 MVA 4 wheel Vs Car Vs Van Pekerja,
Kemaman
11
2007 Bas sekolah MVA 1 33
2008 Car VS Van Pelancong, Cherating 1 8
9/7/08 MVA Trak tentera Vs Van, Cherating 1 20
15/7/09 Fire Engine slide, Manir 9
Terengganu Experience
1.Motor vehicle accident
Date Disaster/Major Incident/MCI Dead Injured
2000 Lack of O2 di Perwaja Steel Sdn Bhd 6
2001/2 Keracunan gas di Kaw Perindustrian Telok
Kalong ( See Sen)
10/15
2002 Letupan Gas Petronas GPP 01 1 6
2003 Kebakaran dan letupan di KSB 2
2000 Pembakaran sampah di asrama SMKSI 20
2002 Keracunan UiTM Dungun 20
2009 Roof of Stadium SMZA collapsed
Terengganu Experience
2.Industrial Accidents/Poisoning/Building Collapse
The Guidance
MEMBERS OF NSC
Chairman : Prime Minister
Deputy Chairman : Deputy Prime Minister

Members : Minister of Defense
Minister of Home Affairs
Minister of Foreign Affairs
Minister of Information
Chief Secretary to The Government
Chief of The Armed Forces
Inspector General of Police

Secretary : Director General
National Security Division
Directive 20 of the National
Security Council.
Disaster
An event that occurs suddenly.
Complex in nature.
Loss of lives
Destruction of property and/or environment.
Disruption of the community daily activities.

Divided into 3 main level of categories depending on the
management capability and capacity
LEVEL 1
Localized major incident
under control
not complex
small no. of casualties and property loss
minor disruption of daily community activities
manageable by the local authorities not
requiring multi sectoral involvement.

e.g. bus accident, train derailment, landslide.
DIRECTIVE 20 NATIONAL SECURITY
COUNCIL
LEVEL 2
Widespread over a large area but under control
Complicated and complex
Large no. of casualties and property loss.
Affecting daily community activities
Not manageable by the local authorities
requiring assistance from other states or
National Authorities
Support required, Regional or National Support


e.g. Highland Towers Collapse, Greg Storm
Sabah, Bright Sparklers.
LEVEL 3
Involves a very large area.
Loss of many lives.
Total Destruction of infrastructure and public facility.
Complicated and complex.
High risk to rescue workers.
Complete disruption of daily community activities.
Major destruction of resources.
All local resources destroyed and assistance from
external resources required.

e.g. Earthquake, typhoons, volcanoes, war
ORGANISASI PENGURUSAN BENCANA
SEKRETARIAT /
URUSETIA
OPERASI
PDRM
JBPM
SMART
JPA3
ATM
RELA
Perkhidmatan
Perubatan
kecemasan
Lembaa Pelesenan
Atom
PDRM
JBPM
SMART
JPA3
ATM
RELA
Perkhidmatan
Perubatan
kecemasan
Lembaa Pelesenan
Atom
SOKONGAN /
LOGISTIK

PERUBATAN
ATM
PDRM
JKR
Majlis Daerah
Tempatan
Pejabat Daerah
TNB
Telekom


Perkhidmatan
Perubatan
Kecemasan
ATM
PBSM
St. John
Ambulance

KEBAJIKAN
KAWALAN
KESELAMATAN
PDRM
RELA

Jabatan
Kebajikan
Masyarakat
Perkhidmatan
Perubatan
Kecemasan
PBSM
St. John
Ambulance
RELA
MEDIA
Jabatan Penerangan
Jabatan Penyiaran
INSIDEN /
BENCANA
YELLOW ZONE
RED ZONE
Access Road
Guard Post Guard Post
PKTK
Operating zone for Specialised
Search And Rescue Units
INCIDENT SITE
SMART
PDRM
Emergency
Medical Services
JBPM
PKTK
Pertahanan
Awam
ATM
YELLOW ZONE
RED ZONE
Access Road
Guard Post
Operating zone for Specialised
Search And Rescue Units
SMART
PDRM
Emergency
Medical Services
JBPM
PKTK
Pertahanan
Awam
ATM
YELLOW ZONE
RED ZONE
Access Road
Guard Post Guard Post
Operating zone for Specialised
Search And Rescue Units
GREEN ZONE
Aid Agencies and NGOs
Family
Bereavement
Centre
Counseling
Centre
Temporary
Mortuary
Media
Centre
Rest Area
Food Store
Safety First !
Emergency Medical response
Mass Casualty Management System
Disasters/MCI
Survival skills is the key element for victims
Elemental needs of the human person
Aim to survive until help arrives (days / weeks / never)
Community Resilience
Principle for responders
doing the most for the most
Limited resources requires responders to provide
assistance to those with a good chance of survival
Best available treatment may not be sending the patient
to the hospital
Elemental care is vital
Save life
Prevent escalation of the incident
Relieve suffering
Protect the environment
Protect property
Rapidly restore normality
Assist any criminal investigation @ enquiry
Perform the above in a coordinated, and safe way
Recovery and lessons learnt
Emergency Medical response
Rescuing the rescue team ??
A Multi-sector Rescue Chain
INAPPROPRIATE APPROACH
SCOOP & RUN - competition & no coordination
CLASSICAL CARE APPROACH - basic triage
& field before evacuation but no coordination
between the field organization & the receiving
healthcare organization.
MCM APPROACH
Pre-established procedures for resource mobilization,
field management & hospital reception.
Approach is adapted according to specific situational
problems (topography, infrastructure, communication,
health facilities)
Triage
Triage,
Immediate
Evacuation
FIELD ORGANIZATION
EVACUATION
SCENARIOS
1
3
2
Advance Medical Post
Triage
Stabilization
Controlled Evacuation
Non-Triage
Immediate
Evacuation
Triage
Triage
Stabilization
Immediate
Evacuation
4
Triage
Triage
Stabilization
Immediate &
Delayed Evacuation
5
Scoop & Run
Stay & Play
Mass Casualty
Management System
The Impact of a Mass-Casualty / Disaster
Event on the Hospital service
Disruption of on-going and routine services
Overwhelming of ED resources
Mobilisation of staff and resources
Unaccustomed working environment
Event stress leading to post-traumatic stress
Adverse effect on quality of care
Control of situations with patients, relatives, press, other
hospital staff
Information control
Event disrupts ability of hospital to respond or mobilise
Always-be-ready concept
Anytime anywhere
Activation and Response phases
In any mass casualty or disaster, the role of the
medical team deployed includes....
Primary ambulance response
Disaster triage
Control of Medical Operations at site of incident
On-scene/site management
Transfer decisions
Hospital activation
Receiving of in-coming patients
Disaster/MCI Preparedness
Disaster Plan
2 main phases
Emergency Dept activation phase
Hospital Activation phase

3-stage Alert system
Yellow Alert
Red Alert
Green stand-down
ALERTING PROCESS
Notification & verification.
To evaluate the extent of the problem.
To ensure that appropriate resources are informed &
mobilized.
MOBILE/FLYING/ASSESSMENT TEAM
COMMUNICATIONS!!!!!
Phases of Medical Response
Activation
event is first discovered
Scene assessed
Command established
Implementation
Search and rescue
Triage
Stabilization
Transport
Definitive management of
patients and scene


Recovery
Withdrawal from scene
Resume normal operations
Debriefing
Analysis of event
Mitigation
Lessons learnt
Risk Mapping
Contingency Planning
INCIDENT SITE MANAGEMENT
1. Zoning and coding
2. Work matrix
3. Medical Base Station Layout
4. Role & responsibilities
5. Human resource management
6. Triage
- Primary
- Secondary
7. Forensic activities
8. Public Health
9. Psychological Management
Management of the Event itself is as important as the
management of the individual patient
Principles of FIELD MCM
SAFETY MEASURES
IMPACT ZONE (red): strictly restricted to
professional rescuers.
SECONDARY AREA (yellow): restricted to
authorized staff involved in the rescue operation
TERTIARY AREA (green): restricted to press
officials & public
Action for 1
st
team on-site
1. Report to PKTK
Introduce yourself
Ask for brief situational report
Safety hazards
2. Situation evaluation
3. Inform Hospital
Actual situation
Estimated number of casualties
Type of casualties
Back-up required
1
st
team. (cont)
4. Set-up Base Station
5. Communication
6. Temporary Zoning
7. Temporary morgue
8. Logistics
9. Head count duty
10. Get other agencies to aid if/ when reqd
11. Operative until stand down declared by OSC
S-S-S-S-S
S Safety
S Scene Size-Up
S Send Information
S Set-up
S START
ADVANCE MEDICAL POST
AREA-Medical Base Station
Location: safe area, direct access to the evacuation road,
short distance from the Command Post, clear
communication zone.
Good triage capacity.
Specifically trained medical teams.
Good communications between the field & the hospital.
Good coordination of all involved sectors.
Design of Basic AMP-Medical
Base Station
PRINCIPLE OF INJURY
MANAGEMENT
3 T principle
TRIAGE/TAG
TREAT
TRANSFER/TRANSPORT
SEARCH & RESCUE
Safety first
Locate & remove victims from
unsafe locations to collecting
point, if necessary
On site triage
First aid, if necessary
Transfer victims to the AMP,
if necessary
TRIAGE SYSTEM
-Disaster Field Triage
1. Basic Aim : To do the most good for the most
people
2. Transport priority for the most salvageable with
the most urgent problems
3. Transport those who are treatable in hospitals but
fatal in the field first
4. Sieve and Sort using the START system

TRIAGE SIEVE
First look triage
Decision undertaken at Incident
Site
Rapid, simple, safe &
reproducible
Not perfect
Walking wounded to leave
danger area under their own
power
Critical patients carried to
casualty clearing station
TRIAGE SORT
Retriage at Casualty
Clearing Station
Right patient to the
Right place at the
Right time
TRIAGE SYSTEM
-Disaster Field Triage
Disaster Triage Tags
Most effective
Internationally recognized Color codes
Defines severity of injury and also defines urgency of
transport
Useful to incorporate ID codes here

Red: critically injured (need immediate specialty care)
Yellow: less critically injured
Green: no life/ limb threatening injury
White/Black: fatal injuries or dead
RULES OF EVACUATION

NO VICTIM MAY BE REMOVED FROM AMP TO THE
HOSPITAL BEFORE:

the victim is in the most stable possible condition
the victim is adequately equipped for the transfer
the hospital is correctly informed & ready to receive the victim
the best possible vehicle & escort are available
THE NORIA PRINCIPLE
Victim movement - one way direction, without
crossings.
Victim movement - organized as conveyor belt
(from basic first aid care level to sophisticated levels)
each transport level will have to use its own limited
resources in a rotating system.

Victims Flow
Emergency Operations Centre
Bilik Gerakan
Coordination and Control centre
Dispatch centre for all field operations
Development of networks between agencies
Communications centre
Control of resources and resource matrix
Information control centre
Responder check-in and check-out centre
Emergency Dept Activation
Notification and Activation sequences
Chain of Command
Setting up the Emergency Operations Centre
Initiation of Field Operations
Mobilising resources and staging area
Triage and patient flow systems
Control of area and traffic flow
Re-designated treatment areas
Specialized areas for family, media, mortuary, forensics
Hospital Activation
Preplanned Response
Documented & accessible
Tested & analysed
User challenged
Dynamic
Table top exercise
Disaster drill


Hospital Activation Phase


A Hospital Response NOT Emergency Dept.
Response
A Hospital Strategy
Handled by Hospital Authority
A Mandatory requirement by Ministry of
Health, Malaysia
ALL Hospital personnel must be AWARE of
the Response Plan.
INFORMATION FLOW: PRESENT MALAYSIAN SCENARIO
INCIDENT SITE
Informer/Caller : Provide the following Info:
Identification of Caller
Time of Incident
Type of Incident
Location
999
999
999
Red Crescent Police
Fire & Rescue
Civil Defence
Hospital
Deployment of
Rescue Team
Deployment of
Rescue Team
Analysis of Information
Stand Down
on Yellow
Alert
Yellow
Alert
Standby
Red Alert
Declaration of
Disaster
Activate
Hospital
Alert
System
Deployment of Search &
Rescue Team
INCIDENT SITE
MANAGEMENT OF MAJOR INCIDENT IN MALAYSIA
HOSPITAL ACTIVATION PHASE
PRIMARY RESPONDING HOSPITAL

The Main Hospital Leading The Management
Fulfill Criteria Of A Leading Hospital
Coordinating Role
Closest & Most Well Equipped Hospital
Identified & Selected By Authorities
Resource Development
Skill Training

SECONDARY RESPONDING HOSPITAL

- Other Hospitals Involved In The Management Of
Victims

- Activated Only When Called By Primay Responding
Hospital

ROLE:

1.Provide logistic support , Eg. Manpower, Equipment, Wards For Admission

2. Managed & Accommodate Victims etc
MANAGEMENT OF MAJOR INCIDENT IN MALAYSIA
HOSPITAL ACTIVATION PHASE
ORGANISATIONAL ASPECT
HOSPITAL ACTIVATION PHASE
COORDINATOR
HOSP. DIRECTOR
ADMIN.
COORDINATOR
DEP. DIRECTOR OF
HOSP.
MATRON SECURITY SUPERVISOR
DIETICIAN
ADMIN
PERSONNEL
PHARMACIST
CLINICAL
COORDINATOR
SENIOR
CLINICIAN
HODs Senior AMO
OF ED
SISTER ED
PHARMACIST
ADMINISTRATIVE COORDINATOR
Resource & Logistic Management
Resource & Logistic Deployment
Continous Requirement Assessment
Patient Accomodation
Inventory Management
Transport Requirement
SETTING UP OF VARIOUS Mx AREAS
Relative Areas
Control Centre


CLINICAL COORDINATOR
Organize Clinical Team
o Critical, S. Critical, Non Critical
Deploy On Site Management Team
Deploy Sar Team
Set Up Clinical Management Area
Set Up & Manage Triage Centre
Coordinate The Forensic Service Team
o Pathologist & Maxillofacial
Coordinate Psychiatrist & Counselor Service
Liaise With Admin Coordinator For Bed
Requirement, Pharmacist
In Close Liaison With OMC
Summary
1. Understand how disaster affect us.
2. Alerting Process
3. Situation Assessment & Field Area Identification
4. Safety measures
5. Command Post
6. Communication Tools
7. Search & Rescue
8. Triage & Stabilization
9. Controlled Evacuation
10. Hospital disaster preparedness plan !!!
CONCLUSIONS

1. Coordination
2. Familiarization
3. Abide By The Directive From The National
Security Council Of Pm Dept., MALAYSIA
( Arahan 20, MKN )
Arts of War Sun Tzu
The Art of War teaches us to rely not on the
likelihood of the enemys not coming, but on
our readiness to receive him; not on the
chances of his not attacking, but rather on
the fact we have made our position steadfast

Thank you.. 1Malaysia Boleh