Disaster Preparedness, Emergency Response, and Recovery
Introduction to Disaster Medicine for MCCQE1
Disaster preparedness and response fall under the Population Health, Ethical, Legal, and Organizational Aspects of Medicine (PHELO) category of the MCCQE1. As a future Canadian physician, you are expected to understand the framework of the Canadian emergency management system, the principles of triage in mass casualty incidents (MCI), and the physician’s role within the CanMEDS framework (specifically as Medical Expert, Collaborator, and Leader).
Canadian Context: In Canada, emergency management adopts a “bottom-up” approach. Emergencies are managed first at the local level, escalating to provincial/territorial and then federal levels only if capacity is exceeded.
The Four Pillars of Emergency Management
The Canadian framework for disaster management is built upon four interdependent components. Understanding these is crucial for the MCCQE1.
1. Mitigation
Prevention and Mitigation
Actions taken to eliminate or reduce the impact of disasters in order to protect lives, property, and the environment.
- Examples: Floodway construction (e.g., Red River Floodway in Manitoba), implementing building codes for seismic safety, vaccination programs to prevent epidemics.
- Physician Role: Advocacy for public health measures, disease surveillance.
Canadian Emergency Response Framework
Jurisdictional Responsibilities
The Emergency Management Act sets out the federal role. However, healthcare is primarily a provincial responsibility.
| Level of Government | Responsibility | Key Organization/Act |
|---|---|---|
| Municipal | First responders (Police, Fire, EMS). Management of local incidents. | Local Emergency Plans |
| Provincial/Territorial | Requests from municipalities when overwhelmed. Coordination of health services. | Provincial Emergency Management Organizations (EMOs) |
| Federal | Requests from provinces/territories. National security, border health, international aid. | Public Safety Canada, Public Health Agency of Canada (PHAC) |
The Incident Management System (IMS)
Canada utilizes the Incident Management System (IMS) to coordinate response across different agencies. It is a standardized approach to emergency management.
IMS Command Structure
You do not need to be an expert commander, but you must know where a physician fits in.
- Command: Overall responsibility (Incident Commander).
- Operations: The “Doers” (Medical staff, Police, Fire).
- Planning: The “Thinkers” (Developing action plans).
- Logistics: The “Getters” (Supplies, facilities, food).
- Finance/Admin: The “Payers” (Tracking costs, compensation).
Mass Casualty Incidents (MCI) and Triage
For the MCCQE1, the most high-yield clinical skill in this domain is Triage. In a disaster, the goal shifts from “doing the best for each patient” to “doing the greatest good for the greatest number” with limited resources.
START Triage Protocol
Simple Triage and Rapid Treatment (START) is the standard adult triage method used in Canada during MCIs.
Step 1: Ambulatory (The “Walking Wounded”)
Ask all patients who can walk to move to a designated area.
- Tag: Green (Minor)
- Note: These patients are assessed later.
Step 2: Respiration (RPM - R)
Check for breathing.
- Not breathing: Open airway.
- Still not breathing? → Tag: Black (Deceased/Expectant)
- Starts breathing? → Tag: Red (Immediate)
- Breathing: Check Rate.
- Rate >30 breaths/min? → Tag: Red (Immediate)
- Rate <30 breaths/min? → Proceed to Step 3.
Step 3: Perfusion (RPM - P)
Check Radial Pulse or Capillary Refill (CR).
- No Radial Pulse OR CR > 2 seconds? → Tag: Red (Immediate)
- Radial Pulse present OR CR < 2 seconds? → Proceed to Step 4.
Step 4: Mental Status (RPM - M)
Check ability to follow simple commands (e.g., “Squeeze my hand”).
- Cannot follow commands (Unconscious/Altered)? → Tag: Red (Immediate)
- Can follow commands? → Tag: Yellow (Delayed)
Triage Color Coding Summary
| Color | Priority | Definition | Examples |
|---|---|---|---|
| RED | Immediate | Life-threatening but treatable injuries requiring rapid intervention. | Tension pneumothorax, major hemorrhage, airway obstruction (resolvable). |
| YELLOW | Delayed | Serious but stable. Can wait 1-2 hours. | Stable abdominal wounds, fractures (open or closed) with pulses. |
| GREEN | Minor | ”Walking wounded.” | Minor lacerations, sprains, superficial burns. |
| BLACK | Deceased | Dead or unsalvageable injuries given resources. | Cardiac arrest, massive head trauma with exposed brain, 90% burns. |
Critical MCCQE1 Concept: In a normal ER setting, a cardiac arrest is a top priority. In a Mass Casualty Incident (MCI), a cardiac arrest is tagged BLACK. Do not attempt CPR in an MCI until sufficient resources are available.
Specific Public Health Emergencies
Pandemics and Outbreaks
The Public Health Agency of Canada (PHAC) leads the response.
- Key Legislation: Quarantine Act.
- Physician Role: Reporting notifiable diseases, vaccination, PPE adherence, telemedicine implementation.
- Resources: National Emergency Strategic Stockpile (NESS) provides medical supplies.
CBRNE Events
Chemical, Biological, Radiological, Nuclear, Explosives.
- Chemical: Decontamination is the priority before entering the hospital.
- Mnemonic: SLUDGE for Organophosphate poisoning (Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis).
- Biological: High index of suspicion for clustered symptoms (e.g., Anthrax, Smallpox).
- Radiological: Time, Distance, Shielding. Treat life-threatening trauma before radiation decontamination unless it interferes with care.
Canadian Guidelines: Code Orange
Most Canadian hospitals use standardized color codes. Code Orange signifies a disaster or mass casualty incident.
Key Physician Actions during Code Orange:
- Discharge: Rapidly discharge stable patients to free up beds (Reverse Triage).
- Cancel: Cancel elective surgeries and non-urgent clinics.
- Report: Report to the assigned manpower pool/personnel centre (do not just run to the ER).
- Role: Adhere to the specific role assigned by the Incident Commander.
Key Points to Remember for MCCQE1
- Jurisdiction: Local first, then Provincial, then Federal.
- Ethics: Utilitarianism applies in disasters (greatest good for greatest number).
- Triage: Know the START protocol. Red = Immediate, Yellow = Delayed, Green = Minor, Black = Deceased/Unsalvageable.
- Safety: Scene safety is paramount. Do not enter an unsafe scene (e.g., chemical spill) without proper PPE.
- Communication: Use plain language; avoid codes when speaking to other agencies.
- Vulnerable Populations: Children, elderly, and those with disabilities require specific planning (e.g., JumpSTART for pediatric triage).
Sample Question
Question
A 45-year-old male is involved in a multi-vehicle collision on a major highway involving a bus and several cars. Emergency Medical Services (EMS) declare a mass casualty incident. You are the first physician on the scene assisting with triage using the START protocol. The patient is lying on the ground, unable to walk. On assessment, he is not breathing. You manually open his airway, and he begins to breathe spontaneously at a rate of 35 breaths per minute. He has a weak radial pulse.
Which one of the following is the most appropriate triage category for this patient?
- A. Green (Minor)
- B. Yellow (Delayed)
- C. Red (Immediate)
- D. Black (Deceased)
- E. Blue (Expectant)
Explanation
The correct answer is:
- C. Red (Immediate)
Detailed Analysis:
This question tests your application of the START (Simple Triage and Rapid Treatment) protocol, which is the standard for adult triage in mass casualty incidents in Canada.
- Walking? The patient is unable to walk. (Not Green).
- Breathing? Initially, he was not breathing.
- Action: Open the airway.
- Result: He starts breathing.
- Assessment: If a patient starts breathing after the airway is opened, they are automatically tagged Red (Immediate).
- Secondary Check (for confirmation): His respiratory rate is 35 breaths/min. According to START, any respiratory rate > 30 breaths/min is tagged Red.
Why other options are incorrect:
- A. Green: This is for “walking wounded.” The patient cannot walk.
- B. Yellow: This category is for patients who cannot walk but have stable ABCs (Respirations < 30, Perfusion present/CR < 2s, Mental Status intact). This patient has tachypnea (>30) and required airway maneuvering.
- D. Black: This is assigned if the patient remains apneic (does not breathe) after the airway is opened. Since this patient started breathing, he is salvageable.
- E. Blue: This is not a standard color in the START protocol (though sometimes used in other systems for expectant/palliative, usually synonymous with Black in strict START contexts).
References
- Public Health Agency of Canada. (n.d.). Emergency Preparedness and Response. Retrieved from Canada.ca
- Medical Council of Canada. (n.d.). MCCQE Part I Objectives: Population Health.
- Public Safety Canada. (2017). An Emergency Management Framework for Canada.
- Benson, M., & Koenig, K. L. (2006). START Triage. In: Disaster Medicine.
- Royal College of Physicians and Surgeons of Canada. CanMEDS 2015 Physician Competency Framework.