Emergency medicine is full of surprises, twists, and turns. We don’t know what type of patient we will encounter prior to a shift, but we are ready for any and all. That being said, preparation is essential prior to the arrival of critical patients. This is why the airway cart is checked before starting a shift or the position of the bedside ultrasound machine is always mentally tracked in order to quickly grab if needed.

Unfortunately, individual preparation is not sufficient for large scale disasters. This level of preparation must happen on a hospital and interdepartmental level such as coordination between trauma surgery, orthopedics, and emergency medicine with agreed upon policies.

Anticipating injuries based on mechanism

But there are things that individual providers can do to get ready when large scale disasters do occur that can significantly impact the medical outcome for patients involved in large scale disasters. These actions are based upon anticipation. Anticipating the types of injuries and illnesses that can occur based on the event, mechanism of injury and then preparing accordingly will lead to better outcomes for a larger number of patients.

We have seen signs of this in the latest disasters that have been in the news. The Boston Marathon Bombing is a great example of how the operating rooms were activated; knowing in advanced that there would likely be a higher level of orthopedic injuries. By anticipating this, they were able to allocate resources and mobilize hospital personnel effectively. Being aware of the news and knowing that a plane had crashed-landed in San Francisco allowed the local hospitals to prepare for patients that likely had internal organ injuries and seat belt related injuries. It is inspiring to know how the EM providers have responded in these cases.  The list goes on including the Denver Movie Shooting, responses during Hurricane Sandy, and on and on.

Anticipation, Preparation, and Medical Education

Unique to EM, our training focuses upon development of a differential diagnosis on disease processes that can “kill” you first, rather than casting a broad net. We anticipate what type of “badness” could be going on in a patient and then approach the work up in that manner. All this is conducted on a large scale during disasters. In fact, this anticipation is almost a skill that becomes intuitive for providers, to the point of almost becoming instinctive. EM medical education must focus specifically on honing and developing this skill.

I hope you are all as proud as I am when reading the news and editorials about the impact EM providers have during these events. Just know that with a background in EM, we are prepared to handle virtually anything thrown our way and continue to provide the best medical care possible during times of great fear and uncertainty. We also owe it to our learners to focus on incorporating anticipation and preparation throughout the medical education process.

Emergency Medicine and Mass Casualty Experiences

Please read the following articles and editorials showcasing the hard work down by our colleagues around the country.

  • Boston Marathon 1,2
  • Learning from Mass Casualties3
  • Central Texas Fertilizer Plant Explosion 4
  • Hurricane Sandy 5
  • Fukushima Earthquake and Japanese Nuclear Power Disaster 6
The Boston Marathon bombings: a post-event review of the robust emergency response. ED Manag. 2013;25(7):73-78. [PubMed]
Biddinger P, Baggish A, Harrington L, et al. Be prepared–the Boston Marathon and mass-casualty events. N Engl J Med. 2013;368(21):1958-1960. [PubMed]
Tami G, Bruria A, Fabiana E, Tami C, Tali A, Limor A. An after-action review tool for EDs: learning from mass casualty incidents. Am J Emerg Med. 2013;31(5):798-802. [PubMed]
Zuzek C. The night West blew up. Tex Med. 2013;109(7):41-45. [PubMed]
Powell T, Hanfling D, Gostin L. Emergency preparedness and public health: the lessons of Hurricane Sandy. JAMA. 2012;308(24):2569-2570. [PubMed]
Murakawa M. Anesthesia department preparedness for a multiple-casualty incident: lessons learned from the Fukushima earthquake and the Japanese nuclear power disaster. Anesthesiol Clin. 2013;31(1):117-125. [PubMed]
Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
Nikita Joshi, MD


Emergency Medicine Doctor Associate Editor of ALiEM Gun Sense Advocate #FOAMed #Docs4GunSense #MomsDemandAction Tweets represent my own views and opinions