Role of anesthesiologist in disaster management
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role of anesthesiologist in disaster management mass casualty incidents
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Role of the Anesthesiologist in Disaster Management
Anesthesiologists occupy a uniquely privileged position in disaster response. Their daily work demands mastery of airway management, hemodynamic monitoring, pharmacology, resuscitation, critical care, and high-stakes decision-making under pressure - all of which map directly onto the demands of mass casualty incidents (MCIs) and large-scale disasters.
1. Why Anesthesiologists Are Uniquely Suited
Compared to other specialists, anesthesiologists bring a skill set that spans the full perioperative and critical care spectrum:
| Skill | Disaster Application |
|---|---|
| Advanced airway management (intubation, supraglottic airways) | Immediate life-saving airway in field/triage |
| Hemodynamic monitoring and resuscitation | Rapid stabilization of shocked, polytrauma patients |
| Regional anesthesia and pain management | Analgesia without opioid dependency in resource-limited settings |
| Perioperative coordination | Managing patient flow pre-op → OR → ICU |
| Critical care expertise | ICU surge capacity, ventilator management |
| Pharmacological knowledge | Drug improvisation in austere environments |
| Simulation and patient safety training | Drills, exercises, and protocol development |
| Leadership under stress | DMAT team command, resource allocation decisions |
(Miller's Anesthesia 10e, Chapter 85 - Emergency Preparedness)
2. Phases of Disaster and the Anesthesiologist's Role
Disaster management is organized into four phases: mitigation, preparedness, response, and recovery. Anesthesiologists have a role in every phase.
A. Mitigation and Preparedness (Pre-Disaster)
- Participation in the hospital disaster/emergency preparedness committee - a multidepartmental planning group that develops the Hospital Comprehensive Disaster Response Plan.
- Conducting hazard vulnerability analyses (HVA) to identify the most likely local threats (earthquake, flood, chemical incident, mass shooting, pandemic).
- Developing anesthesiology-specific disaster response plans - including OR surge protocols, equipment caches (ketamine, regional anesthesia kits, portable ventilators), and staff call-back trees.
- Running simulation exercises and drills (tabletops and full-scale) to keep protocols "alive in the minds" of the team rather than just on paper. Evidence supports that exercising for MCI preparedness materially improves response quality (Moss & Gaarder, Br J Anaesth, 2022).
- Training in triage systems: START (Simple Triage and Rapid Treatment), SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport), and JumpSTART for pediatric patients.
- Involvement in crisis standards of care (CSC) policy development - defining how care delivery shifts during resource scarcity.
B. Response (During the Disaster)
i. Triage
The shift from conventional care ("do the most for the individual patient") to disaster care ("do the most good for the most patients") is the fundamental paradigm change. Anesthesiologists, with their rapid assessment skills, are well-suited to perform triage:
| Category | Color | Action |
|---|---|---|
| Immediate (T1) | Red | Life-saving intervention possible and needed now |
| Delayed (T2) | Yellow | Can safely wait 2-4 hours |
| Minimal (T3) | Green | "Walking wounded" |
| Expectant (T4) | Black/Gray | Unsurvivable or would require disproportionate resources |
Anesthesiologists are equipped to rapidly assess hemodynamic status, airway patency, and need for emergency intervention - the core of field triage.
ii. Airway Management in the Field
This is arguably the single most critical contribution. In disasters, airway management must be adapted for:
- Limited lighting, unstable surfaces, noise, and restricted patient access (e.g., collapsed buildings)
- Lack of standard OR infrastructure (no pipeline gases, no capnography)
- High-volume, simultaneous demand
Techniques used include rapid sequence intubation (RSI) with ketamine and succinylcholine, supraglottic airways (LMAs), and surgical airways when necessary.
iii. Operating Room and Perioperative Surge
After major disasters (earthquakes, explosions, terror attacks), fracture injuries account for approximately half of casualties, and a majority require operative intervention. Anesthesiologists:
- Manage OR throughput - coordinating multiple simultaneous cases
- Apply damage control anesthesia principles - short, stabilizing procedures to control hemorrhage and contamination, avoiding prolonged physiology-altering anesthesia
- Use ketamine-based anesthesia as the cornerstone drug (does not require oxygen/electricity infrastructure, maintains hemodynamic stability, provides analgesia)
- Deliver regional and neuraxial anesthesia where appropriate - particularly valuable in resource-limited settings to avoid the need for general anesthesia and ICU-level monitoring
iv. Critical Care and Ventilator Management
Anesthesiologists serve as the primary drivers of ICU surge capacity - both physical (converting ORs and PACUs to ICU beds) and personnel (staffing ventilated patients). This role was powerfully demonstrated during the COVID-19 pandemic, where anesthesia departments established intubation teams and dramatically expanded critical care capacity.
- Miller's Anesthesia notes: "In response to COVID-19, anesthesia departments set up intubation teams and strategies to increase critical care capacity both from a physical space perspective and personnel who can provide critical care and ventilatory capacity."
v. Pain Management
In mass casualties with extensive limb trauma:
- Regional anesthesia (peripheral nerve blocks, fascial plane blocks) reduces opioid requirements and allows patients to be transported and recover with less respiratory compromise
- Particularly important when opioid supply chains are disrupted or when post-disaster logistics limit pharmacy access
vi. Field and Deployed Medicine (DMAT)
Disaster Medical Assistance Teams (DMATs) - pre-organized, federally registered teams deployable to disaster scenes - frequently include anesthesiologists in leadership roles. In Japan (post-Fukushima, post-2011 earthquake and tsunami), anesthesiologists led DMAT operations, coordinating:
- Field airway and hemodynamic management
- Hospital evacuation of ICU and OR patients
- Aeromedical transport triage
- Interdisciplinary team command
The Japanese experience from 1995 to 2024 is particularly well-documented and demonstrates anesthesiologist leadership across all disaster response domains.
C. Recovery (Post-Disaster)
- Continued care of surgically managed patients through the postoperative period
- Second victim support - anesthesiologists who experience moral injury from triage and expectant patient decisions require structured psychological debriefing
- Participation in after-action reviews to improve future plans
- Contribution to rebuilding disaster-resilient perioperative protocols
3. Special Considerations
Pediatric Patients
Pediatric patients in MCIs present distinct challenges - altered triage algorithms (JumpSTART), different drug dosing, smaller airways. A 2022 review in Br J Anaesth (Desmond, Schwengel, Chilson) called for specific anesthesiologist preparation for pediatric mass casualty scenarios, noting they are systematically under-prepared in most disaster plans.
Ethical Dilemmas
In MCIs, anesthesiologists may face decisions about:
- Withdrawing or withholding life-sustaining treatment to reallocate resources to patients with better survival prospects
- Crisis standards of care - operating under a formal framework that modifies the standard duty of care based on resource scarcity
- Clear documentation, family communication, and defined institutional protocols are essential
Cybersecurity and Infrastructure Threats
Modern disaster preparedness extends beyond natural and mass-casualty events. Ransomware attacks on hospital systems (up 86% in one recent period) can disable OR scheduling, electronic health records, and drug dispensing. Anesthesiologists must have paper-based backup protocols and understand manual drug calculation and record-keeping.
4. Regulatory and Institutional Framework (US)
- Joint Commission requires a comprehensive emergency management (CEM) plan - mitigation, preparedness, response, recovery - since 2001.
- CMS Conditions of Participation mandate emergency preparedness plans for all Medicare/Medicaid-participating hospitals.
- ASPR (Assistant Secretary for Preparedness and Response) oversees the National Disaster Medical System (NDMS) and the Hospital Preparedness Cooperative Agreement Program.
- CISA (Cybersecurity and Infrastructure Security Agency), established in 2018, coordinates cross-sector including healthcare preparedness.
5. Key Takeaways
- Anesthesiologists are not peripheral to disaster response - they are central. Their skill set is arguably the best match for the acute demands of MCIs.
- Triage requires a paradigm shift from individual-focused to population-focused care; anesthesiologists must train explicitly for this.
- Airway management, damage control anesthesia, regional techniques, and critical care surge are the four clinical pillars of the anesthesiologist's disaster role.
- Leadership in DMATs and hospital emergency committees is a well-established and important non-clinical role.
- Training and simulation are not optional - preparedness that exists only on paper fails in real events.
- Recovery and second-victim support are often neglected but are essential for workforce sustainability after disaster.
Key Sources:
- Miller's Anesthesia 10e, Chapter 85 (Emergency Preparedness), pp. 12555-12569
- Lam CM, Murray MJ. The multiple casualty scenario: role of the anesthesiologist. Curr Anesthesiol Rep. 2020;10(3):308-316.
- Gangadharan M et al. A call to action: Why anesthesiologists must train, prepare, and be at the forefront of disaster response for MCIs. Anesth Analg. 2024.
- Desmond M, Schwengel D, Chilson K. Paediatric patients in mass casualty incidents. Br J Anaesth. 2022.
- OpenAnesthesia - Disaster Preparedness (updated March 2026)
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