Medical Author: Benjamin C. Wedro, MD, FAAEM
Medical Editor: Melissa Conrad Stoppler, MD

May 6, 2008 - It is not often that the NCAA basketball tournament and the cyclone that has ravaged Myanmar could be related. But except for the distance of a few blocks, the disaster in an Asia country could easily have happened in Atlanta.

As the death toll rises (as I write this, it is estimated at 22,000 dead with 41,000 more people missing), because of its relative isolation and poverty, it is possible to presume that what is happening in Myanmar would never happen in the US. Not two months ago, severe storms hit the Atlanta area as a men's college basketball game had the Georgia Dome packed with fans. Parts of the roof were ripped off by high winds, while tornados touched down nearby. Imagine the devastation if the tornado had hit the Dome: 60,000+ people in jeopardy.

But this is the United States. There are plenty of emergency workers to respond, people to lend help, and hospitals to care for the injured and ill. Except that perception is far from reality. No longer can emergency departments, operating rooms, and intensive care units handle an unexpected influx of disaster victims.

As a practicing emergency physician, I have a dog in this fight. Over the past many years, hospitals have closed, emergency departments have shut their doors, and the shortage of critical care nurses and doctors has increased. Inner cities and rural areas are affected equally. The inability to find medical care has become a crisis across the country as the decreased capacity to care for patients has caused longer waits for patients, ambulance diversions when ERs are overflowing, and patients being cared for in hallways and closets. With the system filled, the question that needs to be asked is what happens when disaster strikes? The ability to handle a surge of patients would overwhelm the system that exists today.

All cities and countries have disaster management plans that are practiced routinely, addressing such issues as who goes to the scene of the accident, how victims are triaged or sorted, communications, and transportation of victims to treatment areas. The planning and practices go well, because when it's over the victims/actors get up and leave. What happens when they have to stay around and get their definitive treatment?

The disaster doesn't need to be of great proportions to overwhelm the system. Imagine what would happen to your local hospital if 10 patients came in from a car accident needing care. It might take all the surgeons, emergency physicians, anesthesiologists, nurses, technicians, lab technicians, and cleaning staff to look after them. And what happens to the patients already there? And the ones that normally arrive because of illness or injury; where do they go?

Now imagine 100 patients arriving at once. That is more than the average number of patients seen in an emergency department in a single day.

Now imagine the Georgia Dome. 60,000 people all with potential injuries.

As the disaster unfolds in Myanmar, it is too easy to presume that the response to the devastation is inadequate because it is a third world country. But an adequate response would be difficult even with the affluence of the United States. A spot survey of numerous large city hospitals taken on March 25, 2008, found that all the hospitals were full and had no space in the emergency departments, operating rooms, or intensive care units. These facilities were incapable of responding to a terrorist attack. It would seem that the government survey would equally apply to a natural disaster or an infectious epidemic. There is just no room at the inn.

In times of disaster, tough choices have to be made. Those who can benefit from care are treated, while those who are deemed to have non-survivable injuries are left to die. Sadly, the country is at a point where plans are being made to triage ahead of time. In a report published this month in the journal Chest, doctors are discussing who should not be treated when resources are scare. So far the list includes the very elderly, severely burned patients, victims of severe trauma, and those with dementia.

Regardless of where nature strikes, the ability to save 60,000 people is not possible, but as our medical resources get even tighter, each community should decide if we can save even 60.

Reference: "Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care" Chest 2008; 133:51S-66

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