British Journal of Anaesthesia, 119 (S1): i126–i134 (2017)

doi: 10.1093/bja/aex353
Prehospital Care

PREHOSPITAL CARE

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Managing anaesthetic provision for global disasters
R. M. Craven*
Department of Anaesthesia, Bristol Royal Infirmary, University Hospitals Bristol, NHS Foundation Trust,
Bristol, UK
*E-mail: rachael.craven@uhbristol.nhs.uk

Abstract
The numbers of people affected by large-scale disasters has increased in recent decades. Disasters produce a huge burden of
surgical morbidity at a time when the affected country is least able to respond. For this reason an international disaster
response is often required. For many years this disaster response was not coordinated. The response consisted of what was
available not what was needed and standards of care varied widely producing a healthcare lottery for the affected popula-
tion. In recent years the World Health organisation has initiated the Emergency Medical Team programme to coordinate the
response to disasters and set minimum standards for responding teams. Anaesthetists have a key role to play in Level 2
Surgical Field Hospitals. The disaster context produces a number of logistical challenges that directly impact on the anaes-
thetist requiring adaptation of anaesthetic techniques from their everyday practice. The context in which they will be work-
ing and the wider scope of practice that will be expected from them in the field mandates that deploying anaesthetists
should be trained for disaster response. There have been significant improvements in recent years in the speed of response,
equipment availability, coordination and training for disasters. Future challenges include increasing local disaster response
capacity, agreeing international standards for training and improving data collection to allow for future research and
improvement in disaster response. The goal of this review article is to provide an understanding of the disaster context and
what logistical challenges it provides. There has been a move during the last decade from a globally uncoordinated, unregu-
lated response, with no consensus on standards, to a globally coordinated response through the World Health Organisation
(WHO). A classification system for responding Emergency Medical Teams (EMTs) and a set of agreed minimum standards
has been defined. This review outlines the scope of the role of the anaesthetist in a Level 2 field hospital and some of the
challenges that this scope and context present. It focuses mainly on natural disasters, but also outline some of the differen-
ces encountered in responding to other global disasters such as conflict and infectious outbreaks, and concludes with some
of the challenges for the future.

Key words: anaesthesia; critical care; disasters; earthquakes; emergencies; disease outbreaks; warfare

The disaster context

The World Health Organisation (WHO) defines a disaster as “A
sudden event causing severe destruction of infrastructure, peo-
ple and the economy and which overwhelms the resources of
that country, region or community.”1 These disasters may be
caused by natural events such as earthquakes, tsunamis and
disease epidemics or man-made disasters such as war and
industrial accidents. Natural disasters have in recent decades
increased in frequency.2 This may be partly because of an
increased rate of reporting but there is clear evidence that global
flood events have increased in recent years.3 Whilst the rate of
earthquake events appear to be unchanged the numbers of
those affected has risen as a result of their occurring in high
population density areas.2
Disasters lead to a number of logistical challenges. The local
government may be severely affected itself by the disaster, as

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i126

was the case after the 2010 Haiti earthquake. As a result the
local organisations that would normally coordinate any disaster
response may not be operational. The infrastructure is usually
badly damaged, either because of physical destruction or as a
result of the absence of the workforce; and so water, electricity,
food and transport may all be absent or at best in short supply.
In addition, the local healthcare structures and staff are also
severely affected;4 5 so just at the point where there is a massive
surge in healthcare needs there is also a large reduction in
healthcare capacity (Fig. 1).
Whilst the logistical challenges across disasters are fairly
consistent the medical challenges vary widely. Different types
of disaster have different patterns of mortality and morbidity.
As anaesthetists the disaster that tends to represent our “worst
case scenario” is the urban earthquake. Urban earthquakes pro-
duce a high ratio of injuries to deaths (three injuries:one death)
compared with flooding and tsunamis (one injury:nine deaths).
This is because in flooding type disasters anyone with signifi-
cant injuries is likely to drown.6 7 The type of injury in an earth-
quake is also more likely to require surgical and therefore
anaesthetic care. Typically, earthquakes produce severe blunt
trauma with crush injuries, wound infections and burns, often
requiring multiple surgical procedures.8 9 After tsunamis and
flood events patients are more likely to present with near
drowning, pneumonia, hypothermia, and infected soft tissue
injuries.10 11
Different disaster types also follow different timelines in
terms of presentation to hospital. In a “typical” natural disaster
there will be an initial peak of injuries directly related to the
event. These may present over several days as a result of the
difficulties of getting to a hospital. There may then be a second
peak of admissions after two to three weeks “the second
emergency,” when medical teams who only have resources for
a few weeks deployment go home and their patients must be
transferred. In conflict situations by contrast there tend to be
smaller recurrent peaks of casualties (Fig. 2).12 In both situations
over weeks to months there is a gradual increase in presenta-
tions of exacerbation of chronic health conditions reflecting
breakdown in primary care and difficulty accessing medicines;
an increase in burns because of displaced populations using
kerosene lamps and stoves; an increase in infectious diseases
Fig 1 Trinite hospital, the MSF trauma centre destroyed in the 2010 Haiti
earthquake.
Managing anaesthetic provision for global disasters | i127
as a result of cramped poor living conditions in displaced per-
sons camps; and an increase in obstetric emergencies reflecting
lack of access to antenatal care. For the duration of the emer-
gency period there is not usually capacity for scheduled cancer
and elective surgery.13–15
Organisation of the international disaster
response
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Until recent years there was no coordinated, organised global
medical response to global disasters. Whilst some of the large
international non-governmental organisations such as
Medecins sans Frontieres (MSF) or the International Committee
of the Red Cross (ICRC) individually had a very high quality
organised response, these were not integrated with other res-
ponders. Integration often relied on personalities on the ground
rather than at the headquarters level and usually only after
deployment of teams. In recent years social media and 24 h
news has led to very rapid and extensive reporting of disasters.
One effect of this has been a raised awareness in the global
medical population of disasters as they happen, and an under-
standable desire to do something to help. This combination of
widespread media coverage and a large healthcare population
wishing to help came to a head in the 2010 Haitian earthquake.
Large numbers of medical teams responded, at its height
around 40 medical teams a day were registering with the United
Nations on arrival in Haiti, with more than 300 in place by the
end of the second week. Other medical teams, in contrast, did
not know to or chose not to register. These teams were
extremely variable in terms of experience and training in disas-
ter response. Many teams performed well but lack of coordina-
tion with other providers led to duplication of services and
wasted resources. Some teams arrived without the necessary
logistical support, causing a drain on already stretched local
resources, and eventually left without ever treating any
patients. In a few cases teams carried out inappropriate proce-
dures, that they were not qualified to do in their own countries,
with inadequate anaesthesia and analgesia, on the grounds that
it was the best that could be done in a disaster. The local popu-
lation was left with a healthcare “lottery” with very different
standards of care depending on which team they presented to.
The population were very aware of this and if able to “shopped”
Natural disaster
Number pressenting
Conflict
Days Weeks Months
Fig 2 Conceptual graph of numbers of patients presenting to hospital over
time in conflict vs natural disaster.
 i128 | Craven

around visiting different teams. This led to problems of delayed
treatment, discontinuity of care and wasted resources.16
After Haiti there was a general call from the international
medical community for an improvement in standards and coor-
dination for disaster response.17 This has led to the production
by the WHO of the Emergency Medical Team (EMT) Classification
and Programme. This programme lays down minimum stand-
ards for emergency medical teams responding to a disaster.
Teams are categorised into three levels: Level 1 - outpatient
emergency care; Level 2 - inpatient surgical emergency care; and
for the majority of life-threatening injuries and these teams are
arriving mainly at the phase of limb salvage and reduction of
long-term morbidity. This delay also means that even for non
life-threatening injuries timely debridement of dirty wounds
and open fractures is not possible with worse long-term out-
comes. For at least the first 48 h many local staff are effectively
on their own. There are three main options open to them. First,
they may be able to salvage equipment and work in a limited
way to provide life-saving surgery. This was the initial approach
that the MSF trauma hospital in Haiti had to take for the first

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Level 3 - inpatient referral hospital with ICU facilities.18 The
standards lay down the technical and logistical capabilities that
teams must possess at each level, the speed with which they can
be deployed and the human resources required. The majority of
anaesthetists will find themselves deployed in Level 2 type field
hospitals (Table 1). A Level 2 field hospital must be capable of
being fully independent with a structure to work in (generally
tented), generators and the capability to provide its own water
and food. Technically it must provide emergency medical, surgi-
cal and obstetric care with the ability to stabilise more serious
patients for transfer to referral hospitals with ICU facilities.
In addition to the classification and standards the pro-
gramme holds an international register of teams that have been
inspected and accredited to these standards with the aim of
guaranteeing a minimum set standard of care. Governments
affected by a disaster now contact the WHO with a request for
what number and types of team they require. The teams from
the register are then invited to respond to the disaster with the
aim of better matching the response to the needs. In the field,
the WHO works closely with the local ministry of health to task
teams to the most appropriate geographical areas working in
coordination with existing local healthcare structures and staff.
The aim is to reduce duplication of effort and wasted resources
and provide better continuity of care for patients once the inter-
national teams leave. Teams who attend a disaster who have
not been invited are likely to find themselves turned away on
arrival at the airport.
Local disaster response
In Figure 3 we can see how quickly (and how many) teams were
able to arrive in the field for some of the major disasters of the
last few years. Whilst the international response has become
more coordinated and faster into the field over recent years it
can be seen Figure 3 that very few teams can arrive in under
24 h and most take at least 48 h to arrive, but they may then take
several more days to become operational. This is clearly too late
48 h but sterility and capacity were far from ideal (Fig. 4).
Secondly, if areas of the country have not been affected it may
be possible to rapidly transfer a large number of patients out of
the affected region: this happened to a large extent after the
2015 Nepal earthquake. Kathmandu remained mainly func-
tional and so large numbers of patients could be transferred
quickly to the capital from the worst affected regions. Finally, in
large countries such as India and China there may be capacity
for local disaster response teams to deploy. This is the ideal sit-
uation as they can arrive faster than an international team, gen-
erally speak the same language and understand the existing
healthcare system providing better exit planning and continuity
of care.19 Whether the emergency medical team is local or inter-
national the goal is that they will be working to the same stand-
ards and have the same level of training.
The role of the anaesthetist
The EMT classification and standards gives clear guidance on
human resources for deploying EMTs. Any organisation deploy-
ing a Level 2 field hospital must provide at least one medically
qualified anaesthetist. Some previous teams have deployed
with no anaesthetist assuming that they would have access to a
local anaesthetist, or deployed only with nurse anaesthetists
leaving gaps in perioperative and critical care management for
patients. The classification and standards have made it clear
what services should be provided by an EMT and therefore what
roles, knowledge and skill sets will be required from the anaes-
thesia team. These include:
Anaesthesia set up
The anaesthetist in the first team to deploy must be fully
trained and prepared to set up for anaesthesia and/or resuscita-
tion for the operating theatre, delivery room, recovery room,
high dependency area and emergency room. This may include
building furniture, and setting up oxygen concentrators, suc-
tion, airway equipment and anaesthesia draw-over systems.

Table 1 Minimum standards for Level 2 emergency medical team, inpatient surgical emergency care: inpatient acute care, general and
obstetric surgery for trauma and other major conditions18

Medical Organisational

Surgical triage, assessment and advanced life support
Definitive wound and basic fracture management
Damage control surgery
Emergency general and obstetric surgery
Inpatient care for non trauma emergencies
Basic anaesthesia, x-ray, blood transfusion, lab and
rehab services
Acceptance and referral service
Use existing or deployable facility
Clean operating theatre environment
Care appropriate to context and changing burden of disease
Multidisciplinary team experienced in working in resource scarce settings
One operating theatre with one operating room to 20 inpatient beds
Seven major or 15 minor operations/day
24 h services
 Managing anaesthetic provision for global disasters | i129

40
38

Number of EMTs arriving per day

34
32
30
28
26

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24
22
20
18
16
14
12
10
8
6
4
2

0 5 10 15 20 25
Days after disaster

Fig 3 Emergency medical teams registering each day during recent disasters. From: WHO EMT initiative Jan 2017. Available from https://extranet.who.int/emt/
sites/default/files/EMT_Updatednews_19.01.2017.pdf (accessed 21 September 2017).

Fig 4 Makeshift operating theatre in use for the first few days after the Fig 5 Typical Level 2 operating theatre deployed to the Nepal earthquake.
Haiti earthquake.

They will need to stock all the areas with disposable equipment,
drugs and paperwork and ensure ready access to all necessary
protocols such as antibiotic prophylaxis, thromboprophylaxis
and the WHO checklist (Fig. 5).
Provision of anaesthesia
One challenge for deploying anaesthetists is the range of spe-
cialties across which they will have to work. For many there will
be at least one area that does not form part of their daily routine
practice. Anaesthetists on the team need to be able to manage
the perioperative care and provision of anaesthesia for trauma
patients including high dependency unit level care for tetanus
and crush injury; obstetric emergencies and neonatal resuscita-
tion; general surgical emergencies; burns and very importantly
paediatrics which may make up to 25% of cases. They also need
to be prepared to manage acute and chronic pain issues on the
wards, particularly those arising from neuropathic pain as nerve
 i130 | Craven
injuries are extremely common especially in earthquakes16 and
conflicts.
There are also a number of technical challenges for the
deploying anaesthetist caused by the context in which they are
working:
Oxygen and inhalation anaesthesia. One challenge is lack of access
to compressed gases, – specifically oxygen. Oxygen cylinders
are very heavy and difficult to transport so it is not practical for
teams to take oxygen with them. Even if cylinders are available
refilling them is not an option. In most disasters oxygen plants
are no longer operational or accessible and, in the case of con-
flict, driving full oxygen cylinders around is very dangerous. For
this reason EMTs rely on oxygen concentrators. These are very
reliable but require an electricity supply and produce oxygen at
a pressure of just over one bar. This pressure is not sufficient for
our familiar Boyles type anaesthetic machines and so if a team
wishes to provide inhalation anaesthesia it is necessary to use
draw-over anaesthesia systems. Drawover systems have a
number of advantages in this context: they are small and easy
to transport, they continue to work when the electricity fails,
they are very economical in oxygen usage (1 l min 1 provides an
FIO2 of 0.3), it is not possible to give a hypoxic mixture so inspired
oxygen monitoring is less vital, and they are non-rebreathing
circuits so agent monitoring is not essential. However, most
anaesthetists in their daily practice will have never set them up
or used them so some training pre-deployment is required.
I.V. Anaesthesia. Teams may wish to avoid inhalation anaesthesia
altogether and rely on total i.v. anaesthesia using either propofol
or ketamine. Most anaesthetists from high resource settings are
very familiar with giving propofol total i.v. anaesthesia (TIVA).
Unfortunately, propofol TIVA also has a number of disadvantages
in this context. Propofol anaesthetics require quite a large volume
of propofol that must be transported to the disaster zone, con-
trasted with ketamine which comes in high strength ampoules
one of which will be sufficient for several anaesthetics. Ketamine
is also much more forgiving of extremes of temperature during
transport and storage compared with propofol. Propofol causes
respiratory depression and apnoea is common in contrast to ket-
amine. This becomes important when the electricity and there-
fore oxygen supply is unreliable. In addition, teams frequently
work alongside local anaesthetic nurses and officers who have a
lot of experience monitoring people receiving ketamine anaes-
thesia but not propofol and do not always have the skills to reli-
ably recognise and manage airway obstruction, hypoventilation
and apnoea. The same points apply to the recovery room. Finally,
ketamine also provides good postoperative analgesia whereas
propofol does not. This is important as transport of opioids into
disaster zones can be frequently delayed because of customs
restrictions. For all these reasons most experienced disaster
response teams (such as MSF and the ICRC) rely heavily on ket-
amine anaesthesia.20 21 During the MSF response to the Haiti
earthquake 90% of general anaesthetics were carried out under
ketamine with only 10% of patients receiving a general inhalation
anaesthesia.12 Again, most anaesthetists from high resource set-
tings will not have had much experience with ketamine anaes-
thesia so pre-deployment training is required.
Regional Anaesthesia. Spinal anaesthesia is a common anaes-
thetic technique in this context and is usually considered for
any patient requiring surgery below the umbilicus that is not
shocked. There can be issues of communication so the presence
in theatre of a translator or local staff member throughout the
case is extremely important. It can be expected that around 20%
of cases will be performed under spinal anaesthesia.12 Epidural
analgesia and anaesthesia is not generally performed as a result
of the difficulties of postoperative surveillance of patients.
Regional blocks are extremely valuable. Surgeries may be
performed under regional block alone, although the nature of
the injuries covering more than one site often means that it
needs to be combined with general anaesthesia. It is still very
useful in this context however as it reduces the amount of gen-
eral anaesthesia required with speedier, safer recovery. In addi-
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tion, it provides excellent postoperative analgesia.
Postoperative analgesia. Analgesia can be a real challenge in this
setting with restricted supplies of opioids and inadequate post-
operative patient monitoring as a result of overwhelming patient
numbers. Regional block techniques, although gaining in popu-
larity, are still relatively underused in this setting, but their
safety and usefulness is established22 23 and they are recom-
mended in the WHO/ICRC management of limb injury guide-
lines.24 Most emergency medical teams now deploy with
portable ultrasound for a number of uses including regional
anaesthesia, and so facility with ultrasound-guided lower limb,
upper limb and some trunk blocks such as transverse abdominus
plane and serratus anterior plane blocks is extremely useful.
Critical and perioperative care
Whilst Level 2 field hospitals are not expected to provide inten-
sive care they will need to stabilise critically ill and injured
patients – both medical and surgical. Ideally these patients
would be transferred to a referral or Level 3 hospital but in prac-
tice this is not always possible. Usually a dedicated bed either in
the emergency room or the recovery area (dependent on nurs-
ing skill mix and staffing levels) is set up for high dependency
patients. The anaesthetist on the team may be the most senior
person available to lead stabilisation of patients arriving in the
emergency room and manage their care if necessary. Whilst
this might not be a problem for surgical emergencies, manage-
ment of medical emergencies may be less familiar. Crucially the
team anaesthetist will also need to help with the medical man-
agement of ward patients with comorbidities such as diabetes
mellitus and hypertension in addition to recognition and man-
agement of perioperative complications. The International
Surgical Outcomes Study showed that in elective patients in
lower resourced settings there were fewer complications com-
pared with higher resourced settings, as might be expected
when the patients had lower baseline risk. However the overall
mortality rates were the same, suggesting failure to salvage
from complications.25 It is likely that this risk would be even
higher in the emergency setting and emphasises the fact that
providing safe surgery and anaesthesia cannot be in isolation
from good perioperative care.
Other roles
The anaesthetist on the team also needs to be prepared to take
on a number of roles and tasks with which they may have no
experience.
Pharmacy skills: keep an inventory of their drugs and disposables
to make sure that they reorder supplies in good time, bearing in
mind that resupply can take weeks; and monitor or delegate the
monitoring of drug refrigerators including maximum and mini-
mum temperatures for cold chain security for refrigerated drugs
and vaccines.

Infection control skills: ensure that anaesthetic equipment is
cleaned, disinfected and sterilised as appropriate.
Laboratory skills: perform simple tests such as Haemacue,
malaria and infectious disease rapid checks and bedside blood
group testing.
Management and teaching skills: manage a small team of local
anaesthetic officers, and in the later stages of the emergency
some teaching may be appropriate.
Audit and quality improvement: data collection is vitally important
both to inform the health cluster and country Ministry of Health
about the evolution of the emergency to improve coordination
but also for analysis after the event to improve the response for
future disasters. The anaesthetist on the team will have a role
in physically collecting data and a leadership role in ensuring
the completeness and quality of the data.
Personal considerations for volunteers
When can I volunteer?
Working in disaster response involves working unsupervised,
and sometimes solo, in a very high-pressure environment both
in terms of professional technical challenges and managing
team dynamics. In addition, the anaesthetic role can involve
working with and supervising experienced local anaesthetists.
For these reasons, most EMTs require anaesthetists to be of con-
sultant level or equivalent. Some teams who deploy with more
than one anaesthetist have the ability to take anaesthetists in
training, although priority for these places is usually given to
anaesthetists of consultant grade who do not yet have overseas
experience. Some EMTs (e.g. the UK EMT) allow trainees to sign
up for training, be part of a community of practice and be
involved in non-disaster response deployments. Any consultant
volunteering needs to consider the requirement for often short
notice deployments, with the need to be away for around three
weeks, and whether this will be possible both professionally
and personally.
Registration and insurance
In the EMT system registration with the local Ministry of Health
is carried out on arrival at the Health Emergency Coordination
Centre. Copies of relevant General Medical Council and
Certificate of Completion of Training certificates must be pro-
vided. The practitioner is then provided with a disaster response
identification card, generally with limited registration to work
only in their own EMT facility. Medical indemnity insurance is
usually provided by the deploying EMT, but this should be
checked when signing up. Both the Medical Protection Society
and The Medical Defence Union may also agree to extend pro-
tection to their members (at no extra cost) for carrying out this
work, but this must be prearranged by phone on a case by case
basis. Personal insurance for health, medical evacuation and
kidnap is provided by the deploying organisation. But insurance
against theft and loss of personal items is the individual’s own
responsibility, and in many of the areas visited will not be possi-
ble to obtain.
Health and safety
Working in these environments carries inherent risks which
whilst they cannot be avoided should be mitigated by responsi-
ble deploying organisations. Questions to consider are: is there
Managing anaesthetic provision for global disasters | i131
someone on the team with responsibility for safety and security;
what are the identified risks for this context; what has been
done to mitigate these risks; what is the plan if one of these
risks occurs; and does the benefit of the team being deployed
outweigh these risks? If your deploying organisation is unable
to answer these questions then you should think carefully
before deploying. Potential risks depending on the context
include: infectious diseases, transportation accidents, further
flooding/aftershocks, etc, robbery, kidnap, and violence against
the team as collateral damage and intentional targeting of the
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team.
One of the most common questions asked is regarding psy-
chological health and the impact of working in these contexts.
Most people who deploy will have no long-term psychological
sequelae. The majority of people experience a stress reaction on
returning to “normal” life after deployment often referred to as
“re-entry syndrome” or “reverse culture shock,” and a minority
may go on to experience burnout and in some cases post-
traumatic stress disorder.26 To minimise these stress reactions
and ensure any problems are rapidly identified and treated,
deploying EMTs should have a psychological health programme
for their volunteers. The content of these programmes is beyond
the scope of this review, but should include specific briefing for
the deployment (expectations), education on how to minimise
stress and maximise resilience on deployment and manage-
ment of re-entry, post-deployment debriefing (immediate and
delayed), recognition of abnormal stress reactions and routes
for getting help.
Progress so far and challenges for the future
The gold standard for disaster response is to have local emer-
gency medical teams who are able to be operational within 12 h,
providing a high standard of care and increased capacity, in
order to manage life-threatening injuries from the disaster.
These teams can then be augmented over 24–72 h by interna-
tional emergency medical teams to provide increased capacity
and more rapid management of non-life threatening injuries,
thereby decreasing the burden of long-term morbidity and dis-
ability. These teams must also be prepared to help with both
disaster and non-disaster related on-going demand for emer-
gency surgical and medical care. The aim should be that both
local and international teams would be working to the same set
of minimum standards.
Local disaster response
The major challenge is how to provide that local emergency
medical team response. Even countries with high levels of
resources and well advanced disaster planning, such as Japan,
struggle.27 There are four accepted pillars for local disaster
preparedness:
1. Structural preparedness: ability of a structure to withstand the
hazardous event.
2. Non-structural preparedness: ability of equipment to withstand
the hazardous event.
3. Functional preparedness: ability of a hospital to operate prop-
erly such as availability of necessary drugs and disposables,
sufficient beds, water and oxygen, etc.
4. Human resources: existence and ability of healthcare staff.
Most people who are affected by disasters live in low- and
middle-income countries (LMICs). For many hospitals in LMICs
providing these four pillars of preparedness just for everyday
 i132 | Craven
healthcare needs is a struggle let alone in the disaster setting.28–30
The priority currently for LMICs is to improve local healthcare
infrastructure. This agenda has been strengthened in recent years
by the Lancet Commission on Global Surgery31 and the World
Health Assembly resolution to strengthen emergency and essen-
tial surgical and anaesthetic care.32 This is clearly a massive
undertaking and further discussion of progress in this area is
beyond the scope of this review. High-income countries still have
work to do to attain this level of preparedness – especially around
provision of local disaster emergency teams.27
International disaster response
These same four pillars of preparedness are also relevant for
international emergency teams. In this area through the WHO
EMT programme significant progress has been made. The WHO
accredited teams will now arrive in the disaster zone with a
suitable structure to work in, they will be using equipment that
is suitable for the context and will have full logistical support
providing their own water and electricity and sufficient medical
supplies. The responding teams will have appropriate human
resources for the capacity they are providing and these staff will
have had training for the context in which they will be working.
There are still areas for improvement for the international
response:
Speed of response
For many countries a high quality, high capacity local disaster
response is not yet attainable. For this reason international
emergency teams need to be able to respond as fast as possible.
Whilst response time has been improving, for the most part, it is
still too slow to help those with life-threatening injuries. Barriers
to a rapid response and their potential solutions include:
1. Travel time: EMTs from the countries nearest the disaster
should be invited to respond but this has not always been
the case. The WHO EMT programme can play a key role in
ensuring that the appropriate teams are activated.
2. Customs export and import restrictions: this can significantly
delay supply of equipment, drugs and disposables to the dis-
aster, with teams arriving days before their equipment.
Customs problems can be reduced by having modules of
drugs and equipment pre-approved by customs offices.
Equipment and supplies can also be stockpiled in regions
and countries likely to be affected by disasters.
3. Runway space and other transport restrictions: having modular
systems enable teams to deploy with a smaller rapid response
kit to provide life-saving treatment whilst awaiting the rest of
their field hospital equipment.33 Pre-agreed standard operat-
ing procedures for air traffic control priorities in case of disas-
ter can also improve the flow of staff and supplies.
4. Release of staff from existing roles: use of standby rotas and
agreements with employers to release staff. The UK
International Emergency Team has staff on three month
rotas, with the pre-agreement of their employers that they
will be released immediately for disaster response.
Whilst most teams and countries use some of these meas-
ures to improve response time few have all in place.
Training
Anaesthetists who formed part of an EMT in the past reported
significant gaps in skills and knowledge for their role.34 35 This
should not be surprising when one considers the technical
differences and wider scope of practice discussed above. There
are now a range of training materials and courses available for
anaesthetists who wish to deploy with EMTs such as the Royal
College of Anaesthetists’ online Humanitarian Anaesthesia
eLearning module,36 the ICRC Anaesthesia Handbook for disas-
ter and conflict,37 and the ICRC War surgery course. Pilot studies
of on-line training have demonstrated self-reported improve-
ments in preparedness once deployed.38
Whilst the WHO EMT programme mandates that anaesthe-
tists should be trained, there is not currently an agreed curricu-
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lum for what that training should consist of.39 This is true for all
the deployed specialties and an international group is currently
working to produce agreed curricula.
Responding to conflict and outbreak disasters
The WHO EMT Initiative was primarily targeted at disaster
response for natural disasters such as earthquakes and tsuna-
mis. In recent years the WHO has also used the same frame-
work to coordinate the response to the Ebola outbreak in West
Africa. In the future there is no reason why it could not also be
used to coordinate response in conflict as well. For anaesthetists
responding to these disasters there are a number of different
training needs compared with natural disasters: security, man-
agement of bullet, blast and chemical injuries, infection control
and use of Nuclear, Biological, Chemical (NBC) suits or Personal
Protective Equipment as required. Whilst the conflict role has
many overlaps with response to natural disaster the role of the
anaesthetist in outbreaks is very different. The anaesthetist
may have a role in responding directly to the outbreak disaster
(helping with fluid management, i.v. and intraosseous access,
very limited critical care and some transfer of patients). But it is
likely that in the future they will also be deployed as members
of teams helping to provide normal emergency surgical and
obstetric services to support healthcare systems that have bro-
ken down as a result of the effects of the outbreak.40
Audit, quality improvement and research
Coordinating and improving disaster response relies on good
quality data. This can be a real challenge in the high pressure,
extremely busy disaster context. Previously there has been no
agreed data set for medical teams to collect in disasters. Some
teams have not collected any data at all. Analysis of previous
disasters has had to rely on collating incomplete and differing
data sets from different organisations. The WHO EMT initiative
has now produced a minimum data set to be derived from
patient records and to be collected by all EMTs responding to a
disaster.41 This should provide much better quality data for
analysis of the effectiveness of disaster response and for disas-
ter planning in the future.
Conclusions
The disaster context produces immense logistical challenges for
responding EMTs and different types of disaster produce different
patterns and timescales of injury and disease for teams to respond
to. Understanding and being prepared for these different contexts
is vital for an effective disaster response. The last seven years since
the Haiti 2010 earthquake has seen enormous progress in the pro-
fessionalization of disaster response. Through the WHO EMT initia-
tive there have been significant improvements in the speed,
coordination and quality of the international disaster response.
The response is now much better matched to the needs of the

affected population. There are clear standards for logistics, equip-
ment, capacity and human resources for deploying teams and a
process of accreditation. Anaesthetists have a key role to play,
especially in the Level 2 emergency medical teams. The technical
challenges and wider scope of practice in this context mandates
that all deploying anaesthetists should receive training for anaes-
thesia in disaster response. Future challenges include improving
local disaster response and organisation of local EMTs, reducing
the time for teams to be operational in the field and agreeing train-
ing standards for deploying teams. Collection and analysis of the
minimum data set will allow teams to compare and evaluate their
response and help to plan more effectively for future disasters.
Declaration of interests
The author is a Volunteer Anaesthetist with Medecins sans
Frontieres; Ex lead Anaesthetist UK Emergency Medical Team;
and Member of International Committee of Red Cross – World
Federation of Societies of Anaesthetists Liaison Committee.
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