CHPPC Module 16, Section 1: Mass-Casualty Response
MODULE 16: OPERATIONS UNDER STRESS & CRISIS MANAGEMENT

Section 1: Mass-Casualty Response

In this section, we address the ultimate test of a hospital’s readiness: the Mass-Casualty Incident (MCI). An MCI is any event that generates more patients than the hospital can manage using its routine, day-to-day resources. This could be a natural disaster, a terrorist attack, a chemical spill, or a pandemic. During an MCI, the normal rules of healthcare change. The focus shifts from providing optimal care for an individual patient to providing the best possible care for the greatest number of patients. You will learn how your role as a pharmacist scales from a clinical practitioner to a critical logistics and operations commander within the hospital’s formal emergency management structure.

1.1 The Paradigm Shift: From Individual Care to Population Management

Understanding the fundamental change in mindset during an MCI.

Every aspect of your training, both in community and hospital practice, is focused on providing the best possible, individualized care for a single patient in front of you. During an MCI, this paradigm is turned on its head. The guiding principle becomes “utilitarian ethics”—the greatest good for the greatest number. This means making difficult decisions about resource allocation. A ventilator that might be used for a patient with a poor prognosis in normal times may be reallocated to a patient with a higher chance of survival. Expensive, limited medications may be reserved for those most likely to benefit. This is the world of triage, where every decision—including medication decisions—is viewed through the lens of population-level outcomes. As a pharmacist, you must shift your thinking from “what is best for this one patient?” to “what is the best use of our limited medication resources for all of our patients?”

Retail Pharmacist Analogy: Managing the First Big COVID-19 Rush

Think back to the first few weeks of the COVID-19 pandemic. Suddenly, your pharmacy was inundated with people seeking masks, hand sanitizer, thermometers, and prescriptions for unproven therapies. Your normal “first-come, first-served” model broke down. You had to make triage decisions. You likely implemented a policy: “Limit one bottle of hand sanitizer per customer” to ensure as many people as possible could get some. You had to field hundreds of questions about a novel virus with limited information, becoming a public health communicator. You prioritized filling prescriptions for the elderly and immunocompromised. You were no longer just serving individuals; you were managing the health needs of your community population under duress. You were already practicing the core principles of crisis management.

A hospital MCI is the institutional-scale version of that experience. The “hand sanitizer” is now a life-saving ventilator or a limited supply of a crucial antibiotic. Your role is to help manage that scarce resource, not for a single customer, but for a surge of critically ill patients, all within a structured, formal command system.

1.2 The Hospital Incident Command System (HICS): Your Place in the Structure

Deconstructing the organizational chart of a hospital crisis.

When an MCI is declared (often announced overhead as “Code Triage” or “Disaster Alert”), the hospital immediately abandons its normal administrative structure and reorganizes into the Hospital Incident Command System (HICS). HICS is a standardized, flexible management system designed to bring order to the chaos of a crisis. It establishes a clear chain of command, defined roles, and a common language. Understanding this structure is essential, because you, the pharmacist, have a specific and vital role within it. The Director of Pharmacy or their designee often becomes a key leader in the Logistics Section, responsible for the entire medication and supply chain.

1.2.1 The Five Pillars of HICS

HICS is organized into five functional sections, all reporting up to a single Incident Commander.

HICS Section Core Function Pharmacy’s Role & Interaction
Command The Incident Commander (IC) has overall responsibility. The Public Information Officer (PIO) and Safety Officer report here. You will receive your overarching objectives from Command (e.g., “Prepare for 100 trauma patients”). You provide critical medication-related safety information back up to the Command Center.
Operations The “doers.” Manages the hands-on patient care: triage in the ED, surgery in the OR, inpatient care on the floors. This is your primary “customer.” The Operations section will be requesting medications, supplies, and clinical pharmacy support for the treatment areas.
Logistics The “getters.” Responsible for providing all supplies, personnel, and equipment needed to support the response. This is where Pharmacy lives. The Director of Pharmacy (or designee) often assumes the role of Medical Supply Unit Leader or a similar position within the Logistics section. Your entire department becomes a key branch of Logistics, responsible for the medication supply chain.
Planning The “thinkers.” Gathers intelligence, tracks the status of patients and resources, and plans for the next operational period (e.g., “What will we need in 12 hours?”). You will feed critical inventory data to the Planning section. “We have 24 hours of IV morphine left at the current burn rate.” This allows them to plan for future shortages.
Finance/Admin The “payers.” Tracks all costs associated with the response for potential reimbursement and manages personnel timekeeping. You must meticulously track every medication dispensed from emergency caches for billing and inventory purposes after the event.

The Pharmacy Unit Leader: Your Role as an Incident Commander

During a declared disaster, the pharmacy department essentially becomes its own incident command post, led by a designated Pharmacy Unit Leader. This leader (who could be you!) is responsible for managing all aspects of the pharmaceutical response. Their responsibilities include:

  • Activating the Pharmacy Emergency Plan: Every hospital has a detailed plan. Your first job is to open the binder and start executing it.
  • Staffing Triage: Recalling essential personnel, assigning roles (e.g., “You are in charge of the IV room,” “You will be our runner to the ED”), and ensuring staff are getting adequate rest and food.
  • Inventory Command: Gaining immediate control of all medication inventory, especially controlled substances and emergency caches.
  • Communication Hub: Serving as the single point of contact between the hospital’s Command Center and the pharmacy department, ensuring a clear flow of information.

1.3 The Pharmacist’s Role in Preparedness: Building the Arsenal

Your work before the disaster determines success during the disaster.

A successful MCI response is not improvised; it is the execution of a well-rehearsed plan built upon a foundation of meticulous preparation. The pharmacy department plays a central and ongoing role in this preparedness phase. This work, which happens during “peacetime,” is what ensures the right medications and supplies are in the right place at the right time when the crisis hits.

1.3.1 Developing the Emergency Formulary & Caches

You cannot stockpile every drug in the hospital formulary. The foundation of pharmaceutical preparedness is a specific, limited emergency formulary of drugs most likely to be needed in a disaster. This formulary is then used to build physical disaster caches—large, sealed containers or carts stored in secure locations, ready for immediate deployment.

Your role as a clinical pharmacist is to help the P&T committee and emergency management team decide what goes in these caches, based on the most likely disaster scenarios for your region.

Disaster Scenario Key Medication Classes for the Cache
Mass-Trauma (e.g., Bombing, Shooting) Analgesics (IV opioids, ketamine), Tetanus toxoid, IV antibiotics for open fractures, IV fluids, Hemostatic agents (TXA).
Mass-Burn High-potency IV opioids, Silver sulfadiazine cream, IV fluids in massive quantities, Broad-spectrum antibiotics.
Chemical Exposure (Nerve Agent) Atropine, Pralidoxime (2-PAM), Diazepam (often in auto-injectors, e.g., DuoDote, AtroPen). These are often supplied via federal CHEMPACKs.
Infectious Disease Outbreak/Pandemic Antivirals (e.g., Oseltamivir, Remdesivir), Antibiotics for secondary bacterial pneumonias, Vasopressors, Sedatives, Neuromuscular blockers (for ventilated patients).

1.3.2 The Strategic National Stockpile (SNS) and CHEMPACK Program

No single hospital can stockpile enough medication for a large-scale public health emergency. This is the role of the Strategic National Stockpile (SNS), a federal repository of pharmaceuticals and medical supplies. In a declared emergency, state health departments can request SNS assets, which can be delivered to the affected area within 12 hours. Your hospital’s emergency plan will include a protocol for how to receive, store, and dispense these assets.

Masterclass on the CHEMPACK Program

The most important and pharmacist-relevant component of the SNS for an acute event is the CHEMPACK program. These are strategically placed, forward-deployed containers of nerve agent antidotes designed for immediate use in a terrorist attack. Many hospitals are designated CHEMPACK host sites.

  • Contents: The kits contain atropine, pralidoxime (2-PAM), and diazepam in various formulations, including multi-dose vials and auto-injectors (like the DuoDote).
  • Pharmacist’s Role (as a host site): You are the custodian of the CHEMPACK. Your responsibilities include:
    • Maintenance: Performing monthly inventory and temperature checks without breaking the seal, and reporting these back to the state health department.
    • Deployment: In a declared nerve agent event, you will be responsible for “breaking the seal” and immediately deploying the antidotes to the Emergency Department and other treatment areas. You will be the primary expert responsible for guiding the rapid preparation of IV infusions from the multi-dose vials for severely ill patients.

1.4 The Pharmacist’s Role During the Response: A Masterclass

Your leadership in action when the “Code Triage” is called.

When the MCI is activated, your preparedness plan is put into motion. Your role as a pharmacist will be multifaceted, spanning logistics, clinical support, and communication. You and your team will be among the busiest and most critical players in the entire hospital.

1.4.1 The First 15 Minutes: Immediate Actions

  1. Huddle the Team: The Pharmacy Unit Leader immediately gathers all available staff. Announce the nature of the event (“We have a confirmed mass-casualty trauma event, expect 50+ patients”).
  2. Activate the Plan & Assign Roles: Open the emergency preparedness binder. Assign specific roles: “You are the IV room lead,” “You are the controlled substance lead,” “You and you are the runners for the ED,” “You are the procurement officer.”
  3. Secure the Pharmacy: The pharmacy may need to be locked down to control access and prevent well-intentioned but chaotic grabbing of supplies. Establish a single, secure window for all medication requests.
  4. Deploy the Caches: The highest priority is to get the pre-built disaster caches to their designated locations (usually the ED and OR).
  5. Establish the Pharmacy Command Center: Designate a central area in the pharmacy with whiteboards, computers, and phone lines to track inventory, requests, and deployments.

1.4.2 Ongoing Responsibilities During the Crisis

Logistical & Operational Roles

  • Inventory Management: This is a critical logistical function. You must have a real-time system (often a simple whiteboard) to track the “burn rate” of critical supplies like IV fluids, opioids, and antibiotics. This information is fed to the hospital’s Planning Section.
  • Procurement: The designated procurement pharmacist will be on the phone with wholesalers, neighboring hospitals, and the state health department to secure additional supplies. Your knowledge of ordering systems is invaluable here.
  • Compounding: The IV room will go into mass-production mode, preparing STAT drips, antibiotics, and other critical sterile products.
  • Controlled Substance Management: You must maintain as strict control as possible. This may involve setting up a satellite pharmacy or a secure ADC in the ED to dispense narcotics, ensuring every dose is documented even in the chaos.

Clinical Roles

Beyond the central pharmacy, pharmacists will be deployed to patient care areas to serve as embedded medication experts.

  • The ED Pharmacist: This is the front line. You will be assisting with drug selection for trauma patients, preparing STAT medications, providing drug information on antidotes or unusual agents, and helping to manage the medication flow for dozens of patients at once.
  • The ICU/OR Pharmacist: As the most critical patients move from the ED to the OR or ICU, you will be there to manage the complex infusions (vasopressors, sedation, MTP) and provide continuity of care.
  • The Drug Information Specialist: One pharmacist should be designated as the central “drug information” hub, fielding calls from all treatment areas to provide rapid, evidence-based answers and preserve the cognitive bandwidth of the frontline clinicians.

Masterclass on Recovery and Demobilization

The crisis does not end when the last patient is treated. The recovery phase is just as important and is a primary pharmacy responsibility.

  • Inventory & Reconciliation: This is a massive task. Every dose from every deployed cache must be accounted for. All controlled substance records must be meticulously reconciled. This forensic accounting is a critical, legally required function.
  • Restocking and Rebuilding: All used caches must be broken down, cleaned, and completely rebuilt. All borrowed supplies must be returned or reordered. This process can take days or weeks.
  • The “Hot Wash” or Debrief: The pharmacy department must conduct its own internal debriefing session. What went well? What broke down? Did we run out of a critical drug we hadn’t anticipated? The lessons learned from this “hot wash” are used to update and improve the emergency preparedness plan for the next event. Your honest, constructive feedback is vital to this process of continuous improvement.