This document discusses disasters, mass casualty incidents, and terrorism. It provides definitions for disasters, mass casualty incidents, and terrorism. Disasters are events that disrupt basic services and cause widespread losses exceeding local response capacity. Mass casualty incidents involve large numbers of casualties that overwhelm normal healthcare services. Terrorism involves man-made external disasters. The document outlines three levels of disasters according to Malaysia's Directive 20 from the National Security Council and describes the formation of the National Disaster Management Agency. It also discusses disaster response, including contingency planning, and provides an overview of various weapons that could potentially be used in terrorist attacks.

1. Disasters and Mass Casualty
Incidents
Dr. Chew Keng Sheng
Professor/Emergency Physician,
Faculty of Medicine and Health Sciences,
Universiti Malaysia Sarawak

2. Objectives
n Definitions
n Key criteria for determining a terrorist attack
n Overview on selected terrorists’ attacks and WMDs
n Major Lessons Learnt from Previous Disasters
n Syndromic Surveillance

3. Definitions of Disaster, Mass
Casualty Incidents and
Terrorism

4. Definitions
n Disaster – defined as a sudden ecologic
phenomenon of sufficient magnitude to
require external assistance
n In the Emergency Department, disaster exists
when the number of patients presenting in any
given space of time are such that even
minimal care cannot be offered without
external assistance.

5. Definitions
n Disasters occur when normal, basic services
of a society become disrupted to such extent
that widespread human and environmental
losses exceed the community’s management
capacity (SAEM Disaster Medicine White Paper
Subcommittee)
n Disasters characterized by large numbers of
deaths and injuries are also referred to “Mass
Casualty Incidents”

6. Definitions
n Mass Casualty Incidents (MCI) – events
resulting in a numbers of victims large
enough to disrupt normal course of
emergency and health care services of the
affected community
n Disasters result in MCIs, but encompass a
broad range of calamities beyond just the high
numbers of casualties
n “All MCIs are disastrous, but not all disasters are
due to MCIs”

7. Definitions
n Disasters can be divided into two:
n Natural Disasters OR Man-made Disasters
n External Disasters (events occurring outside the
hospital) OR Internal Disasters (events involving
the physical structures of hospital itself - e.g. fire,
lab accident involving radioactive materials)
n Terrorism – man made, external disasters

8. Directive 20, National Security
Council
n A Disaster is
1. an event that occurs
suddenly.
2. complex in nature.
3. loss of lives.
4. destruction of property
and/or environment.
5. disruption of the
community daily
activities

9. Three Levels According to Directive
20, NSC
n Level 1
n Localized, well-controlled, manageable by local
authorities
n Level 2
n Well-controlled, management at state or national
level
n Level 3
n Complete destruction, disruption of routine
activities,

10. Directive 20, NSC
n Disaster can be divided into 3 level
LEVEL 1
1. Localized major incident
2. Under controlled
3. Not complex
4. Small no. of casualties and property loss
5. Minor disruption of daily community activities
6. Manageable by the local authorities requiring
7. Multisectoral involvement.
n Example: bus accident, train derailment, landslide.

11. Directive 20, NSC
n LEVEL 2 Disaster
1. Widespread over a large area but under controlled
2. Complicated and complex
3. Large no. of casualties and property loss.
4. Affecting daily community activities
5. Not manageable by the local authorities requiring
6. Assistance from other states or National Authorities
7. Support required, Regional or National Support
n Examples: Highland Towers Collapse, Greg Storm
Sabah, Bright Sparklers.

12. Directive 20, NSC
n LEVEL 3 Disaster
1. Involves a very large area.
2. Loss of many lives.
3. Total Destruction of infrastructure and public facility.
4. Complicated and complex.
5. High risk to rescue workers.
6. Complete disruption of daily community activities.
7. Major destruction of resources.
8. All local resources destroyed and assistance from external
resources required.
n e.g. Earthquake, typhoons, volcanoes, war.

13. Formation of NADMA
(National Disaster Management Agency)
n In Dec 2014, Malaysia faced its worst flood
affecting several states with Kelantan being
worst hit. More than 500,000 people affected
with RM2.58 billion loss
n 1 Oct 2015 – NADMA formed with the
consolidation of Disaster Management Division
of NSC, Post-flood Recovery Unit of PM Dept
and Special Malaysia Disaster Assistance and
Rescue Agency (SMART)

14. NADMA website

15. COVID-19 Cases

16. Disasters Vs Emergencies
Routine Emergencies Disasters
Interaction with familiar
parties
Interaction with unfamiliar
parties
Familiar tasks/procedures Unfamiliar
tasks/procedures
Intra-organization
coordination
Intra- and inter-
organization coordination
Intact communications,
roads, etc.
Disrupted
communications, blocked
roads, etc

17. Disasters Vs Emergencies
Routine Emergencies Disasters
Familiar terminology Unfamiliar, organization-
specific terminology
Local press attention National/international
media attention
Resources adequate for
management
Resources overwhelmed for
management capacity

18. Preparedness
Response
Recovery
Mitigation
Phases of Disaster
Activities prior to disaster;
contingency/preparedness planning,
training/exercise, warning system
Activities during a
disaster: search and
rescue, emergency
operations
Activities after a disaster:
temporary shelter, food, clean
water, sanitary needs, claims and
aid, counseling
Long term planning –
rebuilding of lives,
repairs, situational
analysis, risk analysis DISASTER

19. Disaster Response

20. Contingency Planning
“an event (as an emergency) that may but is not certain to occur”
- Merriam Webster Dictionary

23. Contingency Planning
n Situational Analysis.
n Risk Analysis and Risk Assessment.
n Risk Communication.
n Hazard Control and Prevention Strategy.
n Capacity Assessment.
n Capacity Building:
n Resource Development
n Resource Matrix.

24. Information received
Verification
Hospital Disaster Activation Phase
Fake
Stand Down
True
Yellow Alert Red Alert
Admin MxClinical Mx
Green cases Mx
(diversion?)
Control
Center
Information
center/Press Media
Red/yellow zone cases
Decontamination
needed?
Forensic/Morgue
Security

25. HRM Planning
Analysis of ImpactRisk Analysis
Risk Assessment
Type of Threat and Form
YELLOW
ZONE
RED
ZONE
GREEN
ZONE
Incident Site
Management
Hospital Activation
Phase (HAP)
SITUATIONAL
ANALYSIS
Alert System
Preparation & Activation
Resource
Development
TRIAGE
ZONE
Adminisrative
Coordinator
Clinical
Coordinator
Support Group
Activation
CONTIGENCY
PLANNING

26. ON SITE MANAGEMENT
YELLOW ZONE
OSC
(POLICE )
COMMAND POST
F.F.C. - BOMBA
SAR TEAM
RED ZONE
WORK MATRIX
P.K.T.K.
O.M.C.
BOMBA
MEDICAL
BASE
CRTICAL
S.CRITICAL
N.CRITICAL
DEAD
RESCUERS
FORENSIC
M.E.L.O.
QUARTER
MASTER
M.E.S.A.R.O.
SAR
SAR
SPECIALISTS
SJAM
MRCS
JPA 3
BOMBA
S.B.

27. ON SITE MANAGEMENT – TRIAGE SYSTEM
TO NEAREST APPROPRIATE HOSPITAL
GREEN

28. Victims Collecting Point
COLLECTING POINT
Working Area
Impact Zone
Advance Medical Post

29. Simple Triage and Rapid Treatment
* Victims who can
walk are first identified
and be diverted to one
designated area
START Triage System

30. Disaster Operation and the SAVE
Concept

31. Standard Advanced Medical Post
RED YELLOW
GREENWHITE
TRIAGE
AREA
EVACUATION
NON-
ACUTE
ACUTE
NON-ACUTE
ACUTE

32. Disaster Zoning

33. Initiating Isolation
n Ideally be decontaminated outside the hospital
n Approach from upwind direction
n Isolate at least 100 m radius (initial isolation) for hot zone
n If large spill, 500 m; and if on fire (flammable substances), 800 m
n Establish three zones
n Hot zone
n where the spill/contamination occurred
n Only trained personnel with proper attire to enter
n Only the most immediate life threats addressed here – like opening up airway,
cervical spine immobilization, bleeding control
n Warm zone
n area for thorough decontamination
n Theoretically no risk of primary contamination but secondary contamination
still possible

34. Initiating Isolation
Initial Isolation
Protective
Action Zone

35. Principles of Decontamination
n Removal of clothings
n most important step
(accomplishes 80-90% of
decon)
n From top to bottom
n The more the better
n Privacy is an issue
n Water flushing the best
n Typically shower 3 – 5min
n Decon ASAP
n Expect a 5:1 of unaffected:
affected casualties ratio
n First responders must self-
decon too

36. Decontamination

38. Current Problems of MCI
Management in Malaysia
n Conventional Approach: Malaysia Scenario
n Response Plan exist but no one knows about it !
n Response on ad hoc basis
n Inappropriate motivational drive
n Confusion and uncontrolled environment
n Uncoordinated activities

39. PRE-HOSPITAL MANAGEMENT ORGANIZATION
Hospital Director
INCIDENT SITE
MEDICAL
MANAGER
Red Team
Leader
Medical
Triage Officer
NGO ADVANCED MEDICAL POST
Yellow Team
Leader
Evacuation
Officer
Admin.
Clerk
Transport
Officer
Ambulance
Drivers
Acute Treatment Manager
Admin.
Clerk Doctors & Paramedics
•JPA 3
•MRCS.
•SJAM
Medical/Health Officer
COMMAND POST Temporary
Morgue
Green Team
Leader
Know Your Role!

40. Overview
n Chemical Weapons
n Nerve Agents – G series (GA,
GB, GD), V series
n Blood Agents - cyanides
n Blistering Agents
n Biological Weapons
n Biological Agents – viruses (e.g
Ebola), bacteria (Yersenia
pestis, anthrax)
n Biological Toxins – botulism,
ricin, Staphylococcal
Enterotoxin B
n Radiation
n α radiation
n β radiation
n γ radiation
n Nuclear
n A bomb (Atomic)
n H bomb (Hydrogen)
n Explosives
n Large scale - Incendiary
bombs, Napalm-B, Mark 77
n Smaller scale - Molotov
Cocktail (Poor man’s hand
grenades)