Cardiopulmonary resuscitation is an emergency procedure that is performed to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in respiratory or cardiac arrest.1 This is a procedure all experienced clinical respiratory therapists, paramedics, and EMTs are familiar with—more often in a controlled clinical setting, such as a hospital or transport vehicle.

The ideal resuscitation strategy for a multiply-injured patient is physiologically specific: address airway management, hemorrhage, and shock. Hypotensive, cardiocerebral, hypertonic saline, colloid, and damage-control resuscitations are considered life-saving techniques that can be used in stabilizing trauma victims of automobile accidents, mass casualty events, and massive battlefield injuries.2-5 There are questions regarding the effectiveness of these strategies, and more evidence needs to be considered.

Preparation for Disaster

Abraham Lincoln once said, “Give me six hours to chop down a tree and I will spend the first four sharpening the axe.”6 Are we prepared? It’s not a question of if an emergency will occur but when and how bad.

The events of September 11, 2001; hurricanes Katrina, Gustaf, and Ike; and the earthquake in Haiti underscore the urgent need for federal, state, regional, and public health care agencies to respond in unison and to respond effectively to such emergencies.7 As a first responder with the Disaster Medical Assistance Team CA-6, I concern myself with the immediate casualties in the impacted area and in our mobile receiving center, as well as in the primary receiving medical center. The mission is to stabilize and transport the patients to the appropriate medical facility having the best chance of saving them. That being said, resuscitation is really a matter of “whatever it takes” to save lives.

In an event where multiple casualties are present, bystanders may, in fact, be the first responders and will, perhaps reluctantly, assume the role of lifesaver and apply basic CPR skills. In a clinical paper written on this subject concerning drowning victims,8 the authors concluded, “bystander rescue and resuscitation … seems to contribute to a positive outcome,” and the behavior of bystanders plays a critical role in the patients’ survival.

Our emergency care system is overburdened, and we will be hard pressed to handle disasters that result in a large surge of victims.9 The role of resuscitation is critical, however, and it may be necessary to recruit all available personnel at the scene, including bystanders, to assist in stabilizing the victim by stopping the bleeding, establishing an airway, and ventilation.

While CPR training is mandatory for professional health care providers in order to maintain their licenses, it is also available publicly and commercially to anyone who is interested in saving a life.10 Cardiopulmonary resuscitation requires the ability to provide chest compressions as well as ventilate the patient. Coordination and skill are necessary in order to successfully apply this technique.

In a situation where a multiple casualty scenario exists, however, a compression-only technique (without artificial respiration) is the method of choice for the untrained rescuer, as it is easier to perform and instruct over the phone. This is referred to as CCR (continuous chest resuscitation), which is a protocol reserved for cases in which field casualty (out of hospital) arrests are presumed to be cardiac in origin.4,11

Guidelines and Protocols

Guidelines and protocols are useful tools that provide standardized care to the patient. This efficient method of decision-making reduces the risk of clinical error and increases worker efficiency, especially when caring for multiple patients requiring intensive care.

An excellent source of guidelines and protocols can be found in the American Association for Respiratory Care “Guidelines for Acquisition of Ventilators to Meet the Demands for Pandemic Flu and Mass Casualty Incidents.”12 These guidelines provide a strategy to deal with patient surges and limited resources.

The establishment and management of the airway, which is a key factor in resuscitation during mass casualty respiratory failures, may lead to many challenges, not least of which will simply be to identify the need. Reviewing guidelines and protocols at this point is not a substitute for training in emergency tactics.13

Two specific sets of guidelines for multiple trauma victims are the ATLS14 (Advanced Trauma Life Support) and Tactical Combat Casualty Care Guidelines,15 which focus on complete patient stabilization including partial resuscitation of blood loss. The bottom line is that the successful resuscitation of a victim crosses multiple clinical disciplines of independent physiological systems and is often referred to as damage control.

That being said, however, in a resource-poor environment, such as a mass casualty event, guidelines should be provided and a policy set for determining criteria for resource allocation and withdrawal, to assist the physician and other health care providers in the decision-making process, to defend strategies for individual cases, and to improve consistency.16


A critical component in the successful stabilization of patients in a mass casualty event is having competent staffing in order to effectively utilize available resources to address the situation, which in all likelihood will be no less than organized chaos. Scenarios that will result in an overwhelming number of patients exceeding equipment inventories and the number of respiratory therapists available are expected.

One solution to this problem will be for the Department of Health and Human Services (HHS) to deploy experienced respiratory therapists, such as Disaster Medical Assistance Teams, to affected areas. The other option is to train nonrespiratory professionals to perform certain tasks through a program called Project XTREME. As part of this program, the HHS has released a DVD, “Cross Training Respiratory Extenders for Medical Emergencies,”17 to train nonrespiratory therapists to provide basic respiratory care and ventilator management to adult patients during a mass casualty event in order to expand our respiratory capacities. The DVD consists of six interactive training modules covering infection control, respiratory care terms and definitions, manual ventilation, mechanical ventilation (using ventilators currently in the government’s Strategic National Stockpile), airway maintenance, and airway suctioning.


Emergency medical care in the United States is on the verge of collapse. Overcrowded emergency departments result in long waits that place an even greater hardship on staff and resources. From 1993 to 2003, the population in the United States grew by 12%, while emergency department visits increased by 27%—from 90 million to 114 million. During that same time, 452 emergency departments closed, along with approximately 700 hospitals and nearly 200 beds.18

Many urban medical centers are experiencing severe budget constraints and are asked to cut back on resources rather than to prepare for and increase their investment in mass casualty event response. As a result, many respiratory care departments and medical institutions believe that the federal government (cavalry) will come to the immediate rescue. Nothing could be further from the truth, especially in the event of a pandemic where multiple regions of the country are affected.

In fact, according to the Agency for Healthcare Research and Quality, an evidence-based review reported, “Our nation’s emergency care system, including emergency medical services, hospital based emergency departments, and the inpatient wards and intensive care units of many hospitals are so overburdened that currently most are ill prepared to cope with a large scale public emergency.”19,20 And that, regardless of the etiology of a major disaster, “it can be reasonably foreseen that under current conditions, health care providers and systems will be hard pressed to manage a large-scale surge of victims of a mass casualty event.”21

Triage: Who Lives and Who Dies?

With all of these realities in mind, triage will be all the more important in mass casualty situations.

The purpose of triage is to concentrate the use of limited resources or staff to those patients who will probably survive if they are treated but are likely to die if they are not. It is essential that the practice of triage be effectively applied, especially during a disaster or mass casualty event.22 Explaining who is to be resuscitated is beyond the scope of this article, but the triage process—whether it be a simple or advanced model—will determine the success or failure of the emergency response. A triage protocol must be unquestionably accepted and agreed upon by all factions, especially during a mass casualty event. For playing God, as some would say, can be a life-altering event in many ways.


Fortunately, resuscitating a victim is not brain surgery, and there has been significant progress in effective training and technology that will assist in saving lives. We should not have to reinvent the wheel. There are already successful models of emergency medical response and training.

In Israel, the emergency medical services are provided by the Magen David Adom23 (a member of the International Red Cross and Red Crescent Societies). This is Israel’s national emergency medical disaster, ambulance, and blood-bank service, responsible for maintaining a volunteer infrastructure and training them in first aid and basic and advanced life support, including various levels of resuscitation and mobile intensive care units.

The organization is staffed mainly by volunteers, is cost-effective, and has more than 10,000 people volunteering more than 1 million hours per year. All volunteers complete a 60-hour course that covers a wide range of skills, ranging from common medical conditions, to trauma, to mass casualty events. Volunteers are then dispatched throughout the country and work with local volunteers in ambulances to provide initial care.

They take this business seriously and prepare for the worst. It’s time for us to do the same.

The many disasters that have occurred since 9/11 are testimonies to how unprepared we are to effectively respond to and manage disasters and mass casualty events. Let’s take a lesson from successful programs like Israel’s and focus on strategies that can do the most good in time of crisis.

Michael E. Donnellan, RRT-NPS, MBA, is a respiratory therapist at Sutter Alta Bates Summit Medical Center, Oakland, Calif; and first responder, Disaster Medical Assistance Team CA-6, National Disaster Medical System, US Department of Health and Human Services. For further information, contact [email protected]

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