DISASTER MANAGEMENT

April 8, 2023April 8, 2023 Subs-Specializations Pre Hospital Post Basic ESubs-Specializations Pre Hospital Post Basic Emergency Care 06_azlanmergency Care 06_azlan

11

“Sudden ecological phenomenon of sufficient magnitude to require external assistance”

(World Health Organisation)(World Health Organisation)

AN ACCIDENT WITH SO MANY CASUALTIES AS TO REQUIRE EXTRAORDINARY MOBILIZATION OF EMERGENCY SERVICES

(Rutherford 1975)


22

Situation in which Situation in which the needthe need of medical care of medical care exceeds the immediately available resourcesexceeds the immediately available resources and in which and in which extraordinary and coordinated extraordinary and coordinated measuresmeasures are necessary if normal quality are necessary if normal quality standards are to be maintained.standards are to be maintained.

(Dato’ Abu Hassan Asaari Abdullah )(Dato’ Abu Hassan Asaari Abdullah )

When When normalnormal community and organizational community and organizational arrangements are arrangements are overwhelmedoverwhelmed by an event and by an event and extraordinary responsesextraordinary responses need to be instituted. need to be instituted.

( Disaster Medicine-Australian Emergency Manual)( Disaster Medicine-Australian Emergency Manual)

DISASTER


33

Mass Casualty IncidentMass Casualty Incident

Situation in which Situation in which the loadthe load on medical facilities on medical facilities is is so great in relation to available so great in relation to available resourcesresources,even following reinforcement, that ,even following reinforcement, that normal quality standards cannot be maintained.normal quality standards cannot be maintained.

Civil emergenciesCivil emergencies in areas that produce in areas that produce many many casualtiescasualties (and properties), but do not (and properties), but do not necessarily affecting a large geographical areanecessarily affecting a large geographical area


44

All definitions based on imbalance between available resources and needs.Sudden

increase in needs or reduction in available resources may cause

disaster. The greater the imbalances,the more serious the

consequences will be.


55

Casualty Profile in Disaster• Immediate death (50-60%) - largely due to brain damage, injury to the heart and large vessels. Other groups, many of which can be prevented, airway obstruction and massive haemorrhage.

• Early death (30-50%) - due to damage to CNS, Thoracic or Abdominal injury with internal haemorrhage, extensive skeletal damage or multiple injury with great loss of blood. Exception of cranial injury, largely treatable.

• Subsequent death (20-30%) - days or weeks later, majority caused by infection and sepsis and multiple organ failure with impaired or destroyed respiratory, kidney and liver functions.


66

Casualty Profile MCI• Immediate death (10-20%) - largely due to brain damage, injury to the heart and large vessels. Other groups, many of which can be prevented, airway obstruction and massive haemorrhage.

• Early death (25-40%) - due to damage to CNS, Thoracic or Abdominal injury with internal haemorrhage, extensive skeletal damage or multiple injury with great loss of blood. Exception of cranial injury, largely treatable.

• Subsequent death (50%>) - days or weeks later, majority caused by infection and sepsis and multiple organ failure with impaired or destroyed respiratory, kidney and liver functions and even due effects of mismanagement.


77


88

World’s Worst Major IncidentWorld’s Worst Major Incident Flood Flood Hwang-ho river, China Hwang-ho river, China 1931 1931 3,700,000 3,700,000 Earthquake Earthquake Shensi Province, ChinaShensi Province, China 1956 1956 830,000 830,000 Landslide Landslide Kansu Province China Kansu Province China 1920 1920 200,000200,000 Snow AvelancheSnow Avelanche Huaras,Peru Huaras,Peru 1941 1941 ~5,000 ~5,000 Toxic release Toxic release Bhopal, India Bhopal, India 1984 1984 25002500

(100,000inj)(100,000inj) Mine Uranium,Mine Uranium, East Germany East Germany 1949 1949 2300 - 3700 2300 - 3700 Dam burst Dam burst South Fork Dam, Penn South Fork Dam, Penn 1889 1889 2209 2209 Explosion Explosion Halifax, N Scotia, CanadaHalifax, N Scotia, Canada 1917 1917 1963 1963 Fire (single building) Fire (single building) The Theatre,Canton,ChinaThe Theatre,Canton,China 1845 1845 1670 1670 Aircraft Aircraft KLM/ Pan Am 747's, Tener KLM/ Pan Am 747's, Tener 1977 1977 579 579 Railway Railway Modane, France Modane, France 1917 1917 543 543 Gas pipeline Gas pipeline Urals, Russia Urals, Russia 1989 1989 >500 >500 LPG Storage LPG Storage Mexico City Mexico City 1984 1984 500 (4,000 inj) 500 (4,000 inj) Road Road Sotouboua Sotouboua 1965 1965 >125 >125 Crude tanker Crude tanker Bantry Bay, Eire Bantry Bay, Eire 1979 1979 50 50 Nuclear power station Nuclear power station Chernobyl,Rusia Chernobyl,Rusia 1985 1985 >30 (200 ac. >30 (200 ac.

(radiation) (radiation) poisoning up to poisoning up to 30,000 30,000

delayed delayed deathsdeaths


99

Tsunami destroying Messina & Reggio, 1908Estimated dead ~ 160000

http://www.historia-antigua.com/img/atlantida/tsunami.jpg


1010

Cyclone destroying Bangladesh. Nov, 1970Estimated dead ~ 200 000

http://images.google.com/imgres?imgurl=www.fao.org/WAICENT/FAOINFO/AGRICULT/AGL/swlwpnr/Banglade/images/cyclone.gif&imgrefurl=http://www.fao.org/WAICENT/FAOINFO/AGRICULT/AGL/swlwpnr/Banglade/e_climhz.htm&h=136&w=191&prev=/images%3Fq%3Dbangladesh%2Bcyclone%26start%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8%26sa%3DN


1111

Sinking of Titanic – April, 19121403 death

http://images.google.com/imgres?imgurl=www.rootsweb.com/~nwa/titanic.jpg&imgrefurl=http://www.rootsweb.com/~nwa/survivors.html&h=200&w=223&prev=/images%3Fq%3Dtitanic%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8


1212

Riot at Orkney, South Africa – Jan, 199140 death, 50 injured

http://news.bbc.co.uk/media/images/38064000/jpg/_38064808_oveturnap300.jpg


1313

World Trade Center attack, NY – 9, Nov, 2001Estimated death ~ 30 000

http://www.ishipress.com/happened.htm


1414

Earthquake & Tsunami, 26th Dec 2004


1515

Source: ADRC, Japan based on CRED EM-DAT database, 2003Source: ADRC, Japan based on CRED EM-DAT database, 2003

Summary of Natural DisastersSummary of Natural Disasters(1975-2002)(1975-2002)

Number ofDisasters

Number ofKilled

Number of TotallyAffected People

Amount of Damage(1,000 US$)

World 7,104 2,063,633 4,797,950,112 982,894,232

Asia 2,676 (38%) 1,182,637 (57%) 4,269,422,754 (89%) 480,536,348 (49%)


1616

Malaysia’s Worst Major IncidentMalaysia’s Worst Major IncidentJetty collapse - Butterworth 1988Jetty collapse - Butterworth 1988

20 dead; 1674 injured20 dead; 1674 injuredBright Sparkles Factory explosion - 1991Bright Sparkles Factory explosion - 1991

22 dead; 103 injured22 dead; 103 injuredHighland Towers Collapse 1993Highland Towers Collapse 1993

48 dead; 1000 homeless48 dead; 1000 homelessGenting Highlands Highway Landslide 1995Genting Highlands Highway Landslide 1995

20 dead; 22 injured20 dead; 22 injuredGenting Highlands Bus Plunge 1996Genting Highlands Bus Plunge 1996

17 dead; 20 injured17 dead; 20 injuredPos Kuala Dipang, Perak Mudslide - 1996Pos Kuala Dipang, Perak Mudslide - 1996

44 dead; 200 homeless44 dead; 200 homelessTropical Storm Greg - Sabah 1996Tropical Storm Greg - Sabah 1996

307 dead; 2400 missing307 dead; 2400 missing


1717


1818

11 December 199311 December 1993–Highland tower collapsed, 48 Highland tower collapsed, 48 dieddied


1919

Genting Highlands Bus Plunge 1996

17 dead; 20 injured


2020

Mudslide in Orang Asli Settlement ( Pos Dipang) Kampar, Mudslide in Orang Asli Settlement ( Pos Dipang) Kampar, Perak, August 1996Perak, August 1996

Estimated dead ~ 44 and ~ 30 houses washed awayEstimated dead ~ 44 and ~ 30 houses washed away


2121

Hurricane Greg in Sabah, December 1996Estimated dead ~ 307 died and ~ 6,000 home ruined


2222mass casualty incident (highway pile-up): 55 casualties- 9 deaths,28 seriously injured,18 slightly injured.


2323

Malaysia’s Worst Major IncidentMalaysia’s Worst Major Incident Enteroviral Outbreak in Sibu Sarawak 1-30.4.97 Enteroviral Outbreak in Sibu Sarawak 1-30.4.97

25 dead25 dead Country wide haze particularly in Sarawak Jul-Oct,1997Country wide haze particularly in Sarawak Jul-Oct,1997

Environmental problem,health Environmental problem,health hazard & economical losses.hazard & economical losses.

Fire & explosion @SMDS Bintulu Sarawak Fire & explosion @SMDS Bintulu Sarawak 2 injured2 injured

Forest & peat fire throughout the country Feb-May 1988Forest & peat fire throughout the country Feb-May 19883000 hectares of forest burnt3000 hectares of forest burnt

Japanese Encephalitis Outbrek, Perak & N.Sembilan Oct,1998-Jun,1999Japanese Encephalitis Outbrek, Perak & N.Sembilan Oct,1998-Jun,1999101 dead101 dead

Ruan Changkul,Simunjan Sarawak. 28.01.2002Ruan Changkul,Simunjan Sarawak. 28.01.200216 dead; 200 homeless16 dead; 200 homeless

SARS & Anthrax Scare, 2003SARS & Anthrax Scare, 2003 Avian Flu, 2004Avian Flu, 2004


2424

Bencana Tahap 1

Bencana Tahap II.

Bencana Tahap III.

MKN ARAHAN 20

TAHAP-TAHAP BENCANA


2525

Level ONE DisasterLevel ONE Disaster

This level is also known as This level is also known as Mass Casualty IncidentMass Casualty Incident which bears the following characteristics:which bears the following characteristics:a ) An incidenta ) An incident localisedlocalised in nature to a certain region or in nature to a certain region or district with no potential spread or involvement of district with no potential spread or involvement of others.others.b)b) Non-complexNon-complex in nature. in nature.c) Extent to loss of lives and belongings are c) Extent to loss of lives and belongings are minimalminimal..d) Routine daily chores of the resident is d) Routine daily chores of the resident is not affected.not affected.e) The incident can be handled e) The incident can be handled succesfullysuccesfully by the local by the local releif agencies and does not require assistance from releif agencies and does not require assistance from other district. other district.


2626

Level TWO DisasterLevel TWO DisasterA more serious incident potentially A more serious incident potentially involving other districts or regions and involving other districts or regions and possibly affecting the possibly affecting the State AdministrativeState Administrative level. The incident causes level. The incident causes hugehuge lost of lost of lives, properties and infrastructures and lives, properties and infrastructures and severely affecting the normal daily activities severely affecting the normal daily activities of the residents within these regions. The of the residents within these regions. The incident becomes more complex and incident becomes more complex and difficulties in saving lives overwhelms the difficulties in saving lives overwhelms the existing resources leading to assisstance existing resources leading to assisstance from adjacent region or even state.from adjacent region or even state.


2727

Level THREE DisasterLevel THREE DisasterThis is a more This is a more widespreadwidespread incident incident requiring involvment from requiring involvment from Federal Federal GovernmentGovernment level. The incident is level. The incident is very complex and assisstance of very complex and assisstance of various specialities required from various specialities required from other nations, international relief other nations, international relief agencies.agencies.


2828

Objectives of medical measure to minimize the consequences in terms of both somatic and psychological sequel.

maintain the results of medical treatment at a normal level for the large majority of patients.

collaboration of hospital work with other or agencies involved in the rescue organization.


2929

Casualty Care Objectives• to assure and stabilise vital functions (ABC of Trauma Mx) before transportation.

• to take other steps preparatory to transport so as to lessen possible risk of worsening and unnecessary sufferings.

• set optimal priorities for the injured before they are transported.• give primary psychological care to those directly and indirectly affected.

distribute the injured optimally among different hospitals. Account on nature of injury and optimal use of medical care and transport resources.


3030

Main objectives of Health Main objectives of Health ServicesServices

Providing adequate emergency medical Providing adequate emergency medical servicesservices

In the shortest possible time in order to In the shortest possible time in order to reduce the morbidity & mortality of the reduce the morbidity & mortality of the victimsvictims


3131

Mass Casualty Management Mass Casualty Management SystemSystem


3232

Hospitals Disaster Response Plan

SearchRescueFirst Aid

Advance Medical PostTriageStabilizationEvacuation

Traffic Control

Regulation of

Evacuation

Command Post

Emergency Department

Mass Casualty Management System Impact Zone

Traffic ControlRegulation of Evacuation

PRE-HOSPITAL ORGANIZATIONHOSPITAL

ORGANIZATION


3333

IMMEDIATETRANSFER

NO TIME TO TAG “TAG”

IMMEDIATE TRANSFER


3434

TAG

TREAT(Field)

TREAT( Medical Base)


3535

TAG

TREAT(Medical Base)

CONTROLLED TRANSFER


3636

Advance Medical Post

Manager

Triage Officer

Triage Officer

Hospital Radio Communication NetworkHospital Radio Communication Network

HOSPITAL

Control Centre

Command

Post


3737

SITE

Medical base

station

Ambulance loading

point

Ambulance parking

point

OUT

Inner cordon Outer cordon

IN


3838

Disaster Site Allocations.Disaster Zone Disaster Zone (50-100 mtr R)(50-100 mtr R)

Evacuation Zone Evacuation Zone (100-150mtr R)(100-150mtr R)

Safety Zone Safety Zone (200mtr R)(200mtr R)

Disaster Command PostDisaster Command Post

MEDICALMEDICAL

SMARTSMART

991991

MRCS/SJAMRCS/SJA

NGO & Other NGO & Other Releif AgenciesReleif Agencies

Inner Cordon

Outer Cordon

POLICEPOLICE

BOMBABOMBAPKTK

Guard Post

Guard Post

ACCESS EXIT


3939

Setting up prioritiesRequires that the priority on the extent of injuries the victim receives must continuously be assessed and adapted to:

• the patient’s state and the result of measures taken.

• the overall casualty profile.

• available care and transport resources.

• stage in the chain of attention (place of injury - assembly point - transport)


4040

CategorizationCategorizationCategoryCategory Color codeColor code ConditionCondition Emergency Emergency

actionactionPriorityPriority

11 REDRED Life @ limb threatening; death if no Life @ limb threatening; death if no intervention. Injuries affecting ABCintervention. Injuries affecting ABC

IMMEDIATEIMMEDIATE TOPTOP

22 YELLOWYELLOW Serious but stable injuries; not Serious but stable injuries; not immediately life threatening. May immediately life threatening. May

deteriorate without Rxdeteriorate without Rx

URGENTURGENT SECONDSECOND

33 GREENGREEN Non serious, minor stable injuries. Non serious, minor stable injuries. DeferrableDeferrable

NON NON URGENTURGENT

THIRDTHIRD

44 BLACKBLACK Dead, decapitated, mutilated, severed, Dead, decapitated, mutilated, severed, apneic, pulseless, incinerated; deemed apneic, pulseless, incinerated; deemed

unsalvageableunsalvageable

DELAYEDDELAYED LOWESTLOWEST


4141

Triage Card


4242


4343

Emergency Treatment• importantly the objective is stabilising vital functions.

• transporting casualties with untreated shock, partially blocked airways, poor oxygenation or an unstabilised fracture is of no excuse/value.Delay in transport, thus time consuming, should be optimised before the patient being actually attended in / at a more established medical facility.

• Particularly at times of disaster/mass casualty whereby the number of casualties far more exceeding the available number of available transport, the precious time available should be materialised for stabilising as many casualties as possible.


4444

EMERGENCY DEPARTMENT, SARAWAK GENERAL HOSPITAL, KUCHING.EMERGENCY DEPARTMENT, SARAWAK GENERAL HOSPITAL, KUCHING.FLOORPLAN DURING ROUTINE DAILY ACTIVITYFLOORPLAN DURING ROUTINE DAILY ACTIVITY

1

23

4

5

6

7

Water Supply Point

Water Supply Point


4545

EMERGENCY DEPARTMENT, SARAWAK GENERAL HOSPITAL, KUCHING.EMERGENCY DEPARTMENT, SARAWAK GENERAL HOSPITAL, KUCHING.FLOORPLAN DURING LEVEL 1 MASS CASUALTY & DISASTER OPERATIONFLOORPLAN DURING LEVEL 1 MASS CASUALTY & DISASTER OPERATION

1

23

4

5

6

7

Water Supply Point

Water Supply Point

Victim/casualty Handling Capacity:-a) Critical = 9 Cases. b)Semi-Critical = 30 cases c)Non-Critical = 30 Cases .If the patient in any of the above-mentioned category reaches the level, next strategy will immediately be activated.


4646

EMERGENCY DEPARTMENT, SARAWAK GENERAL HOSPITAL, KUCHING.EMERGENCY DEPARTMENT, SARAWAK GENERAL HOSPITAL, KUCHING.FLOORPLAN DURING LEVEL II MASS CASUALTY & DISASTER OPERATIONFLOORPLAN DURING LEVEL II MASS CASUALTY & DISASTER OPERATION

1

23

4

5

6

7

Water Supply Point

Water Supply Point

Victim/casualty Handling Capacity:-a) Critical = 25 Cases. b)Semi-Critical = 30 cases c)Non-Critical Cases will be managed at the SGH Main Lobby and Information Counter


4747

HOSPITAL RECEPTION - Flow of Victims

Command PostEmergency DepartmentRed Area

Holding Area

TriageArea

Red

Green

Yellow

Green Area

Yellow Area

Operating Theater


4848

Disaster Preparedness LevelsA.Disaster Preparedness. (state of preparedness)

- implies spot reinforcement of important medical care functions.

• non-urgent treatments or operations that can wait are postponed.

• staff ending their shift remains on duty.

• spot reinforcement through key staff in e.g.administrative, emergency, anaesthesiological and surgical wards being called in.


4949

Disaster Preparedness Levels (cont…)

B. Highest Disaster Preparedness. (state of disaster)

• implies all medical care functions required for dealing with large number of casualties are used and reinforced including calling in all off-duty officers.

• invoked when large resources will be required within the shortest possible time allocation.


5050

Organising the team At the Emergency Department.

- get the telephone operator to inform relevant senior officers and wards.

- get ED cleared of non-critical patients and made ready to receive casualties.

- get the 2nd and subsequent teams ready for dispatch.

- brief all available officers on the situation.

- make a record all officers and assign relevant tasks as they report in.

• MA I/c of the shift will be the initial Commander of Operation(CO) until the next senior officer comes and take over the role. Among other things he should:-


5151

Team members at the disaster siteFirst Responding Team.

Their individual roles:

MO – On-Site Medical Coordinator

- until the next senior (Medical) officer takes over.

EMT1 ED,MA - Triage Officer.

Nurse - Medical/Nursing (Care) Officer.

Driver - Transport Officer.

Med.Attendant – assisting in setting up the Command

Post.

Ideally, all team members are from the existing on-shift Emergency Department.


5252

Responsibilities of First Responding Team

• Report to the On-Scene-Commander of Operation(OSC)

• Gather essential information: locality, nature of incident, extent of damage, possible number of casualties, wind directions, gradient, incoming and outgoing route for back-up teams, essential back-up equipment and resources.

• Relay back message to base station(ED) on the latest relevant information and co-ordinate activities and requirements.

• Ensure safety of team members(safety limit from the disaster zone is at the discretion of the MC) and proceed establishing the command post, triage/assembly point for victims.


5353

The Second Team1 MO from Medical Unit.

1 MA from ED

1 Nurse from Medical Unit

1 Attendant(Male) from ED

1 EMT Driver from ED

Subsequent Back-up TeamsThe Third Team

1 MO from Orthopaedic Unit

1 MA from MA College

1 Nurse from Orthopaedic Unit

1 Attendant(Male) from 1st/2nd Class

1 Driver from ED(pool)

These teams will respond immediately whenever their presence is summoned. They are to report themselves to the On-Site Medical Coordinator and anticipate their roles and responsibilities as dictated by the former.


5454

Why setting up assembly point? • to permit an overall assessment of the casualties, continuously.• to concentrate equipment and personnel resources for qualified first aid measures.

• to stabilize vital functions prior to transportation and to make other preparation so as to alleviate sufferings and avoid deterioration on conditions.• to distribute patients optimally among available care institutions on the basis of the above continuous assessment.• to register all patients before they leave the assembly point.


5555

Team set up at ED1. Reception of casualties. (Triage)The team will be headed by the Medical Specialist-On-Call and will be joined in by other ED MAs and Medical MOs.

2. Green and Yellow Zone Teams.The leader is the Orthopaedic Specialist, assisted by ED MAs. Other members are the Orthopaedic MOs and the Medical ward nurses

3. Equipment & Supply Team.The leader is a Senior MA(ED).The other members are ED MA & Nurse and F/Medical ward nurse.


5656

Team set up at ED (cont…)4. Resuscitation Team.The team leader is the ED MO combining his effort with the Surgical Specialist. Other members of the team are Surgical MO, ED Nurse and Orthopaedic Nurse.

Other Officers available - Please report to the Commander of Operation at the ED Registration counter for further instructions.


5757

Other (Senior) Officers and their roles.

Hospital Director - Overall Operation Commander(OC)Deputy Director - Setting up of Disaster Operation RoomMatron I - Setting up of relevant recipient wards & CSSD & other supplies. Matron II & Nursing Sister On-Duty - Setting up of OT and back up nursing group.

Pharmacist - Taking Charge of Store & Pharmacy supplies.Head of ED (Specialist) - Out to the scene and takes over the role of On-Site-Medical Coordinator (OSMC )


5858

Other (Senior) Officers and Their Roles (cont…)MA U36 - Takes over Crowd Control,together with Police and other Security Officers. ED MA U32(Admin) - Assisting the Commander Of Operation. Works closely together with Hospital Director.

ED MA U32(In-patient) - In Charge of Supplies & Equipment. Keeps in contact with Pharmacist.

ED MA U32(Pre-Hospital) - In charge of Ambulance & Transport, and Decontamination Area.

Senior Medical Attendant(ED) – In charge of clearing the ED, get as many trolleys, wheelchairs and hospital attendants to assist in patient transfers.


5959

Summary of Mass Casualty Summary of Mass Casualty managementmanagement

Notification and verificationNotification and verification Initiate incident management systemInitiate incident management system Search and rescueSearch and rescue START – treat - 1° survey – stabilizationSTART – treat - 1° survey – stabilization Evacuate/transfer Evacuate/transfer ED managementED management Definitive managementDefinitive management


6060

Level I Universal Precaution During Interaction and Procedure involving “High Risk Contamination” Situation: interaction less than 3 feet distance, procedure involving body fluids spillage (intubation surgery, post mortem, suction) Precaution System :o Protective Head with Filter Masko Mask – N95/ N100o OT Uniformo Water proof gowno Plastic aprono Double gloveo Goggles / Eye Protection or Spectacles

Universal Protection System for Infectious Disease Outbreak


6161

Level IILevel II Universal Precaution Universal Precaution

During During Treatment and Treatment and Minor ProcedureMinor Procedure

Situation: interaction Situation: interaction less less than 3 feet distancethan 3 feet distance

Precaution System :Precaution System :o Mask – N95/ N100Mask – N95/ N100o OT UniformOT Uniformo Water proof gownWater proof gowno Plastic apronPlastic aprono Double gloveDouble gloveo Goggles / Eye Protection or Goggles / Eye Protection or

SpectaclesSpectacles

Universal Protection for Infectious Diseases Outbreak.


6262

Universal Protection for Infectious Diseases Outbreak

Level III Front line basic personnel protection Location : Triage Counter, Clinic Area, Counselling Room Precaution System :o 3 feet away from patiento Mask – N95/ N100 & 2 layer of surgical masko OT Uniform & Plastic Aprono Goggles / Eye Protection or Spectacles

Decontamination ProcessDecontamination Process of theof the VictimVictim

Protection Suit


6565

Being unable to predict disaster doesn’t mean that we cannot be prepared

( National Geographics )

“ The Art of War teaches us to rely not on the likelihood of the enemy’s not coming, but on our readiness to receive him; not on the chances of his not attacking, but rather on the fact we have made our position steadfast ”

( The art of War – Sun Tzu )

FURTHER DISCUSSION


6666

Devastating Incident Seriously Affecting Social (structural) Tranquility and Economic of a Region.


6767

THANK YOUTHANK YOU

DISASTER MANAGEMENT

Documents

need of medical care

multiple injury

subsequent death

early death

abdominal injury

disaster immediate death

available resources

brain damage