Tornado Mass-Casualty Surge at a Hospital With One OR Team
At 15:10 a tornado touches down 6 km from a 220-bed hospital with a 12-bed emergency department and 6 adult ICU beds. By 15:50, 47 casualties arrive: 9 critically injured, 17 moderate, 21 walking wounded. One OR team and one anesthesia provider are in-house; the second OR team is 35 minutes out. The CT scanner is offline for scheduled maintenance until 18:00. The ambulance bay has 10 cm of standing water from a broken main, and two ambulances are blocked. The hospital's incident command is activated with the nursing supervisor as incident commander; she has completed only an online awareness course. The regional trauma center 40 km away is on diversion for an unrelated surge, and the county EOC reports two additional tornadic cells approaching. The ED charge nurse asks whether to declare an internal disaster and go on diversion.
1. Identify the incident commander's first 30-minute priorities and the ICS gaps that must be filled immediately.
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The nursing supervisor can retain command initially - someone must - but she should not carry the event alone. First 30 minutes: establish one command post and one operational picture; declare internal disaster if the surge plan requires it; appoint a medical branch director and a triage officer with clinical authority, because the supervisor cannot simultaneously allocate 6 ICU beds, 1 OR team, and 47 casualties; request the second OR team immediately and activate the labor pool; assign a facilities lead to clear the ambulance bay flooding and designate a dry patient-receiving entrance; and stand up patient tracking and family reunification.
The critical ICS gap is span of control. With 47 casualties and two more cells inbound, one untrained commander cannot run operations, planning, logistics, and finance at once. Fill Operations with an ED physician or surgeon, Planning with someone tracking bed, OR, and CT capacity plus weather, and Logistics with facilities/security for water and routes. The online awareness course is not equivalent to ICS-300/400; request a qualified incident commander from the county or a partner hospital to shadow now and assume command at a defined trigger such as a second casualty wave or the first out-of-hospital transfer.
2. Should the hospital go on diversion? Address EMTALA and the regional context in your answer.
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Diversion is a system-level decision made through the EMS/EOC structure, not a unilateral hospital announcement, and it never suspends EMTALA. The hospital must still provide a medical screening examination and stabilizing treatment to everyone who presents, including the 47 already inside. Going on diversion now would push patients toward a trauma center already on diversion 40 km away, during an active tornado warning - that is worse for the 9 critical patients than treating them here with constrained resources.
The better move is to declare limited capability through the EOC and EMS system: "no CT until 18:00, one OR team, ambulance bay compromised," and ask EMS to route walking wounded and minor injuries to a surge site or alternate facility. Notify the regional medical operations center and document the capability constraints.
The real EMTALA exposure is transferring an unstabilized patient without benefit or without the required physician certification. If a critical patient must go, document the capability gap, the receiving facility's acceptance, and the risk-benefit reasoning. Reassess at 18:00 when CT returns, and pre-script the trigger at which diversion becomes unavoidable if a second cell strikes.
3. How should the 6 ICU beds and the single OR team be allocated, and what must be documented?
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First create capacity before rationing: discharge or transfer 2-3 stable ICU patients, use PACU and endoscopy as monitored overflow, and restrict the OR to damage-control and life-saving procedures. If demand still exceeds supply, move to a formal scarce-resource process rather than first-come allocation. The trauma surgeon and ED physician should jointly sort patients into immediate, delayed, minimal, and expectant categories using physiology and immediacy, with the rationale written at the time.
The single OR team should take patients whose survival depends on surgery within minutes - uncontrolled hemorrhage, airway compromise, tension physiology. Non-operative stabilization continues in the ED. Because the second team arrives at roughly 16:25, hold a reversible decision for any patient who can tolerate 30 minutes; that is a resource-arrival calculation, not a delay tactic.
Documentation must capture who decided, what information was available, alternatives considered, criteria used, and the reassessment interval. Do not rely on any clinician's memory. Brief the team that allocation can change as resources arrive or deteriorate, notify families, and involve the ethics committee where policy requires it.