05-Effects of mass casualty incidents on anxiety, depression and PTSD among doctors and nurses- a systematic review protocol.

ProtocolOpenaccessEffects of mass casualty incidents on anxiety, depression and PTSD among doctors and nurses: a systematicBMJ Openreview protocolHelal Uddin <a href="http://orcid.org/0000-0002-0767-3174">c</a> ,1,2,3 Md Khalid Hasan <a href="http://orcid.org/0000-0002-9293-9693">c</a> ,4 Rafael Castro-Delgado <a href="http://orcid.org/0000-0001-9520-656X">o</a> 3,5To cite: Uddin H, Hasan MK, Castro-Delgado R. Effects of mass casualty incidents on anxiety, depressionand PTSD among doctors and nurses: a systematic review protocol. BMJ Open2023;13:e075478. doi:10.1136/ bmjopen-2023-075478► Prepublication history andadditional supplemental material for this paper are availableonline. To view these files,please visit the journal online (<a href="http://dx.doi.org/10.1136/bmjopen-2023-075478">http://dx.doi.org/10.1136/</a> <a href="http://dx.doi.org/10.1136/bmjopen-2023-075478">bmjopen-2023-075478</a>).Received 09 May 2023Accepted 30 August 2023<img src="/media/202408//1724856293.8179798.png" /><a href="http://crossmark.crossref.org/dialog/?doi=10.1136/bmjopen-2023-075478&amp;domain=pdf&amp;date_stamp=2023-09-11"><img src="/media/202408//1724856293.840638.png" /></a>© Author(s) (or theiremployer(s)) 2023. Re-usepermitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.For numbered affiliations see end of article.Correspondence toHelal Uddin;md.helal.uddin@stud.ki.seABSTRACTIntroduction Both doctors and nurses showed a greaterrisk of being exposed to different mental health conditions following mass casualties. This systematic review aimsto synthesise the existing evidence on the prevalence ofanxiety, depression and post-traumatic stress disorder and their associated risk factors among doctors and nursesfollowing mass casualty incidents.Methods and analysis Seven electronic databases(PubMed, PsycINFO, MEDLINE Ovid, Embase,CINAHL, Web of Science and Nursing &amp; Allied Health database) will besearched from 2010 to 2022 with peer-reviewed articles in English language using the predefined keywords.Two reviewers will independently screen the titles andabstracts, as well as review the full texts using theeligibility criteria, then extract data independently. TheNational Institutes of Health Quality Assessment Tools(NIH-QAT) for quantitative studies, the Critical AppraisalSkills Programme (CASP) Checklist for qualitative studies and the Mixed-Methods Appraisal Tool (MMAT) for mixed- method studies will be used to measure the qualityappraisal of eligible studies. A third reviewer will resolvethe discrepancies when the two reviewers cannot reach an agreement in any step. The result from the eligible studies will be described following narrative synthesis with the key characteristics and findings of the included studies, andmeta-analysis will be performed, if applicable.Ethics and dissemination This systematic review deals with existing published studies without any personallyidentifiable information of participants. Therefore, ethical approval from the research committee is not required.Findings from this review will be disseminated in peer- reviewed journals and presented at relevant international conferences.PROSPERO registration number CRD42023412852.INTRODUCTIONMass casualty incidents (MCIs) and disasters are frequently used interchangeably in the literature, although they describe specific conditions and entities. From a medical perspective,a disaster is an event that brings injuries, disease or contamination to people or may be linked to structural and physical damages without affecting public health and the healthcare system<a href="#bookmark1">.1</a> On the other<table><tr><td>STRENGTHS AND LIMITATIONS OF THIS STUDY → To the best knowledge, this is the first systematic re- view on two crucial medical responders (emergency doctors and nurses), and their three mental health outcomes (anxiety, depression and post-traumatic stress disorder) following mass casualty incidents.→ Another biggest strength of this review is that it strictly follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and uses standard quality assessment tools.→ Above and beyond, the review will incorporate stud- ies irrespective of location or geography.→ However, excluding grey literature and including studies published only in English will miss some po- tential studies that may be a source of publication bias.→ As different authors use heterogeneous tools to measure the outcomes, there will be a possibility of reporting bias.</td></tr></table>hand, MCI is well-defined as an incident that overwhelms the local healthcare system, where the level of casualties notably exceeds the ability to face the healthcare needs of victims with local resources and capabilities in a short period<a href="#bookmark2">.2–4</a> More specifically, MCIs focus on the outstrips of the capacity of the first responders at the incident scene or the medical workers at the hospital to deliver optimal care to all victims at a time.<a href="#bookmark1">1</a> While almost all MCIs may be disasters that affect communities, not all disasters are considered as MCIs<a href="#bookmark1">.1</a> Hence, the incidents generating MCIs or disasters may be remarkably hetero- geneous in nature, creating a different level of severity and impact on the population, envi- ronment, rescue system, medical responders and patient care management<a href="#bookmark3">.5</a>Large-scale incidents, including mass acci- dents and emergencies, result in mortality,severe physical, social, organisational damages.<a href="#bookmark4">6</a>and andmorbidity economicMoreover, mass incidents have a significantBMJ Open: first published as 10.1136/bmjopen-2023-075478 on 11 September 2023. Down loaded from <a href="http://bmjopen.bmj.com/">http://bmjopen bmj com/</a> on December 3, 2023 by guest Protected by copyright <a href="http://bmjopen.bmj.com/">BMJ</a> Uddin H, et al. BMJ Open 2023;13:e075478. doi:10.1136/bmjopen-2023-075478 1Open accessdetrimental effect on the physical and mental well-being of the exposed population<a href="#bookmark5">.7</a> For example, post-traumatic stress disorder (PTSD), depression, anxiety and substance use are the most common mental conditions following a mass event or emergency.<a href="#bookmark6">8 9</a> However, people exposed to mass incidents are not only victims of mental health conditions but also include family members, coworkers and, most importantly, first responders and frontline healthcare workers.<a href="#bookmark6">8 10 11</a>Recent studies showed that rescuers and first responders, such as Emergency Medical Service workers in prehos- pital and hospital settings, including firefighters, police and military personnel, emergency health workers and mortuary staff reported adverse mental health conditions following MCIs and disasters<a href="#bookmark6">.8</a> Healthcare personnel, particularly emergency department (ED) workers, always encounter severely critical and demanding situations following a mass event. Consequently, healthcare workers met different stressors along with their occupational risk factors (eg, long working hours, heavy workload, poor working conditions and sleep disturbance) and showed a greater likelihood of reporting adverse psycholog- ical health<a href="#bookmark7">.12</a> Moreover, healthcare workers, particularly nurses and doctors in the ED, are more susceptible to psychological stress as they experience repetitive trau- matic situations due to the nature of their work<a href="#bookmark6">.8 13</a>First responders frequently worked under dangerous conditions where they had a greater risk for infec- tious diseases, adverse environmental exposures, trau- matic injuries, and particularly, negative mental health outcomes from caring for severely injured persons, expe- riencing dead bodies, body parts, treating someone who has lost their loved ones and dealing with unsuccessful efforts for the victims following a mass causality event<a href="#bookmark8">.14</a> For example, traumatic events, such as severe burns/inju- ries, suicide victims or a child with unintentional injuries, positively correlate with peritraumatic distress and PTSD symptoms of nurses who work in the ED.<a href="#bookmark9">15</a> Similarly, a study in the Netherlands showed that nearly one out of three nurses in ED reported subclinical levels of depres- sion, anxiety and somatic symptoms, with more than 8% meeting a clinical level of PTSD<a href="#bookmark10">.16</a> Moreover, another study on German physicians in ED reported that almost 8% of doctors had depressive symptoms, about 17% had probable PTSD and more than 3% had clinical depressive symptoms<a href="#bookmark11">.17</a> Among Belgian emergency doctors, almost 15% had a clinical level of PTSD, about 11% had anxiety and almost 8% had depression after traumatic incidents.<a href="#bookmark12">18</a>During MCIs, the ED became the epicentre of health- care deliveries. Emergency doctors and nurses had a higher risk of reported mental outcomes than other healthcare workers, which calls for an investigation to explore the prevalence of mental health outcomes and their associated risk factors among doctors and nurses. Consequently, early detection of these adverse mental health conditions and risk factors would help in under- taking required actions that have important implications for the stress and mental health management of nursesand doctors. Moreover, some critical gaps in the existing literature must be addressed. First, most previous reviews investigated either the psychological outcomes of all types of healthcare workers in general or used disasters and MCIs interchangeably,<a href="#bookmark6">8 19 20</a> which demands special atten- tion (1) for a particular group like doctors and nurses who play a critical role in response to any mass casual- ties, and (2) for a distinctive investigation to measure the effect of MCIs on mental health. Second, much of the current research studied only PTSD as a significant mental health outcome following disasters and MCIs,<a href="#bookmark13">21</a> which may overlook other potential mental health conditions, such as anxiety and depression, of healthcare workers. Therefore, our study will answer the following research question: What are the levels of anxiety, depression and PTSD and their associated risk factors reported among emergency doctors and nurses in healthcare facilities and prehospital settings following mass causality incidents?Aims of the studyOur study aims to summarise the current evidence on the prevalence of anxiety, depression, and PTSD and their associated risk factors among doctors and nurses in the hospital and prehospital setting following a mass causality incident.METHODS AND ANALYSISStudy designThis systematic review protocol is prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines<a href="#bookmark14">22 23</a> (<a href="https://dx.doi.org/10.1136/bmjopen-2023-075478">online supplemental table S1</a>). For maintaining complete transparency and reporting, particularly in the Methods section, and for identifying, selecting and summarising the eligible studies, we will follow the PRISMA-P state- ment and Narrative Synthesis Method.<a href="#bookmark15">24</a> The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number (CRD42023412852).Eligibility criteriaThe eligible studies will be peer-reviewed full-text English- language articles published between 1 January 2010 and 31 December 2022 that explored the prevalence and risk factors for any of the three mental health outcomes (anxiety, depression or PTSD) among nurses and doctors in the hospital and prehospital setting following MCIs. Additionally, this review will include studies with quantita- tive, qualitative or mixed-methods research designs, and there will be no restrictions on the geographical setting of the included studies. However, this review will exclude studies if they (1) include nurses and doctors who worked in the general department, (2) include disasters or wars as exposure, (3) include nurses and doctors who already have chronic mental disorders, (4) measuremental health outcomes without Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification<img src="/media/202408//1724856293.949943.png" />BMJ Open: first published as 10.1136/bmjopen-2023-075478 on 11 September 2023. Down loaded from <a href="http://bmjopen.bmj.com/">http://bmjopen bmj com/</a> on December 3, 2023 by guest Protected by copyright 2 Uddin H, et al. BMJ Open 2023;13:e075478. doi:10.1136/bmjopen-2023-075478<a id="bookmark16"></a>Open accessTable 1 Inclusion and exclusion criteria of the systematic review<table><tr><td colspan="3">Inclusion criteria Exclusion criteria</td></tr><tr><td>Population Doctors and nurses worked in the emergency department of healthcare facilities and prehospital settings</td><td colspan="2">Doctors and nurses in the general departments</td></tr><tr><td colspan="3">Intervention MCIs Disasters and wars</td></tr><tr><td colspan="3">Comparison Doctors vs. nurses</td></tr><tr><td>Outcome Investigated the prevalence and risk factors for anxiety,depression or PTSD (defined following DSM-III, DSM-III-R, DSM-IV or DSM-V and ICD-10 and ICD-11 criteria)</td><td colspan="2">Already chronic mental disorders, any other mental conditions, did not measure the DSM and ICD-defined symptoms</td></tr><tr><td colspan="2">Study All quantitative, qualitative and mixed-methods peer-reviewed studies, including RCTs, non-RCTs, cohort studies, cross-sectional studies and surveys. The study must consider at least one outcome following MCIs</td><td>Protocols, editorials, letters to editors,commentaries, conference abstracts andposters, and opinion pieces that are not peer- reviewed, including grey literature</td></tr><tr><td colspan="3">Setting Irrespective of location and geography</td></tr><tr><td colspan="3">Date range 1 January 2010 to 31 December 2022 Published before January 2010 and afterDecember 2022</td></tr><tr><td colspan="3">Language English Studies published in languages other thanEnglish</td></tr><tr><td colspan="3">MCIs, mass casualty incidents.</td></tr></table>of Diseases (ICD)-10, and ICD-11 defined criteria or (5) are other review articles, protocols, editorials, letter to editors, conference abstracts, commentaries and opinion pieces (<a href="#bookmark16">table 1</a>).Information sourcesThe following seven databases will be systematically searched from 1 January 2010 to 31 December 2022 to retrieve relevant articles: PubMed, PsycINFO, MEDLINE Ovid, Embase, CINAHL, Web of Science and Nursing &amp; Allied Health database. These databases were also used to search the literature by the previous systematic reviews on healthcare workers' mass casualty or mental health outcomes. Moreover, this review will screen the refer- ences of all eligible articles to find possible further rele- vant studies due to literature saturation.Search strategyA systematic and detailed search strategy has been devel- oped on PubMed/MEDLINE database using MESH terms and keywords. The search will use the Boolean operators (AND, OR and NOT) and truncations (*) following the specifications of the database. In addition, the search strategy will be modified to fit other electronic databases depending on database-specific filters (<a href="https://dx.doi.org/10.1136/bmjopen-2023-075478">online supple-</a> <a href="https://dx.doi.org/10.1136/bmjopen-2023-075478">mental table S3</a>). The systematic search strategy includes keywords/terms related to the study’s population, inter- vention and outcomes of interest (<a href="#bookmark17">table 2</a>). Moreover, the search terms will be finalised after consultation with experts in this field and a research librarian.Study recordsScreening procedures of eligible studiesAfter the initial systematic search, all the search records will be managed with Rayyans Qatar Computing Research Institute (QCRI) software, a web-based online tool formanaging and reporting systematic reviews and meta- analyses<a href="#bookmark18">.25</a> All the retrieved articles will be stored in a single library to detect and remove duplicates. Then, a three-phase screening process will be followed to select eligible articles from the remaining articles. The firstTable 2 Key terms for preparing the comprehensive search <a id="bookmark17"></a>strategy<table><tr><td colspan="2">Key terms</td></tr><tr><td colspan="2"># Population nurse, emergency nurse, prehospitalnurse, registered nurse, intern nurse, nurse in emergency department, physician,doctor, medical doctor, emergency doctor, prehospital doctor, medical officer, doctor in the emergency department</td></tr><tr><td># Intervention/ exposure</td><td>mass casualty incident, MCI, explosion,plane crash, air crash, air accident, trainderailment, train bombing, road traffic, bus bombing, bus crash, car crash, suicidebombing, bombing, terror attack, terrorism, bioterrorism, accident, industrial accident, fire, factory fire, chemical spill, CBRNEincident, building collapse, mass injury,gunshot, mass shooting, massive chemical contamination, radiological dispersal device (RDD), dirty bomb, emergency, volcaniceruptions, earthquake</td></tr><tr><td colspan="2"># Outcome anxiety, depression, posttraumatic stress disorder, PTSD, mental health disorder, psychological disorder, psychologicalcondition, psychological distress,psychological impact, mental outcome, mental condition, emotional impacts</td></tr><tr><td colspan="2">MCI, mass casualty incident; PTSD, post-traumatic stress disorder; RDD, radiological dispersal device.</td></tr></table><img src="/media/202408//1724856293.981424.png" />BMJ Open: first published as 10.1136/bmjopen-2023-075478 on 11 September 2023. Down loaded from <a href="http://bmjopen.bmj.com/">http://bmjopen bmj com/</a> on December 3, 2023 by guest Protected by copyright Uddin H, et al. BMJ Open 2023;13:e075478. doi:10.1136/bmjopen-2023-075478 3Open access<img src="/media/202408//1724856294.0023181.jpeg" /><a id="bookmark19"></a>Figure 1 Study selection flow diagram (Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009).<a href="#bookmark20">26</a>screening step will be assessing the relevancy of the article title to the review topic independently by two reviewers (HU and MKH). Irrelevant studies will be excluded,and those that meet the review criteria will be kept. In the second step of screening,a pair of indepen- dent researchers (HU and MKH) of the research team will conduct the abstract screening for eligibility of the remaining studies and exclude studies that do not meet the inclusion criteria. In the final step, the full text of the remaining articles will be obtained and further assessed for inclusion by two reviewers (HU and MKH). A third reviewer (RCD) of the research team will be consulted to resolve any disagreement in screening titles, abstracts and full-text articles. A flow diagram will be prepared to report the study selection process and reasons for exclu- sion following the Preferred Reporting Items for System- atic Reviews and Meta-Analyses guidelines<a href="#bookmark20">26</a> (<a href="#bookmark19">figure 1</a>).Data extraction and managementA standardised data extraction template in an Excel sheet will be prepared, and two reviewers (HU and MKH) will collect specific information from the eligible studies following an instruction manual. The data extraction and information items will be included based on the Population, Intervention, Comparison and Outcomes(PICO) structure<a href="#bookmark21">.27</a> For example, participant charac- teristics (gender, age, marital status, education, years of experience, type of work), intervention/exposure charac- teristics (types of mass casualty, frequency, duration and the severity of the incident) and outcome characteristics (types, tools for measurement, prevalence and duration of the conditions) will be extracted. Moreover, general infor- mation (eg, article title, author, reviewer, record number, date of data extraction),study characteristics (aim/objec- tive of the study, study design, countries, sample size) and the main findings from the eligible studies related to our research questions will be extracted. In case of missing information ineligible studies, an email will be sent to the corresponding authors for missing details. After the data extraction by two reviewers, a third reviewer will verify and resolve any disagreement if it happens.Quality appraisal/Risk of biasThe methodological quality and risk of bias will be assessed for the finally included studies to examine whether each study addresses the required dimensions of research quality. The National Institutes of Health Quality Assess- ment Tools (NIH-QAT) for quantitative studies<a href="#bookmark22">28</a> and the Critical Appraisal Skills Programme (CASP) Checklist for qualitative studies<a href="#bookmark23">29</a> and the Mixed-Methods Appraisal<img src="/media/202408//1724856294.133792.png" />BMJ Open: first published as 10.1136/bmjopen-2023-075478 on 11 September 2023. Down loaded from <a href="http://bmjopen.bmj.com/">http://bmjopen bmj com/</a> on December 3, 2023 by guest Protected by copyright 4 Uddin H, et al. BMJ Open 2023;13:e075478. doi:10.1136/bmjopen-2023-075478Open accessTool (MMAT)<a href="#bookmark24">30</a> for mixed-method studies will be used to measure the quality appraisal of the eligible studies. The overall quality of the studies will berated as poor, fair and good quality following the Grading of Recommendations Assessment, Development and Evaluation approach<a href="#bookmark25">.31</a> Two reviewers (HU and MKH) will independently eval- uate the quality assessment of the included studies. Any discrepancies in the process and the grading of qualityappraisal will be resolved through group discussion;if necessary, a third reviewer will settle any unresolved conflicts. After the quality evaluation, only the studies with fair and good categories will be considered for this review.Data synthesis and analysisAfter the full-text screening of the included studies, this review will explore the prevalence of the outcomes and their associated risk factors among the study population. As the eligible studies are expected to be heterogeneous in terms of measurements of variables, methods and results, this review will follow the narrative synthesis method along with using the key characteristics and findings of the studies. One of the benefits of narrative synthesis is to offer the opportunity to compare the findings of the eligible studies, particularly focusing on the population, intervention and outcome. Based on the different health- care settings (hospital vs prehospital), or different risk factors, subgroup analysis will be executed depending on data availability. Even if possible, this review will conduct a meta-analysis of the quantitative data. Any modification to the protocol considered by the research team will be well reported in the review with proper explanation.Assessment of publication biasPublication bias assessment will be performed statisti- cally by conducting Egger’s test and visually by producing funnel plots. This review does not consider examining the meta-bias or confidence in cumulative evidence.Patient and public involvementPatients or the public were not engaged in this research design, reporting, or dissemination plan.DISCUSSIONMany studies reported the adverse effect of mass emer- gencies on medical responders' mental health and well- being, where nurses and doctors reported a higher risk of being exposed to the outcomes<a href="#bookmark6">.8</a> Moreover, the prev- alence and risk factors may vary based on the nature of the mass casualties. However, previous studies have documented the prevalence of mental health outcomes, particularly PTSD, among healthcare workers in different disasters. There is no systematic review on anxiety, depres- sion and PTSD among emergency doctors and nurses following MCIs. Therefore, this systematic review will fill the gap in the literature on the prevalence and the associ- ated risk factors of anxiety, depression and PTSD amongnurses and doctors. The findings will offer vital informa- tion for public health stakeholders, healthcare managers, policymakers and researchers to design and develop mental health management programmes for emergency doctors and nurses.CONCLUSIONSThe findings of this systematic review will offer a synthesis of current evidence on the prevalence and the associ- ated risk factors of anxiety, depression and PTSD among doctors and nurses following MCIs. These findings will help health organisations, managers, and all types of hospitals, regardless of geographical location, to adopt preventive measures for reducing adverse psychological outcomes among doctors and nurses after mass casualties.Ethics and disseminationThis systematic review deals with existing published studies without any personally identifiable information of participants. Therefore, ethical approval from the research committee is not required. Findings from this review will be disseminated in peer-reviewed journals and presented at relevant international conferences.Author affiliations1Department of Global Public Health, Karolinska Institute, Stockholm, Sweden 2Department of Sociology, East West University, Dhaka, Bangladesh3Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain4Institute of Disaster Management and Vulnerability Studies, University of Dhaka, Dhaka, Bangladesh5Health Service of the Principality of Asturias (SAMU-Asturias), Health Research Institute of the Principality of Asturias (Research Group on Prehospital Care and Disasters, GIAPREDE), Oviedo, Asturias, SpainContributors HU, MKH and RCD developed the idea and design for this protocol. HU wrote the first draft of the manuscript and developed the search strategy and methodology. RCD and MKH critically revised this manuscript. HU and MKH willperform the study selection and data extraction. RCD will supervise this study. All the authors critically revised the methodology and approved the final version of this manuscript.Funding The authors have not declared a specific grant for this research from anyfunding agency in the public, commercial or not-for-profit sectors. Competing interests None declared.Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.Patient consent for publication Not applicable.Provenance and peer review Not commissioned; externally peer reviewed.Supplemental material This content has been supplied by the author(s). It hasnot been vetted by BMJ Publishing Group Limited (BMJ) and may not have beenpeer-reviewed. Any opinions or recommendations discussed are solely thoseof the author(s) and are not endorsed by BMJ. BMJ disclaims all liability andresponsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.Open access This is an open access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-NC 4.0) license, whichpermits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: <a href="http://creativecommons.org/licenses/by-nc/4.0/">http://creativecommons.org/licenses/by-nc/4.0/</a>.<img src="/media/202408//1724856294.27156.png" />BMJ Open: first published as 10.1136/bmjopen-2023-075478 on 11 September 2023. Down loaded from <a href="http://bmjopen.bmj.com/">http://bmjopen bmj com/</a> on December 3, 2023 by guest Protected by copyright Uddin H, et al. BMJ Open 2023;13:e075478. doi:10.1136/bmjopen-2023-075478 5<a id="bookmark9"></a>OpenaccessORCID iDsHelal Uddin <a href="http://orcid.org/0000-0002-0767-3174">http://orcid.org/0000-0002-0767-3174</a>Md Khalid Hasan <a href="http://orcid.org/0000-0002-9293-9693">http://orcid.org/0000-0002-9293-9693</a>Rafael Castro-Delgado <a href="http://orcid.org/0000-0001-9520-656X">http://orcid.org/0000-0001-9520-656X</a>REFERENCES<a id="bookmark1"></a>1 Lynn M, Lieberman H, Lynn L, et al. Disasters and mass casualtyincidents. 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