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Anesthesiologists, An Overlooked Resource: An Exposé on Anesthesiologists as Leaders in Disaster Preparedness and Response

Published online by Cambridge University Press:  21 July 2025

Deborah SchwengelOpen the ORCID record for Deborah Schwengel[Opens in a new window],
Meera Gangadharan,
Kelly Chilson,
Ellen Choi,
Ashley Weinhold,
Amanda Widing,
Wendy Binstock,
Robert Greenberg and
Christina Diaz
Deborah Schwengel*
Affiliation:
Johns Hopkins University School of Medicine, Department of Anesthesiology, Critical Care Medicine and Pediatrics, Baltimore, MD, USA
Meera Gangadharan
Affiliation:
University of Texas Health Science Center at Houston, Department of Anesthesiology, Critical Care, and Pain Medicine, Houston, TX, USA
Kelly Chilson
Affiliation:
Department of Anesthesiology, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, USA
Ellen Choi
Affiliation:
University of Chicago, Department of Anesthesia and Critical Care, Chicago, IL, USA
Ashley Weinhold
Affiliation:
Department of Anesthesiology, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, USA
Amanda Widing
Affiliation:
Medical College of Wisconsin/Children’s Wisconsin, Department of Anesthesiology, Milwaukee, WI, USA
Wendy Binstock
Affiliation:
Department of Pediatric Anesthesiology, Ann & Robert H Lurie Children’s Hospital of Chicago, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA
Robert Greenberg
Affiliation:
Johns Hopkins University School of Medicine, Department of Anesthesiology, Critical Care Medicine and Pediatrics, Baltimore, MD, USA
Christina Diaz
Affiliation:
Johns Hopkins University School of Medicine, Department of Anesthesiology, Critical Care Medicine and Pediatrics, Baltimore, MD, USA
*
Corresponding author: Deborah Schwengel; Email: dschwen1@jhmi.edu
Rights & Permissions [Opens in a new window]

Abstract

Anesthesiologists are broadly trained members of the health care workforce, managing patients daily using advanced stabilization/resuscitative techniques. They work in a collaborative, team-based model and lead multidisciplinary teams. Their work includes prioritizing patients according to the complexities of their disease presentations, and threats to life and limb. Trauma care is a regular part of the anesthesiologist’s job. The presence of anesthesiologists is required in hospitals to achieve the designation “level 1” trauma center. Anesthesiology is a specialty known for promoting safe practice principles and improving quality of care, utilizing crisis resource management and implementing cognitive aids. Despite these skillsets, anesthesiologists are generally overlooked in disaster preparedness. The number of trained anesthesiologists is similar to that of emergency medicine physicians, and they are nearly twice as abundant as general surgeons. In countries outside the US, anesthesiologists are often included in the pre-hospital team.

The purpose of this article is to emphasize the skillsets of anesthesiologists and to advocate for their inclusion in disaster preparedness teams. Due to their presence and comfort throughout the hospital system, broad training in emergent and elective cases, resuscitation skills, procedural skills, communication skills, daily triage, and team management, anesthesiologists should be considered essential leaders during mass casualty incident preparation and response.

Keywords

anesthesiologistmass casualty incidentsmass casualty preparednessskillscrisis resource management

Information

Type
Concepts in Disaster Medicine
Information
Disaster Medicine and Public Health Preparedness , Volume 19 , 2025, e198
Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of Society for Disaster Medicine and Public Health, Inc

Anesthesiologists are versatile, broadly trained physicians with experience in many of the skillsets essential for leadership in preparation and response to mass casualty incidents (MCI). Additionally, in many hospitals, including these authors’ institutions, anesthesiology is one of the largest departments in their schools of medicine. In the US, according to the Association of American Medical Colleges (AAMC), there were 43095 active anesthesiologists in 2023. At the same time, there were 50654 emergency medicine specialists and 26426 general surgeons. 1

Anesthesiologists’ Roles

Despite a sizeable workforce, anesthesiologists are a misunderstood resource. Indeed, the responsibilities and capabilities of anesthesiologists are a mystery to many in the lay public and even some health care professionals. Common beliefs are that anesthesiologists simply administer anesthetic medications for surgery, and some even believe that the anesthesiologist leaves the patient’s side once anesthetizing medications are given. Reference Swinhoe and Groves2,Reference Onutu3,Reference Marulasiddappa and Nethra4,Reference Uma and Hanji5,Reference Lee, Lee and Park6,Reference Arefayne, Getahun and Melkie7,Reference Almutairi, Alorainy and Aldayel8,Reference Sherer9 That the role of the anesthesiologist is to ensure patient safety perioperatively may be misunderstood by many patients, given that they are sedated or anesthetized while the anesthesiologist is performing the tasks of maintaining their vital functions. The anesthesiologist is responsible for the total medical management of the patient in the operating room (OR) and typically performs procedures that are considered life-saving, such as placing breathing tubes and establishing vascular access for blood and fluid resuscitation. These tasks are performed during both routine and high-pressure, high-acuity conditions in ORs, imaging procedure suites, emergency departments, critical care units, endoscopy suites, cardiac catherization labs, and other locations as needed throughout the hospital. During an operation or procedure, a patient’s clinical status may deteriorate quickly, leaving little time to respond before dire consequences occur. Unlike other specialties where the physician contemplates a diagnosis, produces a treatment plan, and then writes an order that someone else, typically a nurse or technician, executes, an anesthesiologist diagnoses and personally administers the treatment immediately. The nature of the job involves task shifting and constant reassessment of patient conditions, requiring prioritization of tasks, working through competing diagnoses, and taking active steps to address problems as they occur. Anesthesiologists routinely use simulation to assess and manage unexpected problems during training and to maintain skill readiness, similar to pilots using flight simulation to prevent airplane crashes. When a crisis occurs, the surgeon looks to the anesthesiologist to lead the team and manage the situation (Figure 1). Anesthesiologists direct the operating room team to work together to save the patient’s life. 10 , 11 , Reference Hepner, Arriaga and Cooper 12 They are the only medical doctors who combine and embody the responsibilities of acute care physician, nurse, pharmacist, and respiratory therapist in their daily practice.

Figure 1.

Anesthesiologists regularly address crises and use principles of crisis resource management to ensure effective coordination, communication, and decision-making in a team-based environment. This approach ensures that all responders work cohesively to improve outcomes.

Discussion

Scope of Practice

It is essential to understand that the scope of anesthesiology practice is not limited to intraoperative care. Anesthesiologists are experts in perioperative medicine, providing preoperative optimization, perioperative pain management, postoperative intensive care, and enhanced recovery after surgery programs. Multiple anesthesiology subspecialty areas command high levels of expertise, including but not limited to acute and chronic pain management, pediatric, obstetric, cardiothoracic, neurosurgical, transplant, and trauma. Anesthesiologists are credited with creating the first intensive care units (ICU),Reference Kelly, Fong and Hirsch 13 with anesthesiology being at one time the main training route to critical care medicine. Anesthesiologists are still required to train in critical care medicine and often comprise a major workforce in critical care units, which was evidenced prominently in the recent COVID-19 pandemic, providing us with abundant evidence of the skills, flexibility, adaptability, and overall value of anesthesiologists during crises. Anesthesiology staff were deployed throughout hospitals for perioperative care, critical care, airway and rapid response, and cardiac arrest teams.Reference Wang, Hastie and Wagener 14 Perioperative care areas were considered surge spaces, and during times of ventilator shortage, anesthesia machines were considered potential back-up ventilators.Reference Notz, Herrmann and Stumpner 15 , Reference Canelli, Spence and Kumar 16 , Reference Haina 17

Unlike multiple medical specialties that mainly practice in 1 area of the hospital such as the outpatient clinic or hospital ward or emergency department, anesthesiologists can be found throughout the hospital system. As the demand for sedation and anesthesia has grown, anesthesiologists routinely work in the ORs, interventional radiology and diagnostic radiology suites, gastroenterology suites, obstetric floors, and critical care units. Familiarity with these services and working relationships with their personnel promotes a broad knowledge base of hospital services, and requires excellent interprofessional communication, adaptability to different work environments, and stewardship for effective patient throughput and safe patient care.

Emergency Experience and Trauma Care

Anesthesiologists are broadly and expertly trained for emergency situations. Care of trauma patients is a routine part of the job of an anesthesiologist. Anesthesiologists are expected to manage unexpected complications related to surgery, pharmacology, and airway management, as well as patient comorbidities in areas as diverse as the operating room, the post anesthesia care unit (PACU), nonoperating room locations, and ICUs. Each area has a distinct set of resources in terms of space, staff, and supplies. Additionally, these issues occur at all times of the day and year when resources are further constrained. Thus, resource utilization and prioritization, a signature requirement during the mass casualty response, is routine practice for the anesthesiologist.

There are times of urgency in which the cause of patient instability is uncertain. In the OR, it is the anesthesiologist who manages and coordinates the strategy of treatment. Optimal team leadership requires expert communication and honors the input of all team members. For safer patient outcomes, anesthesiology has incorporated the principles of crisis resource management (CRM). Like the crew resource management that is a mandatory part of aviation team training, 18 anesthesiology adopted CRM training in the 1980s. 11 Although CRM training approaches are now common to many specialties,Reference Lei 19 the field of anesthesiology embraces this principle as a safety standard and a common training platform. The principles of CRM focus on individual and team behaviors in daily and crisis situations and are detailed in the textbox.

Crew/Crisis Resource Management (CRM) focuses on ensuring effective coordination, communication, and decision-making among responders to optimize outcomes. Key CRM principles include:

  1. 1. Training and Preparation

    • • Regular Drills: Simulated crisis exercises to practice CRM principles.

    • • Competency in Triage Systems: Ensuring familiarity with triage protocols.

    • • Crisis Resource Management Training: Integrating CRM principles into training programs for all team members.

  2. 2. Leadership and Decision-Making

    • • Role Clarity: Clearly defined roles and responsibilities.

    • • Incident Command System (ICS): Implementing ICS principles to facilitate coordinated action.

    • • Adaptive Leadership: Flexible, rapid decision-making, to prioritize tasks under changing conditions.

  3. 3. Communication

    • • Clear and Concise Information Sharing

    • • Standardized Communication Protocols: Using frameworks like SBAR or standardized radio procedures.

    • • Overcoming Communication Barriers: Addressing noise, stress, or language barriers.

  4. 4. Situational Awareness

    • • Big-Picture Awareness: Understanding the scope of the incident, available resources.

    • • Dynamic Risk Assessment: Continuously evaluating changing priorities as the situation evolves.

    • • Avoiding Tunnel Vision: Ensuring individuals and teams do not focus solely on specific tasks, losing sight of overall goals.

  5. 5. Teamwork and Collaboration

    • • Interdisciplinary Coordination: Seamless cooperation among hospital teams.

    • • Trust and Cohesion: Building mutual trust within the team to ensure efficient task delegation.

    • • Resource Sharing: Optimal allocation and sharing of limited resources.

  6. 6. Decision-Making Under Pressure

    • • Prioritization of Tasks: Focusing on actions with the greatest benefit, especially when resources are limited.

    • • Time-Sensitive Decisions: Making quick yet effective decisions to stabilize the situation and save lives.

  7. 7. Stress and Fatigue Management

    • • Managing Stress: Recognizing and addressing stress responses that can impair judgment.

    • • Fatigue Mitigation: Rotating staff to ensure sustained performance.

  8. 8. Debriefing and Feedback

    • • Post-Incident Analysis: Conducting debriefings to identify what went well and areas for improvement.

    • • Feedback Loops: Encouraging open communication about challenges faced during the incident to refine future responses.

In some countries, anesthesiologists are deployed to provide high-quality, life-preserving service in the pre-hospital phase of care – a vital component of MCI management. Adults with traumatic brain injury who were treated on-scene by anesthesiologists had better neurological outcomes and lower mortality than those treated by paramedics.Reference Pakkanen, Nurmi and Huhtala 20 In France, the world-renowned Service d’Aide Médicale Urgente requires that their mobile units be staffed by anesthesiologists.Reference Drouet 21 , Reference Drouet 22 Anesthesiologists can provide resuscitative care, triage, peripheral nerve blocks for pain relief, and other anesthesia services on the scene.Reference Spoelder, Slagt and Scheffer 23 Hence, national, state, regional, and local disaster management systems would be wise to utilize anesthesiologists in their planning and response. During MCIs, pediatric victims might be treated in adult facilities and vice-versa, like what occurred when a cargo truck drove into a crowd of people on Bastille Day in Nice, France.Reference Walker, d’Arville and Lacey 24 Anesthesiologists are trained to provide care for all age groups and can be an instrumental resource in these instances.

An example of anesthesiology trauma deployment during a ballistic terrorism MCI in Israel again demonstrates the clinical flexibility, adaptability, and value of anesthesiologists during an MCI. In the report by Shamir et al.,Reference Shamir, Weiss and Willner 25 anesthesiologists were forward deployed to the emergency department to help with airway management, vascular access, and emergency stabilization of trauma victims; to imaging suites including computed tomography (CT) scanners and angiography for provision of anesthesia to trauma patients; to ORs, ICUs, and to the PACU to provide care to pre- and postoperative patients; and to provide care in surge operating rooms or ICU overflow areas.

In a disaster, a country’s ability to provide adequate medical care may be overwhelmed. In these circumstances, foreign medical teams (FMT) might offer their assistance. The World Health Organization published a document 26 that describes the minimum standards that FMTs should meet. This document also classifies FMT according to their service capabilities. Type 2 and 3 teams provide surgical services and are required to have “basic anesthesia” and “high level adult and pediatric anesthesia,” respectively. Interestingly, there is no anesthesiologist among the authors of this document despite the provision of anesthesia being listed as a requirement for these FMTs. Rather, 2 emergency medicine physicians, a general surgeon, an orthopedic surgeon, and a quality improvement specialist are listed as authors, demonstrating that anesthesiologist involvement was overlooked, and the specialty’s importance perhaps underappreciated.

The role of the anesthesiologist in trauma care has been recognized by the American College of Surgeons (ACS). For a hospital to be designated as a Level 1 Trauma Center, ACS requires anesthesia services to be available within 15 minutes and requires an anesthesiologist liaison to the trauma program. 27 However, as hospital systems develop and implement MCI plans, the role of the anesthesiologist is often overlooked, minimized, or confined solely to OR. The Joint Commission requires hospitals to conduct biannual drills, but these are often focused on the emergency department and not the OR. Many in-hospital exercises involve only 1 department. 28 This lack of cohesive involvement on the hospital level is amplified by the dearth of education regarding MCI within academic anesthesiology departments, especially regarding biological and chemical incidents.Reference Candiotti, Kamat and Barach 29 In a poll of the members of the Society for Pediatric Anesthesia, most respondents at level 1 trauma centers reported having a mass casualty policy in place; however, the robustness of these policies is unknown and may only provide a communication tree to call in additional resources. Scant published data on disaster preparedness exists.Reference Gabbe, Veitch and Mather 30

Critical Skills for MCIs

An MCI is characterized by medical needs exceeding resources. The response requires that medical personnel perform tasks that may be outside their routine practice. Very few tasks required in the care of the mass casualty victim fall outside of the routine practice of the anesthesiologist, who can diagnose and stabilize the critically ill, place intravenous and arterial catheters, manage critical airways, prepare and administer medications, and set up and manage ventilators. Interestingly, anesthesiologists are the only physicians who personally transfuse blood products. Other specialties write orders and nurses administer the blood products.

In their daily practice, anesthesiologists are routinely called upon to assess and determine the patient’s readiness for surgery and to triage urgent/emergent cases as they present. Since 1941, the American Society of Anesthesiologists (ASA) physical classification score has been used to stratify a patient’s overall risk. 31 The anesthesiologist must have an understanding of the patient’s entire health composition and navigate the potentially competing needs of various disease processes, and as such, are experienced at triaging and assessing patients’ conditions in resource-restricted medical locations, such as during medical mission trips. 32 The anesthesiologist is called upon to diagnose, resuscitate, and treat all comorbidities and medical conditions that develop while under their care. Anesthesiologists regularly resuscitate and treat trauma patients and can quickly judge the severity of many surgical injuries and promptly start managing them.

During an MCI, there is a large potential for conflict and miscommunication. One of the simplest definitions of conflict describes the matter of 2 differing opinions. Anesthesiologists work in the extraordinarily complex operating room environment and regularly face unpredictable, everchanging situations while managing the multidisciplinary needs of the patient. The OR is one of the most volatile and complex working environments, where 2 physicians of equal status must share ownership of the same patient.Reference Attri, Sandhu and Mohan 33 , Reference Katz 34 It is partly due to this work environment that anesthesiologists have developed high-level communication and conflict resolution skills, as well as the ability to work within and lead multidisciplinary teams. Anesthesiologists also recognize that good teamwork is required to provide excellent, safe patient care.Reference Attri, Sandhu and Mohan 33 , Reference Katz 34 MCIs can be incredibly intense, stressful, and demanding, leading to a greater chance of miscommunication and conflict. Anesthesiologists are experienced and equipped to manage the competing demands of patients and care teams and can work efficiently within this unpredictable environment.

Conclusions

Anesthesiologists are crucial for the success of mass casualty mitigation, preparation, response, and recovery. Anesthesiologists must be included at a leadership level during hospital disaster response planning to ensure a smooth transition from the emergency room to the operating room. Participation in planning, tabletop exercises, and full-scale drills is necessary to build confidence in the anesthesiology team and reveal training and preparedness gaps. Anesthesiologists have been involved in small scale and hospital-wide MCI simulations and drills to improve planning and response, with positive results.Reference Schwengel, Divito and Burgess 35 , Reference Tallach, Schyma and Robinson 36 , Reference Gangadharan, Hayanga and Greenberg 37 Anesthesiologists are experts in simulation and possess organizational and communication skills that span hospital departments, translating to effective leadership in high pressure scenarios.Reference Brohi and Tallach 38 During an MCI, the anesthesiologist will serve as a vital resource in the command center, in the emergency department, in the triage area, in the operating room, in the recovery room, and in the ICU. The anesthesiologist can easily take on a variety of roles outside of the operating room including re-triage, creation of teams to perform intubations and line placement, stabilization of patients awaiting surgery, and assistance with critical care functions in the ICU if needed. 27 Indeed, in the aftermath of one such MCI in the UK, a hospital revised their MCI plan to include 3 valuable functions provided by anesthetists: “immediate trauma resuscitation, damage control anesthesia, and maintaining hospital safety.”Reference MacKinnon, Slater and Pukk-Härenstam 39 It would be to the detriment of the entire health care team to ignore the invaluable strengths, skills, and resources of anesthesiologists.

Anesthesiologists have proven their multifaceted role during the COVID-19 pandemic, working as part of the health care team to provide operating room anesthesia, critical care, leadership, and facilitating communication and collaboration across institutions.Reference van Klei, Hollmann and Sneyd 40 Anesthesiologists should be at the frontlines of planning and responding to MCIs. Durable and effective MCI planning requires all members of the hospital workforce to prepare in a cooperative fashion. Due to their pervasive presence throughout the hospital, broad training in emergency cases, resuscitation skills, CRM, and daily triage and team management, anesthesiologists should be considered essential leaders during MCI preparation and response. We acknowledge that the entire anesthesiology workforce needs education and active training on the topics of the incident command structure and surge management.Reference Hayanga, Barnett and Shallow 41 , Reference Gangadharan, Hayanga and Greenberg 37 , Reference Schwengel 42 However, their expertise in CRM; team dynamics; communication; repeated reassessment of situations; and familiarity with ORs, ICUs, PACUs, imaging suites, and procedure rooms makes them well prepared to be leaders in MCI management.

Funding statement

None.

Competing interests

None.

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Figure 1.Anesthesiologists regularly address crises and use principles of crisis resource management to ensure effective coordination, communication, and decision-making in a team-based environment. This approach ensures that all responders work cohesively to improve outcomes.