Evacuation priorities in mass casualty terror-related events: implications for contingency planning

Surgical Services and Transformation of Civil Hospital During “August War 2008” in Georgia

Structural transformation of a civil hospital into a military one during “August War 2008” (August 8–12) in Georgia is presented. Damage-control principles, such as hemorrhage control, liver-packing and abdominal tamponade, gastrointestinal tract resection without formation of anastomoses, and other temporary interventions were prioritized. This provided a chance to empty the hospital in a short period to provide the admission of an increased number of combat casualties. There were soldiers from Georgian troops, civilians, and captives of war. The number of total admitted patients was 739. Fifty-two patients were operated on in the surgery department. The following operations were carried out: removal of foreign bodies from the neck region, 6 cases; isolated thoracotomy, pulmorrhaphy, and drainage, 2 cases; laparotomy, hepatorrhaphy, gastrorrhaphy, splenectomy, resection of small intestine, and colostomy, 18 cases; combined operations (thoracotomy plus laparotomy), 9 cases; extended debridement and dressing of wounds, 11 cases; angiosurgical operations, 4 cases; and coloplasty, 2 cases. There were 2 cases of mortality, 1 case of rethoracotomy, and 3 cases of relaparotomy: 2 because of intracavital bleeding and 1 because of sanation.

[Blast lung injuries]

In armed conflicts and during terrorist attacks, explosive devices are a major cause of mortality. The lung is one of the organs most sensitive to blasts. Thus, today it is important that every GP at least knows the basics and practices regarding treatment of blast victims. We suggest, following a review of the explosions and an assessment of the current threats, detailing the lung injuries brought about by the explosions and the main treatments currently recommended.

Suicide bombings: process of care of mass casualties in the developing world

In recent times Pakistan's biggest city, Karachi, has witnessed numerous terrorist attacks. The city does not have an emergency response system and only one of the three public sector hospitals has a trauma centre. We describe the pattern of injuries and management of two terror-related mass casualty incidents involving suicide bombers in a developing nation with limited resources. The first incident occurred in May 2002 with 36 casualties, of whom 13 (36%) died immediately and 11 (30.5%) died at the primary receiving hospitals. The second incident was targeted against the local population in May 2004. The blast resulted in 104 casualties, of which 14 (13.46%) died at the site. All patients had their initial assessment and treatment based on Advanced Trauma and Life Support principles and documented on a trauma form.

Transforming an academic military treatment facility into a trauma center: lessons learned from Operation Iraqi Freedom

BACKGROUND

To manage the influx of patients with predominately extremity injuries from Operation Iraqi Freedom (OIF), our center was required to transform from a nontrauma academic hospital to a trauma hospital by using a multidisciplinary approach.

STUDY DESIGN

A retrospective chart review was performed of casualties from OIF who were received over 14 months.

RESULTS

A total of 313 casualties were received. The average number of admissions was 16 per month, except during November 2004, when there were 88 admissions over 7 days. The mean ISS for all patients was 14.1 +/- 10.3. A total of 113 patients (36%) required admission to the intensive care unit for an average of 7.5 +/- 5.2 days. The mean interval between injury and arrival in the continental United States was 6.5 +/- 4.6 days. Most casualties suffered multisystem trauma, with extremity injuries predominating. The multidisciplinary approach to casualty care consisted of several meetings a week and included everyone involved in caring for these combat casualties.

CONCLUSIONS

A multidisciplinary approach transformed an existing medical center into a trauma receiving hospital capable of managing and maintaining a surge in patient admissions resulting in minimal morbidity and mortality. This model further supports a multidisciplinary approach to trauma care and could serve as a guideline for transforming existing medical centers into trauma receiving hospitals to deal with patient overflow in the event of future civilian mass casualties.

Israeli hospital preparedness for terrorism-related multiple casualty incidents: can the surge capacity and injury severity distribution be better predicted?

BACKGROUND

The incidence of large-scale urban attacks on civilian populations has significantly increased across the globe over the past decade. These incidents often result in Hospital Multiple Casualty Incidents (HMCI), which are very challenging to hospital teams. 15 years ago the Emergency and Disaster Medicine Division in the Israeli Ministry of Health defined a key of 20 percent of each hospital's bed capacity as its readiness for multiple casualties. Half of those casualties are expected to require immediate medical treatment. This study was performed to evaluate the efficacy of the current readiness guidelines based on the epidemiology of encountered HMCIs.

METHODS

A retrospective study of HMCIs was recorded in the Israeli Defense Force (IDF) home front command and the Israeli National Trauma Registry (ITR) between November 2000 and June 2003. An HMCI is defined by the Emergency and Disaster Medicine Division in the Israeli Ministry of Health as >or=10 casualties or >or=4 suffering from injuries with an ISS>or=16 arriving to a single hospital.

RESULTS

The study includes a total of 32 attacks, resulting in 62 HMCIs and 1292 casualties. The mean number of arriving casualties to a single hospital was 20.8+/-13.3 (range 4-56, median 16.5). In 95% of the HMCIs the casualty load was <or=52. Based on severity scores and ED discharges 1022 (79.2%) casualties did not necessitate immediate medical treatment.

CONCLUSION

Hospital preparedness can be better defined by a fixed number of casualties rather than a percentile of its bed capacity. Only 20% of the arriving casualties will require immediate medical treatment. Implementation of this concept may improve the utilisation of national emergency health resources both in the preparation phase and on real time.

Impact of military conflict on a civilian receiving hospital in a war zone

OBJECTIVE

To study the impact of war on the workload/finances of a community hospital adjacent to the front.

SUMMARY BACKGROUND DATA

Community hospitals located nearby/within military conflict zones treat trauma casualties while providing routine surgical services to the community.

METHODS

Observational study conducted in Ziv hospital (1 of 3 designated receiving hospitals during the second Lebanon War (12/7/2006-14/8/2006). Data were documented in real-time and retrieved retrospectively from computerized databases.

RESULTS

Ziv treated 1509 military/civilian casualties. Seven percent were at least moderately injured. 27.5% of the casualties required admission, preferentially to surgical wards. Critical mortality rate was 7%. There were 48 secondary transfers, half from the department of emergency medicine (ED) and half after in-hospital stabilization/emergency surgery including 7 to free intensive care (ICU) beds to accommodate expected casualties. The General Surgery department (GSD) performed 81 operating room (OR) procedures, including explorations/debridements for casualties (n = 24, 0-3 per-day), laparotomies for acute abdomen (n = 33) and cancer surgery (n = 11).Compared with previous/later years, there were 23% more trauma casualties presenting to the ED and an increased OR workload for Orthopedic surgery. Decreases occurred in the number of elective and emergency admissions (10%), obstetric deliveries (28%), OR procedures (33%), GSD OR procedures (44%), hospital revenues (up to 43%), yearly hospitalization days (7%), number of hospitalized patients, bed occupancy rates, and visits to outpatient clinics (all 5%).

CONCLUSIONS

Treatment of civilian/military casualties resulted in reorganization of hospital operations with significantly decreased accrued revenue. The bulk of the GSD workload shifts from the OR to the ED/wards while Orthopedic procedures and ICU beds become bottlenecks to patient flow during war.

[Diagnostic imaging departments' responses to terrorist attempts with multiple victims.]

OBJECTIVES

To analyze whether the radiological management of seriously injured victims from the March 11 terrorist attempt was affected by the large number of victims treated at two hospitals in Madrid. To evaluate the organization for providing imaging services, detect failings, and propose a protocol for diagnostic imaging departments.

MATERIAL AND METHODS

Two hundred and fifty one patients arrived at hospital A and 36 at hospital B. Both centers have emergency imaging areas and protocols for the treatment of patients with multiple trauma. We compared organizational aspects (classification, identification), material resources, human resources, healthcare resources (number and type of examinations), as well as the initial radiological management with the usual protocol and with the recommendations for incidents with multiple victims.

RESULTS

In hospital A, patients' injuries were classified as severe (175) or minor (76); in hospital B, injuries were classified as extremely severe (13), severe (4), or minor (19). Additional staff were assigned to the emergency imaging areas in both hospitals. In hospital A, 62 portable plain-film radiographs, 39 ultrasonographic examinations, 25 cranial CT examinations, 6 cervical CT examinations, 2 chest CT examinations, and 2 abdominopelvic CT examinations were performed. In hospital B, 19 portable plain-film radiographs (74 in total), 9 ultrasonographic examinations, 17 cranial-chest-abdominopelvic CT examinations, 2 cervical CT examinations, 2 orbital CT examinations, and 2 CT examinations of the sinuses were performed.

CONCLUSION

In both hospitals, each victim was managed as if he or she were the only patient. The discrepancies between the two hospitals were due to differences in the usual protocol for multiple trauma patients. In light of the organizational errors discovered, we propose a plan of action based on the identification and progressive activation of material and human resources until sufficient levels are achieved.

Evaluation of a CT triage protocol for mass casualty incidents: results from two large-scale exercises

The purpose of this study was to evaluate the feasibility, stability, and reproducibility of a dedicated CT protocol for the triage of patients in two separate large-scale exercises that simulated a mass casualty incident (MCI). In both exercises, a bomb explosion at the local soccer stadium that had caused about 100 casualties was simulated. Seven casualties who were rated "critical" by on-site field triage were admitted to the emergency department and underwent whole-body CT. The CT workflow was simulated with phantoms. The history of the casualties was matched to existing CT examinations that were used for evaluation of image reading under MCI conditions. The times needed for transfer and preparation of patients, examination, image reconstruction, total time in the CT examination room, image transfer to PACS, and image reading were recorded, and mean capacities were calculated and compared using the Mann-Whitney U test. We found no significant time differences in transfer and preparation of patients, duration of CT data acquisition, image reconstruction, total time in the CT room, and reading of the images. The calculated capacities per hour were 9.4 vs. 9.8 for examinations completed, and 8.2 vs. 7.2 for reports completed. In conclusion, CT triage is feasible and produced constant results with this dedicated and fast protocol.

Musculoskeletal injuries in terrorist attacks--a comparison between the injuries sustained and those related to motor vehicle accidents, based on a national registry database

Terror-related injuries are becoming more prevalent. The predominant mechanism of damage is related to blast effects. These include penetrating injury due to material in the explosives and blunt trauma due to objects falling after detonation. However, the more commonly encountered severe trauma in civilian centres is related to motor vehicle accidents. A comparison between the two, although problematic, might enhance the knowledge of orthopaedic traumatologists dealing with these injuries. Thus 1072 in-patients, treated in levels I and II centres in Israel for orthopaedic injuries due to terrorist attack from November 2000 to December 2003, were compared with 9714 similar in-patients injured in motor vehicle accidents (controls). Analysis included age, gender, severity of injuries, diagnoses, lengths of intensive care unit and hospital stay, operations and mortality. The victims of terrorist attack included significantly more young adults, males, severe associated injuries and operations, and increased lengths of stay and mortality. Prompt recognition and awareness of the unique character of terror-related injuries is required.

Mass-casualty incidents: how does an ICU prepare?

Despite the ever-present risk of mass-casualty incidents (MCIs) in all geographical regions, there is a limited body of literature detailing specifically how an intensive care unit (ICU) prepares for such an event. When responding to an overwhelming volume of severely injured victims, the intensivist must make a paradigm shift away from providing complete care to all patients to one of preferentially administering care to those with the greatest likelihood of survival. To do this effectively, ICU directors must possess a detailed understanding of the entire disaster response, including organization, triage, staffing, and treatment. This article provides a comprehensive review of each of these topics, as well as a framework on specific elements of critical care and treatment based on published literature and expert opinion to assist the clinician in directing care to where it is most appropriate.

Magen David Adom—The EMS in Israel

Israel is a small country with a population of around 7 million. The sole EMS provider for Israel is Magen David Adom (MDA) (translated as 'Red Shield of David'). MDA also carries out the functions of a National Society (similar to the Red Cross) and provides all the blood and blood product services for the country. Nationwide, the organisation responds to over 1000 emergency calls a day and uses doctors, paramedics, emergency medical technicians and volunteers. Local geopolitics has meant that MDA has to be prepared for anything from everyday emergency calls to suicide bombings and regional wars. MDA also prides itself in being able to rapidly assemble and dispatch mobile aid teams to scenes of international disasters. Such a broad range of activities is unusual for a single EMS organisation.

Distribution of maxillofacial injuries in terrorist attacks

Terrorist attacks have been occurring in Israel since the early 1970s. Israeli oral and maxillofacial surgeons are involved in the treatment of victims, because facial injuries are generally present after these attacks. Facial wounds are caused by blocks and stone throwing, stabbings, gunshots, and suicide bombings. The characteristics of each type of injury and their treatment are described.

The significance of a small, level-3 'semi evacuation' hospital in a terrorist attack in a nearby town

Terrorist attacks can occur in remote areas causing mass-casualty incidents MCIs far away from level-1 trauma centres. This study draws lessons from an MCI pertaining to the management of primary and secondary evacuation and the operational mode practiced. Data was collected from formal debriefings during and after the event, and the medical response, interactions and main outcomes analysed using Disastrous Incidents Systematic Analysis through Components, Interactions and Results (DISAST-CIR) methodology. A total of 112 people were evacuated from the scene-66 to the nearby level 3 Laniado hospital, including the eight critically and severely injured patients. Laniado hospital was instructed to act as an evacuation hospital but the flow of patients ended rapidly and it was decided to admit moderately injured victims. We introduce a novel concept of a 'semi-evacuation hospital'. This mode of operation should be selected for small-scale events in which the evacuation hospital has hospitalization capacity and is not geographically isolated. We suggest that level-3 hospitals in remote areas should be prepared and drilled to work in semi-evacuation mode during MCIs.

Civilian hospital response to a mass casualty event: the role of the intensive care unit

BACKGROUND

We studied the response of the Shaare Zedek Medical Center (SZMC) in Jerusalem, Israel, to terrorist multiple- or mass-casualty events (TMCEs) that occurred between 1983 and 2004, to document the role of the intensive care unit (ICU) in this response.

METHODS

The SZMC Disaster Plan was reviewed in detail. Hospital and ICU records were retrospectively reviewed for all patients presenting to SZMC between 1983 and 2004 after a TMCE. Data were coded for age, sex, injuries, length of stay, and mortality.

RESULTS

Eight hundred seventy-five patients presented to SZMC after 31 TMCEs. The number of patients presenting ranged from 1 to 84 with an average of 28 patients per TMCE. Forty-one (4.7%) of the patients were admitted to the ICU. The age of the ICU patients ranged from 4 to 80 with an average of 30.9 years. Twenty-nine (70%) of the patients had blast lung injury, 3 (7%) had intestinal blast injury, and 30 (73%) had ruptured tympanic membranes. Forty-two surgical procedures were performed in 23 patients. Thirty (73%) patients required mechanical ventilation. One patient (2.4%) died of multiple organ failure caused by a delay in diagnosis of intestinal blast injury.

CONCLUSION

Of the patients presenting to SZMC after TMCE, 4.7% required ICU care. Seventy-three percent of the ICU patients required mechanical ventilation. The ICU plays a critical role in the SZMC response to TMCEs.

The Approach to Suicide Bombing Attacks: Changing Concepts

Suicide bombing attacks have emerged as a lethal weapon in the hands of terrorist groups. Our aim was to review the medical experience acquired in Israel, Spain, the United Kingdom and the United States in managing terrorist attacks, and prepare medical systems for the difficult task of managing these events. EMS protocols are amended to deal with a large number of victims in an urban setting who must be rapidly evacuated to a medical center where resuscitative as well as definitive care is delivered. A combination of extensive soft tissue damage caused by penetrating injuries, blast injury to the lungs and tympanic membranes, and burns are common among survivors. Preparation must include establishment of a clear chain-of-command lead by a general surgeon who manages the event and is responsible for decisions regarding OR preferences and ICU admissions. The emergency department is re-organized to handle the influx of numerous severely injured casualties. Professional personnel and resources are recruited and re-directed away from routine tasks towards treating the victims. This is achieved by deferring non-urgent operations, procedures and imaging studies. Victims are frequently re-assessed and re-evaluated to control chaos, minimize missed injuries and ensure delivery of an adequate level of care.

Significance of a Level-2, "selective, secondary evacuation" hospital during a peripheral town terrorist attack

INTRODUCTION

Mass-casualty incidents (MCIs) can occur outside of major metropolitan areas. In such circumstances, the nearest hospital seldom is a Level-1 Trauma Center. Moreover, emergency medical services (EMS) capabilities in such areas tend to be limited, which may compromise prehospital care and evacuation speed. The objective of this study was to extract lessons learned from the medical response to a terrorist event that occurred in the marketplace of a small Israeli town on 26 October 2005. The lessons pertain to the management of primary and secondary evacuation and the operational practices by the only hospital in the town, which is designated as a Level-2 Trauma Center.

METHODS

Data were collected during the event by Home Front Command Medical Department personnel. After the event, formal and informal debriefings were conducted with EMS personnel, the hospitals involved, and the Ministry of Health. The medical response components, interactions (mainly primary triage and secondary distribution), and the principal outcomes were analyzed. The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) methodology.

RESULTS

The suicide bomber and four victims died at the scene, and two severely injured patients later died in the hospital. A total of 58 wounded persons were evacuated, including eight severely injured, two moderately injured, and 48 mildly injured. Forty-nine of the wounded arrived to the nearby Hillel Yafe Hospital, including all eight of the severely injured victims, the two moderately injured, and 39 of the mildly injured. Most of the mildly injured victims were evacuated in private cars by bystanders. Five other area hospitals were alerted, three of which primarily received the mildly injured victims. Two distant, Level-1 Trauma Centers also were alerted; each received one severely injured patient from Hillel Yafe Hospital during the secondary distribution process. Emergency medical services personnel were able to treat and evacuate all severely and moderately injured patients within 17 minutes of the explosion. A total of 12 of the 21 ambulances arriving on-scene within the first 20 minutes were staffed by EMS volunteers or off-duty workers.

CONCLUSION

When a MCI occurs in a small town that is in the vicinity of a Level-2 Trauma Center, and located a > 40 minute drive from Level-1 Trauma Centers, the Level-2 Trauma Center is a critical component in medical management of the event. All severely and moderately injured patients initially should be evacuated to the Level-2 Trauma Center, and given advanced, hospital-based resuscitation. The patients needing care beyond the capabilities of this facility should be distributed secondarily to Level-1 Trauma Centers. To alleviate the burden placed on the local hospital, some of the mildly injured victims can be evacuated primarily to more distant hospitals. The ability to control the flow of mildly injured patients is limited by the large percentage of them arriving by private cars. The availability of EMS in small towns can be augmented significantly by enrolling off-duty EMS workers and volunteers to the rescue effort. Level-2 hospitals in small towns should be prepared and drilled to operate in a "selective evacuation" mode during MCIs.

Mortality in terrorist attacks: a unique modal of temporal death distribution

BACKGROUND

Terror-related multiple casualty incidents (MCI) in Israel since September 2000 have resulted in a new pattern of injury as a result of the mechanisms of trauma. The objective of this study was to asses the temporal death distribution among the civilian casualties in the Jerusalem vicinity during a 3-year period.

METHODS

All terrorist attacks in the Jerusalem district from September 2000 to September 2003 were included in this study. The data of all deaths were processed including the time of the attack, the evacuation time to the hospitals, and the time of death.

RESULTS

During the study period 28 terror-related MCI occurred. A total of 2328 victims were injured and 273 died, for an overall fatality rate of 11.7%. A unique temporal death distribution was identified; 82.8% of the deaths occurred immediately, at the scene of the attack (scene death); of the remaining 17.2% of patients who died in the hospital, half died within 4 hours of arrival (immediate death), one quarter within 5-24 hours (early death), and one quarter later than that (late death). The temporal death distribution was significantly different when classifying the mechanism of trauma to suicide bombings versus shooting. The scene mortality was higher in the suicide bombings than in shooting attacks (86.7% versus 77%, P = 0.039 ). In contrast, the mortality within 1-24 hours was higher in the shooting attacks (17% versus 6.3%, P = 0.05).

CONCLUSIONS

Terror-related MCI occurring in civilian settings have a unique temporal death distribution. A very high scene mortality is seen compared to the classical description of Donald Trunkey1 in 1983. The late deaths, which composed 30% of the mortality in civilian settings, comprise only 4.4% of the total mortality in MCIs. A rough estimate of the in-hospital mortality could be achieved after the first 4 hours, allowing the assessment and distribution of hospital resources. Futile care should be identified early and availability of ICU beds can be calculated according to the immediate mortality.

Mass casualty incident after the Taba terrorist attack: an organisational and medical challenge

Two suicide bombings in and around Taba, Egypt, on 7 October 2004 created a complex medical and organisational situation. Since most victims were Israeli tourists, the National Emergency and Disaster Management Division handled their evacuation and treatment. This paper describes the event chronologically, as well as the organisational and management challenges confronted and applied solutions. Forty-nine emergency personnel and physicians were flown early to the disaster area to reinforce scarce local medical resources. Two hundred casualties were recorded: 32 dead and 168 injured. Eilat hospital was transformed into a triage facility. Thirty-two seriously injured patients were flown to two remote trauma centres in central Israel. Management of mass casualty incidents is difficult when local resources are inadequate. An effective response should include: rapid transportation of experienced trauma teams to the disaster zone; conversion of local medical amenities into a triage centre; and rapid evacuation of the seriously injured to higher level medical facilities.

Suicide bombers form a new injury profile

BACKGROUND

Recent explosions of suicide bombers introduced new and unique profiles of injury. Explosives frequently included small metal parts, increasing severity of injuries, challenging both physicians and healthcare systems. Timely detonation in crowded and confined spaces further increased explosion effect.

METHODS

Israel National Trauma Registry data on hospitalized terror casualties between October 1, 2000 and December 31, 2004 were analyzed.

RESULTS

A total of 1155 patients injured by explosion were studied. Nearly 30% suffered severe to critical injuries (ISS > or = 16); severe injuries (AIS > or = 3) were more prevalent than in other trauma. Triage has changed as metal parts contained in bombs penetrate the human body with great force and may result in tiny entry wounds easily concealed by hair, clothes etc. A total of 36.6% had a computed tomography (CT), 26.8% had ultrasound scanning, and 53.2% had an x-ray in the emergency department. From the emergency department, 28.3% went directly to the operating room, 10.1% to the intensive care unit, and 58.4% directly to the ward. Injuries were mostly internal, open wounds, and burns, with an excess of injuries to nerves and to blood vessels compared with other trauma mechanisms. A high rate of surgical procedures was recorded, including thoracotomies, laparotomies, craniotomies, and vascular surgery. In certain cases, there were simultaneous multiple injuries that required competing forms of treatment, such as burns and blast lung.

CONCLUSIONS

Bombs containing metal fragments detonated by suicide bombers in crowded locations change patterns and severity of injury in a civil population. Specific injuries will require tailored approaches, an open mind, and close collaboration and cooperation between trauma surgeons to share experience, opinions, and ideas. Findings presented have implications for triage, diagnosis, treatment, hospital organization, and the definition of surge capacity.

Civilian preparedness and counter-terrorism: conventional weapons

Most terrorist attacks involve conventional weapons. These explosive devices produce injury patterns that are sometimes predict-able. The chaos produced from these weapons can be greatly reduced with prior planning, response practice, and realization by the entire medical community of the need to participate in preparation for these devastating events.

Unstable Ethical Plateaus and Disaster Triage

Disasters are defined medically as mass casualty incidents in which the number of patients presenting during a given time period exceeds the capacity of the responders to render effective care in a timely manner. During such circumstances, triage is instituted to allocate scarce medical resources. Current disaster triage attempts to do the most for the most, with the least amount of resources. This article reviews the nature of disasters from the standpoint of immediate medical need, and places into an ethics framework currently proposed utilitarian triage schema for prioritizing medical care of surviving disaster victims. Specific questions include whether resources truly are limited, whether specific numbers should dictate disaster response, and whether triage decisions should be based on age or social worth. The primary question the authors pose is whether disaster triage, as currently advocated and practiced in the western world, is actually ethical.

Responding to Challenges in Modern Combat Casualty Care: Innovative Use of Advanced Regional Anesthesia

BACKGROUND

The war in Iraq has resulted in a high incidence of severe extremity injury requiring multiple surgical procedures and extensive rehabilitation. We describe the use of advanced regional anesthesia to meet this significant medical challenge.

METHODS

From March 2003 to December 2004, 4,100 casualties have been evacuated to Walter Reed Army Medical Center (WRAMC). Of 1,400 inpatients, 750 have been battle-injured with 500 having extremity injuries. Of these, 287 (57%) received surgical care incorporating regional anesthesia including single-injection peripheral nerve blocks and continuous peripheral and epidural infusion catheters. Wounding, surgical, anesthetic, and outcomes data have been prospectively collected.

RESULTS

Over 900 operations (mean 4+/-2/patient) were performed on 287 casualties prior to arrival at WRAMC, and 634 operations (mean 2+/-1/patient) were performed at WRAMC. Thirty-five percent of this cohort was amputees. In the study group, 646 advanced regional anesthesia procedures, including 361 continuous peripheral nerve blocks (CPNBs), were performed with a mean catheter infusion time of 9 days (1-34). Catheter-related complications occurred in 11.9% of casualties and were technical or minor in nature. Catheter-related infection rate was 1.9%. In 126 casualties with indwelling CPNB catheters, a significant decrease in pain score over 7 days was apparent (mean 3.7+/-0.2 to 2.2+/-0.2, P<0.001).

CONCLUSION

Advanced regional anesthetic techniques allowed for safe perioperative surgical anesthesia and analgesia in the management of the modern combat casualty.

Development of an accelerated MSCT protocol (Triage MSCT) for mass casualty incidents: comparison to MSCT for single-trauma patients

During multiple casualty incidents (MCI) emergency radiology departments have to deal with a large number of patients with suspected severe trauma within a short period of time. The aim of this study was to develop a suitable accelerated multislice computed tomography (MSCT) protocol to increase patient throughput for this kind of emergency situation. We presumed a scenario of 15 patients being admitted to the trauma service with suspicion of severe injuries after a MCI over a period of 2 h. An accelerated Triage MSCT protocol was developed and evaluated for MSCT scanner productivity (patients per hour) and time (minutes) needed for a total MSCT body workup using an anthropomorphic phantom. In addition, time (minutes) for transfer and preparation was measured. These timeframes were compared to a control group consisting of 144 single patients with multiple trauma undergoing standard MSCT according to our trauma room protocol. All MSCT studies were conducted using a 4-detector row scanner. (1) For the study group (Triage MSCT), average time for patient transfer and preparation was 2.9 min (2.5-4.3 min), mean CT examination time was 2.1 min (1.7-2.4 min); image reconstruction took 4.0 min (3.3-4.3 min). Total time in scanner room was 8.9 min (7.7-11.3 min), resulting in a maximal productivity of 6.7 patients per hour. Image transfer to the digital picture archive and communication system archive was completed after an average 9.5 min (8.9-10.8 min). (2) For the control group (single casualty MSCT), the mean time for patient transfer and preparation was 20.4 min (9.0-39.2 min), mean examination time was 6.0 min (3.1-11.3 min). Times for image reconstructions were not recorded in the patient series. Mean total time in scanner room was 25.3 min (11.0-72.4 min), resulting in a patient throughput of 2.4 patients per hour. MSCT has potential to serve as a powerful tool in triage of multiple casualty patients. The introduction of a Triage MSCT scanning protocol resulted in an increase of patient throughput per hour by a factor of almost 3.

Suicide bombing attacks: Can external signs predict internal injuries?

OBJECTIVE

To report the distribution and types of injuries in victims of suicide bombing attacks and to identify external signs that would guide triage and initial management.

SUMMARY BACKGROUND DATA

There is a need for information on the degree to which external injuries indicate internal injuries requiring emergency triage.

METHODS

The medical charts and the trauma registry database of all patients who were admitted to the Hadassah Hospital in Jerusalem from August 2001 to August 2004 following a suicide bombing attack were reviewed and analyzed for injury characteristics, number of body areas injured, presence of blast lung injury (BLI), and need for therapeutic laparotomy. Logistic analysis was performed to identify predictors of BLI and intra-abdominal injury.

RESULTS

The study population consisted of 154 patients who were injured as a result of 17 attacks. Twenty-eight patients suffered from BLI (18.2%) and 13 patients (8.4%) underwent therapeutic laparotomy. Patients with penetrating head injury and those with > or =4 body areas injured were significantly more likely to suffer from BLI (odds ratio, 3.47 and 4.12, respectively, P < 0.05). Patients with penetrating torso injury and those with > or =4 body areas injured were significantly more likely to suffer from intra-abdominal injury (odds ratio, 22.27 and 4.89, respectively, P < 0.05).

CONCLUSION

Easily recognizable external signs of trauma can be used to predict the occurrence of BLI and intra-abdominal injury. The importance of these signs needs to be incorporated into triage protocols and used to direct victims to the appropriate level of care both from the scene and in the hospital.

Are Surgical Residents Prepared for Mass Casualty Incidents?

OBJECTIVE

We hypothesized that resident education is inadequate with respect to management of mass casualty incidents that may involve chemical, biological, and nuclear exposures.

METHODS

Chief level residents in surgery (n = 10), emergency medicine (n = 10), and anesthesia (n = 8) were asked to complete a survey questionnaire. Responses were tabulated and statistically analyzed with Mann-Whitney Rank Sum, Student's t test, and Kruskal-Wallis one-way analysis of variance.

RESULTS

All of the residents were similar with respect to age, sex, and intended setting of clinical practice. Only a single resident reported military experience. Two residents (7.1%) had administered medical care while wearing a protective suit. Compared with emergency medicine residents, surgical residents reported significantly less formal teaching in mass casual incidents (P = 0.02), trauma triage (P = 0.01), and nuclear, biological, chemical agents (P = 0.002). When surgical residents were compared with anesthesia residents, there was significantly less training for surgical residents in nuclear, chemical, and biological agents (P = 0.02). Multiple/mass casualty incident experience did not differ between residents. However, the most common incident involved only three to five patients with blunt trauma. Emergency medicine residents were significantly more comfortable in treating patients with exposure to anthrax (P = 0.01), sarin (P = 0.04), and nuclear exposure (P = 0.01).

CONCLUSIONS

Surgical residents have significantly less formal training in mass casualties, triage, and chemical, biological, and nuclear exposures than residents in other specialties. Therefore, surgical residents are less comfortable treating these types of patients. Because surgeons often are expected to take leadership roles in mass casualty incidents, surgical education should be modified to match or exceed that of other specialties.

In-hospital resource utilization during multiple casualty incidents

OBJECTIVE

To suggest guidelines for hospital organization during terror-related multiple casualty incidents (MCIs) based on the experience of 6 level I trauma centers.

SUMMARY BACKGROUND DATA

Most terror-related MCIs are bombings. The sporadic nature of these events complicates in-hospital preparation.

METHODS

Data were collected at all level I Trauma centers during/after MCIs for the Israel National Trauma registry. Patients were included if they were admitted or died in hospital following injury in suicide bombings (October 1, 2000 to June 30, 2003), which fulfilled Ministry of Health suggested criteria for MCIs (number of admissions, severity of injury).

RESULTS

Included were 325 casualties from 32 events, 34% of which had an Injury Severity Score >16. A third of the admissions arrived within 10 minutes and 65% within 30 minutes. Forty percent of the patients underwent CT scans directly from the ED. Operative procedures were performed on 60% of patients and 36% were transferred directly from the ED to the OR. Initiation of surgical procedures peaked at 1 to 1.5 hours, mainly multidisciplinary abdominal, thoracic, and vascular surgery. Orthopedic and plastic surgery predominated later. A third of the patients were admitted to ICUs, often (31%) directly from the ED.

CONCLUSIONS

High staffing demands for ED, OR, and ICU overlap. Anesthesiologists, general, thoracic, and vascular surgeons are in immediate demand. ICU admissions occur simultaneously with ongoing patient arrival to the ED. Most patients operated within the first 2 hours require multidisciplinary surgical teams. Demand for orthopedic and plastic surgery and anesthesiology services continues for >24 hours.

An integrated physical dispersion and behavioral response model for risk assessment of radiological dispersion device (RDD) events

A radiological dispersion device (RDD) or "dirty" bomb is a conventional explosive wrapped in radiological material. Terrorists may use an RDD to disperse radioactive material across a populated area, causing casualties and/or economic damage. Nearly all risk assessment models for RDDs make unrealistic assumptions about public behavior in their health assessments, including assumptions that the public would stand outside in a single location indefinitely. In this article, we describe an approach for assessing the risks of RDD events incorporating both physical dispersion and behavioral response variables. The general approach is tested using the City of Pittsburgh, Pennsylvania as a case study. Atmospheric models simulate an RDD attack and its likely fallout, while radiation exposure models assess fatal cancer risk. We model different geographical distributions of the population based on time of day. We evaluate aggregate health impacts for different public responses (i.e., sheltering-in-place, evacuating). We find that current RDD models in use can be improved with the integration of behavioral components. Using the results from the model, we show how risk varies across several behavioral and physical variables. We show that the best policy to recommend to the public depends on many different variables, such as the amount of trauma at ground zero, the capability of emergency responders to get trauma victims to local hospitals quickly and efficiently, how quickly evacuations can take place in the city, and the amount of shielding available for shelterers. Using a parametric analysis, we develop behaviorally realistic risk assessments, we identify variables that can affect an optimal risk reduction policy, and we find that decision making can be improved by evaluating the tradeoff between trauma and cancer fatalities for various RDD scenarios before they occur.

Conventional terrorist bomb incidents and the intensive care unit

PURPOSE OF REVIEW

A terror bombing creates a momentary stress on acute care services, including the emergency medical system, emergency departments, and intensive care units. A knowledge of the progression of events, the anticipated volume of injured survivors, and the pattern of injuries will enable the physician in the intensive care unit to prepare the unit quickly and efficiently for the expected rush of injured survivors.

RECENT FINDINGS

In the past 2 years it has become apparent in the medical literature that terror bombing causes more complicated injuries than other types of trauma. The injuries are a combination of blast, penetrating, and blunt trauma, as well as burns. As a result, a significant number of patients will need care in the intensive care unit for a long time. Treating these injuries mandates an understanding of the combination of injury mechanisms because the ideal treatment for one mechanism might cause harm if another coexists. In addition, recent literature delineates the volume of admissions an intensive care unit should anticipate. This information should allow the preparation of sufficient vacant intensive care unit beds and facilitate the efficient use of equipment and personnel.

SUMMARY

This review, based on recently published data, aims to provide the intensive care unit physician with crucial information about the anticipated progression of events, the possible numbers of patients, and the nature of their injuries after a terrorist bombing. This information should aid in rational crisis planning.

Clinical review: the Israeli experience: conventional terrorism and critical care

Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for critically injured patients. To do so we have developed a highly flexible operational system for managing the general intensive care unit (GICU). The focus of this review will be on the organizational steps needed to provide operational flexibility, emphasizing the importance of forward deployment of intensive care unit personnel to the trauma bay and emergency room and the existence of a chain of command to limit chaos. A retrospective review of the hospital's response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical center's trauma registry and from GICU patient admission and discharge records. Patients are described with regard to the severity and type of injury. The organizational work within intensive care is described. Finally, specific issues related to the diagnosis and management of lung, brain, orthopedic and abdominal injuries, caused by bomb blast events associated with shrapnel, are described. This review emphasizes the importance of a multidisciplinary team approach in caring for these patients.

How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis

BACKGROUND

The aim of this modeling study was to examine how casualty load affects the level of trauma care in multiple casualty incidents and to define the surge capacity of the hospital trauma assets.

METHODS

The disaster plan of a U.S. Level I trauma center was translated into a computer model and challenged with simulated casualties based on 223 patients from 22 bombing incidents treated at an Israeli hospital. The model assigns providers and facilities to casualties and computes the level of care for each critical casualty from six variables that reflect the composition of the trauma team and access to facilities.

RESULTS

The model predicts a sigmoid-shaped relationship between casualty load and the level of care, with the upper flat portion of the curve corresponding to the surge capacity of the trauma assets of the hospital. This capacity is 4.6 critical patients per hour using immediately available assets. A fully deployed disaster plan shifts the curve to the right, increasing the surge capacity to 7.1. Overtriage rates of 50% and 75% shift the curve to the left, decreasing the surge capacity to 3.8 and 2.7, respectively.

CONCLUSION

This model defines the quantitative relationship between an increasing casualty load and gradual degradation of the level of trauma care in multiple casualty incidents, and defines the surge capacity of the hospital trauma assets as a rate of casualty arrival rather than a number of beds. The study demonstrates the value of dynamic computer modeling as an important tool in disaster planning.

[General surgery]

Terrorist explosions with multiple victims produce disaster situations that test health systems' ability to respond. The Gregorio Maranon University Hospital attended more than 300 victims within a few hours. Most of these victims had mild or moderate lesions, although 29 patients arrived in a serious or critical condition. In the first 24 hours, 37 major surgical interventions were performed in 34 patients. Of these, patients 7 underwent laparotomy, 2 of which were negative and one was non-therapeutic. One patient died during reintervention for damage limitation. Three angiographic embolizations were performed for bleeding of the intercostal artery, liver and liver-spleen, respectively and hemostasis was achieved in all three patients. The most common lesions and visceral injuries in particular were similar to those described in previous reports of similar situations. We reflect on our experience and discuss data from the literature.

[Orthopedic surgery and traumatology]

Terrorist explosions cause destruction of material goods and human injury on such a scale that the provision of healthcare in available centers can be compromised. In the last few years we have witnessed terrible terrorist attacks that affect us increasingly closely. The authors describe the intervention of the Department of Traumatology of a university hospital in response to a terrorist attack that left nearly 2,000 persons wounded and 191 dead. As usually occurs in these attacks, the victims' lesions were characterized by the severity and extension of the tissue damage, including penetrating wounds, blast injuries and burns. Critical analysis of previous disasters described by our colleagues in the medical literature is useful to avoid future errors.

[Medical-surgical emergency department]

We describe and analyze the response of the emergency department (ED) to the events of 11 March, 2004. The ED played a major role in the care of victims who survived the initial explosions. Of the 976 victims transferred to hospital that day, 325 (32%) were attended in the ED of the Gregorio Maranon University Hospital. Nine percent were critically ill and only 5 died. The first step was to evaluate and transfer the 123 patients who were already in the ED when the explosions took place, thus freeing the emergency area. Victim triage was organized in three stages: external triage, triage in the ED, and a third triage in the critical care unit. The emergency areas were reclassified into resuscitation, major trauma and minor trauma. There were no staff shortages as personnel spontaneously volunteered. Finally, the main factors related to the success of the interventions, as well as the deficiencies found, are discussed.

Managing a Combined Burn Trauma Disaster in the Post-9/11 World: Lessons Learned from the 2003 West Pharmaceutical Plant Explosion

At 1:37 pm on January 29, 2003, an explosion occurred at the West Pharmaceutical chemical plant in Kinston, North Carolina. The explosion killed three people at the scene and resulted in more than 30 admissions to area hospitals. The disaster resulted in 10 critically ill burn patients, who were all intubated with inhalation injuries, many with combined burn and trauma injuries. All 10 critically injured patients were admitted to a tertiary care facility 100 miles away with both a Level I trauma center and a verified burn center. Ultimately, 7 of 10 patients survived (a mortality rate of 30%), and none were transferred to another trauma or burn center. This article analyzes the unique challenges that combined burn and trauma patients present during a disaster, critically examines the response to this disaster, describes lessons learned, and presents recommendations that may improve the response to such disasters in the future.

Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings

BACKGROUND

At 07:39 am on March 11th, 2004, ten terrorist bomb explosions occurred almost simultaneously in four commuter trains in Madrid, Spain, killing instantly 177 people and injuring >2,000. There were 14 subsequent in-hospital deaths, bringing the definite death toll to 191 victims. This article describes the organization of the clinical management and patterns of injuries in casualties who were taken to the closest hospital, with emphasis on the critical patient population.

RESULTS

There were 312 patients taken to that center, and 91 were hospitalized, 89 of them (28.5%) for >24 hrs. Sixty-two patients only had superficial bruises or emotional shock, but the remaining 250 patients had more severe lesions. The data on 243 of the latter form the basis of this report. Tympanic perforation occurred in 41% of 243 victims with moderate-to-severe trauma, chest injuries in 40%, shrapnel wounds in 36%, fractures in 18%, first- or second-degree burns in 18%, eye lesions in 18%, head trauma in 12%, and abdominal injuries in 5%. Between 8:00 am and 5:00 pm, 34 surgical interventions were performed on 32 victims. Twenty-nine casualties (12% of the total or 32.5% of those hospitalized) were deemed in critical condition, and two of them died within minutes of arrival. The other 27 survived to be admitted to intensive care units, and three of them died, bringing the critical mortality rate to 17.2% (5/29). The mean Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores of critical patients were 34 and 23, respectively. Among these critical patients, soft-tissue and musculoskeletal injuries predominated in 85% of cases, ear blast injury was identified in 67%, and blast lung injury was present in 63% (17 cases). Fifty-two percent suffered head trauma.

CONCLUSIONS

There was probably an overtriage to the closest hospital, and the time of the blasts proved crucial for the adequacy of the medical and surgical response. The number of blast lung injuries seen is probably the largest reported by a single institution, and the critical mortality rate was reasonably low.