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

A four-step approach for establishment of a national medical response to mega-terrorism

A simplified, four-step approach was used to establish a medical management and response plan to mega-terrorism in Israel. The basic steps of this approach are: (1) analysis of a scenario based on past incidents; (2) description of relevant capabilities of the medical system; (3) analysis of gaps between the scenario and the expected response; and (4) development of an operational framework. Analyses of both the scenario and medical abilities led to the recommendation of an evidence-based contingency plan for mega-terrorism. An important lesson learned from the analyses is that a shortage in medical first responders would require the administration of advanced life support (ALS) by paramedics at the scene, along with simultaneous, rapid evacuation of urgent casualties to nearby hospitals by medics practicing basic life support (BLS). Ambulances and helicopters should triage casualties from inner to outer circle hospitals secondarily, preferentially Level-1 trauma centers. In conclusion, this four-step approach based on scenario analysis, mapping of medical capabilities, detection of bottlenecks, and establishment of a unique operational framework, can help other medical systems develop a response plan to mega-terrorist attacks.

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.

Disaster preparedness, triage, and surge capacity for hospital definitive care areas: optimizing outcomes when demands exceed resources

Disaster planning must anticipate how demands imposed by a disaster reconcile with the capacity of the treating facility. Resources must be organized before an event so that they are optimally used to treat as many victims as possible, as well as to avoid overwhelming available resources.

The radiological management of bomb blast injury

A need to understand the nature and patterns of bomb blast injury, particularly in confined spaces, has come to the fore with the current worldwide threat from terrorism. The purpose of this review article is to familiarize the radiologist with the imaging they might expect to see in a mass casualty terrorist event, illustrated by examples from two of the main institutions receiving patients from the London Underground tube blasts of 7 July 2005. We present examples of injuries that are typical in blast victims, as well as highlighting some blast sequelae that might also be found in other causes of multiple trauma. This should enable the radiologist to seek out typical injuries, including those that may not be initially clinically apparent. Terror-related injuries are often more severe than those seen in other trauma cases, and multi-system trauma at distant anatomical sites should be anticipated. We highlight the value of using a standardized imaging protocol to find clinically undetected traumatic effects and include a discussion on management of multiple human and non-human flying fragments. This review also discusses the role of radiology in the management and planning for a mass casualty terrorist incident and the optimal deployment of radiographic services during such an event.

Inpatient disposition classification for the creation of hospital surge capacity: a multiphase study

BACKGROUND

The ability to provide medical care during sudden increases in patient volume during a disaster or other high-consequence event is a serious concern for health-care systems. Identification of inpatients for safe early discharge (ie, reverse triage) could create additional hospital surge capacity. We sought to develop a disposition classification system that categorises inpatients according to suitability for immediate discharge on the basis of risk tolerance for a subsequent consequential medical event.

METHODS

We did a warfare analysis laboratory exercise using evidence-based techniques, combined with a consensus process of 39 expert panellists. These panellists were asked to define the categories of a disposition classification system, assign risk tolerance of a consequential medical event to each category, identify critical interventions, and rank each (using a scale of 1-10) according to the likelihood of a resultant consequential medical event if a critical intervention is withdrawn or withheld because of discharge.

FINDINGS

The panellists unanimously agreed on a five-category disposition classification system. The upper limit of risk tolerance for a consequential medical event in the lowest risk group if discharged early was less than 4%. The next categories had upper limits of risk tolerance of about 12% (IQR 8-15%), 33% (25-50%), 60% (45-80%) and 100% (95-100%), respectively. The expert panellists identified 28 critical interventions with a likelihood of association with a consequential medical event if withdrawn, ranging from 3 to 10 on the 10-point scale.

INTERPRETATION

The disposition classification system allows conceptual classification of patients for suitable disposition, including those deemed safe for early discharge home during surges in demand. Clinical criteria allowing real-time categorisation of patients are awaited.

Positive-pressure ventilation equipment for mass casualty respiratory failure

In the event of an influenza pandemic, patients with severe acute respiratory failure (ARF) due to influenza will require positive-pressure ventilation (PPV) in order to survive. In countries with widely available critical care services, PPV is delivered almost exclusively through use of full-feature mechanical ventilators in intensive care units (ICUs) or specialized hospital wards. But the supply of these ventilators is limited even during the normal course of hospital functioning. Purchasing and maintaining additional full-feature mechanical ventilators to be held in reserve and used only during mass casualty events is too expensive to allow the stockpiling of such equipment. Consequently, planning and preparedness efforts to respond to a severe influenza pandemic have stimulated consideration of limited-feature, less-expensive ventilation devices to augment traditional PPV capacity. This article offers guidance to authorities charged with preparing for mass casualty PPV in deciding which PPV equipment would be adequate for ventilating patients for days, weeks, or even months during a medical catastrophe.

Blast injuries from Madrid terrorist bombing attacks on March 11, 2004

Blast injuries after terrorist attacks are seen with increasing frequency worldwide. Thousands of victims were attended in the hospitals of Madrid, Spain, on March 11, 2004 after the bombing attacks against the commuter trains. Thirty-six patients were attended in our institution. Seventeen of them suffered from severe or life-threatening injuries, and 19 had mild injuries. The most common lesions were thoracic trauma and blast lung injury, acoustic trauma, and orbital and paranasal sinus fractures. Other findings were hepatic and splenic lacerations, and vertebral and limb fractures. Emergency radiology had an important role in the correct management of the victims. Prompt radiological diagnoses of these complex lesions are crucial to efficient treatment. Therefore, radiologists have to become familiar with the injury patterns and specific lesions caused by blast wave.

Do Trauma Centers Have the Capacity to Respond to Disasters?

BACKGROUND

Concern has been raised about the capacity of trauma centers to absorb large numbers of additional patients from mass casualty events. Our objective was to examine the capacity of current centers to handle an increased load from a mass casualty disaster.

METHODS

This was a cross-sectional study of Level I and II trauma centers. They were contacted by mail and asked to respond to questions about their surge capacity as of July 4, 2005.

RESULTS

Data were obtained from 133 centers. On July 4, 2005 there were a median of 77 beds available in Level I and 84 in Level II trauma centers. Fifteen percent of the Level I and 12.2% of the Level II centers had a census at 95% capacity or greater. In the first 6 hours, each Level I center would be able to operate on 38 patients, while each Level II center would be able to operate on 22 patients. Based on available data, there are 10 trauma centers available to an average American within 60 minutes. Given the available bed capacity, a total of 812 beds would be available within a 60-minute transport distance in a mass casualty event.

CONCLUSIONS

There is capacity to care for the number of serious non-fatally injured patients resulting from the types of mass casualties recently experienced. If there is a further continued shift of uninsured patients to and fiscally driven closure of trauma centers, the surge capacity could be severely compromised.

Management of Conventional Mass Casualty Incidents: Ten Commandments for Hospital Planning

The successful management of mass casualty incidents (MCIs) requires standardization of planning, training, and deployment of response. Recent events in the United States, most importantly the Hurricane season in 2005, demonstrated a lack of a unified response plan at local, regional, state, and federal levels. A standard Israeli protocol for hospital preparedness for conventional MCIs, produced by the Office of Emergency Preparedness of the Israeli Ministry of Health, has been reviewed, modified, adapted, and tested in both drills and actual events at a large university medical center in the United States. Lessons learned from this process are herein presented as the10 most important steps (ie, Commandments) to follow when preparing hospitals to be able to respond to conventional MCIs. The standard Israeli emergency protocols have proved to be universally adaptable, flexible, and designed to be adapted by any healthcare institution, regardless of its size and location.

Terrorist Homicide Bombings: A Primer for Preparation

Contemporary planning for disaster response to terrorist events usually assumes the use of chemical, radiological, or biological weapons. Historically, most victims of terrorist attacks are injured by the use of conventional explosives rather than weapons of mass destruction. Such attacks will likely produce victims who have suffered burn injuries along with conventional trauma. Alternately, the large number of patients sustaining conventional soft-tissue or crush injuries will benefit from burn center expertise. This study summarizes the current state of knowledge related to the management of terrorism mass casualty incidents caused by the use of conventional explosives. A review of pertinent medical, technical, and popular literature relating to terrorism and explosives, along with instruction received at Hadassah Hospital, Jerusalem, Israel on the management of mass casualty terrorism events was undertaken, and the pertinent medical and scientific literature relating to bomb delivery methods, blast mechanics, blast pathophysiology, and medical response to a terrorist bombing is presented here. Although terrorist use of chemical, radiological, or biological weapons is possible, historical analysis consistently demonstrates that the most likely terrorist weapon causing a mass casualty event is a standard explosive device detonated in a crowded area. The medical basis for management of such casualties is herein described.

The Southern Region Burn Disaster Plan

A regional burn disaster plan for 24 burn centers located in 11 states comprising the Southern Region of the American Burn Association was developed using online and in-person collaboration between burn center directors during a 2-year period. The capabilities and preferences of burn centers in the Southern Region were queried. A website with disaster information, including a map of regional burn centers and spreadsheet of driving distances between centers, was developed. Standard terminology for burn center capabilities during disasters was defined as open, full, diverting, offloading, or returning. A simple, scalable, and flexible disaster plan was designed. Activation and escalation of the plan revolves around the requirements of the end user, the individual burn center director. A key provision is the designation of a central communications point colocated at a burn center with several experienced burn surgeons. In a burn disaster, the burn center director can make a single phone call to the communications center, where a senior burn surgeon remote from the disaster can contact other burn centers and emergency agencies to arrange assistance. Available options include diversion of new admissions to the next closest center, transfer of patients to other regional centers, or facilitation of activation of federal plans to bring burn care providers to the affected burn center. Cooperation between regional burn center directors has produced a simple and flexible regional disaster plan at minimal cost to institute or operate.

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.

TERRORISM AND BLAST EXPLOSIONS: LESSONS FOR THE AUSTRALIAN SURGICAL COMMUNITY

The prospect of a terrorist attack against Australian interests is currently being debated across our society. The explosive blast attack is most favoured by terrorists. Blast injuries create unique patterns of multisystem injury with contaminated wounds and extensive devitalized tissue. Australian civilian surgeons are increasingly likely to be involved in the management of these injuries, either in response to a terrorist incident in Australia or as part of delayed management of Australian nationals injured overseas. An appreciation of the unique complexities of blast injuries is equally important to both military and civilian surgeons. This paper covers the mechanisms and pathophysiology of blast injuries and discusses issues of surgical management as they would apply to an Australian civilian setting.

Disaster management teams

PURPOSE OF REVIEW

All disasters, regardless of cause, have similar medical and public health consequences. A consistent approach to disasters, based on an understanding of their common features and the response expertise they require, is becoming the accepted practice throughout the world. This strategy is called the mass casualty incident response. The complexity of today's disasters, particularly the threat of terrorism and weapons of mass destruction, has increased the need for multidisciplinary medical specialists as critical assets in disaster response. A review of the current literature emphasizes the expanding role of disaster management teams as an integral part of the mass casualty incident response.

RECENT FINDINGS

The incident command system has become the accepted standard for all disaster response. Functional requirements, not titles, determine the organizational hierarchy of the Incident Command System structure. All disaster management teams must adhere to this structure to integrate successfully into the rescue effort. Increasingly, medical specialists are determining how best to incorporate their medical expertise into disaster management teams that meet the functional requirements of the incident command system.

SUMMARY

Disaster management teams are critical to the mass casualty incident response given the complexity of today's disaster threats. Current disaster planning and response emphasizes the need for an all-hazards approach. Flexibility and mobility are the key assets required of all disaster management teams. Medical providers must respond to both these challenges if they are to be successful disaster team members.

Is the Australian hospital system adequately prepared for terrorism?

Australian hospitals need to be prepared to deal with mass casualties from terrorist strikes, including bomb blasts and chemical, biological and radiation injury. Injuries from bomb explosions are more severe than those commonly seen in Australian hospitals. In disasters involving mass casualties in urban areas, many of the injured make their own way to hospital, often arriving before the more seriously injured casualties. Major hospitals in Australia should plan for large numbers of undifferentiated and potentially contaminated casualties arriving with minimal warning. It is critical that experienced and trained senior medical officers perform the triage of casualties in emergency departments, with frequent reassessment to detect missed injuries (especially pulmonary blast injury). Hospitals require well developed standard operating procedures for mass casualty events, reinforced by regular drills. Preparing for a major event includes training staff in major incident management, setting up an operational/control unit, nominating key personnel, ensuring there is an efficient intra-hospital communication system, and enhancing links with other emergency services and hospitals.

Predictors of mortality in close proximity blast injuries during Operation Iraqi Freedom

BACKGROUND

Blast injury is an increasingly common problem faced by military surgeons in the field. Because of urban terrorism worldwide, blast injury is becoming more common in the civilian sector as well. Blast injuries are often devastating and can overwhelm medical resources. We sought to determine whether simple factors easily obtained from the clinical history and primary survey could be used to triage patients more effectively.

STUDY DESIGN

A retrospective review of 18 consecutive close-proximity blast injury patients presenting to a forward deployed surgical unit in Iraq was performed. Patients' injuries and outcomes were recorded. We compared the presence of sustained hypotension, penetrating head injury, multiple (three or more) long-bone fractures, and associated fatalities (whether another patient involved in the same explosion died) between nonsurvivors and survivors using Fisher's exact test.

RESULTS

All patients who presented alive but exhibited sustained hypotension (n = 5) died, versus 0% who did not exhibit sustained hypotension (n = 9, p < 0.01). There was no marked increase in mortality with presence of multiple long-bone fractures, penetrating head injury, or associated fatalities individually. Having two or more of these factors was associated with a mortality of 86% (6 of 7) versus 20% (2 of 10, p = 0.015) in those who had less than two factors.

CONCLUSIONS

Blast injury can overwhelm military and civilian trauma systems alike. Sustained hypotension and presence of two or more easily determined factors, including three or more long-bone fractures, penetrating head injury, and associated fatalities, are associated with increased mortality and can potentially help triage patients and allocate scarce resources more efficiently.

Blast lung injury: clinical manifestations, treatment, and outcome

BACKGROUND

Blast lung injury (BLI) is a major cause of morbidity after terrorist bomb attacks (TBAs) and is seen with increasing frequency worldwide. Yet, many surgeons and intensivists have little experience treating BLI. Jerusalem sustained 31 TBAs since 1983, resulting in a local expertise in treating BLI.

METHODS

A retrospective study of clinical and radiologic characteristics, management, and outcome of victims of TBAs sustaining BLI who were admitted to ICU during December 1983 to February 2004. Long-term outcome was determined by a telephone interview.

RESULTS

Twenty-nine patients met inclusion criteria. Hypoxia and pulmonary infiltrates in chest x-ray were sine qua non for the diagnosis. Seventy-six percent required mechanical ventilation, all within 2 hours of admission. One patient died. Seventy-six percent had no long-term sequelae.

CONCLUSIONS

Most patients with significant BLI injury require mechanical ventilation. Late deterioration is rare. Death because of BLI in patients who survived the explosion is unusual. Timely diagnosis and correct treatment result in excellent outcome.

Terrorist attacks: learning from the past and planning for the future

Terrorist bomb attacks on the UK mainland are not a new phenomenon. However, since the IRA ceasefire, such incidents have been relatively few. Unlike IRA bombings, which generally targeted commercial property or military personnel and were often preceded by warning phone calls, the attacks in London and Madrid deliberately targeted civilians with no warning. The detonation of devices at multiple sites and in densely packed, enclosed areas was intended to maximize the number of fatalities and inflict severe injuries on survivors. Indiscriminate outrages such as those perpetrated in London on 7 July are unlikely to be ‘one offs’ and may be repeated in the near future.

London bombings July 2005: The immediate pre-hospital medical response

On July 7th 2005 a series of terrorist bombs exploded in London. The transport system was targeted and at least 54 passengers were killed and around 700 injured. This paper describes the immediate pre-hospital medical response to the four scenes. From the perspective of the London Helicopter Emergency Medical Service the deployment, difficulties on scene and the initial lessons learned are discussed.

Critical care during epidemics

We recommend several actions that could improve hospitals' abilities to deliver critical care during epidemics involving large numbers of victims. In the absence of careful pre-event planning, demand for critical care services may quickly exceed available intensive care unit (ICU) staff, beds and equipment, leaving the bulk of the infected populace without benefit of potentially lifesaving critical care. The toll of death may be inversely proportional to the ability to augment critical care capacity, so critical care health care professionals must take the lead for planning and preparing to care for numbers of seriously ill patients that far exceed available ICU beds.