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

Multiple Casualty Incidents at a Level I Trauma Center: A 15-year Analysis

INTRODUCTION

Limited evidence regarding multiple casualty outcomes exists. Given resource strain with increasing patient load, we hypothesized that patients involved in a multiple casualty incident have worse outcomes compared to standard trauma patients.

METHODS

Multiple casualty victims from 2006 to 2021 at our institution were identified; admission data and trauma outcomes were then compared to standard trauma patients. Chi-square tests and Mann-Whitney U-tests were performed for categorical and non-normal continuous data, respectively. Logistic regression was performed to evaluate associations with mortality and intensive care unit (ICU) admission.

RESULTS

We identified 39,924 patients, of which 612 were multiple casualty patients (1.5%). Multiple casualty involvement was associated with younger age (29 y versus 44 y, P < 0.001) and higher rates of penetrating trauma (26.1% versus 21.4%; P < 0.001). Multiple casualty involvement was associated with higher injury severity score (ISS) (11.6 versus 7.9, P < 0.001), mortality (2.4% versus 1.5% P < 0.005), and ICU admission (17% versus 13%, P < 0.005). On logistic regression analysis, age, ISS, shock index, presence of the COVID-19 pandemic, and mechanism all independently predicted mortality (P ≤ 0.003), while multiple casualty involvement did not (P = 0.302).

CONCLUSIONS

Although multiple casualty incidents are associated with patient factors that increase hospital resource strain, when controlling for age, ISS, shock index, presence of the COVID-19 pandemic, and trauma mechanism, involvement in multiple casualty incident was not independently associated with ICU admission or mortality. Improved understanding of the impact of high-volume trauma may allow us to improve our care of this at-risk population.

Optimizing Mass Casualty Triage: Using Discrete Event Simulation to Minimize Time to Resuscitation

BACKGROUND

Urban areas in the US are increasingly focused on mass casualty incident (MCI) response. We simulated prehospital triage scenarios and hypothesized that using hospital-based blood product inventories for on-scene triage decisions would minimize time to treatment.

STUDY DESIGN

Discrete event simulations modeled MCI casualty injury and patient flow after a simulated blast event in Boston, MA. Casualties were divided into moderate (Injury Severity Score 9 to 15) and severe (Injury Severity Score >15) based on injury patterns. Blood product inventories were collected from all hospitals (n = 6). The primary endpoint was the proportion of casualties managed with 1:1:1 balanced resuscitation in a target timeframe (moderate, 3.5 U red blood cells in 6 hours; severe, 10 U red blood cells in 1 hour). Three triage scenarios were compared, including unimpeded casualty movement to proximate hospitals (Nearest), equal distribution among hospitals (Equal), and blood product inventory-based triage (Supply-Guided).

RESULTS

Simulated MCIs generated a mean ± SD of 302 ± 7 casualties, including 57 ± 2 moderate and 15 ± 2 severe casualties. Nearest triage resulted in significantly fewer overall casualties treated in the target time (55% vs Equal 86% vs Supply-Guided 91%, p < 0.001). These differences were principally due to fewer moderate casualties treated, but there was no difference among strategies for severe casualties.

CONCLUSIONS

In this simulation study comparing different triage strategies, including one based on actual blood product inventories, nearest hospital triage was inferior to equal distribution or a Supply-Guided strategy. Disaster response leaders in US urban areas should consider modeling different MCI scenarios and casualty numbers to determine optimal triage strategies for their area given hospital numbers and blood product availability.

Limitations of Available Blood Products for Massive Transfusion During Mass Casualty Events at US Level 1 Trauma Centers

INTRODUCTION

Exsanguination remains a leading cause of preventable death in traumatically injured patients. To better treat hemorrhagic shock, hospitals have adopted massive transfusion protocols (MTPs) which accelerate the delivery of blood products to patients. There has been an increase in mass casualty events (MCE) worldwide over the past two decades. These events can overwhelm a responding hospital's supply of blood products. Using a computerized model, this study investigated the ability of US trauma centers (TCs) to meet the blood product requirements of MCEs.

METHODS

Cross-sectional survey data of on-hand blood products were collected from 16 US level-1 TCs. A discrete event simulation model of a TC was developed based on historic data of blood product consumption during MCEs. Each hospital's blood bank was evaluated across increasingly more demanding MCEs using modern MTPs to guide resuscitation efforts in massive transfusion (MT) patients.

RESULTS

A total of 9,000 simulations were performed on each TC's data. Under the least demanding MCE scenario, the median size MCE in which TCs failed to adequately meet blood product demand was 50 patients (IQR 20-90), considering platelets. Ten TCs exhaust their supply of platelets prior to red blood cells (RBCs) or plasma. Disregarding platelets, five TCs exhausted their supply of O- packed RBCs, six exhausted their AB plasma supply, and five had a mixed exhaustion picture.

CONCLUSION

Assuming a TC's ability to treat patients is limited only by their supply of blood products, US level-1 TCs lack the on-hand blood products required to adequately treat patients following a MCE. Use of non-traditional blood products, which have a longer shelf life, may allow TCs to better meet the blood product requirement needs of patients following larger MCEs.

Surge Capacity and Mass Casualty Incidents Preparedness of Emergency Departments in a Metropolitan City: a Regional Survey Study

BACKGROUND

Emergency departments (EDs) generally receive many casualties in disaster or mass casualty incidents (MCI). Some studies have conceptually suggested the surge capacity that ED should have; however, only few studies have investigated measurable numbers in one community. This study investigated the surge capacity of the specific number of accommodatable patients and overall preparedness at EDs in a metropolitan city.

METHODS

This cross-sectional study officially surveyed surge capacity and disaster preparedness for all regional and local emergency medical centers (EMC) in Seoul with the Seoul Metropolitan Government's public health division. This study developed survey items on space, staff, stuff, and systems, which are essential elements of surge capacity. The number of patients acceptable for each ED was investigated by triage level in ordinary and crisis situations. Multivariate linear regression analysis was performed on hospital resource variables related to surge capacity.

RESULTS

In the second half of 2018, a survey was conducted targeting 31 EMC directors in Seoul. It was found that all regional and local EMCs in Seoul can accommodate 848 emergency patients and 537 non-emergency patients in crisis conditions. In ordinary situations, one EMC could accommodate an average of 1.3 patients with Korean Triage and Acuity Scale (KTAS) level 1, 3.1 patients with KTAS level 2, and 5.7 patients with KTAS level 3. In situations of crisis, this number increased to 3.4, 7.8, and 16.2, respectively. There are significant differences in surge capacity between ordinary and crisis conditions. The difference in surge capacity between regional and local EMC was not significant. In both ordinary and crisis conditions, only the total number of hospital beds were significantly associated with surge capacity.

CONCLUSION

If the hospital's emergency transport system is ideally accomplished, patients arising from average MCI can be accommodated in Seoul. However, in a huge disaster, it may be challenging to handle the current surge capacity. More detailed follow-up studies are needed to prepare a surge capacity protocol in the community.

Mass casualty management during a pandemic surge: The American University of Beirut Medical Center experience

Mass casualty incidents can be devastating events associated with a large number of fatalities, morbidities, and long-lasting sequelae. The negative outcomes can be further amplified if the incident occurred during a pandemic surge, such as what occurred in Beirut, Lebanon with the August 4, 2020 Beirut Port explosion. To decrease the mortality and morbidity and avoid inefficiency, management depends on having an established coordinated multidisciplinary approach from transport and triage to emergency department care and in-hospital management. In this article, the mass casualty management and the impact of the coronavirus disease 2019 pandemic will be discussed based on the American University of Beirut Medical Center experience.

Prehospital and First Hospital System Response to a Terrorist Attack in Bogotá, Colombia

Background:

Assembling an effective medical response for an overwhelming number of casualties has become a priority worldwide. Terrorist attacks have been part of the Colombian contemporaneous history. On February 7, 2003, a terrorist car bomb explosion occurred inside a private club in Bogotá, causing the largest number of casualties of all terrorist attacks for over 15 years. The present study analyses the hospital and prehospital responses to this mass casualty event by characterizing the patterns of injury, resource allocation, and outcome in a tertiary-level hospital where most of the casualties were treated.

Materials and methods:

This is a retrospective chart review of the patients brought to a single hospital (La Clínica del Country), which was the nearest to the terrorist attack. Demographics, severity of injury, patterns of injury, prehospital care, and outcomes were determined from the hospital medical records and government registries.

Results:

Of the 240 victims, 35 died at the explosion site (immediate mortality 17%). The 205 survivors were dispersed throughout the city, of whom 63 patients came to La Clínica del Country hospital. Most of these patients were evaluated only clinically and deemed not serious. The main mechanism of trauma was blunt (81.4%). The mean injury severity score (ISS) was 5.6 ± 8.3. Ten patients required emergent surgical intervention and 14 patients were admitted. The in-hospital mortality was 20%.

Conclusion:

This mass casualty event was a true test for the Colombian emergency medical system and disaster preparedness. The medical response and resource optimization resulted in an overall mortality rate similar to those observed in the recent European and North American bombings. Despite the limited resources, the continuous challenge of terrorist’s attacks in Colombia made the country feel the need for training and preparing the healthcare professionals, allowing effective delivery of medical care.

Equipping Public Spaces to Facilitate Rapid Point-of-Injury Hemorrhage Control After Mass Casualty

In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.

Hospital Surge Capacity during Expo 2015 in Milano, Italy

IntroductionHospital Acute Care Surge Capacity (HACSC), Hospital Acute Care Surge Threshold (HACST), and Total Hospital Capacity (THC) are scales that were developed to quantify surge capacity in the event of a multiple-casualty incident (MCI). These scales take into consideration the need for adequate care for both critical (T1) and moderate (T2) trauma patients. The objective of this study was to verify the validity of these scales in nine hospitals of the Milano (Italy) metropolitan area that prepared for a possible MCI during EXPO 2015.

METHODS

Both HACSC and HACST were computed for individual hospitals. These were compared to surge capacities declared by individual hospitals during EXPO 2015, and also to surge capacity evaluated during a simulation organized on August 23, 2016.

RESULTS

Both HACSC and HACST were smaller compared to capacities measured and reported by the hospitals, as well as those found during the simulation. This resulted in significant differences in THC when this was computed from the different methods of calculation.

CONCLUSIONS

Surge capacity is dependent on the method of measurement. Each method has its inherent deficiencies. Until more reliable methodologies are developed, there is a benefit to analyze surge capacity using several methods rather than just one. Emergency committee members should be aware of the importance of critical resources when looking to the hospital capacity to respond to an MCI, and to the possibility to effectively increase it with a good preparedness plan. Since hospital capacity during real events is not static but dynamic, largely depending on occupation of the available resources, it is important that the regional command center and the hospitals receiving casualties constantly communicate on specific agreed upon critical resources, in order for the regional command center to timely evaluate the overall regional capacity and guarantee the appropriate distribution of the patients. FaccincaniR, Della CorteF, SesanaG, StucchiR, WeinsteinE, AshkenaziI, IngrassiaP. Hospital surge capacity during Expo 2015 in Milano, Italy. Prehosp Disaster Med. 2018;33(5):459-465.

Impact of Superstorm Sandy on Medicare Patients' Utilization of Hospitals and Emergency Departments

INTRODUCTION

National health security requires that healthcare facilities be prepared to provide rapid, effective emergency and trauma care to all patients affected by a catastrophic event. We sought to quantify changes in healthcare utilization patterns for an at-risk Medicare population before, during, and after Superstorm Sandy's 2012 landfall in New Jersey (NJ).

METHODS

This study is a retrospective cohort study of Medicare beneficiaries impacted by Superstorm Sandy. We compared hospital emergency department (ED) and healthcare facility inpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20% random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012 (N=224,116). Outcome measures were pre-storm discharges (or transfers), average length of stay, service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission.

RESULTS

In the pre-storm week, hospital transfers from skilled nursing facilities (SNF) increased by 39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prior year. In the post-storm week, ED visits increased by 14% statewide; of these additional "surge" patients, 20% were admitted to the hospital. The increase in ED demand was more than double the statewide average in the most highly impacted coastal regions (35% versus 14%).

CONCLUSION

Superstorm Sandy impacted both pre- and post-storm patient movement in New Jersey; post-landfall ED surge was associated with overall storm impact, which was greatest in coastal counties. A significant increase in the number and severity of pre-storm transfer patients, in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attention to the importance of collaborative regional approaches to healthcare in large-scale events.

Criteria and models for the distribution of casualties in trauma-related mass casualty incidents: a systematic literature review protocol

BACKGROUND

One of the most critical practices in mass casualty incident management is vacating the victims from scene of the incident and transporting them to proper healthcare facilities. Decision on distribution of casualties needs to be taken on pre-developed policies and structured decision support mechanisms. While many studies tried to present models for the distribution of casualties, no systematic review has yet been conducted to evaluate the existing models on casualty distribution following mass casualty incidents. A systematic review is therefore needed to examine the existing models of patient distribution and to provide a summary of the models. This systematic review protocol is aimed to examine the existing models and extracting rules and principles of mass casualty distribution.

METHODS

This study will comprehensively investigate existing papers with search phrases and terms including "mass casualty incident", distribution, evacuation, and Mesh terms directly corresponding to search phrases. No limitations on the type of studies, date of publication, or language of the relevant documents will be imposed. PubMed, Web of Science, Scopus, and Google Scholar will be searched to access the relevant documents. Included papers will be critically appraised by two independent reviewers. The data including incidents type, scene characteristics, patient features, pre-hospital resources, and hospital resources will be categorized. Subgroup analysis will be conducted when possible.

DISCUSSION

To the best of our knowledge, no study has yet addressed the effects and interaction of contributing factors on the decision-making processes for casualty's distribution. This is the first study that comprehensively assesses and critically appraises the current models of casualty distribution. This study will provide evidences about models and criteria for casualty distribution following mass casualty incidents.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Registration Number: CRD42016049115.

Disaster Preparedness and Response for the Burn Mass Casualty Incident in the Twenty-first Century

The effective and efficient coordination of emergent patient care at the point of injury followed by the systematic resource-based triage of casualties are the most critical factors that influence patient outcomes after mass casualty incidents (MCIs). The effectiveness and appropriateness of implemented actions are largely determined by the extent and efficacy of the planning and preparation that occur before the MCI. The goal of this work was to define the essential efforts related to planning, preparation, and execution of acute and subacute medical care for disaster burn casualties. This type of MCI is frequently referred to as a burn MCI."

Patients as Patches: Ecology and Epidemiology in Healthcare Environments

The modern healthcare system involves complex interactions among microbes, patients, providers, and the built environment. It represents a unique and challenging setting for control of the emergence and spread of infectious diseases. We examine an extension of the perspectives and methods from ecology (and especially urban ecology) to address these unique issues, and we outline 3 examples: (1) viewing patients as individual microbial ecosystems; (2) the altered ecology of infectious diseases specifically within hospitals; and (3) ecosystem management perspectives for infection surveillance and control. In each of these cases, we explore the accuracy and relevance of analogies to existing urban ecological perspectives, and we demonstrate a few of the potential direct uses of this perspective for altering research into the control of healthcare-associated infections. Infect Control Hosp Epidemiol. 2016;1507-1512.

Virtual Laboratory and Imaging: an online simulation tool to enhance hospital disaster preparedness training experience

OBJECTIVE

Hospitals play a pivotal role as basic healthcare providers during mass casualty incidents (MCIs). Radiological studies and emergency laboratory test are of high importance for the management of hospital patients. However, it is known that during these events, they can generate significant bottlenecks. Appropriate request of such tests is of utmost importance to not generate delays in the patient flow. The aim of this paper is to describe a software designed to increase the realism of hospital-based MCI training through a realistic reproduction of radiology and laboratory departments.

METHODS

In this paper, we present a Virtual Laboratory and Imaging system that we designed with the goal of increasing the realism of full-scale mass casualty simulations. The system is able to dynamically manage the speed and load of virtual departments while collecting data on usage and load, and provide data useful for the after-event debriefing. We tested this system in two pilot simulations involving, respectively, 105 and 89 simulated casualties.

RESULTS

The system, by measuring the number of requests and exams' turnaround time, enabled an objective measurement of the laboratory and radiology workload during simulated MCIs. It was possible to identify bottlenecks and consequently use these data for after-action debriefing.

CONCLUSION

The tool not only increased the simulation realism by adding the radiology and laboratory departments but also provided valuable data that could be used for educational and organizational purposes.

40 years of terrorist bombings - A meta-analysis of the casualty and injury profile

INTRODUCTION

Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide.

METHODS

Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords "terrorist", and/or "suicide", and/or "bombing") from 1970 to 2014 was performed.

RESULTS

58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P<0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semi-confined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD±17.828) and 15.63 (SD±10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD±141.147), compared to CS, 79.20 (SD±59.8). Extremity related wounds were the commonest injuries seen (32%).

DISCUSSION/CONCLUSION

Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days.

The Second Lebanon War Experience at Western Galilee Hospital

The summer of 2006 in northern Israel served as the battleground for the second war against Hezbollah based along Israel's border with southern Lebanon. Western Galilee Hospital (WGH), which is located only 6 miles from the Lebanese border, served as a major medical center in the vicinity of the fighting. The hospital was directly impacted by Hezbollah with a Katyusha rocket, which struck the ophthalmology department on the 4th floor. WGH was able to utilize a 450-bed underground facility that maintained full hospital functionality throughout the conflict. In a major feat of rapid evacuation, the entire hospital population was relocated under the cover of darkness to these bunkers in just over 1 hour, thus emptying the building prior to the missile impact. Over half of the patients presenting during the conflict did not incur physical injury but qualified as acute stress disorder patients. The particulars of this evacuation remain unique owing to the extraordinary circumstances, but many of the principles employed in this maneuver may serve as a template for other hospitals requiring emergency evacuation. Hospital functionality drastically changed to accommodate the operational reality of war, and many of these tactics warrant closer investigation for possible implementation in other conflict zones.

Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

This article provides consensus suggestions for expanding critical care surge capacity and extension of critical care service capabilities in disasters or pandemics. It focuses on the principles and frameworks for expansion of intensive care services in hospitals in the developed world. A companion article addresses surge logistics, those elements that provide the capability to deliver mass critical care in disaster events. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with injured or critically ill multiple patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify evidence on which to base key suggestions. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force were also included for validation by the expert panel.

RESULTS

This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care, including the role of critical care in disaster planning; the surge continuum; targets of surge response; situational awareness and information sharing; mitigating the impact on critical care; planning for the care of special populations; and service deescalation/cessation (also considered as engineered failure).

CONCLUSIONS

Future reports on critical care surge should emphasize population-based outcomes as well as logistical details. Planning should be based on the projected number of critically ill or injured patients resulting from specific scenarios. This should include a consideration of ICU patient care requirements over time and must factor in resource constraints that may limit the ability to provide care. Standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and used in disaster events.

Rural hospital mass casualty response to a terrorist shooting spree

BACKGROUND

Civilian mass casualty incidents may occur infrequently and suddenly, and are caused by accidents, natural disasters or human terrorist incidents. Most reports deal with trauma centre management in large cities, and data from small local hospitals are scarce. A rural hospital response to a mass casualty incident caused by a terrorist shooting spree was evaluated.

METHODS

An observational study was undertaken to evaluate the triage, diagnosis and management of all casualties received from the Utøya youth camp in Norway on 22 July 2011 by a local hospital, using data from the hospital's electronic records. Descriptive data are presented for patient demographics, injuries and patient flow.

RESULTS

The shooting on Utøya youth camp left 69 people dead and 60 wounded. A rural hospital (Ringerike Hospital) triaged 35 patients, of whom 18 were admitted. During the main surge, the hospital triaged and treated 22 patients within 1 h, of whom 13 fulfilled the criteria for activating the hospital trauma team, including five with critical injuries (defined as an Injury Severity Score above 15). Ten computed tomography scans, two focused assessment with sonography for trauma (FAST) scans and 25 conventional X-rays were performed. During the first 24 h, ten surgical procedures were performed and four chest drains inserted. No patient died.

CONCLUSION

Critical deviation from the major incident plan was needed, and future need for revision is deemed necessary based on the experience. Communication systems and the organization of radiological services proved to be most vulnerable.

Impact of helicopter emergency medical services in major incidents: systematic literature review

INTRODUCTION

Helicopter emergency medical services (HEMS) aim to bring highly specialised crews to the major incident for triage, treatment and transport. When the site is difficult to access, HEMS may be the only mode of transportation of both personnel and patients. This systematic review will identify, describe and appraise literature regarding the role of HEMS in medical response to major incidents. We aim to improve knowledge on HEMS role in a major incident and provide a basis for future research.

METHODS AND ANALYSIS

A systematic literature review will be conducted with search phrases that combine HEMS and major incidents to identify when and how HEMS have been used. Included literature will be subject to quality appraisal and data extraction.

ETHICS

No ethical approval is sought because this is a literature review. It will be submitted to a peer-reviewed journal and the PRISMA guidelines will be followed.

REGISTRATION DETAILS

PROSPERO CRD42013004473.

Mass casualty triage after an airplane crash near Amsterdam

INTRODUCTION

Triage is an important aspect of the management of mass casualty incidents. This study describes the triage after the Turkish Airlines Crash near Amsterdam in 2009. The results of the triage and the injuries of P3 casualties were evaluated. In addition, the role of the trauma mechanism and its effect on spinal immobilisation during transport was analysed.

METHODS

Retrospective analysis of investigational reports, ambulance forms, and medical charts of survivors of the crash. Outcomes were triage classification, type of injury, AIS, ISS, emergency interventions and the spinal immobilisation during transport.

RESULTS

A minimal documentation of prehospital triage was found, and no exact numbers could be recollected. During inhospital triage 28% was triaged as P1, 10% had an ISS ≥ 16 and 3% met the modified Baxt criteria for emergency intervention. 40% was triaged P3, 72% had an ISS ≤ 8 and 63% was discharged from the Emergency Department after evaluation. In hospital over-triage was up to 89%. Critical mortality rate was 0%. Nine per cent of P3 casualties and 17% of 'walking' casualties had serious injuries. Twenty-two per cent of all casualties was transported with spinal immobilisation. Of the casualties diagnosed with spinal injury 22% was not transported with spinal immobilisation.

CONCLUSION

After the Turkish Airlines Crash documentation of prehospital triage was minimal. According to the Baxt criteria the overtriage was high. Injuries sustained by plane crash survivors that seem minimally harmed must not be underestimated. Considering the high energy trauma mechanism, too little consideration was given to spinal immobilisation during transport.

Is Overtriage Associated With Increased Mortality? Insights From a Simulation Model of Mass Casualty Trauma Care

Purpose: To examine the relationship between overtriage and critical mortality after a mass casualty incident (MCI) using a simulation model of trauma system response.

Methods: We created a discrete event simulation model of trauma system management of MCIs involving individual patient triage and treatment. Model variables include triage performance, treatment capability, treatment time, and time-dependent mortality of critically injured patients. We model triage as a variable selection process applied to a hypothetical population of critically and noncritically injured patients. Treatment capability is represented by staffed emergency department trauma bays with associated staffed operating rooms that are recycled after each use. We estimated critical and noncritical patient treatment times and time-dependent mortality rates from the trauma literature.

Results: In this simulation model, overtriage, the proportion of noncritical patients among all of those labeled as critical, has a positive, negative, or variable association with critical mortality depending on its etiology (ie, related to changes in triage sensitivity or to changes in the prevalence and total number of critical patients). In all of the modeled scenarios, the ratio of critical patients to treatment capability has a greater impact on critical mortality than overtriage level or time-dependent mortality assumption.

Conclusions: Increasing overtriage may have positive, negative, or mixed effects on critical mortality in this trauma system simulation model. These results, which contrast with prior analyses describing a positive linear relationship between overtriage and mortality, highlight the need for alternative metrics to describe trauma system response after MCIs. We explore using the relative number of critical patients to available and staffed treatment units, or the critical surge to capability ratio, which exhibits a consistent and nonlinear association with critical mortality in this model. (Disaster Med Public Health Preparedness. 2007;1(Suppl 1):S14–S24)

Health systems' "surge capacity": state of the art and priorities for future research

CONTEXT

Over the past decade, a number of high-impact natural hazard events, together with the increased recognition of pandemic risks, have intensified interest in health systems' ability to prepare for, and cope with, "surges" (sudden large-scale escalations) in treatment needs. In this article, we identify key concepts and components associated with this emerging research theme. We consider the requirements for a standardized conceptual framework for future research capable of informing policy to reduce the morbidity and mortality impacts of such incidents. Here our objective is to appraise the consistency and utility of existing conceptualizations of health systems' surge capacity and their components, with a view to standardizing concepts and measurements to enable future research to generate a cumulative knowledge base for policy and practice.

METHODS

A systematic review of the literature on concepts of health systems' surge capacity, with a narrative summary of key concepts relevant to public health.

FINDINGS

The academic literature on surge capacity demonstrates considerable variation in its conceptualization, terms, definitions, and applications. This, together with an absence of detailed and comparable data, has hampered efforts to develop standardized conceptual models, measurements, and metrics. Some degree of consensus is evident for the components of surge capacity, but more work is needed to integrate them. The overwhelming concentration in the United States complicates the generalizability of existing approaches and findings.

CONCLUSIONS

The concept of surge capacity is a useful addition to the study of health systems' disaster and/or pandemic planning, mitigation, and response, and it has far-reaching policy implications. Even though research in this area has grown quickly, it has yet to fulfill its potential to generate knowledge to inform policy. Work is needed to generate robust conceptual and analytical frameworks, along with innovations in data collection and methodological approaches that enhance health systems' readiness for, and response to, unpredictable high-consequence surges in demand.

Duration and predictors of emergency surgical operations--basis for medical management of mass casualty incidents

BACKGROUND

Hospitals have a critically important role in the management of mass causality incidents (MCI), yet there is little information to assist emergency planners. A significantly limiting factor of a hospital's capability to treat those affected is its surgical capacity. We therefore intended to provide data about the duration and predictors of life saving operations.

METHODS

The data of 20,815 predominantly blunt trauma patients recorded in the Trauma Registry of the German-Trauma-Society was retrospectively analyzed to calculate the duration of life-saving operations as well as their predictors. Inclusion criteria were an ISS≥16 and the performance of relevant ICPM-coded procedures within 6h of admission.

RESULTS

From 1,228 patients fulfilling the inclusion criteria 1,793 operations could be identified as life-saving operations. Acute injuries to the abdomen accounted for 54.1% followed by head injuries (26.3%), pelvic injuries (11.5%), thoracic injuries (5.0%) and major amputations (3.1%). The mean cut to suture time was 130min (IQR 65-165min). Logistic regression revealed 8 variables associated with an emergency operation: AIS of abdomen ≥3 (OR 4,00), ISS ≥35 (OR 2,94), hemoglobin level ≤8 mg/dL (OR 1,40), pulse rate on hospital admission <40 or >120/min (OR 1,39), blood pressure on hospital admission <90 mmHg (OR 1,35), prehospital infusion volume ≥2000 ml (OR 1,34), GCS ≤8 (OR 1,32) and anisocoria (OR 1,28) on-scene.

CONCLUSIONS

The mean operation time of 130min calculated for emergency life-saving surgical operations provides a realistic guideline for the prospective treatment capacity which can be estimated and projected into an actual incident admission capacity. Knowledge of predictive factors for life-saving emergency operations helps to identify those patients that need most urgent operative treatment in case of blunt MCI.

UK triage--an improved tool for an evolving threat

INTRODUCTION

A key challenge at a major incident is to quickly identify those casualties most urgently needing treatment in order to survive - triage. The UK Triage Sieve (TS) advocated by the Major Incident Medical Management (MIMMS) Course categorises casualties by ability to walk, respiratory rate (RR) and heart rate (HR) or capillary refill time. The military version (MS) includes assessment of consciousness. We tested whether the MS better predicts need for life-saving intervention in a military trauma population. Ideal HR, RR and Glasgow Coma Score (GCS) thresholds were calculated.

METHODS

A gold standard Priority 1 casualty was defined using resource-based criteria. Pre-hospital data from a military trauma database allowed calculation of triage category, which was compared with this standard, and presented as 2×2 tables. Sensitivity and specificity of each physiological parameter was calculated over a range of values to identify the ideal cut-offs.

RESULTS

A gold standard could be ascribed in 1657 cases. In 1213 both the MS and TS could ascribe a category. MS was significantly more sensitive than TS (59% vs 53%, p<0.001) with similar specificity (89 vs 88%). Varying the limits for each parameter allowed some improvements in sensitivity (70-80%) but specificity dropped rapidly.

DISCUSSION

Previous studies support the inclusion of GCS assessment for blunt as well as penetrating trauma. Optimising the physiological cut-offs increased sensitivity in this sample to only 71% - a Sieve based purely on physiological parameters may not be capable of an acceptable level of sensitivity.

CONCLUSIONS

The MS is more sensitive than the TS. Major incident planners utilising the Sieve should consider adopting the military version as their first line triage tool. If validated, altering the HR and RR thresholds may further improve the tool.

The Fort Hood Massacre: Lessons learned from a high profile mass casualty

BACKGROUND

On November 5, 2009, an army psychiatrist at Fort Hood in Killeen, TX, allegedly opened fire at the largest US military base in the world, killing 13 and wounding 32.

METHODS

Data from debriefing sessions, news media, and area hospitals were reviewed.

RESULTS

Ten patients were initially transferred to the regional Level I trauma center. The remainder of the shooting victims were triaged to two other local regional hospitals. National news networks broadcasted the Level I trauma center's referral phone line which resulted in more than 1,300 calls. The resulting difficulties in communication led to the transfer of two victims (one critical) to a regional hospital without a trauma designation.

CONCLUSIONS

Triage at the scene was compromised by a lack of a secure environment, leading to undertriage of several patients. Overload of routine communication pathways compounded the problem, suggesting redundancy is crucial.

LEVEL OF EVIDENCE

Prognostic study, level V.

A web-based model to support patient-to-hospital allocation in mass casualty incidents

BACKGROUND

In a mass casualty situation, evacuation of severely injured patients to the appropriate health care facility is of critical importance. The prehospital stage of a mass casualty incident (MCI) is typically chaotic, characterized by dynamic changes and severe time constraints. As a result, those involved in the prehospital evacuation process must be able to make crucial decisions in real time. This article presents a model intended to assist in the management of MCIs. The Mass Casualty Patient Allocation Model has been designed to facilitate effective evacuation by providing key information about nearby hospitals, including driving times and real-time bed capacity. These data will enable paramedics to make informed decisions in support of timely and appropriate patient allocation during MCIs. The model also enables simulation exercises for disaster preparedness and first response training.

METHODS

Road network and hospital location data were used to precalculate road travel times from all locations in Metro Vancouver to all Level I to III trauma hospitals. Hospital capacity data were obtained from hospitals and were updated by tracking patient evacuation from the MCI locations. In combination, these data were used to construct a sophisticated web-based simulation model for use by emergency response personnel.

RESULTS

The model provides information critical to the decision-making process within a matter of seconds. This includes driving times to the nearest hospitals, the trauma service level of each hospital, the location of hospitals in relation to the incident, and up-to-date hospital capacity.

CONCLUSION

The dynamic and evolving nature of MCIs requires that decisions regarding prehospital management be made under extreme time pressure. This model provides tools for these decisions to be made in an informed fashion with continuously updated hospital capacity information. In addition, it permits complex MCI simulation for response and preparedness training.

Traumatic Brain Injuries after Mass-Casualty Incidents: Lessons from the 11 September 2001 World Trade Center Attacks

Introduction:

The 11 September 2001 terrorist attacks on the World Trade Center (WTC) resulted in thousands of deaths and injuries. Research on previous bombings and explosions has shown that head injuries, including traumatic brain injuries (TBIs), are among the most common injuries.

Objective:

The objective of this study was to identify diagnosed and undiagnosed (undetected) TBIs among persons hospitalized in New York City following the 11 September 2001 WTC attacks.

Methods:

The medical records of persons admitted to 36 hospitals in New York City with injuries or illnesses related to the WTC attacks were abstracted for signs and symptoms of TBIs. Diagnosed TBIs were identified using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Undiagnosed TBIs were identified by an adjudication team of TBI experts that reviewed the abstracted medical record information. Persons with an undiagnosed TBI were contacted and informed of the diagnosis of potential undetected injury.

Results:

A total of 282 records were abstracted. Fourteen cases of diagnosed TBIs and 21 cases of undiagnosed TBIs were identified for a total of 35 TBI cases (12% of all of the abstracted records). The leading cause of TBI was being hit by falling debris (22 cases). One-third of the TBIs (13 cases) occurred among rescue workers.More than three years after the event, four out of six persons (66.67%) with an undiagnosed TBI who were contacted reported they currently were experiencing symptoms consistent with a TBI.

Conclusions:

Not all of the TBIs among hospitalized survivors of the WTC attacks were diagnosed at the time of acute injury care. Some persons with undiagnosed TBIs reported problems that may have resulted from these TBIs three years after the event. For hospitalized survivors of mass-casualty incidents, additional in-hospital, clinical surveys could help improve pre-discharge TBI diagnosis and provide the opportunity to link patients to appropriate outpatient services. The use and adequacy of head protection for rescue workers deserves re-evaluation.

Disaster metrics: a proposed quantitative model for benchmarking prehospital medical response in trauma-related multiple casualty events

INTRODUCTION

Quantitative benchmarking of trauma-related prehospital response for Multiple Casualty Events (MCE) is complicated by major difficulties due to the simultaneous occurrences of multiple prehospital activities.

HYPOTHESIS/PROBLEM

Attempts to quantify the various components of prehospital medical response in MCE have fallen short of a comprehensive model. The objective of this study was to model the principal parameters necessary to quantitatively benchmark the prehospital medical response in trauma-related MCE.

METHODS

A two-step approach was adopted for the methodology of this study: an extensive literature search was performed, followed by prehospital system quantitative modeling. Studies on prehospital medical response to trauma injuries were used as the framework for the proposed model. The North Atlantic Treaty Organization (NATO) triage categories (T1-T4) were used for the study.

RESULTS

Two parameters, the Injury to Patient Contact Interval (IPCI) and Injury to Hospital Interval (IHI), were identified and proposed as the principal determinants of the medical prehospital response in trauma-related MCE. IHI is the time interval from the occurrence of injury to the completion of transfer of care of critical (T1) and moderate (T2) patients. The IHI for each casualty is compared to the Maximum Time Allowed described in the literature (golden hour for T1 and Friedrich's time for T2). In addition, the medical rescue factor (R) was identified as the overall indicator for the prehospital medical performance for T1 and T2, and a numerical value of one (R = 1) was proposed to be the quantitative benchmark.

CONCLUSION

A new quantitative model for benchmarking prehospital response to MCE in trauma-related MCE is proposed. Prospective studies of this model are needed to validate its applicability.

Utstein-style template for uniform data reporting of acute medical response in disasters

BACKGROUND

In 2003, the Task Force on Quality Control of Disaster Management (WADEM) published guidelines for evaluation and research on health disaster management and recommended the development of a uniform data reporting tool. Standardized and complete reporting of data related to disaster medical response activities will facilitate the interpretation of results, comparisons between medical response systems and quality improvement in the management of disaster victims.

METHODS

Over a two-year period, a group of 16 experts in the fields of research, education, ethics and operational aspects of disaster medical management from 8 countries carried out a consensus process based on a modified Delphi method and Utstein-style technique.

RESULTS

The EMDM Academy Consensus Group produced an Utstein-style template for uniform data reporting of acute disaster medical response, including 15 data elements with indicators, that can be used for both research and quality improvement.

CONCLUSION

It is anticipated that the Utstein-style template will enable better and more accurate completion of reports on disaster medical response and contribute to further scientific evidence and knowledge related to disaster medical management in order to optimize medical response system interventions and to improve outcomes of disaster victims.

Effect of a mass casualty incident: clinical outcomes and hospital charges for casualty patients versus concurrent inpatients

OBJECTIVES

A mass casualty incident (MCI) may strain a health care system beyond surge capacity, affecting patterns of care for casualties and other patients. Prior studies of MCIs have assessed clinical care for casualty patients, but have not examined outcomes or expenditures for noncasualty inpatients in the same time period.

METHODS

This was a retrospective analysis of administrative hospital claims in a state where an MCI with over 200 casualties occurred; two hospitals that admitted casualties of >5% of their inpatient capacity were studied. The "surge period" was defined as 7 days after the MCI. Using diagnostic codes, patients admitted on the MCI day with diagnoses of burns or inhalation injury were included in the "MCI surge cohort." Patients admitted within a time frame of 7 days prior to 7 days after the MCI who were inpatients during the surge period were included in the "non-MCI surge cohort." The authors compared the MCI and non-MCI surge cohorts to a mutually exclusive reference cohort (all inpatients during 6 weeks prior to the MCI), regarding key outcomes of hospital length of stay (LOS) and hospital charges adjusted for age, sex, race/ethnicity, and severity of illness.

RESULTS

Fifty-five patients met criteria for the MCI surge cohort, 1,369 for the non-MCI surge cohort, and 5,980 for the reference group. Compared with the reference group and adjusted for covariates, the mean (±SD) hospital LOS was 4.90 (±1.85) days longer for the MCI surge cohort (95% confidence interval [CI] = 1.67 to 8.84) and 1.34 (±0.16) days longer for the non-MCI surge cohort (95% CI = 1.00 to 1.65). The MCI cohort also had significantly longer mean hospital LOS than the non-MCI surge cohort (difference = 3.56 days; 95% CI = 0.36 to 7.36). Also adjusted for covariates, mean (±SD) total hospital charges for the MCI surge cohort were $22,349 (±$8,342) greater than for the reference group (95% CI = $8,182 to $39,485). Mean (±SD) charges for the non-MCI surge cohort were $4,028 (±$633) greater than for the reference group (95% CI = $2,792 to $5,196). The MCI cohort also had higher mean total charges than the non-MCI surge cohort (difference = $18,321; 95% CI = $4,488 to $34,980).

CONCLUSIONS

When adjusted for severity of illness, casualty patients and noncasualty patients receiving concurrent hospital care have significantly longer LOS and higher charges than typical hospital patients at times unaffected by MCIs. Spillover effects from MCIs for noncasualty patients have not been previously described and have implications for clinical and hospital management in MCI and other high-surge circumstances.

The role of the radiology department during the London bombings, 7 July 2005: Lessons learnt and strategy in 2011

In the modern age, any major hospital needs to be prepared for a major incident and the radiology department plays a vital role in managing severely injured patients in an efficient manner in this setting. With this in mind, this article describes the impact of the London bombings of 7 July 2005 on the radiology department of the Royal London Hospital in East London. We will describe some of the underlying principles and concepts in major incident management, how the major incident was managed, the lessons learnt from our performance and changes to policies and protocols that have been initiated in response to these lessons.

In 'big bang' major incidents do triage tools accurately predict clinical priority?: a systematic review of the literature

INTRODUCTION

The term "big bang" major incidents is used to describe sudden, usually traumatic,catastrophic events, involving relatively large numbers of injured individuals, where demands on clinical services rapidly outstrip the available resources. Triage tools support the pre-hospital provider to prioritise which patients to treat and/or transport first based upon clinical need. The aim of this review is to identify existing triage tools and to determine the extent to which their reliability and validity have been assessed.

METHODS

A systematic review of the literature was conducted to identify and evaluate published data validating the efficacy of the triage tools. Studies using data from trauma patients that report on the derivation, validation and/or reliability of the specific pre-hospital triage tools were eligible for inclusion.Purely descriptive studies, reviews, exercises or reports (without supporting data) were excluded.

RESULTS

The search yielded 1982 papers. After initial scrutiny of title and abstract, 181 papers were deemed potentially applicable and from these 11 were identified as relevant to this review (in first figure). There were two level of evidence one studies, three level of evidence two studies and six level of evidence three studies. The two level of evidence one studies were prospective validations of Clinical Decision Rules (CDR's) in children in South Africa, all the other studies were retrospective CDR derivation, validation or cohort studies. The quality of the papers was rated as good (n=3), fair (n=7), poor (n=1).

CONCLUSION

There is limited evidence for the validity of existing triage tools in big bang major incidents.Where evidence does exist it focuses on sensitivity and specificity in relation to prediction of trauma death or severity of injury based on data from single or small number patient incidents. The Sacco system is unique in combining survivability modelling with the degree by which the system is overwhelmed in the triage decision system. The practicalities, training implications, performance characteristics and reliance on computer technology during a mass casualty incident require further evaluation.

Role of emergency medical services in disaster response: resource document for the National Association of EMS Physicians position statement

The National Association of EMS Physicians (NAEMSP) advocates for a strong emergency medical services (EMS) role in all phases of disaster management--preparedness, response, and recovery. Emergency medical services administrators and medical directors should play a leadership role in preparedness activities such as training and education, development of performance metrics, establishment of memoranda of understanding (MOUs), and planning for licensure and liability issues. During both the planning and response phases, EMS leadership should advocate for participation in unified command, modified scope of practice appropriate for providers and the event, and expanded roles in community and federal response efforts. To enhance recovery, EMS leadership should strongly advocate for national recognition for EMS efforts and further research into strategies that foster healthy coping techniques and resiliency in the EMS workforce. This resource document will outline the basis for the corresponding NAEMSP position statement on the role of EMS in disaster management.

Poorer outcomes for mass casualty events victims: is it evidence based?

BACKGROUND

The sudden influx of patients during mass casualty events (MCEs) may compromise the quality of care provided and possibly impact on the medical outcomes of these patients. To test this assumption, a comparison must be made between injuries sustained in MCE and non-MCE events caused by the same mechanism. The mechanism of injury selected for this study was gunshot wounds, which occur in both types of event.

METHODS

A retrospective study was carried out using the Israel's National Trauma Registry data on patients hospitalized between November 1, 2000, and December 31, 2005, as a result of high-energy gunshot trauma. Descriptive statistics and bivariate analysis were used to characterize injury patterns, and multivariate analysis was used to determine factors influencing inpatient mortality.

RESULTS

Of 462 patients with gunshot wounds, 120 cases (26.38%) were defined as MCE and 342 (73.62%) as non-MCE. Both populations had ∼30% of severely injured patients (Injury Severity Score 16+). MCE patients had undergone significantly fewer operational procedures. No differences between MCE and non-MCE were found in intensive care units utilization. The likelihood of death as a result of MCE was 2.75 (CI 1.09-7.02) times higher than non-MCE. Factors influencing this difference are the number of injured regions and injuries to the brain, chest, and abdomen.

CONCLUSIONS

MCE patients have a significantly higher mortality than non-MCE patients, not manifesting substantial differences in the severity of injuries. The absence of difference in intensive care units utilization may be related to the effectiveness of existing protocols for dealing with MCEs.

Disaster metrics: quantitative benchmarking of hospital surge capacity in trauma-related multiple casualty events

OBJECTIVES

Hospital surge capacity in multiple casualty events (MCE) is the core of hospital medical response, and an integral part of the total medical capacity of the community affected. To date, however, there has been no consensus regarding the definition or quantification of hospital surge capacity. The first objective of this study was to quantitatively benchmark the various components of hospital surge capacity pertaining to the care of critically and moderately injured patients in trauma-related MCE. The second objective was to illustrate the applications of those quantitative parameters in local, regional, national, and international disaster planning; in the distribution of patients to various hospitals by prehospital medical services; and in the decision-making process for ambulance diversion.

METHODS

A 2-step approach was adopted in the methodology of this study. First, an extensive literature search was performed, followed by mathematical modeling. Quantitative studies on hospital surge capacity for trauma injuries were used as the framework for our model. The North Atlantic Treaty Organization triage categories (T1-T4) were used in the modeling process for simplicity purposes.

RESULTS

Hospital Acute Care Surge Capacity (HACSC) was defined as the maximum number of critical (T1) and moderate (T2) casualties a hospital can adequately care for per hour, after recruiting all possible additional medical assets. HACSC was modeled to be equal to the number of emergency department beds (#EDB), divided by the emergency department time (EDT); HACSC = #EDB/EDT. In trauma-related MCE, the EDT was quantitatively benchmarked to be 2.5 (hours). Because most of the critical and moderate casualties arrive at hospitals within a 6-hour period requiring admission (by definition), the hospital bed surge capacity must match the HACSC at 6 hours to ensure coordinated care, and it was mathematically benchmarked to be 18% of the staffed hospital bed capacity.

CONCLUSIONS

Defining and quantitatively benchmarking the different components of hospital surge capacity is vital to hospital preparedness in MCE. Prospective studies of our mathematical model are needed to verify its applicability, generalizability, and validity.

Overall Asessment of the Response to Terrorist Bombings in Trains, Madrid, 11 March 2004

OBJECTIVES

To provide an overall assessment of the response to the terrorist bombings in Madrid, 11 March 2004, which were considered the deadliest terrorist attack on European soil in modern times.

MATERIALS AND METHODS

Overall data on the number of victims treated at the scenes and at primary care facilities and hospitals, as well as the logistics involved, were reported by the EMS and the Health Authority of the Comunidad de Madrid local government. Data were mainly obtained by retrospective chart review, and did not include casualties who had only emotional shock, superficial bruises or transient hearing loss from barotraumas without eardrum perforation. We defined as critical any casualty with an Injury Severity Score (ISS) >15.

RESULTS

Over 70,000 personnel were mobilized in the care of the victims. EMS response and total evacuation times at the four blast scenes averaged 7 and 99 min, respectively. There were around 2,000 casualties, and a typical bimodal distribution of deaths, with 177 immediate fatalities and 14 subsequent in-hospital deaths. Almost 60% of casualties were taken to the two closest hospitals. Problems related to security, identification of casualties and record-keeping were encountered at the closest hospital. Closed doors increased the immediate fatality rate in the trains. Most survivors had noncritical injuries, but 14% of the 512 casualties assessed had an ISS >15. The critical mortality rate was 19.5%. The most frequently injured body regions were the head/neck and face. In all, 124 major surgical interventions were performed on 82 victims in the first 24 h, and orthopedic trauma procedures accounted for 50% of the case load. Most patients with lung injuries from the blasts required intubation and mechanical ventilation, and their survival rate was 88.3%. Also, 35% of laparotomies were either negative or nontherapeutic.

CONCLUSION

There was a rapid EMS response and evacuation, but also overtriage, uneven distribution of casualties and difficulties in communication. The sizes and resources of the closest hospitals, as well as the early hour, were probably decisive in the adequacy of the overall response.

'Damage control orthopaedics' in patients with delayed referral to a tertiary care center: experience from a place where Composite Trauma Centers do not exist

BACKGROUND

Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted on 51 cases after reviewing their records and complete management one year after the trauma.

RESULTS

At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality.

CONCLUSION

In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases.

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.

[Estimation of surgical treatment capacity for managing mass casualty incidents based on time needed for life-saving emergency operations]

The surgical treatment capacity of a hospital constitutes a significant restriction in the capability to deal with critically injured patients from multiple or mass casualty incidents (MCI). With regard to the time needed for life-saving operative interventions there are no basic reference values available in the literature, which can aid in detailed planning for management of mass casualty incidents. The data of 20,815 trauma patients, recorded in the trauma registry hosted by the German Association for Trauma Surgery DGU, were analyzed to extract the median duration of life-saving surgical interventions carried out in an operating theatre. Inclusion criteria were an ISS > or = 16 and the performance of relevant ICPM coded procedures within 6 h after trauma room admission. Orthopedic procedures as well as the placement of ICP catheters and chest tubes or performance of laparoscopies were not included. Complete data sets with the required variables were available from 9,988 trauma patients with an ISS > or = 16, and included 7,907 interventions that took place within 6 h after hospital admission. From among 1,228 patients 1,793 operations could be identified as relevant life-saving emergency operations. Acute injury to the abdomen was the major cause accounting for 54.1% of all emergency surgical procedures with a median intervention duration of 137 min followed by head injuries accounting for 26.3% with a median duration of 110 min. Interventions in the pelvis amounted to 11.5% taking an average of 136 min, 5.0% were in the thorax requiring 91 min and 3.1% major amputations with 142 min. The average cut to suture time for all emergency surgical interventions was 130 min. A prerequisite for estimating the surgical operation capacity for critically injured patients of an MCI is the number of OR teams available during and outside of the normal working hours of the hospital. The average operation time of 130 min calculated from investigation of 1,793 emergency life-saving surgical procedures provides a realistic guideline. Used in combination with the number of available OR teams the prospective treatment capacity can be estimated and projected into an actual incident admission capacity. The identification and numerical value of such significant variables are the basis for operations research and realistic planning in emergency and disaster medicine.

Caring for a surge of Hurricane Katrina evacuees in primary care clinics

Primary care physicians are rarely mentioned in medical disaster plans. We describe how a group of mostly family physicians and administrators of the JPS Health Network (JPS) took primary responsibility for 3,700 evacuees of Hurricane Katrina who came to Tarrant County, Texas. JPS provided medical care to 1,664 (45%) evacuees during a 2-week period. The most common needs were medications for chronic illnesses and treatment of skin infections (primarily on the feet). The JPS Emergency Department saw only 148 evacuees, most of whom arrived by their own transportation and were not seriously ill. JPS created a triage center located several miles from the hospital that referred almost all evacuees with health care needs to a primary care clinic. It was an effective approach for caring for the medical needs of disaster victims and prevented an emergency department and hospital from being overwhelmed. The JPS experience may guide future planning efforts for natural or manmade disasters, especially pandemic threats.

Pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care

BACKGROUND

Federal planners have suggested that one strategy to accommodate disaster surges of 500 inpatients per million population would involve altering standards of care. No data are available indicating the extent of alterations necessary to meet disaster surge targets.

OBJECTIVE

Our goal was to, in a Monte Carlo simulation study, determine the probability that specified numbers of children could be accommodated for PICU and non-ICU hospital care in a disaster by a set of strategies involving altered standards of care.

METHODS

Simulated daily vacancies at each hospital in New York City were generated as the difference between peak capacity and daily occupancy (generated randomly from a normal distribution on the basis of empirical data for each hospital). Simulations were repeated 1000 times. Capacity for new patients was explored for normal standards of care, for expansion of capacity by a discretionary 20% increase in vacancies by altering admission and discharge criteria, and for more strictly reduced standards of care to double or quadruple admissions for each vacancy. Resources were considered to reliably serve specified numbers of patients if that number could be accommodated with a probability of 90%.

RESULTS

Providing normal standards of care, hospitals in New York City would reliably accommodate 250 children per million age-specific population. Hypothetical strict reductions in standards of care would reliably permit hospital care of 500 children per million, even if the disaster reduced hospital resources by 40%. On the basis of historical experience that as many as 30% of disaster casualties may be critically ill or injured, existing pediatric intensive care beds will typically be insufficient, even with modified standards of care.

CONCLUSIONS

Extending resources by hypothetical alterations of standards of care would usually satisfy targets for hospital surge capacity, but ICU capacity would remain inadequate for large disasters.