The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster

Organisational learning from the public health response to the COVID-19 pandemic: findings from a qualitative interview study

System learning from major incidents is essential for enhancing preparedness for responding to future adverse events. Sharing learning not only stimulates further improvements, preventing the repetition of mistakes, but may also promote collaboration and the adoption of evidenced-based best practises. As part of a qualitative interview study designed to explore lessons learned, this paper describes the experiences and perspectives of 30 staff from the public health agency responsible for the national COVID-19 response in the United Kingdom. The focus of the interviews was on enabling factors and practises that worked well, as well as those that were more challenging, and which, if addressed, could improve responses to future infectious disease incidents. The interviews elicited valuable insights across various thematic areas that could inform emergency preparedness activities for future infectious disease outbreaks. The outcomes of this study, while integral for the UK agency responsible for public health, extend beyond organisational boundaries and contribute to a broader spectrum of activities aimed at facilitating global learning from the COVID-19 response.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]

BACKGROUND

Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment.

OBJECTIVE

The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany.

MATERIAL AND METHOD

The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account.

RESULTS AND DISCUSSION

The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

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.

The Oregon District Shooting: Reviewing the Pre-Hospital Protocols and the Role of the Resident During a Multiple Casualty Event

Background: Review of multiple casualty events (MCEs) protocols in an academic trauma center and more importantly role of residents in management of MCEs has not been discussed. Also, no real-world examples have been described. This study reviews utilization of multiple casualty protocols by the area hospitals and EMS along with role of residents in one such real-world MCEMethods: A mass shooting event in the Oregon District in Dayton, Ohio from 2019 was reviewed. MCE protocols from a Level I trauma center were reviewed as well as patient outcomes and role of residents.Results: A total of 10 casualties were observed and 38 patients presented to hospitals throughout the city. There were 25 patients presented to the Level I trauma center, 1 to the Level II trauma center, and 12 to the Level III trauma centers in the community. Surgical and Emergency residents performed initial triage upon arrival to the ED, managed resuscitation, and performed various procedures under supervision of attending staff. A total of 5 patients required emergent surgery and 4 patients required tourniquets. All patients that were presented to the hospitals survived.Conclusion: MCEs are going to continue, and healthcare systems should have protocols in place. Residents are a valuable resource to hospital systems that provide trauma services. Creation of a protocol with the assistance of EMS will allow first responders to utilize resources available. We recommend testing of this protocol, as an MCE in your area may not be a matter of if, but when.

The State of the Union: Trauma System Development in the United States

Injury is both a national and international epidemic that affects people of all age, race, religion, and socioeconomic class. Injury was the fourth leading cause of death in the United States (U.S.) in 2021 and results in an incalculable emotional and financial burden on our society. Despite this, when prevention fails, trauma centers allow communities to prepare to care for the traumatically injured patient. Using lessons learned from the military, trauma care has grown more sophisticated in the last 50 years. In 1966, the first civilian trauma center was established, bringing management of injury into the new age. Now, the American College of Surgeons recognizes 4 levels of trauma centers (I-IV), with select states recognizing Level V trauma centers. The introduction of trauma centers in the U.S. has been proven to reduce morbidity and mortality for the injured patient. However, despite the proven benefits of trauma centers, the U.S. lacks a single, unified, trauma system and instead operates within a "system of systems" creating vast disparities in the level of care that can be received, especially in rural and economically disadvantaged areas. In this review we present the history of trauma system development in the U.S, define the different levels of trauma centers, present evidence that trauma systems and trauma centers improve outcomes, outline the current state of trauma system development in the U.S, and briefly mention some of the current challenges and opportunities in trauma system development in the U.S. today.

American Trauma Care: A System of Systems

OBJECTIVE

The benefits of organized trauma systems have been well-documented during 50 years of trauma system development in the United States. Unfortunately, despite this evidence, trauma system development has occurred only sporadically in the 50 states.

METHODS

The relevant literature related to trauma system design and development was reviewed based on relevance to the study. Information from these sources was summarized into a SWOT (strengths, weaknesses, opportunities, and threats) analysis.

RESULTS

Strengths discovered were leadership brought forth by the American College of Surgeons Committee on Trauma and meaningful change generated from The National Academy of Sciences, Engineering, and Medicine report addressing the fractionation of the nation's trauma systems, whereas weaknesses included patient outcome disparities due to the lack of a national governing authority, undertriage, underresourced rural trauma, and underfunded trauma research. Opportunities included the creation of level IV trauma centers; telemedicine; the development of rural trauma management courses; air medical transport to bring high-intensity care to the patient, particularly in rural areas; trauma research; and trauma prevention through outreach and educational programs. The following threats were determined: mass casualty incidents, motor vehicle collisions because of the high rate of motor vehicle collision deaths in the United States relative to other developed countries, and underfunded trauma systems.

CONCLUSION

Much work remains to be done in the development of an American trauma system. Recommendations include implementation of trauma care governance at the federal level; national oversight and support of emergency medical services systems, particularly in rural areas with strict reporting processes for emergency medical services programs; national organization of our mass casualty response; increased federal and state funding allocated to trauma centers; a consistent model for trauma system development; and trauma research.

Are trauma surgeons prepared? A survey of trauma surgeons' disaster preparedness before and during the COVID-19 pandemic

Objective

US trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However, trauma surgeons may lack formal MCI training. The recent COVID-19 pandemic drove multiple patient surges, overloaded Emergency Medical Services (EMS) agencies, and stressed TCs. This survey assessed trauma surgeons' MCI training, experience, and system and personal preparedness before the pandemic compared with the pandemic's third year.

Methods

Survey invitations were emailed to all 1544 members of the American Association for the Surgery of Trauma in 2019, and then resent in 2022 to 1575 members with additional questions regarding the pandemic. Questions assessed practice type, TC characteristics, training, experience, beliefs about personal and hospital preparedness, likelihood of MCI scenarios, interventions desired from membership organizations, and pandemic experiences.

Results

The response rate was 16.7% in 2019 and 12% in 2022. In 2022, surgeons felt better prepared than their hospitals for pandemic care, mass shootings, and active shooters, but remained feeling less well prepared for cyberattack and hazardous material events, compared with 2019. Only 35% of the respondents had unintentional MCI response experience in 2019 or 2022, and even fewer had experience with intentional MCI. 78% had completed a Stop the Bleed (STB) course and 63% own an STB kit. 57% had engaged in family preparedness activities; less than 40% had a family action plan if they could not come home during an MCI. 100% of the respondents witnessed pandemic-related adverse events, including colleague and coworker illness, patient surges, and resource limitations, and 17% faced colleague or coworker death.

Conclusions

Trauma surgeons thought that they became better at pandemic care and rated themselves as better prepared than their hospitals for MCI care, which is an opportunity for them to take greater leadership roles. Opportunities remain to improve surgeons' family and personal MCI preparedness. Surgeons' most desired professional organization interventions include advocacy, national standards for TC preparedness, and online training.

Level of evidence

VII, survey of expert opinion.

Rethinking the Current "Stage-and-Wait" Paradigm

INTRODUCTION

The experience of terrorist incidents involving a secondary explosive device that targeted rescue forces led to changes in the safety protocols of these forces in most countries of the world. These protocols are the foundation of the current "Stage-and-Wait" paradigm that prohibits the entry of Emergency Medical Services (EMS) from entering the scene and treating casualties until it is deemed safe. These guidelines were established absent of an evidence-base detailing the risk to responders and the potential consequences to the injured on-scene. The lack of clarity is compounded by the fact that different situations, as well as operational considerations, such as the length of time until bomb squad arrival at the scene versus time of massive bleeding injuries, for example, impact outcomes must be taken into account.

OBJECTIVE

This study sought to shed light on this matter while employing an evidence-based approach exploring the investigations of the frequency of secondary explosion threats in terrorist attacks over the last 20 years and discussing some of the ethical challenges and ramifications ensuing. While this study does not propose an outright change to current guidelines, in light of the evidence gathered, an open review and discussion based on the findings may be beneficial.

METHODS

The Global Terrorism Database (GTD) was used as the data source of bombing incidents world-wide.

RESULTS

The results revealed that approximately 70 per-1,000 bombing incidents involved secondary explosions across regions and countries within the study period.

CONCLUSION

This study emphasizes the need to rethink the current "Stage-and-Wait" paradigm by recommending brainstorming conferences comprised of multi-sectoral experts aimed at deliberating the matter. World-wide experts in emergency medicine, bioethics, and disaster management should cautiously consider all aspects of bomb-related incidents. These brainstorming deliberations should consider the calculated risk of secondary explosions that account for approximately 70 per-1,000 bombing incidents. This study highlights the need to re-examine the current versus new paradigm to achieve a better balance between the need to ensure EMS safety while also providing the necessary and immediate care to improve casualty survival. This ethical dilemma of postponing urgent care needs to be confronted.

Education and training as a key enabler of successful patient care in mass-casualty terrorist incidents

BACKGROUND AND PURPOSE

The increase in terrorist attacks with sometimes devastating numbers of victims has become a reality in Europe and has led to a fundamental change in thinking and a reorientation in many fields including health policy. The purpose of this original work was to improve the preparedness of hospitals and to provide recommendations for training.

MATERIAL AND METHODS

We conducted a retrospective literature search based on the Global Terrorism Database (GTD) for the period 2000 to 2017. Using defined search strategies, we were able to identify 203 articles. We grouped relevant findings into main categories with 47 statements and recommendations on education and training. In addition, we included data from a prospective questionnaire-based survey on this topic that we conducted at the 3rd Emergency Conference of the German Trauma Society (DGU) in 2019.

RESULTS

Our systematic review identified recurrent statements and recommendations. A key recommendation was that regular training should take place on scenarios that should be as realistic as possible and should include all hospital staff. Military expertise and competence in the management of gunshot and blast injuries should be integrated. In addition, medical leaders from German hospitals considered current surgical education and training to be insufficient for preparing junior surgeons to manage patients who have sustained severe injuries by terrorist events.

CONCLUSION

A number of recommendations and lessons learned on education and training were repeatedly identified. They should be included in hospital preparations for mass-casualty terrorist incidents. There appear to be deficits in current surgical training which may be offset by establishing courses and exercises.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Impact of time and distance on outcomes following tourniquet use in civilian and military settings: A scoping review

BACKGROUND

The last two decades have seen the reintroduction of tourniquets into guidelines for the management of acute limb trauma requiring hemorrhage control. Evidence supporting tourniquet application has demonstrated low complication rates in modern military settings involving rapid evacuation timeframes. It is unclear how these findings translate to patients who have prolonged transport times from injury in rural settings. This scoping review investigates the relationship between time and distance on metabolic complications, limb salvage and mortality following tourniquet use in civilian and military settings.

METHODS

A systematic search strategy was conducted using PubMed, Embase, and SafetyLit databases. Study characteristics, setting, mechanism of injury, prehospital time, tourniquet time, distance, limb salvage, metabolic response, mortality, and tourniquet removal details were extracted from eligible studies. Descriptive statistics were recorded, and studies were grouped by ischemia time (< 2 h, 2-4 h, or > 4 h).

RESULTS

The search identified 3103 studies, from which 86 studies were included in this scoping review. Of the 86 studies, 55 studies were primarily in civilian environments and 32 were based in military settings. One study included both settings. Blast injury was the most common mechanism of injury sustained by patients in military settings (72.8% [5968/8200]) followed by penetrating injury (23.5% [1926/8200]). In contrast, in civilian settings penetrating injury was the most common mechanism (47.7% [1633/3426]) followed by blunt injury (36.4% [1246/3426]). Tourniquet time was reported in 66/86 studies. Tourniquet time over four hours was associated with reduced limb salvage rates (57.1%) and higher mortality rates (7.1%) compared with a tourniquet time of less than two hours. The overall limb salvage and mortality rates were 69.6% and 6.7% respectively. Metabolic outcomes were reported in 28/86 studies with smaller sample sizes and inconsistencies in which parameters were reported.

CONCLUSION

This scoping review presents literature describing comparatively safe tourniquet application when used for less than two hours duration. However, there is limited research describing prolonged tourniquet application or when used for protracted distances, such that the impact of tourniquet release time on metabolic outcomes and complications remains unclear. Prospective studies utilizing the development of an international database to provide this dataset is required.

Incidence and Epidemiology of Traumatic Tympanic Membrane Rupture: A National Trauma Data Bank Analysis

The incidence of traumatic tympanic membrane rupture (TTMR) has increased over recent decades. The association of certain external injury causes and bone fracture patterns with TTMR is anecdotal. It has been suggested that a diagnosis of TTMR may be missed during the acute trauma admission. The authors sought to evaluate the incidence of TTMR according to external injury cause and evaluate the association of skull fracture patterns with TTMR using a national trauma database. A cross-sectional analysis of trauma encounters was conducted using the National Trauma Data Bank (NTDB) from 2008 to 2015. Demographic and injury data were abstracted. Poisson regression was used to determine the incidence rate ratios of tympanic membrane rupture by external injury cause and logistic regression was used to estimate odds ratios (OR) of TTMR by skull fracture type. A total of 8214 patients were identified with TTMR during acute admission. The majority were on average 30 years old, 76% male, 71% White, had a mean Injury Severity Score of 14, and 42% were admitted to level I centers. The incidence rate ratio was only higher in lightning related injuries [5.262; 95% confidence interval (CI): 4.194-6.602] when using those caused by explosives as a reference. Basilar skull (OR: 12.95; 95% CI: 12.095-12.866) and cranial vault (OR: 2.938; 95% CI: 2.647-3.260) fractures were most associated with TTMR. The high incidence TTMR in association with certain external causes of injury and types of skull fractures should drive screening in the acute setting in order to increase detection and reduce morbidity from missed injuries.

Making Space to Save Lives: A Critical Role for the Hospitalist During Mass Casualty Incidents

OBJECTIVE

An effective hospital response to mass casualty incidents (MCIs) requires rapid mobilization of personnel capable of caring for critically ill trauma patients and availability of resuscitation resources.

METHODS

Hospitals facing an MCI wrestle with the challenge of immediately adjusting their overextended clinical operations to resuscitate a large number of rapidly arriving patients without compromising the care of existing patients.

RESULTS

Hospitalists are well positioned to add significant value by off-loading the emergency department (ED) given their broad clinical expertise. We describe our institution's protocol to generate immediate and sustained surge capacity by integrating our hospitalist service into MCI response.

CONCLUSIONS

Our protocol details the safe and rapid transfer of care of existing ED patients to hospitalist teams to make ED staff and space available to care for incoming MCI patients.

Chemical, biological, radiological, nuclear, and explosives (CBRNEs) preparedness for sporting event mass gatherings: A systematic review of the literature

OBJECTIVE

Sporting events often constitute mass gatherings (MGs) featuring large crowds of spectators and participants. Our objective is to understand the current state of emergency preparedness for sporting events by examining past MG sporting events to evaluate mitigation, preparedness, response, and recovery against chemical, biological, radiological, nuclear, and explosive (CBRNE) events.

METHODS

In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature review was carried out among 10 literature databases. The quality and risk of bias in each reviewed publication was assessed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 5,597 publications were identified. Of these, 81 papers were selected for full text reads and 25 publications were accepted. The included articles documented sporting events worldwide, ranging from incidents occurring from 1972 to 2020. Cross-cutting themes found in best practices and recommendations were strategic communication, surveillance, planning and preparedness, and training and response.

CONCLUSION

More evidence-based guidelines are needed to ensure best practices in response and recovery for CBRNE incidents at sporting events. Public health risks as well as implementation barriers and opportunities to prepare for potential CBRNE threats at sporting event MGs require further investigation.

U.S. cities will not meet blood product resuscitation standards during major mass casualty incidents: Results of a THOR-AABB working party prospective analysis

BACKGROUND

Mass casualty incidents (MCIs) create an immediate surge in blood product demand. We hypothesize local inventories in major U.S. cities would not meet this demand.

STUDY DESIGN AND METHODS

A simulated blast in a large crowd estimated casualty numbers. Ideal resuscitation was defined as equal amounts of red blood cells (RBCs), plasma, platelets, and cryoprecipitate. Inventory was prospectively collected from six major U.S. cities at six time points between January and July 2019. City-wide blood inventories were classified as READY (>1 U/injured survivor), DEFICIENT (<10 U/severely injured survivor), or RISK (between READY and DEFICIENT), before and after resupply from local distribution centers (DC), and features of DEFICIENT cities were identified.

RESULTS

The simulated blast resulted in 2218 injured survivors including 95 with severe injuries. Balanced resuscitation would require between 950 and 2218 units each RBC, plasma, platelets and cryoprecipitate. Inventories in 88 hospitals/health systems and 10 DCs were assessed. Of 36 city-wide surveys, RISK inventories included RBCs (n = 16; 44%), plasma (n = 24; 67%), platelets (n = 6; 17%), and cryoprecipitate (n = 22; 61%) while DEFICIENT inventories included platelets (n = 30; 83%) and cryoprecipitate (n = 12; 33%). Resupply shifted most RBC and plasma inventories to READY, but some platelet and cryoprecipitate inventories remained at RISK (n = 24; 67% and n = 12; 33%, respectively) or even DEFICIENT (n = 11; 31% and n = 6; 17%, respectively). Cities with DEFICIENT inventories were smaller (p <.001) with fewer blood products per trauma bed (p <.001).

DISCUSSION

In this simulated blast event, blood product demand exceeded local supply in some major U.S. cities. Options for closing this gap should be explored to optimize resuscitation during MCIs.

Evidence-based Principles of Time, Triage and Treatment; Refining the Initial Medical Response to Massive Casualty Incidents

BACKGROUND

The overall approach to massive casualty triage has changed little in the past 200 years. As the military and civilian organizations prepare for the possibility of future large scale combat operations, terrorist attacks and natural disasters, potentially involving hundreds or even thousands of casualties, a modified approach is needed to conduct effective triage, initiate treatment and save as many lives as possible.

METHODS

Military experience and review of analyses from the Department of Defense Trauma Registry are combined to introduce new concepts in triage and initial casualty management.

FINDINGS

The classification of the scale of MASCAL, timeline of lifesaving interventions, immediate first pass actions prior to formal triage decisions during the first hour after injury, simplification of triage decisions, and the understanding that ultra-MASCAL will primarily require casualty movement and survival needs with few prehospital life-saving medical interventions are discussed.

CONCLUSION

Self-aid, bystander and first responder interventions are paramount and should be trained and planned extensively. Military and disaster planning should not only train these concepts, but should seek innovations to extend the timelines of effectiveness and to deliver novel capabilities within the timelines to the greatest extent possible.

LEVEL OF EVIDENCE

Level III, Prognostic and Epidemiological.

Civilian Population Victimization: A Systematic Review Comparing Humanitarian and Health Outcomes in Conventional and Hybrid Warfare

OBJECTIVE

The main objective of this study was to summarize the Hybrid War's core characteristics and humanitarian and medical impacts.

METHOD

A Systematic Literature Review according to PRISMA guidelines, using the following keywords, 'Hybrid War,' 'Humanitarian Law,' 'Human Rights,' 'Lawfare,' and search engines PubMed, Scopus, Web of Science, and Gothenburg University's database to collect literature from 2000 to 2022 in English was conducted. The eligibility of qualified articles was assessed, an inductive qualitative thematic analysis was applied, and the scientific evidence of each selected piece was evaluated.

RESULTS

The objectives of a Hybrid War are to achieve the tactical and strategic goals in a battle rather than to save civilian lives. It involves networks of state and non-state actors with various means of military and militia influences and strategies, creating difficulties in implementing, controlling, and evaluating the International Humanitarian Law's "A State responsibility" principle, to gain insight into an armed conflict. It targets populated civilian areas and raises ethical and moral concerns by using Lawfare.

CONCLUSIONS

Hybrid War's multi-domain action should be met with multi-dimensional approaches and a doctrine of 'acceptable losses.' Its characteristics and consequences should be learned and taught. Several measures need to be implemented to counteract its impacts, and a flexible surge capacity should be designed, planned, and executed.

An Analysis of Risk Factors for Emergencies in the Taipei Dome Complex

(1) Background: The Taipei Dome Complex is a composite park with a baseball dome, a shopping mall, restaurants, cinemas, and an office building. Sustainable cities and communities is one of the Sustainable Development Goals of the United Nations. Since it constitutes urban infrastructure, the sports park’s disaster risk management must be discussed. (2) Methods: This study focused on equipment safety, traffic, staffing, potential public risks, security management, and disaster events using an analytic hierarchy process (AHP) to determine the emergency risk factors. (3) Results: The top 14 risk factors for the Taipei Dome Complex’s tolerable risk probability account for almost 70% reliability (a moderate safety); they include insufficient fire facilities, fire, terrorist attack, earthquake, unclear escape or fire facilities signage, shortcomings in evacuation guidance, insufficient police resources, insufficient firefighting resources, MRT emergency, shortcomings in a moving line, hypoxia, insufficient medical personnel, a lack of staff training, and insufficient broadcast facilities. (4) Conclusions: Among the top 14 risk factors, security management ranks first, with a ratio of 80% (4/5), disaster events rank second, with a ratio of 75% (3/4), and staffing ranks third, with a ratio of 60% (3/5).

The Beirut Port Explosion Injuries and Lessons Learned: Results of the Beirut Blast Assessment for Surgical Services (BASS) Multicenter Study

OBJECTIVE

This multicenter study aims to describe the injury patterns, emergency management and outcomes of the blast victims, recognize the gaps in hospital disaster preparedness, and identify lessons to be learned.

SUMMARY BACKGROUND DATA

On August 4th, 2020, the city of Beirut, Lebanon suffered the largest urban explosion since Hiroshima and Nagasaki, resulting in hundreds of deaths and thousands of injuries.

METHODS

All injured patients admitted to four of the largest Beirut hospitals within 72 hours of the blast, including those who died on arrival or in the emergency department (ED), were included. Medical records were systematically reviewed for: patient demographics and comorbidities; injury severity and characteristics; prehospital, ED, operative, and inpatient interventions; and outcomes at hospital discharge. Lessons learned are also shared.

RESULTS

An estimated total of 1818 patients were included, of which 30 died on arrival or in the ED and 315 were admitted to the hospital. Among admitted patients, the mean age was 44.7 years (range: 1 week-93 years), 44.4% were female, and the median injury severity score (ISS) was 10 (5, 17). ISS was inversely related to the distance from the blast epicenter (r = --0.18, P = 0.035). Most injuries involved the upper extremities (53.7%), face (42.2%), and head (40.3%). Mildly injured (ISS <9) patients overwhelmed the ED in the first 2 hours; from hour 2 to hour 8 post-injury, the number of moderately, severely, and profoundly injured patients increased by 127%, 25% and 17%, respectively. A total of 475 operative procedures were performed in 239 patients, most commonly soft tissue debridement or repair (119 patients, 49.8%), limb fracture fixation (107, 44.8%), and tendon repair (56, 23.4%). A total of 11 patients (3.5%) died during the hospitalization, 56 (17.8%) developed at least 1 complication, and 51 (16.2%) were discharged with documented long-term disability. Main lessons learned included: the importance of having key hospital functions (eg, laboratory, operating room) underground; the nonadaptability of electronic medical records to disasters; the ED overwhelming with mild injuries, delay in arrival of the severely injured; and the need for realistic disaster drills.

CONCLUSIONS

We, therefore, describe the injury patterns, emergency flow and trauma outcome of patients injured in the Beirut port explosion. The clinical and system-level lessons learned can help prepare for the next disaster.

Lessons learned from terror attacks: thematic priorities and development since 2001-results from a systematic review

Purpose

The threat of national and international terrorism remains high. Preparation is the key requirement for the resilience of hospitals and out-of-hospital rescue forces. The scientific evidence for defining medical and tactical strategies often feeds on the analysis of real incidents and the lessons learned derived from them. This systematic review of the literature aims to identify and systematically report lessons learned from terrorist attacks since 2001.

Methods

PubMed was used as a database using predefined search strategies and eligibility criteria. All countries that are part of the Organization for Economic Cooperation and Development (OECD) were included. The time frame was set between 2001 and 2018.

Results

Finally 68 articles were included in the review. From these, 616 lessons learned were extracted and summarized into 15 categories. The data shows that despite the difference in attacks, countries, and casualties involved, many of the lessons learned are similar. We also found that the pattern of lessons learned is repeated continuously over the time period studied.

Conclusions

The lessons from terrorist attacks since 2001 follow a certain pattern and remained constant over time. Therefore, it seems to be more accurate to talk about lessons identified rather than lessons learned. To save as many victims as possible, protect rescue forces from harm, and to prepare hospitals at the best possible level it is important to implement the lessons identified in training and preparation.

Estimating the Number of Civilian Casualties in Modern Armed Conflicts-A Systematic Review

Objective: To examine the possibility of estimating the number of civilian casualties in modern armed conflicts. Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Scopus, and Web of Science search engines. The outcome was analyzed using a qualitative inductive thematic analysis. The scientific evidence of selected article was assessed, using the Health Evidence Quality Assessment Tool. Findings: The review of 66 included articles in this study indicates that with an increasing number of public health emergencies and the lack of vital elements of life such as water and food, emerging armed conflicts seem to be inevitable. In contrast to military-led cross-border traditional wars, modern armed conflicts affect internally on local communities and take civilian lives. Consequently, the measures and tools used in traditional military-led cross-border wars to adequately tally wounded and dead for many decades under the mandates of the International Humanitarian Law, is insufficient for modern warfare. While casualty counting during modern conflicts is deficient due to organizational, political or strategic reasons, the international organizations responsible for collecting such data (the International Federation of Red Cross and Red Crescent and International Institute of Humanitarian Law) face difficulties to access the conflict scene, resulting in under-reported, unreliable or no-reported data. Conclusion: There are challenges in estimating and counting the number of civilian casualties in modern warfare. Although the global need for such data is evident, the risks and barriers to obtaining such data should be recognized, and the need for new international involvement in future armed conflicts should be emphasized.

Mass casualty, intentional vehicular trauma and anaesthesia

The use of motor vehicles to initiate mass casualty incidents is increasing in frequency and such events are called intentional vehicular assaults. Perpetrators are inspired by a range of terrorist ideologies or have extremist views, criminal intent, or mental health issues. Assaults using a motor vehicle as the principal weapon of attack are easy to launch and require little to no forward planning. This makes them difficult for police and security agencies to predict, prevent, or interdict. With the increasing frequency of intentional vehicular assaults, anaesthesiologists in various settings may be involved in caring for victims and should be engaged in preparing for them. This narrative review examines the literature on vehicle assaults committed around the world and provides an overview of the unique injury patterns and considerations for the pre-hospital, perioperative, and critical care management of victims of these mass casualty events. The article discusses planning, education, and training in an attempt to reduce the mortality and morbidity of intentional vehicular assaults.

UK healthcare staff experiences and perceptions of a mass casualty terrorist incident response: a mixed-methods study

INTRODUCTION

System learning from major incidents is a crucial element of improving preparedness for response to any future incidents. Sharing good practice and limitations stimulates further actions to improve preparedness and prevents duplicating mistakes.

METHODS

This convergent parallel mixed methods study comprises data from responses to an online survey and individual interviews with healthcare staff who took part in the responses to three terrorist incidents in the UK in 2017 (Westminster Bridge attack, Manchester Arena Bombing and London Bridge attack) to understand limitations in the response and share good practices.

RESULTS

The dedication of NHS staff, staff availability and effective team work were the most frequently mentioned enabling factors in the response. Effective coordination between teams and a functional major incident plan facilitated an effective response. Rapid access to blood products, by positioning the blood bank in the ED, treating children and parents together and sharing resources between trauma centres were recognised as very effective innovative practices. Recent health emergency preparedness exercises (HEPEs) were valued for preparing both Trusts and individual staff for the response. Challenges included communication between ambulance services and hospitals, difficulties with patient identification and tracking and managing the return to 'normal' work patterns post event. Lack of immediately available clinical protocols to deal with blast injuries was the most commonly mentioned clinical issue. The need for psychosocial support for responding and supporting staff was identified.

DISCUSSION

Between-agencies communication and information sharing appear as the most common recurring problems in mass casualty incidents (MCIs). Recent HEPEs, which allowed teams, interdisciplinary groups, and different agencies to practice responding to similar simulated incidents, were important and informed actions during the real response. Immediate and delayed psychosocial support should be in place for healthcare staff responding to MCIs.

A composite sponge based on alkylated chitosan and diatom-biosilica for rapid hemostasis

Rapid control of bleeding is of great significance in military trauma and traffic accidents. In this study, alkylated chitosan (AC) and diatom biosilica (DB) were combined to develop a safe and effective hemostatic composite sponge (AC-DB sponge) for hemorrhage control. Due to the procoagulant chemical structure of AC-DB sponge, it exhibited rapid hemostatic ability in vitro (clotting time was shortened by 78% than that of control group), with favorable biocompatibility (hemolysis ratio < 5%, no cytotoxicity). The strong interface effect between AC-DB sponge and blood induced the erythrocyte and platelets activation, deformation and aggregation, intrinsic coagulation pathway activation, resulting in significant coagulation acceleration. AC-DB sponge had excellent performance in in vivo assessments with shortest clotting time (106.2 s) and minimal blood loss (328.5 mg). All above results proved that AC-DB sponge had great potential to be a safe and rapid hemostatic material.

The Direct and Indirect Costs of Treating the Victims of the 2016 Nice Terror Attacks in a Single Pediatric Hospital

OBJECTIVE

To analyze the cost of the terror attack in Nice in a single pediatric institution.

METHODS

We carried out descriptive analyses of the data coming from the Lenval University Children's Hospital of Nice database after the July 14, 2016 terror attack. The medical cost for each patient was estimated from the invoice that the hospital sent to public insurance. The indirect costs were calculated from the hospital's accounting, as the items that were previously absent or the difference between costs in 2016 versus the previous year.

RESULTS

The costs total 1.56 million USD, corresponding to 2% of Lenval Hospital's 2016 annual budget. Direct medical costs represented 9% of the total cost. The indirect costs were related to human resources (overtime, sick leave), revenue shortfall, and security and psychiatric reinforcement.

CONCLUSION

Indirect costs had a greater impact than did direct medical costs. Examining the level and variety of direct and indirect costs will lead to a better understanding of the consequences of terror acts and to improved preparation for future attacks.

Healthcare system impacts of the 2017 Manchester Arena bombing: evidence from a national trauma registry patient case series and hospital performance data

Introduction

In response to detonation of an improvised explosive device at the Manchester Arena on 22 May 2017, we aimed to use detailed information about injured patients flowing through hospital healthcare to objectively evaluate the preplanned responses of a regional trauma care system and to show how routinely collected hospital performance data can be used to assess impact on regional healthcare.

Methods

Data about injury severity, management and outcome for patients presenting to hospitals were collated using England’s major trauma registry for 30 days following hospital attendance. System-wide data about hospital performance were collated by National Health Service England’s North West Utilisation Management Unit and presented as Shewhart charts from 15 April 2017 to 25 June 2017.

Results

Detailed information was obtained on 153 patients (109 adults and 44 children) who attended hospital emergency departments after the incident. Within 6 hours, a network of 11 regional trauma care hospitals received a total of 138 patients (90%). For the whole patient cohort, median Injury Severity Score (ISS) was 1 (IQR 1–10) and median New ISS (NISS) was 2 (IQR 1–14). For the 75 patients (49%) attending a major trauma centre, median ISS was 7.5 (IQR 1–14) and NISS was 10 (IQR 3–22). Limb and torso body regions predominated when injuries were classified as major life threatening (Abbreviated Injury Scale>3). Ninety-three patients (61%) required hospital admission following emergency department management, with 21 (14%) requiring emergency damage control surgery and 24 (16%) requiring critical care. Three fatalities occurred during early resuscitative treatment and 150 (98%) survived to day 30. The increased system-wide hospital admissions and care activity was linked to increases in regional hospital care capacity through cancellations of elective surgery and increased community care. Consequently, there were sustained system-wide hospital service improvements over the following weeks.

Conclusions

The systematic collation of injured patient and healthcare system data has provided an objective evaluation of a regional major incident plan and provided insight into healthcare system resilience. Hospital patient care data indicated that a prerehearsed patient dispersal plan at incident scene was implemented effectively.

Implementation of disaster medicine education in German medical schools - a nationwide survey

Objectives: Floods, earthquakes and terror attacks in recent years emphasize the importance of disaster preparedness for the medical community. To best prepare doctors for providing optimal care in disaster situations, specific education and training should start at the medical school level. This study containes an online survey among German medical schools to evaluate the status quo of teaching disaster medicine and to reveal potential obstacles. Methods: The dean's offices of 36 German medical schools were contacted from April 2016 to May 2017. Via an e-mail link, recipients could anonymously and voluntarily access an online questionnaire (74 items, 42 with a four-point "Likert-like" scale, 12 yes/no questions and 20 with listed items to choose from). The answers were analyzed by descriptive statistics. Results: A total of 25 medical schools participated in the survey. Twenty respondents were in favor of expanding disaster medicine teaching at their institutions. Incorporating single topics ranging from triage (n=21) to accidents involving radioactive materials (n=4) into the curriculum varied widely. Only two schools had established a teaching coordinator for disaster medicine and only one e-learning course had been established. Twenty-one respondents regarded funding issues and 18 regarded organizational matters to be major hurdles in the future. Conclusion: Though most faculty representatives indicated that they favor expanding and implementing disaster medicine education, German medical schools still have a lot of room for enhancement in this field. The incorporation of e-learning tools could facilitate the expansion of disaster medicine teaching while simultaneously addressing the expressed concerns of the survey's participants and guarantee nationwide standardization.

An innovative emergency transportation scenario for mass casualty incident management: Lessons learnt from the Formosa Fun Color Dust explosion

The purpose of this research is to analyze and introduce a new emergency medical service (EMS) transportation scenario, Emergency Medical Regulation Center (EMRC), which is a temporary premise for treating moderate and minor casualties, in the 2015 Formosa Fun Color Dust Party explosion in Taiwan. In this mass casualty incident (MCI), although all emergency medical responses and care can be considered as a golden model in such an MCI, some EMS plans and strategies should be estimated impartially to understand the truth of the successful outcome.Factors like on-scene triage, apparent prehospital time (appPHT), inhospital time (IHT), and diversion rate were evaluated for the appropriateness of the EMS transportation plan in such cases. The patient diversion risk of inadequate EMS transportation to the first-arrival hospital is detected by the odds ratios (ORs). In this case, the effectiveness of the EMRC scenario is estimated by a decrease in appPHT.The average appPHTs (in minutes) of mild, moderate, and severe patients are 223.65, 198.37, and 274.55, while the IHT (in minutes) is 18384.25, 63021.14, and 83345.68, respectively. The ORs are: 0.4016 (95% Cl = 0.1032-1.5631), 0.1608 (95% Cl = 0.0743-0.3483), and 4.1343 (95% Cl = 2.3265-7.3468; P < .001), respectively. The appPHT has a 47.61% reduction by employing an EMRC model.Due to the relatively high appPHT, diversion rate, and OR value in severe patients, the EMS transportation plan is distinct from a prevalent response and develops adaptive weaknesses of MCIs in current disaster management. Application of the EMRC scenario reduces the appPHT and alleviates the surge pressure upon emergency departments in an MCI.

Mass Casualty Incident Management for Resource-Limited Settings: Lessons From Central Haiti

OBJECTIVE

Mass casualty incidents (MCIs) have gained increasing attention in recent years due multiple high-profile events. MCI preparedness improves the outcomes of trauma victims, both in the hospital and prehospital settings. Yet most MCI protocols are designed for high-income countries, even though the burden of mass casualty incidents is greater in low-resource settings.

RESULTS

Hôpital Universitaire de Mirebalais (HUM), a 300-bed academic teaching hospital in central Haiti, developed MCI protocols in an iterative process after a large MCI in 2014. Frequent MCIs from road traffic collisions allowed protocol refinement over time. HUM's protocols outline communication plans, triage, schematics for reorganization of the emergency department, clear delineation of human resources, patient identification systems, supply chain solutions, and security measures for MCIs. Given limited resources, protocol components are all low-cost or cost-neutral. Unique adaptations include the use of 1) social messaging for communication, 2) mass casualty carts for rapid deployment of supplies, and 3) stickers for patient identification, templated orders, and communication between providers.

CONCLUSION

These low-cost solutions facilitate a systematic response to MCIs in a resource-limited environment and help providers focus on patient care. These interventions were well received by staff and are a potential model for other hospitals in similar settings.

Medicine at mass gatherings: current progress of preparedness of emergency medical services and disaster medical response during 2020 Tokyo Olympic and Paralympic Games from the perspective of the Academic Consortium (AC2020)

Mass gatherings are events characterized by “the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community.” Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health‐care system, it can provide the opportunity for long‐term benefits of public health‐care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID‐19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium.

Important learning points arising from the focused issue dedicated to the Terror and Disaster Surgical Care (TDSC®) course on mass casualty incident management

The Terror and Disaster Surgical Care (TDSC®) course on mass casualty incident management was formulated in Germany by military medical personnel, who have been deployed to conflict areas, but also work in hospitals open for the lay public. In this manuscript we discuss different concepts and ideas taught in this course as these are described in a focused issue recently published in the European Journal of Trauma and Emergency Surgery. We provide reinforcement for some of the ideas conveyed. We provide alternative views for others. Injuries following explosions are different from blunt and penetrating trauma and at times demand a different approach. There are probably several ways to manage a mass casualty incident depending on the setup of the organization. An open discussion on the topics presented in the manuscripts included in the focused issue on military and disaster surgery should enrich everyone.

Immediate response to major incidents: defining an immediate responder!

PURPOSE

There is a gap in time between the occurrence of a mass casualty incident (MCI) and the arrival of the first responders to the scene, which offers an opportunity for the public (immediate responders) to perform life-saving measures. The purpose of this study was to identify these measures and the public's willingness to conduct them.

METHOD

An extensive literature review was performed to identify the possible measures that can be undertaken by the public. A group of experts were asked to prioritize and rank the feasibility of performing the measures by the public. Finally, the public was asked whether they were willing to do the chosen measures before and after an appropriate education.

RESULTS

Twenty different measures were identified and presented in a questionnaire as statements, which were prioritized and ranked by the expert group into four categories: what (1) should be done, (2) is good to know how, (3) is not necessary to know, and (4) should not be done. All statements were converted into understandable statements and were sent to the public. There were some differences and some agreements between the experts and the public regarding what an immediate responder should do. However, the willingness of the public to perform most of the measures was high and increased after being offered an appropriate education.

CONCLUSION

The use of immediate responders is a life-saving approach in MCIs and in situations when every minute counts and every human resource is an invaluable asset. Multiple steps, such as education, empowerment, and access, should be taken into consideration to enable bystanders to effectively help struggling survivors.

Exploring Peaks in Hospital Blood Component Utilization: A 10-Year Retrospective Study at a Large Multisite Academic Centre

Peak demand analysis is common in industries such as the energy sector, but can also be applied to the field of transfusion to characterize the nature and timing of peak days in hospital blood utilization. This information can be used to forecast future peak days or to inform hospital emergency preparedness plans. The aims of this study are to characterize peak days in red blood cell (RBC) utilization over the past 10 years at our hospital, and to compare RBC peaks with peaks in platelet, plasma, and cryoprecipitate utilization. This was a retrospective cohort study of RBC, platelet, plasma, and cryoprecipitate transfusions in the inpatient and emergency department setting between May 2009 and April 2019 at a large academic hospital, containing regional trauma and cardiovascular surgery centers. For each blood product, a peak in utilization was defined as a day with a ≥50% increase in the number of units transfused compared to the previous 90-day average. Descriptive and inferential analyses were performed to characterize peak days. There were on average 20,501 RBCs transfused per year and 56 RBCs transfused per day over the 10-year period. A total of 134 peaks in RBC utilization occurred over the study period, with an average of 14 peaks per year. RBC peak days required on average 69% more RBC units compared to nonpeak days (P< .0001). 77% of RBC peaks were caused either solely or in part by surgical bleeding, 34% were caused entirely or in part by trauma, and other causes were infrequent. RBC peaks occurred most often on Fridays and least often on weekends (P< .0001). While there were 134 RBC peaks over the study period, there was a larger number of platelet (n = 292), plasma (n = 467), and cryoprecipitate peaks (n = 579). RBC peak days often coincided with plasma peak days, but less frequently with platelet and cryoprecipitate peaks. More studies are needed to determine whether analysis of peak usage will be of value to hospital blood banks for emergency planning and blood inventory management.

Preparing for Mass Casualty Events

There are many forms of mass casualty events, including mass trauma, exposure to radiation and chemical agents, biological exposure (pandemics and bioterrorism), or a combination of insults. The underlying theme is that the number and severity of patients outstrip the resources available. These events are more common than thought. Planning and preparation allow institutions to better respond to the patient surge and thus mitigate the consequences-ultimately saving lives and reducing morbidity.

[Exit wave plan for structured secondary patient distribution : Logistic concept for mass victims of terrorist attacks]

BACKGROUND

Following a terrorist attack a second hit is to be feared. The adequate reaction of the emergency services on site is to clear the scene. Since in such cases no treatment areas are set up at the scene of the incident, the injured are quickly admitted to the nearest hospital, either by themselves or by the emergency services and are largely untreated. Therefore, the hospital has to be ready to take in a significantly larger number of injured people in a very short period of time than after a conventional mass casualty incident. Due to the conceivably large number of wounded persons the emergency department can ensure primary medical care but nowhere near all casualties admitted to the hospital can be definitively treated.

OBJECTIVE

In order to provide injured patients with individual medical care after initial treatment according to the criteria of damage control resuscitation, a concept should be developed that enables a well-organized secondary transfer to receiving hospitals with appropriate equipment.

MATERIAL AND METHODS

Within a radius of 100 km from Ulm, all hospitals certified by the German Society for Trauma Surgery were contacted and asked to indicate how many emergency patients of the triage categories T1 (red), T2 (yellow) and T3 (green) could be admitted and treated around the clock (24/7). Special features such as a helicopter landing pad, neurosurgical care and pediatric traumatology care were considered.

RESULTS

Of the 32 hospitals within a 100 km radius of Ulm 29 (91%) provided information on the admission capacity. In these hospitals 45 T1, 121 T2 and 333 T3 patients could be admitted around the clock (24/7). A helicopter landing pad is available at 26 of the 29 hospitals (90%), 11 hospitals (38%) can treat patients for emergency neurosurgery and 18 hospitals (62%) have the possibility of pediatric traumatological emergency care. Based on this information the structured exit wave plan was developed, which enables a secondary transfer of at least 100 patients to qualified trauma centers.

CONCLUSION

The University Hospital of Ulm has made preparations to admit at least 100 injured patients for initial medical treatment following a terrorist attack. This corresponds to 10% of the hospital beds as required in the literature. Together with the neighboring Military Hospital and the University and Rehabilitation Hospital Ulm up to 300 injured patients can be treated; however, the number of available intensive care unit (ICU) beds and capacities in normal wards for definitive care is much lower, therefore, patients treated according to the principles of damage control resuscitation have to be relocated. By documenting the capacity of the hospitals within a 100 km radius around Ulm and taking their specific features into account, an exit wave plan could be created that enables patient distribution for definitive care without time-consuming procedures.

Cost-effectiveness of a video game versus live simulation for disaster training

Introduction

Disaster triage training for emergency medical service (EMS) providers is unstandardised. We hypothesised that disaster triage training with the paediatric disaster triage (PDT) video game ‘60 s to Survival’ would be a cost-effective alternative to live simulation-based PDT training.

Methods

We synthesised data for a cost-effectiveness analysis from two previous studies. The video game data were from the intervention arm of a randomised controlled trial that compared triage accuracy in a live simulation scenario of exposed vs unexposed groups to the video game. The live simulation and feedback data were from a prospective cohort study evaluating live simulation and feedback for improving disaster triage skills. Postintervention scores of triage accuracy were measured for participants via live simulations and compared between both groups. Cost-effectiveness between the live simulation and video game groups was assessed using (1) A net benefit regression model at various willingness-to-pay (WTP) values. (2) A cost-effectiveness acceptability curve (CEAC).

Results

The total cost for the live simulation and feedback training programme was $81 313.50 and the cost for the video game was $67 822. Incremental net benefit values at various WTP values revealed positive incremental net benefit values, indicating that the video game is more cost-effective compared with live simulation and feedback. Moreover, the CEAC revealed a high probability (>0.6) at various WTP values that the video game is more cost-effective.

Conclusions

A video game-based simulation disaster triage training programme was more cost-effective than a live simulation and feedback-based programme. Video game-based training could be a simple, scalable and sustainable solution to training EMS providers.

Incidence, casualties and risk characteristics of civilian explosion blast injury in China: 2000-2017 data from the state Administration of Work Safety

BACKGROUND

Civilian explosion blast injury is more frequent in developing countries, including China. However, the incidence, casualties, and characteristics of such incidents in China are unknown.

METHODS

This is a retrospective analysis of the State Administration of Work Safety database. Incidents during a period from January 1, 2000 to April 30, 2017 were included in the analysis. The explosions were classified based on the number of deaths into extraordinarily major, major, serious and ordinary type. Descriptive statistics was used to analyze the incidence and characteristics of the explosions. Correlation analysis was performed to examine the potential correlations among various variables.

RESULTS

Data base search identified a total of 2098 explosions from 2000 to 2017, with 29,579 casualties: 15,788 deaths (53.4%), 12,637 injured (42.7%) and 1154 missing (3.9%). Majority of the explosions were serious type (65.4%). The number of deaths (39.5%) was also highest with the serious type (P = 0.006). The highest incidence was observed in the fourth quarter of the year (October to December), and at 9:00-11:00 am and 4:00-6:00 pm of the day. The explosions were most frequent in coal-producing provinces (Guizhou and Shanxi Province). Coal mine gas explosions resulted majority of the deaths (9620, 60.9%). The number of explosion accidents closely correlated with economic output (regional economy and national GDP growth rate) (r = - 0.372, P = 0.040; r = 0.629, P = 0.028).

CONCLUSIONS

The incidence and civilian casualties due to explosions remain unacceptabe in developing China. Measures that mitigate the risk factors are of urgently required.

The effectiveness of junctional tourniquets: A systematic review and meta-analysis

BACKGROUND

Junctional tourniquets have been incorporated into tactical combat casualty care for junctional vascular trauma. They apply external compression to stop blood flow in the groin and axilla.

OBJECTIVES

The primary outcome was effectiveness in achieving arterial occlusion. Secondary outcomes included time to application and pain scores.

DATA SOURCES

Medline and EMBASE databases were searched.

STUDY APPRAISAL AND SYNTHESIS METHODS

A random-effects meta-analysis was conducted to estimate the average effectiveness and time to effective application for each device.

RESULTS

Eight studies reported the effectiveness of junctional tourniquets in healthy volunteers. The average effectiveness was 52% (95% confidence interval [CI], 15-87%) for the abdominal application of the abdominal aortic and junctional tourniquet (AAJT), 83% (95% CI, 73-89%; 26%) for the junctional Emergency Treatment Tool, 87% (95% CI, 79-92%; 15%) for the SAM junctional tourniquet (SJT), and 95% (95% CI, 90-98%) for the Combat Ready Clamp. The groin application of the AAJT was studied in two articles with 100% in both studies. The average time to application was 101 seconds for the SAM junctional tourniquet (95% CI, 50-152 seconds) and the Combat Ready Clamp (95% CI, 63-139 seconds), while it was 130 seconds (95% CI, 85-176 seconds) for the Junctional Emergency Treatment Tool. The abdominal application of AAJT had an average time to application of 92 and 171 seconds in two studies.

LIMITATIONS

All studies were conducted in healthy volunteers.

CONCLUSION AND IMPLICATIONS

Junctional tourniquets may meet a medical need in combat, and in the civilian environment, to control hemorrhage from these difficult injuries. All four Food and Drug Administration-approved devices demonstrate the ability to achieve vascular occlusion in healthy volunteers; however, effectiveness in patient transport has not been evaluated, and outcomes of their use in the field need to be captured and reported.

LEVEL OF EVIDENCE

Systematic review, level III.

Catastrophe in Radiology: Considerations Beyond Common Emergencies

Disasters often occur without warning and have the potential to affect large numbers of people. Those in the radiology environment experience unique effects on them, their equipment, and their ability to provide quality patient care. Lessons can be learned by reviewing events and their impact on imaging departments around the world. Radiology departments need to be actively involved in the disaster planning and the management of disasters when they occur. Common themes emerge regardless of the type of disaster, and these themes should be included in all planning.

Blood transfusions in mass casualty events: recent trends

BACKGROUND AND OBJECTIVES

The US AABB disaster task force recommends estimating 3 RBC units per admission (UPA) for mass casualty events (MCEs). In a previous analysis, median MCE UPA were 2·7 RBCs, 1·2 plasmas and 0·27 platelet doses (Vox Sang 2017; 112:648). Additional recent data were sought from the current era of balanced massive transfusion protocols (bMTPs).

MATERIALS AND METHODS

Publications in English from 1980 to 2020 were reviewed for MCEs using ≥50 RBCs/event and with numbers of admissions available. MCE reports were stratified by era and event-wide or trauma-centre source. The bMTP era included all MCEs since 2010 plus a 2008 bMTP military report.

STATISTICS

Mann-Whitney test.

RESULTS

Thirty-two MCEs met analysis criteria. Event-wide reports used medians [interquartile ranges] of 1·8 [1·2-3·9] RBC, 0·6 [0·3-0·9] plasma and 0·14 [0·06-0·26] platelet-dose UPA. Trauma centres transfused 3·4 [2·7-6·3] RBC, 2·4 [1·3-4·1] plasma and 0·41 [0·34-0·50] platelet-dose UPA, all P < 0·05 vs event-wide. Same-event median post-day-1 transfusions were 50% of day-1 use for RBC, 28% for plasma and 16% for platelets. Compared to prior years, the median plasma/RBC transfusion ratio rose from 0·28 to 0·67 in the bMTP era (P < 0·01). In recent mass shootings, trauma centres transfused up to 42 platelets (range 0·45-0·57 UPA) on day 1.

CONCLUSION

Based on available mass casualty data, we recommend planning for 3 RBC, 1 plasma and one-fourth platelet-dose units per admission for blood centres (event-wide), and 6, 4 and one-half UPA, respectively, for trauma centres, which have seen rising plasma usage and large mass-shooting platelet needs.

Back to Basics: Mass Casualty Incidents

Terrorist attacks, mass shootings, violent crimes, and other disasters may leave those affected feeling afraid and overwhelmed with emotion. It has been more than 17 years since the attacks on the World Trade Center in New York City killed almost 3,000 people. Since that time, the world has experienced a profuse number of mass casualty events; they are becoming commonplace and a risk that everyone recognizes as part of daily life. When disasters occur, health care providers may be required to mobilize and should be prepared for anything. Regardless of the size of the facility or the trauma level designation, perioperative nurses need to be aware of how they may be affected by traumatic events. This Back to Basics article reviews some significant mass casualty incidents and explores strategies for perioperative staff members to execute a successful response.

ASPiH Conference 2019 keynote paper. Quality improvement through simulation: a missed opportunity?

As the use of simulation has become more established in the delivery of healthcare education and training, there has been a corresponding increase in healthcare simulation research. Simulation-based research can be divided into research about simulation (answers research questions in which the focus is on simulation itself) and research through simulation (simulation as a method/tool for research). However, there are barriers, particularly for smaller less well-resourced simulation centres, that may prohibit participation in research. Therefore, it is suggested that quality improvement (QI) through simulation may be a pragmatic way in which simulation centres of all sizes can contribute to improving patient care beyond education and training. QI is defined as systematic, data-guided activities designed to bring about immediate, positive changes in the delivery of healthcare. Although not the case in healthcare, other industries routinely used simulation to support QI. For example, in aviation simulation is used to inform the design of the working environment, the appropriate use of technology, to exercise emergency procedures and to ‘re-fly’ flights following an adverse event as part of the mishap investigation. Integrating simulation within healthcare QI can support the development of novel interventions as well helping to address heretofore intractable issues.

How to Stop the Bleed: First Care Provider Model for Developing Public Trauma Response Beyond Basic Hemorrhage Control

INTRODUCTION

Since 2013, the First Care Provider (FCP) model has successfully educated the non-medical population on how to recognize life-threatening injuries and perform interventions recommended by the Committee for Tactical Emergency Casualty Care (C-TECC) and the Hartford Consensus in the disaster setting. Recent programs, such as the federal "Stop The Bleed" campaign, have placed the emphasis of public training on hemorrhage control. However, recent attacks demonstrate that access to wounded, recognition of injury, and rapid evacuation are equally as important as hemorrhage control in minimizing mortality. To date, no training programs have produced a validated study with regard to training a community population in these necessary principles of disaster response.

METHODS

In our study, we created a reproducible community training model for implementation into prehospital systems. Two matched demographic groups were chosen and divided into "trained" and "untrained" groups. The trained group was taught the FCP curriculum, which the Department of Homeland Security recognizes as a Stop the Bleed program, while the untrained group received no instruction. Both groups then participated in a simulated mass casualty event, which required evaluation of multiple victims with varying degree of injury, particularly a patient with an arterial bleed and a patient with an airway obstruction.

RESULTS

The objective measures in comparing the two groups were the time elapse until their first action was taken (T1A) and time to their solution of the simulation (TtS). We compared their times using one-sided t-test to demonstrate their responses were not due to chance alone. At the arterial bleed simulation, the T1A for the trained and untrained groups, respectively, were 34.75 seconds and 111 seconds (p-value = .1064), while the TtS were 3 minutes and 33 seconds in the trained group and eight minutes in the untrained groups (physiologic cutoff) (p-value = .0014). At the airway obstruction simulation, the T1A for the trained and untrained groups, respectively, were 20.5 seconds and 43 seconds (p-value = .1064), while the TtS were 32.6 seconds in the trained group and 7 minutes and 3 seconds in the untrained group (p-value = .0087). Simulation values for recently graduated nursing students and a local fire department engine company (emergency medical services [EMS]) were also given for reference. The trained group's results mirrored times of EMS.

CONCLUSION

This study demonstrates an effective training model to civilian trauma response, while adhering to established recommendations. We offer our model as a potential solution for accomplishing the Stop The Bleed mission while advancing the potential of public disaster response.

UNIFIED: Understanding New Information from Emergency Departments Involved in the San Bernardino Terrorist Attack

INTRODUCTION

Emergency departments (ED) are on the front line for treating victims of multi-casualty incidents. The primary objective of this study was to gather and detail the common experiences from those hospital-based health professionals directly involved in the response to the San Bernardino terrorism attack on December 2, 2015. Secondary objectives included gathering information on experiences participants found were best practices.

METHODS

We undertook a qualitative study using Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines by performing semi-structured interviews with physicians, nurses, and incident management staff from multiple institutions responding to the San Bernardino terrorist attack. We coded transcripts using qualitative analysis techniques and we delineated and agreed upon a refined list with code definitions using a negotiated group process. Final themes were developed and analyzed.

RESULTS

A total of 26 interviews were completed; 1172 excerpts were coded and categorized into 66 initial themes. Six final categories of communication, training, unexpected help, process bypassed, personal impact/emotions, and practical advice resulted.

CONCLUSION

Our study provides context regarding the response of healthcare personnel from multiple institutions to a singular terrorist attack in the United States. It elucidates several themes to help other institutions prepare for similar events. Understanding these common experiences provides opportunity to prepare for future incidents and develop questions to study in future events.