Management of Major Accidents and Disasters: An Important Responsibility for the Trauma Surgeons

Towards resilient health systems: opportunities to align surgical and disaster planning

Natural disasters significantly contribute to human death and suffering. Moreover, they exacerbate pre-existing health inequalities by imposing an additional burden on the most vulnerable populations. Robust local health systems can greatly mitigate this burden by absorbing the extraordinary patient volume and case complexity immediately after a disaster. This resilience is largely determined by the predisaster local surgical capacity, with trauma, neurosurgical, obstetrical and anaesthesia care of particular importance. Nevertheless, the disaster management and global surgery communities have not coordinated the development of surgical systems in low/middle-income countries (LMIC) with disaster resilience in mind. Herein, we argue that an appropriate peridisaster response requires coordinated surgical and disaster policy, as only local surgical systems can provide adequate disaster care in LMICs.

We highlight three opportunities to help guide this policy collaboration. First, the Lancet Commission on Global Surgery and the Sendai Framework for Disaster Risk Reduction set forth independent roadmaps for global surgical care and disaster risk reduction; however, ultimately both advocate for health system strengthening in LMICs. Second, the integration of surgical and disaster planning is necessary. Disaster risk reduction plans could recognise the role of surgical systems in disaster preparedness more explicitly and pre-emptively identify deficiencies in surgical systems. Based on these insights, National Surgical, Obstetric, and Anesthesia Plans, in turn, can better address deficiencies in systems and ensure increased disaster resilience. Lastly, the recent momentum for national surgical planning in LMICs represents a political window for the integration of surgical policy and disaster risk reduction strategies.

A pilot registry of trauma surgeons willing and ready to respond to disasters

BACKGROUND

A well-defined means of organizing surgeons based on functional capabilities in disaster response has been lacking. We sought to create a pilot registry of surgeons, organized by functional capacities, available to respond to disasters in conjunction with the American College of Surgeons Operation Giving Back and to better understand their participation in disaster medicine training.

METHODS

The authors conducted a survey of the members of the American Association for the Surgery of Trauma and the Eastern Association for the Surgery of Trauma aimed at establishing a pilot registry of qualified trauma surgeons available to respond to disasters. Data from the surveys were analyzed retrospectively for surgical and subspecialty training, board certification, disaster response training, and military or civilian disaster experience to better understand the respondents' functional capacities and disaster training backgrounds.

RESULTS

Of 211 respondents, 96% self-identified as trauma surgeons, whereas 87% and 89% reported active practice in acute care surgery and/or critical care. Nearly all had primary board certifications in general surgery (93%), and many had additional certifications in surgical critical care (65%). While many reported participation in American College of Surgeons-sponsored trauma courses, only 30% of those surveyed received disaster-specific training in Federal Emergency Management Agency courses, and even fewer received training in the Disaster Management and Emergency Preparedness course. Few had military (26%) or civilian (19%) experience in disaster response.

CONCLUSIONS

This initiative complements efforts to organize a registry of trauma surgeons who are qualified and willing to respond in all aspects of disaster response. While trauma surgeons are optimally positioned to provide a wide range of surgical expertise in a disaster, this study further demonstrated the lack of a universally accepted disaster training program for surgeons willing to respond to mass casualty incidents. Standardized disaster response training for surgeons remains a challenge for the future.

LEVEL OF EVIDENCE

Care management, level IV.

Volunteer First Responders for Optimizing Management of Mass Casualty Incidents

Objective

Rapid response to a trauma incident is vital for saving lives. However, in a mass casualty incident (MCI), there may not be enough resources (first responders and equipment) to adequately triage, prepare, and evacuate every injured person. To address this deficit, a Volunteer First Responder (VFR) program was established.

Methods

This paper describes the organizational structure and roles of the VFR program, outlines the geographical distribution of volunteers, and evaluates response times to 3 MCIs for both ambulance services and VFRs in 2000 and 2016.

Results

When mapped, the spatial distribution of VFRs and ambulance stations closely and deliberately reflects the population distribution of Israel. We found that VFRs were consistently first to arrive at the scene of an MCI and greatly increased the number of personnel available to assist with MCI management in urban, suburban, and rural settings.

Conclusions

The VFR program provides an important and effective life-saving resource to supplement emergency first response. Given the known importance of rapid response to trauma, VFRs likely contribute to reduced trauma mortality, although further research is needed in order to examine this question specifically. (Disaster Med Public Health Preparedness. 2019;13:287–294)

Paramedic Application of a Triage Sieve: A Paper-Based Exercise

Introduction Triage is the systematic prioritization of casualties when there is an imbalance between the needs of these casualties and resource availability. The triage sieve is a recognized process for prioritizing casualties for treatment during mass-casualty incidents (MCIs). While the application of a triage sieve generally is well-accepted, the measurement of its accuracy has been somewhat limited. Obtaining reliable measures for triage sieve accuracy rates is viewed as a necessity for future development in this area.

OBJECTIVE

The goal of this study was to investigate how theoretical knowledge acquisition and the practical application of an aide-memoir impacted triage sieve accuracy rates.

METHOD

Two hundred and ninety-two paramedics were allocated randomly to one of four separate sub-groups, a non-intervention control group, and three intervention groups, which involved them receiving either an educational review session and/or an aide-memoir. Participants were asked to triage sieve 20 casualties using a previously trialed questionnaire.

RESULTS

The study showed the non-intervention control group had a correct accuracy rate of 47%, a similar proportion of casualties found to be under-triaged (37%), but a significantly lower number of casualties were over-triaged (16%). The provision of either an educational review or aide-memoir significantly increased the correct triage sieve accuracy rate to 77% and 90%, respectively. Participants who received both the educational review and aide-memoir had an overall accuracy rate of 89%. Over-triaged rates were found not to differ significantly across any of the study groups.

CONCLUSION

This study supports the use of an aide-memoir for maximizing MCI triage accuracy rates. A "just-in-time" educational refresher provided comparable benefits, however its practical application to the MCI setting has significant operational limitations. In addition, this study provides some guidance on triage sieve accuracy rate measures that can be applied to define acceptable performance of a triage sieve during a MCI. Cuttance G , Dansie K , Rayner T . Paramedic application of a triage sieve: a paper-based exercise. Prehosp Disaster Med. 2017;32(1):3-13.

A pathway care model allowing low-risk patients to gain direct admission to a hospital medical ward--a pilot study on ambulance nurses and Emergency Department physicians

A pathway care model allowing low-risk patients to gain rapid admission to a hospital medical ward - a pilot study on ambulance nurses and Emergency Department physicians.

BACKGROUND

Patients with non-urgent medical symptoms who nonetheless require inpatient hospital treatment often have to wait for an unacceptably long time at the Emergency Department (ED). The purpose of this study is to evaluate the feasibility and effect on length of delay of a pathway care model for low-risk patients who have undergone prehospital assessment by an ambulance nurse and ED assessment by a physician within 10 minutes of arrival at the ED.

METHODS

The pilot study comparing two low-risk groups took place in western Sweden from October 2011 until January 2012. The pathway model for low-risk patients was used prospectively in the rapid admission group (N = 51), who were admitted rapidly after being assessed by the nurse on scene and then assessed by the ED physician on ED admission. A retrospectively assembled control group (N = 51) received traditional care at the ED. All p-values are age-adjusted.

RESULTS

Patients in the rapid admission group were older (mean age 80 years old) than patients in the control group (mean age 73 years old) (p = 0.02). The median delay from arrival at the patient's side until arrival in a hospital medical ward was 57 minutes for the rapid admission group versus 4 hours 13 minutes for the control group (p < 0.0001). However, the median delay time from the ambulance's arrival at the patient's side until the nurse was free for a new assignment was 77 minutes for the rapid admission group versus 49 minutes for the control group (p < 0.0001). The 30-day mortality rate was 20% for the rapid admission group and only 4% for the control group (p = 0.16).

CONCLUSION

The pathway care model for low-risk patients gaining rapid admission to a hospital medical ward shortened length of delay from the first assessment until arrival at the ward. However, the result was achieved at the cost of an increased workload for the ambulance nurse. Furthermore patients who were rapidly admitted to a hospital ward had a high age level and a high early mortality rate. Patient safety in this new model of fast-track assessment needs to be further evaluated.

Development and evaluation of a new simulation model for interactive training of the medical response to major incidents and disasters

BACKGROUND AND AIMS

The need for and benefit of simulation models for interactive training of the response to major incidents and disasters has been increasingly recognized during recent years. One of the advantages with such models is that all components of the chain of response can be trained simultaneously. This includes the important communication/coordination between different units, which has been reported as the most common cause of failure. Very few of the presently available simulation models have been suitable for the simultaneous training of decision-making on all levels of the response. In this study, a new simulation model, originally developed for the scientific evaluation of methodology, was adapted to and developed for the postgraduate courses in Medical Response to Major Incidents (MRMI) organized under the auspices of the European Society for Trauma and Emergency Surgery (ESTES). The aim of the present study was to describe this development process, the model it resulted in, and the evaluation of this model.

METHODS

The simulation model was based on casualty cards giving all information normally available for the triage and primary management of traumatized patients. The condition of the patients could be changed by the instructor according to the time passed since the time of injury and treatments performed. Priority of the casualties as well as given treatments could be indicated on the cards by movable markers, which also gave the time required for every treatment. The exercises were run with real consumption of time and resources for all measures performed. The magnetized cards were moved by the trainees through the scene, through the transport lines, and through the hospitals where all functions were trained. For every patient was given the definitive diagnosis and the times within certain treatments had to be done to avoid preventable mortality and complications, which could be related to trauma-scores.

RESULTS

The methodology was tested in nine MRMI courses with a total of 470 participants. Based on continuous evaluations and accumulated experience, the setup of the simulation was step-wise adjusted to the present model, including also collaborating agencies such as fire and rescue services as well as the police, both on-scene and on superior command levels. The accuracy of the simulation cards for this purpose was evaluated as "very good" by 63 % of the trainees and as "good" by 33 %, the highest two of the six given alternatives. The participants' ranking of the extent that the course increased their competencies related to the given objectives on a 1-5 scale for prehospital staff had an average value of 4.25 ± 0.77 and that for hospital staff had an average value of 4.25 ± 0.72. The accuracy of the course for the training of major incident response on a 1-5 scale by prehospital staff was evaluated as 4.35 ± 0.73 and that by hospital staff as 4.30 ± 0.74.

CONCLUSIONS

The simulation system tested in this study could, with adjustments based on accumulated experience and evaluations, be developed into a tool for the training of major incident response meeting the specific demands on such training based on recent experiences from major incidents and disasters. Experienced trainees in several courses evaluated the methodology to be accurate for this training, markedly increasing their perceived knowledge and skills in fields of importance for a successful outcome of the response to a major incident.

Online Victim Tracking and Tracing System (ViTTS) for major incident casualties

INTRODUCTION

Dealing with major incidents requires an immediate and coordinated response by multiple organizations. Communicating and coordinating over multiple geographical locations and organizations is a complex process. One of the greatest challenges is patient tracking and tracing. Often, data about the number of victims, their condition, location and transport is lacking. This hinders an effective response and causes public distress. To address this problem, a Victim Tracing and Tracking system (ViTTS) was developed.

METHODS

An online ViTTS was developed based on a wireless network with routers on ambulances, and direct online registration of victims and their triage data through barcode injury cards. The system was tested for feasibility and usability during disaster drills.

RESULTS

The formation of a local radio network of hotspots with mobile routers and connection over General Packet Radio Service (GPRS) to the central database worked well. ViTTS produced accurately stored data, real-time availability, and a real-time overview of the patients (number, seriousness of injury, and location).

CONCLUSION

The ViTTS provides a system for early, unique registration of victims close to the impact site. Online application and connection of the various systems used by the different chains in disaster relief promotes interoperability and enables patient tracking and tracing. It offers a real-time overview of victims to all involved disaster relief partners, which is necessary to generate an adequate disaster response.

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.

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.

Mass casualty modelling: a spatial tool to support triage decision making

BACKGROUND

During a mass casualty incident, evacuation of patients to the appropriate health care facility is critical to survival. Despite this, no existing system provides the evidence required to make informed evacuation decisions from the scene of the incident. To mitigate this absence and enable more informed decision making, a web based spatial decision support system (SDSS) was developed. This system supports decision making by providing data regarding hospital proximity, capacity, and treatment specializations to decision makers at the scene of the incident.

METHODS

This web-based SDSS utilizes pre-calculated driving times to estimate the actual driving time to each hospital within the inclusive trauma system of the large metropolitan region within which it is situated. In calculating and displaying its results, the model incorporates both road network and hospital data (e.g. capacity, treatment specialties, etc.), and produces results in a matter of seconds, as is required in a MCI situation. In addition, its application interface allows the user to map the incident location and assists in the execution of triage decisions.

RESULTS

Upon running the model, driving time from the MCI location to the surrounding hospitals is quickly displayed alongside information regarding hospital capacity and capability, thereby assisting the user in the decision-making process.

CONCLUSIONS

The use of SDSS in the prioritization of MCI evacuation decision making is potentially valuable in cases of mass casualty. The key to this model is the utilization of pre-calculated driving times from each hospital in the region to each point on the road network. The incorporation of real-time traffic and hospital capacity data would further improve this model.

Evaluation of admissions to the Major Incident Hospital based on a standardized protocol

Introduction

The Major Incident Hospital (MIH) is a unique facility strictly reserved to provide immediate large-scale emergency care for victims of disasters and major incidents. We evaluated the implemented organization to identify strengths and weaknesses, and provide knowledge essential for further improvement of preparedness.

Method

According to the Protocol for Reports from Major accidents and Disasters (PRMD) and along with our five scenarios for activation, we analyzed all the data from evaluation reports of all our deployments since the MIH was founded in 1991.

Results

The MIH was able to provide group-wise emergency care to military (29 admissions) as well as civilian victims of major incidents and disasters, both national (260) and international (226). Group-wise treatment was advantageous for quarantine, logistics, registration, emotional support and (pre)arrangements for family, media and security. Strong points are preparedness and availability of a dedicated facility, including ICU, X-ray and OR facilities, irrespective of MRSA status and prearranged cooperation, e.g., with a trauma centre, poison centre and the military. Evaluation, research and training resulted in a barcode registration system and continuous adaptations to improve preparedness. Shortage of resources did not occur; use of the MIH’s available resources for national incidents though, could be further optimized.

Conclusions

Recommendations for the future are: improvement of imbedding in regional and national procedures, continued dedicated time and staff for training, research and development, improvement of nuclear/biological/chemical decontamination facilities and preparedness, implementation of standardized scoring systems and expansion of registration systems to the prehospital setting.

Electronic supplementary material

The online version of this article (doi:10.1007/s00068-010-0067-0) contains supplementary material, which is available to authorized users.

Characteristics and triage of a maritime disaster: an accidental passenger ship collision in Korea

The aim of this study was to analyze the characteristics of and responses to a maritime disaster, by reviewing the events surrounding the accidental collision of a high-speed passenger ship in South Korea. Of the 215 boarded passengers on a high-speed passenger ship sailing from Fukuoka to Busan, we retrospectively examined information of 114 victims of the ship's collision with a whale on 12 April 2007. We referenced reports from the on-site disaster medical assistance team members; recorded notifications to the Busan 1339 Emergency Medical Information Centre, from the scene of the accident and data from the ship's insurer. The 114 victims were transported to 20 different hospitals. Many patients were transported to nearby local hospitals from the scene of the accident; other patients were transported to more distant hospitals. Eighty-five patients were transported to hospitals through mobile emergency support units, whereas the other patients were transported directly by fire officers from the 119 Fire Officer Centre. One patient died in the transport. In conclusion, our national emergency medical service and disaster response system each suffer from many problems - especially a lack of cooperation among related departments and insufficient communication therein. The onboard planning and practice of a disaster plan is required, and a reliable information system between the scene of a maritime disaster and our emergency medical service system should be developed.

Triage: Principles and Pressures

The aim of this paper is to review the art and science underpinning the application of effective triage. The paper also attempts to cut through the fog of confusion surrounding the topic and to point a way towards a generally-agreed unified approach. Triage needs to be understood in the context of the environment in which it is applied, and the paper deals with this in some detail.

Evaluation of the Response of the Swedish Healthcare System to the Tsunami Disaster in South East Asia

OBJECTIVES

When the tsunami in South East Asia hit the coast of Thailand on December 26, 2004, approximately 20,000 Swedish tourists were in the disaster zone. Of these, 548 died or were lost and more than 1500 were injured. The aim of this study was to evaluate the response of the Swedish health care system to the disaster in terms of assessment and support in the disaster zone, evacuation back to Sweden and continued treatment in Sweden.

METHODS

The evaluation was carried out based on (1) structured questionnaires to the staff of Thai hospitals, injured Swedish citizens and Swedish voluntary workers in the disaster zone; (2) semi-structured interviews with representatives of involved authorities, regional health care centres in Thailand and Sweden, hospital command centres, individuals treated for injuries and volunteer workers involved with supporting the injured; (3) on-site visits in the disaster zone; (4) analysis of reports following the tsunami.

RESULTS

A total of 11,000 injured were treated during the first 3 days following the tsunami at the six major hospitals in the Phang Nga, Phuket and Krabi provinces where the majority of the Swedish citizens were primarily taken care of. Of these 11,000, 3000 required hospital admission against a total bed capacity of 1400. Almost 1500 surgical operations were performed during the first 3 days across 33 operating theatres. Thai health care representatives and staff confirmed the requirement for teams from countries with many tourists in the area for practical and psychological support, interpretation, assessment for evacuation and undertaking early evacuation to home nations to release local health care resources. This need was also supported by the injured. Sweden, having the highest number of injured citizens next to the host country, was very late compared to other countries in sending assessment teams to the area and in supplying the needed support.

CONCLUSIONS

With increased international travelling, many countries today have large numbers of their citizens in other parts of the world. For Sweden, this has been estimated to be 400,000 at any one time, often in areas known to be risk zones for natural disasters and terrorism. This fact of modern-day life demands welldesigned plans to support both citizens in the area and the local health care in several ways: non-medical support by mediating contact between injured and local medical staff, psychological and practical support, support in evacuating own citizens from the area to release local health care and (under specific conditions) medical support. This planning has to include prepared assessment teams that can be rapidly deployed to the scene and a command structure permitting rapid and accurate decisions on a governmental level.

Mass Casualty Event During a Musical Parade: Lessons Learned

OBJECTIVE

In the Netherlands, major incidents are sparse, and so there is a general feeling of a relatively low risk. Upon evaluating multiple casualty events (MCEs) in the Netherlands over the last 60 years, it is worth noting 39 major events. Our objective was to report the experiences from a mass casualty incident in an urban area, performing a critical evaluation of the response and outcome related to the scenario in order to learn from our past and to train for the future.

MATERIALS AND METHODS

In a retrospective patient record analysis we collected all of the data concerning an MCE we encountered in August 2006.

RESULTS

There were 21 casualties at the scene. Of our 19 patients, 12 were seen in the crash room. The average age of the patients was 30 years (range 22-53). In all, 87 X-rays, 1 ultrasound and 15 CT scans were performed. Four patients were admitted: ten patients received definitive wound treatment in the ED. Psychological support was given to all patients. One patient died three days later.

CONCLUSION

Triage supported by one person and two trauma teams worked well. The amount of over- and undertriage was in line with the literature. Numbering the patients worked well but also caused enormous problems with the supporting facilities. Centralizing the trauma care yielded certain advantages; however, we must respect our surge capacity of 20 patients. When the number of patients surpasses 20, an alternative plan must be followed. This event has been an eye-opener for our organization; it has given us new tools to prepare for a potential new disaster.

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.