Ethics in disaster, mass casualty care, and critical care

The primary ethical principle guiding general medical practice is autonomy. However, in mass casualty (MASCAL) or disaster scenarios, the principles of beneficence and justice become of foremost concern. Despite multiple reviews, publications, and training courses available to prepare for a MASCAL incident, a minority of physicians and healthcare providers are abreast of these. In this review, we describe several MASCAL scenarios and their associated ethical, moral, and medicolegal quandaries in attempts to curb potential future misadventures.

Walking blood bank: a plan to ensure self-sufficiency in an era of blood shortage

Mass casualty incidents and massive transfusion requirements continue to plague the USA with hemorrhage remaining the number one cause of death in trauma. The unfortunate reality of numerous mass shootings in Southwest Texas has led to the need for a way in which to provide blood during these events as rapidly as it is required. Multiple agencies within the Southwest Texas system have united to help provide this life-saving blood to people when they need it most. This effort began with the development of a system for safe, efficient, and now widespread use of whole blood in the region. After demonstrating the success of delivering large quantities of blood during the Uvalde shooting, we have begun to develop a walking blood bank that is similar to what the miliary uses on the battlefield. The concept behind this initiative is to have a cohort of whole blood donors who are preselected to join the program which is now dubbed 'Heroes in Arms'. These donors will be called upon to donate whole blood during a massive transfusion event. Their blood will be rapidly screened prior to transfusion to the patient. This blood will still undergo the normal rigorous testing and, should any potentially transmissible diseases by discovered post-transfusion, the individual who received that product will be treated accordingly. Given the low rate of transmissible disease among this preselected population, combined with rapid screening prior to transfusion, the risk of a person receiving a transmissible disease is insignificant in comparison to the benefit of having blood to transfuse during hemorrhage. This model is a promising collaborative effort to provide in a timely and sufficient blood product in cases of major need which will consequently minimize the number of traumatically injured civilian patients who die from hemorrhage.

Evaluation of prehospital preparedness for major incidents on a national level, with focus on mass casualty incidents

PURPOSE

To investigate prehospital preparedness work for Mass Casualty Incidents (MCI) and Major Incidents (MI) in Norway.

METHOD

A national cross-sectional descriptive study of Norway's prehospital MI preparedness through a web-based survey. A representative selection of Rescue and Emergency Services were included, excluding Non-Governmental Organisations and military. The survey consisted of 59 questions focused on organisation, planning, education/training, exercises and evaluation.

RESULTS

Totally, 151/157 (96%) respondents answered the survey. The results showed variance regarding contingency planning for MCI/MI, revisions of the plans, use of national triage guidelines, knowledge requirements, as well as haemostatic and tactical first aid skills training. Participation in interdisciplinary on-going life-threatening violence (PLIVO) exercises was high among Ambulance, Police and Fire/Rescue Emergency Services. Simulations of terrorist attacks or disasters with multiple injured the last five years were reported by 21/151 (14%) on a regional level and 74/151 (48%) on a local level. Evaluation routines after MCI/MI events were reported by half of the respondents (75/151) and 70/149 (47%) described a dedicated function to perform such evaluation.

CONCLUSION

The study indicates considerable variance and gaps among Prehospital Rescue and Emergency Services in Norway regarding MCI/MI preparedness work, calling for national benchmarks, minimum requirements, follow-up routines of the organisations and future reassessments. Implementation of mandatory PLIVO exercises seems to have contributed to interdisciplinary exercises between Fire/Rescue, Police and Ambulance Emergency Service. Repeated standardised surveys can be a useful tool to assess and follow-up the MI preparedness work among Prehospital Rescue and Emergency Services at a national, regional and local level.

Multicenter assessment of impairments and disabilities associated with Beirut blast injuries: a retrospective review of hospital medical records

Objectives

This study aims to describe the injury patterns of the Beirut blast victims and assess hospitals' disaster management and preparedness during the 2020 Beirut port blast.

Methods

A cross-sectional retrospective multicenter study was conducted in two stages. Data were collected on blast victims presented to participating hospitals from August 4 till August 8, using three designed questionnaires. Stage 1 included all blast patients' records and stage 2 examined a subset of inpatient and outpatient records. Binary logistic regression was performed to assess the factors associated with death and disability for blast patients.

Results

A total of 3278 records were collected, 83% were treated at emergency departments and 17% were admitted to hospitals. Among those, 61 deaths and 35 long-term disabilities were reported. Extremity operations (63%) were mostly performed. Outpatients (n=410) had a mean age of 40±17.01 years and 40% sustained lacerations (40%). 10% of those patients sustained neurological complications and mental problems, and 8% had eye complications. Inpatients (n=282) had a mean age of 49±20.7 years and a mean length of hospital stay of 6±10.7 days. Secondary (37%) and tertiary (25%) blast injuries were predominant. 49% sustained extremity injuries and 19% head/face injuries. 11 inpatient deaths and 20 long-term disabilities were reported. Death was significantly associated with tertiary concussion and crush syndrome (p<0.05). Of the 16 hospitals, 13 implemented disaster plans (87%), and 14 performed a triage with a mean time of 0.96±0.67 hours. One hospital (6%) performed psychological evaluations, without follow-up.

Conclusion

Beirut blast victims suffered deaths and disabilities associated with their injuries. They predominantly sustained lacerations caused by shattered glass. Tertiary injuries were associated with death. Triage, disaster plans, and hospital preparedness should be effectively implemented to enhance patients' clinical outcomes.

Level of evidence

Prognostic and epidemiological/Level III.

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.

Healthcare utilization after mass trauma: a register-based study of consultations with primary care and mental health services in survivors of terrorism

BACKGROUND

Knowledge on healthcare utilization after mass trauma is needed to strengthen the public health preparedness to such incidents. Using register-based data, this study had a unique opportunity to investigate how young survivors' use of primary care physicians (PCP) and mental health services (MHS) changed after a terrorist attack.

METHODS

We examined register-based data on PCP and MHS consultations among 255 survivors (52% male) of the 2011 Utøya youth camp attack in Norway 3 years before and after the attack, and their reason for encounter with the PCP according to the International Classification for Primary Care (ICPC- 2).

RESULTS

The PCP and MHS consultation rates (CR) were higher in female than male survivors both acutely and at long-term. The mean yearly CRs increased from 2.25 to 4.41 for PCP and 1.77 to 13.59 for MHS the year before and after the attack in female survivors, and from 1.45 to 3.65 for PCP and 1.02 to 11.77 for MHS in male survivors. The third year post-attack CRs for PCP were 3.55 and 2.00; and CRs for MHS were 5.24 and 2.30 in female and male survivors, respectively. Among female survivors, 76% consulted PCP and 12% MHS the year preceding the attack; post-attack 93% consulted PCP and 73% MHS the first year; decreasing to 87 and 40% the third year. Among male survivors, 61% consulted PCP and 7% MHS the year preceding the attack; post-attack 86% consulted PCP and 61% MHS the first year, and 67 and 31% the third year. As for PCP consultations, there was a particular increase in psychological reasons for encounter following the attack.

CONCLUSIONS

This study indicates that it is important to anticipate an increased healthcare utilization several years following mass trauma, particularly of MHS. Both PCP and MHS practitioners played important roles in providing healthcare for psychological problems in young survivors of terrorism in a country with universal and largely publicly financed healthcare and a gatekeeping system. The healthcare utilization could be different in countries with other health systems or psychosocial care responses to mass trauma.

Accuracy of Triage Systems in Disasters and Mass Casualty Incidents; a Systematic Review

Introduction

To prioritize patients to provide them with proper services and also manage the scarce resources in emergencies, the use of triage systems seems to be essential. The aim of this study was to evaluate the accuracy of the existing triage systems in disasters and mass casualty incidents.

Methods

The present study is a systematic review of the accuracy of all triage systems worldwide. The results of this study were based on the articles published in English language journals. In this research, all papers published from the beginning of 2000 to the end of 2021 were sought through different databases. Finally, a total of 13 articles was ultimately selected from 89 articles.

Results

13 studies on the accuracy of triage systems were reviewed. The START, mSTART, SALT, Smart, Care Flight, ASAV, MPTT, Sieve and ESI triage systems, had an accuracy, sensitivity, and specificity of less than 90%. Only the Smart triage system had an overall accuracy of more than 90%.

Conclusion

According to the findings of the current systematic review, the performance of the existing triage systems in terms of accuracy of prioritizing the injured people and other performance indexes is not desirable. Therefore, to improve the performance and increase the precision of triage systems, the world nations are recommended to change or revise the indexes used in triage models and also identify other influential factors affecting the accuracy of triage systems.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of Interaction Between Emergency Medical System and Hospital Network During a Train Derailment in Milano

On January 25, 2018 a 5-car train derailed in Pioltello, 10 kilometers North-East of Milano City. A standardized post-hoc form was distributed to the hospitals involved in the management of the victims and allowed for an evaluation of the response to the incident.The management of the incident by EMS (Emergency Medical System) was effective in terms of organization of the scene and distribution of the patients, although the time for the first severe patient to reach the closest appropriate hospital was very long (2 hours). This can be partially explained by the extrication time.None of the alerted hospitals exceeded their capacity, as patients were distributed carefully among the hospitals. The overall outcome was quite satisfactory; no deaths were reported except for those on scene. Some responding hospitals reported that there was an over-activation based on the services ultimately needed. However this is common in MCIs, as an over-activation is preferable to an under-estimation. To address this concern, as more data are available, activation should be scaled down based on a plan established prior to it; this mechanism of scaling down seems to have failed in this event.It is of note that the highest performing hospitals underwent recently to an educational program on MCI management.

MADVent: A low-cost ventilator for patients with COVID-19

The COVID‐19 pandemic has produced critical shortages of ventilators worldwide. There is an unmet need for rapidly deployable, emergency‐use ventilators with sufficient functionality to manage COVID‐19 patients with severe acute respiratory distress syndrome. Here, we show the development and validation of a simple, portable and low‐cost ventilator that may be rapidly manufactured with minimal susceptibility to supply chain disruptions. This single‐mode continuous, mandatory, closed‐loop, pressure‐controlled, time‐terminated emergency ventilator offers robust safety and functionality absent in existing solutions to the ventilator shortage. Validated using certified test lungs over a wide range of compliances, pressures, volumes and resistances to meet U.S. Food and Drug Administration standards of safety and efficacy, an Emergency Use Authorization is in review for this system. This emergency ventilator could eliminate controversial ventilator rationing or splitting to serve multiple patients. All design and validation information is provided to facilitate ventilator production even in resource‐limited settings.

Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach

BACKGROUND:

Injuries caused by emergencies and accidents are increasing in the world. To prioritise patients to provide them with proper services and to optimally use the resources and facilities of the medical centres during accidents, the use of triage systems, which are one of the key principles of accident management, seems essential.

AIM:

This study is an attempt to identify available triage systems and compare the differences and similarities of the standards of these systems during emergencies and disasters through a review study.

METHODS:

This study was conducted through a review of the triage systems used in emergencies and disasters throughout the world. Accordingly, all articles published between 1990 and 2018 in both English and Persian journals were searched based on several keywords including Triage, Disaster, Mass Casualty Incidents, in the Medlib, Scopus, Web of Science, PubMed, Cochrane Library, Science Direct, Google scholar, Irandoc, Magiran, Iranmedex, and SID databases in isolation and in combination using both and/ or conjunctions.

RESULTS:

Based on the search done in these databases, twenty different systems were identified in the primary adult triage field including START, Homebush triage Standard, Sieve, CareFlight, STM, Military, CESIRA Protocol, MASS, Revers, CBRN Triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, MPTT, TEWS Triage, Medical Triage, SALT, mSTART and ASAV. There were two primary triage systems including Jump START and PTT for children, and also two secondary triage systems encompassing SAVE and Sort identified in this respect. ESI and CRAMS were two other cases distinguished for hospital triage systems.

CONCLUSION:

There are divergent triage systems in the world, but there is no general and universal agreement on how patients and injured people should be triaged. Accordingly, these systems may be designed based on such criteria as vital signs, patient’s major problems, or the resources and facilities needed to respond to patients’ needs. To date, no triage system has been known as superior, specifically about the patients’ clinical outcomes, improvement of the scene management or allocation of the resources compared to other systems. Thus, it is recommended that different countries such as Iran design their triage model for emergencies and disasters by their native conditions, resources and relief forces.

Epidemiology of Emergency Medical Services-Assessed Mass Casualty Incidents according to Causes

To effectively mitigate and reduce the burden of mass casualty incidents (MCIs), preparedness measures should be based on MCIs' epidemiological characteristics. This study aimed to describe the epidemiological characteristics and outcomes of emergency medical services (EMS)-assessed MCIs from multiple areas according to cause. Therefore, we extracted the records of all MCIs that involved ≥ 6 patients from an EMS database. All patients involved in EMS-assessed MCIs from six areas were eligible for this study, and their prehospital and hospital records were reviewed for a 1-year period. The EMS-assessed MCIs were categorized as being caused by fire accidents (FAs), road traffic accidents (RTAs), chemical and biological agents (CBs), and other mechanical causes (MECHs). A total of 362 EMS-assessed MCIs were identified, with a crude incidence rate of 0.6-5.0/100,000 population. Among these MCIs, 322 were caused by RTAs. The MCIs involved 2,578 patients, and 54.3% of these patients were women. We observed that the most common mechanism of injury varied according to MCI cause, and that a higher number of patients per incident was associated with a longer prehospital time. The highest hospital admission rate was observed for CBs (16 patients, 55.2%), and most patients in RTAs and MECHs experienced non-severe injuries. The total number of deaths was 32 (1.2%). An EMS-assessed MCI database was established using the EMS database and medical records review. Our findings indicate that RTA MCIs create a burden on EMS and emergency department resources, although CB MCIs create a burden on hospitals' resources.

Nurses' requirements for relief and casualty support in disasters: a qualitative study

Background:

Nurses are among the most important groups engaged in casualty support, regardless of the cause, and they are one of the largest care groups involved in disasters. Consequently, these workers should gain proper support and skills to enable effective, timely, responsible and ethical emergency responses.

Objectives:

In this study, we investigated the needs of nurses for proper casualty support in disasters, to facilitate better planning for disaster management.

Materials and Methods:

This was a qualitative content analysis study. Interviews were performed with 23 nurses, at educational hospitals and the Faculty of Nursing at Kerman Medical University, who had a minimum of five years working experience and assisted in an earthquake disaster. Intensity and snowball sampling were performed. Data was collected through semi-structured interviews. Interviews were transcribed and coded into main themes and subthemes.

Results:

Four major themes emerged from the data; 1) psychological support, 2) appropriate clinical skills education, 3) appropriate disaster management, supervision and programming, and 4) the establishment of ready for action groups and emergency sites. The participants’ comments highlighted the necessity of training nurses for special skills including emotion management, triage and crush syndrome, and to support nurses' families, provide security, and act according to predefined programs in disasters.

Conclusions:

There are a wide range of requirements for disaster aid. Proper aid worker selection, frequent and continuous administration of workshops and drills, and cooperation and alignment of different governmental and private organizations are among the suggested initiatives.

Scientific framework for research on disaster and mass casualty incident in Korea: building consensus using Delphi method

We aimed to determine the scientific framework for research on disaster and mass casualty incident (MCI) in Korea, especially Korean terminology, feasible definition, and epidemiologic indices. The two staged policy Delphi method was performed by instructors of National Disaster Life Support (NDLS®) with the constructed questionnaire containing items based on the literature review. The first-stage survey was conducted by 11 experts through two rounds of survey for making issue and option. The second-stage survey was conducted by 35 experts for making a generalized group based consensus. Experts were selected among instructors of National Disaster Life Support Course. Through two staged Delphi survey experts made consensus: 1) the Korean terminology "jaenan" with "disaster" and "dajung-sonsang-sago" with "MCI"; 2) the feasible definition of "disaster" as the events that have an effect on one or more municipal local government area (city-county-district) or results in ≥ 10 of death or ≥ 50 injured victims; 3) the feasible definition of MCI as the events that result in ≥ 6 casualties including death; 4) essential 31 epidemiologic indices. Experts could determine the scientific framework in Korea for research on disaster medicine, considering the distinct characteristics of Korea and current research trends.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS

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

REGISTRATION DETAILS

PROSPERO CRD42013004473.

Systematic literature review of templates for reporting prehospital major incident medical management

OBJECTIVE

To identify and describe the content of templates for reporting prehospital major incident medical management.

DESIGN

Systematic literature review according to PRISMA guidelines.

DATA SOURCES

PubMed/MEDLINE, EMBASE, CINAHL, Scopus and Web of Knowledge. Grey literature was also searched.

ELIGIBILITY CRITERIA FOR SELECTED STUDIES

Templates published after 1 January 1990 and up to 19 March 2012. Non-English language literature, except Scandinavian; literature without an available abstract; and literature reporting only psychological aspects were excluded.

RESULTS

The main database search identified 8497 articles, among which 8389 were excluded based on title and abstract. An additional 96 were excluded based on the full-text. The remaining 12 articles were included in the analysis. A total of 107 articles were identified in the grey literature and excluded. The reference lists for the included articles identified five additional articles. A relevant article published after completing the search was also included. In the 18 articles included in the study, 10 different templates or sets of data are described: 2 methodologies for assessing major incident responses, 3 templates intended for reporting from exercises, 2 guidelines for reporting in medical journals, 2 analyses of previous disasters and 1 Utstein-style template.

CONCLUSIONS

More than one template exists for generating reports. The limitations of the existing templates involve internal and external validity, and none of them have been tested for feasibility in real-life incidents.

TRIAL REGISTRATION

The review is registered in PROSPERO (registration number: CRD42012002051).