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Mass casualties and major incidents
SURGERY FOR MAJOR INCIDENTS
Mass casualties and major incidents
good reliable communications with the pre-hospital providers can be extremely valuable to improve the hospital response. As an example, terrorist bombing incidents usually generate a relatively small number of dead (the majority of whom die immediately or very soon after the initial explosion). They also generate large numbers of patients with minor injuries, and a smaller number of patients with severe, life-threatening injuries. Explosions in confined spaces (e.g. bus or train bomb) cause more blast injuries and burns than the equivalent detonation outside. Some incidents may generate a single injury pattern (e.g. crush injuries in stadia), while others produce complex casualty types (e.g. mass transit incidents). Thus, although major incident planning should be appropriate for all hazards, good-quality information during a specific event can fine tune a particular response at the time.
Ian Nesbitt
Abstract Major incidents are a rare- or never-event in the professional lifetime of most individual clinicians, but are predictably unpredictable, and relatively common worldwide. This article describes definitions, casualty demographics, and consequences of major incidents, principally from the perspective of a hospital practitioner. The ideal pre- and intra-hospital processes and organizational techniques to mitigate against some of the more common problems encountered are also discussed, but covered in more detail in specific articles elsewhere in this issue.
Triage and over-triage
Keywords Major incident; mass casualty; organization; triage
It is important to address patients’ needs using a priority system so that those with the least severe injuries (who can wait for definitive treatment) do not prevent those with more severe, but treatable injuries, from receiving appropriate care. Equally, time and resources should not usually be devoted to those who cannot expect to benefit from even highly aggressive, resource intensive treatments. This process of sorting patients into priority groups is called triage. Although a number of systems exist, typically, triage is carried out on physiological grounds (described in more detail in Preparation for and organisation during a major incident and Major incident pre-hospital care on pages 413e418 and 419e423 respectively). P1 patients receive the most urgent care, then P2, then P3. P4, or expectant, patients (those with extreme injuries, who are unlikely to survive even with immediate care) are usually reassessed and treated after the P3 group. Triage is a vitally important task. Doctors tend to overlay the simple triage tool with their own assessment of the patient’s condition, and will typically rank many P3 patients as P2, and P2 as P1. This overwhelms the ability of the system to deal with true P1 and P2 patients, and has been shown to result in a higher avoidable mortality rate in this group. Many authorities recommend that non-medical staff carry out initial triage using triage cards to help prevent this over-triage effect.
Introduction Complex clinical situations (e.g. major trauma) require specific education and practice to manage well. The same is true from an organizational perspective. Advanced Trauma Life Support (ATLS) and similar courses (e.g. European Trauma Course) address the basics of this at an individual patient management level, while Major Incident Medical Management and Support (MIMMS)1 and Hospital Major Incident Medical Management and Support (HMIMMS)2 address the systematic approach and planning for incident management. This article aims to highlight a number of the key elements in the overall systematic approach to a major incident, many of which will be detailed further in other articles in this issue.
Definitions Although ‘An incident, the magnitude or nature of which produces sufficient live casualties to require an extraordinary response from the healthcare system’ is a concise and full description, the definition of a major incident depends somewhat on the perspective of the person defining it. Thus, while a single responder may regard a car crash with four adult casualties as a major incident, most hospitals would not. An incident requiring specialist care (e.g. burns, paediatrics) will cause greater pressure on a healthcare system than one with more common injury demographics. The definition of major incidents and associated phenomena are listed in Table 1, along with some examples.
The pre-hospital process Most emergency services in the developed world have welldeveloped cascade and escalation processes for responding to major incidents. Typically, the emergency services (police, fire, ambulance) will have similar escalation mechanisms determined by the nature of the incident. Often, the police take overall responsibility for scene security and access. The fire service is responsible for scene safety, and the ambulance service for patient care. The adage about safety priorities ‘Self-Scene-Survivors’ is important, and healthcare providers involved in prehospital care should have specific training to avoid being a liability and danger to others in these complex situations. Some terrorist actions include secondary explosive devices or ‘stay behind shooters’ to specifically target the rescue response, so the delay between an initial incident and a scene being declared safe enough for healthcare staff may be significant. Similar delays
Casualty demographics Some knowledge of the expected casualty types is useful for planning and for management of an individual incident. Thus,
Ian Nesbitt FRCA DICM(UK) is a Consultant in Anaesthesia and Critical Care at Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none.
SURGERY 33:9
410
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY FOR MAJOR INCIDENTS
Classification and examples of major incidents Incident
Definition
Examples
Simple
The number or nature of casualties overwhelms usual medical capacity
Compound
Infrastructure (e.g. hospitals, transport capability) also disrupted
Compensated
An adequate and timely response can be generated with effort (e.g. neighbouring organizations provide aid) An adequate response cannot be generated An uncompensated compound incident
Beslan school massacre 2004 Tokyo Sarin attack 1995 Madrid bombings 2004 London bombings 2005 New York World Trade Centre attack 2001 Asian floods 2007 Indian Ocean Tsunami 2004
Uncompensated Disaster Table 1
may be incurred during exclusion or management of chemical contamination of casualties, or in making buildings or infrastructure safe. In these circumstances, potentially salvageable casualties may die. Survivors are usually collected near the scene and transported to a nearby hospital or hospitals depending on local agreements and casualty numbers. The collection, triage and transfer organization is usually the responsibility of the ambulance service. A functioning pre-hospital system will therefore deliver the most seriously ill casualties to the most appropriate hospital soonest, and will transfer the least injured to this location later, or to other locations as required. Conversely, the failure of the system may simply result in a single hospital being overwhelmed by a large number of undifferentiated casualties, and will then be unable to direct care appropriately.
suppliers, administrative support) will also have higher activity levels for a prolonged period following an incident. Figure 1 shows the early effects of the London bombings in emergency departments, theatres and ICU. Depending on the number and nature of casualties, and the resources available, individual patient management may require a different mind-set and approach from usual: investigations (including blood sampling and radiology) may be reduced, treatments may be temporized (e.g. damage control approach), and the threshold for palliative care altered. These are often difficult decisions to make, so predefined lines of responsibility and decision-making should be included in the major incident plan for an organization. Communications between key areas of the hospital are highly likely to prove difficult, so several back-up communication systems should be developed, tested and verified as part of preparation for major incidents and general business continuity planning.
The in-hospital process Regeneration/reconstitution
Ideally (but not always) a hospital will have some prior notice of a major incident, and will have activated its major incident plan. A major incident plan should be generic enough to be applicable to multiple risks, yet specific enough that each individual in the organisation knows what they are expected to do. Key staff will have action cards, and generally, a control team will be formed to take a strategic view and executive actions. All these plans should be tested and trained to at regular intervals. Small incidents during daylight hours are likely to be easier to manage than large incidents out of hours, so planning should be predicated on the worst case situation. All staff should be trained and aware of their roles and responsibilities during a major incident, and a failure to do so will impede the whole organizational response. Generally, the emergency department will be very busy in the initial stages of a hospital response, but this is often relatively short lived, perhaps only for several hours. Progressively, deeper parts of the hospital become involved (operating theatres, critical care, general wards etc.) and the duration of activity increases:hours to days for operating theatres, days to weeks for critical care and perhaps weeks to months for general wards. Associated services (catering, sterilizing services, laundry
SURGERY 33:9
A vital part of responding to a major incident is the recovery and regeneration of capability. This may be as simple as equipment and disposable resupply, but typically involves much more. A large amount of this work may be carried out by non-clinical staff, but is of vital importance in facilitating the abilities of clinical staff to discharge their duties effectively. Examples would include appropriate changes in staff shift organisation, rescheduling elective work in response to reduced ongoing availability of critical care beds and operating theatre sessions, organizing the repatriation of injured patients to and from other facilities, catering, the provision of documentation and information technology facilities, reordering laboratory supplies, blood products and drugs, cooperation with forensic or police follow-up, debriefing and adaption of the organizational major incident plan. Regeneration and reconstitution (business continuity) should be started early in an incident, and should be an integral part of an organizational major incident plan. Depending on the nature of a particular incident, regeneration may be rapid (e.g. military units in a combat area) or may take many months to completely resolve (e.g. civilian hospitals with a
411
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY FOR MAJOR INCIDENTS
P1/ P2 pat ients in ED
b
16 14 12 10 8 6 4 2 0
Majors area Resuscitation room
Operating room activity
a
10 8 6 4 2 0 –2 –4 –6 –8
Major incident patients Other patients
ICU bed use
Time-dependent workload during the 2005 London bombings
12 10 8 6 4 2 0
c
Beds available Beds used
0
1
2
3
4
5
6
7
8
9
10 11
12 13
14
15
Hours after first explosion Figure 1 (Adapted from Ref. 3).
executing the incident plan. If you fail to plan, you are planning to fail. A
large number of long-term injured patients requiring multiple operations and critical care length of stay).
Conclusion
REFERENCES 1 Major incident medical management and support: the practical approach at the scene (MIMMS), 3rd edn. 2 Major incident medical management and support: the practical approach in the hospital (HMIMMS). €nig TC, Brennan NW, et al. Reduction in critical mortality 3 Aylwin CJ, Ko in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 2006; 368: 2219e25.
For many clinical staff, a major incident is a once in a lifetime event. Although the nature and number of casualties may be outwith their usual practice, many staff will have the requisite clinical skills to manage adequately. Much more challenging are the demands on the leadership and control of the overall hospital responses. For both clinical and control functions, adequate knowledge of the organizational plan is essential, as is regular practice and verification of the mechanics of activating and
SURGERY 33:9
412
Ó 2015 Elsevier Ltd. All rights reserved.
Mass casualties and major incidents
good reliable communications with the pre-hospital providers can be extremely valuable to improve the hospital response. As an example, terrorist bombing incidents usually generate a relatively small number of dead (the majority of whom die immediately or very soon after the initial explosion). They also generate large numbers of patients with minor injuries, and a smaller number of patients with severe, life-threatening injuries. Explosions in confined spaces (e.g. bus or train bomb) cause more blast injuries and burns than the equivalent detonation outside. Some incidents may generate a single injury pattern (e.g. crush injuries in stadia), while others produce complex casualty types (e.g. mass transit incidents). Thus, although major incident planning should be appropriate for all hazards, good-quality information during a specific event can fine tune a particular response at the time.
Ian Nesbitt
Abstract Major incidents are a rare- or never-event in the professional lifetime of most individual clinicians, but are predictably unpredictable, and relatively common worldwide. This article describes definitions, casualty demographics, and consequences of major incidents, principally from the perspective of a hospital practitioner. The ideal pre- and intra-hospital processes and organizational techniques to mitigate against some of the more common problems encountered are also discussed, but covered in more detail in specific articles elsewhere in this issue.
Triage and over-triage
Keywords Major incident; mass casualty; organization; triage
It is important to address patients’ needs using a priority system so that those with the least severe injuries (who can wait for definitive treatment) do not prevent those with more severe, but treatable injuries, from receiving appropriate care. Equally, time and resources should not usually be devoted to those who cannot expect to benefit from even highly aggressive, resource intensive treatments. This process of sorting patients into priority groups is called triage. Although a number of systems exist, typically, triage is carried out on physiological grounds (described in more detail in Preparation for and organisation during a major incident and Major incident pre-hospital care on pages 413e418 and 419e423 respectively). P1 patients receive the most urgent care, then P2, then P3. P4, or expectant, patients (those with extreme injuries, who are unlikely to survive even with immediate care) are usually reassessed and treated after the P3 group. Triage is a vitally important task. Doctors tend to overlay the simple triage tool with their own assessment of the patient’s condition, and will typically rank many P3 patients as P2, and P2 as P1. This overwhelms the ability of the system to deal with true P1 and P2 patients, and has been shown to result in a higher avoidable mortality rate in this group. Many authorities recommend that non-medical staff carry out initial triage using triage cards to help prevent this over-triage effect.
Introduction Complex clinical situations (e.g. major trauma) require specific education and practice to manage well. The same is true from an organizational perspective. Advanced Trauma Life Support (ATLS) and similar courses (e.g. European Trauma Course) address the basics of this at an individual patient management level, while Major Incident Medical Management and Support (MIMMS)1 and Hospital Major Incident Medical Management and Support (HMIMMS)2 address the systematic approach and planning for incident management. This article aims to highlight a number of the key elements in the overall systematic approach to a major incident, many of which will be detailed further in other articles in this issue.
Definitions Although ‘An incident, the magnitude or nature of which produces sufficient live casualties to require an extraordinary response from the healthcare system’ is a concise and full description, the definition of a major incident depends somewhat on the perspective of the person defining it. Thus, while a single responder may regard a car crash with four adult casualties as a major incident, most hospitals would not. An incident requiring specialist care (e.g. burns, paediatrics) will cause greater pressure on a healthcare system than one with more common injury demographics. The definition of major incidents and associated phenomena are listed in Table 1, along with some examples.
The pre-hospital process Most emergency services in the developed world have welldeveloped cascade and escalation processes for responding to major incidents. Typically, the emergency services (police, fire, ambulance) will have similar escalation mechanisms determined by the nature of the incident. Often, the police take overall responsibility for scene security and access. The fire service is responsible for scene safety, and the ambulance service for patient care. The adage about safety priorities ‘Self-Scene-Survivors’ is important, and healthcare providers involved in prehospital care should have specific training to avoid being a liability and danger to others in these complex situations. Some terrorist actions include secondary explosive devices or ‘stay behind shooters’ to specifically target the rescue response, so the delay between an initial incident and a scene being declared safe enough for healthcare staff may be significant. Similar delays
Casualty demographics Some knowledge of the expected casualty types is useful for planning and for management of an individual incident. Thus,
Ian Nesbitt FRCA DICM(UK) is a Consultant in Anaesthesia and Critical Care at Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none.
SURGERY 33:9
410
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY FOR MAJOR INCIDENTS
Classification and examples of major incidents Incident
Definition
Examples
Simple
The number or nature of casualties overwhelms usual medical capacity
Compound
Infrastructure (e.g. hospitals, transport capability) also disrupted
Compensated
An adequate and timely response can be generated with effort (e.g. neighbouring organizations provide aid) An adequate response cannot be generated An uncompensated compound incident
Beslan school massacre 2004 Tokyo Sarin attack 1995 Madrid bombings 2004 London bombings 2005 New York World Trade Centre attack 2001 Asian floods 2007 Indian Ocean Tsunami 2004
Uncompensated Disaster Table 1
may be incurred during exclusion or management of chemical contamination of casualties, or in making buildings or infrastructure safe. In these circumstances, potentially salvageable casualties may die. Survivors are usually collected near the scene and transported to a nearby hospital or hospitals depending on local agreements and casualty numbers. The collection, triage and transfer organization is usually the responsibility of the ambulance service. A functioning pre-hospital system will therefore deliver the most seriously ill casualties to the most appropriate hospital soonest, and will transfer the least injured to this location later, or to other locations as required. Conversely, the failure of the system may simply result in a single hospital being overwhelmed by a large number of undifferentiated casualties, and will then be unable to direct care appropriately.
suppliers, administrative support) will also have higher activity levels for a prolonged period following an incident. Figure 1 shows the early effects of the London bombings in emergency departments, theatres and ICU. Depending on the number and nature of casualties, and the resources available, individual patient management may require a different mind-set and approach from usual: investigations (including blood sampling and radiology) may be reduced, treatments may be temporized (e.g. damage control approach), and the threshold for palliative care altered. These are often difficult decisions to make, so predefined lines of responsibility and decision-making should be included in the major incident plan for an organization. Communications between key areas of the hospital are highly likely to prove difficult, so several back-up communication systems should be developed, tested and verified as part of preparation for major incidents and general business continuity planning.
The in-hospital process Regeneration/reconstitution
Ideally (but not always) a hospital will have some prior notice of a major incident, and will have activated its major incident plan. A major incident plan should be generic enough to be applicable to multiple risks, yet specific enough that each individual in the organisation knows what they are expected to do. Key staff will have action cards, and generally, a control team will be formed to take a strategic view and executive actions. All these plans should be tested and trained to at regular intervals. Small incidents during daylight hours are likely to be easier to manage than large incidents out of hours, so planning should be predicated on the worst case situation. All staff should be trained and aware of their roles and responsibilities during a major incident, and a failure to do so will impede the whole organizational response. Generally, the emergency department will be very busy in the initial stages of a hospital response, but this is often relatively short lived, perhaps only for several hours. Progressively, deeper parts of the hospital become involved (operating theatres, critical care, general wards etc.) and the duration of activity increases:hours to days for operating theatres, days to weeks for critical care and perhaps weeks to months for general wards. Associated services (catering, sterilizing services, laundry
SURGERY 33:9
A vital part of responding to a major incident is the recovery and regeneration of capability. This may be as simple as equipment and disposable resupply, but typically involves much more. A large amount of this work may be carried out by non-clinical staff, but is of vital importance in facilitating the abilities of clinical staff to discharge their duties effectively. Examples would include appropriate changes in staff shift organisation, rescheduling elective work in response to reduced ongoing availability of critical care beds and operating theatre sessions, organizing the repatriation of injured patients to and from other facilities, catering, the provision of documentation and information technology facilities, reordering laboratory supplies, blood products and drugs, cooperation with forensic or police follow-up, debriefing and adaption of the organizational major incident plan. Regeneration and reconstitution (business continuity) should be started early in an incident, and should be an integral part of an organizational major incident plan. Depending on the nature of a particular incident, regeneration may be rapid (e.g. military units in a combat area) or may take many months to completely resolve (e.g. civilian hospitals with a
411
Ó 2015 Elsevier Ltd. All rights reserved.
SURGERY FOR MAJOR INCIDENTS
P1/ P2 pat ients in ED
b
16 14 12 10 8 6 4 2 0
Majors area Resuscitation room
Operating room activity
a
10 8 6 4 2 0 –2 –4 –6 –8
Major incident patients Other patients
ICU bed use
Time-dependent workload during the 2005 London bombings
12 10 8 6 4 2 0
c
Beds available Beds used
0
1
2
3
4
5
6
7
8
9
10 11
12 13
14
15
Hours after first explosion Figure 1 (Adapted from Ref. 3).
executing the incident plan. If you fail to plan, you are planning to fail. A
large number of long-term injured patients requiring multiple operations and critical care length of stay).
Conclusion
REFERENCES 1 Major incident medical management and support: the practical approach at the scene (MIMMS), 3rd edn. 2 Major incident medical management and support: the practical approach in the hospital (HMIMMS). €nig TC, Brennan NW, et al. Reduction in critical mortality 3 Aylwin CJ, Ko in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 2006; 368: 2219e25.
For many clinical staff, a major incident is a once in a lifetime event. Although the nature and number of casualties may be outwith their usual practice, many staff will have the requisite clinical skills to manage adequately. Much more challenging are the demands on the leadership and control of the overall hospital responses. For both clinical and control functions, adequate knowledge of the organizational plan is essential, as is regular practice and verification of the mechanics of activating and
SURGERY 33:9
412
Ó 2015 Elsevier Ltd. All rights reserved.