Mass Casualty Situations An Educational Framework

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Mass Casualty SituationsAn Educational Framework

• Charles Stewart MD EMDM

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Why?

• Unthinkable Wont happen here Thats other
  places (like California!)

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The Study Of Disaster Medicine Is Easy In
Oklahoma

• We are blessed with disasters
• This presents abundant opportunity to excel
• But. Its difficult to excel without
  preparation.

Lone Grove, OK
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What Im going to talk about

• Ill talk about
• Definitions
• Triage
• Ethics of triage
• Triage categories
• Where you can get education about disaster
  medicine
• This is a HUGE topic and we could talk for hours

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First reality testing

• Why?
• As a health care facility YOU ARE REQUIRED TO
  MAKE THESE PLANS
• Unless, of course, you dont get any federal
  money and your health care facility isnt JCAHO
  certified

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JCAHO Standard EC.4.10

• 12. The plan provides processes for evacuating
  the entire building (both horizontally, and when
  applicable, vertically) when the environment
  cannot support adequate care, treatment, and
  services.
• The plan provides processes for establishing an
  alternate care site that has the capabilities to
  meet the needs of patients when the environment
  cannot support care, treatment, and services
  including processes for the following
• Transporting patients, staff, and equipment to
  the alternative care site(s)
• Transferring to and from the alternative care
  site(s) the necessities of patients (for example,
  medications, medical records)
• Tracking of patients
• Inter-facility communication between the hospital
  and the alternative care site(s)

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What is a MassCal?

• A Mass Casualty Situation occurs when the call
  comes in and it becomes rapidly obvious that
  there are more of them than there are of you.

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MassCal in Oklahoma

• Hazardous weather
• Tornado/heavy weather
• Ice storm with extended service disruption.
• Fires
• Internal fires
• Wildfires
• Floods
• Hazardous Materials Release
• Human Threat
• Utility Failure

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Hazardous Weather

• May be the most likely reason for involvement of
  a health care facility in Oklahoma in aMass Cal.

Sumter Regional
Hospital
Americus, GA lt Picher, OK tornado

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Oklahoma Ice Storms
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Nursing Home Fires

• Small fire leads to nursing home evacuation
• Thursday, November 12, 2009
• Pittsburgh Post-Gazette
• About 40 elderly people had to be evacuated from
  a nursing home in Cranberry this morning after a
  fire, but no one was hurt.
• The fire started just before 9 a.m. in a heating
  and air conditioning unit in the east wing of
  UPMC Cranberry Place and filled the facility with
  smoke.

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Nursing Home Fires

• Hartford CT Convalescent Home

• Colorado Wild fire

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Floods

• Some of the most shocking scenes from Hurricane
  Katrina came from hospitals and nursing homes.
• In Louisiana, about 100 residents died when they
  were trapped or abandoned in retirement centers.
• We really need to talk about ethics later!

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Floods

• St. Rita's Nursing Home in St. Bernard Parish was
  flooded during Hurricane Katrina, killing 34
  residents.
• Louisiana's attorney general charged the owners
  of the home, Salvador A. Mangano and Mable B.
  Mangano, with negligent homicide. (Subsequently
  acquitted)

Erich Schlegel / Dallas Morning News / Corbis
(Dina Rudick / The Boston Globe)
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Types of Mass Casualties

• Low Impact 5-10 patients
• A little stressful
• Called a Multiple Casualty Incident (MCI) by some
• Often no ICS or only a supervisor
• High Impact 10-50 patients Resources
  Challenged
• A lot of stress but the local folks can usually
  handle
• Some Systems can handle this
• Lot of Stress for most systems
• Sometimes called a Mass Casualty Scene or
  Incident
• Often a single IC

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Resources challenged
(P Patient)
R
Do the best for each individual
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Types of Mass Casualties

• Disaster
• Destroys the regional emergency system
• Usually its a disaster in multiple areas
• JOINT ICS activated (and needed)
• Extra resources may be needed
• Federal or State resources activated

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Do the greatest good for the greatest number
(P Patient)
Resources overwhelmed
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GOALS OF MCI MANAGEMENT

• Greatest good for greatest number
• Management of Resources (usually scarce)
• DONT RELOCATE THE DISASTER!

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Why is this important?

• Long term care facilities
• May be involved in the disaster?
• May be recipients of patients from the disaster?
• May be unable to use normal resources for their
  own patients.
• Must be self sufficient
• YOYO96 is a very good rule.

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Healthcare Facilities

• May be involved in the disaster?
• Tornado?
• Flood?
• Ice storm?
• Snow storm?
• Hazardous materials?

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SitREP

• Situation Report.
• Who you are.
• Where you are.
• What you have.
• How many are affected.
• What you have done.
• What you need.

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Triage

• Most medical providers know the origins of
  triage
• In many cases, the term is misused for example
• A waiting list for organs may be triaged by
  survivability of the patients on the list.
• The same would apply to allocation of ventilators
  in a flu epidemic.

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Why we make the decisions we make in triage
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When Do Fatalities Occur in MCI?

• Immediate phasePhase 1- within seconds to
  minutes after the incident
• The largest number of deaths occurs in phase 1
  due to injuries incompatible with survival.
• You are not likely to save these patients.
• Death within seconds to minutes at the disaster
  site results from head injuries and thoracic
  injuries involving the heart, aorta or large
  blood vessels.
• We can only save those who have large vessel
  external bleeds.
• Some folks have an acronym DRT.

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When Do Fatalities Occur in MCI?

• Immediate phasePhase 1- within seconds to
  minutes after the incident does have some
  preventable deaths!
• The United States Military has found that there
  are significant gains to be made by rapidly
  evaluating and treating potentially
  exsanguinating hemorrhage.
• Likewise, they have found that needle chest
  decompression may save significant numbers of
  casualties.
• Note that these are both IMMEDIATE therapies.

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When Do Fatalities Occur in MCI?

• Phase 2 - within minutes to hours after the
  incident
• Death occurring within minutes to hours following
  the primary injuries due to subdural and epidural
  hematomas, hemopneumothorax, lacerations of large
  organs such as liver, spleen, gut, pelvic
  fractures or other multiple injuries with
  significant occult blood loss.
• Most of these injuries require operative time to
  fix.
• We need to get them to a hospital equipped to
  handle the casualties.

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When Do Fatalities Occur in MCI?

• The largest number of preventable deaths occurs
  in the second phase of fatalities.
• Patients who will probably die even with
  appropriate treatment and those who will live
  WITHOUT treatment become lower priority.
• The key medical issues during the Second Phase
  are
• Rescue of victims
• Provision of timely immediate care
• Evacuation of patients with life/limb threatening
  injuries to medical facilities

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When Do Fatalities Occur in MCI?

• Phase 3 - Within days to weeks after the incident
• Death occurs several days or weeks after the
  incident due to sepsis or multiple organ system
  failure.
• The quality of patient care during the first two
  phases corresponds directly to the outcome of the
  third phase our efforts at the scene have
  effects on the long-term outcome.
• Preventive medicine during the days to weeks
  following the disaster is another issue

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Return to Triage
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Triage

• There are multiple versions of triage...
• I'm NOT going to talk about one of the many
  acronyms... but rather the science and philosophy
  behind the schemes.
• Some folks talk about primary and secondary
  triage
• I think you need to re-evaluate everybody on a
  regular basis after all, we really do under and
  over-triage.
• It is NOT an exact science

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Triage

• The main concept behind triage is not to save
  everyone right away, but
• to prioritize patients based on their likelihood
  to benefit from treatment
• to provide greatest benefits to the largest
  number of people.
• The underlying assumption here is that this
  triage method is applied only when resources are
  limited.
• You dont need triage when you have enough help!

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Military Triage

• Military triage recognizes the limitations of
  availability and supports the overall mission of
  the military to win battles.
• The motto of the Army medical corps is To
  Preserve the Fighting Strength.
• Triage in the Military is a bit different
• It is based on that mottomore than you think

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Speaking of The Military

• Military triage divides casualties into three
  categories
• Minimalambulatory with superficial wounds that
  can be treated in the field and returned to duty.
• The LEAST injured are first to receive medical
  attention, consistent with the need to return
  soldiers to battle quickly so as to preserve the
  fighting strength.
• Seriousrequires field treatment with evacuation
  to field or base hospital.
• Those with serious but potentially survivable
  injuries are treated next.
• Based on resources and transportation
• Expectantdying with injuries incompatible with
  life despite maximal therapy surgery futile
  (hopelessly wounded).
• These folks are given palliative care

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Disaster Triage

• Whew
• We cant follow the military guidelines in the
  civilian world.
• Political suicide
• May be career suicide Katrina, Mercy Medical
  Center
• Expectant patients are a foreign concept to the
  medical provider and often unpalatable to the
  community at large.
• Most of the Minimal category patients are NOT
  going to go back to the war/disaster.

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Civilian Disaster Care

• There isnt any Universal Triage System.
• Four big categories are common and a possible
  5th.
• You need to do something NOW. RED
• You need to do something right soon. Yellow
• Its not a bit cool in the hot placeGreen
• We need for them to waitBlack
• Maybe.Blue

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Civilian Disaster Care

• While the principles of triage are the same
  throughout different levels of care Application
  of triage categories must be flexible depending
  on the type of disaster, availability of
  resources, transportation problems, and a myriad
  of other factors.
• Triage is Dynamic! - Expect Change!
• Semper Gumby! (Always flexible)

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Undertriage

• Undertriage is underestimating the severity of an
  illness or injury.
• An example of this would be categorizing a
  Priority 1 (Immediate) patient as a Priority 2
  (Delayed) or Priority 3 (Minimal).
• We want to keep undertriage to about 5 if
  possible.
• Undertriaged patients often have a worse outcome
  because they had delay of care.

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Overtriage

• Overtriage is overestimating the level to which
  an individual has experienced an illness or
  injury.
• An example of this would be categorizing a
  Priority 3 (Minimal) patient as a Priority 2
  (Delayed) or Priority 1 (Immediate).
• Most acronym systems expect 50 overtriage in the
  field
• Overtriage diminishes as you get closer to
  definitive care/diagnosis.

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Overtriage

• Overtriage means that you are sending easy
  problems to the difficult hospitals which means
  that they may not have the ability/resources to
  manage the difficult patients
• Overtriage may be less likely when performed by
  hospital medical teams.
• Overtriage appears to be more common as you use
  inexperienced people in triage.

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How does this affect Me?

• While the disaster is ongoing
• The 90 year old patient may (likely WILL NOT) be
  EMS highest priority patient.
• The Long Term Care Facility surely wont be the
  highest priority UNLESS you are part of the
  disaster.
• Not having power is inconvenient
• Not having heat is inconvenient
• Not having water is inconvenient
• None of these are really an emergency problem.

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Ethics in triage
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Ethics

• The ethical principles pertinent triage are
• Fidelity
• Veracity
• Autonomy
• Justice
• Beneficence
• Only two of these areas are a little grey for
  Triage.

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Fidelity

• Fidelity is the establishment of trust between
  the medical provider and the patient.
• Fidelity should not be broken by triage if the
  individual patient understands that the medical
  provider has delayed care for the purpose of
  caring both for sicker patients and for the group
  as a whole.

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Veracity

• Veracity means the medical provider will tell
  them the truth.
• Without veracity, there can be no fidelity.
• Veracity does not mean that all dying patients
  need to be told that they are going to die.
• Veracity does mean that hard questions require
  difficult but completely true answers at all
  times.

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Autonomy

• Autonomy is a number of different concepts
  including free choice, accepting responsibility
  for ones own choices, and respect of thoughts,
  will and actions of others.
• Unfortunately, respect for individual autonomy
  cannot always be honored such as when a single
  patient places their needs above other more
  seriously ill patients
• Respect of autonomy is relative to the situation.

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Justice

• Justice is fairness Triage must be equitable.
• Equitable triage does not mean equal treatment,
  but rather that equal conditions will be treated
  equivalently despite race, color, creed, or
  religion.
• Example is the Geneva Convention regarding
  wounded prisoners.

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Beneficence

• Beneficence is the requirement of benefit for the
  patient.
• In triage, clearly, the benefit is for society as
  a whole, rather than simply for the potential
  good of a single human being.
• This means that when care is rationed by triage,
  the medical provider is violating the principle
  of beneficence for the single patient to ensure
  it for others or the group as a whole.

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Beneficence
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How does that apply to me?

• Hmmm
• If Ive got to decide the fate of folk based on
  the information available
• Where does the multiple co-morbidity potentially
  septic patient fit in?
• Where should I put my available resources?

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Return to Topic
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Patient Movement

• Management of patient movement from the scene to
  the receiving Hospitals requires that YOU know
• Who is able to accept patients,
• How many they are able to accept
• What kind of casualties they can handle.
• If you send a patient with brain injuries to a
  hospital without a neurosurgeon, you can easily
  cause delay that kills the patient.
• I can give multiple other examples, but generally
  you need to send the patient to a place where
  best care can be given (priority), adequate care
  can be given (acceptable, but not optimum), or
  where stabilization can occur (generally
  suboptimal).

This is a complex dance
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Far-First

• Coordinating patient destination is one of the
  more complicated functions.
• There are a lot of variations here...
• I like the Israeli FAR-FIRST technique...
• Send your serious people out of the area if you
  can.
• You will still have Urgent and Minors in the
  local area
• Dont relocate the disaster to the nearest
  hospital!

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MERC

• In many areas, you wont have much choice of
  hospitals In many cities there are only one or
  two hospitals this limits your choices
  considerably.
• In areas where there are more than one hospital,
  its imperative that we not relocate the disaster
  to the closest hospital.
• In other cities, such as Tulsa, there may be 5 or
  more hospitals and a central coordinating system
  that will help you manage transportation
  decisions.
• A system for the distribution of patients to area
  hospitals must be established in advanced and
  utilized properly by emergency personnel.
• Ours is the MERC

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Where can I get education about disasters and
emergency management functions?

• OU Courses
• http//www.oudem.org/
• Core Disaster Life Support course
• Recommended for all nursing home staff
• 4 hour course
• May be done online
• Basic Disaster Life Support course
• Recommended for all patient care professionals
• RN, LPN, pharmacy, EMS, PA, Physicians
• 8 hour course OU offers 12 times per year.
• AMA CME offered for professionals

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More Training

• Advanced Disaster Life Support Course
• 16 hour (2 day course) for medical providers
• Hands on experience
• Simulations
• Disaster drills
• Protective gear introduction
• 16 hours CME AMA.
• OU 4 times per year.

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FEMA Courses

• FEMA Courses
• Available at
• Both online and in-house courses are available.
• Incident Command Structure ICS 100 (basic), 200
  (more basic)
• Hospital incident command structure courses
  available.
• Exercise planning courses (3 day) HSEEP available
  .

http//training.fema.gov/
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Oklahoma Department of Emergency Management

• Available at http//www.ok.gov/OEM/
• Training opportunities
• Help with mitigation,
• Warnings about weather, hazards, and even road
  conditions.
• Daily brief available

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American Red Cross

• Chapters in most large cities in Oklahoma
• Not just aid after the emergency, but teaching
  BEFORE the emergency.
• The Red Cross helps people prevent, prepare for
  and respond to emergencies. 
• First Aid
• CERT - (Tulsas CERT authority is the Tulsa
  chapter of ARC).
• (OKCs CERT authority is Oklahoma City
  Emergency Management)
• http//www.citizencorps.gov/cert/index.shtm

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Really really involved in thinking about
disasters?

• OSU offers a Masters and a PhD in Emergency
  Management.
• OSU offers a fellowship in Disaster and EMS for
  DOs
• European educational consortium offers the
  European Master of Disaster Medicine
• OU offers a MPH with disaster preparedness
  specialty
• OU offers a Disaster Medicine rotation for
  Medical, Nursing, Pharmacy, and PA students.

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Oklahoma Disaster Institute

• Our very own Oklahoma Disaster Institute offers a
  yearly symposium on one aspect of disaster
  medicine each year.
• This years symposium will be on Austere
  Medicine what to do when the lights go out.
• OU is planning a 15 credit Certificate in
  Disaster Medicine

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Summary

• Ive talked about
• Definitions
• Healthcare Facility involvement
• Fatality phases in a disaster
• Ethics of triage
• Triage categories
• Educational opportunities

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GOALS OF MCI MANAGEMENT

• Greatest good for greatest number
• Scarce resource management
• DONT RELOCATE THE DISASTER!

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Questions?

• Final Thoughts. The feds are at least 24 hours
  away and probably 72 hours.
• YOYO 96!
• Plan to be self-sufficient 
• IF YOU DONT PLAN FOR FAILURE, YOU HAVE FAILED
  TO PLAN

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http//www.oudem.org/ Charles Stewart MD
EMDMcharles-e-stewart_at_ouhsc.edu