Presentacin de PowerPoint

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MADRID 11-M
The Impact on Hospitals from a Terrorist
Event Lessons from the Madrid Train Bombing
Dr. Javier Ortiz
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11 March Bombing Overview
On March 11th between 0739 and 0742 local time,
10 explosive devices were detonated in 4 commuter
trains along the train line, which runs from
Guadalajara to the Atocha, train Station in
Madrid.
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11 March Bombing Overview

• Estimates are that
• Up to 700 people were on each of the trains.
• An average of 100 people were in each of the
  passenger cars.

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CASUALTIES

• 2062 Casualties
• 199 Deaths
• ? 177 Immediate
• ? 14 In-Hospital
• 83 Critical

5
RESOURCES MOBILIZED

• Thousands of Health personnel
• Over 300 Ambulances
• 650 Firemen
• 14,188 Calls to the Emergency phone 112
• 948 Psicologists
• 95 Forensic Surgeons
• 4,600 Blood donations in Madrid and over 2,500
  from the rest of the country
• Economic Cost gt 26.540.544

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INDEX

• Health System EMS
• Field Management of Disaster Victims
• Hospital Gregorio Marañón
• Activation of the Hospital Disaster Plan
• ED Triage, treatment areas, flow of patients
• Patterns of Injury, Severity, and Mortality
• Conclusions and Lessons Learned

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MADRID EMS

• Phone 112
• SUMMA 112
• SAMUR

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MADRID EMS

• SUMMA 112
• 061 Home emergencies
• SERCAM Suburbs

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MADRID EMS
SAMUR Urban emergencies
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INDEX

• Health System EMS
• Field Management of Disaster Victims
• Hospital Gregorio Marañón
• Activation of the Hospital Disaster Plan
• ED Triage, treatment areas, flow of patients
• Patterns of Injury, Severity, and Mortality
• Conclusions and Lessons Learned

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Time and Location of Blasts
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10 Bombs in 4 Trains
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SAMUR FIELD HOSPITAL
FIELD HOSPITAL
Over 250 patients attended
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SAMUR-SUMMA INTERVENTION
1 - ATOCHA STATION
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SAMUR-SUMMA INTERVENTION
2 TELLEZ ST.
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SAMUR-SUMMA INTERVENTION
3 EL POZO STATION
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SAMUR-SUMMA INTERVENTION
4 SANTA EUGENIA STATION
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SAMUR-SUMMA INTERVENTION
HUMAN RESOURCES
Number
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SAMUR-SUMMA INTERVENTION
VEHICLES
Number
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SAMUR-SUMMA INTERVENTION
VICTIMS ATTENDED IN THE FIELD AS CLASSIFIED BY
SAMUR
252
Number
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VICTIMS
2,062 injured
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BLASTS AND HOSPITAL LOCATIONS
Ramón y Cajal
MORGUE
58
La Paz
P. Asturias
Clínico
La Princesa
G. Marañón
Field Hospital
12 Octubre
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INDEX

• Health System EMS
• Field Management of Disaster Victims
• Hospital Gregorio Marañón
• Activation of the Hospital Disaster Plan
• ED Triage, treatment areas, flow of patients
• Patterns of Injury, Severity, and Mortality
• Conclusions and Lessons Learned

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MADRID SANITARY MAP
Census(2001) 5,423,384
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SANITARY AREAS OF MADRID
Madrid 2001 Census 5,423,384
Hospital G. Marañón
Population 674,417
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HOSPITAL GREGORIO MARAÑÓN
PHYSICAL RESOURCES
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HOSPITAL GREGORIO MARAÑÓN
HUMAN RESOURCES
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HOSPITAL GREGORIO MARAÑÓN
HOSPITAL ACTIVITY (2003)
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HOSPITAL GREGORIO MARAÑÓN
EMERGENCY DEPARTMENT
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INDEX

• Health System EMS
• Field Management of Disaster Victims
• Hospital Gregorio Marañón
• Activation of the Hospital Disaster Plan
• ED Triage, treatment areas, flow of patients
• Patterns of Injury, Severity, and Mortality
• Conclusions and Lessons Learned

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HOSPITAL GREGORIO MARAÑÓN
NOTIFICATION OF THE DISASTER TO THE HOSPITAL

• 745 am Radio, TV.
• 756 am first 2 walking wounded victims
  entered the ED.
• 800 oficial communication The ED is informed of
  the inminent arrival of victims

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ACTIVATION OF THE DISASTER PLAN
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DISASTER PLAN Assessment of the Hospital Capacity

• Beds
• Operating rooms
• ICU capacity
• Personnel
• Supplies

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DISASTER PLAN OPERATING ROOMS (OR)
810 830 AM

• 66 Elective Surgeries were Cancelled
• 22 OR ready for emergency surgery

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DISASTER PLAN ICU CAPACITY
810 830 AM

• 36 Medical ? Surgical ICU Beds
• Most of the ICU patients were transferred to more
  intermediate care

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DISASTER PLAN HOSPITAL BEDS
830 1030 AM

• Discharge patients from the hospital
• 347 Medical and Surgical beds available for
  victims in the first 2 hr

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DISASTER PLAN ED SITUATION AND ACTIONS
800 am 123 patients remained under observation
in the ED
915 am 30 Admitted 83 Discharged 10 Remained
in the ED
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DISASTER PLAN PERSONNEL

• 800 am Most on duty. Way to work
• Night shifts remained on duty
• Spontaneous
• collaboration from ALL
• More than needed
• in the ED

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DISASTER PLAN SUPPLIES

• Wheelchairs, stretchers to receiving area
• Essential equipment
• I.V. lines
• Medications
• Blood bank

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DISASTER PLAN MEDIA RELATIONS AND FAMILY
900 am
Teaching Pavillion
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DISASTER COMMAND DECISIONS
Specific data base system of casualties. Available
to other hospitals and local health authorities
at 1100h.
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INDEX

• Health System EMS
• Field Management of Disaster Victims
• Hospital Gregorio Marañón
• Activation of the Hospital Disaster Plan
• ED Triage, treatment areas, flow of patients
• Patterns of Injury, Severity, and Mortality
• Conclusions and Lessons Learned

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ED TRIAGE ? TREATMENT AREAS
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ED TRIAGE
Trauma care in the new millenium. Surg Clin
Noth Am 61541-1558, 1999
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ED TRIAGE
SENIOR SURGEON SENIOR ICU
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ED TRIAGE ? TREATMENT AREAS
ED RESUCITATION ROOM CAPACITY
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ED Medical and Surgical Observation

• Emergency medicine physician
• Resident in medical or surgical specialty
• Nursing

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HGUGM Distribution of Casualties
312 victims treated in the Hospital
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Nº OF SURVIVORS ADMITTED TO THE ED BY TIME OF
THE DAY
100
N 325
80
60
Number of Survivors
40
20
0
800
900
1000
1100
1200
1300
1400
1500
1600
2000
740
Time of Day
Data included only survivors attended at the GM
Hospital
50
ER Visits Comparison First 2-Hr (800 - 1000 AM)
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CUMULATIVE OF SURVIVORS ADMITTED TO THE ED BY
TIME OF THE DAY
100
N 325
80
60
Percent of Survivors
40
20
0
800
900
1000
1100
1200
1300
1400
1500
1600
2000
740
Time of Day
Data included only survivors attended at the GM
Hospital
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Nº OF SURVIVORS ADMITTED TO THE HOSPITAL BY TIME
OF THE DAY
100
N 119
80
60
Number of Survivors
40
20
0
800
900
1000
1100
1200
1300
1400
1500
1600
2000
740
Time of Day
Data included only survivors attended at the GM
Hospital
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CUMULATIVE OF SURVIVORS ADMITTED TO THE
HOSPITAL BY TIME OF THE DAY
100
N 119
80
60
Number of Survivors
40
20
0
800
900
1000
1100
1200
1300
1400
1500
1600
2000
Time of the Day
740
Data included only survivors attended at the GM
Hospital
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INDEX

• Health System EMS
• Field Management of Disaster Victims
• Hospital Gregorio Marañón
• Activation of the Hospital Disaster Plan
• ED Triage, treatment areas, flow of patients
• Patterns of Injury, Severity, and Mortality
• Conclusions and Lessons Learned

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HGUGM CASUALTIES AGE GENDER
Mean age 32 yr.
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HGUGM CASUALTIES MOST FREQUENT LESIONS (N243)
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HGUGM CASUALTIES SURGICAL INTERVENTIONS DAY1
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CRITICAL MORTALITY RATE
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RADIOGRAPHIC STUDIES IN THE ED
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BLOOD BANK
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SEVERITY CLINICAL MANAGEMENT
Frykberg E.R. J Trauma 200253201-212.
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MORTALITY CRITICAL PATIENTS
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OVERTRIAGE

• Proportion of survivors assigned to immediate
  care, hospitalization, or evacuation who are not
  critically injured.
• Rate of 50 is necessary to reduce
  life-threatening undertriage to zero.
• In mass casualty disaster overtriage could be
  also life-threatening

Frykberg E.R. J Trauma 200253201-212.
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Relation of Overtriage to Critical Mortality
Frykberg E.R. J Trauma 200253201-212
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PSYCHOLOGIC CARE
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INDEX

• Health System EMS
• Field Management of Disaster Victims
• Hospital Gregorio Marañón
• Activation of the Hospital Disaster Plan
• ED Triage, treatment areas, flow of patients
• Patterns of Injury, Severity, and Mortality
• Conclusions and Lessons Learned

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KEYS IN THE RESPONSE OF THE EMS

• Decisive effect of the training process
  (simulation).
• Rapid response (except for 1 focus) and
  evacuation.
• Triage by trained physicians
• Acceptable management of critical patients.
• Excellent collaboration of all the personnel.

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KEYS IN THE RESPONSE OF THE GM HOSPITAL

• Decisive effect of the time of the blast (740).
• Experience of the medical STAFF in the management
  of politrauma.
• Spontaneous collaboration of all the personnel.

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HOSPITAL CAPACITY TO RESPOND TO A DISASTER
3 4 PATIENTES PER HOUR PER 100 BEDS
Costich JF, Scutchfield FD. Public health
preparedness and response capacity inventory
validity study J Public Health Manag Pract
200410225-33.
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WEAKNESS

• Initial chaos due to
• ? 4 different focus. Not managed as 1 focus
• ? Delay in notification of 1 focus
• ? Overtriage of patients to hospitals.
• ? Unequal distribution of victims between
  hospitals

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WEAKNESS

• Poor communication with disaster site.
• Deficiencies in the security, identification of
  patients and record keeping.
• Initially, severe problems handling family
  members looking for their love ones.

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FINAL CONCLUSIONS FROM THE HGUGM EXPERIENCE

• Terrorist activity continues to threaten the
  civilian community
• New chalenge of a mass casualty event with 4
  different focus.
• A dissater plan must incorporate both
  pre-hospital and hospitals values

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FINAL CONCLUSIONS FROM THE HGUGM EXPERIENCE

• Disaster plan must be based on published
  experience.
• These plans should be rehearsed periodically.
• Surgeons must become more involved in the
  planning process.
• Include training in mass casualty events in the
  curriculum

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Madrid, 12-M 2004.