Transcript Slide 1
Mass Casualty Situations
An Educational Framework
Charles Stewart MD EMDM
Why?
Unthinkable…
Won’t happen here…
That’s other places…
(like California!)
The Study Of Disaster Medicine Is
Easy In Oklahoma…
We are ‘blessed’ with disasters…
This presents abundant ‘opportunity to excel’
But…. It’s difficult to excel… without preparation.
Lone Grove, OK
What I’m going to talk about
I’ll 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
First… reality testing
Why?
As a health care facility… YOU ARE
REQUIRED TO MAKE THESE PLANS
Unless, of course, you don’t get any federal money and your
health care facility isn’t JCAHO certified…
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.
13. 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:
1.
2.
3.
4.
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)
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.
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
Hazardous Weather
May be the most likely reason
for involvement of a health
care facility in Oklahoma in a
Mass Cal.
^
Sumter Regional Hospital
Americus, GA
< Picher, OK tornado
Oklahoma Ice Storms
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.
Nursing Home Fires
Hartford CT Convalescent
Home
Colorado Wild fire
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!
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)
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
Resources challenged
(P = Patient)
Do the best for each individual
Types of Mass Casualties
Disaster
Destroys the regional emergency system
Usually it’s a disaster in multiple areas
JOINT ICS activated (and needed)
Extra resources may be needed
Federal or State resources activated
Do the greatest good for the
greatest number
(P = Patient)
GOALS OF MCI MANAGEMENT
Greatest good for greatest number
Management of Resources (usually scarce)
DON’T RELOCATE THE DISASTER!
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.
Healthcare Facilities
May be involved in the disaster?
Tornado?
Flood?
Ice storm?
Snow storm?
Hazardous materials?
SitREP
Situation Report.
Who you are.
Where you are.
What you have.
How many are affected.
What you have done.
What you need.
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.
Why we make the decisions we
make in triage…
When Do Fatalities Occur in MCI?
Immediate phase…Phase 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.
When Do Fatalities Occur in MCI?
Immediate phase…Phase 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.
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.
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
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…
Return to Triage
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
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 don’t need triage when you have enough help!
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 motto…more than you think
Speaking of The Military
Military triage divides casualties into three categories:
Minimal–ambulatory 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.
Serious–requires field treatment with evacuation to field or
base hospital.
Those with serious but potentially survivable injuries are treated
next.
Based on resources and transportation
Expectant–dying with injuries incompatible with life despite
maximal therapy; surgery futile (hopelessly wounded).
These folks are given palliative care
Disaster Triage
Whew…
We can’t 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.
Civilian Disaster Care
There isn’t any “Universal” Triage System.
Four big categories are common… and a possible 5th.
RED
You need to do something right soon. Yellow
It’s not a bit cool in the hot place…Green
We need for them to wait…Black
Maybe….Blue
You need to do something NOW.
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)
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.
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.
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.
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 won’t 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.
Ethics in triage…
Ethics
The ethical principles pertinent triage are:
Fidelity
Veracity
Autonomy
Justice
Beneficence
Only two of these areas are a little grey for Triage.
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.
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.
Autonomy
Autonomy is a number of different concepts including free
choice, accepting responsibility for one’s 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.
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.
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.
Daily Emergencies
Do the best for each individual.
Beneficence
Disaster Settings
Do the greatest good for the
greatest number. Maximize
survival.
How does that apply to me?
Hmmm…
If I’ve 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?
Return to Topic…
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…
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
Don’t relocate the disaster to the nearest hospital!
MERC
In many areas, you won’t 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, it’s 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
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
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.
FEMA Courses
FEMA Courses
Available at:
http://training.fema.gov/
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 .
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
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 - (Tulsa’s CERT authority is the Tulsa chapter of ARC).
(OKC’s CERT authority is Oklahoma City Emergency Management)
http://www.citizencorps.gov/cert/index.shtm
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 DO’s
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.
Oklahoma Disaster Institute
Our very own Oklahoma Disaster Institute offers a yearly
symposium on one aspect of disaster medicine each year.
This year’s symposium will be on Austere Medicine…
“what to do when the lights go out.”
OU is planning a 15 credit Certificate in Disaster Medicine
Summary
I’ve talked about
Definitions
Healthcare Facility involvement
Fatality phases in a disaster
Ethics of triage
Triage categories
Educational opportunities
GOALS OF MCI MANAGEMENT
Greatest good for greatest number
Scarce resource management
DON’T RELOCATE THE DISASTER!
Questions?
Final Thoughts….
The feds are at least 24 hours away…
and probably 72 hours.
YOYO 96!
Plan to be self-sufficient
IF YOU DON’T PLAN FOR FAILURE,
YOU HAVE FAILED TO PLAN
http://www.oudem.org/
Charles Stewart MD EMDM
[email protected]