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Mass Casualty Situations An Educational Framework

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Title: Mass Casualty Situations An Educational Framework


1
Mass Casualty Situations An Educational Framework
  • Charles Stewart MD EMDM

2
Why?
  • Unthinkable Wont happen here Thats other
    places (like California!)

3
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
4
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

5
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

6
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)

7
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.

8
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

9
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 lt Picher, OK tornado

10
Oklahoma Ice Storms
11
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.

12
Nursing Home Fires
  • Hartford CT Convalescent Home
  • Colorado Wild fire

13
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!

14
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)
15
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

16
Resources challenged
(P Patient)
R
Do the best for each individual
17
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

18
Do the greatest good for the greatest number
(P Patient)
Resources overwhelmed
19
GOALS OF MCI MANAGEMENT
  • Greatest good for greatest number
  • Management of Resources (usually scarce)
  • DONT RELOCATE THE DISASTER!

20
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.

21
Healthcare Facilities
  • May be involved in the disaster?
  • Tornado?
  • Flood?
  • Ice storm?
  • Snow storm?
  • Hazardous materials?

22
SitREP
  • Situation Report.
  • Who you are.
  • Where you are.
  • What you have.
  • How many are affected.
  • What you have done.
  • What you need.

23
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.

24
Why we make the decisions we make in triage
25
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.

26
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.

27
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.

28
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

29
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

30
Return to Triage
31
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

32
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!

33
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

34
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

35
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.

36
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

37
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)

38
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.

39
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.

40
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.

41
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.

42
Ethics in triage
43
Ethics
  • The ethical principles pertinent triage are
  • Fidelity
  • Veracity
  • Autonomy
  • Justice
  • Beneficence
  • Only two of these areas are a little grey for
    Triage.

44
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.

45
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.

46
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.

47
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.

48
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.

49
Beneficence
50
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?

51
Return to Topic
52
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
53
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!

54
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

55
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

56
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.

57
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/
58
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

59
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

60
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.

61
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

62
Summary
  • Ive talked about
  • Definitions
  • Healthcare Facility involvement
  • Fatality phases in a disaster
  • Ethics of triage
  • Triage categories
  • Educational opportunities

63
GOALS OF MCI MANAGEMENT
  • Greatest good for greatest number
  • Scarce resource management
  • DONT RELOCATE THE DISASTER!

64
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

65
http//www.oudem.org/ Charles Stewart MD
EMDM charles-e-stewart_at_ouhsc.edu
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