Surgical Response to Mass Casualty Incidents

The Israeli Experience

William P Schecter

William P Schecter

Professor, Clinical Surgery University of California, San Francisco, USA.

Sharon Einav-Bromiker

Sharon Einav-Bromiker

Lecturer, Anesthesiology and Critical Care Medicine, Hebrew University, Israel.

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When a Mass Casuality Incident occurs, the establishment of a defined system with central control is critical for the orderly evacuation and transfer of patients through a cascade of treatment from resuscitation and damage control to definitive care and eventually to rehabilitation.

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The frequency of recorded Mass Casualty Incidents (MCIs) has increased over the past 50 years with almost 2 billion people being affected by disasters during the past 10 years alone1,2. Approximately half of all natural disasters occur in Asia even though it comprises only 31% of the total world area. In the second half of the last century approximately 70% of all disaster-related deaths occurred in this region that contains 58% of the total world population3.

The medical sequelae of an MCI generally occur in three phases. The largest number of deaths occurs in the Initial Phase due to injuries incompatible with survival. The largest number of preventable deaths occurs in the Second Phase, occurring minutes to hours following the MCI4. The key medical issues during the Second Phase are rescue of the victims, provision of timely first aid and early evacuation of patients with life and limb threatening injuries to medical facilities. The initial responders to MCIs resulting in complete destruction of social infrastructure are often uninjured local citizens4. The large number of casualties presenting for care usually overwhelms surviving local medical personnel and facilities5.

The major issue in the Third Phase, which occurs days to weeks following the disaster, is preventive medicine. Provision of adequate food, potable water, clothing, energy sources and shelter is essential6. Organisation of human waste and garbage disposal is also important7,8. Provision of primary healthcare for the local population should optimally begin as soon as 24-48 hours after the MCI. Circumstances will differ depending upon the location of the incident, the previous level of medical care received by the local population and the degree of destruction of local infrastructure.

Access to emergency medical care, delivery room services and maintenance medication are all important issues requiring consideration7,9,10. Surviving community hospitals must respond to waves of civilian and military casualties while maintaining routine medical and surgical service to the community depending upon the nature of the incident11,12. Treatment of late medical complications such as sepsis, multiple organ failure and the psychological sequelae of the incident are also major issues which occur in the Third Phase13.

Pre-event Management

A thoughtful disaster plan outlining the mobilisation and optimal utilisation of available medical resources is critical. Fewer additional resources are required if systems are in place to optimise the use of existing resources14. Individual patient survival is highly dependent on early transfer to a medical facility capable of providing life and limb salvage surgery15. The utility of front-line military evacuation hospitals was demonstrated both during the 1973 Yom Kippur War in the Sinai Peninsula16,17 and during the 1982 Lebanon War18. A similar concept has been employed in other military deployments and by civilian rescue organisations responding to disasters19. Following resuscitation and initial damage control surgery, patients are transferred in an orderly fashion to hospitals remote from the incident for definitive care freeing up beds in the evacuation hospital for the next wave of casualties.

During the Second Lebanon War in 2006, most casualties were evacuated to nearby civilian medical centers because of the proximity of the conflict to civilian population centers. Four hospitals in the north of Israel were designated as receiving hospitals. Only one of these hospitals functions as a Level 1 Trauma Centre during peacetime. Prior preparation for a disaster response is imperative to ensure a smooth transition to the changed circumstances. Optimal prior preparation includes not only a disaster plan but organisation of a system that has a central control responsible for conducting regularly scheduled MCI drills as well as ensuring provision of adequate supplies20.

The establishment of a defined system with central control is critical for the orderly evacuation and transfer of patients through a cascade of treatment from resuscitation and damage control to definitive care and eventually to rehabilitation. Inter-hospital competition can be minimised when a disinterested third party governs the system. The Israel Emergency Medical System (Magen David Adom) determines the evacuation destination after MCIs during peacetime. The Israel Defense Forces Medical Corps determines the evacuation destination for casualties during war. The goal is conversion of an MCI in the field to a multiple casualty event for each receiving hospital.

A recent review of the Military Trauma System in Iraq identified a number of key clinical issues which are important for disaster planners. These issues include transfer of casualties from point of injury to the most appropriate level of care, the development of trauma clinical practice guidelines, the use of standard forms at all care stations, the institution of standard prophylactic antibiotic regimens, on-line regulation of medical evacuation, implementation of a performance improvement programme including a careful report of morbidity and mortality statistics and trauma registry data21.

Estimation of receiving hospital surge capacity including alternate site capacity is a key element in disaster planning22. Unfortunately, the optimal method of surge capacity evaluation remains unknown23. Both computer simulation models24 and annual bed statistics have been used to estimate surge capacity. Annual bed statistics25 do not account for daily variation in patient volume and within-year variation in bed supply26 and may, therefore, be misleading. Some types of MCIs result in increased use of specific resources (e.g. intensive care, surgery) and prolonged hospital stay thereby affecting surge capacity27,28. Although many patients can be discharged from the hospital within 24-72 hours following injury to increase bed availability, overzealous early ICU discharge may adversely affect outcome.

Staff training is an obvious crucial element of disaster planning. Training should include: 1. The principles of Advanced Trauma Life Support®, 2. Acquaintance with the unique patterns of injury caused by manmade and natural disasters27,31, 3. Participation in mass casualty drills32 and 4. Mental preparation for acceptance of adequate rather than optimal care of the injured under dire circumstances requiring triage.

Finally, the disaster plan should clearly delineate the in-hospital chain of command to limit the inevitable competition and ego-clashes that occur within hospitals. Senior surgeons assume the clinical leadership role in almost all Israeli hospitals following a mass casualty event30.

Event Management

All hospitals in the vicinity of a mass casualty event will likely participate in the care of casualties5,33,34 . The key concepts for orderly patient management are unidirectional patient flow throughout the hospital35 and thorough documentation36,37. Anaesthesiologists, general and orthopaedic surgeons are in immediate demand30.

Initial triage of patients should occur outside of the department of emergency medicine (ED)30. Physicians and nurses who do not have special training in the surgical disciplines should segregate ambulatory patients in an area outside of the ED itself where they can be evaluated. Ambulatory patients injured in a blast should be screened for asymptomatic pneumothorax and / or tympanic membrane rupture at diagnostic ENT and radiology stations prior to discharge from hospital.

Stretcher cases should be admitted directly to the ED for secondary triage to Immediate or Delayed Care. Following initial resuscitation, Immediate Care patients are transferred to the operating theater (OR), intensive care unit, the Post-Anaesthesia Care Unit (PACU) or the Radiology department depending on the diagnostic and therapeutic requirements of the individual patient. The PACU is an ideal venue for establishing an extended ICU to accommodate the surge of critically ill patients28,30.

Most patients will require diagnostic X-rays and many require CT imaging. Insidious and missed injuries are a major concern38. The Radiology department is the main bottleneck impeding the orderly flow of patients through the diagnostic and therapeutic intra-hospital triage cascade. This can be prevented with staff training and prior preparation of radiology protocols unique to MCIs39.

Critically ill patients who have suffered penetrating injuries or traumatic amputations may require immediate access to the OR. Upon notification of a disaster, elective surgery should be immediately suspended until the scale of the event is clarified28. Patients who have not yet been anaesthetised should be returned to the pre-operative holding area or their wards. Patients who have been anaesthetised but have not yet received surgery can be considered on an individual basis. Depending upon the severity of their condition, the anticipated length of the procedure and the scale of the event, a decision may be made to either abort the procedure or proceed with surgery. Surgical procedures underway at the time of notification of the incident should proceed to completion30.

Post-event Management

Early debriefing, usually on the day of the event, is important to record the events, create order out of the initial confusion and identify opportunities for performance improvement40,41. An orderly and timely flow of casualties through the diagnostic and therapeutic triage cascade will clear the ED which may easily be inundated otherwise42 and hastens return of the hospital to routine operation. Return to normal hospital routine may, however, take hours to days, dependant on the number of casualties received and the nature of the incident. The medical consequences of the event in terms of prolonged ICU and hospital care, the need for multiple reconstructive operations, rehabilitation care27,28,43,44 as well as psychiatric and social services are immense45-49.

The psychological impact of MCIs (and in particular those that have been caused by human acts of aggression) on healthcare workers should not be underestimated. Post-Traumatic Stress Disorder (PTSD) is common among healthcare workers deployed to combat settings50. Work in a directly threatened civilian environment (e.g. a general hospital targeted by missiles, a community comonly affected by acts of terror) predisposes hospital staff to PTSD51,52.

Conclusion

A coordinated response to a disaster or MCI requires a system-wide plan with central control. The initial medical issues include rescue of victims, provision of first aid and evacuation of patients with life and limb threatening injuries to more sophisticated medical facilities. Early attention to provision of food, potable water and sources of energy, clothing and shelter and waste disposal are critical to prevent epidemic disease following a disaster. All hospitals in the vicinity of the incident will likely be called upon for help. A hospital disaster plan is essential to define lines of authority, identify diagnostic and therapeutic triage stations and facilitate the orderly treatment of a large number of patients. The goal is conversion of an MCI in the field to a multiple casualty event for each hospital.

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