I will not attempt to recreate those events, I have no first hand experience with such horror or chaos, and any attempt would likely seem contrived and diminishing. But, I would like each of us to think about this disaster, and others that could come through our door at any time.
Think about what you would do if you you were first on the scene, (if you were volunteering in the medical tent?) What would you focus on, what resources would you request, and how would you triage patients?
What if these patients came to your Emergency department? What would you prioritize? Are you familiar with the disaster plan for your department? Do you know how to access it?
My update will be a brief summary of Disaster Preparedness, Blast Injuries, and Pediatric Trauma specifically related to such events. Complete coverage of these topics is outside the scope of this blog, Hopefully, I can offer a few pearls and reminders.
I do not know if reviewing this topic will ever decrease suffering or reduce tragedy.
I DO KNOW THAT IF WE IGNORE OUR MEDICAL RESPONSE TO THESE TRAGEDIES, FAILURE IS GARUNTEED.
Thank you for your interest and continued participation.
THANK YOU FOR YOUR COMMITMENT TO EMERGENCY MEDICINE.
------------WEEKEND UPDATE----------------
Disaster defined (medical): Whether a multiple car crash involving 4 or 5 seriously injured patients which overwhelms a small rural hospital or a mass casualty resulting in 25 injured patients rapidly overwhelming a large Level I Trauma Center; the definition of disaster is partly defined by the concept of "massive disruptive impact" to the medical system.
In the field:
Rescue personnel often use a Simple Triage And Rapid Treatment (START) technique that utilizes quick assessment of Respirations, Perfusion, and Mental Status (RPM).
I would fall back on my primary survey, ABC's and possibly prioritize Circulation if indicated, I would also prioritize Environment if the surrounding conditions were unsafe:
Airway: Make sure that the airway is patent and that there is no obstruction.
Breathing: Identify the presence of respirations, and whether or not they are labored.
Circulation: Feel for pulses, note skin color, identify areas of bleeding an apply pressure/tourniquet.
Disability: Is the patient Alert/Oriented, eyes open, talking, moving all extremities.
Exposure: Visualize all parts of the patient (remove clothing), examine the back.
Environment: If environment is a factor, address it or adapt to it. (This includes your safety.)
I would guess that EM residents trained at a Level I Trauma Center run through this mnemonic 2000 times before graduating. It quickly becomes hardwired. I find the mantra "Airway, Breathing, Circulation, IV, O2, Monitor" incredibly helpful whenever I feel "stuck." I go back to my ABC's. I make sure I am seeing the vital signs. If something is abnormal, I address it. In the field I would reflexively turn to the ABC's and let them guide me. I'll never forget my first trauma shift in Boston. A crashing bloody patient: Gowns, Masks, IV's, CHAOS,...and I froze....stared at the scene like a deer in headlights. One of the ER nurses, who was young but seasoned (her father was a Boston cop), loud, and very assertive; saw the look on my face. She stared intently into my eyes and in a deep Boston accent said; "AY IS FAH' AYAWAY." It worked. I reassessed the patient and got busy. The message is clear: keep it simple. Focus on the basics and you are less likely to be affected by the noise and chaos.
Back to the field...
When transportation resources are available, on-site medical care can proceed in fairly normal manner (meaning rapid stabilization and transport on injured to nearby hospitals). Transport is a major priority. In cases of prolonged extrication, life saving interventions should be initiated in the field, e.g. IV fluids for hypovolemic shock. Additionally, rapid transport with minimal treatment should be practiced when there is danger to the rescuers such as: fire, explosion, falling buildings, hazardous materials, extreme weather conditions.
When transportation resources are overwhelmed, advanced field medical and surgical treatment may be beneficial. This may necessitate the formation of field hospitals where patients can be brought for further assessment and initial treatment. After stabilization/observation, they may be sent home, or if indicated, transported to an available hospital.
In mass casualty events, EMS protocol suggests transporting patients in equal distribution to appropriate centers, however this can easily be undermined by challenges in communication. Additionally, the problem is exacerbated by "walking wounded" and "worried well" who may arrive on foot to a nearby facility and quickly overwhelm it's capacity to care for patients with greater urgent need.
When local hospitals are overwhelmed (or likely to be overwhelmed) it may be better to treat victims in the field. Field triage my be applicable and separating patients into 3 categories is suggested:
1. those who will die regardless of how much care they receive
2. those who will survive whether or not they receive care
3. those who will benefit significantly from field interventions
In the Emergency Department:
It is important to have a disaster plan which describes: Activation of the plan, Assessment of the hospital's capacity, Establishment of disaster command, Communications, Supplies, Hospital disaster and treatment areas, Training and drills, Security and crowd control.
The traditional concept of TRIAGE becomes essential to disaster management.
The most common triage classification still involves assigning color codes to 4 categories of injury:
Red: First priority, MOST URGENT, Life threatening shock or hypoxia is present or imminent, but the patient can likely be stabilized and, if given immediate care, will probably survive.
Yellow: Second priority, URGENT, The injuries have systemic implications of effects, but patients are not yet in life-threatening shock or hypoxia; although systemic decline may ensue, given appropriate care, can likely withstand a 45 to 60 minute wait without immediate risk.
Green: Third Priority, NON-URGENT, Injuries are localized without immediate systemic implications; with a minimum of care, these patients generally are unlikely to deteriorate for several hours, if at all.
Black: Fourth Priority, Dead, No distinction can be made between clinical and biological death in a mass casualty incident, and any unresponsive patient who has no spontaneous ventilation or circulation is classified as dead. Some place catastrophically injured patients who have a poor chance for survival regardless of care in this triage category.
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Blast Injuries:
Large amounts of energy in the form of expanding gases compress and superheat surrounding air, creating a "Blast Wave", which then delivers high over pressures to surrounding surfaces. Surfaces that are pliable will "spring back" (internal organs) and surfaces that are rigid (bones) will shatter. The blast wave also induces shear forces which can tear tissues beyond their tensile strength.
4 types of injuries:
Primary: Injury related to the immediate effect of a high pressure wave on the body. Air contracting, then expanding, can cause severe damage to gas filled organs: ears, sinuses, lungs, and bowel. Additionally, "spalling" is a phenomenon that occurs when the blast wave moves from an initial higher density medium to another of lesser density. This leads to micro and macroscopic tears at the surface of the two medium.
Secondary: Injury caused by flying debris, projectiles can cause both penetrating and blunt force injury. Eyes are often effected. All parts of the body are subject to penetrating missiles.
Tertiary: Injuries sustained when victims are thrown by the blast wave.
Quaternary: Any injury that is "other" than the above. Examples include burns and inhalation injury. Exacerbation of chronic disease are also included here.
Specific Injuries to consider:
Airway Compromise: (massive hemoptysis, decreased loc, face/neck trauma, and inhalation injury)
Treatment: Intubate/secure airway
Ventilatory Insufficiency:
Treatment: Oxygen, CPAP, positive pressure ventilation
External Hemorrhage: bleeding wounds, amputation.
Treatment: direct pressure, tourniquet.
Tension Pneumothorax:
Treatment: needle thoracostomy followed by tube thoracostomy when available
Shock: external/internal hemorrhage, tension pneumothorax, hypoxia, pulmonary embolus
Treatment: Correct cause and administer IV fluids and blood products.
Arterial Air Embolism: (consider in sudden deterioration: mental status, seizure, chest pain)
Treatment: Hyperbaric oxygen
Pulmonary Primary Blast Injury: hemo/pneumothorax, lung contusion, infiltrate. (Can be occult)
Treatment: Specific to injury
Gastrointestinal Primary Blast Injury: similar to blunt abdominal trauma
Treatment: Specific to injury
**EXTERNAL HEMORRHAGE IS MUCH MORE LIKELY THAN AIRWAY COMPROMISE**
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Pediatric Trauma Considerations:
From Lecture by: Daniel Fagbuyi, George Washington University
http://www.childrensnational.org/files/PDF/ForDoctors/cme/GrandRounds/GRounds09-26-12.pdf
Summary:
Most terrorist attacks involve explosive devices.
It is false to believe that terrorists will not target children.
Children have unique characteristics which place them at risk for blast associated injuries.
Some Slide Highlights:
Additional Sources for this Blog:
Emergency Medicine A Comprehensive Study Guide, 6th edition; Tintinalli, Kelen, Stapcynski
Blast Injuries, A Review; Medscape Emergency Medicine Education; S Sutphen 11/9/05
US Dept of Health and Human Services, American College of Emergency Physicians; Blast Injury Radiologic Diagnosis, 2009
Dedication:
Dedicated to the victims of the April 15th Boston Marathon Bombing and to all Boston Medical Providers who cared for them. You are a model to our Nation. Thank you.
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