MCI or Disaster? Dilemmas and traps

1. MCI or Disaster? Dilemmas and traps Kostas A. Papaioannou, MD, MSc Plastic Surgeon F. President of MSF-Greece European Master in Disaster Medicine

2. The referring doctor, the patient or his environment determine, what constitutes an "emergency", and define the reason, time and point of entry into the system, regardless of age and the ultimate nature of the illness or injury The Medical staff in ED, manages the unanticipated and unscheduled unpredictable volume of patients with injuries and conditions of undetermined and varying severity and complexity

3. The Student Manual for Disaster Management and Planning for Emergency Physician's Course (ACEP:1-2): Level I: A localized multiple casualty emergency wherein local medical resources are available and adequate to provide for field medical treatment and stabilization, including triage. The patients will be transported to the appropriate local medical facility for further diagnosis and treatment. Level II: A multiple casualty emergency where the large number of casualties and/or lack of local medical care facilities are such as to require multi-jurisdiction (regional) medical mutual aid. Level III: A mass casualty emergency wherein local and regional medical resource's capabilities are exceeded and/or over-whelmed. Deficiencies in medical supplies and personnel are such as to require assistance from state or federal agencies.

4. unpredictable events 1.Cataclysmic events, both natural and man-made 2. War, either full-scale or more insidious 3. Terrorist actions, often connected with either of the two situations listed above

5. Airport →air crash → mass casualties with many survivors suffering brain injury, smoke inhalation, and conventional trauma Chemical weapons development in laboratory → accidental release of agent(s) →mass casualty situation with victims ultimately suffering compromise of airway patency or respiratory, circulatory, and neurologic system failure Sports stadium→ bleacher collapse → mass casualty situation with multiple fractures, head and spine injuries, as well as crush syndrome

6. Differences in Disasters

7. Differences in Disasters ( 2 )

8. Differences in Disasters (3)

10. N An incident resulting in one or more casualties, with varying severity of injuries, S , will be met by medical assistance of a specific capacity, C Whether it is characterized an MCI or a disaster , it has to be defined

11. Medical Severity Index = (N xS)/C

12. An MSI>1 is indicative of a disaster An MSI of 0.4 means a sizeable incident, whereas an MSI of 4.2 indicates a substantial disaster

13. Empirical determination of the number of casualties (N) in a disaster immovable immovables

14. Empirical determination of the number of casualties (N) in a disaster Mobile objects

15. The Average Severity of Injuries

16. Medical Severity Factor  S= (T1+T2) / T3. J de Boer. Tools for evaluating disasters: Preliminary results of some hundreds of disasters.Eur J Emerg Med 4:107–110, 1997

17. Capacities (C) in the Medical Assistance Chain MAC The transport of casualties and their distribution among hospitals in the vicinity MTC The site of the incident or disaster MRC The hospital HTC This capacity, C, indicates, among other things, the MSI and thus the turning point between incident and disaster.

18. how many casualties can be ‘‘processed’’ per hour by a doctor and a nurse, assisted by one or more first aid staff. 1 T1 + 3 T2 / h Medical Rescue Capacity (MRC) = The number of ambulances, X, required at a disaster is directly proportional to the number of casualties to be hospitalized, N, and the average time of the return journey between the site of the disaster and the surrounding hospital, t, and inversely proportional to the number of casualties to be conveyed per journey and per ambulance, n, and the total fixed length of time, T, during which N have to be moved Medical Transport Capacity (MTC) = X=N x t/T x n 2 to 3 patients per hour per 100 beds HospitalTreatmentCapacity (HTC) =

19. CLASSIFICATION AND ASSESSMENT OF DISASTERS 1 2 0 1 2 0 1 2 0 1 0 1 2 <1 1-2 >2 0 1 2 0 1 2 TOTAL 1-13

20. the disaster severity scale (DSS) Beaufort scale for wind speed Mercalli scale for the intensity of an earthquake

21. Assessment of Medical Response Capacity in the time of Disaster: the Estimated Formula of Hospital Treatment Capacity (HTC), the Maximum Receivable Number of Patients in Hospital AKIRA TAKAHASHI et al, Kobe J. Med. Sci., Vol. 53, No. 5, pp. 189-198, 2007

22. Required Medical Personnel (in Kobe University Hospital) 1 patient with severe trauma 2 emergency doctors (EMDs) Operation or angiography required? Yes 　　No • ・Operation: 2EMDs+1Surgeon+1Anesthetist • 2 EMDs Angiography: 2EMDs+1Radiologist

23. The average length of treatment time for the three types of conditions in ER

24. The estimated Formula for Hospital Treatment Capacity (HTC) The maximum receivable number of patients in hospital (MRN) = HTC = The maximum integer of (≤B1/A1∩≤B2/A2∩…∩≤Bn/An∩≤D1/C1∩≤D2/C2∩…∩≤Dn/Cn)

25. The estimated Formula for HTC (MRN) within H hours

26. H.T.C Ventilators available Operating rooms Emerg. Op. rooms) χ 2.5 = Χ ( + + 3 2 For the 1st Hr

27. Crucial questions/decisions for mass casualty situations ( Dilemmas ) 1. When to start in-hospital staff mobilization? 2. Is there a need for out-of-hospital staff recruitment? 3. Does the condition demand stabilizing the patients and referring them elsewhere? 4. Are treatment sites sufficient or there is a need for opening new treatment sites? 5. Does the condition mandate stopping routine hospital work (OR, hospital clinics, …)? 6. Prioritizing OR use 7. Shortening OR waiting list by referring patients to other hospitals 8. Does the condition mandate opening a public information center? 9. Assessing critical shortages during conducting the MCS (staff, equipment, supply…) Collect the right information regarding : the type of incident, the time and the location, The weather condition the number of people involved etc It depends on the magnitude of the event The type of the event The population involved The shifting hours of the personnel It depends on The magnitude and the type of the event The severity of victims Specific morbidity ( burns, blast injuries, CBRN cases etc ) The distance from the definite treatment services It refers To the scene ( dispersed or not victims, High number of T1 and T2, accessibility of the site..) For in hospital services ( No of victims, need for decontamination, isolation etc ) Is there the only hospital to accept victims Is there morning or a night shift? …

28. ACCIDENT NO EXCEEDS EMERGENCY RESPONSE CAPACITY YESCALAMITY AFFECTED AREA NO INCIDENTCASUALTIES YES EXCEEDS MEDICAL EMERG RESP CAPACITYYESDISASTER AFFECTED AREA NO ACCIDENT

29. Conclusion • Emergency medicine and disaster medicine share the characteristics of: - unpredictability in volume and severity - concept of triage - team effort • Need for special education and training for all the players.

30. THANK YOU