Mass Casualty Situations An Educational Framework

1. Mass Casualty SituationsAn Educational Framework Charles Stewart MD EMDM

2. Why? • Unthinkable… Won’t happen here… That’s 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…. It’s difficult to excel… without preparation. Lone Grove, OK

4. 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

5. 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…

6. 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) JCAHO Standard EC.4.10

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 aMass Cal. ^ Sumter Regional Hospital Americus, GA < 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. Hartford CT Convalescent Home Colorado Wild fire Nursing Home Fires

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. P P P P P P P P P P P P P P P P P P P P P P P P Resources challenged (P = Patient) R Do the best for each individual

17. 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

18. P P P P P P P P P P P P P P P P R P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P 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) DON’T 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 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.

26. 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.

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 don’t 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 motto…more than you think

34. 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

35. 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.

36. Civilian Disaster Care • There isn’t 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 • It’s not a bit cool in the hot place…Green • We need for them to wait…Black • 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 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.

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 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.

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. Daily Emergencies Do the best for each individual. Disaster Settings Do the greatest good for the greatest number. Maximize survival. Beneficence

50. 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?