MASCAL Response: Lessons Learned from Baghdad to Boston

WA R R E N A . B O D I N E , D O FA O A S M

A S S I S TA N T R E S I D E N C Y D I R E C T O R , L AW R E N C E FA M I LY M E D I C I N E R E S I D E N C Y

C L I N I C A L A S S O C I AT E P R O F E S S O R T U F T S U N I V E R S I T Y

B O S T O N , M A S S A C H U S E T T S

Goal: To understand basic principles of triage when reacting to a community MASCAL Incident (MCI)

Objectives

Discuss and review lessons learned from MASCAL events during a one year deployment to Iraq

Discuss and review lessons learned from the Boston Marathon bombings

Review personal and event preparedness for a potential MASCAL incident in the community

My background 2001 deployment to the Balkans. Combat zone. MASCAL exercises with the Hungarians, and hospital inspections in Hungary, Croatia, and Bosnia

2003-2004 deployment with 28th Combat Support Hospital. 6 months in desert and 6 months in Baghdad. MASCALS weekly sometimes daily. 12 hour shifts x 5 months. ED/trauma physician. MASCAL Triage Officer

2013 Boston Marathon bombing. Chief Medical Officer “Finish Line Tent B”

What is a MASCAL incident? - Natural events (lightening, wind, flooding, etc.)

- Accidental (collapsed staging, cyclist colliding, etc.)

- Terrorist (Boston Marathon) or active shooter

or active shooter

Iraq IED blasts- what we treated

Boston Marathon

Overview of casualty care during OIF

Overview of casualty care in Boston

How did we prepare for casualties in Iraq?

- What was the mission? Who will we be treating and for how long?

- Stabilize patients

- Staging at Fort Bragg

- Staging in Kuwait

- Classes (setup of chemical protective CSH, chemical attacks, medics trained up)

How did we prepare for casualties in Boston? - Historical review of lessons learned from past races

- Meetings and phone calls with all key players (all year long)

- Countless lessons learned from intense heat of 2004 and 2012 races

- More supplies, tent space, on course support, better communication

- Boston EMS practiced MASCAL event frequently

So what lessons did we learn in Baghdad?

- Preparedness: we did not expect severe burns, blast injuries, pediatric, and injuries in women

So what lessons did we learn in Baghdad?

- Initial response: secure the scene, stop bleeding (airway rarely an issue), stabilize fractures if time, get away from danger, and keep your patient warm.

So what lessons did we learn in Baghdad? - Triage and stabilization: Use experienced doc or nurse (not dental officer), save greatest number by stopping bleeding….tourniquets and secured direct pressure, beware of hidden neck and back injuries, and if blunt trauma then expect pelvic fracture with rapid decline. Beware of hypothermia.

We had to make some tough decisions. In MASCAL unlikely to save everyone

So what lessons did we learn in Baghdad? - Communications: Always challenging with often inaccurate information from MEDEVAC

So what lessons did we learn in Baghdad? - Patient flow and tracking

◦ Proper identification of the injured

◦ Contact with unit was challenging

◦ Air Evacuation to Germany and US went well since we ruled the air

Boston Marathon Finish Area

Boston Marathon Finish Area

So what did we learn in Boston?

- Preparedness ◦ - MASCAL response in 2004 and 2012

◦ Bigger tents with more beds

◦ Immediate cooling of heat casualties

◦ Teach CPR to runners

◦ More medical volunteers

Emergency Action Plan (EAP) Written medical/safety plan that outlines how the medical staff will handle various types of medical emergencies

Plans should include:

I. Emergency Plan Personnel

II. Emergency Communication

III. Emergency Equipment

IV. Map of Venue

V. Storm Safety Plan

VI. Follow up

So what did we learn in Boston?

- Initial response ◦ Hard to secure the scene. People just

jumped the fences in and out of danger ◦ Focus was at the bomb scene. But don’t

forget what else is going on around you ◦ What about second and third bombs?

“Dirty” bombs? Snipers? ◦ Non-conventional transport methods work ◦ Now, roaming Rapid Reaction Force ◦ CERFP at the start. Imagine if the bombs

were detonated in Hopkinton!

So what did we learn in Boston? - Triage and stabilization

◦ Once again tourniquets saved lives!

◦ “Scoop and run” with any means possible

◦ Lot of people helped out. May not have that response

So what did we learn in Boston?

- Communication ◦ Totally focused on the bomb scene

◦ Radios/cell phones silenced. No communication with Tent B

◦ Need well established Incident Command Center with medical coordinator in place

◦ Need multiple modes of communications

Communication

-Cell phones: Master cell phone list—designated person at each aid station

-Ham radios/walkie-talkie radios:

-Separate channels.

-Don’t use too many channels

-Let local ER’s and ambulance companies know when your event is

So what did we learn in Boston?

- Patient flow and tracking ◦ Nice job by EMS to log in patients

before transport to hospitals

◦ Prior coordination and practice was well worth it

Patient Flow and Tracking

MASCAL incident at an athletic event

- Could it REALLY happen?

- Structure collapse

- Natural disaster (earthquake, lightening strike, flash flood)

- Terrorist attack

- Active shooter

What would you do?

Attending High School Football Game

◦ 1000 + people attending high school football game ◦ Chaos as people flee from active shooter ◦ You are right there when this happens!

What would you do?

- First response: “Do I want to get involved, or get away as quickly as possible?”

- Ok, “I am in!” Now what??

S.T.A.R.T (Simple Triage and Rapid Treat)

- Simple Triage and Rapid Treatment

-Swamped with varying degrees of “wounded”

- Is the scene safe? How big is this problem?

- Start where you are and tune out the distractions

- Separate the “walking wounded”

- Call for help with best estimate of casualties

S.T.A.R.T (Simple Triage and Rapid Treat)

Green, Yellow, Red, Black

- Green: minimal scrapes etc.

- Yellow: delayed care is okay

- Red: immediate care (L-L-E)

- Black: sorry but likely all over

* Help the greatest number you can!

S.T.A.R.T

- People scrambling and screaming

- No one has taken charge yet

- Scene appears safe and police have arrived

- Direct the walking wounded to a safer refuge

- Look for people willing to help you with basic first aid and gathering supplies

S.T.A.R.T

“RPM”

-Respirations

- Perfusion

- Mental status

S.T.A.R.T

- You come across 4 people; 2 crawling towards you and 2 on lying on the ground

- Who do you treat first?

- R.P.M. (Respirations, Perfuse, Mental Status)

- Respirations ◦ - No? Reposition airway

◦ - Now? None = Expectant (Black)

◦ - Breathing now? Yes… Red

S.T.A.R.T

- RR > 30 per minute: RED

- RR < 30 per minute: Check perfusion

- Perfusion ◦ Radial pulse absent or cap refill > 2

seconds then RED ◦ Radial pule < 2 seconds or strong

then check: - Mental status: follow simple commands?

- No RED - Yes YELLOW

Your first 4 casualties Lady #1: Hyperventilating RR > 30, bloody face

- What category?

Lady #2: Talking, RR < 30, clammy and cap refill > 4 seconds

- What category?

Man #1: Wrist deformity, RR < 30, cap refill < 2 seconds, answering questions correctly

- What category?

Man #2: Crawls towards you, looks up and then unconscious. Not breathing, reposition airway, still not breathing.

- What category?

Now what?

- Tag/mark

- Safeguard in triage specific areas

- Treat and re-assess when able

- Prepare for transport

- Seek guidance from incident commander or other senior authority

So what did we learn from B to B?

- Prepare for the most likely but also for the unexpected. (Incident command and EOC)

- Always have situational awareness

- Initial response will be chaotic. Add darkness or bad weather and exponentially harder!

- Be careful if you suspect terrorist attack or active shooter

- Separate the “walking wounded” first

So what did we learn from B to B?

- Not a medical center; basic first aid and go!

- Stop life threatening bleeding with whatever means you have

- Don’t spend a lot of time on airway

- Use any transport (pick ups, wheelchairs, etc.)

- Assign someone to track the injured

- Call for help and communicate

So what did we learn from B to B?

- Communications may be your hardest challenge

- You may not have a clear leader so just work as a team

- Prevent casualty hypothermia

- You may not save everyone

- Always take care of yourself and your people

- Talk about what you experienced!

What would I bring?

- 2 means of communication

- Kerlix and ACE wraps

- Tourniquets

- Oral airways

- Gloves

- Sharpie

- Colored ribbon for triage

- Heart rate monitor

Tourniquet

- Basic principles ◦ - Place proximal on the limb

◦ - Direct pressure over artery

◦ - Do not release

◦ - Mark time applied if able

Resources

https://delvalle.bphc.org/course/view.php?id=244&utm_source=July+2013+Newsletter&utm_campaign=July+newsletter&utm_medium=email

(Devalle Institute for Emergency Preparedness: online)

FEMA Center for Domestic Preparedness (CDP), Anniston, AL

https://cdp.dhs.gov/training/resident/

Community Emergency Response Team: CERT Training Videos online