mass casualty and disaster management: lessons …...mass casualty and disaster management: lessons...
TRANSCRIPT
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MASS CASUALTY AND DISASTER MANAGEMENT: LESSONS LEARNED FROM THE COLORADO SHOOTINGS
Christopher B. Colwell M.D.Department of Emergency MedicineZuckerberg San Francisco General Hospital and Trauma Center
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ROCKY MOUNTAIN HIGH!
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CALIFORNIA HIGH!
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WORLD TRADE CENTER
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SCHOOL SHOOTINGS
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VIRGINIA TECH
April 16th, 2007
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December 14th, 2012
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BOSTON MARATHON
April 15th, 2013
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ASIANA AIRLINES FLIGHT 214
July 6th, 2013
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ORLANDO SHOOTING
June 12th, 2016
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LAS VEGAS SHOOTING
October 1st, 2017
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PARKLAND SCHOOL SHOOTINGS
• February 14th, 2018
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COLORADO SCHOOL SHOOTING 2019
• STEM School
• Highlands Ranch, Colorado
• May 7th, 2019
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COLUMBINE HIGH SCHOOL SHOOTINGS
April 20th, 1999
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AURORA SHOOTINGS
July 20th, 2012
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BUS CRASH
• 8:30 AM on Wednesday morning
• 38 passengers and 1 driver
• 4 critical, 2 serious
• Everyone else has neck pain
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LOUIS PASTEUR
• “Chance favors the prepared mind”
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WE MUST BE PREPARED
• What would I do?
• What WILL you do?
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HOPE?
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CDC DISASTER
• A serious disruption of the functioning of society causing widespread human, material, or environmental losses that exceeds the local capacity to respond.
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DISASTER MANAGEMENT
• A change from priority forto access to
• Are you ready to ration care?
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CONTINUUM OF MEDICAL CARE
• Conventional care
• Usual resources
• Contingency care
• Functionally equivalent
• Crisis care
• Inadequate resources
• Care to the level possible
• Altered standards of care are designed to preserve as many lives as possible
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CRISIS STANDARD OF CARE?
• Legal standard: What a reasonable person would do under similar circumstances
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COLORADO SHOOTINGS
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GREATER DENVER METRO AREA
Century
16 Theatre
Medical
Center of
Aurora
University CO
Hospital Children’s
Hospital CO
Denver Health
Medical Center
Swedish Medical
Center
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DIVERSION
• 11:20 Hours - Report of Explosion and Grassfire at Chatfield and Wadsworth
• “There was an explosion in the backyard. I don’t know if it was a car or a propane tank, a big ball of fire, now there is smoke. There are several people pulled off to the side of the road”
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SECONDARY DEVICE
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ACTIVE SHOOTER?
• Where are they more likely to go?
• Not great data, but ED is a common target
• What will you do?
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TIMELINE
⚫11:20 : report of explosion and grassfire
⚫11:26: first report of shots fired at the school
⚫11:36: call for physician to the scene
⚫12:02: first 3 victims transported
⚫12:08: 4th victim transported/sniper has training chief in sites
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SCIENCE AREA
⚫Shooters move back upstairs into hallway shooting through doors into classrooms
⚫Dave Sanders shot in the science area.
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CAFETERIA
⚫Attempt to detonate explosive devices placed under tables
⚫Propane tank explodes, activating 5 sprinkler heads
⚫Exchange of fire with school resource officer.
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TIMELINE
⚫15:30: last surviving victim from the library is transported with multiple GSWs
⚫16:30: 14 students (2 shooters) and 1 teacher pronounced dead
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TIMELINE
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TOTAL NUMBERS
• Columbine
• 15 died
• 24 transported
• All survived
• Aurora theater
• 12 died
• 70 transported
• 69 survived
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MASS CASUALTY AND DISASTER MANAGEMENT
• Mass casualty management
• Lessons learned from the Colorado shootings
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MASS CASUALTY MANAGEMENT
• Overall assessment• Communicate• Command post• Triage• Treatment• Transport
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COMMAND POST
• At the scene
• At the hospital
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MASS CASUALTY MANAGEMENT
• Communicate• Regional trauma
center• Activate HICS• Obtain information from
all area hospitals regarding:
• Emergency department capacity
• Operating room/critical care capabilities
• Hospital bed availability
• Accurate?
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MASS CASUALTY MANAGEMENT
• Triage• Sorting and classifying
patients into categories according to priority of treatment
• Aim is to do the most goodfor the largest number of victims
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GREATEST GOOD
• “What does the greatest good mean when it comes to medicine? Is it number of lives saved? Years of life saved? Best “quality” years? Something else?”
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TRIAGE
• Four categories• Severe (red)• Moderate (yellow)• Minor (green)• Mortally wounded or
dead (black)
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TRIAGE
• Severe (red)• Given available care,
have a reasonable chance of survival, BUT
• Without care have a markedly diminished chance of survival
• Highest priority
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TRIAGE
• Moderate (yellow)• Those whose injuries will
not lead to significant morbidity or mortality if they do not receive immediate care and transport
• Clearly need medical management
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TRIAGE
• Minor (green)• “Walking wounded”:• Injuries are not anticipated
to lead to significant morbidity while they wait for treatment/transport of higher categories
• Busses• May not need to go to
hospitals
• Some will self-transport• Important to keep track
for distribution
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TRIAGE
• Mortally wounded/dead• Cardiac arrest
• Electrical injury is exception
• Non-survivable injuries• Not breathing on their own
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TRIAGE
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TREATMENT
⚫Hemorrhage control⚫ Tourniquets
⚫Address airway⚫ Simple maneuvers
⚫Oxygen administration
⚫Needle decompression
⚫Immobilization⚫No back boards!
⚫Will depend on the size and scope of the event
⚫Physician role is generally NOT treatment at the scene
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ALTERNATE CARE SITES
• Many options
• High school
• Rec center
• Church
• Treatment may be more extensive
• Can manage greens and even yellows
• Liberal protocols
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TRANSPORT/TRANSFER
• Rush to the nearest?• Destination is crucial
• Don’t simply displace disaster
• Helicopters• Less acuity further
away?• Coordinate effort!
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LESSONS LEARNED FROM THE COLORADO SHOOTINGS
⚫Communication
⚫Temptation
⚫Organization
⚫ Identification
⚫Resources
⚫Media
⚫Call down
⚫Debriefing
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COMMUNICATION
• Arrange in advance• Different agencies on
different frequencies• Appropriate and
necessary• Cell phones useless• Batteries
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COMMUNICATION
• Hand held P25 interoperable radios
• Allows multiple agencies to share common frequencies
• Can communicate through mobile data terminals (MDTs)
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TEMPTATION
• Rush and treat• Is the scene safe?
• What good is done by adding to victim list
• Where are efforts needed most?
• “The good of the many over the good of the few”
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TEMPTATION
• Rush and transport• Rush to nearest
hospital• Simply transplant
disaster• Equal and appropriate
distribution• Avoid self-destination• Walking wounded
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TEMPTATION
• Rush to scene
• Rest of the city still needs care
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ORGANIZATION
• Everyone will arrive• Importance of staging
• Vehicles everywhere• Crowds
• Staging in the ED as well!
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AMBULANCE BAY
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IDENTIFICATION
• Triage area• Freelancers• Sniper incident• ED
• Attending in charge• Charge nurse• Transport
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RESOURCES
• Victims AND providers• Water • Clothing
• Hospital cafeteria• Pediatrics
• Equipment• Destination for families?
• Do not separate unless absolutely necessary
• Tracking
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CALL DOWN
• Communicate the incident is over
• Plane crash in Washington D.C.
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MEDIA• Onslaught WILL occur
• At scene• At hospital• For weeks on end
• Aid versus hinder• PREPARE!
• Information to release• Variations on a story• Sound bites
• Nothing is “off the record”
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WHAT CAN YOU SAY?
• HIPAA
• Condition
• Good
• Fair
• Serious
• Critical
• Treated and released
• Treated and transferred
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AFTERMATH
• Critical Incident Stress Debriefing (CISD)
• Involved personnel
• Off duty personnel
• Spouses
• Staff support
• Take care of your own
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AFTERMATH• Incident review
▪ Constructive vs. armchair quarterbacks
▪ Egomaniacs
• Don’t underestimate the impact this can have
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DEBBIE CRAWFORD
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HOSPITAL PREPAREDNESS
• Surge capacity• Not just “open” beds
• Empty out the ED!• First to arrive
• Not by ambulance• Often not the sickest
• Triage breakdown• 10-20% reds
• <10% will need the OR emergently
• 30% yellow• 50% green
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HOSPITAL PREPAREDNESS
• Designated areas• Red • Yellow• Green
• Should not get in the ED
• Triage is a dynamic process!
• Documentation• Tracking• Pictures
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HOSPITAL PREPAREDNESS
• Sudden event vs. insidious
• Triage hospital?• Decontamination
• Know how• Likely won’t need to
• Security• Drills
• Only as good as the level of participation
• Everyone’s problem
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WHY?
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Time
Why?
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RESPONSE
• Highlight the victims• Kendrick Castillo
• Don’t focus on the perpetrator
• “hero” status
• Copycat events
• “Stay in your lane”??• This is most definitely our
lane
• We have a long history of successful prevention efforts
• Please advocate for what you believe
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SUMMARY
• It will happen to you• Beware of second hit
• Never let your guard down
• Have a plan• Test it• Use it
• Drill• Communication and
cooperation are the keys
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