mci
DESCRIPTION
Mass Casualty Incident responseTRANSCRIPT
Anesthesia Support of Mass Casualty Incidents
COL Paul C. Reynolds, M.D.
Mass Casualty Incidents
• A disaster is an emergency that disrupts normal community function and causes concern for the safety, property, and lives of its citizens.
• An MCI is a medical disaster that is associated with the production of human injuries.
MCI Levels
• MCI Level 1 - manageable
• MCI Level 2 - multi-jurisdictional mutual aid
• MCI Level 3 - overwhelming, requiring state or federal aid
Philosophy of Disaster Care
• Normally - maximal time and resources devoted to individuals
• MCI - greatest good for the greatest number• Expectant category• CPR• Acceptable results
Unaltered Precepts
• ABC’s• Systematic assessment• Triage and re-triage• Patient dignity• Pain Control
The Plan
• Plan / Practice
• Organization
• Communication– internal– external
• Execution / Evacuation
• Debriefing
JCAHO
• A plan must be formulated
• The plan must be written down
• The plan must be disseminated
• The plan must be practiced
Mass Casualty(examples)
• Gallant Eagle
• Beirut, Lebanon
• Urgent Fury
• Bhopal, India•Gander, Newfoundland •Desert Storm•Ft Bragg, NC•Shemaya, Alaska•Tokyo, Japan
Gallant Eagle ‘82(30 March 1982)
• Parachute Operation: Ft Irwin, CA
• 158 injuries
• 6 deaths
• On-site Physicians Assistants
• Community Hospital - 10 miles
• 93rd Evacuation Hospital
Gallant Eagle(continued)
• Prior coordination
• Planned & practiced
• Communication
• Situation driven decisions- DZ evac - Individual intiative- Referrals - Hospital expansion- X-rays - Accountability
Beirut, Lebanon(23 October 1983)
• 234 immediately killed
• 96 seriously injured
• Medical officer killed
• On-site coordination
• USS Iwo Jima
• British Royal Hospital
Beirut(continued)
• Planned / practiced
• Assessment / treatment / recording
• Evacuation
• Coordination
Urgent Fury - Grenada(24 October 1983)
• USS Guam
• 76 casualties
• Initial triage staffing
• Surgical team
• Role of ATLS
• “Walking blood bank”
Urgent Fury - Grenada(USS Guam)
Overflow207 beds
Starboard
Port
Urgent Fury - Grenada(nature of wounds)
• Traumatic– Orthopedic 66
– Head & face 19
– Chest 16
– Back & neck 11
– Penetrating• Abdomen 10
• Soft tissue 10
• Burns 2
• Genital 1
• ARDS 1
•Non-traumatic– Heat exhaustion 5– Cellulitis 1– Battle fatigue 1– Unstable angina 1– Post-partum hemorrhage 1
Bhopal, India(3 December 1984)
• 100,000 casualties in the first 24 hours
• 500 deaths - prior to treatment
• 6,000 severe injuries - 2,000 died in the first week
• 150,000 - 200,000 some injury
Gander, Newfoundland(12 December 1985)
• 256 deaths
• Radiologic support
• Pathologic support
• FBI support
8th Evacuation Hospital(21 January 1991 - Desert Storm)
• Mass casualty situation in garrison
• Anti-tank weapon in billeting area
• Evac hospital
• 14 casualties arrived during mass casualty exercise
• 4 immediate, 1 delayed, 9 minimal
Pope Air Force Base(23 March 1993)
• F-14 crashes into group of paratroopers
• 104 casualties arrive within 5 minutes
• 13 dead
• 20 operative procedures
• 25 intubations
Pope Air Force Base(C141 at Green Ramp)
On-site
• Triage
• Treatment
• Evacuation
Intubations & evacuation
Transport
• Local EMS
• Anything that rolls
• Walking wounded
Initial Assessment
• Airway
• Breathing
• Circulation
• Airway management team / expertise
Outside the Operating Room
• Unfamilar– support– personnel– terminology– timing
• Rounds
• Consultation
Traige(intubations)
• Morphine
• Lidocaine
• Succinylcholine
Problematic Intubation
“Our (unpublished) data suggest that in military trauma, the first-attempt failure rate [of intubations] could exceed 40%, although it is less for experienced medical officers. The rate of field-executed cricothyroidotomies also suggests a high occurrence of failed intubations.”
OR Support
The Next Day
• Continuing operations– other ongoing operations– planning for secondary
interventions– evacuation stabilization
• Rationing personnel
• Rest cycles
Personal Experience
• “How did we do that?”
• What went well?
• What went badly?
• Psychological after effects
• Planning the next one!
China Eastern MD-11(5 April 1993)
• Shemaya Island - Aleutian chain
• Medical clinic
• One staff physician
• 3 hours until first medical reinforcements
• 64 litter evacuations
• 93 ambulatory evacuations
Tokyo Subway Sarin Gas Attack
• Methyl phosphonofluoridic acid 1-methylethyl ester (Sarin)
• Sarin is an organophosphate nerve agent.
• Dilute solutions in containers hidden on three different commuter train lines.
• 5,500 patients
EMT limitations
• Japanese emergency life-saving technicians– Combitube– Laryngeal Mask Airway– Intravenous line– Cardioversion
• Cannot be carried out without physician orders
Communications
• Tokyo Metropolitan Ambulance Control Center (TMACC) “was in total confusion”
• Incoming information exceeded ability to manage communications
• Lack of cooperation and communication between agencies involved
Hospital response
• Cessation of normal operations
• Change to disaster response
• Triage
• Lack of decontamination
• Supply redistribution
National response
• Japanese Self Defense Forces
• Planning was centered on local threats
• Acceptance of international help– Especially regarding nerve agent treatment
“Although some knowledge exists of the long-term effects of sarin on animals, there is little information about its effects on humans. Follow-up of the victims of this large-scale exposure is essential for that purpose.”
Mass casualty incidents
• Summary
Doyle, CJ. Mass Casualty Incidents, Integration with Prehospital Care. Emergency Medicine Cliics of North America. 1990; 8: 163-175.Timboe HL. Mass Casualty Situation: Gallant Eagle 82 Airborne Operations: A Case Report. Military Medicine. 1988; 153: 198-202.Frykberg ER, et al. Diaster in Beirut: An Application of Mass Casualty Principles. Military Medicine. 1987; 152: 563-566.Lorin HG, et al. The Bhopal Tradgedy-What has Swedish Disaster Medicine Planning Learned from it? The Jouranl of Emergency Medicine. 1986; 4: 311-316.Walsh DP, et al. The effectiveness of the Advanced Trauma Life Support System in a Mass Casualty Situation by Non-trauma Experienced Physicians: Grenada 1983. The Journal of Emergency Medicine. 1989; 7: 175-180.Mulligan ME, et al. Radiographic Evaluation of Mass Casualty Victims: Lessons from the Gander, Newfoundland, Accident. Radiology 1988; 168: 229-233.Satava RM, et al. A Mass Casualty While in Garrison during Operation Desert Storm. Military Medicine. 1992; 157: 299-300.Towne LE. China Eastern MD-11 Mass Casualty-Expect the Unexpected: A Case Report. Aviation, Space, and Environmental Medicine. 1995; 66 (10): 998-1000.
Bibliography
Shalev AY. Editorial: The Role of Mental Health Professionals in Mass Casualty Events. Israeli Journal of Psychiatry Related Sciences. 1994; 31(4): 243-245.Rozin RR, et al. Integration of Military Unit and Civilian Hospital during Mass Casualty Situation: Experience during the 1982 Lebanon War. Military Medicine. 1986; 151: 580-582.Durham TW, et al. The Psychological Impact of Disaster on Rescue Personnel. Annals of Emergency Medicine. 1985; 14: 664-668.Phillips WJ, et al. Anesthesia during a Mass Casualty Disaster: The Army’s Experience at Fort Bragg, North Carolina, March 23, 1994. Military Medicine. 1997; 162: 371-373.Abraham RB, et al. Problematic Intubation in Soldiers: Are there Predisposing Factors? Military Medicine. 2000; 165: 111-113.Leibovici D, et al. Prehospital Cricothyroidotomy by Physicians. American Journal Emergency Medicine. 1997; 15: 91-93.Okumura T, et al. The Tokyo Subway Sarin Attack: Diaster Management, Part 1: Community Emergency Response. Academic Emergency Medicine. 1998; 5(6): 613-617.Okumura T, et al. The Tokyo Subway Sarin Attack: Diaster Management, Part 2: Hospital Response. Academic Emergency Medicine. 1998; 5(6): 618-624.Okumura T, et al. The Tokyo Subway Sarin Attack: Diaster Management, Part 3: National and International Responses. Academic Emergency Medicine. 1998; 5(6): 615-628.
Bibliography