mass casualty management: what we’ve learned in europe linda e. pelinka, md, phd medical...
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MASS CASUALTY MANAGEMENT:
What we’ve learned in EuropeLinda E. Pelinka, MD, PhD
Medical University of Viennaand Ludwig Boltzmann Institute
for Experimental & Clinical TraumatologyVienna, Austria, European Union
TRAUMA
LONDON
MADRIDISTANBUL
What happened?
Management: what went right?
Management: what went wrong?
Lessons learned
Management & support priorities
Command & controlSafetyCommunicationTriageTreatmentTransport
Istanbul, TurkeyTargets Synagogues
Date Sunday, November 15th, 2003
Time 9.30 a.m.
Number 2 truck bombs: improvised (400 kg) explosive devices. Ammonium sulfate, ammonium nitrite, compressed fuel oil mixed in containers
Attack Type Suicide bombing
Dead 30
Injured ~300
SYNAGOGUE BOMBING
Neve Shalom & Beth Israel SYNAGOGUES
DAMAGED STREETS: wide craters 2 m deep
DAMAGED BUILDINGS >100 m away,
windows shattered >200 m away
INJURED SHOPPERS outside > worshippers
inside (protected by façade of synagogue)
5 days later5 days later
Istanbul, TurkeyTargets Hong Kong Shanghai Banking
Corporation, British Consulate
Date Friday, November 20th, 2003
Time 10.55-11.00 a.m.
Number 2 truck bombs, improvised (700 kg) explosive devices
Attack Type Suicide bombing
Dead 33
Injured 450
Blast destroys 6 buildings
Damages another 38 buildings
Rips out storefronts
Blows out windows hundreds of m away
Downs electrical and phone lines
Flings body parts through the air
ISTANBUL : what went RIGHT?
3 min after blast, ambulances start arriving at
disaster sites
ISTANBUL: what went WRONG?
30 AMBULANCES arriving
at disaster sites within 15 min of blasts
POLICE just beginning
to establish site security
FIRST RESPONDERS rushing
to sites without protective
equipment despite stench of
ammonia
ISTANBUL: what went WRONG?
CHAOS AND CONFUSION
TV headquarters across the street from scene, broadcasts disaster & confusion within 12 min of the blast, causing more confusion,
more bystanders
Public receives info from the media only, is shocked by images shown.
Turkish government bans broadcasting.
TRAFFIC GRIDLOCK EMS CANNOT REACH VICTIMS
Streets clogged by debrisTraffic, narrow streets parked carsAmbulances, medical personnelPolice, fire brigadeMedia, bystanders, volunteers
ISTANBUL: what went WRONG?
MALDISTRIBUTION of INJUREDNO TRIAGE
Severely injured require slower transport and
need to travel further (maldistribution)
Lightly injured hurry to nearest hospitals,
overloading hospital capacity
Transportation: ambulances, private vehicles, on
foot. Patients with minor injuries grab passing
ambulances.
2003 Terrorist bombings in Istanbul
Problems related to triage:
• No knowledge of first aid (citizens, police)
• No knowledge of triage (police in charge of evacuation)
• Turkish mentality
no confidence in public/medical authorities
family transports patient to hospital
try to load patients before ambulance halts
K Taviloglu et al, Int J Disaster Med 3/1-4: 45-49; 2005
Mass-Casualty Terrorist Bombings in Istanbul: Events and Prehospital
Emergency Response
Main problems:
• First responders risked exposure to secondary
hazards “come-hither” bombs
• Maldistribution of patients: minor injuries
overload closer hospitals, severe injuries need
to travel further
U Rodoplu et al, Prehosp Disaster Med 19: 134-145; 2004
NO COMMAND
NO CONTROL
Police unable to establish control Scene not securedAll ambulances dispatched simultaneously,
many not needed No protective gear (stench of ammonia)Bystanders in the way, digging
independentlyCommunication network collapses
Mass-Casualty Terrorist Bombings in Istanbul: Events and Prehospital
Emergency Response
Lessons learned:
• Establish emergency plan and preparedness
• Establish unified command to coordinate/organize
• Establish/upgrade communication links between EMS and hospitals
• Establish uniform EMS triage protocols
• Conduct regular disaster training and practice
U Rodoplu et al, Prehosp Disaster Med 19: 134-145; 2004
WHAT DID
THE TERRORIST ATTACK
TEACH THE TURKISH?INDEPENDENCE &
IMPROVISATION
MAY BE GOOD, BUT……STEP BY STEP TEAMWORK
IS BETTER
Madrid, SpainTargets Commuter Train
Date Thursday, March 11th, 2004
Time 7.30-8.00 a.m.
Number 13 bombs (22 lbs of explosives each) on 4 trains in 3 stations. 3 bombs failed to explode
Attack Type Backpacks, cell phone detonation
Dead 191
Injured 2050
7.37 a.m.
7.39 a.m.
Train 1 inside Atocha Station
Train 2 approaching Atocha Station 2 min late
8.00 Ambulances arrive
8.30 EMS sets up field hospital
at sports stadium
nearby
8.40 a.m. Spanish Red Cross issues urgent
appeal for blood, supplies running low
Number of victims higher than in any similar
action in Spain, far surpassing Basque
attacks.
Worst incident of this kind in Europe since
Lockerbie bombing in 1988.
MADRID: what went RIGHT?
Sufficient resources availableGood in-hospital care
Atocha station, doors of train open: less
deaths8.00 “Cage Operation” goes into effect to
prevent terrorists from escaping from Madrid8.45 National & international rail traffic in
and out of Madrid shut down completely
MADRID: what went RIGHT?
According to experience from ETA attacks
stay and stabilize policy in the field
prevents immediate hospital overload
Minor injuries
treated at temporary hospitals at each station
and at a sports stadium nearby
Severe injuries
flown to hospitals by helicopter
Insufficient
COMMAND
CONTROL
COMMUNICATION
MADRID: what went WRONG?
London, United Kindom
Targets Underground and bus
Date Thursday, July 7th, 2005
Time 8.50-9.47 a.m.
Number 4 bombs, 10 lbs of high explosives each (home-made acetone peroxide)
Attack Type Suicide bombings
Dead 52 + 4 suicide bombers
Injured ~700
Daily morning commuters in London
370,000 Underground passengers
325,000 Bus passengers
“The deadliest single act of terrorism in
the United Kingdom since the Lockerbie
incident, the bombing of Pan Am Flight
103 in 1988, killing 270.”
BBC
Underground bombs explode within 50 secs, as trains are passing each other,
thus affecting 2 trains each plus tunnels.
ORIGINAL TERRORIST PLAN:
CROSS OF FIRE centered at King’s Cross by 4 Underground
bombs. Because Northern Line is temporarily
suspended (technical problems), 4th bomber
takes bus instead.
Circle Line Liverpool St eastbound
Sub-surface cut and cover,
21 ft deep, and wide to
accommodate 2 parallel tracks
Circle Line Edgeware Rd westbound
Piccadilly Line King’s Cross southbound
Deep-level, 100 ft, 11ft single-track tube, 6 in clearance
BLASTS VENT FORCE
INTO TUNNEL,
REDUCING LETHALITY
BLAST FORCE
REFLECTED BY TUNNEL,
INCREASING LETHALITY
9.19 Code Amber Alert. London Underground
shut down, all passengers evacuated
9.35 Bus 30 arrives at Euston Station,
continues to Hackney Wick.
This bus is on a diversion route due to King’s
Cross road closures.
9.47 Rear of Bus 30 explodes on Tavistock
Square. Roof ripped off.
“..half a bus flying through the air”.
LONDON: what went RIGHT?
Large areas evacuated and sealed
off entirely
All traffic re-routed. Monitors on ring road:
“Avoid London: area closed – turn on radio”
I have trained for such a situation for years, but on
the assumption that I would be part of a rescue team,
properly dressed and equipped, moving with
semi-military precision. Instead, I am in shirtsleeves.
Technically, I am an uninjured victim.
My objectives: command, control, communication,
coordination and cooperation. Fail to achieve these,
and we will have chaos, losing lives needlessly.
PJP Holden, NEJM 353/6: 541-543; 2005
The London attacks – a chronicle. Improvising in an emergency.
The London attacks – a chronicle. Improvising in an emergency.
Until supplies arrive, we have nothing except
bandages, chin lift, jaw thrust, and c-spine control.
Our aim is
To get each patient to the right hospital in the right
time frame.
Our function is
To triage, resuscitate, prioritize for transport, and feed
patients into the rescue chan in an orderly fashion.
PJP Holden, NEJM 353/6: 541-543; 2005
London bombings July 2005: The immediate pre-hospital medical
response.
• Critical interventions on scene provided for seriously injured (n=350).
• Quick transport to appropriate hospitals.• Local medical infrastructure was able to cope. • Injury assessment areas were set up for patients
with minor injuries. Thus, patients with serious injuries had the full attention of the EDs.
• Helicopters allowed rapid deployment of staff and equipment (not patients) in gridlocked traffic.
DJ Lockey et al, Resuscitation 66; 2005
LONDON: what went WRONG?
PUBLIC TRANSPORTATION CRIPPLED
underground and busses shut down
CONFUSION
CAUSE of blasts: not due to power surge
because of person under train. Vice versa!
NUMBER of blasts: 3 rather than 6,
because blasts were between stations,
people exiting from both stations
COMMUNICATION
“I was left with the clear impression
that opportunities to pass vital
Information between the services were
missed.”
D. Fennell, OBE, investigation into King’s Cross Underground Fire.
DELAYS DUE TO POOR COMMUNICATION
Poor communication within
underground and from tunnel to
surface
Managers at scene unable to
communicate with control
Ambulances meant for Russel Sq.
misdirected to Tavistock Square
INTERCOMS & RADIOS
Many trains have no facility for
driver to talk to passengers in an
emergency
Train radios failed on all 3 affected
trains: antennae damaged by blasts
CELL PHONES
Heavy reliance by all EMS on cell phones
Cell phones and hospital switchboards went
out due to overload.
Incident commanders isolated
because cell phones were not working
“We have become too reliant
on cell phones and this must
change.”
London Ambulance Service
LACK OF COMMUNICATION
“Effective communication from trains
could have led to more rapid assessment
of what happened and where.”
“The way we obtained info was from
station staff running down the tracks.”
“All time and access to communication are
valuable. If you have nothing to say, stay
off the air.”
TREATMENT: What can and did happen in London
Ran out of
Tourniquets
Fluids
Triage tags
Limiting factors
OR space
ICU beds
Personnel
London bombings July 2005: The immediate pre-hospital medical
response.
• Mobile telephone networks: overload and location (underground)
• Unsuitable attire: Hospital workers were sent to the scene in OP clothing. The could not and did not work underground.
• Scene safety: Not secured. Any of the scenes might have contained secondary explosive devices. Additionally: risk of structural collapse, inhalation of airborne particles, contamination.
DJ Lockey et al, Resuscitation 66; 2005
The London bombings of 7 July 2005: what is the main lesson?
The fragmentation in planning, with each agency
thinking inwards rather than outwards,
with each agency declaring a major incident
individually rather than collectively,
is where the real lesson lies.
Too many cooks are spoiling the broth.
G Hughes, Emerg Med J 23: 666; 2006
LESSONS LEARNED
fighting TERRORISM
MANAGEMENT & SUPPORT PRIORITIES
COMMAND & CONTROL
SAFETY
COMMUNICATION
TRIAGE
TREATMENT
TRANSPORT
COMMAND & CONTROL
COMMAND
Vertical transmission
of authority within
each emergency and
support service.
Each service
has one individual
in command
CONTROL
Horizontal transmission
of authority across
each emergency and
support service.
Each incident
has one individual
in overall control
COMMAND & CONTROLCornerstones of effective major incident
management
All health services attending an incident
must report to the Ambulance Command
Point
Medical and nursing staff at the scene
should complement rather than challenge
the role of ambulance personnel
COMMAND & CONTROLMedical providers at the scene must be
properly equipped, personally & medically
If ill equipped, inexperienced, inadequately
killed, or UNDISCIPLINED, they may pose a
threat to the welfare of the casualties and to
other rescuers
There are no official guidelines for this. The
standard of preparation, equipment and
training is variableTJ Hodgetts, Major Incident Medical Management, BMJ Books, 2002
There are no official guidelines for
COMMAND
& CONTROL.
The standard of
preparation, equipment & training is variable.
SAFETY: PROTECTIVE CLOTHING
hazard Protective clothing
Emergency vehicles High visibility jacket
Elements: wind, rain Waterproof, insulated
Injury to head Hard hat with chinstrap
Injury to eyes Safety goggles
Injury to face Visor
noise Ear defenders
Injury to hands Heavy duty gloves
Blood, body fluids Patient treatment gloves
Injury to feet Heavy duty boots, acid resistant
“COME-HITHER” BOMBS
Terrorists often
install a second bomb,
designed solely to kill
health care providers
after first attack
COMMUNICATION
Poor communication
is the most common failure
in mass casualty management
Lack ofInformationConfirmationCoordination
ACCOLC ACCess OverLoad Control
EMS may have access to phones operating
on special cells: ACCOLC
ACCOLC (cell phone lines which can be
opened centrally) were only partially
activated
City of London police activated ACCOLC
around Aldgate: Immensely improved
communication
ONSITE COMMUNICATIONAmbulance provides radio gear for
communication between
Key medical staff at scene
Ambulance vehicles at scene
Ambulance Control
Receiving hospitals
Police and Fire Stations
Ambulance control will establish control &
maintain radio communications with
Ambulance services command vehicle at
scene
Ambulances traveling to scene or to
hospital
Receiving hospitals
Neighboring ambulance services
OFFSITE COMMUNICATION
COMMUNICATION METHANE
acronym of key info to be passed
M Major incident Standby or declaredE Exact location Grid referenceT Type of incident Rail, chemical, roadH Hazards Present and potentialA Access Direction, approachN No of casualties Incl type and severityE Emergency services Present and required
Quick and simple, based upon:
PATTERN OF INJURY
VITAL SIGNS
AGE
Aim:
Survival for greatest number of patients.
Color-coded tagging systems for
Rapid identification of victims in the field.
TRIAGE Rapid Patient Assessment
RED TAG: IMMEDIATE CARE
Severely injured patients with
high probability for
survival
requiring procedures of moderately
short duration to prevent death
(e.g. emergency amputation).
YELLOW TAG: DELAYED CARE
sufficient for good outcome
(e.g. major fractures,
uncomplicated major burns).
GREEN TAG: MINIMAL CARE
No serious injury
to vascular structures or nerves.
Walking injured requiring
minimally trained personnel.
BLACK TAG: DECEASED OR EXPECTANT
Complicated, time-consuming requirements
Slim chance of survival. In natural disaster scenario:
analgesia & sedation until yellow and red tags have been treated.
TRIAGE
Use whenever number of casualties
> number of skilled
rescuers available
Triage is a dynamic process:
Assessment and re-assessment
TRIAGE =
ASSESSING & RE-ASSESSING
Total chaos:
Several injuries missed
during primary assessment
TRIAGE = LIMITED TIME
The worst decision
is the lack of a decision.
TREATMENT
Treatment is the SECOND step,
after triage
First treatment likely to be basic
first aid from unskilled people
Attention to ABC is most often all
that is required at the scene
TREATMENT: HOW MUCH & WHAT?
Aim at the scene: allow casualty to
reach hospital safely
Amount of treatment at the scene
corresponds to triage priority
Most treatment at the scene
directed at ABC, simple equipment
TREATMENT
BASIC ADVANCEDSpinal control
Manual CS stabilization
Cervical collar, spinal board
AirwayOpening:chin lift, jaw thrust
Oro/nasopharyngeal airway, ETT, surg. airway
BreathingMouth/mouthmouth/nose
Mouth to mask, bag valve mask, chest drain, needle thoracocentesis
CirculationControl ext. hemorrhage
Peripheral/central venous intraoss access, defib
TREATMENT: First AidLife Saving Intervention
Equipment
Clear airway Manual suction apparatus
Maintain airway Oro/nasophar airway
Support ventilation Pocket mask
Seal open pneumothorax
Asherman chest seal
Arrest hemorrhage Absorbent pressure dressings
ADDITIONAL EQUIPMENT for ALS
INTERVENTION EQUIPMENT
Secure airway LMA/ETT
Deliver oxygen Portable O2 source & mask
Support ventilation Bag valve mask
Spinal immobilization Cerv collar, vac mattress
Decompress tension pn Needle thoracocentesis
Treat cardiac arrest Defib/i.v. drugs
Replace fluid I.v. cannula, intraoss, fluid
Relieve pain Splint, i.v. drugs
CRITERIA for TRANSPORT
Capacity
Availability
Suitability
TRANSPORTEffective organization of ambulance
circuit vital for smooth evacuation
Ambulances form mainstay of
transport
Helicopters more suitable when
road transport cannot be used
Short flight may be safer than
ambulance transfer
TRANSPORT
The most severely injured patients
reach hospital later
than less severely injured patients
Less severely injured patients
self-evacuate and go to hospital
on their own,
sometimes
clogging resources
FINAL THOUGHTS
20% of the population live in the rural
United States.
80% of the population live in the urban
And suburban United States.
Guess where the next terror attack
is going to be.Carr, Prehosp Emerg Care 2006
FINAL THOUGHTS
A bioterrorism attack
in the 21st century
Is inevitable.
A Fauci, Clin Infectious Dis 32: 678; 2001
FINAL THOUGHTS
The Geneva Convention
was based on reciprocity
“I help my wounded enemy and vice
versa.”
Henri Dunand, Red Cross
FINAL THOUGHTS
“It couldn’t happen to us” is not
an acceptable excuse for being
ill-prepared to deal with a major incident.A major incident may occur at any time,
anywhere.
Colonel TJ Hodgetts, Emergency Med & Trauma University of Birmingham, UK, 2005
Nothing replaces well-trained,
competent, motivated people. Nothing.