Multiple casualty incidents: lessons from the front line.

Have you ever stood in the emergency room of your hospital, trying to keep your wits about you as bloodied and screaming casualties of a terrorist bombing pour in? If you haven't yet, chances are that you will. While this editorial is being written, no less than 9 terrorist-related bombings occurred in cities around the world, including 2 double bombings in Istanbul, Turkey, within 5 days. Can you imagine coping with the mayhem on a regular basis, once or twice a month? Such extraordinary experience is reflected in the preceding 3 articles from Israel, which provide insight into the medical consequences of terrorism in a trauma system that is roughly based on the North American model. What can we learn from the Israeli experience? What are the lessons for surgeons preparing for similar contingencies in their own communities? Compared with previous reports,1,2 the Israeli experience is exceptional in duration and intensity, but not in the scope of individual incidents. Each multiple casualty incident (MCI) temporarily strained, but did not overwhelm, hospital resources because the number of casualties did not exceed the bed capacity of emergency rooms in participating hospitals. Nevertheless, the sudden surge in the inflow of injured patients presented 2 types of challenges. The logistical challenge was to rapidly process a large number of casualties through the system. The medical challenge was to provide the best possible trauma care to severely wounded patients. The article by Einav and colleagues emphasizes the tremendous speed with which a modern EMS system can respond to an urban MCI. This speed virtually precluded external control of the rescue and transport phase. Israel has a system that tightly integrates the EMS system, hospitals, and civilian and military agencies at the state level. However, by the time this system was activated, all casualties had already been transported to hospitals. Not surprisingly, many wounded patients ended up in hospitals that routinely see little or no major trauma just because they were close to the bombing site. The lesson is clear: if a hospital happens to be located in proximity to an MCI, lack of trauma designation or experience will not shield it from incoming casualties. The tendency of EMS teams to scoop and run to the nearest hospital raises some concerns. An alarmingly low number of casualties underwent secondary transfer from these smaller hospitals to trauma centers. One cannot but wonder if considerations of institutional prestige and public image created reluctance to transfer out casualties from the emergency room to other hospitals. The article by Almogy, Belzberg, and Rivkind provides a vivid description of a large university hospital coping with the consequences of a bombing incident. Anyone who has seen an Israeli hospital in action during an MCI cannot fail to notice the commitment of the entire hospital staff to the institutional effort. Every hospital employee, from the chief of staff to the cashier in the outpatient clinics, has a predefined role in the emergency plan and regularly participates in disaster drills. In North America, despite increased awareness since 9/11, emergency preparedness is not ingrained in hospital culture and remains the province of a select group of dedicated health-care providers and administrators. This may be sufficient for a limited MCI, but will never be good enough for a high-volume scenario. The major obstacle we face in preparing for large-scale incidents or weapons of mass destruction is this institutional culture of selective participation, not the lack of sophisticated protective gear or decontamination equipment. Commitment, not technology, is the key to a robust emergency response. Terrorist bombings bring with them a host of new and vexing clinical problems, as reflected in the articles by Almogy et al and Peleg et al. What do you do with a hemodynamically stable, awake, and alert patient harboring dozens of small metal fragments in multiple body cavities, including the brain? How do you manage a “human remains shrapnel,” a fragment of the suicide bomber's bone embedded in the chest of an asymptomatic patient? What if the suicide bomber was carrying a transmissible disease? Unexpected encounters with difficult clinical problems are a hallmark of MCIs. The answers must be learned from experience and rapidly disseminated to other surgeons facing the same challenges. How can we improve hospital emergency planning? In their article, Almogy et al demonstrate how experience with multiple MCIs led them to modify their hospital emergency plan. They learned the importance of reassessing seemingly stable bombing casualties for occult life-threatening injuries, and found ways to compensate for triage errors. What if you do not have the benefit of real-life experience? One option is to produce and study a digital MCI on your desktop using system analysis tools. For example, discrete-event simulation, a methodology widely used in operations research, can identify bottlenecks and other obstacles to the flow of casualties in a MCI and helps optimize the emergency plan.3,4 How should we train hospital staff to cope with the unforeseeable? The flow of casualties between hospital facilities, as described by Almogy et al, is essentially transit between decision points. A casualty neither enters a facility (like a resuscitation bay or a CT scanner) nor leaves it without someone making a decision. In other words, at the heart of every hospital emergency plan is a core of decision makers whose choices determine how the emergency response will evolve. For example, while the emergency room may be filled with a large number of health care providers and ancillary personnel, the real engines behind the effort are only 3–4 key individuals such as the triage officer, the surgeon in charge, and the charge nurse. These decision-makers must be able to think outside the box and to improvise unconventional solutions to difficult situations. What do you do when a new severe casualty arrives while all resuscitation bays are busy? Can you rapidly improvise a resuscitation bay in the fracture room? What if there is no available operating room for a bleeding patient in shock? Can you accommodate 2 teams operating on 2 patients simultaneously in a single operating room? The ability to improvise solutions to such problems is an acquired skill that can be developed through simple table-top exercises and interactive discussions, a method pioneered by Professor Sten Lennquist from Linkoping University in Sweden. This crucial aspect of emergency preparedness has gained popularity in Europe but remains largely unknown to most North American institutions, where the emphasis still remains on training the hospital staff where to go, not how to think when disaster strikes. One important question that the preceding articles do not address is the impact of an MCI on the quality of trauma care. The prevailing view is that a heavy patient load adversely affects the quality of care of individual patients, because multiple casualties are competing for limited hospital resources. Yet the implicit goal of the medical response to a limited MCI is to provide critically injured patients with a level of care comparable to the care given to similar patients under normal circumstances. This may seem like a paradox, but it isn't. From the trauma care perspective, a small number of critical patients requiring immediate care are immersed within a larger group of less severe casualties who can tolerate delays and some degree of suboptimal care, the so-called “minimal acceptable care.”5 An effective response to limited MCIs hinges on temporarily diverting trauma-related resources from casualties with nonurgent injuries to the critically wounded. A patient with a femur fracture will wait longer for definitive fixation, but a hypotensive patient with hemoperitoneum should undergo an urgent laparotomy despite the chaos. It is important to emphasize that from the trauma care perspective, successfully coping with an urban bombing does not mean streamlining the flow of 80 casualties, but rather providing high-quality trauma care to very few critical (but salvageable) patients. How well did the emergency plan work? How many deaths were preventable? The truth is that we never know for sure. Bearing in mind the high public profile of these emotionally shattering incidents, it is not surprising that such questions have never been addressed in published reports, and the current articles are no exception. Yet for the surgeon facing 30 victims of urban terrorism, the 3–4 badly injured but salvageable patients are the hidden crux of the entire effort. Urban terrorism, the scourge of the 21st century, is already at our doorstep and surgeons are called upon to play leadership roles in shaping the emergency response in their hospitals. Learning from the experience of those for whom the unthinkable has become a daily reality can help us develop and implement more effective answers to the threats in our own communities.