SPECIAL REPORT
Defining the Problem, Main Objective, and Strategies of Medical Management in MassCasualty Incidents Caused by Terrorist Events Itamar Ashkenazi, MD;1 Boris Kessel, MD;1 Oded Olsha, MD;2 Tawfik Khashan, RN;1 Meir Oren, MD;1 Jacob Haspel, MD;1 Ricardo Alfici, MD1 1. Hillel Yaffe Medical Center, Israel 2. Shaare Zedek Medical Center, Israel Correspondence: Itamar Ashkenazi, MD Surgery B Department, Trauma Unit Hillel Yaffe Medical Center Hadera, POB 169 Israel 38100 E-mail:
[email protected] Keywords: blast injury, bomb injuries, masscasualty incident, terrorism, triage Abbreviations: HYMC = Hillel Yaffe Medical Center MCI = mass-casualty incident SIC = surgeon in charge Received: 24 April 2007 Accepted: 29 May 2007 Revised: 23 July 2007 Web publication: 15 February 2008
Abstract Based on the experience of managing >20 such events during the last decade, the authors’ understanding of a mass-casualty incident is that it is an event in which there may be many victims, but only a few that actually suffer from lifethreatening injuries. To make an impact on survival, one must identify those who are severely wounded as quickly as possible and offer those patients optimal care. Experienced trauma physicians are the most important resource available to achieve this objective, and they should be allocated to the treatment of seriously injured victims instead of more traditional management roles such as triage and incident manager. Ashkenazi I, Kessel B, Olsha O, Khashan T, Oren M, Haspel J, Ricardo A: Defining the problem, main objective, and strategies of medical management in mass-casualty incidents caused by terrorist events. Prehospital Disast Med 2008;23(1):82–89. Introduction A commonly used guiding principle of management of a mass-casualty incident (MCI) is that it requires a paradigm change from the application of unlimited resources for the greatest good of each individual patient to the allocation of limited resources for the greatest good of the greatest number of casualties.1 This and other similar messages recently published in the English medical literature are misinterpreted as recommending that injuries of moderate severity, rather than greatest severity, should take priority.2–4 Between 1994 and 2004, 20 MCIs, from bombing to shooting incidents, were managed at the Hillel Yaffe Medical Center in Hadera (HYMC). These add up to six more MCIs than were experienced by two of the authors while working in another hospital in Jerusalem. Of the 20 MCIs treated in HYMC, 16 were caused by terrorist bombers. In total, >600 patients were treated. The objective of this manuscript is to summarize our experience and offer a different view on the principles of management of a MCI. Methods This study is a retrospective cohort study of all MCIs caused by terrorist acts that were recorded in HYMC’s trauma registry. Included in this registry are all casualty admissions to the hospital, including admissions, in-hospital deaths, transfers to other hospitals, and patients discharged from the emergency department. The severity of injury was defined at 24 hours from admission according to the Israel Defense Forces’ classification of severity of injury: 1. Mild—the injury is not endangering life and will not lead to permanent disability; 2. Moderate—the injury is not endangering life immediately, but may do so if not appropriately handled, or, an injury leading to permanent disability. 3. Severe—an injury endangering life.5 Results Patient Load A total of 604 victims of 20 MCIs were admitted to the emergency department at the HYMC during a 10-year period (Table 1). Patient characteristics
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Ashkenazi, Kessel, Olsha, et al Date of incident (day.month.year)
13.04.1994
83 Number of victims killed (both on site and in-hospital)*
Mechanism of injury
Number of wounded victims*
Bomb
65
22
62
3
22.01.1995 17.01.2000 22.11.2000
01.01.2001 04.03.2001 18.05.2001 25.05.2001 16.07.2001
Bomb Bomb Bomb Bomb Bomb
13
Shooting
09.03.2002
Shooting
27.03.2002 19.05.2002 05.06.2002 21.10.2002 30.03.2003
60
Bomb
Bomb
17.01.2002 20.03.2002
60 100
Shooting
17.02.2002
26
Bomb
28.10.2001 29.11.2001
33
Bomb
Shooting Bomb
66 52 10 36 15 57 30
6
19 32 66
2
13
4
55
3
10
6
36
0
15
2
31
7
17
40
16
0
38
Bomb
65
5
Bomb
62
26
3
29
Bomb
35
0
140
59
33
0
Bomb Bomb
Number of victims treated in HYMC
10 44
3
16
9
14
63
0
10
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Table 1—Description of incidents *Note: Number of victims wounded or killed refers to overall number in each incident, whether treated in Hillel Yaffe Medical Center (HYMC) or in any other medical facility. Head
Body Area Injured
Face, eyes, neck
Spinal column/spinal cord Chest
Abdomen
Pelvic area Extremities Other
Number 58
104
7
28 21 39
117 16
% of Hospitalized Patients 24.9 44.6 3.0
12.0 9.0
16.7 50.2 6.9
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Table 2—Body areas injured in 233 mass-casualty incident victims hospitalized in Hillel Yaffe Medical Center between 2000–2003* *data retrieved from the National Trauma Registry
January–February 2008
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Head
Medical Management in Mass-Casualty Incidents Body Areas Operated
Number 1
Eyes
7
Chest and Vascular
13
Musculoskeletal System
23
Abdomen
5.6 8.2 9.9
25
Other
0.4 3.0
19
Skin
% of Hospitalized Patients
10.7
1
0.4
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Table 3—Body areas operated in 233 mass-casualty incident victims hospitalized in Hillel Yaffe Medical Center between 2000–2003* *Data retrieved from the National Trauma Registry were included in a larger patient population previously published by Peleg et al (Tables 2 and 3).6 The average number of victims per MCI was 30.2 ±19.5, (range 9–66). In 10 of 20 MCIs, all of the victims were transported to the HYMC emergency department. In 10 other MCIs, HYMC’s emergency department was one of two to five other emergency departments to admit the victims. In those incidents in which HYMC served as the only admitting facility, the average number of victims per incident was 38.2 ±22.5 (range 10–66). In those incidents in which victims were primarily distributed to several medical facilities, the average number of victims per incident admitted to the HYMC was 22.2 ±12.3 (range 9–44). The bed capacity of HYMC’s emergency department is 32 beds. In eight (40%) of the MCIs, the bed capacity of the emergency department was exceeded. The total number of victims approached the total bed capacity during three other incidents. Casualty flow in one of the most severe MCIs is outlined in Figure 1. Severity Load According to the Israel Defense Forces’ classification of severity of injury, 449 (74%) were mildly injured, 77 (13%) were moderately injured, and 78 (13%) were severely injured. The average number of severely injured victims per incident was 3.9 ±4.1 (range 0–15). Of those severely injured, 15 (19%) eventually died, averaging 0.75 ±1.12 (range 0–3) per incident. The smallest number of victims admitted to the emergency department in any one MCI was nine, while the largest number was 66. Paradoxically, of the nine victims admitted to the emergency department in the MCI with the fewest victims, six were either severely or moderately injured. One of the patients was admitted in an agonal state and died during the primary resuscitation phase. A second patient was admitted in shock secondary to intra-abdominal hemorrhage, coupled with penetrating injuries to the bowel. He also suffered from severe facial injuries, bone fractures, and traumatic laceration of the brachial artery. Another patient suffered from ipsilateral fractures to the femur, tibia, and fibula coupled with extensive damage to skin and soft tissue. Other patients suffered from burns, mainly of the face and extremities, coupled with penetrating injuries to soft tissue and tympanic membrane perforations. In the incident with the most victims, 65 of the 66 Prehospital and Disaster Medicine
victims admitted to the emergency department suffered from either relatively mild injuries or acute stress reactions, and only one suffered an injury of moderate severity. Thus, the smallest MCI presented the staff of the emergency department with victims with a relatively larger severity load as opposed to the largest MCI. Identification of Severe Injuries All patients entering the emergency department were assessed by the triage officer. Decisions made by the triage officer helped allocate the victims to the various treatment sites. Primary and secondary surveys were conducted on all patients within minutes, with the aim of identifying those who were severely wounded. The proper evaluation of symptoms and detailed physical examination are the key to identifying the real magnitude of injury. These are crucial in deciding on the appropriate follow-up and workup, including a decision as to whether further laboratory tests and radiological examinations are needed, and if needed, which tests are needed and whether these can be delayed or not. Of 78 severely injured victims admitted in all the MCIs, life-threatening injuries were identified in 75 (96.2%) victims following the primary and secondary survey. In three victims (3.8%), life-threatening injuries were not diagnosed during their primary and secondary surveys. All of three patients suffered from distracting injuries to other organs. The first patient suffered from a ruptured pancreas coupled with a severe upper extremity injury. The second patient suffered from bowel lacerations and intraperitoneal hemorrhage, coupled with non-life-threatening facial injuries. The third patient suffered from a shattered spleen, coupled with penetrating injury to the popliteal fossa leading to distal limb ischemia. All these life-threatening injuries eventually were recognized and treated. None of these victims died. Discussion Defining the Problem There is confusion as to what kind of magnitude of the problem the medical community in any one medical facility may face once a terrorist attack occurs. The magnitude of destruction and death tolls seen in the terrorist attacks on the World Trade Center in 2001 in New York, the Murrah Federal Building in the Oklahoma City bombing in 1995, the American embassies in Kenya and Tanzania,
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Figure 1—Casualty flow of patients admitted in the first two hours following a bomb explosion in the Park Hotel’s dining room (Passover night, 27 March 2002) and the US Marines barracks in Beirut in 1983, only add to the catastrophic vision of the medical consequences of these terrorist attacks.7 This has led many experts to define tools of catastrophe management for dealing with such events. This is far from the reality that has been encountered at HYMC after multiple terrorist attacks. The magnitude of the medical problem is not dictated by the number of those dying on-site. Rather, those who stay alive and make it to the hospital impose the burden upon the admitting medical facility. In fact, those victims suffering from moderate and severe injuries constitute the real treatment load. Israel has experienced two major waves of terrorist attacks in the last two decades. Almogy, who summarized 71 such attacks occurring in the last surge, shows that the average number of casualties per attack was only 38.3.7 Table 4 presents data on severity load from other MCIs experienced around the world that were caused by terrorist attacks, and for which data are available in the English medical literature.9–23 Though the authors of this article do not wish to dismiss the possibility that, eventually, terrorists may succeed in perpetrating such a catastrophic event January–February 2008
that would overwhelm the medical facilities, to date, this has not been the case in the various incidents to which the medical system has responded. Thus, the experience gained at HYMC is not unique, but represents a truthful picture of the most commonly experienced medical scenario to date. Based on the experience of managing 20 such events over the last decade, the authors’ understanding of a MCI is that this is an event in which there may be many victims, but there only are a selected few who actually suffer from a life-threatening injury.24 Defining the Main Objective in the Management of a MCI Defining the main objective of any contingency plan is the crucial point in the development of any plan, since it allows a common understanding leading to a common vocabulary in establishing priorities and formulating procedures. The main objective should tackle the problem being presented. This has been the problem of most articles written to date on this subject, since most authors, including Israeli authors, advocate the use of tools of catastrophe management and this seems inappropriate in MCIs.1,2,4,6
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Old Bailey (1973)9 Bologna (1980)10 Beruit (1983)11 Buenos Aires (1994)12
Oklahoma City (1995)13,14
Dhahran (1996)15
Hospital Description
# Critically Injured
Critically Injured per Hospital
5 hospitals
600 beds per hospital
25
5
Clinicas Univ. Hospital
500 bed capacity
Hospital Response St. Bartholomew’s Hospital Navy ship*
13 hospitals N/A
N/A N/A
Level-I Trauma Center
Atlanta (1996)16
Grady Memorial Hospital*
Nairobi (1998)17
Kenyatta National Hospital*
2,000 bed capacity 15 OR
Belleview*
Level-I
New York (2001)
Bali (2002)20
Turkey (2003)21 Turkey (2003)21 Madrid (2004)22
London
(2005)23,24
NYU*
St. Vincent’s* N/A
16 hospitals 16 hospitals Gregorio Marañon Univ. Hospital* 12 Octubre Hospital
Overall 7 hospitals
170 bed, Level-II
0–3
19
19
52
4
18
Average 43.6 112
18
86
200 wounded victims overall
N/A
555 wounded overall
213 died, >4,000 injured, 524 hospitalized
Average 29.7
N/A
5
All 5 transported to Grady Mem. Hospital
Average 24, 35 transported to Grady Mem. Hospital
N/A
N/A
1,800–2,500
12
12
350
21
21
800
8
Remarks
160
4
8
Level-I
0–3
Patients per Hospital
169
N/A
N/A
N/A
Range 20–200
Mainly burn victims
N/A
N/A
N/A
Average 28
194 victims admitted
N/A
N/A
1,712 beds 64 ICU beds 40 operating theaters 1,200 bed capacity
Royal London Hospital*
N/A
Average 19
21
21
312
N/A
N/A
255
8
8
16
2.3
Average 56.8 208
Admitted >4 hours
398 wounded overall
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Table 4—Summary of single major mass-casualty incidents caused by terror attacks (N/A = not available; NYU = New York University) *Data based on single institution reports—usually those which received the largest amount of casualties For example, Michaelson et al advocate giving priority to victims suffering from moderate to severe injuries.4 Those with severe injuries and who have a very low chance of survival are allocated to a no treatment site. Only one doctor and one nurse are allocated to these patients, to ensure that no mistakes were made in triage. Peleg et al promote the provision of “minimal acceptable care” as long as there is an ongoing flow of casualties and the eventual Prehospital and Disaster Medicine
number of victims is unknown.6 “Minimal acceptable care” refers to concentrating efforts on a maximal number of salvageable patients, while maintaining the conservation of critical hospital resources as a key consideration. Frykberg advocates avoiding blood transfusions, endotracheal intubations, and emergency room thoracotomies during the initial phase of casualty influx.2 The position statement, published in 2003 by the Committee on Trauma of the
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Figure 2—Unidirectional Flow Plan: Most of the mildly wounded are eventually discharged after minor trauma and/or acute stress reaction has been addressed. Those seriously and moderately injured are admitted. The recovery room commonly is used to concentrate those severely injured and those in need of surgery. Subsequently, these patients are admitted to the intensive care unit or other departments. Victims in need of specialized treatment not available locally are transferred to the appropriate medical facility.
American College of Surgeons, advocates allocating resources to the greatest good of the greatest number of casualties during these events.1 Since no definition is offered as to what transforms a particular terrorist attack into a disaster, these and other similar messages are misinterpreted as recommendations that injuries of moderate severity, rather than greatest severity, should take priority. The authors do not accept an expectant category, whose criteria rely on the fact that there are multiple casualties. An expectant category based on advanced trauma life support (ATLS) principles that are applicable to the solitary victim, irrespective of how many other victims there are in the emergency department, is accepted. Relying on the observation that the number of those suffering from lifethreatening injuries usually is not overwhelming, it was concluded that it is unacceptable to deny these patients timely optimal treatment only because their injuries occur in the context of a MCI. The main objective should be to make an impact on survival. This can only be achieved by identifying those who are severely injured as quickly as possible, and to offer these patients optimal care. This should be done even if the influx of victims has not yet terminated. Withholding timely, optimal treatment from those identified with severe injuries, just because other seriously injured victims may eventually be admitted, makes no sense and is not supported by the numbers of seriously injured victims commonly encountered. January–February 2008
Defining the Strategy to Achieve the Main Objective To define “saving lives” as the main objective may seem straightforward to most of those involved with planning for the response to MCIs. Nevertheless, it is questionable if many of the systems described to date, specify a strategy that really helps achieve this objective. Those advocating catastrophe management give up on the treatment of those severely injured as a principle. Other systems emphasize the efficient work-up of all victims as their main strategy, not just those who are identified as severely wounded.2,7 Whether these systems make an impact on survival has yet to be proved. The assumption of the authors is that they do not. It is self-evident that the most important asset that can make a difference in survival is the experienced trauma physician.The trauma physician cannot affect survival if he or she is taking care of everyone from a management position. The “Unidirectional Flow Plan” is a prime example of a strategy that emphasizes the efficient work-up of all victims. The Unidirectional Flow Plan is the preferred strategy adopted by almost all Israeli hospitals. The main concept emphasized by this plan is that each patient goes through an individualized process, which is unidirectional. The patient is passed from one station to the other according to his/her needs, and never is returned to the previous station. A diagram of the Unidirectional Flow Plan is provided in Figure 2. The primary benefit of the Unidirectional Flow Plan is that it is easy to comprehend and use as the basis for establishing the contingency plan. The different stations of treatment easily are conceived and the appropriate personnel are allocated to each station. Another important benefit is that the emergency department quickly is emptied of patients. This is important due to the possibility of having to respond to sequential terrorist attacks. The Unidirectional Flow Plan facilitates the rapid work-up of all of the victims, both seriously and non-seriously injured. An important belief supporting this strategy is that during a MCI, missing injuries during the primary assessment is common. It is for this reason that Almogy and colleagues repeatedly instruct to give attention to those moderately injured, as these patients may harbor immediate life-threatening injuries.8 This common belief that lifethreatening injuries often are missed during the primary evaluation never has been supported by concrete evidence. Out of 78 severely injured victims in 20 different MCIs, the authors have experienced only three cases in which primary evaluation did not reveal the real severity of the injury. Thus, it is a mistake to prioritize repeated reassessments if one wants to make an impact on survival. Commonly, those who adopt the Unidirectional Flow Plan place their most experienced trauma leaders in management roles, such as triage, emergency department management, and radiology department triage. Following a bombing incident in a restaurant, Almogy and colleagues placed their most able trauma leader in command of the medical management of the incident, the “surgeon in charge” (SIC).8 According to their plan, the SIC receives the incoming emergency medical services crews, triages the victims, and thereafter, during the initial 6–8 hours, conducts repeated reassessment of the victims. The SIC does
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not participate in surgical procedures in the preliminary phases of triage and evaluation. Thus, during the crucial moments of the MCI, Almogy and his colleagues advocate investing their most capable trauma physician in a management role. A similar policy was adopted by Belleview’s staff during the 2001 terrorist attack in Manhattan.18 The most experienced trauma physician was placed in charge of triage and other senior trauma physicians were placed in charge of geographical areas within the emergency department, leaving the surgical oncologist to be in charge of the operative procedures. Experienced trauma leaders are the most important resource that can impact the survival of severely injured victims. These include trauma surgeons, emergency physicians, anesthesiologist, and intensivists who have demonstrated skills and training in trauma care. The ability to save lives in institutions adopting the unidirectional flow plan, or any similar plans, depends on how many capable trauma leaders there are in the institution at the time a MCI occurs. If there are only a few experienced trauma leaders, placing them in management roles only can come at the expense of their ability to be intimately involved in the continuous treatment of those victims with life-threatening injuries. This difference will be felt especially in those institutions in which the number of staff experienced in trauma is small. The HYMC, and most other institutions, probably fit into this category. The Customized Plan The customized plan is the authors’ alternative to the Unidirectional Flow Plan and other similar plans. The customized plan attempts to address the major issues in developing a contingency plan for a MCI due to a terrorist bombing, wherever this act is committed. These issues include defining the: (1) problem; (2) main objective; and (3) strategy to achieve the main objective. The main objective emphasized by the customized plan is that severely injured victims should be identified and all needed resources should be allocated to their treatment. “The others can wait” is an important motto of this plan. In most MCIs to-date, the number of surviving victims who suffer from life-threatening injuries has been relatively small and within the treatment capacity of most hospitals that admit trauma patients. Unlike what has been written by other authors quoted above, it seems that optimal treatment should not be delayed until the eventual number of victims is known.2,6 The customized plan takes into consideration that the most important limited resource is experienced trauma leaders, whether these are surgeons, emergency physicians, intensivists, or anesthesiologists. The few experienced in trauma care are placed in direct charge of the treatment of the severely injured victims once they are identified. This is in clear contradiction to the Unidirectional Flow Plan, where those experienced in trauma classically are allocated to management roles such as triage officer, incident manager in the emergency department, and incident management in the radiology department. In the customized plan, these important roles are taken over by other surgeons and emergency physicians. Prehospital and Disaster Medicine
There are two major problems with the customized plan. First, it may leave the emergency department congested with many slightly wounded victims. Second, delayed presentation of serious injuries may be missed if patients are treated by inexperienced personnel. Hospitalizing most of the victims and performing a tertiary survey within several hours can adequately address both of these problems. This has been the preferred solution of the authors. Alternatively, mildly injured patients, who compose the vast majority of the patients, can be allocated to a secondary site, such as the outpatient clinics. There, patients are observed clinically for a few hours before a decision to discharge them is made. Tertiary survey is implemented once a team of physicians experienced in trauma care can be allocated for this task. In the authors’ experience, tertiary survey usually was implemented between one and two hours after the incident had started. The customized plan should not deter medical institutions from partially incorporating the Unidirectional Flow Plan and other process-oriented plans into their contingency plan. In HYMC, all of the victims go through an individualized process, which is unidirectional. Sites similar to those defined in the Unidirectional Flow Plan were defined in our contingency plan. Most of the hospital personnel are allocated to the different sites and each person has a specific role. The main difference is that trauma leaders, intensive care unit personnel, and experienced anesthesiologists are not allocated to any role or specific site, and are free to join the treatment effort of those suffering from life-threatening injuries. Summary Emergency planning for MCIs due to terrorist attacks should incorporate an understanding of the usual proportions of the problem, a definition of the main objective of treatment, and the strategy that will allow us to attain this main objective. The customized plan is based on experience gained in 20 MCIs treated in HYMC. There are no reports in the medical literature that demonstrate that the magnitude of the medical problem is in any sense, different from these experiences in most terrorist-related MCIs experienced by the medical community to date. The customized plan clearly defines that the main objective in treatment is to save lives and since only those seriously injured are in immediate danger of dying, the customized plan defines this patient population as the focus of attention in the medical work-up and treatment. The customized plan dictates that these patients should receive optimal care. According to this plan, optimal care is dependent on the right care being given at the right time by a team experienced in providing trauma care, headed by an experienced trauma physician. These tenets of the customized plan can and should be applied universally. Acknowledgements The authors thank Professor Omri Lernau for contributing to the insight in the management of MCIs. The authors also thank Kobi Peleg and the staff of the Gertner Institute who maintain the Israeli National Trauma Registry.
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