Learning from terrorist mass casualty incidents: a global survey

Managing a mass casualty, lessons learned

PURPOSE OF REVIEW

Mass casualty incidents (MCIs) strain available healthcare resources requiring unusual actions. Within a trauma system, hospitals receiving patients from an MCI have a defined key role in the care of the casualties and their preparedness is critical for patient outcome. The aim of this review is to address recent relevant literature to highlight important elements necessary for an adequate hospital response to an MCI.

RECENT FINDINGS

That disaster preparedness is a prerequisite for success during an MCI is undisputable. Key components in the hospital response to an MCI like triage, communication, leadership, security, and surge capacity are areas that still need attention. There has been an increased focus on optimal treatment of children and their families, and the psychosocial support for patients and staff involved.

SUMMARY

The complexity and unpredictability of MCIs demands a predefined strategy within every hospital. This strategy should include increased attention to the specific needs for children, physical security and psychological support but not at the expense of frequent training of staff. Involvement of dedicated clinical leadership both during disaster preparedness planning, training and during actual MCIs is irreplaceable.

Increasing prehospital tourniquet use attributed to non-indicated use: an 11-year retrospective study

PURPOSE

The use of prehospital tourniquets (PHTQ) for haemorrhage control in the civilian trauma population has increased over the past decade with some reports documenting the overuse of the device. The aim of this study was to identify the proportion of PHTQ use that is non-indicated and determine how this proportion is changing over time.

METHODS

An 11-year retrospective study was performed at a Level-1 Trauma Centre on all trauma patients admitted with a PHTQ. Local PHTQ guidelines were used to define non-indicated use. Collected variables included patient demographics, injury characteristics, tourniquet application characteristics, prehospital data, emergency department data, and clinical outcomes. The primary outcome was non-indicated PHTQ use. The secondary outcome was complications attributed to PHTQ use.

RESULTS

There were 88 PHTQ applications to 88 extremity injuries in 86 patients (n = 86, median (IQR) age 43 (28-57) years, 85% male). PHTQ use was deemed non-indicated in 68 cases (68/88, 77% [95%CI 67-86%]). The proportion of non-indicated PHTQ use increased over the period of the study period (p = 0.03). At least one complication potentially from PHTQ use was seen in 33 patients (33/86, 38%). In patients with prolonged tourniquet time (n = 13), at least one complication from PHTQ use was seen in 11 patients (11/13, 85%).

CONCLUSION

Over this 11-year period, we identified that the increase in PHTQ use in civilian trauma is from increasing non-indicated use. Given that complications are associated with unnecessary PHTQ use, the adherence to the guidelines needs to be urgently reinforced.

Assault rifle injuries in civilians: ballistics of wound patterns, assessment and initial management

PURPOSE

Wounds from assault rifles and their commercial offspring have been encountered with increasing frequency in civilian practice. Our aim is to summarize wound ballistics related to the main injury patterns that can also affect management strategies.

METHODS

An online search of the PubMed was conducted for research and review articles published after 2000 in English, using the MeSH terms "gunshot wounds", "mass casualty incidents", "war-related injuries", "soft tissue injuries", "vascular system injuries", "colon injuries", "wound infection", "antibiotic prophylaxis", "debridement", "hemorrhage", "penetrating head injuries", "pneumothorax" and additional free-text terms. Other academic databases were also searched for relevant articles and book chapters.

RESULTS

Consensus regarding recognition of high energy wounds from assault rifle projectiles is largely based on war experience. Studies of such wounds inflicted by expanding projectiles suggest that their wounding effects significantly increase tissue damage and adverse outcomes following injury, as a result of the temporary cavity and bullet fragmentation. The use of assault rifles in mass shootings has prompted utilization of tourniquet for control of life-threatening hemorrhage, also derived from military experience, while limited evidence indicates that tension pneumothorax rather than extremity wounds is the leading cause of potentially preventable death in these incidents.

CONCLUSIONS

Wound ballistics provides a system for evaluation of injuries from assault rifles and risk analysis of shooting incidents. Lessons learned from armed conflicts can improve the management of victims, with due consideration given to characteristics of civilian injuries. Further research is required to define the impact on survival by key life-saving procedures in the prehospital setting, in order to prioritize these interventions.

Mastering multicasualty trauma care with the Trauma Non-technical Skills Scale

BACKGROUND

Multicasualty events present complex medical challenges. This is the first study to investigate the role of nontechnical skills in prehospital multicasualty trauma care. We assessed the feasibility of using the Trauma Nontechnical Skills Scale (T-NOTECHS) instrument, which has not yet been investigated to evaluate these scenarios.

METHODS

We conducted an observational study involving military medical teams with Israel Defense Forces Military Trauma Life Support training to assess the T-NOTECHS' utility in predicting prehospital medical team performance during multicasualty event simulations. These teams were selected from a pool of qualified military Advanced Life Support providers. Simulations were conducted in a dedicated facility resembling a field setting, with video recordings to ensure data accuracy. Teams faced a single multicasualty scenario, assessed by two instructors, and were evaluated using a 37-item checklist. The T-NOTECHS scores were analyzed using regression models to predict simulation performance.

RESULTS

We included 27 teams for analysis, led by 28% physicians and 72% paramedics. Interrater reliability for simulation performance and T-NOTECHS scores showed good agreement. Overall T-NOTECHS scores were positively correlated with simulation performance scores ( R = 0.546, p < 0.001). Each T-NOTECHS domain correlated with simulation performance. The Communication and Interaction domain explained a unique part of the variance ( β = 0.406, p = 0.047). Assessment and Decision Making had the highest correlation ( R = 0.535, p < 0.001). These domains significantly predicted specific items on the simulation performance checklist. Cooperation and Resource Management showed the least correlation with checklist items.

CONCLUSION

This study confirms the T-NOTECHS' reliability in predicting prehospital trauma team performance during multicasualty scenarios. Key nontechnical skills, especially Communication and Interaction, and Assessment and Decision Making, play vital roles. These findings underscore the importance of training in these skills to enhance trauma care in such scenarios, offering valuable insights for medical team preparation.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level III.

Acute response to the October 7th hostage release: rapid development and evaluation of the novel ReSPOND protocol implementation within a children's hospital

BACKGROUND

The decision to allocate hospitals for the initial reception of hostages abducted on the October 7th Hamas attack introduced an array of unprecedented challenges. These challenges stemmed from a paucity of existing literature and protocols, lack of information regarding captivity conditions, and variability in hostage characteristics and circumstances.

OBJECTIVE

To describe the rapid development, implementation and evaluation of the Hostage-ReSPOND protocol, a comprehensive trauma-informed procedure for the care of hostages, including young children, their caregivers and families, immediately following their release from prolonged captivity.

METHODS

A multidisciplinary expert focus group conducted a comprehensive literature review to develop the ReSPOND protocol, consisting of: Readiness of teams via multifaceted trainings, utilizing live simulations and video debriefings; Specialized professional teams experienced in providing holistic trauma-informed care; Personalized care tailored to individualized and developmentally-informed needs; Optimal safety rooted in creating a secure environment and trauma-informed response to young children, adolescents, caregivers and families; and Navigating Discharge, through coordination with community-based care systems.

RESULTS

A designated facility at the Children's hospital was carefully prepared for receiving 29 hostages, aged 3.9-80 years, 28% under the age of 18. Implementation of the ReSPOND protocol, which prioritized holistic psychosocial interventions above urgent medical care, proved feasible and effective in managing the diverse and complex needs of returnees as per provider report. Finally, systemic assessment of returnee's immediate and long-term mental health needs proved highly challenging.

CONCLUSIONS

There is currently no literature addressing the response to released hostages, especially those involving infants, young children and families within a children's hospital facility. This study has the potential to fill a crucial gap in knowledge by introducing a novel protocol which could offer valuable insights for public health organizations tasked with providing acute care to diverse individuals and families experiencing extreme, multi-layered mass traumatization.

A Call to Action: Why Anesthesiologists Must Train, Prepare, and Be at the Forefront of Disaster Response for Mass Casualty Incidents

Disasters, both natural and man-made, continue to increase. In Spring 2023, a 3-hour workshop on mass casualty incidents was conducted at the Society for Pediatric Anesthesia-American Academy of Pediatrics Annual conference. The workshop used multiple instructional strategies to maximize knowledge transfer and learner engagement including minididactic sessions, problem-based learning discussions in 3 tabletop exercises, and 2 30-minute disaster scenarios with actors in a simulated hospital environment. Three themes became evident: (1) disasters will continue to impact hospitals and preparation is imperative, (2) anesthesiologists are extensively and comprehensively trained and their value is often underestimated as mass casualty incident responders, and (3) a need exists for longitudinal disaster preparedness education and training over the course of a career. In this special article, we have sought to further define the problem and evidence, the capacity of anesthesiologists as leaders in disaster preparedness, and the rationale for preparation with current best practices to guide how best to move forward.

Trauma systems in high socioeconomic index countries in 2050

Considerable political, structural, environmental and epidemiological change will affect high socioeconomic index (SDI) countries over the next 25 years. These changes will impact healthcare provision and consequently trauma systems. This review attempts to anticipate the potential impact on trauma systems and how they could adapt to meet the changing priorities. The first section describes possible epidemiological trajectories. A second section exposes existing governance and funding challenges, how these can be met, and the need to incorporate data and information science into a learning and adaptive trauma system. The last section suggests an international harmonization of trauma education to improve care standards, optimize immediate and long-term patient needs and enhance disaster preparedness and crisis resilience. By demonstrating their capacity for adaptation, trauma systems can play a leading role in the transformation of care systems to tackle future health challenges.

Optimizing Mass Casualty Triage: Using Discrete Event Simulation to Minimize Time to Resuscitation

BACKGROUND

Urban areas in the US are increasingly focused on mass casualty incident (MCI) response. We simulated prehospital triage scenarios and hypothesized that using hospital-based blood product inventories for on-scene triage decisions would minimize time to treatment.

STUDY DESIGN

Discrete event simulations modeled MCI casualty injury and patient flow after a simulated blast event in Boston, MA. Casualties were divided into moderate (Injury Severity Score 9 to 15) and severe (Injury Severity Score >15) based on injury patterns. Blood product inventories were collected from all hospitals (n = 6). The primary endpoint was the proportion of casualties managed with 1:1:1 balanced resuscitation in a target timeframe (moderate, 3.5 U red blood cells in 6 hours; severe, 10 U red blood cells in 1 hour). Three triage scenarios were compared, including unimpeded casualty movement to proximate hospitals (Nearest), equal distribution among hospitals (Equal), and blood product inventory-based triage (Supply-Guided).

RESULTS

Simulated MCIs generated a mean ± SD of 302 ± 7 casualties, including 57 ± 2 moderate and 15 ± 2 severe casualties. Nearest triage resulted in significantly fewer overall casualties treated in the target time (55% vs Equal 86% vs Supply-Guided 91%, p < 0.001). These differences were principally due to fewer moderate casualties treated, but there was no difference among strategies for severe casualties.

CONCLUSIONS

In this simulation study comparing different triage strategies, including one based on actual blood product inventories, nearest hospital triage was inferior to equal distribution or a Supply-Guided strategy. Disaster response leaders in US urban areas should consider modeling different MCI scenarios and casualty numbers to determine optimal triage strategies for their area given hospital numbers and blood product availability.

Five Decades of Trauma Anesthesiology

We present a brief history of the scientific and educational development of trauma anesthesiology. Key milestones from the past 50 years are noted, as well as the current standing of the subspecialty and prospects for the future.

When disaster strikes: staff recall and the use of staff recall systems during mass patient influx at Norwegian emergency primary health care centers - a cross-sectional study

BACKGROUND

In Norway, planning for disasters has been specifically emphasized since the incidents on July 22nd, 2011. Every municipality is now legislated to have a contingency plan that includes plans for staff recall during situations with mass influx of patients. Whether the primary health care services in Norway are prepared for mass influx of patients remains unclear.

AIMS OF THE STUDY

The aims of this study were (1) to assess the experiences of head doctors at emergency primary health care centers (EPHCC) in Norway with mass influx of patients, (2) to explore mass influx and staff recall procedures in use, (3) to assess head doctors' experiences with staff recall systems, and (4) to assess their perspective on automatized staff recall systems. We also wanted to assess whether there were differences between small and large EPHCCs regarding whether they had plans in place.

METHODS

The study had a cross-sectional, multicenter design, using a self-developed questionnaire. The questionnaire was developed utilizing recommendations from the Delphi technique, including an expert group and piloting. A purposive sampling strategy was used, including head doctors from Norwegian EPHCCs (n = 169). Data were analyzed using the Statistical Package for the Social Sciences, and included descriptive statistics, Chi-Square tests and Shapiro-Wilks. Free-text answers were analyzed by content analysis.

RESULTS

A total of 64 head doctors responded to the questionnaire. The results show that 25% of the head doctors had experienced mass influx of patients at their EPHCC. In total 54.7% of Norwegian EPHCCs did not have disaster plans that consider mass influx situations. The majority of EPHCCs plan to recall staff one by one (60.3%) or through Short-Message-Systems (34.4%). Most EPHCCs had available telephone "alarm" lists (81.4%), that are updated regularly (60.9%). However, only 17.2% had plans that consider loss of mobile phone connection or internet. In total, 67,2% of the head doctors reported to have little experience with automatized staff recall systems, and 59,7% reported to have little knowledge about such systems. There were no significant difference between small and large EPHCCs in having plans or not.

CONCLUSION

Even though our results show that few EPHCCs experience mass influx of patients, it is important to be prepared when such incidents do occur. Our results indicate that it is still potential for improvement regarding plans for staff recall and implementation of staff recall systems at Norwegian EPHCCs. Involving national disaster medicine experts in the process of generating tools or checklists could aid when constructing disaster plans. Education and implementation of training for mass influx situations at all levels should always be highlighted.

Smart Glasses: A New Tool for Assessing the Number of Patients in Mass-Casualty Incidents

INTRODUCTION

Mass-casualty incidents (MCIs) are events in which many people are injured during the same period of time. This has major implications in regards to practical concerns and planning for both personnel and medical equipment. Smart glasses are modern tools that could help Emergency Medical Services (EMS) in the estimation of the number of potential patients in an MCI. However, currently there is no study regarding the advantage of employing the use of smart glasses in MCIs in Thailand.

STUDY OBJECTIVE

This study aims to compare the overall accuracy and amount of time used with smart glasses and comparing it to manual counting to assess the number of casualties from the scene.

METHODS

This study was a randomized controlled trial, field exercise experimental study in the EMS unit of Srinagarind Hospital, Thailand. The participants were divided into two groups (those with smart glasses and those doing manual counting). On the days of the simulation (February 25 and 26, 2022), the participants in the smart glasses group received a 30-minute training session on the use of the smart glasses. After that, both groups of participants counted the number of casualties on the simulation field independently.

RESULTS

Sixty-eight participants were examined, and in the smart glasses group, a total of 58.8% (N = 20) of the participants were male. The mean age in this group was 39.4 years old. The most experienced in the EMS smart glasses group had worked in this position for four-to-six years (44.1%). The participants in the smart glasses group had the highest scores in accurately assessing the number of casualties being between 21-30 (98.0%) compared with the manual counting group (89.2%). Additionally, the time used for assessing the number of casualties in the smart glasses group was shorter than the manual counting group in tallying the number of casualties between 11-20 (6.3 versus 11.2 seconds; P = .04) and between 21-30 (22.1 versus 44.5 seconds; P = .02).

CONCLUSION

The use of smart glasses to assess the number of casualties in MCIs when the number of patients is between 11 and 30 is useful in terms of greater accuracy and less time being spent than with manual counting.

Mass casualty medicine: time for a 21st century refresh

Mass casualty events are on the rise globally, as we face increasing pressures from scarcity of resources, population growth, systemic inequalities, geopolitical instabilities, and polarised discourse. Although they are rare events for an individual practitioner, they are going to happen to someone, somewhere, this week, this month, this year. And whilst they are often the last consideration for healthcare systems under constant pressures from daily routine work, individuals, departments, hospitals, and systems have to step up effectively in times of crisis. Failure to do so can lead to suboptimal outcomes for casualties, and even perceived failures can have crippling consequences on staff, families, and communities for years.

Preparing for mass casualty events despite COVID-19

Preparedness for mass casualty events is essential at local, national, and global levels. Much more needs to be done by all stakeholders to avoid unnecessary morbidity and mortality despite the challenges that COVID-19 continues to present. In this editorial, we highlight the challenges and solutions for mass casualty incident preparations.