Critical care medicine, terrorism and disasters: are we ready?

Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL

BACKGROUND

Plausible disasters may yield hundreds or thousands of critically ill victims. However, most countries, including those with widely available critical care services, lack sufficient specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients. Shifting critical care disaster preparedness efforts to augment limited, essential critical care (emergency mass critical care [EMCC]), rather than to marginally increase unrestricted, individual-focused critical care may provide many additional people with access to life-sustaining interventions. In 2007, in response to the increasing concern over a severe influenza pandemic, the Task Force on Mass Critical Care (hereafter called the Task Force) convened to suggest the essential critical care therapeutics and interventions for EMCC.

TASK FORCE SUGGESTIONS

EMCC should include the following: (1) mechanical ventilation, (2) IV fluid resuscitation, (3) vasopressor administration, (4) medication administration for specific disease states (eg, antimicrobials and antidotes), (5) sedation and analgesia, and (6) select practices to reduce adverse consequences of critical illness and critical care delivery. Also, all hospitals with ICUs should prepare to deliver EMCC for a daily critical care census at three times their usual ICU capacity for up to 10 days.

DISCUSSION

By using the Task Force suggestions for EMCC, communities may better prepare to deliver augmented critical care in response to disasters. In light of current mass critical care data limitations, the Task Force suggestions were developed to guide preparedness but are not intended as strict policy mandates. Additional research is required to evaluate EMCC and revise the strategy as warranted.

Definitive care for the critically ill during a disaster: medical resources for surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL

BACKGROUND

Mass numbers of critically ill disaster victims will stress the abilities of health-care systems to maintain usual critical care services for all in need. To enhance the number of patients who can receive life-sustaining interventions, the Task Force on Mass Critical Care (hereafter termed the Task Force) has suggested a framework for providing limited, essential critical care, termed emergency mass critical care (EMCC). This article suggests medical equipment, concepts to expand treatment spaces, and staffing models for EMCC.

METHODS

Consensus suggestions for EMCC were derived from published clinical practice guidelines and medical resource utilization data for the everyday critical care conditions that are anticipated to predominate during mass critical care events. When necessary, expert opinion was used. TASK FORCE MAJOR SUGGESTIONS: The Task Force makes the following suggestions: (1) one mechanical ventilator that meets specific characteristics, as well as a set of consumable and durable medical equipment, should be provided for each EMCC patient; (2) EMCC should be provided in hospitals or similarly equipped structures; after ICUs, postanesthesia care units, and emergency departments all reach capacity, hospital locations should be repurposed for EMCC in the following order: (A) step-down units and large procedure suites, (B) telemetry units, and (C) hospital wards; and (3) hospitals can extend the provision of critical care using non-critical care personnel via a deliberate model of delegation to match staff competencies with patient needs.

DISCUSSION

By using the Task Force suggestions for adequate supplies of medical equipment, appropriate treatment space, and trained staff, communities may better prepare to deliver augmented essential critical care in response to disasters.

Coordinación general de las actuaciones en el hospital

The present article describes the organizational and general coordination measures taken by the hospital management to attend the 325 victims who arrived at our hospital after the terrorist attack on the morning of 11 March. Firstly, we summarize the activity performed by the extra-hospital emergency services and the distribution of the victims in centers. Secondly, we describe in greater detail the interventions performed to initiate the External Emergency Action Plan in our hospital, the triage system and identification of patients who used it, as well as the resources in terms of beds, operating rooms and personnel that were used on that day. Lastly, by way of discussion, we provide a critical analysis of our interventions.

Miracles take a little longer: the challenges of the uncompensated major incident

The challenges of managing uncompensated major incidents (UMI) are many and complex. A concomitant loss of infrastructure is common in large-scale disasters. Significant planning, including liaison with relevant agencies on an international basis is necessary to facilitate a rapid and co-ordinated response to such events. UMIs must be managed in a structured manner in common with that utilized for smaller-scale major incidents, although some modification may be appropriate. Use of the ‘expectant’ triage category should be implemented at an early stage to prevent scarce health service resources being monopolized by patients with no possibility of survival. Many patients will be suitable for treatment at the scene without subsequent urgent referral to hospital facilities. The early involvement of military forces is vital to provide manpower, tents (for casualty clearing stations and temporary shelter), high volume transportation and forward dressing stations at the scene and at receiving hospitals. The military can also facilitate the restoration of infrastructure, including access and egress routes. The risk of uncompensated major incidents occurring is real and is not limited to natural catastrophes occurring in developing countries.

The World Trade Center attack. Is critical care prepared for terrorism?

This commentary on the World Trade Center attack is written from the perspective of a New York City critical care service, with a long history of activity in disaster management, which is located at the Montefiore Medical Center/Albert Einstein College of Medicine. The paper describes some of the local concerns of the service in the first hours, the reality of dispersal of victims throughout the New York City hospital system, and some of the resources made available and their utilization. In general, the US Critical Care Medicine System receives massive resources in terms of gross national product expenditure when compared with other developed countries. A large capacity is subsequently in place to provide care to critically ill patients resulting from manmade as well as natural disasters. It was the nature of the World Trade Center attack in terms of the ratio of injured survivors to dead victims that did not allow the full capacity and capability of the system to engage.