The World Trade Center attack. Observations from New York's Bellevue Hospital

Lessons learned from terror attacks: thematic priorities and development since 2001-results from a systematic review

Purpose

The threat of national and international terrorism remains high. Preparation is the key requirement for the resilience of hospitals and out-of-hospital rescue forces. The scientific evidence for defining medical and tactical strategies often feeds on the analysis of real incidents and the lessons learned derived from them. This systematic review of the literature aims to identify and systematically report lessons learned from terrorist attacks since 2001.

Methods

PubMed was used as a database using predefined search strategies and eligibility criteria. All countries that are part of the Organization for Economic Cooperation and Development (OECD) were included. The time frame was set between 2001 and 2018.

Results

Finally 68 articles were included in the review. From these, 616 lessons learned were extracted and summarized into 15 categories. The data shows that despite the difference in attacks, countries, and casualties involved, many of the lessons learned are similar. We also found that the pattern of lessons learned is repeated continuously over the time period studied.

Conclusions

The lessons from terrorist attacks since 2001 follow a certain pattern and remained constant over time. Therefore, it seems to be more accurate to talk about lessons identified rather than lessons learned. To save as many victims as possible, protect rescue forces from harm, and to prepare hospitals at the best possible level it is important to implement the lessons identified in training and preparation.

Medical students as disaster volunteers: A strategy for improving emergency department surge response in times of crisis

Disasters resulting in mass casualty incidents can rapidly overwhelm the Emergency Department (ED). To address critical manpower needs in the ED’s disaster response, medical student involvement has been advocated. Duke-National University of Singapore Medical School is in proximity to Singapore General Hospital and represents an untapped manpower resource. With appropriate training and integration into ED disaster workflows, medical students can be leveraged upon as qualified manpower. This review provides a snapshot of the conceptualization and setting up of the Disaster Volunteer Corps – a programme where medical students were recruited to receive regular training and assessment from emergency physicians on disaster response principles to fulfil specific roles during a crisis, while working as part of a team under supervision. We discuss overall strategy and benefits to stakeholders, emphasizing the close symbiotic relationship between academia and healthcare services.

Securing the Emergency Department During Terrorism Incidents: Lessons Learned From the Boston Marathon Bombings

Terrorist incidents that target hospitals magnify morbidity and mortality. Before a real or perceived terrorist mass casualty incident threatens a hospital and its providers, it is essential to have protocols in place to minimize damage to the infrastructure, morbidity, and mortality. In the years following the Boston Marathon bombings, much has been written about the heroic efforts of survivors and responders. Far less has been published about near misses due to lack of experience responding to a mass casualty incident resulting from terrorism. After an extensive review of the medical literature and published media in English, Spanish, and Hebrew, we were unable to identify a similar event. To the best of our knowledge, this is the first reported experience of a bomb threat caused evacuation of an emergency department in the United States while actively responding to multiple casualty terrorist incidents. We summarized the chronology of the events that led to a bomb threat being identified and the subsequent evacuation of the emergency department. We then reviewed the problematic nature of our response and described evidence-based policy changes based on data from health care, law enforcement, and counterterrorism. (Disaster Med Public Health Preparedness. 2019;13:791-798).

Leadership During the Boston Marathon Bombings: A Qualitative After-Action Review

Objective

On April 15, 2013, two improvised explosive devices (IEDs) exploded at the Boston Marathon and 264 patients were treated at 26 hospitals in the aftermath. Despite the extent of injuries sustained by victims, there was no subsequent mortality for those treated in hospitals. Leadership decisions and actions in major trauma centers were a critical factor in this response.

Methods

The objective of this investigation was to describe and characterize organizational dynamics and leadership themes immediately after the bombings by utilizing a novel structured sequential qualitative approach consisting of a focus group followed by subsequent detailed interviews and combined expert analysis.

Results

Across physician leaders representing 7 hospitals, several leadership and management themes emerged from our analysis: communications and volunteer surges, flexibility, the challenge of technology, and command versus collaboration.

Conclusions

Disasters provide a distinctive context in which to study the robustness and resilience of response systems. Therefore, in the aftermath of a large-scale crisis, every effort should be invested in forming a coalition and collecting critical lessons so they can be shared and incorporated into best practices and preparations. Novel communication strategies, flexible leadership structures, and improved information systems will be necessary to reduce morbidity and mortality during future events. (Disaster Med Public Health Preparedness. 2015;9:489–495)

Prehospital Mass-Casualty Triage Training—Written Versus Moulage Scenarios: How Much Do EMS Providers Retain?

Introduction

The aim of this study was to assess the effectiveness of written and moulage scenarios using video instruction for mass-casualty triage by evaluating skill retention at six months post intervention.

Methods

Prehospital personnel were instructed in the START method of mass-casualty triage using a video. Moulage and written testing were completed by each participant immediately after instruction and at six months post instruction.

Results

There was a significant decrease in performance between initial and six-month testing, indicating skill decay and loss of retention of triage skills after an extended nonuse period. There were no statistically significant differences between written and moulage testing results at either initial testing or at six months. Prior skill level did not influence test performance on the type of testing conducted or long-term retention of triage skills.

Conclusion

These data confirm the skill deterioration associated with an infrequently used triage method. Further research to more precisely define triage criteria, as well as the ability to apply the criteria in a clinical setting and to rapidly identify patients at risk for morbidity/mortality is needed.

RisaviBL, TerrellMA, LeeW, HolstenDLJr. Prehospital mass-casualty triage training—written versus moulage scenarios: how much do EMS providers retain?. Prehosp Disaster Med. 2013;28(3):1-6.

Development of an “All-Hazards” Hospital Disaster Preparedness Training Course Utilizing Multi-Modality Teaching

Objectives:

The objectives of the study were to develop and evaluate an “all-hazards” hospital disaster preparedness training course that utilizes a combi-nation of classroom lectures, skills sessions, tabletop sessions, and disaster exercises to teach the principles of hospital disaster preparedness to hospital-based employees.

Methods:

Participants attended a two-day, 16-hour course, entitled Hospital Disaster Life Support (HDLS). The course was designed to address seven core competencies of disaster training for healthcare workers. Specific disaster situations addressed during HDLS included: (1) biological; (2) conventional; (3) radiological; and (4) chemical mass-casualty incidents. The primary goal of HDLS was not only to teach patient care for a disaster, but more important-ly, to teach hospital personnel how to manage the disaster itself. Knowledge gained from the HDLS course was assessed by pre- and post-test evaluations. Additionally, participants completed a course evaluation survey at the conclu-sion of HDLS to assess their attitudes about the course.

Results:

Participants included 11 physicians, 40 nurses, 23 administrators/direc-tors, and 10 other personnel (n = 84). The average score on the pre-test was 69.1 ±12.8 for all positions, and the post-test score was 89.5 ±6.7, an improve-ment of 20.4 points (p <0.0001, 17.2–23.5).Participants felt HDLS was edu-cational (4.2/5), relevant (4.3/5) and organized (4.3/5).

Conclusions:

Identifying an effective means of teaching hospital disaster pre-paredness to hospital-based employees is an important task. However, the opti-mal strategy for implementing such education still is under debate.The HDLS course was designed to utilize multiple teaching modalities to train hospital-based employees on the principles of disaster preparedness. Participants of HDLS showed an increase in knowledge gained and reported high satisfaction from their experiences at HDLS. These results suggest that HDLS is an effec-tive way to train hospital-based employees in the area of disaster preparedness.

Global health outreach during anesthesiology residency in the United States: a survey of interest, barriers to participation, and proposed solutions

STUDY OBJECTIVE

To assess the interest in and barriers to pursuing global health outreach (GHO) experiences for anesthesiology residents in the United States.

DESIGN

Survey instrument.

SETTING

Academic department of anesthesiology.

SUBJECTS

Anesthesiology residents who were members of the American Society of Anesthesiologists (ASA).

MEASUREMENTS

An online survey was administered to residents in anesthesiology via the ASA membership database. Descriptive statistics, including means, frequencies, and percentages were calculated.

MAIN RESULTS

91% of participants indicated an interest in GHO, of whom fewer than half (44%) had done a GHO medical mission. Seventy-nine percent reported that GHO affected their current practice or education; 33% commented they were now less wasteful with supplies and resources. Permission from work or obtaining work coverage were the primary barriers for both those with and without previous GHO participation. Of all respondents, 78% agreed that the availability of a GHO residency track would influence their ranking of that program for training, and 71% would pursue a GHO fellowship if available.

CONCLUSIONS

Anesthesiology residents have an interest in residency and fellowship GHO programs. Formalization of GHO programs during training may reduce work-related barriers associated with GHO participation and broaden academic program recruitment.

Disaster preparedness in home health and personal-care agencies: are they ready?

BACKGROUND

The use of home health care and personal-care agencies in the United States has increased by nearly 1,000% in less than 20 years. Despite the numerous advantages of keeping older and disabled people at home and fairly independent, new concerns have emerged about how to keep home health care and personal-care clients safe during emergencies and large-scale disasters. To date, little is known about the disaster preparedness activities of home health and personal-care agencies, including what oversight they have for their patients and what capabilities they sustain for preparing their clients for disasters.

OBJECTIVE

The purpose of this study was to explore the disaster preparedness policies and practices of these agencies and to identify opportunities for coordination with disaster preparedness officials.

METHODS

Semi-structured interviews were conducted by phone and in person with 21 home health and personal-care administrators across Georgia and Southern California. Transcripts from the interviews were analyzed for disaster preparedness themes.

RESULTS

We found that most agencies have very limited disaster plans and capabilities. Despite this, most stated either their intentions or outlined past experience which demonstrated their commitment to provide services to clients on a case-by-case basis throughout a large-scale emergency or disaster.

CONCLUSION

The findings from our study help to contribute to the growing interest in disaster preparedness among home health and personal-care agencies and point to the fact that these agencies need assistance to properly lay out their disaster preparedness plans.

Analysis of responses of radiology personnel to a simulated mass casualty incident after the implementation of an automated alarm system in hospital emergency planning

The purpose of this study was to evaluate the response to an automated alarm system of a radiology department during a mass casualty incident simulation. An automated alarm system provided by an external telecommunications provider handling up to 480 ISDN lines was used at a level I trauma center. During the exercise, accessibility, availability, and estimated time of arrival (ETA) of the called in staff were recorded. Descriptive methods were used for the statistical analysis. Of the 49 employees, 29 (59%) were accessible, of which 23 (79%) persons declared to be available to come to the department. The ETA was at an average 29 min (SD ±23). Radiologists and residents reported an ETA to their workplace almost two times shorter compared with technicians (19 ± 16 and 22 ± 16 vs. 40 ± 27 min, p > 0.05). Additional staff reserve is crucial for handling mass casualty incidents. An automated alarm procedure might be helpful. However, the real availability of the employees could not be exactly determined because of unpredictable parameters. But our results allow estimation of the manpower reserve and calculation of maximum radiology service capacities.

An organized, comprehensive, and security-enabled strategic response to the Haiti earthquake: a description of pre-deployment readiness preparation and preliminary experience from an academic anesthesiology department with no preexisting international disaster response program

BACKGROUND

On Tuesday, January 12, 2010 at 16:53 local time, a magnitude 7.0 M(w) earthquake struck Haiti. The global humanitarian attempt to respond was swift, but poor infrastructure and emergency preparedness limited many efforts. Rapid, successful deployment of emergency medical care teams was accomplished by organizations with experience in mass disaster casualty response. Well-intentioned, but unprepared, medical teams also responded. In this report, we describe the preparation and planning process used at an academic university department of anesthesiology with no preexisting international disaster response program, after a call from an American-based nongovernmental organization operating in Haiti requested medical support. The focus of this article is the pre-deployment readiness process, and is not a post-deployment report describing the medical care provided in Haiti.

METHODS

A real-time qualitative assessment and systematic review of the Hospital of the University of Pennsylvania's communications and actions relevant to the Haiti earthquake were performed. Team meetings, conference calls, and electronic mail communication pertaining to planning, decision support, equipment procurement, and actions and steps up to the day of deployment were reviewed and abstracted. Timing of key events was compiled and a response timeline for this process was developed. Interviews with returning anesthesiology members were conducted.

RESULTS

Four days after the Haiti earthquake, Partners in Health, a nonprofit, nongovernmental organization based in Boston, Massachusetts, with >20 years of experience providing medical care in Haiti contacted the University of Pennsylvania Health System to request medical team support. The departments of anesthesiology, surgery, orthopedics, and nursing responded to this request with a volunteer selection process, vaccination program, and systematic development of equipment lists. World Health Organization and Centers for Disease Control guidelines, the American Society of Anesthesiology Committee on Trauma and Emergency Preparedness, published articles, and in-country contacts were used to guide the preparatory process.

CONCLUSION

An organized strategic response to medical needs after an international natural disaster emergency can be accomplished safely and effectively within 6 to 12 days by an academic anesthesiology department, with medical system support, in a center with no previously established response system. The value and timeliness of this response will be determined with further study. Institutions with limited experience in putting an emergency medical team into the field may be able to quickly do so when such efforts are executed in a systematic manner in coordination with a health care organization that already has support infrastructure at the site of the disaster.

Preparedness lessons from modern disasters and wars

Disasters come in all shapes and forms, and in varying magnitudes and intensities. Nevertheless, they offer many of the same lessons for critical care practitioners and responders. Among these, the most important is that well thought out risk assessment and focused planning are vital. Such assessment and planning require proper training for providers to recognize and treat injury from disaster, while maintaining safety for themselves and others. This article discusses risk assessment and planning in the context of disasters. The article also elaborates on the progress toward the creation of portable, credible, sustainable, and sophisticated critical care outside the walls of an intensive care unit. Finally, the article summarizes yields from military-civilian collaboration in disaster planning and response.

Hospital response to a major freeway bridge collapse

BACKGROUND

We describe the hospital system response to the Interstate 35W bridge collapse in Minneapolis into the Mississippi River on August 1, 2007, which resulted in 13 deaths and 127 injuries. Comparative analysis of response activities at the 3 hospitals that received critical or serious casualties is provided.

METHODS

First-hand experiences of hospital physicians, issues identified in after-action reports, injury severity scores, and other relevant patient data were collected from the 3 hospitals that received seriously injured patients, including the closest hospitals to the collapse on each side of the river.

RESULTS/DISCUSSION

Injuries were consistent with major acceleration/deceleration force injuries. The most critical patients arrived first at each hospital, suggesting appropriate prehospital triage. Capacity of the health care system was not overwhelmed and the involved hospitals generally reported an overresponse by staff. Communication and patient tracking problems occurred at all of the hospitals. Situational awareness was limited due to the scope of structural collapse and incomplete information from the scene.

CONCLUSIONS

Hospitals were generally satisfied with their surge capacity and incident management plan activation. Issues such as communications, patient tracking, and staff overreporting that have been identified in past incidents also were problematic in this event. Hospitals will need to address deficiencies and build on successful actions to cope with future, potentially larger incidents.

Management and analysis of out-of-hospital health-related responses to simultaneous railway explosions in Madrid, Spain

OBJECTIVES

On 11 March 2004, 10 simultaneous explosions at four different locations of the rail network in Madrid caused 198 deaths and 2312 persons were injured. The aim of this manuscript is to describe the prehospital health-related activities from the Emergency Medical Service of Madrid and to analyze the responses, the major conclusions, and the lessons learned.

METHODS

Three meetings were held with professionals from the Emergency Medical Service of Madrid who were involved in the catastrophe. Two experts in quality management chaired the meetings. Detailed data were gathered on what occurred at the sites following the explosions. Additional data were gathered from professionals from the Coordination Service of Urgencies and from those who assisted relatives and friends of victims in the days following the bombings. All of the data were collected and were included in the final report.

RESULTS

We describe the activities carried out by the Coordination Service of Urgencies at each site immediately after the explosions and during the 11 days following the catastrophe. The successful performances and those that need to be improved at the four sites and elsewhere are detailed.

CONCLUSIONS

The main reasons for the 'positive responses' are the number of resources that acted, the professional abilities, and the flexibility of the services. The 'areas to be improved' are communications, the establishment of the top of the command at each site, and the organization of supplies for catastrophic assistance. From the analysis, we describe the main lessons learned and we present proposals for improvement, should a future catastrophe occur.

The prospect of using alternative medical care facilities in an influenza pandemic

Alternative care facilities (ACFs) have been widely proposed in state, local, and national pandemic preparedness plans as a way to address the expected shortage of available medical facilities during an influenza pandemic. These plans describe many types of ACFs, but their function and roles are unclear and need to be carefully considered because of the limited resources available and the reduced treatment options likely to be provided in a pandemic. Federal and state pandemic plans and the medical literature were reviewed, and models for ACFs being considered were defined and categorized. Applicability of these models to an influenza pandemic was analyzed, and recommendations are offered for future ACF use. ACFs may be best suited to function as primary triage sites, providing limited supportive care, offering alternative isolation locations to influenza patients, and serving as recovery clinics to assist in expediting the discharge of patients from hospitals.

Communication technology in trauma centers: A national survey

The relationship between information and communication technology (ICT) and trauma work coordination has long been recognized. The purpose of the study was to investigate the type and frequency of use of various ICTs to activate and organize trauma teams in level I/II trauma centers. In a cross-sectional survey, questionnaires were mailed to trauma directors and clinicians in 457 trauma centers in the United States. Responses were received from 254 directors and 767 clinicians. Communication with pre-hospital care providers was conducted predominantly via shortwave radio (67.3%). The primary communication methods used to reach trauma surgeons were manual (56.7%) and computerized group page (36.6%). Computerized group page (53.7%) and regular telephone (49.8%) were cited as the most advantageous devices; e-mail (52.3%) and dry erase whiteboard (52.1%) were selected as the least advantageous. Attending surgeons preferred less overhead paging and more cellular phone communication than did emergency medicine physicians and nurses. Cellular phones have become an important part of hospital-field communication. In high-volume trauma centers, there is a need for more accurate methods of communicating with field personnel and among hospital care providers.

The importance of evidence-based disaster planning

Disaster planning is only as good as the assumptions on which it is based. However, some of these assumptions are derived from a conventional wisdom that is at variance with empirical field disaster research studies. Knowledge of disaster research findings might help planners avoid common disaster management pitfalls, thereby improving disaster response planning. To illustrate the point, this article examines several common assumptions about disasters, compares them with research findings, and discusses the implications for planning. These assumptions are that: 1. Dispatchers will hear of the disaster and send emergency response units to the scene. 2. Trained emergency personnel will carry out field search and rescue. 3. Trained emergency medical services personnel will carry out triage, provide first aid or stabilizing medical care, and--if necessary--decontaminate casualties before patient transport. 4. Casualties will be transported to hospitals by ambulance. 5. Casualties will be transported to hospitals appropriate for their needs and in such a manner that no hospitals receive a disproportionate number. 6. Authorities at the scene will ensure that area hospitals are promptly notified of the disaster and the numbers, types, and severities of casualties to be transported to them. 7. The most serious casualties will be the first to be transported to hospitals. The current status and limitations of disaster research are discussed, and potential interventions to response problems are offered that may be of help to planners and practitioners and that may serve as hypotheses for future research.

Clinical review: communication and logistics in the response to the 1998 terrorist bombing in Omagh, Northern Ireland

The Omagh bombing in August 1998 produced many of the problems documented in other major incidents. An initial imbalance between the demand and supply of clinical resources at the local hospital, poor information due to telecommunication problems, the need to triage victims and the need to transport the most severely injured significant distances were the most serious issues. The Royal Group Hospitals Trust (RGHT) received 30 severely injured secondary transfers over a 5-hour period, which stressed the hospital's systems even with the presence of extra staff that arrived voluntarily before the hospital's major incident plan was activated. Many patients were transferred to the RGHT by helicopter, but much of the time the gained advantage was lost due to lack of a helipad within the RGHT site. Identifying patients and tracking them through the hospital system was problematic. While the major incident plan ensured that communication with the relatives and the media was effective and timely, communication between the key clinical and managerial staff was hampered by the need to be mobile and by the limitations of the internal telephone system. The use of mobile anaesthetic teams helped maintain the flow of patients between the Emergency Department and radiology, operating theatres or the intensive care unit (ICU). The mobile anaesthetic teams were also responsible for efficient and timely resupply of the Emergency Department, which worked well. In the days that followed many victims required further surgical procedures. Coordination of the multidisciplinary teams required for many of these procedures was difficult. Although only seven patients required admission to adult general intensive care, no ICU beds were available for other admissions over the following 5 days. A total of 165 days of adult ICU treatment were required for the victims of the bombing.

Health care facility and community strategies for patient care surge capacity

Recent terrorist and epidemic events have underscored the potential for disasters to generate large numbers of casualties. Few surplus resources to accommodate these casualties exist in our current health care system. Plans for “surge capacity” must thus be made to accommodate a large number of patients. Surge planning should allow activation of multiple levels of capacity from the health care facility level to the federal level. Plans should be scalable and flexible to cope with the many types and varied timelines of disasters. Incident management systems and cooperative planning processes will facilitate maximal use of available resources. However, resource limitations may require implementation of triage strategies. Facility-based or “surge in place” solutions maximize health care facility capacity for patients during a disaster. When these resources are exceeded, community-based solutions, including the establishment of off-site hospital facilities, may be implemented. Selection criteria, logistics, and staffing of off-site care facilities is complex, and sample solutions from the United States, including use of local convention centers, prepackaged trailers, and state mental health and detention facilities, are reviewed. Proper pre-event planning and mechanisms for resource coordination are critical to the success of a response.

Two New York City hospitals' surgical response to the September 11, 2001, terrorist attack in New York City

BACKGROUND

We describe the surgical response of two affiliated hospitals during the day of, and week following, the September 11th, 2001 terrorist attack at the World Trade Center in New York City. The city of New York has 18 state designated regional trauma centers that receive major trauma victims. The southern half of Manhattan is served by a burn center, two regional trauma centers, and a community hospital that is an affiliate of one of the regional trauma centers. This report accounts for the surgical response by a regional trauma center (Hospital A, located 2.5 miles from the World Trade Center) and its affiliate hospital (Hospital B, located 5 city blocks from the World Trade Center) on September 11th when two commercial jets crashed into the Twin Towers at the World Trade Center mall.

METHODS

Hospital A maintained a concurrent log of patients received during the first 5 hours, the first day, and the first week after the disaster which was kept by the Surgical Triage Officer. The trauma registry completed and verified this data by September 18th. Hospital B collected its data by hand counting and verification by chart review. Both hospitals, A and B, had established disaster plans that were implemented.

RESULTS

Nine hundred eleven patients were received by two affiliated hospitals from the World Trade Center attack. Seven hundred seventy six patients (85%) were walking wounded, sustaining mild inhalation and eye irritant injuries. One hundred thirty five (15%) were admitted with 18 (13%) of these undergoing surgery. Twenty two of the 23 transfers were from the community hospital to specialized orthopedic or burn centers. Of the 109 patients admitted to Hospital A, 30 were to the surgical service. The mean ISS score of these patients was 12. There were 4 deaths (within minutes of arrival at the hospital) and 6 delayed deaths (day 1-14). Excluding walking wounded and DOAs, the critical mortality rate was 37.5% overall.

CONCLUSION

The September 11th, 2001, terrorist attack in New York City, involving two commercial airliners crashing into the World Trade Center, led to 911 patients received at two affiliated hospitals in lower Manhattan. One hospital is a regional trauma center and one was an affiliate community hospital. Eighty five percent of the patients received were walking wounded. Of the rest, 13% underwent surgical procedures with an overall critical mortality rate of 37.5%.

Disaster preparation and management for the intensive care unit

The purpose of this report is to provide information regarding preparation for disaster management from the perspective of ICU physicians. Both a framework toward ICU preparation for disaster management and a guide to the relevant literature are presented. Our objective is to show that the understanding of disaster preparedness on multiple levels, including government, hospital, ICU, and clinician, may lead to optimal management in a disaster.

The World Trade Center attack. Lessons for all aspects of health care

The attack on the World Trade Center had the potential to overwhelm New York's health services. Sadly, however, the predicted thousands of treatable patients failed to materialize. Horror and sadness has now been replaced by anger, fear, and the determination to be better prepared next time. This determination not only exists in politics but also in health care, and as with all attempts to enforce change there needs to be a period of collecting opinions and data. This article introduces nine reviews in Critical Care offering varied health care perspectives of the events of 11 September 2001 from people who were there and from experts in disaster management.