Mobilizing an ER department to handle a mass casualty incident
epmonthly.com
epmonthly.com
A bunch of the terms used in this piece (like "crumping", which apparently means dying without doctor permission) are emergency medical jargon, all easy to look up.
A few things that jumped out:
- Thinking ahead to how he was going to handle an MCA probably saved dozens if not hundreds, even if he made some choices that he shouldn’t have if you’re sitting in our present armchairs.
- This is great demonstration of why the incident commander needs good oversight of the whole situation, and why not everyone makes a good incident commander. The three doctors in Station 1 should have felt empowered to solve the bottlenecks, but they did not... they just kept working within established procedure. That’s ok. You need good operators. But the good leaders in incidents are the people who know how and when to establish and communicate new standard procedures.
- Getting ahead of and staying ahead of a cascade failure is a difficult thing to manage, one that we don’t often accomplish in operations/sre incidents. I know I’ve had one or two incidents like that, mostly DDoS or other attack types. This story shows the value again of staying frosty and planning to handle your next problem before it snowballs and hits you from behind.
My experience in emergency services is my greatest asset in ops work. So, half the datacenter has crashed, and the other half is about to buckle under the load. Is anyone literally going to die in the next 5 minutes? Ok, cool, then let's just sort this out and get on with our lives.
Generally there is an "MCI kit", which has a form that can be attached to the patient (an elastic band around the wrist or ankle, generally). That form will contain whatever information we know about the patient, interventions thus far, etc. It stays with them throughout the process (in the triage and treatment areas, to the OR, etc). That being said, documentation is often a tertiary concern at best in large scale events like this.
As far as infection control goes, the OR is obviously using standard sterile procedures. In the ER, infection control is mostly "changing your gloves a lot" (be sure to put on two pairs, any only change the top pair, as your hands are going to get really sweating, and putting a new pair of gloves on your bare hands is going to be impossible).
People came in so grievously injured and so many at a time that Fisher, who is the medical head of trauma services for the hospital, and his colleagues used markers, writing directly on patients, to do triage.
When someone arrived, an emergency room physician would mark their wounds. It was quick, simple and impersonal by necessity.
Fisher says in those first few hours, the patients were functionally anonymous to the surgeons trying to save their lives. "There's no paper charts prepared for all those patients," says Fisher. "No documentation, so literally they just write on the patient. Just write where the wounds are."
https://www.npr.org/sections/health-shots/2017/10/04/5555849...
> As far as infection control goes...
How soon do patients get antibiotics administered?
We did this in the Army.
It's obviously a completely different scale though, and they had some time to prepare before the patients started arriving.
The article doesn't go into detail about your two areas of concern but does mention two items: Infection control was mostly glove changes. Record keeping was on the triage tags from the MCI; cards are attached to patients and travel with the patient. Yes, both of these are a "bare minimum" effort and may not have been used, but when the priority becomes throughput of a system many features of a system can get dropped and picked up again after the crisis is over.
To facilitate discussion though, I'd like to highlight this section:
"By textbook standards, some of these first arrivals should have been black tags, but I sent them to the red tag area anyway. I didn’t black tag a single one. We took everybody that came in—I pulled at least 10 people from cars that I knew were dead—and sent them straight back to Station 1 so that another doc could see them."
There is a reason the "textbook" calls for a black tag. The simplest definition of a "mass casualty incident" is when you need more resources than you have. Sending those dead patients to the treatment area was a waste of the most critical resource they had (the time and attention of medical providers). It is likely some outcomes were worsened by that waste of resources.
In a sense, he was correctly applying the rule of optimizing for the most critical resource -- except that in this case, the most critical resource was his ability to triage incoming patients.
I just want to reiterate though... This facility (and this doctor specifically) did a fantastic job. I look forward to the more in-depth case studies as an opportunity to further my own skills in EMS.
Is it implausible that under these conditions someone would be uncertain whether there was no pulse or simply a weak pulse which they missed?
You're absolutely right that finding a pulse can be tricky (though a carotid or femoral is a lot easier than a radial). There are a handful of good studies that show a fairly high degree of uncertainty, even among well trained providers (ER docs, paramedics, etc). This is why breathing is the "real" criteria, and should have been the decision making criteria used in this case.
"Black tags - are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available."
https://www.medicinenet.com/script/main/art.asp?articlekey=7...
Again, if you are experienced and knowledgeable in triage please disregard my understanding.
The criteria used by all the major triage systems for a black tag classifications is a lack of respirations (and because he's an ER doc, he's going to reflexively check a pulse).
I don't think my experience is especially important (as you said, this is all googleable info), but I'm a paramedic with a little over a decade in EMS.
https://en.wikipedia.org/wiki/Triage#Conventional_classifica...
A better explanation might by that by taking this approach, he was tiering the triage, in much the same way that the neurosurgeon in the article's comments mentioned that they were able to "neuro triage" patients sent to them.
I can't begin to imagine handling this type of situation.
1). He didn't know how many people were going to come in or how serious they would be. Triage in MCI does depend to a certain degree on what your facility is capable of and the expected volume and status of patients. If he underestimated the volume or criticality of the patients about to come in he might have put more into the red pod than he would have otherwise. Underestimating seems plausible in this case because this was the worst mass shooting in history in the US.
2). Medicolegally he might have a fear that he would be judged harshly if he didn't automatically try to save everyone.
This triage system is pretty standard, you can see the same triage armbands in this RNLI medical kit in the bottom right corner[0] (I couldn't find a standard UK ambulance kit image), but I am told that it takes a huge amount of mental discipline to follow this training to the letter in real life. It probably took a few people going through the system for him to get into the swing of it.
I can't imagine having to do this, this guy will be going back over the decisions he made that night for the rest of his life. I hope that in writing this article he has felt validated in himself because it sounds like he and his colleagues did an incredible job.
From my reading of the article, he was the triage officer during the arrival of almost all the critical patients, and it was only after the acuity level started to drop off that he delegated to a nurse.
That said, I have never heard "black tag = not breathing = don't try to help"[1]. I know for a fact that the boundary for who to try to save immediately and who to deprioritize is very grey in many cases (it is why you should have an experienced doctor doing it). A common example why that equivalency is not taught in ATLS is the case of a boat capsizing in frozen waters. There may be many frozen victims who are not breathing but could still be very salvageable medically. If you chose to not help those who are not breathing in that case you would plausibly be found negligent without some extraordinary situation to justify yourself with.
Another example would be mass overdose on fentanyl, many are saveable but none would be breathing when you first see them.
1. https://en.wikipedia.org/wiki/Triage#Conventional_classifica...
I'm not sure where your understanding of triage comes from, but you're mistaken if you think respiratory status isn't the primary determining factor in black/expectant classification (in the US, there may be differences in other international systems I'm not aware of).
The vast majority of triage in US is done using the START system (or START-derived systems, like SALT).
Here is a graphical depiction of the START classification algorithm: http://citmt.org/Start/images/flowchart2.jpg
I think the more interesting concept is the second look. Doctors are trained to be sensitive, then specific. Perhaps it would be easier to black tag people if you knew the next thing that would happen is they would go the red tag area for a second call of "black tag".
This definition is an example of the logical fallacy called begging the question. Nobody would deny that an incident that brings 250 gunshot victims to one center is a "mass casualty." The brilliance of Dr. Menes's approach is that he did not immediately assume insufficient resources. He didn't say this, but it appears to me that he proceeded under the thought that with careful planning and ingenuity, they might have just enough resources. This redefines triage from a rigid algorithm to something like "the optimal deployment of available resources to maximize the utility for as many as possible."
They made do with what they had (very efficient, and very effectively), but the scope of the incident vastly outsized the scope of the available resources.
Your description of triage is great. The algorithm (based on a fair amount of research) is one part of maximizing that utility (it doesn't stand in the way of accomplishing that).
The Red Cross has every day donation centers in larger cities, just not in as many places as health providers.
http://www.militaryblood.dod.mil/Donors/can_i_donate.aspx
Good thing is i don't have a rare blood type.
I'm glad they don't want my blood, I really dislike vampires.
I'm guessing it makes sense as a rough way to limit infectious deceases. You need only look to China to see how far something like AIDS can spread if you don't do blood donations right. If I recalls correctly they infected something like 50k people by accident.
Notice, that the next infectious decease like AIDS might not have been discovered yet. Hence, why a lot of precautions around blood donations makes sense.
By now we also have some Malaria risk areas in Greece and the Italian Po valley.
but does this really exclude enough people to be problematic, if not... then it better to have too many restrictions..
In emergency medicine, the golden hour (also known as golden time) refers to a time period lasting for one hour, or less, following traumatic injury being sustained by a casualty or medical emergency, during which there is the highest likelihood that prompt medical treatment will prevent death. https://en.wikipedia.org/wiki/Golden_hour_(medicine)
Time is off course at a premium, but there seems to not be anything special about the 60 minute mark.
> It is well established that the patient's chances of survival are greatest if they receive care within a short period of time after a severe injury; however, there is no evidence to suggest that survival rates drop off after 60 minutes
It’s a rule of thumb though and in this case it wasn’t so much about survival rates specifically but rather the condition worsening for those with orange and yellow tags during that time frame.
https://hcatodayblog.com/2017/10/06/sunrise-hospital-staff-s...
> FB
> Dr. Anson,
> Did the bullet wounds you saw match the caliber of weapon used in the shooting? I ask because wounds would have been more severe than what is being reported. Thanks.
====
> Dr Menes: There were single bullet-pass through-multiple extremity wounds, entrance/exit through narrow torso, and entrance only through dense torso consistent with 5.56 ballistics.
The standout's for me were:
* Plan - have a plan in place in advance * Flow - recognise and shift bottlenecks + understand the impact to the system * Prioritise - rank what is critical, urgent, or standard - and be ruthless * Process - simplify the processes to make it more effective and efficient * Shift - innovate and adapt in the face of changing circumstances.
These sound like no brainers, but reading the story you get a sense of how one individual pushing these forward in a tough situation had an incredibly powerful impact.
How could we apply these powerful lessons more widely?
Also I know in the UK they do role-play major incidents out using the police and emergency services to test there plans.
BTW this guy and his team deserve an honour of some sort
The trauma center in our region holds similar "mock incidents" at least once a year. Certainly nothing to this scale (there's just no way to practice that...), but they routinely run drills with dozens of patients and simulate various in-hospital system failures.
I should state up front I'm ex-military and volunteer for a disaster response organisation.
I find this to be incredible. Who in their right mind would ostracise a trauma professional for conducting such planning? In fact, who who dare not support such a professional to plan for such eventualities?
I actually can't quite believe the implication here, that there is a systemic reluctance to plan for such events. Maybe things are different in my country (UK) but this 'worry' the doctor has seems frankly absurd!
> The first thing I did was tell the secretaries I needed every operating room open. I needed every scrub tech, every nurse, every perfusionist, every anesthesiologist, every surgeon—they all need to get here right away.
I thought I'd misread the article, maybe I still have, but this sentence seems to back up the claim no MCI plan was already in place.
It may be a product of our troubled history and extensive threat of terrorism (including the Irish dissident threat) but here in the UK Major Incident Response planning is practised extensively, and not just for medical emergencies. Planning is in place at almost every level to deal with such incidents. Almost every large institution, let alone just hospitals/emergency services, will deliver a 'Major Incident Response plan' (just Google 'Major Incident Response Plan UK' and you'll get many many examples), which will almost universally include a Mass Casualty Response Plan.
Indeed, there is even an NHS Tactical Command Framework in place to deal with Mass Casualty Incidents that will usually span several local health trusts and setup a coordinated response framework dedicated to responding to incidents like these.
Equally, all local governments departments have well rehearsed responses, integrating tightly into the UK's Gold/Silver/Bronze Command response coordination structure. Usually our emergency services, military and hospitals will have physically practised inter-operability via joint exercise and will utilise other joint working practices like JESIP and the METHANE reporting system.
I know for a fact the US follows the very well planned ICS system which links into both FEMA and local/state level emergency planning. I find it absolutely unfathomable that no well rehearsed and fully scoped plan of similar thoroughness to the UK was ready to go and instead this doctor simply made it up on the hoof.
Despite my own disbelief, it seems this Dr. actually did have to make it up as he went along - what an amazing, stunning personal achievement, and what a devastating systemic failure.