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Mass Casualty Management Dr.Anil Haripriya
A disaster comprises a sudden massive disproportion
between hostile elements of any kind and the survival
resources that are available to counterbalance these
in the shortest period of time. Disaster is a calamity or
a sudden misfortune. Accoring to Colin Grant (1973) ,
disaster is a catastrophe causing injury and illness to
30 or more people. By WHO definition a disaster is
any occurrence that causes damage , economic
disruption, loss of human life and deterioration o
health and health services on a scale suffecient to
warrant an extraordinary response from outside the
affected community or area.
Classification:
Disaster can be classified as follows:
1. Natural Disorders- earthquakes and volcanic
eruptions (beneath earth surface)
2. Land slides, evalanches (at earth surfaces).
3. Windstorms ( Cyclones, typhoon, hurricane)
4. Hailstorms, Snowstorms, sea surges, floods, droughts.
5. Biological Phnomena; Locust swarms, Epedemics of diseases.
6. Man made disorders- Conventional warfare, Nuclear, Biological and Chemical warfare.
7. Caused by accidents- Vehicular ( Plane, Train, Ship, Boat and Bus)
8. Drowning , Collapse of building, explosions, fires, biological and chemical ( including poisoning)
In mass casuality situations , the demands always
exceeds the capabilities of both personnel and
facilities. The concept of mass casuality management
has occupied the attention of surgeons since the 17th
century. War casualities and sailing ship disasters
were the prime concerns in those eras. Over the last
decades , the spectrum of possible catastrophe has
dramatically increased as result of an increasingly
techonogically sophisticated society. In every
hospital , it is necessary that the hospital emergency
services should function well . Disaster management
is an extension of emergency or casuality services.
Reduction of immediate mortality and morbidity is the
paramount objective. Team work at all levels is
essential to the successful management of a mass
disaster.
General Principles:
Disaster generally involve a significant number of
casualities in a localised region over a limited period
of time. Specific modifications are necessary if the
optimal salvage is to be obtained. In today’s rapidly
expanding mobile society no geographical distribution
is exempt from the possibility of any disaster including
a nuclear accident. Realastic advance planning is the
keystone to successful management of mass
casualities. A general estimate of the number and type
of casualities resulting from specific disasters can be
obtained and appropriate advance planning carried
out. In most civilian disasters , much of the inured
populationwill suffer multiple inuries after a
combination of thermal and blunt trauma.
Thermonuclear explosions may yield a large number
of patients with extensive radiation damage and
thermal injuries, but relatively few peneterating
injuries.
General principles which should be included in the
structure of the disaster plans are as follows:
1. The basic disaster plan should include the basic
principles of mass casuality management which
should be applicable to all the catastrophes. Specific
injuries involved in the disaster should be dealt
separately in the secondary plans. Essential
components of the disaster plan are:
a. Criteria for designation of a disaster situation.
b. Authority for initiation and implementation of the
disaster plan.
c. Mechanisms for implementation of the disaster
plan.
d. Communication network.
e. Triage
f. Transport of injuries.
g. Riot and/ or crowd control.
2. The system should be flexible enough to
withstand the challanges of all types of disaster.If the
burn centre is not there, the possibility of handling
burn victims should be kept and appropriate
arrangement to transfer these patients to Burn Centre
should be made.
3. The plan should be realistic from the angle of
capability of medical fraternity to the response of
catastrophe.More sophisticated therapeutic
interventions must be avoided. Sophisticated
techniques such as microvascular surgery requiring
the extended services of highly trained surgeons,
complicated equipment and supplies should be
avoided. These services no doubt enhance the quality
of life but quantity of life is decreased in the mass
casualities.
4. The communication system should be such that
the appropriate resources can be mobilized quickly to
meet the demands.
Mass Casualty Planning:
This has following components:
Community Planning
Planning of disaster is the responsibility of all the
segments of casuality. Participitation of the police, fire
department, civil defense units, press industrial
groups, religious leaders and community groups is
required to formulate the predisaster planning so as to
make the functioning of plan effecient.First aid
courses should be tought to the groups of the
community to be utilized in the disaster situation. First
aid teaching should stress on the techniques of
emergency care which do not require the equipment ,
supplies and trained personnel because these
facilities may not be available at the site. Other
important points which should be considered are:
1. Location of the disaster is always unknown.
Control Room site and location of site for collection of
casualities should always have primary site and
alternate arrangements.
2. Disaster plans have two systems :
a. The trauma team is transported to the site of
disaster with emergency mobile hospital facility.
Except in the selected disasters it has disadvantage
that there is time lapse between the occurrence of
disaster and arrival of the medical team. If the
medical personnel are shifted to the site there may be
shortage of the medical staff in the hospital where
their services may be utilized in a better way.
b. The trauma team is available in the hospital and
the disaster victims are transported to the hospital by
the skilled paramedicals after preliminary triage. This
option has better utilization.
3. Many injured victims remain at the site of
disaster, while severly injured are transported to the
hospital.Community planning should provide for
necessary personnel and supplies to look after these
victims.
4. Provision for food, clothing and housing for
nonhospitalized victims are a major stress on the
community. Coordinated community plan would
prevent these chaos.
5. Normal communication network may be involved
in the disaster. Predisaster planning must include
alternate mode of communication to initiate and
implement the disaster plan. Two-way radiosystems
and messenger systems should always be included in
the plan in the event of communication failure.
6. Community planning should include the initial
triage and transport of victims to the hospital. In
hospital transfers to meet the specific injury need
should be included in the plan.
7. Riot and / crowd control . Mechanisms for
accesss of medical team to the victims in the hospital
and disaster site should be included in the plan. All the
factors which can prevent easy access may be looked
into during plan.
Hospital Planning
The Disaster Committee
All the hospitals should have a well designated
disaster committee comprising of both medical and
nonmedical reprentatives. The committee should
formulate the disaster plan that should be flexible, and
able to meet any disaster situation. In the hospital site
for the management of the disaster victims should be
identified which may near to the emergency services.
Hospital facilities in terms of equipment, trained
personnels and management of trauma patients
should be reassessed by the committee.
The disaster plan must be tested from time to time i.e., minidrills at least twice in a year in conjunction with the other community services. Hospital disaster committee has the responsibilty of dissemination of the plan to the community and as well as in the hospital personnel. The local personnel must be trained to receive the following medical emergencies.
* Haemorrhages
* Dislocations
* Cardiovascular failure
* Burns
* Respiratory distress
* Exposure to toxic substances
* States of shock
* Electrocution
* Skull injuries
* Drownings
* Fractures
* Cases of accidental hypothermia
The types of emergency vary according to the type of
disaster and how and when it strikes. The disaster
plan director should be a medical personnel
experienced both in adminstration and trauma care .
He is finally responsible for the activation of disaster
plan in the event of catastrophe. Disaster alert has to
be activated by the authorised personnel. There are
three phases of disaster alert.
Phase I alert allows the identification of of an incident
with the potential for a major disaster.Bomb hoax in a
crowded place or leakage of toxic gas from an
industry are the examples of situations for phase I
alert.
Phase II alert indicates that catastophe has occured
and that there are injured victims in the disaster.
Phase III alert designates a disaster situation in which
large number of the disaster victims would be arriving
at a particular designated hospital. Each phase
implies the need for mobilization of personnel and
supplies , transport and provision of hospital beds for
disaster victims. A mechanism for rapid discharge of
hospital indoor patients is important for an effective
disaster plan.
The disaster plan should have the following features:
a. Should be simple and understandable by all.
b. Flexible and fit different types of disorders.
c. Clear and concise - even in noise and
confusion, hospital staff should be able to act upon it
instantaneously.
d. Adoptable during all hours - day and night
including holidays.
e. Extension of normal hospital working so that
people can act upon it immediately in a routine
manner.
Plan Parameters:
a. Distribution of Responsibilities:
The hospital should develop action cards mentioning
the responsibilities of various departments and
personnel involved - adminstrators, medical officers,
incharge casuality, matrons, nursing officers,
telephone operators, clerks, messengers and ward
boys.
b. Chronological:
Initial alert can be by television, telephone, persons
and wireless ; the place and time of accident and the
type of casualities should be clearly communicated.
Based on the above, the hospital plan would be
activated. The medical officers, hospital adminstrator,
controller, the switch board operator should notify the
key personnel, particularly the department of
radiology, operation theatre, blood bank, laboratory,
medical stores, dietory, security, ambulances and the
matrons. The nursing officer should make all the
arrangements in the wards for receiving the
casualities. Maximal number of all the staff in the
above department should be available and on duty
within 10 minutes of the call. The coordination and
control for disaster management should be as
follows:-
The medical superintendent / director would be
responsible for determining the priority for treatment
and evacuation / distribution. He would instruct the
medical officers and make adequate OT
arrangements. The nursing officer would be
responsible for allocation of the nursing and
paramedical staff, deployment of staffand recall of
staff from hostels and homes. The adminstrative
would be responsible to deal with the relatives,
friends, public relations, fire brigades, police and
handling as well as utilization of voluntary workers.
The clinical and OT departments would be responsible
for clinical investigative and therapeutic activities.
Problems in Disaster Management
a. Clinical:
Lack of professional staff , iinvestigative facilities,
drugs, facilities for contaminated casualities,
decontamination, isolation, protective clothing
availibility and usage by the clinical staff.
b. Adminstrative:
Documentation of the injured - consciousness ,
unconsciousness, classification, nature of the
treatment given, documentation for police,
communication to various bodies, telephone, telex,
fax, and other other facilities, communication to
friends and relatives, conselling and support to the
relatives and friends, control of the crowd, voluntary
workers, protection of the patient properties, nature of
infirmation to be provided to the Press and
Broadcasting services , disposal of the dead, post-
mortems and protection of the bodies of VVIPs,
mortuary facilities.
The Triage System:
Triage implies the categorization and distribution of
casualities so as to establish the priority and proper
treatment. One of Senior Medical officer should be
authorised to coordinate the triage and transportation
of victims at the disaster site. Another disaster plan
director or his representative of the rank of Senior
Medical Officer should be made responsible for the
initial assessment of the injured patients and
assignment of appropriate treatment area.. Close to
the emergency room a well definedarea should be
demarcated for triage so that the treatment facilities
are not interfered with.In the nonoperative treatment ,
adequate resuscitation and prevention of further
complications should be the principle. Proper splinting
and immobilization of the injuries of spine and
extremeties will allow definitive treatment to be done
at the apprpriate elective time.In the operative
management , stress should be given for life saving
procedures only in mass casuality management so as
to reduce the mortality. Adequate debridement and
control of haemorrhage are important in the initial
management of mass casualities.
Three factors are essential components of effecient
triage system : Identification, Communication and ,
transport.
1. Identification: Casuality categorization not only
includes the initial evaluation of the injuries but
assigns a value to the injury relative to the mass
casuality situation. A simple method of identification,
such as a tag or identification band tied to the victim,
transmits information regarding patient identification ,
diagnosis, categorization and therapy. One of the
methods for disaster categorization widely used is as
follows:
Category I - Green Tag: Casualities requiring minimal
treatment as outpatients or requiring domicillary care.
Category II - Red Tag: Casualities requiring
immediate treatmentand whose chances of recovery
are good after immediate definitive care ( e.g.,
Compound fracturs, readily controllable haemorrhage
and correctable mechanical respiratory distress etc. ).
Category III - Yellow Tag: Casualities requiring
treatment but who could tolerate delay, with the
chances of recovery considered good after definitive
care ( e.g., blood replacement, closed fractures,
limited thermal injury ).
Category IV - Blue Tag: Casualities requiring
expectant treatment , with poor chances of recovery
because of the magnitude of injury and /or because an
excessive commitment of personnel and material
would be required.
Other method of categorization is as follows:
A. Those who must be sent urgently to the nearest
properly equipped hospital. Among these two orders
of priority may be distinguished:
A 1. Emergency cases that must be operated within
the hour :
* Acute cardio-respiratory insuffeciency
* severe haemorrhages
* internal bleeding
* rupture of the spleen
* injuries to the liver
* severe chest injury
* severe cervico-maxillary lesions
* state of shock
* severe burns ( over 20% )
* skull injuries with coma
A 2. Emergency cases in which it is possible to wait
a few hours before operating:
* ligatured vascular injury
* intestinal injuries, severe haemorrhage or
shock
* open joint and bone injuries
* multiple injuries with shock
* injuries to the eyes
* extensive closed fractures
* less severe burns
* skull injuries without coma
B. Those given attention on the spot. Priority is
given to the most serious cases with a chance of
surviving: there are those who are attended to while
waiting to be shifted to a specialised centre and those
who do not need major medical care and can be
treated on the spot.The B group also includes very
serious cases with no chances of survival that it would
be pointless to move.
2. Communication: The established
communication network must be functional. Rapid
notification of both medical and nonmedical support
groups about the activation of disaster plan is
essential for successful management of mass
casualities.There is provision of central
nondesignated manpower at the discretion of director
for specific disaster needs. Communication system
must allow for continuous reassessment of utilization
of manpower and equipment during the duration of
disaster. There should be effective communication
network between the disaster site , transport vehicles
and referral facilities such as hospital are essential in
meeting the changing demands of the disaster
situation.
3. Transport: A disaster plan must provide
alternative mode of transport if ground transport
cannot be used. Suffecient air transport , often
involving the use of military facilities, must be
available. Mechanism for availing such facility for rapid
mobililization must be well defined.
Medical Supplies and Equipment
Hospital should be well prepared to maintain
reasonable quantity of stored supply and equipment
for use only in mass casualty management. These
should include intravenous lines, solutions, dressing
supply, airway equipment, anaesthetic agents,
drainage tubes such as chest tubes, nasogastric tubes
and urinary catheters, splints and drugs. There should
be well established procedures for procuring
additional requirement of blood and blood products
and facilities for emergency blood donation.
Hypovolaemia is one of the important cause of
mortality in the victims of disaster who arrive live in the
hospital.
SPECIAL CONSIDERATIONS:
Anaesthesia. There is overwhelming demand of
anaesthesia in terms of personnel and time utilization
in a disaster situation.There is increase in the regional
anaesthesia utilization in disaster situations. Regional
anaesthesia provides relief of pain for prolonged
periods and minimal central nervous system ,
respiratory and cardiac depression. Equipment for
regional anaesthesia such as drapes and kits are
sterile and disposable. Thus regional anaesthesia
facility can made available at the disaster site, during
transport or at multiple sites within the hospital
designated for care of disaster victims.
Morgue Facilities. Unfortunately , all disaster plans
must provide for a temporary morgue facility and
method of identification of dead bodies. Newer
modalities of identification such as antemortem dental
records and medical records by telephoto , are being
continuously invesigated for rapid identification of the
fatally injured disaster victims.
Nuclear Accidents. These are the worst disaster
situations of the modern society. There are no clearly
defined risks in both time and space in nuclear
accidents as compared to the many tradional disaster
like earth quakes, , floods and airplane crashes.
Nuclear accidents can increase the risk zone including
the hospital itself. Disaster plan must include the area
wise evacuation in the nuclear accidents.
Decontamination. Procedures for biological,
chemical and irradiation decontamination must be
included in the disaster plan before the arrival of
casualities at the collection area. The main objective
of decontamination is to obviate the spread of
contamination by disposing the clothing of victims,
treating the skin with the neutralizing solutions before
the victims reach the central triage area.
Conclusion:
Mass casuality management includes well organised
predisaster planning , assessment of disaster situation
to avoid chaos. Accurate assessment of of the
magnitude of the disaster can lead to the effecient
management of the disaster so as to lead to the
decreased mortality and morbidity. There should be
suffecient provision of personnel and logistical
support to meet the demands of the mass disaster.
Disaster plan should be flexible, adoptable to all types
of disasters and is the key to the success of
management of mass casualities.