planning for disaster

Monday, April 15, 2013

Joy is stolen in a moment. Cheering crowds give way to fear. The thrill of finishing the Boston Marathon is overtaken by the horror of bomb explosions. The medical teams who train to care for runners with dehydration and exhaustion change to triage medics. Paramedics, waiting behind the finish line, rush toward victims. Crowd management plans used to protect runners are replaced by disaster management plans to care for mass casualties. Terror causes chaos.

The initial chaos of a multiple casualty incident is expected and usually lasts 15-20 minutes while command centers are established and paramedics and first responders arrive at the scene. It is followed by the organization phase that can last a couple of hours as the injured people are triaged, treated and then transported to hospital. The final stage of site clearing can take a variable amount of time depending upon the disaster. The area needs to be made safe and it may be a slow process to allow normalcy to return. In Boston, the chaos phase was likely shortened because of the number of police and medical teams already in the area to care for runners and control crowds, but it takes time to set up communications and match injured victims to the appropriate hospital.

While there were larger numbers of injured because of the bombing, it could be considered a multiple casualty incident where the “patient care resources are overextended but not overwhelmed” (American College of Surgeons: Advanced trauma Life Support for Doctors). The medical facilities in the city could ramp up care for the scores of injured and still look after their normal patient load. This differs from Hurricane Katrina, a mass casualty event, where there is no hope that the medical system can cope. This difference is first felt with on scene triage. In Boston,that triage, the sorting of patients, is meant to get care to the most critically injured or ill as soon as possible. In Katrina, the triage goal is to save the most number of people. Those injured who are unlikely to survive, are given comfort measures only, while those who are salvageable get more aggressive care. In mass casualties, the most injured are allowed to die.

Disaster drills are practiced in individual hospitals but coordinated plans in place for cities and regions so that agencies, from police, fire and ambulance services to hospital ERs and ORs, can coordinate and practice a response to a disaster yet to come. The system needs to have a command center on scene that can direct patients to the proper place. Some hospitals provide burn care; others specialize in major trauma while others can care for the walking wounded. And yet, each hospital has its own daily load of patients. The ability to handle the crush of five, ten or more critically ill and injured patients may be overwhelming. The command center on scene needs to know when one hospital has reached a breaking point so that patients can be directed to another with available resources.

It may not make headlines, but logistics and traffic control are the keys to saving lives. It comes with practice and planning. Information about patient severity is matched with hospital resource availability. Ambulances need to be able to navigate the disaster scene, not an easy exercise when the streets are filled with runners, spectators who have panicked, and good Samaritans rushing to help. Information flows in many directions. Hospitals need to know who is coming; the public, relatives and friends need to be informed.

In the hospital, patient flow is also important. The first wave of critically injured patients need to be cleared to the OR and ICU, making room for the flood of later arriving victims. They may have been stabilized at the scene and can literally arrive by the busload (ambulances will be allocated to those first wave victims) with non-life threatening injuries like lacerations and fractures. Hospital staff is mobilized. It is not only doctors and nurses that are needed, but as important are the operating room crews, lab and x-ray personnel, central supply technicians that sterilize and supply equipment, housekeeping and laundry. At the scene, video captures people running to help and then same occurs in the hospital. Staff come in to help and may not go home for days.

The aftermath of a disaster takes a long time to clean up, whether it is on the street or in the ER. Ambulances need to be readied to return to the street. Operating rooms need to be cleaned, medications restocked, cupboards filled. Personnel need to regroup. Incident debriefing may be needed by some, family consolation by others. The system needs to get ready because another patient will fill the gurney and need the skill and caring of the medical crew.

Marathon day is a celebration for runners who have spent months training for that one special day. Disaster teams also spend years practicing their response to an event they hope never arrives.


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