Civilian Hospital Response to Mass Casualty Events The Israeli Experience
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1 Civilian Hospital Response to Mass Casualty Events The Israeli Experience William Schecter, MD Professor of Clinical Surgery University of California, San Francisco Chief of Surgery San Francisco General Hospital
2 Mass Casualty Events in Israel October 2000-January Events 71 Explosions (78%) 53 Open Space Explosions 1976 injured, 156 dead 37 injured/event, 3 dead/event 18 Closed Space Explosions 911 injured, 177 dead 50 injured/event, 10 dead/event Shamir et al. Anesth Analg 2004;
3 Mass Casualty Drill, Haifa July 2003
4 Mass Casualty Drill, Haifa July 2003
5
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7 Scene of the Explosion, January 29, 2004
8 Scene of the Explosion Magen David Adom Police Fire Army
9 Procedure at the Scene Secure the area limit access to the victims Identify additional terrorist operatives prevent a second hit Search for unexploded ordinance Extract and concentrate victims Airway, Breathing Immediate Evacuation of Victims with Life threatening injuries to hospital Distribute victims to various hospitals to avoid overloading any one hospital
10 Securing the Hospital- Traffic controlled and intersections approaching the hospital Commercial Center Knesset King David Hotel Israel Museum Old City Shaare Zedek Medical Center
11 All ambulances inspected at entrance to hospital
12 Sha arei Zedek Hospital 08:48: Emergency Room notified of terrorist attack ER cleared of patients Patients transported to corridors Aran Storage opened and emergency gurneys removed Front area of ER cleared for Triage Security Commander arrives
13 08:54: All emergency gurneys out of storage and triage area clear Triage physician in initial triage area 08:55: Hospital ready for casualties (7 minutes after report of explosion) Information received from field that 34 casualties will arrive
14 9 minutes after the explosion the Asst Hospital Director arrives to inform the Triage Officer (Hospital Commander) the number of free operating rooms available. Armed guards arrive to control entrance to the ER
15 09:00 12 minutes after the explosion, a representative of MADA arrives providing communication between field commander and hospital commander. Transport begins at approximatley the same time.
16 13 minutes after the explosion, a large number of worried citizens begin to arrive searching for relatives.
17 A large number of professional and nonprofessional volunteers arrive to help (and hinder!!)
18 At 09:06, the first ambulance arrives, 18 minutes and 30 seconds after the explosion Last ambulance arrives at 09:23 15 patients arrive within 17 minutes
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20 Secondary Triage by Senior Surgeon immediately within ER
21 Goal of Secondary Triage The Sickest to the Most Experienced Separate the Critically Injured patients (relatively few) from the large number of patients with non-life threatening injuries
22 Congested Trauma Room
23 Recovery Room Tertiary Triage/ICU Station
24 Delayed Care Each patient is assigned a physician (preferably a junior surgeon) and a nurse A senior surgeon is in charge of the Delayed Treatment area.
25 Walking Wounded One senior surgeon is in charge of this area The patients are managed primarily by nurses and junior doctors
26 Initial Triage Stations Primary Secondary Immediate Walking Wounded Delayed Tertiary OR
27 IMMEDIATE Use ATLS Principles Radiology OR ICU Expectant Ward Intra-hospital Triage
28 Time (min) RR ER CT D/C Hosp Xfer Ward OR Total
29 Terrorist Bombing Victims at SZMC Jan 1995-Jan victims of bombings 14 (1.6%) died during initial resuscitation 32 (3.8%) required ICU admission 160 (19%) admitted to ward 46 Severely Injured Patients
30 Spectrum of Explosive Related Injuries Auditory: Ruptured TM, Ossicular disruption, cochlear damage, foreign body Eye, Orbit, Face: Ruptured globe, foreign body, fracture, air embolus Respiratory: Blast Lung, Pneumothorax, air embolism, Pulmonary Contusion, Aspiration GI: Bowel Perforation, Hemorrhage, Solid Viscus Injury (blunt trauma), mesenteric ischemia (air embolus)
31 Spectrum of Explosive Related Injuries Circulatory: Myocardial Contusion, Myocardial infarction (air embolism), hemorrhagic shock CNS: Concussion, closed and open brain injury, stroke & spinal cord injury (air embolus), spinal cord injury (blunt trauma) Renal Injury: Contusion, laceration, acute renal failure (rhabdomyoslyis, ATN due to shock) Extremity Injury: amputation, crush, fracture, compartment syndrome, etc. Most common reason for surgery ttp://
32 Case 1 Primary Blast Injury 12 yo girl involved in bus bombing Feb 23, 2004 Admitted with sob but hemodynamically stable CT scan ordered 40 minutes after arrival Intubated in CT Scan Fresh blood suctioned from ET tube
33 Case 1 Infiltrates worsen CXR deteriorates Hemodynamic instability requires large infusion of crystalloid Gas exchange deteriorates, requires Fi02 100% and HFPPV
34 Case 1 Patient improves with HFPPV and diuresis Develops diplopia for unclear reasons which improves over 2 month period Returns to school
35 Case 2 Primary and Tertiary 73 yo former Pediatric Head Nurse Bus explosion Jan 29, 2003 Admitted with sob, chest pain Injuries: Flail chest Pulmonary contusion Fracture right humerus Traumatic bilateral finger amputations Partial thickness facial burns Blast Injury
36 Case 2 10 days of mechanical ventilation 1 month of in hospital rehabilitation Prolonged recovery at home
37 Significant Risk of Left Sided Air Embolism Caused by alveolar-pulmonary venous fistula due to disruption of alveoli due to primary blast injury Possible Patent Foramen Ovale Risk increased with positive pressure ventilation Clinical manifestations Blindness Hemiparesis Paraplegia Acute obstruction of other vascular beds
38 Case 3 Primary Blast Injury with Air Embolism and? Intestinal injury 14 yo boy admitted in shock, unconscious with ph 7.0 and pc02 70 Intubated in ER and moved immediately to RR (secondary triage) Resp Status improves CT Chest and Abd ok except for pulm blast injury CT head? Air embolus
39 HD3 BP becomes labile Vomits a small nail Abdominal rigidity develops KUB in the middle of the night suggests free air Dx of delayed intestinal perf due to blast injury or shrapnel injury Exp lap: NORMAL
40 Case 3 Condition at discharge: Left hemiparesis Extremely labile 2 months later Hemiparesis almost Completely resolved, playing soccer
41 Intestinal Blast Injury Jerusalem Bus Bombing reported in dead at the scene and 55 survivors 29 patients hospitalized 2 patients with perforated intestine with late presentation (delayed dx vs delayed perforation) Katz E, Ofek B, Adler J et al. Primary blast injury after a bomb explosion in a Civilian bus. Ann Surg 1989;209:484-8
42 Intestinal Blast Injury
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