Training Surgeons for Disasters

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Arron Daniel
5 years ago
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1 SURGICAL RESPONSE TO DISASTERS Training Surgeons for Disasters M. Margaret Knudson MD, FACS Chief of Surgery, San Francisco General Hospital and Trauma Center A MASS CASUALTY EVENT IS NOT JUST ANOTHER BUSY NIGHT IN AN URBAN TRAUMA CENTER! ACS/COT Mass Casualty Management: A Weekly Event Propper et al: Annals of Surgery 2009 Elster et al: Implications of Combat Casualty Care for Mass Casualty Care, JAMA

2 4 Operating Rooms: 2 pts each Surgical Response in Boston Amputations Vascular Injuries Senior Visiting Surgeon Program Response in Haiti: ACS Operation Giving Back Massive Destruction US Naval Response 2

3 Asiana Flight 214 Departed from Incheon So. Korea for SFO Boeing 777 aircraft 307 passengers on board 70 Chinese high school students en route to summer camp in So. CAL 11:28 Crashed on final approach Plane Crash 3

4 Fate of the Passengers 181 injured passengers 12 critical: 10 SFGH/2 Stanford 2 deaths at the scene Several victims ejected out back Found on the runway still in seats 9 hospitals admitted 182 pts. Fate of the Plane Boeing 777 Held up Well Saturday 11:30 SFGH Trauma surgeon on-call for 24 hours Just finished making rounds Enjoying a Breakfast of Champions Powerbar and a Latte Courtesy call from ED: small plane crash 4

JULY 6 TH 2013; 12:30 pm First wave of injured patients arrive Six

Severe blunt trauma Two very unstable: taken to the OR within

Facial Burns, Inhalation*, Spine #2 Major intestinal, spine with

mandible, > 30% TBSA road burns #4 Extremity injury with

$sternum, extremity fractures 3 Waves of Patients Total seen at$

5 JULY 6 TH 2013; 12:30 pm First wave of injured patients arrive Six critical condition Burns and Inhalation injuries? Severe blunt trauma Two very unstable: taken to the OR within minutes PATIENT CRITICAL INJURIES: FIRST WAVE INJURIES #1 TBI, Facial Burns, Inhalation*, Spine #2 Major intestinal, spine with paralysis; road burns #3 Chest, intestinal, spine with paralysis, mandible, > 30% TBSA road burns #4 Extremity injury with compartment Sx #5 Severe TBI, spine, sternum, ribs #6 TBI, spine, sternum, extremity fractures 3 Waves of Patients Total seen at SFGH: Adults 31 Children 36: Admitted Keeping track of patients/injuries Singular focus: Doing the right thing 5

OPERATING ROOM: FIRST 48 HOURS Other Unique Challenges

$of fracture; fasciotomy Damage control laparotomy; burns$ $Other emergencies Hand fracture Appendectomy Stab wound to$ $the abdomen Wrist fracture Craniotomy Wound debridement$ supply: >100 U Judicious monitored use Chance Plus One

supply: >100 U Judicious monitored use Chance Plus One

$intestinal injuries and spine fractures Most commonly seen$

6 OPERATING ROOM: FIRST 48 HOURS Other Unique Challenges Crash Related Damage control laparotomy; burns Reduction of fracture; fasciotomy Damage control laparotomy; burns Laminectomy; spinal fusion Spinal decompression Craniotomy Spinal fusion Take-back laparotomy Take-back laparotomy Other emergencies Hand fracture Appendectomy Stab wound to the abdomen Wrist fracture Craniotomy Wound debridement Wound debridement Infection Fracture Fracture Blood bank supply: >100 U Judicious monitored use Chance Plus One Chance Fractures: A Rare Occurrence Combination of intestinal injuries and spine fractures Most commonly seen with lap-belt use Severe flexion over a fixed object Most common injuries:spine;chest 6

Potential Toxic Exposure Strange metabolic picture: acidosis, hypocalcemia; hypotension

Hydrogen Fluoride Inhalation Injury: Fire Suppression System Fire suppression System:

binds Ca++: liquifaction/cardiac arrthymias 3/5 soldiers died: survivors treated with

wound care/skin grafts Cardiac arrhythmias, low Ca++, low platelets Renal failure: CVVH

7 Potential Toxic Exposure Strange metabolic picture: acidosis, hypocalcemia; hypotension Persisted for days among survivors Toxic exposure: jet fuels, foam, cargo? Hydrogen Fluoride Inhalation Injury: Fire Suppression System Fire suppression System: HFC-227/US military Converts on heating to HF HF: devastating inhalation injury Fluoride binds Ca++: liquifaction/cardiac arrthymias 3/5 soldiers died: survivors treated with nebulized Ca++ Other Major Challenges Damage control surgery/multiple take-backs Road Burns : wound care/skin grafts Cardiac arrhythmias, low Ca++, low platelets Renal failure: CVVH Intestinal Fistulas Intra-abdominal infections Emotional Stress: Families 2 deaths at the scene Different Customs and Cultures and Languages 7

8 Other Unique Problems Children without parents Families separated by acuity No one had been through customs! Homeland security: set up in cafeteria Media Accurate and regularly scheduled updates They will be there for days camped out One death in our hospital: Black Friday The Tail Goes on for Days/Weeks and Months Long after the press goes home.. And the public almost forgets.. There are still critically injured patients Require multiple surgeries, rehabilitation Decompression for the Team: July!! 8

9 China s Zhejang Province 9

Director, Burn Center MetroHealth Medical Center Professor of Surgery Case Western Reserve University

Director, Burn Center MetroHealth Medical Center Professor of Surgery Case Western Reserve University BLAST INJURY Which of following statements concerning blast lung injury are FALSE? 1)Blast lung injury