SPA Annual Meeting Reviews
Session I: Mass Casualty Events-Prepare and Practice
By Elizabeth Yun, MD
The 2019 SPA Annual Meeting took place on October 18, 2019, in Orlando Florida. Dr. Meera Gangadharan from Galveston, Texas moderated the first session: Mass Casualty Events-Prepare and Practice and introduced three speakers who experienced, and help manage, their hospital's response to mass casualty and natural disaster events.
The first speaker, Chadwick P. Smith, MD, trauma and acute care surgeon at Orlando Regional Medical Center (ORMC) gave the first lecture, Drills: Before and After the Orlando Pulse Nightclub Shooting. He described how his hospital managed the mass casualties from the Pulse nightclub shooting on June 12, 2016. ORMC, a Level 1 trauma center in central Florida cares for 5200 patients annually and is located only two thousand feet from the nightclub. Earlier in the day the hospital had about 400 patients and the ED was half full and busy that night. He was the attending trauma surgeon on call when the emergency room resident notified him at 2:00 am that 20 patients with gunshot wounds were coming from the club. Dr. Smith then gave a very detailed story of the large number of patients that arrived in a very short period of time to the emergency room.
At 2:14 am the first patient arrived awake with gunshot injuries to the abdomen. Before they could even get this patient to the OR, a critical patient with a large chest wound arrived at 2:15 am and needed resuscitation. Within six minutes from the time the first patient arrived, four patients in total had arrived. At that point, Dr. Smith called for backup surgeons. The Orlando police then notified the hospital that a shooting with over twenty gunshot victims had occurred. He immediately called for all his available colleagues and residents to come in and the Incident Command was activated to bring in the administrative team. Ten minutes into the event, there were seven patients, and three deaths, with more patients still coming. By 2:30 am, the five trauma bays started to get overwhelmed by the number of incoming patients. Twenty minutes into the event, they had seven dead patients, including one who died in the elevator on the way to the OR. In less than thirty minutes, nine patients, who most likely would not have survived based on the severity of their injuries, had died. After that time, no more victims passed away.
By 3:10 am, the anesthesia and OR teams from ORMC had arrived. In addition, OR teams from Arnold Palmer Hospital for Children and Winnie Palmer Hospital for Women and Babies came to ORMC to help. They staffed four operating rooms in 40 minutes and six rooms in 120 minutes after the start of the event. At 3:25 am an active shooter rumor in the triage area emerged and police came to the ED to protect the staff. However, back up personnel needed to be redirected so they would not be shot by the police patrolling the area. This first wave of patients had 38 total victims arrive in 53 minutes. At 4:00 am all patients who were not hostages in the nightclub had arrived. That pause provided time to restock equipment and supplies and environmental services as well as the opportunity to clean the trauma bays. Because of all the preparations in the past no one suffered a needle stick or blood exposure injury. At 5:00 am, the second wave arrived.
Dr. Smith showed a slide that summarized the statistics of the shooting: 36 victims in 36 minutes, 29 operations in the first 24 hours, 54 surgeries in the first week. There were 417 team members who responded; 441 units of blood were used; thirty-five survivors and nine fatalities.
Dr. Smith then discussed considerations for disaster management in the second half of his lecture. For ORMC, the key to the success for managing mass casualty events was to anticipate and plan the response to situations and practice that plan many times. In these scenarios the mindset has to change from using unlimited resources for one patient to one of doing the most good for the most patients with limited resources. He defined mass casualty as the point when resources are overwhelmed so one needs to practice to a level of sufficient care versus the standard of care. This level of care varies for each hospital depending on their resources. The importance of practicing the mind shift from standard to sufficient care since healthcare providers are not used to that way of patient management. The entire organization needs to practice to the point of failure to learn the most from these drills. A critical part of these mass casualty plans is to create leaders experienced in dealing with these situations. However, that knowledge needs to be developed, an aspect of training not always addressed in residency programs.
Dr. Smith discussed several studies that demonstrated that the best model for developing comfort in these situations are disaster drills that need to be practiced multiple times, utilizing real case reviews. ORMC does extensive drills which played an important role in the management of the Pulse nightclub shooting. He pointed out other important aspects of disaster management. Local community relationships, like the police and fire departments, need to be developed and nurtured as part of the planning. Since family members of the victims will go to the hospital first for information, a management plan needs to provide ways to assist families with getting information, reunify with or help identify victims and offer support and comfort with the stress of grief. Hospitals also need to coordinate and handle both traditional and social media. He told the story of how his chief resident posted a picture of his shoes the next day on social media and by that evening the picture had made the national news on NBC. He stressed the importance of providing help to all members of teams as they deal with the psychological trauma of the situation. He discussed the lessons learned that included the need to practice and adapt a plan, watch for law enforcement lockdown and other barriers that prevent hospital staff from joining the team inside the hospital, and bringing teams from sister hospitals to help with the OR, personnel, and outsourcing labs and other tests.
Dr. Smith emphasized three important factors for disaster management: preparedness, culture and collaboration. He concluded by stating that this event changed Orlando forever.
Brent Kaziny, MD, an emergency room physician and Assistant Professor at Texas Children’s Hospital/Baylor College of Medicine (TCH), presented Texas Children’s Hospital and Hurricane Harvey: Unique Challenges to Continuing Operations in the Face of Disaster. He used the story of TCH’s management of a natural disaster to discuss the importance of pre-planning in the creation of an 'all hazards' preparedness plan, the hazard vulnerability analysis and its importance in prioritizing institutional efforts for preparedness, and the effects of Harvey on OR caseload. Hurricane Harvey was one of the first natural disasters to affect the Texas Medical System, a large system of hospitals including TCH. He stated that the first step in emergency management plans is the support of hospital administration. As an example, he described how the flood mitigation systems in TCH allowed the hospital to function during Tropical Storm Alice in 2001 while other hospitals in the system without flood mitigation became non-operational. Based on that experience, the hospital system administration invested in flood mitigation for all hospitals.
Dr. Kaziny then explained the importance of drills that test for and create a safe space to practice failures to find the weak links in an emergency disaster plan. He emphasized the need to identify and practice drills for each type of threat. He described the Hazard Vulnerability Analysis, a tool developed by Kaiser Permanente, that identifies threats to a specific location and the likelihood that the threat will happen. The analysis measures the impact on three categories: injury and death, property loss and damage, and interruption of services. The tool scores the changes to be made in preparedness, and internal and external responses. From this analysis, a system can determine the most likely internal and external threats and create a management plan. From the analysis, TCH identified hurricanes as a high external threat and active shooter as the top internal threat. With this information, TCH started a system-wide annual hurricane drill to test the system and find weaknesses that needed improvement. While they were prepared for the initial event, they realized that they needed to focus on what to do for the immediate and long-term recovery period after a hurricane.
He then reviewed how they incorporated their training into the management of Hurricane Harvey. On August 23 and 24, they were notified of a potential hurricane and started executing their plan. First steps included opening their command center, and stocking up on supplies like water and fuel. They organized and prepared hospital staff to stay at the hospital for a predicted storm duration of five days to ensure adequate staffing and to prevent staff from coming to work in hazardous conditions. On August 27, the storm hit, followed by a reprieve on August 28. However, concerns of failing reservoirs led the army corps of engineers to do controlled releases that led to more flooding. By August 31,the urgent care clinics were back up and running although it took longer to get the outpatient clinics open. Overall, a total of 51 inches of rain fell in the area.
Dr. Kaziny reviewed the impact the storm had on operating room volume. There were 432 cases cancelled, of which 80% were outpatient cases due to weather/traffic related issues. He discussed several things that worked well. There was a system-wide culture of preparedness with annual training. They had the right people in the right place at the right time. They had designed policies and procedures to assist the staff with dependent care issues. They had formed good relationships with their regional partners to help them deal with families and patients with complex care issues that presented during the storm. Dr. Kaziny concluded that preparedness came down to identifying threats, drilling for failure and working on a plan that people have trained with many times.
Mohammed Iqubal Ahmed, MD, Associate Professor of Anesthesiology, Children’s Medical Center, University of Texas Southwestern Medical Center gave the final lecture in this session, What Anesthesiologists Should Know about Children in Disaster. He reviewed the unique ways (anatomic, physiological and psychosocial) children are more vulnerable in natural and man-made disasters, analyzed the challenges for anesthesiologists caring for these pediatric victims of disasters and how tools such as checklists can be utilized. He noted that in mass casualty events, both natural and man-made, children comprise 35-40% of the victims. Children have unique needs and characteristics that healthcare professionals need to remember when treating these patients in disaster situations. A small absolute blood loss can be devasting due to their blood volume. They experience a greater transmission of force per unit area and more vulnerability to toxic gas exposure since these gases exist closer to the ground. They are prone to head injuries because their heads are proportionally larger and heavier.
The brain is vulnerable to penetrating trauma and incompletely calcified bones are subjected to orthopedic injuries that are easily missed. The thoracic cage does not protect the heart, lungs and upper abdominal organs leading to hemorrhagic shock. The mediastinum is very mobile leading to increased risk of tension pneumothorax. Their larger body surface area to mass ratio leaves them at higher risk for burn injuries, hypothermia and skin absorption of toxic chemicals. Children can maintain blood pressure in early stages of shock with increased heart rate so knowing normal vital sign ranges is important. Ventilation characteristics mean children can have rapid exposure to larger doses of inhaled biological and chemical agents and they are more slowly cleared. The immunological system is not mature and more susceptible to infection, so infection control is vital for any disaster plan.
Other unique pediatric concerns include the loss of caregivers that leave children unable to escape or survive in these scenarios, no one to provide a child’s medical history or a legal guardian to give informed consent. Children with complex medical needs are especially vulnerable and special consideration is required in pediatric disaster planning in both the community and health system. Other considerations include a hospital’s comfort level in caring for a specific age group in resource-limited settings and the emotional impact on healthcare providers caring for badly injured children. Managing pediatric disasters needs planning at every phase: mitigation, preparedness response and recovery, and requires hospital administration support.
Dr. Ahmed discussed the importance of anesthesiologists being involved in disaster planning and using their skills of anticipation, vigilance and decision making, plus becoming familiar with the OR and ICU. Anesthesia departments will be required to participate in disaster response care for children. He described the many resources available to assist anesthesiologists with education and preparation. The Emergency Medical Services for Children developed by EMSC national resource center in Washington DC complements existing resources in hospital preparedness and defines 10 pediatric-specific domains. The ASA COTEP (Committee on Trauma and Emergency Preparedness) has information on the ASA website to improve the care of patients with traumatic injury and educate anesthesiologists in disaster management. He recommended the MADOM (Manual of Anesthesia Department Operations and Management) that can be downloaded from the COTEP website, although it is not pediatric-specific.
Another resource from COTEP is the Operating Room Mass Casualty checklist to help manage the flow of patients to the OR in a mass casualty incident. Steps in the list include consulting the hospital’s emergency plan, activating the call-in tree, assessing the OR status for 0-2 hours, 2-12 hours, 12-24 hours and holding elective cases. ORs with cases need to finish and prepare for trauma. Other important steps include reporting the OR status to the hospital Incident Command, getting adequate supplies, preparing PACU for a large number of patients, and assigning senior anesthesia clinical staff to the ED to see what is going on and report back to the OR coordinator. Coordination with blood bank, and other patient care areas (ICU, OB, specialty area) should be done.
Dr. Ahmed emphasized that adult only hospitals also need to be prepared for pediatric cases since they may need to care for these patients and conversely, pediatric hospitals need to be prepared for adult trauma, by having supplies, staff and space to care for adults. He concluded with his experience at the Boston Marathon mass casualty event in 2013 when a bomb exploded at the finish line. A total of 264 people, adults and children experienced blast burns and shrapnel injuries and three people died. Several factors helped with the successful management of the injured. EMS distributed the injured evenly among nearby local hospitals. Tufts NEMC, where Dr. Ahmed was practicing at the time, got 18 people, five who went to surgery. Boston has done citywide emergency drills since 9/11 so the city was prepared. The late afternoon timing of the event meant that extra staff were available. Many of the local hospitals near the site were Level 1 trauma centers for pediatrics and adults and were ready to deal with these patients. There was an extensive and well organized medical volunteer system at the finish line that used tourniquets and other techniques to initially stabilize patients.
Dr. Ahmed concluded by stating that anesthesia departments need to plan and prepare to care for the unique concerns of pediatric disaster victims.
Websites from Dr. Ahmed’s lecture:
- ASA Trauma and Preparedness https://www.asahq.org/in-the-spotlight/trauma-and-emergency-preparedness
- US Department of Health and Human Services https://asprtracie.hhs.gov/technical-resources/31/pediatric-children/0
- Disaster Information Management Resource Center https://disasterinfo.nlm.nih.gov/children
- American Academy of Pediatrics https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/default.aspx
