Planning for major burns incidents in the UK using an accelerated Delphi technique

BACKGROUND: Major incidents require careful planning if they are to be managed well. Although a generic plan to deal with all major incidents is essential, a number of "special incidents" deserve special consideration because of their potential to impact on specialist services. This paper examines the problems of managing a major incident involving large numbers of burns casualties. METHOD: A three-round Delphi study was conducted using a multidisciplinary panel of experts from prehospital care, emergency medicine, burns surgery, intensive care and emergency planning. RESULTS: A series of consensus statements on the management of burns incidents are presented. An accompanying paper describes the practical implementation of this guidance. CONCLUSION: Specific consideration should be given to the problems of managing a major incident involving burns casualties.     

Australian major incident nomenclature: it may be a 'disaster' but in an 'emergency' it is just a mess

Background : A standardized major incident nomenclature has practical applications for medical communication and audit of the medical response to incidents. Methods : A telephone and fax survey of major incident nomenclature in State and Territory health service emergency management plans and ‘disaster’ legislation was carried out on 13 August 1999. Results : Within Australia there were a total of 13 different terms to describe incidents that could produce casualties: there were four definitions of the word ‘disaster’, eight definitions of the word ‘emergency’ and one definition of the word ‘incident’. Conclusion : Australia lacks a uniform system of classifying and recording mass casualty incidents. This prevents both the independent clinical audit of the medical response to an incident and the cross‐border comparison of the effectiveness of trauma systems to deal with multiple casualties. Australia’s geography highlights the need to develop a nomenclature that allows medical practitioners, in isolated environments, to accurately describe an incident and the medical support that is required. The Potential Injury‐Creating Event (PICE) nomenclature is a simple system to describe the functional impact of an event upon a community and the level of medical support required. It can be used to provide the basis for the uniform reporting of the medical management of major incidents within Australia.     

Der rettungsdienstliche Ablauf bei Großschadensereignissen Eine Untersuchung von 21 Fällen

Major incidents are high-profile events where many lives are at stake. The response of the health-care-related agencies has to be well-planned and co-ordinated, thus retaining the public’s confidence in the emergency services whilst efficiently responding to those in need. The communication between supervising officers such as medical incident officer (MIO) and ambulance incident officer(AIO) with the ambulance personnel is vital for the proper employment of doctors and ambulance teams at the incident scene. In Germany the experience gained at such events has not yet been collected into a single coherent and comprehensive analysis. This study investigates the delivery of ambulance vehicles and personnel at major incidents. Was appropriate emergency treatment and transport for each seriously injured patient possible? Were the communication structures between the supervising officers and the ambulance teams sufficient to provide effective co-ordination and utilisation of the teams at the scene? Methods: A major incident was defined as any incident with more than ten casualties. All central ambulance controls (CAC) in the five federal states Rhineland-Palatinate, Bavaria, Saarland, Hessen, and Baden-Württemberg were asked by telephone and mail if a major incident had occurred in their area from September 1992 to September 1994. In cases of major incidents in other federal states of West Germany during that period, the appropriate CAC was contacted to collect data. A standardised questionnaire was send to the CACs. The data were split into chronological periods of responses to major incidents. Results: Twenty-one major incidents were included in the study, 11 of them road accidents. The mean time to arrival of physician-staffed ambulances at the scene was calculated as 20 min after alerting of the CAC. In 90% of all cases enough physicians were available to treat each seriously injured patient (NACA score 3–6). In 9 cases a MIO and an AIO were sent out. Their mean time to arrival at the scene was 25 min after alerting of the CAC. In 19 cases (90%) enough ambulance vehicles were provided to rapidly distribute all casualties. With one exception, this was also true for the use of helicopters. On-site communication of the ambulance staff was always by direct personal contact. In 38% of all incidents the arriving ambulance staff had difficulties in contacting senior officers, and thus, nobody defined their roles and responsibilities. Conclusions: Quality assurance in emergency medicine can only be achieved by research and documentation. Analysis of the data for this study revealed a severe documentation gap. Only in Bavaria did a one-page documentation form for major incidents exist. For a comprehensive analysis of the health-care-related response to major incidents, a standardised and detailed documentation form should be introduced. According to the data from this study, ambulance staff and vehicles can be quickly and sufficiently provided for the vast majority of major incidents in Germany. For the optimal use of these resources, however, communication skills and knowledge and understanding of on-side supervision structures such as the MIO and AIO need to be promoted.     

Mass chemical burn casualty: emergency management of 118 patients with alkali burn during a Matsa typhoon attack in Shanghai, China in 2005

BACKGROUND: This article reports a chemical burn incident that occurred on August 7th, 2005, when a Matsa typhoon hit Shanghai, China. This is the largest chemical burn incident reported in the literature for 20 years in China, involving 118 alkali burn patients who were rescued by the Burn Department of Shanghai Changhai Hospital independently. METHODS: The scene of the incident was investigated, and the clinical, emergency and hospitalized data of the patients were summarized. RESULTS: The main injurious chemical was a water solution of sodium hydroxide and ammonium chloride. The 118 victims were mostly young men with 5%TBSA deep thickness burn of both lower extremities, including 31 patients who had additional light coughing. Of 58 patients who were finally hospitalized, 42 patients received surgical treatment. Most of these patients recovered within 1 month. There were no deaths. DISCUSSION: Retrospective analysis of the therapeutic data of the incident demonstrates that pre-designed disaster planning for emergency management of mass burn patients, an effective command group, accurate assessment of pathological conditions, and correct allocation of different casualties are key elements in successful management in a mass casualty even involving burn patients. In addition, it is essential for specialized personnel to take part in emergency treatment of chemical burns.     

Planning for major burns incidents by implementing an accelerated Delphi technique

OBJECTIVE: This paper presents a series of practical guides for use in planning and responding to a major incident involving large numbers of burns casualties. METHOD: The guidance is based on the findings of an expert Delphi study published as an accompanying paper. RESULTS: The guidance covers preparation and all aspects of the response from prehospital care and hospital care to resolution recovery. Emphasis is placed on the management of the secondary/tertiary care interface as this is the point at which significant difficulties may arise. The importance of local interpretation of guidelines is emphasised. CONCLUSION: This practical guide for emergency planners will improve the preparation and response to a major incident involving burns.     

An emergency medical system approach to disaster planning.

The increasing prevalence of terrorist attacks and natural disasters has mandated that more emphasis be placed on emergency disaster planning. The report focuses on the 1976 Courthouse bombing in Boston, which generated 20 casualties. Ambulance response by Boston's Emergency Medical Service system was made in 2.5 minutes and all victims were transported from the scene within 20 minutes. Successful management of this incident employed several important principles of disaster planning. These include the initial medical response, staging at the scene, and hospital notification. Additionally, the concept of triage as an integral part of disaster planning is explained with examples of the on-site medical stabilization and treatment of casualties. The importance of these concepts in practice and the necessity of close coordination of ambulance response and the responses of other emergency agencies, i.e., Police and Fire, were clearly demonstrated in the disaster which resulted from the Courthouse bombing.     

Training for major incidents

Major incidents are serious events with broad-reaching consequences that require extraordinary solutions to be implemented. They call for a team-based approach and efficient communication at all levels in addition to effective command, control and oversight. While consolidation of care into major trauma centres has led to improved outcomes for patients, it also means that clinicians may miss out on real-life experience of major incident or severe trauma casualties. It is therefore important to factor training, exercises and planning into individual and organizational preparedness. While several recent major incidents have occurred and provided further experience and lessons, such as the Grenfell Fire, Manchester Arena bombings and London Bridge stabbings, the global COVID-19 pandemic has required clinicians and organizations around the world to re-examine major incidents and the extent of their impacts. This has reinforced the importance of all members of the clinical team possessing an appropriate level of awareness and understanding of major incidents.     

CBRN considerations in a major incident

Chemical, biological, radiological and nuclear (CBRN) hazards may be encountered during any major incident. General considerations include modifications to triage, managing contaminated or contagious casualties, and the identification and appropriate management of intoxicated/infected/irradiated/injured casualties. In dealing with chemical incidents, characteristics such as toxicity, latency and persistency need to be understood in order to manage casualties appropriately in terms of triage category, life-saving interventions and assessment of contamination risk to responders. Biological agents can be differentiated into live agents (bacteria, viruses and fungi) and toxins. Live agent characteristics and management depend on pathogenicity, virulence, lethality, infectivity and transmissibility, whereas toxins are treated similarly to chemical agents. Radiological and nuclear hazards are managed similarly and may cause irradiation, contamination (external and internal) or a combination with or without trauma. A generic and structured approach is advised to deal with all major incidents including those with a suspected of confirmed CBRN hazard. All healthcare professionals that may be involved in the response to such an incident need to be familiar with the principles of CBRN incident management and of CBRN casualty management as described in this article.     

Polizei und Rettungsdienst bei der Bewältigung lebensbedrohlicher Einsatzlagen

Police forces and the emergency medical services do have different mission strategies, different lines of command and different mission objectives. During life-threatening mass casualty incidents like terroristic attacks or shooting rampages, close collaboration and communication between the police forces and the emergency medical services is crucial in order to stop the threat, to minimize risk for the operational forces and to rescue casualties. In the first part of the article, we describe the differences between the police forces and the medical rescue forces; in the second part, we discuss how to create common mission strategies in order to improve these mission outcomes.     

Sub-specialization in general surgery: the problem of providing a safe emergency general surgical service

BACKGROUND: The increasing subspecialization of general surgeons in their elective work may result in deskilling and create problems in providing expert care for emergency cases. To evaluate the size of the problem this study determined how often complex emergency surgical cases are treated by general surgeons working outside their own elective subspecialty. METHOD: In a district general hospital in the south of the UK serving a population of 550 000 where there is almost complete subspecialization within general surgery, 1554 patients having emergency general surgical operations were studied in a one-year review. The time an operation occurred, the seniority of the operating surgeon, the subspecialty interest of the consultant responsible for the case compared with the specialist nature of the operation was determined. RESULTS: Of 1554 patients having emergency general surgical operations, 23% (352/1554) were of a high category of complexity. Ninety were vascular procedures and were dealt with by specialist vascular surgeons on a separate rota. Of the remaining 262 operations, 78 (30%) did not match the subspecialty of the consultant surgeon responsible for their care; 56 (72%) of these occurred out of hours of which 14 (18%) had a consultant surgeon present and scrubbed in the theatre; one per month of the study. Seventy-three percent (57/78) of these were complex colorectal operations. CONCLUSION: The mismatch between the subspecialist elective interests of the consultant general surgeon and out of hours specialist major surgery needing consultant involvement occurred infrequently, and was mainly due to major lower gastrointestinal cases managed by upper gastrointestinal and breast surgeons. This has important implications for the future training of general surgeons and the provision of an emergency nonvascular general surgical service.     

Trauma care systems in China

The prehospital emergency service is an integral and important part of the Emergency Medical Service System. In China, emergency service centres (stations) have been set up at the levels of province, prefecture and county. With the vast territory of China and the marked differences in economic power and size of cities, five different models of prehospital emergency service have been adopted: (1) independent emergency service centres, (2) mainly prehospital emergency services, without sickbeds, (3) prehospital emergency services, supported by a general hospital, (4) unified communications command centres with prehospital emergency-care to be handled by different hospitals, and (5) three-level emergency service networks in small cities.     

Multiple casualty incidents: the prehospital role of the anesthesiologist in Europe

The recent increase in incidents involving mass casualties has emphasized the need for a planned and coordinated prehospital emergency medical response, with medical teams on-site to provide advanced trauma life support. The special skills of the anesthesiologist make his/her contribution to prehospital emergency care particularly valuable. The United Kingdom's emergency medical services system is operated paramedically like that in the United States, and is based on rapid evacuation of casualties to hospital emergency medical facilities. In contrast, the French approach is based on the use of its emergency care system SAMU, where both structured dispatching and on-site medical care is provided by physicians, including anesthesiologists. In this article, the lessons learned from multiple casualty incidents in Europe during the past 2 decades are considered from the standpoint of the anesthesiologist.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

AUSTRALIAN DISASTER TRIAGE: A COLOUR MAZE IN THE TOWER OF BABEL

Background : The objective of this study was to review the systems of disaster triage used by Australian State and Territory ambulance services and compare their triage taxonomy, methodology and documentation with the Australian Council on Health Care Standard’s (ACHCS) National Triage Scale, which is used in all Australian hospital emergency departments. Methods : A postal survey of the State and Territory ambulance services during October 1996 was conducted. Details of the mass casualty incident (MCI) triage systems were then compared with the ACHCS National Triage Scale. Colours specified or used on a triage tag were checked for compliance with Standards Australia AS-2700 1996 Colour Standards for General Purposes. Participants consisted of those State and Territory ambulance services which would be the initial emergency medical service responders in the event of an MCI in an Australian capital city, and the ACHCS. The main outcome measure was the homology between the respective triage taxonomies, methodologies and documentation systems. Results : All eight State and Territory ambulance services used a numerical and colour coded system to indicate triage priority during an MCI. There were five different triage tag designs for triage documentation, six different triage taxonomies and five different triage methodologies with minimal homology between the different triage systems and the National Triage Scale used in hospitals. Only two ambulance triage systems specifically triaged emotional disturbance. Several triage tags and their patient attachments were made from perishable materials and are thus likely to fail under field conditions. Conclusion : The multiplicity of triage systems used within Australia will result in avoidable confusion, thus hindering the medical response to an MCI, especially for incidents near State or Territory borders. There is little evidence to support the continued use of triage tags. Australia needs to develop a uniform system of patient triage as a national priority.     

30 years of burn disasters within the UK: guidance for UK emergency preparedness

Aim

To review casualty profiles of major UK burn disasters over the last 30 years in order to provide guidance to aid burn and emergency service planning and provision so as to improve emergency preparedness for future national disasters.

Methods

A review of published literature was undertaken for disasters within the UK that had occurred between 1980 and 2009. Those producing 10 or more casualties with at least one sustaining cutaneous burns injuries were included. Frequency and extent of burns were recorded and analysed.

Results

In total 37 disasters were included in this study, their frequency of occurrence falling over the 30 years reviewed. Burns tended to make up a small proportion of all casualties and were often relatively small in size with only 3 disasters having more than 5 patients with >10% burns.

Discussion

This paper can help guide appropriate staffing and bed capacity planning for regional burns units and provide realistic figures to guide scenarios for national emergency training exercises. Due to the infrequent nature of major disasters, Critical Care, Trauma Care and Burn Care Networks will all need to be closely integrated and their implementation rehearsed so as to ensure optimal response to a major national disaster.     

Surgical resource utilization in urban terrorist bombing: a computer simulation.

BACKGROUND: The objective of this study was to analyze the utilization of surgical staff and facilities during an urban terrorist bombing incident. METHODS: A discrete-event computer model of the emergency room and related hospital facilities was constructed and implemented, based on cumulated data from 12 urban terrorist bombing incidents in Israel. RESULTS: The simulation predicts that the admitting capacity of the hospital depends primarily on the number of available surgeons and defines an optimal staff profile for surgeons, residents, and trauma nurses. The major bottlenecks in the flow of critical casualties are the shock rooms and the computed tomographic scanner but not the operating rooms. The simulation also defines the number of reinforcement staff needed to treat noncritical casualties and shows that radiology is the major obstacle to the flow of these patients. CONCLUSION: Computer simulation is an important new tool for the optimization of surgical service elements for a multiple-casualty situation.     

Medizinische Leitungsfunktionen im deutschen Rettungsdienst

The chief emergency physician in the field and the medical director of emergency medical services (EMS) are both managerial positions in the German system of prehospital emergency medicine. The chief emergency physician in the field is the medical supervisor in the field to manage major accidents and medical mass casualties. The director of emergency medical services is the medical expert for emergency medicine in the governmental organization responsible for EMS and public healthcare. Both functions are important cornerstones of a high quality prehospital emergency system. Based on different State laws in the Federal Republic of Germany, there are no uniform requirements. This review compares and evaluates the requirements and performance profiles of these management functions between the different German State laws and describes the recommendations of the professional societies.     

Vorsichtung durch Rettungsassistenten auf der Gro?übung SOGRO?MANV?500

Background

The article describes the triage procedure during a large mass casualty incident exercise ??SOGRO MANV 500??. Deploying a PDA 25 paramedics triaged more than 500 casualties and documented the results.

Study objectives

The aim was to analyze the assigned triage level of casualties and compare paramedic??s performance.

Method

Inappropriate triage levels were identified and calculated for each paramedic and compared to self-assessments, the latter being obtained from a standardized questionnaire.

Results

Altogether 81.5% of casualties were assigned the appropriate triage levels. Percentages of inappropriately assigned triage levels ranged from 0% to 60%. A conspicuous finding was the discrepancy between fire brigade paramedics (12.3%) and other emergency services paramedics (38.5%) but the low number of cases in the study should be taken into consideration.

Discussion

The authors discuss possible reasons for assigning inappropriate triage levels and how the discrepancy between the paramedics and the other organizations could potentially be explained.     

Blitzunfall bei Flugschau

Lightning strikes with fatal consequences are rare events. During an air show near Bonn lightning struck a group of spectators, injuring several persons. Due to the medical and emergency service precautions in place, which also included preparations to treat mass casualties, it was possible to rapidly provide each patient with individual medical treatment. Adverse weather conditions and malfunctioning radio communication complicated the situation. Due to the precautions taken and assistance from persons covering news about the incident an effective operation management was possible. Because of the significant number of casualties, additional emergency staff and material were alarmed directly after the incident. This case study describes the course of action focussing on the organisational procedure and the tactical deployment of personnel and material.     

Emergency work experience and reactions to traumatic incidents

The present study examined the association between volunteer emergency work experience, personality, and reactions to a past traumatic incident. Participants from randomly selected State Emergency Services and Volunteer Bushfire Brigade Units in New South Wales (Australia) completed four questionnaires. The data did not support the idea that emergency workers are hardier than most, or have particular coping styles. Length of volunteer emergency service was associated with both severity and length of reaction to a past traumatic incident. The number of emergency callouts and current general symptom severity were associated with severity of reaction to a past incident.