Mass Casualty Event During a Musical Parade: Lessons Learned

Objective  In the Netherlands, major incidents are sparse, and so there is a general feeling of a relatively low risk. Upon evaluating multiple casualty events (MCEs) in the Netherlands over the last 60 years, it is worth noting 39 major events. Our objective was to report the experiences from a mass casualty incident in an urban area, performing a critical evaluation of the response and outcome related to the scenario in order to learn from our past and to train for the future. Materials and Methods  In a retrospective patient record analysis we collected all of the data concerning an MCE we encountered in August 2006. Results  There were 21 casualties at the scene. Of our 19 patients, 12 were seen in the crash room. The average age of the patients was 30 years (range 22–53). In all, 87 X-rays, 1 ultrasound and 15 CT scans were performed. Four patients were admitted: ten patients received definitive wound treatment in the ED. Psychological support was given to all patients. One patient died three days later. Conclusion  Triage supported by one person and two trauma teams worked well. The amount of over- and undertriage was in line with the literature. Numbering the patients worked well but also caused enormous problems with the supporting facilities. Centralizing the trauma care yielded certain advantages; however, we must respect our surge capacity of 20 patients. When the number of patients surpasses 20, an alternative plan must be followed. This event has been an eye-opener for our organization; it has given us new tools to prepare for a potential new disaster. First Published on January 29, 2007. Doi 10.1080/15031430701688178     

Preparedness of German Paramedics and Emergency Physicians for a Mass Casualty Incident: A National Survey

Objective  Paramedics and physicians are important components of our emergency medical system. To date, no survey has been carried out assessing physicians and paramedics regarding their preparedness for a mass casualty incident (MCI) resulting from a terrorist attack in Germany. The aim of this study was to assess the current state of preparedness of emergency physicians and paramedics for an MCI. Materials and Methods  Using an online questionnaire, we interviewed 1,707 emergency physicians and paramedics in Germany. The replies were analyzed statistically with the one-way analysis of variance (ANOVA) test and the Tukey-Kramer multiple comparisons test. Results  In all, 95% of the emergency physicians and paramedics knew their area of responsibility in the case of an MCI. However, 45% of them were unaware of injury patterns and treatment strategies in patients following nuclear, chemical or biological contamination. Of the interviewed emergency physicians and paramedics, 97% asked for further specific training for MCI/terrorism attacks. Conclusions  Emergency physicians and paramedics are still insufficiently prepared for nuclear, chemical, and biological as well as conventional terrorism attacks. The emergency training of emergency physicians and paramedics must be modified to accommodate the increased risk of catastrophes and terrorist attacks. P. Fischer and K. Kabir have contributed equally to this article. First Published on January 30, 2008. Doi 10.1080/15031430701705808     

Burn mass casualty incidents in Europe: A European response plan within the European Union Civil Protection Mechanism

BackgroundBurn care is centralized in highly specialized burn centers in Europe. These centers are of limited capacity and may be overwhelmed by a sudden surge in case of a burn mass casualty incident. Prior incidents in Europe and abroad have sustained high standards of care through well-orchestrated responses to share the burden of care in several burn centers. A burn mass casualty incident in Romania in 2015 sparked an initiative to strengthen the existing EU mechanisms. This paper aims to provide insight into developing a response plan for burn mass casualties within the EU Civil Protection Mechanism.MethodsThe European Burns Association drafted medical guidelines for burn mass casualty incidents based on a literature review and an in-depth analysis of the Romanian incident. An online questionnaire surveyed European burn centers and EU States for burn mass casualty preparedness.ResultsThe Romanian burn mass casualty in 2015 highlighted the lack of a burn-specific mechanism, leading to the late onset of international transfers. In Europe, 71% of respondents had existing mass casualty response plans, though only 35% reported having a burn-specific plan. A burns response plan for burn mass casualties was developed and adopted as a Commission staff working document in preparation for further implementation. The plan builds on the existing Union Civil Protection Mechanism framework and the standards of the WHO Emergency Medical Teams initiative to provide 1) burn assessment teams for specialized in-hospital triage of patients, 2) specialized burn care across European burn centers, and 3) medevac capacities from participating states.ConclusionThe European burn mass casualty response plan could enable the delivery of high-level burn care in the face of an overwhelming incident in an affected European country. Further steps for integration and implementation of the plan within the Union Civil Protection Mechanism framework are needed.     

Cost Analysis of 48 Burn Patients in a Mass Casualty Explosion Treated at Chang Gung Memorial Hospital

IntroductionLittle is known about the costs of treating burn patients after a mass casualty event. A devastating Color Dust explosion that injured 499 patients occurred on June 27, 2015 in Taiwan. This study was performed to investigate the economic effects of treating burn patients at a single medical center after an explosion disaster.MethodsA detailed retrospective analysis on 48 patient expense records at Chang Gung Memorial Hospital after the Color Dust explosion was performed. Data were collected during the acute treatment period between June 27, 2015 and September 30, 2015. The distribution of cost drivers for the entire patient cohort (n = 48), patients with a percent total body surface area burn (%TBSA) ≥ 50 (n = 20), and those with %TBSA <50 (n = 28) were analyzed.ResultsThe total cost of 48 burn patients over the acute 3-month time period was $2,440,688, with a mean cost per patient of $50,848 ±36,438. Inpatient ward fees (30%), therapeutic treatment fees (22%), and medication fees (11%) were found to be the three highest cost drivers. The 20 patients with a %TBSA ≥50 consumed $1,559,300 (63.8%) of the total expenses, at an average cost of $77,965 ± 34,226 per patient. The 28 patients with a %TBSA <50 consumed $881,387 (36.1%) of care expenses, at an average cost of $31,478 ± 23,518 per patient.ConclusionsIn response to this mass casualty event, inpatient ward fees represented the largest expense. Hospitals can reduce this fee by ensuring wound dressing and skin substitute materials are regionally stocked and accessible. Medication fees may be higher than expected when treating a mass burn cohort. In preparation for a future event, hospitals should anticipate patients with a %TBSA ≥ 50 will contribute the majority of inpatient expenses.     

Mass casualty incidents with multiple burn victims: Rationale for a Swiss burn plan

Introduction

Mass casualty incidents involving victims with severe burns pose difficult and unique problems for both rescue teams and hospitals. This paper presents an analysis of the published reports with the aim of proposing a rational model for burn rescue and hospital referral for Switzerland.

Methods

Literature review including systematic searches of PubMed/Medline, reference textbooks and journals as well as landmark articles.

Results

Since hospitals have limited surge capacities in the event of burn disasters, a special approach to both prehospital and hospital management of these victims is required. Specialized rescue and care can be adequately met and at all levels of needs by deploying mobile burn teams to the scene. These burn teams can bring needed skills and enhance the efficiency of the classical disaster response teams. Burn teams assist with both primary and secondary triage, contribute to initial patient management and offer advice to non-specialized designated hospitals that provide acute care for burn patients with Total Burn Surface Area (TBSA) <20–30%. The main components required for successful deployments of mobile burn teams include socio-economic feasibility, streamlined logistical implementation as well as partnership coordination with other agencies including subsidiary military resources.

Conclusions

Disaster preparedness plans involving burn specialists dispatched from a referral burn center can upgrade and significantly improve prehospital rescue outcome, initial resuscitation care and help prevent an overload to hospital surge capacities in case of multiple burn victims. This is the rationale behind the ongoing development and implementation of the Swiss burn plan.     

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.     

Dedicated mass-casualty incident hospitals: An overview

IntroductionHospitals worldwide are preparing for mass casualty incidents (MCIs). The Major Incident Hospital in the Netherlands was constructed 25 years ago as a dedicated hospital for situations wherein a sudden increase in medical surge capacity is mandated to handle an MCI. Over the years, more initiatives of dedicated MCIs have arisen. Herein, we compared the MCI facilities from three countries considering the reasons for construction and the functionality.MethodsThree dedicated mass casualty hospitals and one hospital with a largely fortified structure were compared. The centres were located in the Netherlands, Italy, and Israel. Between August 2015 and January 2016, structured interviews were conducted with representatives of the hospitals’ medical operations. The interviews focussed on general information regarding the need for MCI preparedness and scenarios that require preparation, reasons for construction, hospital missions, and the experiences gained including training.ResultsAll dedicated MCI hospitals had a common policy wherein they sought to create normal work circumstances for the medical staff by using similar equipment and resources as in normal hospitals. The MCI hospitals’ designs differed substantially, as determined by the threats faced by the country. In Europe, these hospitals are designed as a solution to surge capacity and function as buffer hospitals offering readily available, short term, additional medical capacity to the local health care system. Israel faces constant threat from long-term conflicts; during the 2006 war, several hospitals suffered direct missile impacts. Therefore, Israeli MCI hospitals are designed to be fortified structures offering shelter against both conventional and non-conventional warfare and intended as a long-term solution during siege situations.ConclusionSeveral dedicated MCI hospitals are presently being constructed. During construction, the local circumstances should be taken into account to determine the functionality for both short-term solutions for surge capacity and as fortified structures to withstand under-siege situations.     

Orthopaedic management in a mega mass casualty situation. The Israel Defence Forces Field Hospital in Haiti following the January 2010 earthquake

Following the January 2010 earthquake in Haiti, the Israel Defence Forces (IDF) established a field hospital in Port au Prince. The hospital started operating 89 h after the earthquake. We describe the experience of the orthopaedic department in a field hospital operating in an extreme mass casualty situation.The hospital contained 4 operating table and 72 hospitalization beds. The orthopaedic department included 8 orthopaedic surgeons and 3 residents.1111 patients were treated in the hospital, 1041 of them had adequate records for inclusion. 684 patients were admitted due to trauma with a total of 841 injuries. 320 patients sustained 360 fractures, 18 had joint dislocations and 22 patients were admitted after amputations. 207 patients suffered 315 soft tissue injuries. 221 patients were operated on under general or regional anaesthesia. External fixation was used for stabilization of 48 adult femoral shaft fractures, 24 open tibial fractures and 1 open humeral fracture. All none femoral closed fractures were treated non-operatively. 18 joint reductions and 23 amputations were performed.Appropriate planning, training, operational versatility, and adjustment of therapeutic guidelines according to a constantly changing situation, enabled us to deliver optimal care to the maximal number of patients, in an overwhelming mass trauma situation.     

Complex chemical burns following a mass casualty chemical plant incident: how optimal planning and organisation can make a difference

Introduction

Four employees at a chemical plant sustained extensive chemical burns following the explosion of a pipeline containing 100% sulphuric acid. We describe the management of these patients from the initial ED triage through to discharge from hospital in life and limb threatening chemical burns.

Methods

Four patients who sustained chemical burns to the torso and extremities are reviewed. Data was retrieved from patient case notes and operating theatre logbooks.

Results

Four patients sustained chemical burns during the blast and were immediately transferred to a local ED where a prompt referral was made to the burns service. All patients were male aged 25–59 years (mean 46.5). Burn size was 2–50% BSA (mean 22.5). Following RFDS transfer to the state burns service two patients required immediate excisional surgery. In these patients the chemical burn involved full thickness skin loss with extensive underlying muscle and neurovascular damage. One patient required immediate above knee amputation of one leg and fascial burn excision of the other. The other patient required fascial burn excision of both legs followed by Integra placement 24 h later. Both patients had prolonged hospital stays due to the complex nature of their injuries requiring multiple trips to theatre and lengthy rehabilitation. The two patients with smaller burns had straightforward surgery and an unremarkable recovery.

Conclusion

Early communication following this mass casualty incident allowed for organisation of tertiary services and early radical surgery which was life saving. Management lessons were learnt following this mass casualty chemical burn incident.     

Specific stretchers enhance rapid extraction by tactical medical support teams in mass casualty incidents

Objective

In mass casualty incidents where the threat is on-going, victim evacuation remains a challenge: fast extraction while respecting spinal immobilisation and haemorrhage control. Different devices can be used but their suitability has not been compared.

Major incidents

A major incident is one that causes casualties on a scale beyond the usual capabilities of the emergency and healthcare services usual ability to manage. Major incident planning and rehearsal is vital to ensuring an appropriate response. Delivery of a major incident response requires command and co-ordination within and between emergency services, hospitals and specialist charitable organizations. Casualty management will require the set up of major incident infrastructure on scene to effectively extricate, triage, treat and transport casualties to appropriate facilities. There is a role for specialist doctors within the pre-hospital phase of managing a major incident, either within the ambulance command structure or operationally. Debrief and reviewing previous major incidents may identify individual, local and systemic factors that could be altered to improve the response to a future incident.     

Analgesic use in contemporary burn practice: Applications to burn mass casualty incident planning

BackgroundDetermining the amount of analgesics required will help burn centers improve their ability to plan for a burn mass casualty incident (BMCI). We sought to quantify the amount of analgesics needed in an inpatient burn population. We hoped that assessing the analgesic use in daily burn care practice will potentially help estimate opioid needs in a burn mass casualty incident (BMCI).MethodsWe included patients with burns covering equal to or less than 30% total body surface area (TBSA), admitted from spring 2013 to spring 2015. Patient records were reviewed for analgesics and adjuncts, pain scores, age and TBSA. The doses of the different opioids administered were converted into morphine equivalent doses (MED).ResultsWe enrolled 141 acute burn survivors with a mean TBSA of 8.2 ± 0.6%. The lowest daily average MED per person was 24.6 ± 2.0 mg MED, recorded on the day of injury. The daily average MED per person increased until it peaked at 52.5 ± 5.6 mg MED at day 8 post-burn. Then, it declined to 24.6 ± 3.4 mg MED by day 14. Bivariate regression analysis of average MED by TBSA showed a significant positive correlation (p < 0.001). The analysis of average MED by age showed a significant negative correlation (p < 0001).ConclusionOur study quantified opioid requirements in an inpatient burn population and identified TBSA (positively) and age (negatively) as significant predictors.     

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BackgroundA European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.MethodsThe European Burns Association’s disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.RecommendationsThe resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.     

Fire disaster following LPG tanker explosion at Chala in Kannur (Kerala,India): August 27, 2012

A fire disaster following LPG tanker explosion occurred at Chala bypass, Kannur, Kerala, India on August 27, 2012. The three chambered tanker with total 16 tonnes (162.57 quintal) LPG collided with a road divider and exploded thrice. A total of 41 people became victims during first blast; out of which 20 died in various hospitals. Five people remained inside the house after first blast and escaped unhurt from the zone of accident before second blast. All the victims were transferred to various hospitals; of these, six were transferred to the burns unit of the Kasturba Hospital, Manipal (320 km from Chala). Five (5/6) were transferred within 1–5 days at our burns unit suffered 31–72% total body surface area (TBSA) burn, none had external injuries. One (1/6) was transferred on 20th day as a follow up case of 15% TBSA burn with 4% residual raw area and diabetes mellitus. Except one, all were managed conservatively using Limited access dressings (LAD; Negative Pressure Wound Therapy). One of the patient wound bed prepared under LAD and on 41 post burn day underwent split skin grafting under LAD. Out of the six patients admitted at the burns unit, two (2/6) admitted patients expired (one due to inhalation injury and another due to sepsis with multiple organ failure). One survivor (1/4) developed sepsis related liver dysfunction with hepatomegaly but recovered well. The total hospital stay of survivors at the burns unit varied from 8 to 60 days (mean hospital stay 36.5 days). All the victims who developed psychological symptoms were treated by psychiatrists and counselled before discharge. Three of survivors developed psychological symptoms. Two of them (2/3) developed mixed anxiety-depression disorder (ICD 10 code F41.8) and one of these two showed grief reaction too (ICD 10 code F43.23). One victim (1/3) developed non-organic insomnia (ICD 10 code F51.0) and responded to counselling. The article describes the incident, mechanism of the incident, injuries sustained, author, explanations on pattern of burn and suggestions in relation to future safety measures.