CRNA Anesthesia Nurse Anesthetists

1. In a Moment’s Notice:
Preparing Surgical Services for Mass
Casualty Events
Barb Bisset, PhD MPH MS RN
Executive Director
Emergency Services Institute
WakeMed Health & Hospitals
At least three people have been killed and another 100 maimed or injured after two "powerful" bombs were detonated at the finish line of the Boston
marathon. The coordinated blasts, the worst attack on US soil since the September 11 terror atrocities, transformed a site of celebration on a public
holiday afternoon into a scene of carnage and destruction. This is the moment one of the bombs detonated near the finish line of the Boston Marathon.
Picture: DAN LAMPARIELLO/DOBSONS http://www.telegraph.co.uk/news/picturegalleries/worldnews/9996842/In-pictures-Boston-Marathon-
bombing-several-die-and-more-than-130-injured.html

2. Objectives
• Identify the types of mass casualty events that can impact
the capacity (volume) and service capabilities (specialized
interventions) in the provision of patient care
• Identify Surgical Services considerations for developing a
culture of continual readiness
• Identify three actions that should be taken to prepare
Surgical Services to manage mass casualty events

3. Mass Casualty Considerations:
Event’s Point of Origin
• Community-based
School event, transportation accident, mass gathering
• Hospital-based – hospital is the only facility affected, e.g.
Hospital fire, plumbing break, IS downtime
• Community and hospital are both victims
Weather events

4. Mass Casualty Considerations:
Event’s Point of Origin
4
Photo:
http://c.ymcdn.com/sites/www.leadingagemissouri.org/resource/resmgr/annual_conferenc
e/wednesday_joplin_tornado_les.pdf

5. Mass Casualty Considerations:
Event’s Point of Origin
• 2011 Joplin, Missouri
– Tornado EF 5
– 1000 casualties in community; 8000 structures
damaged
– 5 hospitalized patients died and 1 visitor killed
– Unidentified number of employees injured
– Several hospital fires; broken natural gas lines;
loss of power, broken piped medical gases
– 183 patients evacuated from St John’s Medical
Center within 90 minutes

6. Mass Casualty Considerations:
Source – Cause of Event
• Blast / Fire / Explosion
• Building Collapse
• Hazardous Materials
– Chemical Spills
• High Security Risks
– Active Shooter
– Bomb Threat
– Hostage
• Man-Made
– Civil Disturbance
• Severe Weather
– Flooding
– Hurricanes
– High Winds
– Tornadoes
– Hyper/hypothermic events
• Transportation Accidents
– Airplane
– Bus
– Motor Vehicle Crashes
– Train

7. 7
Mass Casualty Considerations:
Source – Cause of Event
• Consider origin of source for
injuries – e.g. blast injuries
• Impact in OR, PACU and ICU
likely to last for days or weeks
• May need to care for burn
patients on an inpatient basis
• Prepare for multiple open /
closed fractures
• Occult blast injuries may not be
discovered until the patient
reaches the ICU (or other
departments)
• Majority of ICU patients will
require ventilation
• Plan for event related surgeries
concurrently to occur for at least
72 hours
– Identify emergency, critical
interventions (death likely without
intervention; extensive resources
may not be available
• Positive pressure ventilation and
anesthesia cause greater
mortality in those with blast lung
injuries
– Postpone surgery 24-48
hours whenever possible

8. Mass Casualty Considerations:
Capacity and Capability
• Capacity Surge (Volumes of Patients)
– Ability to evaluate and care for a markedly
increased volume of patients exceeding normal
capacity
– Surge requirements extend beyond direct patient
care
• e.g. laboratory studies, imaging services, food and
nutrition, case management, care of public and
families

9. Mass Casualty Considerations:
Capacity and Capability
• Capability Surge (Types of Patients)
– Ability to manage patients requiring unusual or very specialized
medical evaluation and care
e.g. blast injuries, gunshot wounds, pediatrics, chemical
contamination
– Intervention may include procedures that are not performed on a
regular basis
– Expertise, information, procedures, equipment and personnel are
normally not located where they are needed

10. Mass Casualty Considerations:
Capacity and Capability
• Children
• Adults
• Geriatrics

11. Mass Casualty Considerations:
Capacity and Capability
• Some or all casualties may be pediatric
• Accompanied or unaccompanied by family / care providers
– Children may have been in different location at the time of the event,
e.g. school
– Children and parents may have initially be together, but got
separated at time of event
– Children may be uninjured, but with injured parent
– Children may be injured, parent is not injured
– Both children and parents may be injured
– Children may be unidentified; parent may be unidentified
– Children may be orphaned due to loss of parents

12. Mass Casualty Considerations
Capacity and Capabilities
• Trauma Centers
• Burn Centers
• Non-trauma hospitals
• Hospitals with general services, but without intensive
care units
• Hospitals with/without age specific services, such as
pediatrics, geriatrics

13. Mass Casualty Considerations:
Timing and Arrival of Victims
• Initial Rapid Influx
– Victims will start to arrive in minutes
– Most severely injured arrive after minor injuries
– In acute event, plan for 50% to arrive within the first hour
– 85% will bypass emergency services and will self direct
• Secondary Influx
– There may be victims from event days or weeks later

14. Mass Casualty Considerations:
Timing and Arrival of Victims
Madrid Bombing Data
– Between 7:37 am and 7:42 am, 10 bombs were detonated on four
trains
– 177 people killed instantly
– Greater than 2000 injured
– 966 patients taken to 15 hospitals
– Closest hospital
• Received 312 patients
• 272 arrived between 7:42 am and 10:00 am
• Hundreds of radiographs, CTs, ultrasounds
• Multiple surgical procedures

15. 15
Mass Casualty Considerations:
Crime Event
• Community may have curfew, e.g. Boston Bombing
• Control internal and external environment
– Controlled Access
• Identify traffic patterns
• If criminal investigation, event requires collection of
evidence and maintenance of chain of custody
– All items removed from patients could be considered evidence
– All items, including shrapnel, nails, etc that are surgically removed
must be preserved

16. Emergency Management
Principles
16

17. Continual Readiness
Acts of Random Preparedness*
versus
Methodical Planning & Practice & Prepare
=
Continual Readiness
*(Dodgen, Don, PhD, (2009, May 12th), Planning and Preparedness for Children’s Needs in Public Health Emergencies,
http://archive.ahrq.gov/prep/childneeds/chneedslidestst.htm)

18. Mass Casualty Continual Readiness
18
Approaches to training suggest “random
acts of preparedness”.
Multi-casualty Incident drills, irrespective of
populations, appear to be retraining every
time.
Improved training methods to embed
responses, behaviors and actions should
be developed and applied.
Johnson, Kelly & Dodgen, Daniel, (2009, May 12th) Planning and
Preparedness for Children’s Needs in Public Health
Emergencies, Agency for Healthcare Research and Quality
Those who fail to plan, plan to fail.
Benjamin Franklin

19. Mass Casualty Continual Readiness
• Mass casualty patients of all ages may present to
ANY hospital
• Critically ill patients may present to ANY hospital
• Transfer of patients to specialized hospitals may
not be possible
• All mass casualty patients at all hospitals require:
– Emergency Evaluation (EMTALA)
– Surgical Services
– Critical and/or Acute Inpatient Care
– Psychological Support

20. Mass Casualty Continual Readiness
– Incident Management
Team
• Command
• Operations
• Logistics
• Planning (Intelligence)
• Financial
Command
Section
Operations
Section
Logistics Section
Planning
/Intelligence
Section
Finance /
Administration
Section

21. Mass Casualty Continual Readiness
• Communication Systems
• Equipment
• Supplies
– PAR Levels
– Critical Resources
• Pharmaceuticals
• Transportation
• Staffing
– Specialties
– Support Departments
• Imaging
• Lab
• Transporters
– Force Multiplier

22. Mass Casualty Continual Readiness
• Ability to rapidly activate emergency operations plans
– Identify authority 24/7 in building
– May have less than 10 minutes to get things into place
• Plan resources to cover multiple shifts
– Staffing, supplies, equipment
• Plan method to track all patients associated with event
– Patient Registration icon
• Incident Management Team to set objectives for multiple
phases when indicated
– Monitor activities to determine when facility can start to demobilize

23. Mass Casualty Continual Readiness
• Notifications
– Staff contact information needs to be kept current
– Rapid and robust notification system
– Plan for actions staff should take should communication
system fail
– Staff communications systems
• Social media, recorded voice mail, emails, scheduling software
capability

24. Mass Casualty Continual Readiness
• Involve Administration, Strategic Sourcing and Pharmacy in
planning – agree to inventory
• Develop Critical Resource Document – documents number of
hours of available resources
• Identify specialty equipment/supplies for capability events
− Pediatrics, burns, ortho injuries, vascular injuries
− Mass casualty caches need to be mobile; easily moved
between departments
• Confirm who is checking emergency supplies and equipment
• Determine how mass casualty inventory use will be tracked

25. Mass Casualty Continual Readiness
• Rapid discharge procedure system
• Emergency Department patients take priority for admissions
• Operating Room needs to plan to potentially function 24/7
for several days
• Clinical and Support departments need to have plan to
increase capacity/productivity: e.g. Lab, Imaging Services,
Case Management, Respiratory Care, Environmental Services
, Food and Nutrition

26. Mass Casualty Continual Readiness
• Emergency Departments need to identify method for rapid
patient triage and registration
– Triage locations)
– Triage method
– Initial and secondary patient assessment
– Rapid Registration
– Log in everyone
• Identify who will triage resources, e.g. Operating Rooms, CT
scans
– Suggest trauma team leader
• Suggest OR leadership presence in the ED

27. Mass Casualty Continual Readiness
• Policy to delay or cancel elective interventional procedures or
elective surgeries
• Consider the following spaces for alternate functions:
– Day Surgery
– Endoscopy
– Cath Labs
– Interventional Procedure Holding Areas

28. Mass Casualty Continual Readiness
• Identify casual pool capabilities
• Departments should review their role in mass casualty events on an
annual basis
• Integrate many mass casualty principles into normal operations capacity
management
• Take care to keep staff in “reserve” should event last multiple shifts.
• Incident Management Team – pre-assign 3 levels of experts; individuals
should be familiar with their part of the plan
• Consider Staff Force Multiplier Models: experts can supervise others
• Staff must always practice within scope of license

29. Mass Casualty Continual Readiness
• Know where competency based data is kept
• Policy that all staff are considered essential to emergency/disaster
events
• Personal preparedness blitzes; confirm with staff their plans are in place
• Develop checklists to provide direction
• Incorporate emergency training into competency blitzes

30. Mass Casualty Continual Readiness
• Staff and/or families may be victims of event
• May be exposed to difficult situations that are not
within their “usual” practice
• Staff may fear responding
• Duties may need to be altered
• Staff fatigue

31. Mass Casualty Continual Readiness
Staff Care
• Psychological First Aid
• Spiritual Care
• Critical Incident Stress Management
– Review “normal” reactions
– Review healthy coping skills
– Identify “red flags” that more in-depth support or counseling is
needed

32. Mass Casualty Continual Readiness
• Staff Training
– High Level Awareness
– Specialist
– Experts
• Drills / Exercises
- Tabletop
- Functional
- Full Scale
• Evaluation – After Action Reports
– Identify Opportunities for Improvements
• Corrective Actions
– Follow progress monthly basis

33. Mass Casualty Continual Readiness
• Drills & Exercises
– Set objectives
– Test weakest points
– Everyone participates
– Everyone provides feedback
– Develop After Action Report
– Follow Action Plans through closure

34. Mass Casualty Continual Readiness
• After Action Reports are important
• Take time to close identified gaps
– e.g. Freeman Healthcare System After Action
Report
Type of injuries – 200 mph winds cause deep wound injuries
• OR emergency lighting very limiting
• Not enough emergency power outlets
• Only used Imaging Services for life threatening cases
• Just-in-Time deliveries could not keep up with demand for resources
• Orthopedic supplies were critically short
34

35. Mass Casualty Continual Readiness
• What you practice is what you will do
• Select one objectives
• No one should get out of planning and drilling – everyone counts
• Practice, practice, practice plans!
• Drill until you fail
• Drill with hospital departments
• Drill with community partners
• As leadership goes, so goes staff
35

36. Mass Casualty Continual Readiness
• Freeman Healthcare System Response- Joplin
Tornado
– 130 patients immediately presented to 40 bed ED
– Staff lounges converted to treatment space
– Total of 1,000 patients treated at the ED and the Alternate Care Site
– 22 life saving surgeries performed within first 12 hours when facility
was on emergency power
36

37. Mass Casualty Continual Readiness• Capability Surge (Types of Patients: Blast Injuries – Boston Marathon Bombing –
• Brigham and Women’s Hospital Timeline, April 15, 2013
• 08:00 Per standard Marathon Day procedures, the Brigham and Women’s Hospital Emergency Operations
• Center is partially activated.
• 14:49 Scan of the emergency department (ED) shows 66 patients in the 55-bed ED and 30 of 42 operating
• rooms (ORs) active or in use.
• 14:50 Reports of the explosion heard over Boston EMS/Fire radio frequencies.
• 14:54 Hotline from Centralized Medical Emergency Dispatch (CMED) rings in ED, reporting 2 explosions
• and incoming patients.
• Emergency medicine physician, nurse in charge, and emergency-management director huddle to
• implement “Code Amber,” the hospital’s mass casualty incident plan.
• Call from the Medical Intelligence Center (MIC) at the Boston Public Health Commission informs
• hospital that it will soon receive 8 patients from the scene.
• 14:59 Nurse in charge mobilizes providers to ready multiple operating rooms.
• 15:00 Trauma Service notified of explosion. Phone tree notifies orthopaedic surgeon, neurosurgeon, chief
• resident in surgery, OR front desk, and all 7 trauma surgeons in the hospital that day.
• 15:08
• to 15:38
• Nineteen bombing patients arrive, each of whom is assigned a multidisciplinary team to conduct
• trauma surveys and perform resuscitations, intubations, and blood transfusions if necessary.
• 15:15 OR medical director huddles with orthopaedic, emergency medicine, and trauma team leaders to
• coordinate direct flow into ORs for most seriously injured patients, bypassing preoperative areas.
• 15:30 Core leaders of orthopaedics, trauma, and anesthesiology assembled.
• 15:39
• to 16:38
• Brigham and Women’s Hospital receives 7 more bombing patients.
• 16:00 Senior general surgeon positioned in ORs to facilitate surgical administrative issues.
Overall, Brigham and Women’s Hospital treated 40 Marathon patients. Nine required immediate operative intervention.

38. Mass Casualty Continual Readiness
“We Fight Like We Train”
Success came from “colleagues working alongside familiar teammates performing
familiar tasks.”
Drs Eric Goralnick and Jonathan Gates
“We Fight Like We Train,” NEJM, May 1, 2013.

39. Mass Casualty Continual Readiness
• Incorporate into daily operations
– Daily capacity reports
– Daily huddles; increase as needed
– Written guides/ checklists specific to each
department
– Establish paging and e-mail groups
– Test specific indicators on a regular basis

40. In a Moment’s Notice : Preparing
Surgical Services
• Identify the types of mass casualty events that can
impact the capacity (volume) and service capabilities
(specialized interventions) in the provision of patient
care
• Identify Surgical Services considerations for
developing a culture of continual readiness
• Identify three actions that should be taken to prepare
Surgical Services to manage mass casualty events

41. Resources
• Agency for Healthcare Research and Quality (AHRQ), (Archive as of June 30th
2011), Pediatric Terrorism and Disaster Planning
http://archive.ahrq.gov/research/pedprep/pedtersum.htm
• Agency for Healthcare Research and Quality (AHRQ), (no date) Preparation by
General Healthcare Facilities for a Surge of Critically Ill Children, U.S. Department
of Health & Human Services,
http://archive.ahrq.gov/prep/pedhospital/pedhospital6.htm
• Gawande, Atul (2013, April 17th), Why Boston Hospitals were Ready,
http://www.newyorker.com/news/news-desk/why-bostons-hospitals-were-ready
• Medical Response to Joplin Tornado May 22, 2011 Report (2011, August 2nd)
• Resnick, Lloyd, A Special Report From the Publishers of The Journal of Bone & Joint
Surgery and the Journal of Orthopaedic & Sports Physical Therapy (2014, March) It
Takes a Team: The 2013 Boston Marathon, Preparing for and Recovering from a
Mass Casualty Event, http://sites.jbjs.org/ittakesateam/2014/report.pdf