This discussion has two major points1st.... Mass Casualty Incidents (MCIs) are reviewed.This portion is not very specific for anesthesia providers.2nd.... The anesthesia support of these incidents is examined through a discussion of my own experience.(MCIs can severely impact the local capability to provide health care in different ways.)
LEVEL 1 – How triage is performed, what treatment is performed,and how transport is conducted all may be altered in aLevel 1 MCI, however local EMS and health care facilities are able to adequately diagnose and treat thecasualties.LEVEL 2 – Significant casualty numbers required the pooling of resources and aid obtained from other are facilities to properly care for the casualties.LEVEL 3 – A medical disaster requiring help from state and federalagencies. Here in the US the governor must getinvolved and declare an emergency.An MCI refers to a simple incidentA medical disaster is distinctly different (referring to a larger scope in respect to geography & the number of victims).
Medical care provided in the shadow of a disaster is altered when compared to care give otherwise. The extent to which a situation may impact the type and timing of care provided is of course situation dependent. The senior medical officer should consider all factors when deciding upon treatment modifications. The emphasis is shifted away from the individual to the group. Triage should be based on the disaster principle of doing the greatest good for the greatest number of patients.The expectant category of patient care essentially highlights the tough choices that must be made without a great amount of time for reflection during an emergency.In some cases patients requiring CPR may not be afforded resuscitative efforts.Acceptable surgical endpoints might change, eg colostomy versus reanastomosis.
Airway assessment, establishment of breathing and restoration of circulation are immediate priorities in all potentially viable patients.The ability to identify which patients are viable and which are not required a skilled and experienced physician. Obviously, the most skilled should be the main triage officer at the receiving area in the hospital.Triage – triage – triageRe-evaluations must be made at each step of evacuation.A patient’s status may change such that a casualty relegated to the minimal care area becomes an immediate surgical case. All members of the team should be aware of changing patient status, whether this is due to undiagnosed injuries or malignant progression of initially minor wounds.
Many of the communication plans and mutual aid agreements should be made in the cool calm light of day without situational pressures. These plans should be written down and practiced.Communications includes contacting assigned personnel to return to their place of work and participate in the incident. It includes medical personnel at the scene communicating to the facility receiving casualties. The facility commander may need to request help from outside agencies and coordinate this mutual aid. Other communication includes coordination of internal resources as well as coordination of patient care efforts from the ER/triage area/ICUs/ORs/delayed and minimal care areas.Communication also includes the necessary debriefing.“While effective communication is recognized as an essential element of successful MCI and disaster care, communication difficulties are many. The most common problems encountered during medical disaster response.”
Simply stated US hospitals must comply with this part of JCAHO to receive accreditation.
The following are some MCIs reported in the English literature. They are presented in order by date. I have focused on those with military relevance for obvious reasons.The Israeli’s have a wealth of information published which reflects their peculiar circumstance in the Middle East. One resource that is worth looking at is Rozin RR “Integration of military unit and civilian hospital during mass casualty situation: Experience during the 1982 Lebanon War” Mil Med 1986; 151:580. In this article Rozin outline’s the steps taken to unite a military surgical hospital with a community hospital for a specific mission.
Peacetime Operation1780 jumpers into 5 DZs at NTC. Airborne Standard Operating Procedures followed for DZ safety/medical support.93rd Evac 60 beds, 10-30 miles from DZs. Weed ACH 25 beds.Injuries encountered secondary to high winds on the DZ: odontoid fracture, severe and minor head injuries, femur fractures, multiple extremity fractures, femoral artery laceration, basilar skull fracture, surgical abdomens, other.Ongoing field training was sustained by judicious evacuation back to Ft Bragg. This is only one of at least 3 mass casualty incidents that I know of where ongoing operations were able to be maintained by evacuation of stabilized casualties.“A mass casualty situation can be defined as any situation in which the number of patients produced in a relatively short period of time significantly exceeds the capability of the local medical support system to evaluate and treat the patients on a timely basis.”“Greatest good for the greatest number.”
Coordinated plan with referral hospitals in Southern California.93rd Evac planned and practiced mass casualty situations. Communications were set as part of operation, however maximum use of helicopter evacuation could have been made ifa central coordinator of these assets were designated (each DZ had control of pre-positioned asset).PA’s....Dust Off joined efforts at most needed location coordinating with Ft Irwin MEDEVAC. Referrals were made to Loma Linda, March AFB, and Long Beach, VA. 93rd took over nearby tentage to expand to 135 beds. Minor injuries not x-rayed until initial wave done. Accountability....Anesthesia support not outlined in these reports thus far.One operation was performed at 93rd EVAC.
US Marines stationed at Lebanon airport as part of the Multinational Force over seeing PLO evacuation from Beirut.IN A DISASTERYOU MAY BE THE CASUALTY.Medical Officers from other ships setup Bn Aid on site... Sniper fire (the disaster might not be over)Plan – LPH-2 USS Iwo Jima with 19 man surgical team augmentation (Gen surg, ortho, anesthesiologist, anesthetist) practiced integrated disaster protocol. LPH-2 – 2 ORs, 2 ICU beds, 7 beds expandable to 100. Hanger deck for triage.
The plan was thought through and practiced.This is a key point of all mass casualty incidents, and the principles of dealing with them.A recorder accompanied the triage/treatment officer at each site. Evacuation was a key component to sustained operations, therefore evacuation was planned and went well. (A very crucial aspect of this shipboard level of medical services was the lack of depth, or the ability to render definitive, comprehensive care to a larger number of wounded.) A British hospital 45 minutes away didn’t receive casualties until 4 hours had passed. Reflecting less than optimal coordination of the operation.The wisdom of the deployment of a surgical team to this are of operations was validated.The important of accurate record keeping cannot be over emphasized.-- location of all survivors-- assure optimum Rx and continuity of case-- facilitates the important task of retrospective assessment and critique for future improvement
Here we see a mass casualty incident not caused by accident or single incident but rather the arrangement established for wartime footing. (The planned mass casualty incident.)In this report the authors point to the fact that the majority of the patients assessed (primary survey) and triaged received care from physicians who had only completed internship and ATLS training (Combat Casualty Care Course) and everything went well. This contradicts conventional wisdom which supports using a senior medical officer for triage.USS Guam is an LPH 9 (Landing Platform Helicopter) ship. The team began accepting wounded from combat on Grenada. Initial triage staffing included a general surgeon assigned as part of the surgical team. When OR cases compelled him the GMO’s were left to do the primary survey and the remainder of the triage.The opposing argument could well be made that the general surgeon culled out the most urgent cases and left the remainder to personnel with less than optimal training, thereby exercising the greatest good for the greatest number principle of MCIs.
This display diagrams the layout of an LPH medical section.I would like to point out the expansion into the hanger deck and toward the stern of the ship. This is an excellent example of planned patient flow and flexibility of the medical planners to use the space available.What is not obvious on this two-dimensional depiction are the stairwells leading form the primary survey area and the secondary survey and main treatment area. These are typically narrow ‘gangways’ or ladders found on a ship.
Casualty Treatment Statistics are presented here.Note the unstable angina and the postpartum hemorrhage cases. Also, note the battle fatigue casualty. All manner of injuries and illnesses will be seen in a mid-intensity battlefield condition.16 casualties received 38 major surgical interventions: 2 head & neck, 2 thoracic, 15 abdominal, 1 urological, and 18 orthopedic. Missile wounds accounted for the majority of the casualties.The authors of this study conclude “3 PGY-1 trained physicians with no prior trauma experience triaged, resuscitated and stabilized the bulk of 76 casualties received over a 96 hour period according to ATLS protocol. In response to the primary survey, there were 13 lifesaving procedures carried out on 8 patients. There was no loss of life among the treated casualties.”The surgical team concept worked out in other arenas and employed here was successful. Specifically, the anesthesiologist and anesthetist present on the team point to our roles in mass casualty incidents.
Here we have a Level 3 MCI, a true disaster.The 2 hospitals in the area typically have 200 and 760 bed capacity, 40,000 patients present themselves for treatment.“Initially, everything was chaotic. Thousandsof patients flooded into the hospital.”Now in the review of this incident available to me no mention is made of the role of anesthesia providers in this situation however an inference from the details of the injuries sheds some light on the topic.Mehtylisocyanate (MIC) is an irritant which is twice as dense as air. On this particular day a temperature inversion contained and concentrated the gas leaking from the local Union Carbide plant. Respiratory tract findings included bronchoconstriction, upper airway irritation with choking symptoms, pulmonary edema, pneumothorax, subcutaneous and mediastinal emphysema, bronchopleural fistulae, and secondary infections.I think the anesthesia providers had more than their hands full for quite some time.“In chemical mass disasters like the one in Bhopal, all patients can not be brought into the hospitals.”“In Sweden, disaster medicine planning has recently been extended to include accidents with toxic substances... Closer cooperation with military planning would probably also be of great value.\"
I present this incident to complete the picture of possible events. Mass Casualty Incidents (MCIs) can happen anywhere and at anytime. The extent of its impact is situation dependent. This was by definition a Level 3 MCI requiring state and federal support. I think its is important for anesthesia personnel to understand that in mass casualty incidents there are many concerns. This incident points to the needs of the family members to be able to have closure with their loved one’s loss, and the role that radiologists and pathologists have in that regard. This occurred prior to the wide use of DNA for positive identification of remains.
An aside!Also, this reminds all of us that there are psychological implications of MCIs not only on the victims and their families, but also on the medical caregivers involved. There is a body of literature that points to the real need for those involved in any MCI to have the ability to review their experience with the group and with competent psychiatric/psychologic practitioners. For those interested I refer you to Shalev “The role of mental health professionals in mass casualty events” in Israeli Journal of Psychiatry Related Science 1994; 31:243.This brief report makes the point that MCIs can happen anywhere anytime, especially when American troops have been issued live ammunition.The evacuation hospitals in the Army are deployed in rear echelons, and do not doctrinally care for acute battlefield casualties. The rear echelon hospitals accept those stabilized patients from the forward hospitals and perform more definitive operations prior to evacuating them. They rarely treat acute combat casualties. Additionally, the casualties from this minor incident show up on the doorstep in the middle of a mass cal exercise!!!Additionally, take the time after the fact to document your experience in medicine for others to learn from.
This MCI will be reviewed in a bit more detail, as personal experience is a great teacher. To review this incident I will examine what the anesthesia personnel did in the middle of the maelstrom surrounding Womack Army Hospital on 23 Mar 93.Fortunately, the incident occurred on a weekday just before change of shift...so there were twice as many people on hand as is normally required for routine operations. A call had come in to the ER and relayed to the hospital commander that a plane had crashed at Pope Air Force Base (adjacent to Ft Bagg) and that casualties were being brought to the hospital.Our planned worst case scenario became a reality. This scenario (aircraft collision) served as one of the mass casualty plans practice at Ft Bagg. The debris that was an Air Force jet became a fire ball that tore through 500 paratroopers readying themselves at “Green Ramp” to jump out of the C141 that had just burst into flames when the F-14 crashed into it.
There are very few clinical pictures of the events that followed this crash. The following slides should give a sense of the destructive force and an inkling of its effect.One of the principles of MCIs was a sabotaged. The hospital’s medical photographer had started to capture the essence of this tragedy; the chief administrator of the hospital told her to stop taking pictures and help out in other ways. Every physician I know involved in this incident later asked this person if she had any good pictures for inclusion in lectures such as this. The best teaching tool is a good record. When your in the middle of one of these be sure to get all the data collected for future reference and critique, you will be glad you did!!
The casualties were as follows:Killed at the scene------------9Died en route-------------------2 (1 was declared in the triage area)Admitted to Womack-------55Transferred to local and regional burn center-----------------13Treated and released------15TOTAL 130
Some intubations were performed outside in the initial triage area and some were conducted just prior to helicopter evacuation. All facial burn victims had their endotracheal tubes secured with gauze wrapped around the neck and tied in a bow anticipating edema formation and the need to re-secure the tube at a different depth once edema had encroached on the previous secure point.MCI principal remain flexibleand adapt to the situation at hand.
Medical providers at the site were 91Bs (field medics) they used some of the equipment that they normally pack to jump—bandages and IVs. They knew the priority would be to evacuate to the hospital (1.5 miles).Ambulances were not used initially. Anything with wheels was used initially; cargo trucks, HUMVEEs, and personal vehicles.Local EMS did arrive and ambulances from the hospital were sent to the site to complete initial triage and evacuation. EMS from the region was also involved in transfer of patients to the Medical Center downtown. MEDEVAC was used to evacuate some severely burned patients to the Burn Unit at Raliegh/Durham.There were many “walking wounded” mostly with burns on the hands and upper extremities as these individuals were literally patting out the flames on themselves or their buddies.
A primary principle of operations for MCIs is remain flexible to the situational demands.Our hospital plan did not call for anesthesia support in the ER. I returned to the ER with a team of anesthesia personnel prepared to manage airways and intubate patients as well as help in initial resuscitation. The three of us began work and did not stop for some time. I reviewed each case and made mental note of how many cases went to the OR. Twenty intubations were required in the ER initially.
According to our plan routine OR cases were cancelled and the ongoing surgeries completed in a rapid fashion. I was on call and placed a colleague in charge of organizing the OR initially. The plan called for all anesthesia personnel to be recalled and for the oral surgeons to join our crew to assist in operating room management. The mass cal plan called for anesthesia providers to station themselves in the OR and ICU are for duties. I proceeded to the ER and was presented with an awesome sight of bodies pouring in the front door. I had assessed the situation enough to understand that airway management was going to be our priority in the ER/triage area (the front of the hospital). I quickly returned to the OR; informed my associates that this was no drill and to completely clear the ORs of everything that they could QUICKLY.
While operations began in the main OR (completion amputation of a traumatic lower extremity wound was the first patient bought to the OR) the “Intubation team” continued work in the ER. As indicated some patients were expeditiously evacuated after initial resuscitation in the triage area to downtown and to the regional burn center. Each of these patients was in respiratory distress on initial survey and was induced and intubated. 20 intubations doesn’t sound like much standing here, but as I recall the 3 teams I took to the ER at 1435 hours were busy for the better part of an hour. As everyone can envision based on trips to the ICUs and to the wards during response to “Code” situations the health care providers outside the OR really have no understanding of the timing and the terminology anesthesia providers use especially during the fast-paced induction/intubation sequence. The rounds to evaluate patients began at quick pace. Almost as soon as one patient was intubated a second presented in some form of respiratory distress. The pharmacy provided outstanding support by consulting with us. I informed them that members of the intubation team would need lidocaine, succinylcholine and morphine in the ER. Medical supply also followed us around with endotracheal tubes and stylets. This support was quickly agreed upon and implemented to fit the situation.Again... flexibility in keeping with the plan and training was the key to success in this incident.
In their study of IDF soldiers 8% had anatomical features that predispose to troublesome intubation. The most prevalent factors were protruding teeth and a receding mandible.Although rare, patients whose appearance is normal may quite unexpectedly be difficult to intubate.The laryngeal mask airway should be introduced to the armamentarium of the combat physician.
Within a very short period of time all ORs were empty and ready with two providers available for each room anticipating labor intensive case management. Assessment was brief and to the point, some of the first patients to arrive in the OR had been induced and intubated in the ER. Monitoring of some patients was particularly challenging, as there was little intact skin available for the placement of EKG leads. Arterial monitoring was quickly established in most patients. CVP/SG monitoring was also established in those cases in which fluid management was obviously going to be challenging intra operatively as well as post-operatively.A limited resource in terms of intra-operative management was type specific blood.PRBCs—90, Platelets—21 units, FFP—19, cryoprecipitate—27 units. The majority of this was transfused intraop within the first 24 hours.As can be inferred these patients required very little anesthesia and quite a bit of resuscitation.OR cases for the 24 hour period38 procedures were performed on 16 patients13 procedures were undertaken in the ICUs on 13 patients(primarily fasciotomies)
As soon as the limit/extent of the incident is established “next day” considerations should be planned. At Ft Bagg this included canceling all scheduled operations. The busy labor and delivery deck could not discontinue operations...as a matter of fact a caesarian section was performed late in the day/early evening for failure to progress. (Some daily “routine” medical care could not wait for the mass casualty incident to end.) This point cannot be under sold... in addition to the primary incident more mundane medical emergencies continue to occur at the normal rate and at the most inopportune moments.When the extent of our incident could be seen we began sending some people home to unwind and rest ensuring that we would have fresh personnel available for the continuing operation. Anesthesia personnel must remain vigilant during their duties to provide safe and effective anesthetic care in the operating rooms. To ensure this capability the “day after” excess personnel were dismissed as appropriate.The need for secondary operations... faciotomies/debridements was obvious. We set out to prepare for this eventuality.
The fact that we at Womack had planned and practiced the mass casualty drill was evident on 23 Mar 93. The timing was fortuitous – having twice the normal number of health care providers available at the beginning of the emergency was just luck.We remained flexible and changed aspects of the plan as the needs arose. Intubation teams in the ER, airway rounds, positioning an anesthesiologist in the recovery room for the better part of the incidents, all these things enabled our team to best support the delivery of health care in this emergency.Communication should have been better; between the ER, the triage and airway team and the OR. I found myself or one of the airway management team performing messenger duty between the ER, hospital commander and the OR on several occasions... the phone lines were overwhelmed. I alluded to the lack of pictorial documentation. I wish I and other practitioners had the ability to show you some of the scenes from the ER, OR, and ICUs.We did something within the first week after the incident that at the beginning I didn’t think was necessary. A group meeting of all anesthesia providers with a psychologist.......
Shemya Island is in the Alaskan Aleutian chain. It is approximately 350 miles from ADAK (which is the nearest inhabited island.Dr Towne seems to have done the best she could with minimal assistance and technical capability. Principally, I like this report for its timelines (published two years after the event) and her ability to examine her own experience. One major point was she wished she had tasked administrative assistants to stay at her side throughout the ordeal. A recorder for each individual patient, one for overall numbers, and a runner.“The numbers were obviously important because they were being used to obtain the appropriate numbers of medical personnel supplies, and aircraft; but as the lone physician, some delegation of the number crunching would have freed me up to perform more patient care.”
Sarin is colorless, odorless, volatile and highly lethal organophosphate. Inhibition of cholinesterase produces acetylcholine overdose with symptoms of muscarinic and nicotinic hyperactivity and central nervous system toxicity. Sarin can be absorbed through any body surface. Vaporized sarin is mainly absorbed through the respiratory tract and conjunctivae.
The first problem identified in the review of the EMS response was the limited out-of-hospital care imposed by EMT practice restrictions. Their conclusion was to have more physician involvement in the out-of-hospital treatment either thru great communications capability or with physical presence.
Communications is the most often cited problem during MCI practice and real scenarios. Our country is not the only one with turf battles and inadequate cross-communications.Their conclusion“Integration and cooperation of concerned organizations should be established through disaster drills.”
Recognition of the magnitude of the problem by the command structure is imperative to activate the disaster plan as early as possible. At St Luke’s International hospital the President and VP assessed the situation personally and adjusted the operational mode within an hour of the first patient arriving. Adequate staff from internal and external resource pools were mobilized. Despite structural inadequacies at the hospital a method of triage and crowd control was eventually enforced. Their conclusion was “Hospital disaster planning must include guidance of mass casualties, an emergency staff call-up system, and an efficient emergency medical chart system.”Initial storage of 2-pyridine aldoxime chloride (2-PAM) and atropine sulfate in this facility were 100 amps of 2-PAM and 1,030 amps of atropine. They used 1,700 amps of 2-PAM and 2,800 amps of atropine.
The Japanese Defense Forces are proscribed from acting without the Prime Ministers authorization. They are under close civilian control and scrutiny. Their MCI plans were appropriately geared toward response to earthquakes, hurricanes and tsunamis. Local government retains autonomy even during disasters. They must request central government (JSDF) intervention. Their conclusion “Such a concentration of authority (that had been possible and the norm prior to WW II in Japan) may compromise democracy, but in the case of large-scale disasters, a concentration of authority would be valuable. The development of a legal basis for the concentration of authority during major disasters is greatly needed in Japan.”This last quote is a terrific example of a national level after action review.
In summary there are many items to keep in mind when faced with a mass cal situation, be prepared and be flexible.
Anesthesia Support of
Mass Casualty Incidents
COL Paul C. Reynolds, M.D.
Mass Casualty Incidents
• A disaster is an emergency that disrupts
normal community function and causes
concern for the safety, property, and lives of
• An MCI is a medical disaster that is
associated with the production of human
• MCI Level 1 -
• MCI Level 2 - multi-
• MCI Level 3 -
requiring state or
Philosophy of Disaster Care
• Normally - maximal time and resources devoted
• MCI - greatest good for the greatest number
• Expectant category
• Acceptable results
• Systematic assessment
• Triage and re-triage
• Patient dignity
• Pain Control
• Plan / Practice
• Execution / Evacuation
• A plan must be formulated
• The plan must be written down
• The plan must be disseminated
• The plan must be practiced
• Gallant Eagle
• Beirut, Lebanon
• Urgent Fury
• Bhopal, India •Gander, Newfoundland
•Ft Bragg, NC
Gallant Eagle ‘82
(30 March 1982)
• Parachute Operation: Ft Irwin, CA
• 158 injuries
• 6 deaths
• On-site Physicians Assistants
• Community Hospital - 10 miles
• 93rd Evacuation Hospital
“Our (unpublished) data suggest that in
military trauma, the first-attempt failure rate
[of intubations] could exceed 40%,
although it is less for experienced medical
officers. The rate of field-executed
cricothyroidotomies also suggests a high
occurrence of failed intubations.”
The Next Day
• Continuing operations
– other ongoing operations
– planning for secondary
– evacuation stabilization
• Rationing personnel
• Rest cycles
• “How did we do that?”
• What went well?
• What went badly?
• Psychological after effects
• Planning the next one!
China Eastern MD-11
(5 April 1993)
• Shemaya Island - Aleutian chain
• Medical clinic
• One staff physician
• 3 hours until first medical reinforcements
• 64 litter evacuations
• 93 ambulatory evacuations
Tokyo Subway Sarin Gas Attack
• Methyl phosphonofluoridic acid 1-
methylethyl ester (Sarin)
• Sarin is an organophosphate nerve agent.
• Dilute solutions in containers hidden on
three different commuter train lines.
• 5,500 patients
• Japanese emergency life-saving technicians
– Laryngeal Mask Airway
– Intravenous line
• Cannot be carried out without physician
• Tokyo Metropolitan Ambulance Control
Center (TMACC) “was in total confusion”
• Incoming information exceeded ability to
• Lack of cooperation and communication
between agencies involved
• Cessation of normal operations
• Change to disaster response
• Lack of decontamination
• Supply redistribution
• Japanese Self Defense Forces
• Planning was centered on local threats
• Acceptance of international help
– Especially regarding nerve agent treatment
“Although some knowledge exists of the long-term effects of
sarin on animals, there is little information about its effects
on humans. Follow-up of the victims of this large-scale
exposure is essential for that purpose.”
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