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    Disasters and Mass Casualty Incidents: The Nuts and Bolts of Preparedness and Response to Protracted and Sudden Onset Emergencies
    Disasters and Mass Casualty Incidents: The Nuts and Bolts of Preparedness and Response to Protracted and Sudden Onset Emergencies
    Disasters and Mass Casualty Incidents: The Nuts and Bolts of Preparedness and Response to Protracted and Sudden Onset Emergencies
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    Disasters and Mass Casualty Incidents: The Nuts and Bolts of Preparedness and Response to Protracted and Sudden Onset Emergencies

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    Mass Casualty events may occur as a result of natural or human-caused disasters or after an act of terrorism. The planning and response to disasters and catastrophes needs to take into consideration the distinction between progressive   and sudden events. Insidious or slowly progressive disasters produce a large number of victims but over a prolonged time period, with different peaks in the severity of patients presenting to the hospital. For example, radiation events will produce a large number of victims who will present days, weeks, months, or years after exposure, depending on the dose of radiation received. The spread of a biological agent or a pandemic will produce an extremely high number of victims who will present to hospitals during days to weeks after the initial event, depending on the agent and progression of symptoms.
    On the other hand, in a sudden disaster, there is an abrupt surge of victims resulting from an event such as anexplosion or a chemical release. After the sarin gas attack in a Tokyo subway in 1995, a total of 5500 victims were injured and required medical attention at local hospitals immediately after the attack. The car bomb that exploded near the American Embassy in Nairobi, Kenya, killed 213 people and simultaneously produced 4044 injured patients, many requiring medical care at local hospitals. The Madrid train bombing in March 2004 produced more than 2000 injured victims in minutes, overwhelming the city’s healthcare facilities. More than 500 injured patients were treated at local hospital after the mass shooting in Las Vegas. Finally, earthquakes may produce a large number of victims in areas in which the medical facilities are partially or completely destroyed. Sudden events bring an immediate operational challenge to community healthcare systems, many of which are already operating at or above capacity.
    The pre-hospital as well as hospital planning and responseto sudden mass casualty incidents (SMCI’s) is extremely challenging and requires a standard and protocol driven approach.  Many textbooks have been published on Disaster Medicine; although they may serve as an excellent reference, they do not provide a rapid, practical approach for management of SMCI’s. 
    The first edition of “Mass Casualty Incidents: The Nuts and Bolts of Preparedness and Response for Acute Disasters” dealt exclusively with sudden mass casualty incidents.  The second edition will expand its focus and include planning and response for insidious and protracted disasters as well. 
    This new book is designed to provide a practical and operational approach to planning, response and medical management of sudden as well as slow progressive events.  The target audience of the second edition will be health care professionals and institutions, as well as allied organizations, which respond to disasters and mass casualty incidents.  
    Parts I and II are essentially the first edition of the book and consist of planning of personnel, logistic support, transport of patients and equipment and response algorithms.  These 2 parts will be revised and updated and include lessons learned from major mass shootings that occurred recently in the United States and other parts of the world 
    Part III will describe the planning process for progressive disasters and include response algorithms and checklists.
    Part IV will handle humanitarian and mental health problems commonly encountered in disaster areas.
    Part V will deal with team work and communication both critical topics when handling catastrophes and mass casualty incidents. 
    This new book will be a comprehensive tool for healthcare professionals and managers and should perform demonstrably better in sales and downloads.
    LanguageEnglish
    PublisherSpringer
    Release dateNov 10, 2018
    ISBN9783319973616
    Disasters and Mass Casualty Incidents: The Nuts and Bolts of Preparedness and Response to Protracted and Sudden Onset Emergencies

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      Book preview

      Disasters and Mass Casualty Incidents - Mauricio Lynn

      Part IPlanning and Response to Sudden Mass Casualty Incidents

      © Springer Nature Switzerland AG 2019

      Mauricio Lynn, Howard Lieberman, Lior Lynn, Gerd Daniel Pust, Kenneth Stahl, Daniel Dante Yeh and Tanya Zakrison (eds.)Disasters and Mass Casualty Incidentshttps://doi.org/10.1007/978-3-319-97361-6_1

      1. General Information

      Mauricio Lynn¹  

      (1)

      University of Miami Miller School of Medicine, Jackson Memorial Hospital, Department of Surgery, Miami, FL, USA

      Mauricio Lynn

      Email: [email protected]

      Keywords

      DisasterMass Casualty IncidentSuddenProgressiveChaos phase

      Introduction

      This section will set up the stage for the entire book with the objective to better clarify its focus.

      Planning to handle catastrophes should be according to the speed that the initial medical response requires to handle the increased number of patients, and the initial ratio between caregivers and patients.

      From a medical perspective, the most difficult challenge is to respond to an event that occurred suddenly, without prior notice and with a large number of injured or contaminated patients. The Sarin gas attack in the Tokyo subway in 1995, where more than 5000 people were contaminated, the Madrid train bombings in 2004, with more than 2000 casualties and the Mass Shooting incident in Las Vegas in 2017, where more than 800 people were injured, are great examples of large-scale, unplanned mass casualty incidents.

      Therefore, the definition and classification of disasters in this section is different than in other publications. It is the introduction of the concept of sudden mass casualty incident (SMCI).

      Definitions

      In other publications, disasters and mass casualty incidents (MCIs) are interchangeable concepts. Nevertheless, from a medical perspective, there is a need to separate the definitions, since almost all MCIs are ‘disasters’ for the community, but not all disasters are associated with MCIs.

      Disaster

      A disaster is a natural or man-made hazard resulting in significant physical damage or destruction, loss of life or drastic change to the environment (Fig. 1.1).

      From a medical perspective, a disaster may cause injuries, contamination or disease to people, or may be associated with only physical damage, without affecting the health of human beings.

      ../images/302593_2_En_1_Chapter/302593_2_En_1_Fig1_HTML.jpg

      Fig. 1.1

      Exxon oil spill , considered one of the largest ecological disasters in modern history, 1989

      Mass Casualty Incident (MCI)

      A mass casualty incident (MCI) is an event where the number of patients temporarily exceeds the capability of the first responders at the scene or of the medical staff at the hospital to provide optimal care to all victims simultaneously.

      A MCI is a ‘temporary state of insufficiency’ (Fig. 1.2).

      At the pre-hospital phase, the ‘state of insufficiency’ may be due to:

      Insufficient access and evacuation routes for ambulances.

      Insufficient number of ambulances and/or helicopters during the initial phase.

      Insufficient number of personnel (drivers, paramedics, physicians (if applicable) during the first hours.

      Insufficient amount of equipment and supplies.

      At the hospital phase, the ‘state of insufficiency’ may be due to:

      Insufficient number of personnel (doctors, nurses, technicians, transporters, clerks, security guards) during the initial phase.

      Insufficient space in the emergency department (ED) or intensive care unit(s).

      Insufficient number of operating rooms available.

      Insufficient number of available ventilators.

      Insufficient amount of supplies.

      Insufficient number of blood units available for immediate use.

      ../images/302593_2_En_1_Chapter/302593_2_En_1_Fig2_HTML.png

      Fig. 1.2

      Bus explosion by suicide bomber , Jerusalem, Israel, 2006

      Even in countries where MCIs are common, there will always be a ‘state of insufficiency’ both at the pre-hospital and at the hospital.

      The main objective of a well-written and detailed disaster plan combined with frequent live exercises and drills is to shorten the period of ‘insufficiency’.

      Classification

      Disasters and catastrophes may be divided into two major categories, according to the initial medical response:

      Progressive Disasters or Pre-planned Mass Gatherings

      A progressive disaster may occur over a long period of time, such as days, weeks, months or even years.

      From a medical perspective, the individuals inside the Chernobyl nuclear reactor did not survive the initial explosion, but up to these days, there is a higher incidence of thyroid cancer among those people exposed to the radiation (Fig. 1.3).

      ../images/302593_2_En_1_Chapter/302593_2_En_1_Fig3_HTML.png

      Fig. 1.3

      Chernobyl nuclear reactor after the accident , 1986

      A typical progressive event is the slow spread of a biological agent (Fig. 1.4). The total number of infected patients may be enormous, but characteristically, not all arrive at one emergency department (ED) simultaneously. Sick patients will either go to their primary care physician first or to the closest ED.

      ../images/302593_2_En_1_Chapter/302593_2_En_1_Fig4_HTML.png

      Fig. 1.4

      Patient with smallpox

      Another good example of a progressive event is the slow evolution of a hurricane . Typically, the path of a major storm may be known for days before it makes landfall. Its slow progression allows for evacuation of populations at risk and deployment of emergency personnel and equipment prior to storm arrival.

      The medical response for a progressive disaster should be in place before the event reaches its full magnitude.

      Similar planning and response may be used for mass gatherings, such as major sporting events, concerts or air shows. In these situations, risk assessment is performed, potential threats are analyzed and possible medical consequences are considered. According to the findings, all or fractions of the planned medical response may be deployed prior to the event:

      Ambulances

      Medical personnel

      Helicopters

      On-site decontamination facilities

      Pre-planned access and evacuation routes

      Sudden Mass Casualty Incidents

      A sudden mass casualty incidents (SMCI) may be a result of a train or plane crash, earthquake, explosion or mass shooting. The common theme of all these events is that they occur without prior warning. This fact results in a ‘temporary state of insufficiency’, described previously.

      SMCIs may be of conventional nature, more commonly traumatic, blast and burn injuries, chemical exposure to hazardous materials or a radiological dispersal device (RDD) , also known as ‘dirty bomb ’.

      Unlike with progressive disasters, the medical response for SMCIs is initiated after the event has already reached its full magnitude. This circumstance presents as a major challenge for the first responders at the scene as well as for the hospitals that need to absorb and treat a large number of injured patients, with minimal time to prepare.

      A large-scale SMCI (e.g. Madrid train bombing, mass shooting in Las Vegas, earthquakes) may overwhelm the medical resources of a city, its emergency medical services (EMS), medical centres, medical examiner and mortuaries. It is this type of incident that may require external help, from within the state, the country or international.

      Epidemiology of Sudden Mass Casualty Incidents and Its Practical Applications

      The main goal of the medical response to a sudden mass casualty incident (SMCI) is to identify and manage the critical patients in an attempt to save lives. For planning purposes, it is imperative to know the approximate number of severe or critical patients to expect after a SMCI. Therefore, it is important to learn the epidemiology of such events.

      Examples of SMCIs include

      Explosions.

      Plane crashes.

      Train derailments.

      Earthquakes (Fig. 1.5).

      Volcanic eruptions (Fig. 1.6).

      Mass shootings.

      Massive chemical contamination (Fig. 1.7).

      Radiological dispersal device (RDD) or ‘dirty bomb’.

      ../images/302593_2_En_1_Chapter/302593_2_En_1_Fig5_HTML.png

      Fig. 1.5

      Relief efforts, Haiti earthquake , 2010

      ../images/302593_2_En_1_Chapter/302593_2_En_1_Fig6_HTML.jpg

      Fig. 1.6

      Volcanic eruption, Hawaii , 2018

      ../images/302593_2_En_1_Chapter/302593_2_En_1_Fig7_HTML.png

      Fig. 1.7

      Sarin gas attack, Tokyo, 1995

      Regardless of the type of SMCI, the vast majority of the injured or contaminated patients will be walking wounded.

      In all examples above, the number of critical patients, who require immediate attention, is low and rarely exceeds 20% of the total number of injured.

      Planning for a MCI should focus on directing resources, such as personnel, equipment and supplies, to manage those few who are critically injured and/or contaminated and salvageable.

      The concept of ‘the greatest good for the greatest number’ is a myth, and it is not supported by any published literature regarding the severity of injuries in an urban SMCI.

      © Springer Nature Switzerland AG 2019

      Mauricio Lynn, Howard Lieberman, Lior Lynn, Gerd Daniel Pust, Kenneth Stahl, Daniel Dante Yeh and Tanya Zakrison (eds.)Disasters and Mass Casualty Incidentshttps://doi.org/10.1007/978-3-319-97361-6_2

      2. Prehospital Planning and Response to Sudden Mass Casualty Incidents

      Mauricio Lynn¹  

      (1)

      University of Miami Miller School of Medicine, Jackson Memorial Hospital, Department of Surgery, Miami, FL, USA

      Mauricio Lynn

      Email: [email protected]

      Keywords

      PrehospitalIncident commandCommunicationsEmergency Operations CenterTriageBystanders

      Introduction

      This section describes important topics of the planning of the response for the first responders, in particular the emergency medical services (EMS) , to a sudden mass casualty incident (SMCI).

      The section includes the prehospital phases of a sudden mass casualty incident (SMCI), discusses the limitations of deploying a scene incident command (SIC) and regional emergency operations center (REOC) for this type of events, stressing the importance of a coordinated communication system.

      Finally, the section introduces a new concept such as Save and Run and discusses the pitfalls of patient tracking at the scene of the incident and the importance of patient tracking at the hospital.

      Phases and Characteristics of Mass Casualty Incidents

      All sudden mass casualty incidents (SMCIs) have common characteristics. It is important to be familiar with them as they will have a major impact on the prehospital as well as on the hospital planning of the response.

      Chaos Phase

      The initial minutes following any SMCI are known as the chaos phase . It is characterized by a lack of leadership, organization, and control. Bystanders do their best to help, but their efforts are uncoordinated and at times can even exacerbate the already dangerous situation. The arrival of the first ambulances at the scene is not coordinated, and there is little control of their destination. It is during this phase that minor injuries are evacuated first, by private vehicles or by ambulances. As a result, these noncritical patients will be the first to arrive at local hospitals. Awareness of this phenomenon will ensure that the emergency rooms will not be filled and overwhelmed with minor injuries before the critical patients arrive.

      It is almost impossible to control the chaos! The presence of yellow tape surrounding the scene does not mean the chaos, or the scene is under control!

      Clearing the scene, by rapid evacuation of the critically injured, is a key strategy to reduce the

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