Mass Casualty Disaster Research Articles

Introduction to the Special Issue on Wars and Disasters: Advancing Care during Times of Crisis

Civilian mass-casualty disasters and armed conflict share many features, including the fact that both maximally challenge multidisciplinary burn teams. Rigorous training is required to build teams and systems that can respond effectively. One of the critical but potentially overlooked components of readiness for crisis care is a robust clinical research program. Rather than stalling progress, disasters and conflict over the last 100 years consistently energized advances in care. This was made possible by the hard work of our predecessors to learn from the crisis in the midst of the crisis, and resulted in significant reductions in postburn mortality. Now, further work is needed not only to maintain these improvements in mortality, but also to understand the long-term functional outcomes and to improve the quality of life of burn survivors. Clinical research programs to address these issues must be established now, so that we are optimally prepared for the next conflict or disaster.

538 Lessons Learned: Helping Non-Burn Facilities Prepare for Burn Mass Casualty Disasters

538 Lessons Learned: Helping Non-Burn Facilities Prepare for Burn Mass Casualty Disasters

Development and evaluation of a mechanical ventilator-sharing system.

During the COVID-19 pandemic surge in the hospitalization of critically ill patients and the global demand for mechanical ventilators, alternative strategies for device sharing were explored. We developed and assessed the performance of a system for shared ventilation that uses clinically available components to individualize tidal volumes under a variety of clinically relevant conditions. The feasibility of remote monitoring of ventilators was also assessed. By using existing resources and off-the-shelf components, a ventilator-sharing system (VSS) that ventilates 2 patients simultaneously with a single device, and a ventilator monitoring system (VMS) that remotely monitors pulmonary mechanics were developed. The feasibility and effectiveness of VSS and VMS were evaluated in benchtop testing using 2 test lungs on a single ventilator, and then performance was assessed in translational swine models of normal and impaired lung function. In benchtop testing, VSS and VMS delivered the set individualized parameters with minimal % errors in test lungs under pressure- and volume-regulated ventilation modes, suggesting the highest precision and accuracy. In animal studies, the VSS and VMS successfully delivered the individualized mechanical ventilation parameters within clinically acceptable limits. Further, we found no statistically significant difference between the target and measured values. The VSS adequately ventilated 2 test lungs or animals with variable lung conditions. The VMS accurately displayed mechanical ventilation settings, parameters, and alarms. Both of these systems could be rapidly assembled for scaling up to ventilate several critically ill patients in a pandemic or mass casualty disaster situations by leveraging off-the-shelf and custom 3D printed components.

401 Global Neurosurgery Advances from Trenches to Bedside: Lessons from Neurosurgical Care in War, Humanitarian Assistance, and Disaster Response

INTRODUCTION: War has influenced the development of neurosurgery. Armed conflict and mass casualty events, including Humanitarian Assistance Disaster Relief (HADR) missions, require military surgeons to innovate to meet extreme demands. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses METHODS: We performed a narrative review of the literature examining the influence of wars and mass casualty disasters on contemporary global neurosurgery practices. RESULTS: Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, use of combat body armor, and the rise of damage control neurosurgery. Workforce shortages during wars and disasters have promoted task-shifting and task-sharing in low-resource settings that catalyzed the establishment of the physician associate profession in the United States (US). Neurosurgical care has been utilized by the US as a form of "soft power" during natural and humanitarian disasters. Low-and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges— ubiquitous in low-resource settings— have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk. CONCLUSIONS: War and mass casualty disasters have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military with subsequent spread to the civilian sector as military neurosurgeons and civilian neurosurgeons, who are military reservists, returned from the battlefront or other low-resource locations. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.

Delayed renal injury in survivors of hematologic acute radiation syndrome

Purpose A mass casualty disaster involving radiological or nuclear agents continues to be a public health concern which requires consideration of both acute and late tissue toxicities in exposed victims. With the advent of advanced treatment options for the mitigation of hematological injuries, there are likely to be survivors of total body irradiation (TBI) exposures as high as 8–10 Gy. These survivors are at risk for a range of delayed multi-organ morbidities including progressive renal failure. Material and methods Here, we established the WAG/RijCmcr rat as an effective model for the evaluation of medical countermeasures (MCM) for acute hematologic radiation syndrome (H-ARS). The LD50/30 dose for adult and pediatric WAG/RijCmcr rats was determined for both sexes. We then confirmed the FDA-approved MCM pegfilgrastim (peg-GCSF, Neulasta®) mitigates H-ARS in adult male and female rats. Finally, we evaluated survival and renal dysfunction up to 300 d post-TBI in male and female adult rats. Results In the WAG/RijCmcr rat model, 87.5% and 100% of adult rats succumb to lethal hematopoietic acute radiation syndrome (H-ARS) at TBI doses of 8 and 8.5 Gy, respectively. A single dose of the hematopoietic growth factor peg-GCSF administered at 24 h post-TBI improved survival during H-ARS. Peg-GCSF treatment improved 30 d survival from 12.5% to 83% at 8 Gy and from 0% to 63% at 8.5 Gy. We then followed survivors of H-ARS through day 300. Rats exposed to TBI doses greater than 8 Gy had a 26% reduction in survival over days 30–300 compared to rats exposed to 7.75 Gy TBI. Concurrent with the reduction in long-term survival, a dose-dependent impairment of renal function as assessed by blood urea nitrogen (BUN) and urine protein to urine creatinine ratio (UP:UC) was observed. Conclusion Together, these data show survivors of H-ARS are at risk for the development of delayed renal toxicity and emphasize the need for the development of medical countermeasures for delayed renal injury.

Enhancing Mass Casualty Disaster Management Competencies through an Integrated Disaster Simulation Training Program

The Center for Innovations for Disaster Risk Reduction and Management in Health (DRRM-H) in NCR program developed a disaster simulation training aimed to address the challenges in communication, collaboration, and application of incident command system (ICS) during disaster response. This study aims to identify the effectiveness of an integrated didactic and simulation learning approach to disaster training using quantitative and qualitative methods. Results of the study indicate that training participants were able to increase their knowledge on the concepts of communication, collaboration, and application of ICS, and adopt these lessons to their own organizations to increase their capacity and capability during disaster response.

542 Mobile Burn Response Teams: A Scoping Review

IntroductionAdvancements in the treatment of burns have reduced morbidity. However, the resources needed to deliver up-to-date care may be overwhelmed by mass casualty disasters. In 2021, the World Health Organization (WHO) recommended that countries prepare teams of deployable burn experts to assist with responding to a mass casualty disaster including burn patients. The aim of this scoping review was to identify existing literature regarding burn management mobile response team organization, describe the reported effectiveness of these teams, identify challenges in adopting the WHO recommendations and consider how the recommendations may be evolved.MethodsWe conducted a scoping review of all literature types published up to February 2021. Searches of MEDLINE, EMBASE, Scopus, and CINAHL databases were conducted to identify reports informing or reporting the use of mobile burn care specialty teams that respond to events resulting in multiple burn-injured victims, including pediatric victims and military response to civilian events.ResultsOf 5,737 identified reports, 24 publications were reviewed. Three distinct types of mobile burn response teams were identified: 1) teams organized by burn care networks; 2) government-organized medical disaster teams with burn-specific experts, and 3) the US Army Burn Flight Team. Teams have responded to events such as terrorist attacks by providing specialized burn supplies and personnel. Mobile burn response teams have demonstrated expert triage and stabilization advantages but are limited by the number of deployable specialists. A challenge in deploying a mobile team is the removal of experts from a burn centre.ConclusionsAlthough the WHO recommends increasing the number of mobile burn response teams available around the world, few countries have implemented this recommendation. A hybrid model where responders on scene communicate with burn centre experts to manage triage may address these challenges.

Lessons Learned from Health Care Students Playing Victim in Mass Casualty Incident Disaster Drill

Purpose To educate health care students on the importance of emergency preparedness and disaster response training related to self-confidence and critical thinking needed when caring for victims of mass casualty incidents (MCI).
 Method A mixed-method design was employed. A post intervention-survey was administered to radiologic sciences and nursing students following their participation in a full-scale mass casualty disaster drill scenario. The quantitative data are presented as descriptive statistics along with Bowker’s Test of Symmetry. The open-ended questions were analyzed for patterns of similarity and differences among student responses. Several questions asked participants to evaluate their perceived knowledge and confidence before and after their participation in the MCI simulation.
 Results Data demonstrated that participants were made aware of their limited knowledge concerning necessary patient care skills needed during an MCI. In comparing the students’ willingness to care for MCI patients before the mock drill to after the mock drill, the students’ willingness increased and was statistically significant as indicated by a Bowker’s Test of Symmetry. Similarly, in comparing the students’ perceived confidence of their patient care skills before and after the mock drill, the participant's confidence level increased and was statistically significant as indicated by a second Bowker’s Test.
 Discussion Participants gained new knowledge of how community partners work together in response to an MCI event and the different roles each play. Additional take-away lessons revealed an increase in patient empathy. Both qualitative and quantitative questions highlight the students’ emotions and behavioral reactions as a result of acting as a trauma patient in the disaster drill.
 Conclusion The full-scale disaster drill was an effective tool in educating health care students of the diverse emergency operations that take place following a disaster and what is required to save lives.

Effect of different patient peak arrivals on an emergency department via discrete event simulation: a case study

Emergency department (ED) overcrowding is a well-recognized worldwide phenomenon which affects the quality of emergency care. A direct consequence of overcrowding is a long wait for visit and treatment of people who require primary care, possibly endangering the lives of critical patients. Healthcare management literature devoted to analyze ED operational policies is very wide, and many approaches have been proposed to address this important problem. However, less attention has been given to patient peak arrivals caused by the occurrence of some critical events which can strongly strain the operational efficiency of an ED. In this paper, we consider the particular case study of a medium-size ED located in a region of Central Italy recently hit by a severe earthquake, aiming at assessing the effects of such an occurrence on the ED operation. In particular, we propose a discrete event simulation (DES) model to analyze the patient flows through this ED, simulating unusual operational conditions due to a critical event, like a natural disaster, which causes a sudden spike in the number of patient arrivals. The availability of detailed data concerning the ED processes enabled building an accurate DES model and performing extensive scenario analyses. The model provides a valid decision support system for the ED managers in assessing specific emergency plans to be activated in case of mass casualty disasters.

The Role of Veterinarians in Mass Casualty Disasters: A Continuing Need for Integration to Disaster Management.

The need to prepare veterinarians to serve as part of the disaster medical response for mass casualty incidents has been recognized since at least the 1960's. The potential value of incorporating veterinarians for mass casualty disaster response has been noted by organizations throughout the world. Clinical veterinarians are highly trained medical professionals with access to equipment, medications, and treatment capabilities that can be leveraged in times of crisis. The ongoing threat of disasters with the current widespread healthcare access barriers requires the disaster management community to address the ethical constraints, training deficiencies and legal limitations for veterinary medical response to mass casualty disasters. An ethical imperative exists for veterinarians with translatable clinical skills to provide care to humans in the event of a mass casualty disaster with insufficient alternative traditional medical resources. Though this imperative exists, there is no established training mechanism to prepare veterinarians for the provision of emergency medical care to humans. In addition, the lack of clear guidance regarding what legal protections exist for voluntary responders persists as a barrier to rapid and effective response of veterinarians to mass casualty disasters. Measures need to be undertaken at all levels of government to address and remove the barriers. Failure to do so reduces potentially available medical resources available to an already strained medical system during mass casualty events.

Development and Validation of an Instrument to Measure Work-Related Stress among Rescue Workers in Traumatic Mass-Casualty Disasters.

Rescue workers are a population at high-risk for mental problems as they are exposed to work-related stress from confrontation with traumatic events when responding to a disaster. A reliable measure is needed to assess rescue workers’ work-related stress from their surveillance of a disaster scene to help prevent severe PTSD and depressive symptoms. The purpose of this study was to develop and validate the Work-Related Stress Scale (WRSS) designed to measure stress in rescue workers after responding to traumatic mass-casualty events. An exploratory sequential mixed methods procedure was employed. The qualitative phase of the item generation component involved in-depth interviews of 7 experienced rescue workers from multiple specialties who had taken part in 1 or 2 mass-casualty events: the 2018 Hualien earthquake or the 2016 Tainan earthquake. In the quantitative phase, a modified Delphi approach was used to achieve consensus ratings by the same 7 raters on the items and to assess content validity. Construct validity was determined by confirmatory factor analysis using a broader sample of 293 rescue workers who had taken part in 1 of 2 mass-casualty events: the 2018 Hualien earthquake or the 2021 Hualien train derailment. The final WRSS consists of 16 items total and 4 subscales: Physical Demands, Psychological Response, Environmental Interruption, and Leadership, with aggregated alphas of 0.74–0.88. The WRSS was found to have psychometric integrity as a measure of stress in rescue workers after responding to a disaster.

The Importance of Surgical Care to Achieve the United Nations Sustainable Development Goal for Healthy Lives by 2030.

This Viewpoint discusses the global lack of surgical care in mass-casualty disasters and for daily health and proposes integrating civilian, military, national, nongovernmental, and international resources to address the challenges.

Awareness of Temporary Field Emergency Medical Centers Operated by Paramedics on a First-Come-First-Served Basis in a Mass Casualty Disaster

This study was conducted to identify the need for the operation of temporary field emergency medical centers (TFEMC) by paramedics on a first-come-first-served basis at disaster sites where mass casualties occurred. The survey was conducted on 119 emergency doctors and paramedics from five fire departments under the Ulsan City Fire Department. More than 77.9% of the paramedics surveyed had been dispatched for the handling of many casualties at least once, but only 31.5% of them had experienced the establishment and operation of TFEMC. Awareness of triage showed a significant difference according to work career (F = 3.455, p = .009) and assigned work (F = 3.955, p = .004). Awareness of the disaster medical response system was significantly different according to rank (F = 5.299, p = .002), work career (F = 5.575, p = .000), age (F = 3.420, p = .018), and assigned work (F = 3.114, p = .016). There was no statistically significant difference in the awareness regarding TFEMCs. Most of the paramedics answered that they had not received mass casualty-focused education and that they needed related professional education. Therefore, for the efficient operation of TFEMCs managed by paramedics on a first-come-first-served basis, it is necessary to develop and implement various related professional training courses that combine theoretical training and field practice regarding the operation of TFEMCs, thus providing many paramedics an opportunity for education.

Emergency Medical Providers’ Knowledge Regarding Disasters during Mass Gatherings in Saudi Arabia

The Hajj is a recurring annual mass gathering event with over three million attendants taking place at the same site for six days. During such events, major incidents and disasters can occur. It is crucial that Emergency Medical Services providers are sufficiently trained regarding disaster preparedness to respond appropriately. EMS-providers of the Saudi Red Crescent Authority who worked during the Hajj in 2016 were asked to complete a web-based survey, utilizing predetermined responses with 5-point Likert scale responses. Seven hundred respondents identified real disasters as the most common source of information about disaster preparedness and also indicated that a disaster management course was the most desired course for improving knowledge. The study has also highlighted a list of Life Support Courses providers feel should be offered as part of a disaster response training package. These findings highlight the importance of continuing education, which may be obtained through short, focused courses, or for small numbers of specialists through higher educational degrees, such as masters or doctorates. This study also examines the importance of media and its impact on increasing knowledge and awareness for EMS-providers. Consideration should be given to pairing novice providers with experienced personnel to disseminate knowledge and practical experience during Hajj missions. Simulated disaster drilling should be considered to introduce novices to the stress of mass casualty disaster response.

Enhancing Mass Casualty Disaster Management Competencies Through an Integrated Disaster Simulation Training Program

Enhancing Mass Casualty Disaster Management Competencies Through an Integrated Disaster Simulation Training Program

Enhancing Mass Casualty Disaster Management Competencies Through an Integrated Disaster Simulation Training Program

Enhancing Mass Casualty Disaster Management Competencies Through an Integrated Disaster Simulation Training Program

How anthropological approach address social determinants of health in Asmat, Papua

Indonesia faced one of the most tragic and challenging health problems at the beginning of 2018, many children in Papua's Asmat Regency were suffering from malnutrition and measles. More than a thousand children were treated while 78 children under five years of age have died, mostly indigenous children. Asmat Regency is located in Indonesia's easternmost province with poor infrastructure and communication networks, also high transportation costs due to swampy regions criss-crossed by rivers, hard-to-reach from the center to the districts. Asmat's belief in their ancestors has formed their way of life and shaped their behavior, choices, and attitudes towards health issues, such as poor awareness regarding the fulfillment of daily nutritional intake, which is potentially harmful. Curative care is the highest priority in an extraordinary incident such as an outbreak or a mass-casualty disaster. However, establishment of the cultural hegemony of biomedicine will not be achieved overnight. Changing people's health behavior is a significant challenge. To maintain health sustainability, we must reach the entire community, including rural and remote areas, and work together with local indigenous stakeholders to bridge the gaps in sociocultural understanding. Resources that enhance the quality of life can have a significant influence on population health outcomes. By applying what we know about the Social Determinants of Health (SDH), we may not only improve population health but also advance health equity. The author offers a participant observation, discussing the social determinants based on self-experience living in an indigenous community in Asmat. This article aims to provide an overview of SDH in Asmat through the approach of medical anthropology, as the SDH may potentially have roles in health outbreaks, especially in the case of malnutrition and measles in early 2018.

Pediatric Emergency Medicine Disaster Simulation Curriculum: The 5-Minute Trauma Assessment for Pediatric Residents (TRAP-5).

IntroductionPediatric trauma management is a high-stress, high-risk, low-frequency event, and exposure through simulation can help identify and address knowledge gaps. Pediatric residents are likely to provide care for children with traumatic injuries, and it is important they are skilled in performing a rapid trauma assessment.MethodsWe developed a simulation-based rapid pediatric trauma assessment curriculum for pediatric residents in the setting of a mass casualty disaster. The patients were 5-year-olds portrayed by mannequins with varying injuries including intracranial hemorrhage, solid organ injury, and open extremity fractures. Critical actions included assigning roles, completing primary assessment within 2 minutes, and giving summary statement and management priorities within 5 minutes using clear communication techniques. We created a badge-sized reference card as well as scenario-specific debriefing tools to facilitate assessment and discussion of learning objectives following the simulation.ResultsWe conducted two sessions with a total of 49 participants. The case was rated as highly relevant (session 1, m = 4.7; session 2, m = 4.9) and realistic (session 1, m = 4.8; session 2, m = 4.4) by participants on a 5-point Likert scale. During the two sessions participants completed the primary survey in an average of 2.46 and 2.29 minutes, respectively, and the secondary survey with summary statement in an average of 5.08 and 4.27 minutes, respectively.DiscussionThis educational resource supports the setup, production, and debriefing of a low-fidelity simulation focused on the pediatric trauma assessment for the novice learner. Also included are educational reference materials and a participant evaluation form.

Medical Ethics in Extreme and Austere Environments

American society has a history of turning to physicians during times of extreme need, from plagues in the past to recent outbreaks of communicable diseases. This public instinct comes from a deep seated trust in physician duty that has been earned over the centuries through dedicated and selfless care, often in the face of personal risks. As dangers facing our communities include terroristic events physicians must be adequately prepared to respond, both medically and ethically. While the ethical principles that govern physician behavior—beneficence, nonmaleficence, autonomy, and social justice—are unchanging, fundamental doctrines must change with the new risks inherent to terroristic events. Responding to mass casualty disasters caused by terrorists, natural calamities, and combat continue to be challenging frontiers in medicine. Preparing physicians to deal with the consequences of a terroristic disease must include understanding the ethical challenges that can occur.

Orange Alert

It was the 3rd of March, 2013 during my internship year as I was headed off to The Aga Khan University Hospital for an evening shift in the ED. After I arrived in the "Back" (non-critical) area, our endorsement was interrupted by an unusual announcement: "The hospital is on orange alert." We all got extremely worried; orange alert was the color code for a mass casualty disaster! The hospital was anticipating the influx of a lot of patients.