Mass Casualty Research Articles

An Investigation of Double Collisions of Pickup Trucks with Multiple Fatalities in Narathiwat Province, Thailand, October 2023

On 11 Oct 2023, a pickup truck crashed into a roadside tree in Narathiwat Province, southern Thailand after overtaking another vehicle. We conducted a descriptive study by reviewing medical records and interviewing rescuers, officers, survivors, and witnesses. We surveyed the collision site, reviewed video records, and used Haddon’s matrix to assist with the analysis. A pickup truck carrying 11 passengers (including the driver) overtook another pickup truck on a stretch of road. The driver of the first pickup truck lost control due to tire deflation and crashed into a tree resulting in eight deaths (72.7%) and three hospitalizations (27.3%). All deaths were caused by severe head injuries. Multiple factors during pre-crash (vehicle unfamiliarity leading to improper passing sight distance and speeding), the crash (overloaded truck and a roadside tree), and post-crash such as poor communication, contributed to the severity of this event. The driver of the truck had no driving license and was unfamiliar with the vehicle. Six passengers were sitting in the truck’s cab and three were in the cargo bed. Pre-crash and crash speeds were determined to be 80 and 100 kilometers per hour, respectively. The passing sight distance was grossly insufficient. Poor communication in the rescue process and the crowd of people at the scene resulted in improper emergency management. Strengthening law enforcement, increasing the number of speed limit signs, felling roadside trees, and practicing mass casualty incidents should be implemented.

Use of Self-Efficacy Scale in Mass Casualty Incidents During Drill Exercises

IntroductionMedical First Responders (MFRs) in the emergency department SUMMA 112 are tasked with handling the initial management of Mass Casualty Incidents (MCI) and building response capabilities. Training plays a crucial role in preparing these responders for effective disaster management. Yet, evaluating the impact of such training poses challenges since true competency can only be proven amid a major event. As a substitute gauge for training effectiveness, self-efficacy has been suggested.ObjectiveThe purpose of this study is to employ a pre- and post-test assessment of changes in perceived self-efficacy among MFRs following an intervention focused on the initial management of MCI. It also aimed to evaluate a self-efficacy instrument for its validity and reliability in this type of training.MethodIn this study, we used a pretest (time 1 = T1) – post-test (time 2 = T2) design to evaluate how self-efficacy changed after a training intervention with 201 MFRs in initial MCI management. ANOVA within-subjects and between subjects analyses were used.ResultsThe findings reveal a noteworthy change in self-efficacy before and after training among the 201 participants. This suggests that the training intervention positively affected participants’ perceived capabilities to handle complex situations like MCI.ConclusionThe results allow us to recommend a training program with theory components together with practical workshops and live, large-scale simulation exercises for the training of medical first responders in MCI, as it significantly increases their perception of the level of self-efficacy for developing competencies associated with disaster response.

Lessons Learned From a Large-Scale Military Mass Casualty Incident: Reevaluation of the Response to the Khobar Towers Bombing.

The 1996 Khobar Towers bombing, a large-scale mass casualty incident (MASCAL) at a coalition forces housing complex, resulted in 519 casualties. Key lessons learned include the importance of MASCAL exercises, self-aid and buddy care, and casualty triage, all critical to preparation for future terrorist attacks or near-peer combat operations MASCALs.

The need for a whole-of-community, victim-centred approach to mass victimisation incident planning and response

There have been a large number of masscasualty incidents in recent years, including climate change-related disasters, mass shootings, terrorist attacks, transportation accidents and a global pandemic. Communities, families and friends have suffered grief and loss, while nations continue to bear the scars of trauma. Disasters caused by acts with criminality, although necessarily managed by the police for the investigative aspect, must be planned for, and responded to with victim-centred practices by the police, local government and other relevant community stakeholders for the duration of the response and recovery. Inconsistency and confusion over terminology and language in emergency management can lead to a lack of understanding about which stakeholders or agencies should be engaged in, and responsible for different aspects of the planning, preparedness, mitigation and response to a community disaster — regardless of what type of disaster it is, and irrespective of the disaster being caused by a person or persons with ill-intent. This paper discusses how a wholeof- community and victim-centred approach to criminal act disaster response should be applied to support those persons most adversely affected by the incident. It also promotes the application of victim-centred practices to ensure that the needs of victims are regarded ethically, and with compassion following any disaster caused by an act of criminality. The term ‘mass victimisation incident’ will be introduced and applied through a case study.

Evaluation of Sexual Dimorphism Using Condylar and Coronoid Mandibular Parameters in Orthopantomograms: A Pilot Study.

Background Gender determination is critical to forensic science and medico-legal applications. Given that it is the most dimorphic bone in the skull and is frequently found intact, the mandibular bone may be extremely important in determining gender. Orthopantomograms (OPGs) are quite helpful in accurately estimating age and sex in this regard. It is a laborious task for forensics to determine the gender of victims of mass casualties, natural disasters, and severely dismembered bodies. The mandible, which is susceptible to development spurts, has a high degree of accuracy for determining sex. Aim This study aims to evaluate the potential use of coronoid height and condylar height as reliable anatomical markers for determining gender. Materials and methods In this study, 100 samples were used as study samples, 50 of which were male and 50 of which were female, in the age group of 20-30 years. The OPGs were obtained using a Planmeca Promax Scara 3 Digital OPG Machine (Planmeca, Helsinki, Finland), with settings of 70 kVp, 8 mA for 0.9 seconds, ensuring a 1:1 ratio. The images were then transferred to Planmeca Romexis® Viewer Software, Version 6.0 (Planmeca Oy, Helsinki, Finland) for measurement recording. Results Descriptive statistical analysis was done for this study and discriminant analysis was also done to create a population-specific formula. Results showed that the standard mean error for males concerning condylar height was 2.3 and coronoid height was 0.7. The standard mean error for females by condylar height was 1.6 and coronoid height was 0.6. The p-value was significant for coronoid height in both males and females. The p-value was not clinically significant for condylar height in both males and females. Conclusion The study's findings indicate that a larger mandibular angle is advantageous for gender assessment and helps with gender dimorphism. Out of both the parameters evaluated, coronoid height has shown statistical significance in both males and females. Hence, the study concludes that the parameter, coronoid height can be utilized to assess the gender of an individual.

What If Nice Terrorist Attack Would Have Happened in Milan? Drawing a Disaster Plan for Mass Casualty Incidents Involving the Pediatric Population.

Terrorist attacks involving children raised concern regarding the preparedness to treat pediatric trauma patients during mass casualty incidents (MCIs). The purpose of this project was to assess the resources available in Milan to respond to MCIs as the 2016 Bastille Day attack in Nice. Literature and guidelines were reviewed and minimal standard requirements of care of pediatric trauma patients in MCIs were identified. The hospitals that took part in the study were asked to answer a survey regarding their resource availability. An overall surge capability of 40-44 pediatric trauma patients was identified, distributed based on age and severity, hospital resources, and expertise. The findings showed that adult and pediatric hospitals should work in synergy with pediatric trauma centers, or offer an alternative if there is none, and should be included in disaster plans for MCIs. Simulations exercises need to be carried out to evaluate and validate the results.

Terrorist attacks in Türkiye: An analysis of counter-terrorism medicine

Aim: The objective of this research was to perform a counter-terrorism medicine analysis of terrorist attacks in Türkiye. Methods: This study is a retrospective cross-sectional research. The study population consisted of terrorist incidents that occurred in Türkiye, as provided by the START Global Terrorism Database for the period from 1970 to 2020. Various characteristics of terror attacks in Türkiye were analyzed and presented in tabular form. Results: Over the past 51 years, there have been a total of 4,485 terrorist incidents, with 91.2% reaching their intended targets as orchestrated by terrorist organizations in Türkiye. Of these incidents, 2,767 had detrimental economic impacts. Additionally, 17,570 individuals experienced adverse medical effects. Among the 81 provinces in Turkey, Istanbul witnessed the highest number of terrorist incidents and suffered the most significant medical consequences. Conclusion: Türkiye has been significantly impacted by terrorist incidents over the past fifty years especially within the last decade, particularly in metropolitan provinces like Istanbul. These events have negatively affected both the health and economic well-being of many individuals. In response, while the country has implemented various security measures and preparedness strategies to mitigate such incidents, there is also a critical need to improve the readiness of healthcare services to effectively handle the potential consequences of terrorist attacks. This includes advancing anti-terror medicine and tactical medicine capabilities, as well as strengthening mass casualty management systems. Such improvements will ensure a more effective and coordinated response to large-scale emergencies, ultimately saving lives and reducing the long-term impacts on society.

Tranexamic acid needs to be implemented in mass casualty incident protocols

Tranexamic acid needs to be implemented in mass casualty incident protocols

Frequency of deployed emergency donor panel use prior to implementation of the low titre group O whole blood program

IntroductionThe US military has frequently used a ‘walking blood bank’, formally known as an ‘emergency donor panel’ (EDP) to obtain warm fresh whole blood (WFWB) which is then immediately transfused...

Training for a mass casualty incident: Conception, development, and implementation of a crew-resource management course for forward surgical teams.

Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. The purpose of this article is to describe the development of a crew-resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service. The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development of an aircrew-like CRM training combining lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness; (3) Implementation of teamwork evaluation tools. A multidisciplinary team designed a conceptual framework for FST preparedness, 24 French FSTs completed a high-quality training that takes into account both technical and nontechnical skills to maintain quality of combat care during mass-casualty incidents, FSTs' CRM skills were assessed using an audio/video recording of a simulated mass-casualty incident.

Towards a Repository for Datasets of Mass Casualty Incidents

Many mathematical models and algorithms addressing logistics around mass casualty incidents (MCI) have been proposed in the literature. However, hardly any data sets exist that can be used to analyse, validate, and evaluate approaches and solutions. As MCI are comparably rare, real-world data is scarce and often extremely sensitive, making it difficult for researchers to get access and build test datasets. In this paper, we therefore present the firststeps towards a repository for the exchange of datasets to facilitate validation and comparison. We first provide an overview of potential stakeholders such as working groups, review disaster-related databases and existing repositories for other fields followed by a preliminary taxonomy to identify and structure the relevant entities and their characteristics within models for disaster management.

A SURVEY ON CONTINUOUS POSTGRADUATE DISASTER MEDICINE EDUCATION NEEDS IN THE PLOVDIV REGION

Introduction: Disasters, regardless of their origin, have a direct negative impact on the physical and psychological wellbeing of the population. Medical support for the casualties necessitates specific organization and training of medical personnel. Knowledge and skills in the field are considered to be essential for the execution of a rapid response. Purpose: The aim of this research was to study the need for postgraduate disaster medicine education for different categories of medical professionals in the Plovdiv region. Materials and methods: A cross-sectional study was conducted in 2020 through an anonymous inquiry among medical professionals from pre-hospital healthcare, hospital care and the centers for emergency medical aid in the Plovdiv region. Results: The survey was held among 160 medical professionals. They were interviewed regarding their participation in medical support for disasters or mass casualty incidents. 50,3% of them had such experience. 65% of the respondents evaluated their knowledge of disaster medicine as moderate, while only 18,7% reported high self-assessment. Most interviewees knew the knowledge and skills needed for disaster medical support, but half had never trained in these skills. Almost all respondents - 93,1%, considered disaster medicine knowledge useful for medical practice. 89,4% share the opinion that postgraduate courses were necessary. 93,2% preferred to be trained and educated on the subject by the Medical University. Conclusions: The results from our survey highlight the lower than expected self-confidence among medical professionals regarding their disaster medical support knowledge and skills. Postgraduate training could improve disaster resilience by increasing skill and confidence.

Evaluation of urological and gynecological surgeons as force multipliers for mass casualty trauma care.

The clinical demands of mass casualty events strain even the most well-equipped trauma centers and are especially challenging in resource-limited rural, remote, or austere environments. Gynecologists and urologists care for patients with pelvic and abdominal injuries, but the extent to which they are able to serve as "force multipliers" for trauma care is unclear. This study examined the abilities of urologists and gynecologists to perform 32 trauma procedures after mentored training by expert trauma educators to inform the potential for these specialists to independently care for trauma patients. Urological (6), gynecological surgeons (6), senior (postgraduate year 5) general surgery residents (6), and non-trauma-trained general surgeons (8) completed a rigorous trauma training program (Advanced Surgical Skills Exposure in Trauma Plus). All participants were assessed in their trauma knowledge and surgical abilities performing 32 trauma procedures before/after mentored training by expert trauma surgeons. Performance benchmarks were set for knowledge (80%) and independent accurate completion of all procedural components within a realistic time window (90%). General surgery participants demonstrated greater trauma knowledge than gynecologists and urologists; however, none of the specialties reached the 80% benchmark. Before training, general surgery, and urology participants outperformed gynecologists for overall procedural abilities. After training, only general surgeons met the 90% benchmark. Post hoc analysis revealed no differences between the groups performing most pelvic and abdominal procedures; however, knowledge associated with decision making and judgment in the provision of trauma care was significantly below the benchmark for gynecologists and urologists, even after training. For physiologically stable patients with traumatic injuries to the abdomen, pelvis, or retroperitoneum, these specialists might be able to provide appropriate care; however, they would best benefit trauma patients in the capacity of highly skilled assisting surgeons to trauma specialists. These specialists should not be considered for solo resuscitative surgical care. Therapeutic/Care Management; Level IV.

Putting the ready in readiness: A post hoc analysis of surgeon performance during a military mass casualty situation in Afghanistan.

All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient mass-casualty situation (MASCAL). The sample included orthopedic (four) and general surgeons (eight) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan, on August 26, 2021. One orthopedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1, expeditionary knowledge (examination score); 2, procedural skills competencies (performance assessment score); and 3, clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases was reviewed and rated (performance score) by the Joint Trauma System's Performance Improvement Branch, a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each predeployment measure and MASCAL surgical care. Predeployment knowledge and clinical activity measures met program benchmarks. Baseline predeployment procedural skills competency scores did not meet program benchmarks; however, those gaps were closed through retraining, ensuring all surgeons met or exceeded the program benchmarks predeployment. There were very large effect sizes (Cohen's d ) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons. The prescribed program measures ensured that all surgeons achieved predeployment performance benchmarks and provided high-quality trauma care to our nation's service members. Prognostic and Epidemiological; Level IV.

Immediate dry decontamination using efficient absorbent materials is beneficial following skin exposure to low-volatile toxic chemicals.

In a chemical mass casualty incident requiring skin decontamination, dry removal using absorbent materials may be beneficial to enable immediate decontamination. The efficacy of absorbent materials has therefore been evaluated, alone or procedures including both dry and wet decontamination, following skin exposure to two low volatile toxic chemicals using an in vitro human skin penetration model. Additionally, removal using active carbon wipes was evaluated with or without the Dahlgren Decon solution. All dry decontamination procedures resulted in a significantly decreased skin penetration rate of the industrial chemical 2-butoxyethanol compared to the control without decontamination. Wet decontamination following dry absorption significantly improved the efficacy compared to dry removal alone. Dry decontamination post-exposure to the chemical warfare nerve agent VX showed no decontamination efficacy. However, dry and wet decontamination resulted in a decreased agent skin penetration rate during the last hour of the experiment. At -15°C, significantly reduced VX skin penetration rates were demonstrated for both dry decontamination alone and the dry and wet decontamination procedure. The Dahlgren Decon solution significantly reduced the amount of VX penetrating the skin, but the active carbon wipe alone did not impact the skin penetration rate. In conclusion, absorbent materials are beneficial for the removal of low-volatile chemicals from the skin, but the degree of efficacy varies between chemicals. Despite the variability, immediate dry decontamination using available absorbent materials prior to wet decontamination is recommended as a general procedure for skin decontamination. The procedure should also be prioritized in cold-weather conditions to prevent patient hypothermia.

Effectiveness of a virtual reality trainer for retention of tourniquet application skills for hemorrhage control among emergency medicine residents.

With a rise in mass casualty incidents, training in hemorrhage control using tourniquets has been championed as a basic-and lifesaving-procedure for bystanders and medical professionals alike. The current standard for training is in-person (IP) courses, which can be limited based on instructor availability. Virtual reality (VR) has demonstrated the potential to improve the accuracy of certain medical tasks but has not yet been developed for hemorrhage control. The objective of this study was to evaluate the efficacy of a VR hemorrhage trainer in learner retention of tourniquet application when compared to traditional IP instructor teaching among a cohort of emergency medicine residents practicing in a Level I trauma center. This was a prospective, observational study of 53 emergency medicine residents at an inner-city program. Participants were randomly assigned to either the control or the VR group. On Day 0, all residents underwent a training session (IP vs. VR) for the proper, stepwise application of a tourniquet, as defined by the American College of Trauma Surgeons. Each participant was then assessed on the application of a tourniquet by a blinded instructor using the National Registry Hemorrhage Control Skills Lab rubric. After 3 months, each resident was reevaluated on the same rubric, with subsequent data analysis on successful tourniquet placement (measured as under 90 s) and time to completion. Of the 53 participants, the IP training group had an initial pass rate of 97% (28/29) compared to 92% (22/24) in the VR group (p = 0.58). On retention testing, the IP training group had a pass rate of 95% (20/21) compared to 90% (18/20) in the VR group (p = 0.62). Stratifying the success of tourniquet placement by level of resident training did not demonstrate any statistically significant differences. In this pilot study of emergency medicine residents, we found no significant differences in successful hemorrhage control by tourniquet placement between those trained with VR compared to a traditional IP course among emergency medicine residents. While more studies with greater power are needed, the results suggest that VR may be a useful adjunct to traditional IP medical training.

Medical Support Vehicle Location and Deployment at Mass Casualty Incidents

Anticipating and planning for the urgent response to large-scale disasters is critical to increase the probability of survival at these events. These incidents present various challenges that complicate the response, such as unfavorable weather conditions, difficulties in accessing affected areas, and the geographical spread of the victims. Furthermore, local socioeconomic factors, such as inadequate prevention education, limited disaster resources, and insufficient coordination between public and private emergency services, can complicate these situations. In large-scale emergencies, multiple demand points (DPs) are generally observed, which requires efforts to coordinate the strategic allocation of human and material resources in different geographical areas. Therefore, the precise management of these resources based on the specific needs of each area becomes fundamental. To address these complexities, this paper proposes a methodology that models these scenarios as a multi-objective optimization problem, focusing on the location-allocation problem of resources in Mass Casualty Incidents (MCIs). The proposed case study is Mexico City in a earthquake post-disaster scenario, using voluntary geographic information, open government data, and historical data from the 19 September 2017 earthquake. It is assumed that the resources that require optimal location and allocation are ambulances, which focus on medical issues that affect the survival of victims. The designed solution involves the use of a metaheuristic optimization technique, along with a parameter tuning technique, to find configurations that perform at different instances of the problem, i.e., different hypothetical scenarios that can be used as a reference for future possible situations. Finally, the objective is to present the different solutions graphically, accompanied by relevant information to facilitate the decision-making process of the authorities responsible for the practical implementation of these solutions.

Development and Evaluation of an Immersive Cinematic Escape Room for Disaster Preparedness and Self-Efficacy Among Nurses

BackgroundThe occurrence of natural disasters is unpredictable. Nurses need to have the core competency of disaster nursing to effectively respond to natural disasters. This study aimed to develop and evaluate the effectiveness of an immersive cinematic escape room (ICER) instructional approach in disaster preparedness and self-efficacy in nurses. MethodThis quasi-experimental research design used a convenience sample of 115 nurses. The course contents covered establishment of medical stations, incident command system (ICS), personal preparedness and protection in disasters, and mass casualty triage (START). Evaluation of disaster preparedness and self-efficacy occurred before, one week after and four weeks after the course. ResultsThe experimental group, lacking prior disaster preparedness education experiences, demonstrated a statistically significant improvement (p < .01) compared to the control group with more such experiences. At week four, both groups showed improvement in the self-efficacy scores, but the improvement did not achieve statistical significance (p > .05). ConclusionThe ICER approach significantly enhanced nurses’ disaster preparedness and self-efficacy. Educators are encouraged to adopt this approach for comprehensive disaster nursing education.

Training critical care teams for disaster response: Mass casualty incident simulation.

Training critical care teams for disaster response: Mass casualty incident simulation.

Implementation of a workshop for mass casualty incident triage training using an immersive virtual reality simulation.

We offered a workshop at the 2023 annual meeting of the Society for Academic Emergency Medicine to teach the Sort-Assess-Lifesaving Interventions-Treatment/Transport (SALT) triage protocol for responding to mass casualty incidents (MCIs) using an immersive virtual reality (VR) simulator. Here, we report workshop outcomes. After a 1-h didactic on the basics of triage protocols, workshop participants rotated through three skill stations at which learners learned how to use the VR headset and controllers, practiced applying SALT triage skills through a tabletop exercise, and then finally used our VR simulator for training responses to MCIs. During their encounter with VR, participants applied their new knowledge to triaging and treating the victims of an explosion in a virtual subway station. After a brief orientation, participants entered the scene to treat and triage virtual patients who had various life-threatening (e.g., acute arterial bleed, penetrating injury, pneumothorax, amputations) and non-life-threatening injuries (lacerations, sprains, hysteria, confusion). The simulator generated a performance report for each workshop attendee to be used for debriefing by a skilled facilitator. Participants were mostly trainees (residents), all of whom properly initiated their encounter with global sort commands (walk and wave) to identify the most critically injured. On average, participants correctly treated 92% of 18 injuries, with all bleeding injuries being properly controlled (tourniquets or wound packing). On average, participants correctly tagged 87.7% of 11 patients, but only took the pulse of 67% of the 11 patients. Learners had difficulty with cases involving embedded shrapnel and properly tagging patients who were stable after treatments. Our VR simulator provided a practical, portable, reproducible training and assessment system for preparing future emergency medical systems (EMS) medical directors to teach their EMS professionals the triage and lifesaving intervention treatment skills needed to save lives.