Mass Casualty Research Articles

Putting the ready in readiness: A post-hoc analysis of surgeon performance during a military MASCAL 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 MASCAL event. The sample included orthopaedic (4) and general surgeons (8) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan on 26 August 2021. One orthopaedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1. expeditionary knowledge (exam score), 2. procedural skills competencies (performance assessment score), 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 were 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 pre-deployment measure and MASCAL surgical care. Pre-deployment knowledge and clinical activity measures met program benchmarks. Baseline pre-deployment procedural skills competency scores did not meet program benchmarks, however those gaps were closed through re-training, ensuring all surgeons met or exceeded the program benchmarks pre-deployment. 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 all surgeons achieved pre-deployment performance benchmarks and provided high quality trauma care to our nation's servicemembers. Prognostic, Level III/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.

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

Aim: The objective of this research was to perform an medicine analysis of terrorist attacks in Türkiye. Methods: This study is a retrospective cross-sectional research. 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 in Türkiye, there have been a total of 4,485 terrorist incidents, with 91.2% reaching their intended targets as orchestrated by terrorist organizations. 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 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.

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.

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

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

IMPACT OF ARTIFICIAL INTELLIGENCE ON SOCIETY: RISK AND CHALLENGES

Artificial Intelligence (AI) refers to the simulation of human intelligence in machines that are programmed to think and act like humans. These machines are designed to perform tasks that typically require human intelligence, such as visual perception, speech recognition, decision-making, and language translation. AI technologies include machine learning, which enables computers to learn from experience and improve their performance over time without being explicitly programmed, and deep learning, which uses neural networks to process complex patterns and data. AI has applications in various fields, including healthcare, defence, transportation, education, and labour market, and its development has raised ethical, social, educational, and economic implications. The main objective of the study is to explore the literature on the artificial intelligence, its impact on society as well as challenges and risks posed by AI. Recently AI has been utilized in various fields. To cover various societal aspects, literature has been reviewed from various disciplines where AI is applied. These areas include healthcare, automobiles, education, labour market, defence, entertainment, computation, and security. These articles are retrieved from peer-reviewed sources based on the keywords suggesting the role of AI, forecasting & assessment of impact, behavioural & ecological aspects of AI, and AI's relation to employment. In this study it has been concluded that application of Artificial Intelligence has transformed the conventional ways of almost every area of modern society by bringing the significant changes in the industry, commerce, defence, education, labour market and healthcare services. But it has raised certain concerns also such as automation leads to job displacement and economic inequality concentrating revenue among fewer individuals. AI supported Autonomous Weapons to kill could cause mass casualties if misused. Hence the idea is both devastating and exciting and the application of AI should be carefully monitored. 

Comparison of Novel Proteomic Expression Profiles for Radiation Exposure in Male and Female C57BL6 Mice.

There is a need for point-of-care diagnostics for future mass casualty events involving radiation exposure. The development of radiation exposure and dose prediction algorithms for biodosimetry is needed for screening of large populations during these scenarios, and exploration of the potential effects which sex, age, genetic heterogeneity, and physiological comorbidities may have on the utility of biodosimetry diagnostics is needed. In the current study, proteomic profiling was used to examine sex-specific differences in age-matched C57BL6 mice on the blood proteome after radiation exposure, and the usefulness of development and application of biodosimetry algorithms using both male and female samples. Male and female mice between 9-11 weeks of age received a dose of total-body irradiation (TBI) of either 2, 4 or 8 Gy and plasma was collected at days 1, 3 and 7 postirradiation. Plasma was then screened using the SomaScan v4.1 assay for ∼7,000 protein analytes. A subset panel of protein biomarkers demonstrated significant (FDR < 0.05 and |logFC| > 0.2) changes in expression after radiation exposure. All proteins were used for feature selection to build predictive models of radiation exposure using different sample and sex-specific cohorts. Both binary (prediction of any radiation exposure) and multidose (prediction of specific radiation dose) model series were developed using either female and male samples combined or only female or only male samples. The binary series (models 1, 2 and 3) and multidose series (models 4, 5 and 6) included female/male combined, female only and male only respectively. Detectable values were obtained for all ∼7,000 proteins included in the SomaScan assay for all samples. Each model algorithm built using a unique sample cohort was validated with a training set of samples and tested with a separate new sample series. Overall predictive accuracies in the binary model series was ∼100% at the model training level, and when tested with fresh samples, 97.9% for model 1 (female and male) and 100% for model 2 (female only) and model 3 (male only). When sex-specific models 2 and 3 were tested with the opposite sex, the overall predictive accuracy rate dropped to 62.5% for model 2 and remained 100% for model 3. The overall predictive accuracy rate in the multidose model series was 100% for all models at the model training level and, when tested with fresh samples, 83.3%, 75% and 83.3% for Multidose models 4-6, respectively. When sex-specific model 5 (female only) and model 6 (male only) were tested with the opposite sex, the overall predictive accuracy rate dropped to 52.1% and 68.8%, respectively. These models represent novel predictive panels of radiation-responsive proteomic biomarkers and illustrate the utility and necessity of considering sex-specific differences in development of radiation biodosimetry prediction algorithms. As sex-specific differences were observed in this study, and as use of point-of-care radiation diagnostics in future mass casualty settings will necessarily include persons of both sexes, consideration of sex-specific variation is essential to ensure these diagnostic tools have practical utility in the field.

Hospital preparedness assessment for road traffic accidents with mass casualties: a cross-sectional study in Kurdistan Province, Iran

BackgroundRoad traffic accidents (RTAs) are predicted to become the world’s seventh leading cause of death by 2030. Given the significant impact of RTAs on public health, effective hospital preparedness plays a pivotal role in managing and mitigating associated health and life-threatening issues. This study aims to meticulously evaluate the preparedness of selected hospitals in western Iran to handle road traffic accidents with mass casualties (RTAs-MC).MethodsThe study employed a descriptive-analytical approach, utilizing a reliable and valid questionnaire to measure hospitals’ preparedness levels. Descriptive statistics (frequency distribution and mean) were utilized to provide an overview of the data, followed by analytical statistics (Spearman correlation test) to examine the relationship between hospital preparedness and its dimensions with the hospital profile. Data analysis, performed using SPSS software, categorized preparedness levels as weak, moderate, or high.ResultsThe study found that hospitals in Kurdistan province had a favorable preparedness level (70.30) to respond to RTAs-MC. The cooperation and coordination domain had the highest preparedness level (98.75), while the human resource management (59.44) and training and exercise (54.00) domains had the lowest preparedness levels. The analysis revealed a significant relationship between hospital preparedness and hospital profile, including factors such as hospital specialty, number of beds, ambulances, staff, and specialized personnel, such as emergency medicine specialists.ConclusionEnhancing preparedness for RTAs-MC necessitates developing response plans to improve hospital profile, considering the region’s geographic and topographic features, utilizing past experiences and lessons learned, implementing of Hospital Incident Command System (HICS), providing medical infrastructure and equipment, establishing communication channels, promoting cooperation and coordination, and creating training and exercise programs.

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

Radiology Department Disaster Preparedness: Practice, Strategies and Emergency Response

In order to respond effectively to any radiological emergencies, the implementation of disaster management practices is an essential and invaluable aspect. It can be difficult to know in advance exactly what you will be facing when you go to help people in a disaster situation brought about by hurricanes, earthquakes and other events, but the more compact medical technology you can bring in with you, the more you can accurately diagnose and assist those in need. Our disaster plans need to be programmatic, flexible, and should be continuously reviewed and updated. Within a few minutes of a disaster operationalize hospital support for the initial treatment of several injured patients and for ongoing care up to many hours is required. The Radiology Department is at the forefront of patient care in emergency situations, such as mass casualty incidents and natural disasters, providing critical diagnostic services to prioritize and triage patient needs. Radiological imaging is critical for improving patient outcomes and lowering morbidity and mortality, from detecting potentially fatal injuries to guiding surgical procedures. Radiologic technologists, radiologists, nurses, and other paramedic staff must actively participate in patient care. This paper provides an overview of the comprehensive strategy needed to maximize the radiology department’s preparedness and response for disasters.

Field Triage Tools in Mass Casualty Incidents: A Narrative Review

Mass casualty incidents (MCIs) pose significant challenges to healthcare systems, requiring rapid and effective triage strategies to optimize patient outcomes and resource utilization. This narrative review explores the evolution, effectiveness, ethical considerations, global perspectives, and future directions of field triage tools in MCIs. Beginning with the historical perspective, milestones in triage development, such as the Simple Triage and Rapid Treatment (START) protocol and its adaptations like Jump START and Sort, Assess, Lifesaving Interventions, Treat/Transport (SALT), are discussed. Current field triage systems are evaluated, including their application, limitations, and impact on patient outcomes. Training and education programs, challenges in triage education, and ethical/legal considerations in resource allocation and informed consent are examined. Global variations in triage systems, cultural factors, collaboration efforts, and standardization initiatives are explored to understand regional differences and promote interoperability. Future directions emphasize enhancing triage accuracy, integrating triage with healthcare systems, and research priorities. The review concludes with implications for practice and policy, calling for continued research, collaboration, and innovation to advance field triage capabilities and improve emergency response worldwide.

Leveraging technology in emergency management: An opportunity to improve compounding and cascading hazards linked to climate change.

The Intergovernmental Panel on Climate (IPCC) Sixth Assessment report concluded that we will see an increase in frequency of extreme environmental events around the world including, hurricanes, droughts, and wildfires.1 The report further describes cascading hazards when one hazard triggers another in a series such as extreme heat triggering a collapse of the power grid. The IPCC also discusses compounding hazards as multiple disasters occur at the same time for example a hurricane occurring at the same time as COVID-19 and a mass casualty event prompting a Urban Search &amp; Rescue (USAR) response such as the Surfside and the Florida condo collapse.2 Studies suggest that there are gaps relating to Hazard Mitigation Plans (HMP) in addressing cascading events.3,4

Investigating Emergency Medical System Challenges in Mass Casualty Incidents: A Case Report Study in Road Traffic Accidents in Northern Iran

Investigating Emergency Medical System Challenges in Mass Casualty Incidents: A Case Report Study in Road Traffic Accidents in Northern Iran

Proof of principle: An animal field triage protocol for livestock and horses caught in natural disasters and major incidents

Field triage systems are available to address mass casualty incidents involving humans, but lack for animals caught in disasters. This study aimed to develop, as a proof of principle, an animal field triage protocol for livestock, horses and wildlife based on an existing human triage system. A literature review was completed, resulting in choosing the human SALT triage algorithm as a starting point, followed by an expert consultation using a two-round Delphi study to evaluate and create the final version of the triage protocol. Finally, a group of first responders were familiarized with the protocol and triage injured animals in a simulated disaster environment using a purpose-built training game and provide written feedback. For livestock and horses, consensus was reached on the use of global sorting based on the criteria ‘autonomously mobile without obvious major injuries’, and on five of six appropriate physiological criteria applied for individual health state assessment. Triaged animals were placed in one of four categories developed for applicable veterinary care, being beyond saving (black), immediate/urgent (red), delayed (yellow) and minor (green). The expert panel agreed that the veterinary triage model is probably workable for livestock and horses but not for wildlife, and has added value in natural disasters and mass casualty incidents involving animals. Validation of the protocol with first responders on the usability of the triage protocol as a proof of principle warrants a careful introduction for practical use and further evaluation during disasters affecting livestock and horses in the field.

Secondary Ambulance Transfers During the Mass-Casualty Terrorist Attack in Israel on October 7, 2023.

On October 7, 2023, Israel experienced the worst terror attack in its history - 1,200 people were killed, 239 people were taken hostage, and 1,455 people were wounded. This mass-casualty event (MCE) was more specifically a mega terrorist attack. Due to the overwhelming number of victims who arrived at the two closest hospitals, it became necessary to implement secondary transfers to centers in other areas of the country. Historically, secondary transfer has been implemented in MCEs but usually for the transfer of critical patients from a Level 2 or Level 3 Trauma Center to a Level 1 Center. Magen David Adom (MDA), Israel's National Emergency Pre-Hospital Medical Organization, is designated by the Health Ministry as the incident command at any MCE. On October 7, in addition to the primary transport of victims by ambulance to hospitals throughout Israel, they secondarily transported patients from the two closest hospitals - the Soroka Medical Center (SMC; Level 1 Trauma Center) in Beersheba and the Barzilai Medical Center (BMC; Level 2 Trauma Center) in Ashkelon. Secondary transport began five hours after the event started and continued for approximately 12 hours. During this time, the terrorist infiltration was still on-going. Soroka received 650 victims and secondarily transferred 26, including five in Advanced Life Support (ALS) ambulances. Barzilai received 372 and secondarily transferred 38. These coordinated secondary transfers helped relieve the overwhelmed primary hospitals and are an essential component of any MCE strategy.

Developing a Multi-Focal Mass Casualty Drill to Test Surge Capacity of Prehospital and Community Hospital Resources

Developing a Multi-Focal Mass Casualty Drill to Test Surge Capacity of Prehospital and Community Hospital Resources

Prehospital mass casualty incident triage simulation builds knowledge and confidence in medical trainees.

Mass casualty incident (MCI) triage simulation is an increasingly useful tool for teaching triage systems to medical students, trainees, and hospital staff. MCI simulation in the prehospital setting has not yet been studied in this population. We aimed to assess the effectiveness of a prehospital MCI simulation in medical students, residents, and fellows. Our primary outcome was knowledge of the components of the triage algorithms used in MCI response. Our secondary outcome was each participant's confidence level if required to assist with or lead a MCI response. This was an observational study with pre-post surveys. We recruited 30 medical students, 14 emergency medicine (EM) residents, and four pediatric EM fellows to fill out a survey before and after a 3-h simulation session practicing the START and JumpSTART algorithms on two prehospital MCI scenarios. Overall, all groups demonstrated significant improvement in knowledge of triage colors, information needed to assign a triage color, pediatric airway management during a MCI, and indications for breaths-first CPR. They also demonstrated significant increase in confidence both in assisting with and in leading a MCI response. Simulated practice triaging patients in prehospital MCI scenarios improves knowledge of triage algorithms and increases confidence in assisting with or leading a MCI response in medical trainees.

Evaluating emergency response at a hospital near the Gaza border within 24 h of increased conflict

BackgroundFrontline hospitals near active hostilities face unique challenges in delivering emergency care amid threats to infrastructure and personnel safety. Existing literature focuses on individual aspects like mass casualty protocols or medical neutrality, with limited analysis of operating acute services directly under fire.ObjectivesTo describe the experience of a hospital situated meters from hostilities and analyze strategies implemented for triage, expanding surge capacity, and maintaining continuity of care during attacks with limited medical staff availability due to hazardous conditions. A focus will be placed on assessing how the hospital functioned and adapted care delivery models in the event of staffing limitations preventing all teams from arriving on site.MethodsA retrospective case study was conducted of patient records from Barzilai University Medical Center at Ashkelon (BUMCA) Medical Center in Israel within the first 24 h after escalated conflict began on October 7, 2023. Data on 232 admissions were analyzed regarding demographics, treatment protocols, time to disposition, and mortality. Missile alert data correlated patient surges to attacks. Statistical and geospatial analyses were performed.ResultsPatients predominantly male soldiers exhibited blast/multisystem trauma. Patient surges at the hospital were found to be correlated with the detection of incoming missile attacks from Gaza within 60 min of launch. While 131 (56%) patients were discharged and 55 (24%) transferred within 24 h, probabilities of survival declined over time reflecting injury severity limitations. 31 deaths occurred from severe presentation.ConclusionInsights gleaned provide a compelling case study on managing mass casualties at the true frontlines. By disseminating BUMCA's trauma response experience, strategies can strengthen frontline hospital protocols optimizing emergency care delivery during hazardous armed conflicts through dynamic surge capacity expansion, early intervention prioritization, and infrastructure/personnel protection measures informed by risks.

Implementation of a prehospital whole blood program: Lessons learned.

Early blood administration by Emergency Medical Services (EMS) to patients suffering from hemorrhagic shock improves outcomes. Prehospital blood programs represent an invaluable resuscitation capability that directly addresses hemorrhagic shock and mitigates subsequent multiple organ dysfunction syndrome. Prehospital blood programs must be thoughtfully planned, have multiple safeguards, ensure adequate training and credentialing processes, and be responsible stewards of blood resources. According to the 2022 best practices model by Yazer etal, the four key pillars of a successful prehospital program include the following: (1) the rationale for the use and a description of blood products that can be transfused in the prehospital setting, (2) storage of blood products outside the hospital blood bank and how to move them to the patient in the prehospital setting, (3) prehospital transfusion criteria and administration personnel, and (4) documentation of prehospital transfusion and handover to the hospital team. This concepts paper describes our operational experience using these four pillars to make Maryland's inaugural prehospital ground-based low-titer O-positive whole blood program successful. These lessons learned may inform other EMS systems as they establish prehospital blood programs to help improve outcomes and enhance mass casualty response.