Multiple Casualty Research Articles

Incidence of cervical spine injury in victims of dismounted blast: a systematic review

IntroductionDismounted blast has the potential to cause life-threatening injuries to multiple simultaneous casualties, including injury to the cervical spine (c-spine). Spinal immobilisation can be costly in terms of time and...

Utilization of registers to create an evidence-based approach in catastrophes and civil defence

Medical data registers are a key instrument of medical care research and a valuable tool for medical quality assurance. The structured plausibility tested documentation of large case numbers on a longitudinally oriented time axis with different points in time of data acquisition enables statements to be made on numerous relevant outcomes, not only the mortality of patients. For incidents outside the daily routine care in trauma surgery, such as natural disasters, accidents with multiple casualties and nonmilitary treatment of the domestic population in defence situations, such registers can provide data-based recommendations for action. These data, mainly obtained from routine traumatological treatment, enable a targeted resource management in the abovenamed incidents, which are associated with mass casualties. Due to the utilization of registers from the military field or from international registers, the perspective is additionally extended with respect to treatment strategies and injury patterns. Whether data can also be generated in a suitable manner for the abovenamed registers in specific disaster situations and can provide a direct gain of knowledge from the incident, must be critically discussed. The maintenance of the register datasets is time-consuming and has been subjected to a more stringent regulation at least since May 2018, when the European Union General Data Protection Regulation (EU-GDPR) came into force. The future Register Act in Germany will hopefully achieve greater simplification in the documentation of routine data.

Macroseismic Analysis of the 2023 Earthquakes in Jayapura

On January 2 and February 9, 2023, two significant earthquakes struck Jayapura City, leading to widespread panic, severe damage to buildings and public infrastructure, and multiple casualties. In response, the BBMKG V Earthquake Survey Team conducted a macroseismic study to evaluate the geological impacts, assess community responses, and document the overall effects of the earthquakes. The methodology employed included structured interviews and questionnaires administered to affected residents. The study revealed that soft rock conditions in the area contributed to an MMI scale VI impact, which resulted in extensive damage to public facilities and residential buildings. The insights gained from this study offer valuable information for improving future earthquake mitigation strategies and enhancing preparedness in seismically vulnerable regions.

Beyond the flames: understanding the impact of loss without body recovery or identification in fire-related mass disaster contexts

Abstract The World Trade Center attack (2001), the Black Saturday (2009), the Malaysia Airlines Flight 17 (2014), the wildfires of June and October in Portugal (2017), the California wildfires (2018)—these are a few examples of mass disaster events, specifically related to fire and high temperatures, which resulted in multiple casualties and several people unidentified and/or missing. Besides the physical destruction, the lost lives are one of the main consequences of these contexts. Dealing with the loss of a family member may not be an easy process, however, it is easier to accept when there is a body to bury. Conversely, not knowing the whereabouts of a person who might have been involved in a disaster makes mourning and returning to daily life harder. The family of the missing/unidentified lives in doubt and in a state termed as ‘ambiguous loss’. Forensic anthropologists face several challenges and obstacles when detecting and analysing burnt skeletal remains, which are increased in mass disaster contexts. However, the suffering experienced by the families of the victims of these contexts is far superior. Therefore, it is of utmost importance to employ all efforts to achieve the identity of these victims to allow the families to mourn, as well as to reassure society that no death is insignificant. Thus, the importance of identifying the victims of scenarios involving fire/heat is addressed in this paper through a brief description of some mass disaster events, emphasizing the challenges faced in identifying burnt remains and the psychological consequences families endure resulting from it.

Intentionally self-injured patients have lower mortality when treated at trauma centers versus non-trauma centers in South Korea

ObjectiveThis study investigated the characteristics and survival rates of patients with intentional severe trauma (self-harm or suicide) who were transported to either a regional trauma center (TC) or a non-TC...

Evaluating 900 Potentially Harming Fires in Germany: Is the Prescriptive Building Code Effective? German Fire Departments Assessed Fire Safety Measures in Buildings Through On-Site Inspections

Fire statistics mirror the outcome of fire prevention. Most fire statistics in Germany deal with the loss of life, value, and fire department actions (number of interventions, nozzles used, or alarm category like a false alarm). However, these results also represent the safety level the legislator has set through the prescriptive building regulations. The current statistics cannot evaluate the level of fire safety and the fulfillment or necessity of fire safety precautions. Today, expert judgment from firefighters is necessary to fill this gap. Here, we show the first evaluation of fire prevention and hazard protection measures by evaluating 900 potentially harming fires throughout Germany. In contrast to minor fires, these fires have advanced to the extent that they could potentially violate the protection objectives outlined in building regulations. The fire department association developed a questionnaire to evaluate the fire safety level and possibly reduce unnecessary fire safety regulations. One hundred twenty-three fire departments carried out the questionnaire, which are responsible for 25% of the German population. Fire prevention officers of the fire departments went to the scene after the fire was extinguished, and the fire safety concept of the building could be evaluated. We found a high rate of injuries, smoke spread, need for rescue by firefighters, and higher than expected firefighter response times after arrival at the scene. Surprisingly, smoke spread rates correlated with building height and not with building age. It was even possible to assess the risk of multiple casualties. Overall, the questionnaire results give insight into the current level of fire safety in existing buildings. Ways and rates for smoke and fire spread prove the importance of second escape routes and the influence of human misconduct. According to these results, current building code regulations are sufficient to prevent fire spread. On the other hand, smoke spreading is a severe threat to people’s safety. For example, the data shown can be applied in Bayes nets or other risk calculations to optimize individual building designs or even governmental building codes concerning fire safety engineering. Based on our observations, science, and building codes, authorities could in the future establish a performance-based building code instead of the current prescriptive code. This paper presents the first approach in Germany to quantify the expert judgment of fire departments and use it as a source of knowledge for fire prevention.

Are Two Bodies in a Trench a Mass Grave?

WARNING: THIS ARTICLE CONTAINS IMAGES OF MASS GRAVES FROM GENOCIDES, WHICH SOME MAY FIND DISTURBING The definitions for mass graves proposed in the past concentrated on the minimum number of casualties and whether they were in a connected body matrix. This meant that many graves practitioners encounter could not be classified properly. They were neither a single grave nor a mass grave. This article proposes four key measures to address the grave classification issue. Firstly, it introduces three simple criteria to assist in classification. Secondly, it suggests three new grave types (cluster, trench, and serial grave) to name the most common graves. Thirdly, a final grave type, the multiple grave, is added to describe any grave that does not fit into any of the other categories. Finally, this article suggests that the threshold between multiple and many casualties, i.e. how many casualties constitutes a mass grave, should be set for each individual conflict or context rather than aiming for a universal figure. These four measures are designed to be simple, intuitive and flexible enough to allow practitioners to use grave labels that make sense in their particular context for forensic and legal professionals as well as the general public.

A scenario-based robust approach for joint planning of multi-blood product logistics and multi-casualty type evacuation

This paper presents a two-stage hybrid robust programming model that integrates multiple blood products scheduling and multiple casualty types evacuation under facility disruptions risk and casualty number uncertainty. The model seeks to maximize the rescue efficiency and minimize the total operations cost. Under a set of disruption scenarios, we adopt a scenario-based robust method to address disruption risks at temporary medical centres and two robust uncertainty sets to deal with uncertain casualty numbers. We propose a proximal bundle algorithm to solve large-scale instances of the proposed hybrid robust model approximately. Extensive numerical experiments show that: (i) the trade-off between model robustness and solution robustness can help the decision-makers determine an appropriate risk-aversion weight; (ii) compared with the corresponding stochastic and scenario-based robust models, the hybrid robust model can obtain more robust solutions with a slight increase in cost; (iii) the proximal bundle algorithm can produce near-optimal solutions within reasonable computational times; (iv) some model parameters have significant impact on the total cost, which can help decision-makers set the appropriate parameters to achieve the desired outcome. Finally, we also use the real data of the 2008 Wenchuan County Earthquake in Sichuan Province, China, to illustrate the application of the model.

Exploring human factors of major chemical accidents in China: Evidence from 160 accidents during 2011–2022

Major chemical accidents (MCAs) usually cause multiple casualties, property losses, and environmental damage. MCAs in hazardous chemical production enterprises (HCPEs) in China have been frequent in recent years. Understanding past accidents is essential for accident prevention and risk mitigation. However, no accurate statistical analysis and systematic human cause investigation of MCAs in China is available. Hence, this study systematically identified the main characteristics and human factors of MCAs in China during 2011–2022 using official accident investigation reports. First, the 160 MCAs were investigated by mathematical and statistical methods involving eight main characteristics: evolution trend, spatial locations, accident types, domino effects involved, occurrence links, time volatility, hazardous chemicals involved, and enterprise scales. Second, based on the characteristics of MCAs and existing research on chemical accidents, the Human Factors Analysis and Classification System (HFACS) for Chemical Accidents (HFACS-CA), which consists of 26 cause categories and is suitable for the analysis of chemical accidents, was proposed on the basis of HFACS and other extended HFACS. Then, the selected 146 representative MCAs were analyzed using the HFACS-CA framework; the human factors (comprising human and organizational factors (HOFs) and outside factors) of MCAs in China were systematically explored. Finally, according to the main characteristics and human factors of MCAs, comprehensive recommendations for the prevention of MCAs involving enterprises, governments, and interested parties were proposed. This work can provide a useful human factor analysis tool for investigating chemical accidents and valuable information for preventing MCAs in China and other countries.

Stochastic ambulance dispatching and routing in mass casualty incident under road vulnerability

This paper investigates the stochastic ambulance dispatching and routing (SADR) problem with multiple casualty collection points in the mass casualty incidents (MCI) under uncertainty of road vulnerability and traffic congestion caused by an earthquake. A two-stage stochastic mixed-integer nonlinear programming model is formulated to derive a reliable and high-quality ambulance scheduling, dispatching and routing solution for maximizing expected number of survivors of all casualties. An integrated simulation optimization approach combining a data-driven travel time scenario generation algorithm, sample average approximation, and a column-generation-based heuristic method is developed to efficiently solve this complicated two-stage SADR model with a nonlinear objective function and continuous travel time distributions. Collaborating with the National Science and Technology Center for Disaster Reduction (NCDR), an empirical study using a potential real-world earthquake scenario occurring in Taiwan is conducted to demonstrate the usefulness and effectiveness of our proposed model and solution approach compared to the deterministic model and two current-practice heuristics.

Veterinary High-Stakes Immersive Simulation Training With Repeat Practice Following Structured Debriefing Improves Students' Ability to Cope With High-Pressure Situations.

Immersive simulation is used increasingly in medical education, and there is increasing awareness of the impact of simulation scenarios on emotional state and cognitive load and how these impact learning. 1 There is growing awareness of the requirement to equip veterinarians with skills for managing high-pressure environments and provide training on human factors. Veterinary students participated in a high-fidelity immersive simulation of a road traffic collision involving multiple casualties. The students took part in the same simulation twice, the second time after a debrief. Each participant's emotional state and cognitive load were assessed after participating in each simulation. Each participant was asked to score the effect of pressure on their performance. One hundred twenty-five students participated and demonstrated a higher cognitive load with more positive emotional states during the second scenario after the completion of a structured debrief and discussion focusing on pressure relief techniques (cognitive load - ¯ μ Scenario run 1 = 4.44 ± 1.85 [SD], ¯ μ Scenario2 = 5.69 ± 1.74 [SD]). Most (63%) participants described being in a low-performance state of frazzle during the first scenario compared with most (61%) who described being in a high-performance state of flow during the second. Immersive simulation scenarios, with structured debriefing, may allow the measurement of emotional state and cognitive load in participants. Furthermore, this study suggests that curriculum training in human factors and pressure relief techniques, coupled with immersive simulation and debrief, may improve future performance in high-stakes and high-pressure scenarios.

Evaluation of CBRN Preparedness of German Hospitals with Higher Level of Care: A Cross- Sectional Survey.

Chemical, biological, radiological, and nuclear (CBRN) events with multiple casualties are rare events, but preparedness is crucial for hospitals to respond properly. This study evaluated the preparedness and disaster planning of German hospitals for CBRN incidents. In a cross-sectional study, German hospitals with level III (highest level) emergency departments were surveyed using an online questionnaire focusing on risk assessment, infrastructure, hospital disaster planning, and preparedness for CBRN events. Between June and July 2023, 50 hospitals were surveyed. 62.5% of the hospitals had a section on chemical incidents in their disaster plan. A decontamination facility was available in 29.8% of the hospitals and chemical protective suits in 46.8%. The minority of the hospitals trained the correct handling of personal protective equipment (PPE) (39.1%) regularly or had frequent CBRN drills (21.3%). Most hospitals had the infrastructure for medical isolation (93.6%). The level of CBRN preparedness is heterogeneous for German hospitals. Most were well prepared for infectious patients, but only half of all hospitals had sufficient PPE for chemical incidents and only 30% had a decontamination facility available. Overall, the level of CBRN preparedness is still insufficient and needs further improvement.

Ten-year Causes of Cerebral Venous Sinus Thrombosis in Patients Referred to Ghaem Hospital from 2009 to 2019.

Cerebral Venous Sinus Thrombosis (CVST), a complex and infrequent cerebrovascular disorder characterized by the formation of clots within the cerebral venous sinuses, occurs as a result of multiple risk factors and casualties, and its epidemiological picture should be investigated. This descriptive study was conducted retrospectively on patients with a final diagnosis of cerebral vein thrombosis, who were referred to the emergency room of Ghaem Hospital (Mashhad, Iran) between 2009 and 2019. The study included all patients with cerebral vein thrombosis who were older than 18 years. Clinical symptoms and causes were documented and contrasted according to demographics. During the 10 years of this study, 749 cases of cerebral vein thrombosis were observed, with women accounting for the majority (72.8%). The most prevalent symptom was headache (554 cases; 74.0%), followed by seizures (23.1%), blurred vision (16.0%), nausea (7.5%), vomiting (6.9%), double nose (4.9%), and dizziness (3.3%). There was no significant difference in the frequency of symptoms between the two genders (p<0.05). The most commonly identified risk factors were OCP (110 cases; 14.7%), followed by infection (103 cases; 13.8%), malignancies (78 cases; 10.4%), and fasting (15 cases; 2.0%). There was no significant difference in risk factors between the two genders, with the exception that all cases of fasting were in women, and the differences were significant (p=0.015). The most common site of involvement according to Magnetic Resonance Venography (MRV) was the upper sagittal sinus (427 cases; 57.0%). There was no significant difference in terms of the site of the conflict between the two genders (p<0.05). The findings of the present study showed that deep vein thrombosis occurred mainly in women and manifested itself mostly as a headache. Moreover, the upper sagittal sinus was the most common site of involvement.

Video Enhanced Didactic Instruction for Mass Casualty Triage

Abstract Objectives High-Fidelity training in triage for Mass Casualty Incidents (MCI) is resource intensive and therefore limited in frequency despite knowing that this skill degrades with time. Didactic classroom materials offer a non-resource-intensive introduction to foundational concepts, but the extent to which it can prepare providers for real world scenarios is limited. Virtual reality (VR) is an effective training alternative, but in its infancy of development and accessibility. To bridge the gap between these modalities, we propose a video-enhanced method to didactic training. Methods During Uniformed Service University’s (USU) annual Operation Bushmaster field exercise we produced video footage of individual casualties along with multiple casualty scenes consisting of several 5-15 second videos capturing various elements of a primary survey. Results The videos offer a higher-fidelity alternative to written casualty descriptions allowing the learner to visually process casualty presentation that is more representative of reality. The video segments facilitate thinking through specific points in the decision-making process for triage and life saving interventions. Conclusions Video enhanced didactic training offers a bridge between written didactic training and exercise or VR training for MCI triage skills acquisition and sustainment. Assessment and validation of this training methodology with various MCI responders is recommended.

인천 서구 탱크로리 폭발사고로 본 과산화수소 분해반응에 대한 위험성에 관한 연구

In 2020, a significant accident occurred at a chemical plant in Seo-gu, Incheon, involving a tank explosion during the recovery of a mixture of hydrogen peroxide and sodium hydroxide in a tank lorry. This accident caused multiple casualties and extensive property damage. This study investigated the cause of the chemical explosion through a reproduction experiment (reactivity and temperature change) and a component analysis of the field samples. The results revealed a runaway reaction approximately 17 minutes after mixing hydrogen peroxide and sodium hydroxide, resulting in a temperature increase to 85 °C. Component analysis using NMR (Nuclear Magnetic Resonance) and pH analysis confirmed the similarity between the components of the product after the chemical reaction and the sample collected on site. Mechanical and electrical inspections of the exploded tank lorry exhibited a typical brittle fracture shape in the broken steel plate, indicating a structural failure. Electrical assessment ruled out the possibility of explosion due to static electricity and electrical singularities. We infer that the tank lorry explosion occurred due to the accelerated decomposition reaction caused by the positive catalytic action of sodium hydroxide mixed with hydrogen peroxide, which rapidly increased pressure within the tank.

Association between prehospital physician clinical experience and discharge at scene - retrospective cohort study.

Clinical experience has been shown to affect many patient-related outcomes but its impact in the prehospital setting has been little studied. To determine whether rates of discharge at scene, handover to paramedics and supervision are associated with clinical experience. A retrospective study, performed on all prehospital interventions carried out by physicians working in a mobile medical unit ("service mobile d'urgence et de réanimationˮ[SMUR]) at Geneva University Hospitals between 1 January 2010 and 31 December 2019. The main exclusion criteria were phone consultations and major incidents with multiple casualties. The exposure was the clinical experience of the prehospital physician at the time of the intervention, in number of years since graduation. The main outcome was the rate of discharge at scene. Secondary outcomes were the rate of handover to paramedics and the need for senior supervision. Outcomes were tabulated and multilevel logistic regression was performed to take into account the cluster effect of physicians. In total, 48,368 adult patients were included in the analysis. The interventions were performed by 219 different physicians, most of whom were male (53.9%) and had graduated in Switzerland (82.7%). At the time of intervention, mean (standard deviation [SD]) level of experience was 5.2 (3.3) years and the median was 4.6 (interquartile range [IQR]: 3.4-6.0). The overall discharge at scene rate was 7.8% with no association between clinical experience and discharge at scene rate. Greater experience was associated with a higher rate of handover to paramedics (adjusted odds ratio [aOR]: 1.17, 95% confidence interval [CI]: 1.13-1.21) and less supervision (aOR: 0.85, 95% CI: 0.82-0.88). In this retrospective study, there was no association between level of experience and overall rate of discharge at scene. However, greater clinical experience was associated with higher rates of handover to paramedics and less supervision.

Comparing Capabilities ofSimulation Modalities forTraining Combat Casualty Care: Perspectives ofCombat Medics.

Combat casualty care requires learning a complex set of skills to treat patients in challenging situations, including resource scarce environments, multiple casualty incidents, and care under fire. To train the skills needed to respond efficiently and appropriately to these diverse conditions, instructors employ a wide array of simulation modalities. Simulation modalities for medical training include manikins, task trainers, standardized patient actors (i.e., role players), computer or extended reality simulations (e.g., virtual reality, augmented reality), cadavers, and live tissue training. Simulation modalities differ from one another in multiple attributes (e.g., realism, availability). The purpose of this study was to compare capabilities across simulation modalities for combat casualty care from the perspective of experienced military medics. To provide a more complete understanding of the relative merits and limitations of modalities, military combat medics (N = 33) were surveyed on the capabilities of simulation modalities during a 5-day technical experimentation event where they observed medical simulations from industry developers. The survey asked them to rate each of eleven modalities on each of seven attributes. To elicit additional context for the strengths, limitations, and unique considerations of using each modality, we also collected open-ended comments to provide further insight on when and how to use specific simulation modalities. Results showed differences among the simulation modalities by attribute. Cadavers, role play, moulage, and live tissue all received high ratings on two or more attributes. However, there was no modality that was rated uniformly superior to the others. Instead, modalities appear to have unique strengths and limitations depending on the training context and objectives. For example, cadavers were seen as highly realistic, but not very reusable. The study furthers our understanding of simulation modalities for medical training by providing insight from combat medics on the benefits, limitations, and considerations for implementing different modalities depending on the training context. These results may be helpful to instructors in selecting modalities for their programs.

Multiple Casualty Incidents at a Level I Trauma Center: A 15-year Analysis

IntroductionLimited evidence regarding multiple casualty outcomes exists. Given resource strain with increasing patient load, we hypothesized that patients involved in a multiple casualty incident have worse outcomes compared to standard trauma patients. MethodsMultiple casualty victims from 2006 to 2021 at our institution were identified; admission data and trauma outcomes were then compared to standard trauma patients. Chi-square tests and Mann-Whitney U-tests were performed for categorical and non-normal continuous data, respectively. Logistic regression was performed to evaluate associations with mortality and intensive care unit (ICU) admission. ResultsWe identified 39,924 patients, of which 612 were multiple casualty patients (1.5%). Multiple casualty involvement was associated with younger age (29 y versus 44 y, P < 0.001) and higher rates of penetrating trauma (26.1% versus 21.4%; P < 0.001). Multiple casualty involvement was associated with higher injury severity score (ISS) (11.6 versus 7.9, P < 0.001), mortality (2.4% versus 1.5% P < 0.005), and ICU admission (17% versus 13%, P < 0.005). On logistic regression analysis, age, ISS, shock index, presence of the COVID-19 pandemic, and mechanism all independently predicted mortality (P ≤ 0.003), while multiple casualty involvement did not (P = 0.302). ConclusionsAlthough multiple casualty incidents are associated with patient factors that increase hospital resource strain, when controlling for age, ISS, shock index, presence of the COVID-19 pandemic, and trauma mechanism, involvement in multiple casualty incident was not independently associated with ICU admission or mortality. Improved understanding of the impact of high-volume trauma may allow us to improve our care of this at-risk population.

Outcome of severely injured patients in a unique trauma system with 24/7 double trauma surgeon on-call service

BackgroundThe presence of in-house attending trauma surgeons has improved efficiency of processes in the treatment of polytrauma patients. However, literature remains equivocal regarding the influence of the presence of in-house attendings on mortality. In our hospital there is a double trauma surgeon on-call system. In this system an in-house trauma surgeon is 24/7 backed up by a second trauma surgeon to assist with urgent surgery or multiple casualties. The aim of this study was to evaluate outcome in severely injured patients in this unique trauma system.MethodsFrom 2014 to 2021, a prospective population-based cohort consisting of consecutive polytrauma patients aged ≥ 15 years requiring both urgent surgery (≤ 24h) and admission to Intensive Care Unit (ICU) was investigated. Demographics, treatment, outcome parameters and pre- and in-hospital transfer times were analyzed.ResultsThree hundred thirteen patients with a median age of 44 years (71% male), and median Injury Severity Score (ISS) of 33 were included. Mortality rate was 19% (68% due to traumatic brain injury). All patients stayed ≤ 32 min in ED before transport to either CT or OR. Fifty-one percent of patients who needed damage control surgery (DCS) had a more deranged physiology, needed more blood products, were more quickly in OR with shorter time in OR, than patients with early definitive care (EDC). There was no difference in mortality rate between DCS and EDC patients. Fifty-six percent of patients had surgery during off-hours. There was no difference in outcome between patients who had surgery during daytime and during off-hours. Death could possibly have been prevented in 1 exsanguinating patient (1.7%).ConclusionIn this cohort of severely injured patients in need of urgent surgery and ICU support it was demonstrated that surgical decision making was swift and accurate with low preventable death rates. 24/7 Physical presence of a dedicated trauma team has likely contributed to these good outcomes.

Patterns in the Use of Emergency Telemedicine Support in the Management of Traumatic Road Crashes.

Objective: The introduction of emergency telemedicine care models is a common theme in health jurisdictions that include rural and remote populations. How the availability of these models influences the way clinicians manage traumatic road crashes is not yet fully understood. This study seeks to compare road crashes where telemedicine was and was not used and to identify any variables that may increase the likelihood of telemedicine usage by treating clinicians. Methods: Road crashes reported in the state Department of Transport and Main Roads (Queensland, Australia) crash database between January 1, 2019, and November 30, 2020 (n = 23,734) were compared to videoconferencing call logs to determine which crashes resulted in treatment that was supported by telemedicine (n = 204). Analysis was performed to examine differences in characteristics related to the crash depending on whether telemedicine support was requested. Results: Road crashes where telemedicine support was requested on average involved more casualties (1.6 vs. 1.41; t(11,287) = -3.26, p < 0.001, relative risk = 1.13). Crashes that occurred in rural settings accounted for most requests for telemedicine (65.68%; X2 = 159.2, p < 0.001) and a greater percentage of crashes in remote locations (3.36% vs. 2.35%; X2 = 256.97, p < 0.001, relative risk = 1.43). The use of telemedicine support for crashes was associated with a 13% increase in the mean number of casualties, compared to crashes where telemedicine support was not used. Conclusion: Telemedicine support is requested by clinicians providing emergency treatment in the management of road crashes that produce more severe injuries, involve multiple casualties, and take place in more rural settings or remote locations.