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MCI or Disaster? Dilemmas and traps Kostas A. Papaioannou, MD, MSc Plastic Surgeon F. President of MSF-Greece European Master in Disaster Medicine 1.

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Presentation on theme: "MCI or Disaster? Dilemmas and traps Kostas A. Papaioannou, MD, MSc Plastic Surgeon F. President of MSF-Greece European Master in Disaster Medicine 1."— Presentation transcript:

1 MCI or Disaster? Dilemmas and traps Kostas A. Papaioannou, MD, MSc Plastic Surgeon F. President of MSF-Greece European Master in Disaster Medicine 1

2 The referring doctor, the patient or his environment determine, what constitutes an "emergency", and define the reason, time and point of entry into the system, regardless of age and the ultimate nature of the illness or injury The Medical staff in ED, manages the unanticipated and unscheduled unpredictable volume of patients with injuries and conditions of undetermined and varying severity and complexity 2

3 The Student Manual for Disaster Management and Planning for Emergency Physician's Course (ACEP:1-2): Level I: A localized multiple casualty emergency wherein local medical resources are available and adequate to provide for field medical treatment and stabilization, including triage. The patients will be transported to the appropriate local medical facility for further diagnosis and treatment. Level II: A multiple casualty emergency where the large number of casualties and/or lack of local medical care facilities are such as to require multi-jurisdiction (regional) medical mutual aid. Level III: A mass casualty emergency wherein local and regional medical resource's capabilities are exceeded and/or over-whelmed. Deficiencies in medical supplies and personnel are such as to require assistance from state or federal agencies. 3

4 1.Cataclysmic events, both natural and man-made 2. War, either full-scale or more insidious 3. Terrorist actions, often connected with either of the two situations listed above unpredictable events 4

5 Airport →air crash → mass casualties with many survivors suffering brain injury, smoke inhalation, and conventional trauma Chemical weapons development in laboratory → accidental release of agent(s) →mass casualty situation with victims ultimately suffering compromise of airway patency or respiratory, circulatory, and neurologic system failure Sports stadium→ bleacher collapse → mass casualty situation with multiple fractures, head and spine injuries, as well as crush syndrome 5

6 Routine EmergenciesDisasters Interaction with familiar facesInteraction with unfamiliar faces Familiar tasks and proceduresUnfamiliar tasks and procedures Intra-organizational coordination needed Intra- and inter-organizational coordination needed Roads, telephones, and facilities intact Roads may be blocked or jammed, telephones jammed or non- functional, facilities may be damaged Communications frequencies adequate for radio traffic Radio frequencies often overloaded Communications primarily intra- organizational Need for inter-organizational information sharing Differences in Disasters 6

7 Differences in Disasters ( 2 ) Routine EmergenciesDisasters Use of familiar terminology in communicating Communication with persons who use different terminology Need to deal mainly with local press Hordes of national and international reporters Management structure adequate to coordinate the number of resources involved Resources often exceed management capacity 7

8 Routine EmergenciesDisasters The events which are classified as ‘emergencies’ are less common than ‘incidents’ but are still within the capability of responders and their organizations. Emergencies may include large (e.g., apartment) fires, multi-vehicle accidents, and hostage- taking or shooting incidents. ‘Crises’ and ‘disasters’ are defined as abnormal and unique events that occur with some degree of surprise to demand unusual, extensive and taxing response effort. These events are, in fact, ‘turning points’ in the life of individuals, family units, organizations, businesses, communities (e.g., municipalities), and nations with a potential for affecting them in both the short and the long term. Response organizations ordinarily handle these events using extra (i.e., off-shift) resources or mutual aid partners. Other agencies may be involved in the response but these normally include the traditional response agencies (i.e., Fire, Police and Emergency Medical Services). They are events which, by their definition, overwhelm any one response organization and demand a multi-organizational and multi-jurisdictional response. Differences in Disasters (3) 8

9 9

10 An incident resulting in one or more casualties, N with varying severity of injuries, S, will be met by medical assistance of a specific capacity, C Whether it is characterized an MCI or a disaster, it has to be defined 10

11 Medical Severity Index = ( N xS )/ C 11

12 An MSI>1 is indicative of a disaster An MSI of 0.4 means a sizeable incident, whereas an MSI of 4.2 indicates a substantial disaster 12

13 Residential area bPer hectare Low ‑ rise buildings 20 ‑ 50 High ‑ rise buildings 50-200 Business area Per hectare 0 ‑ 800 Industrial area Per hectare 0 ‑ 200 Leisure areaPer type Stadium ‑ h Discotheque Camping site Shops Per type D epartment store ‑ h Arcade - Empirical determination of the number of casualties (N) in a disaster immovables immovable 13

14 Road transport Per 100 M ( length )‘ Multiple collision 5 ‑ 50 Pertype d Coach 10 ‑ 100 Rail transport e Single deck 5 ‑ 400 Double deck 10 ‑ 800 Air transport f Pertype Small 10 ‑ 30 Large 150 ‑ 500 Inland shipping g Pertype Ferry 10 ‑ 1000 Cruise ship 200 ‑ 300 Mobileobjects Empirical determination of the number of casualties (N) in a disaster 14

15 The Average Severity of Injuries Triage: classification of casualties based on severity of injuries sustained T2 Stable victims to be treated within 4 ‑ 6 hours, otherwise they will become unstable. First ‑ aid measures and hospital admission. T3 ABC stable victims with minor injuries not threatened by instability. Can be treated by general practitioners. T1 ABC unstable victims due to obstruction of airway (A) or disturbance of breathing (B) or circulation (C). Immediate life support and urgent hospital admission. T4 ABC unstable victims who cannot be treated under the circumstances given. This classification should be performed by experienced medical personnel! 15

16 S= (T1+T2) / T3. Medical Severity Factor J de Boer. Tools for evaluating disasters: Preliminary results of some hundreds of disasters.Eur J Emerg Med 4:107–110, 1997 16

17 Capacities (C) in the Medical Assistance Chain MAC The site of the incident or disaster MRC The transport of casualties and their distribution among hospitals in the vicinity MTC The hospital HTC This capacity, C, indicates, among other things, the MSI and thus the turning point between incident and disaster. 17

18 Medical Rescue Capacity (MRC) = how many casualties can be ‘‘processed’’ per hour by a doctor and a nurse, assisted by one or more first aid staff. 1 T1 + 3 T2 / h Medical Transport Capacity (MTC) = The number of ambulances, X, required at a disaster is directly proportional to the number of casualties to be hospitalized, N, and the average time of the return journey between the site of the disaster and the surrounding hospital, t, and inversely proportional to the number of casualties to be conveyed per journey and per ambulance, n, and the total fixed length of time, T, during which N have to be moved X=N x t/T x n Hospital Treatment Capacity (HTC) = 2 to 3 patients per hour per 100 beds 18

19 Classification Grade Score Effect on infrastructure (impact site+filter area) Impact time Radius of impact site Number of dead Number of injured (N) Average severity of Injuries sustained Rescue time (rescue+first aid+transport) TOTAL Simple Compound < 1 hour 1 ‑ 24 hours >24 hours <1 km 1 ‑ 10 km >10 km < 100 > 100 < 100 100 ‑ 1000 > 1000 <1 1-2 >2 <6 hours 6 ‑ 24 hours > 24 hours 1212 012012 012012 0101 012012 012012 012012 1-13 CLASSIFICATION AND ASSESSMENT OF DISASTERS 19

20 the disaster severity scale (DSS) Beaufort scale for wind speed Mercalli scale for the intensity of an earthquake 20

21 Assessment of Medical Response Capacity in the time of Disaster: the Estimated Formula of Hospital Treatment Capacity (HTC), the Maximum Receivable Number of Patients in Hospital AKIRA TAKAHASHI et al, Kobe J. Med. Sci., Vol. 53, No. 5, pp. 189-198, 2007 21

22 Required Medical Personnel (in Kobe University Hospital) 1 patient with severe trauma 2 emergency doctors (EMDs) Operation or angiography required? Yes No 2 EMDs Angiography: 2EMDs+1Radiologist ・ Operation: 2EMDs+1Surgeon+1Anesthetist 22

23 The average length of treatment time for the three types of conditions in ER 23

24 The estimated Formula for Hospital Treatment Capacity (HTC) The maximum receivable number of patients in hospital (MRN) = HTC = The maximum integer of (≤B1/A1∩≤B2/A2∩…∩≤Bn/An∩≤D1/C1∩≤D2/C2∩…∩≤Dn/Cn) 24

25 The estimated Formula for HTC (MRN) within H hours 25

26 Ventilators available + Operating rooms + Emerg. Op. rooms) χ 2.5 = Χ 32 ( For the 1 st Hr H.T.C 26

27 1. When to start in-hospital staff mobilization? 2. Is there a need for out-of-hospital staff recruitment? 3. Does the condition demand stabilizing the patients and referring them elsewhere? 4. Are treatment sites sufficient or there is a need for opening new treatment sites? 5. Does the condition mandate stopping routine hospital work (OR, hospital clinics, …)? 6. Prioritizing OR use 7. Shortening OR waiting list by referring patients to other hospitals 8. Does the condition mandate opening a public information center? 9. Assessing critical shortages during conducting the MCS (staff, equipment, supply…) Crucial questions/decisions for mass casualty situations ( Dilemmas ) Collect the right information regarding : the type of incident, the time and the location, The weather condition the number of people involved etc It depends on the magnitude of the event The type of the event The population involved The shifting hours of the personnel It depends on The magnitude and the type of the event The severity of victims Specific morbidity ( burns, blast injuries, CBRN cases etc ) The distance from the definite treatment services It refers To the scene ( dispersed or not victims, High number of T1 and T2, accessibility of the site..) For in hospital services ( No of victims, need for decontamination, isolation etc ) Is there the only hospital to accept victims Is there morning or a night shift? … 27


29 Conclusion Emergency medicine and disaster medicine share the characteristics of: - unpredictability in volume and severity - concept of triage - team effort Need for special education and training for all the players. 29


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