JAAOS series highlights key concepts of treating patients after mass casualty disasters
Recent bombing attempts in the United Kingdom and warnings about the continuing possibility of terrorist attacks against the United States remind us of a sobering reality: mass casualty disasters can occur anywhere, at any time. To help educate orthopaedic surgeons about responding to disasters and mass casualties, the Journal of the AAOS (JAAOS) published a two-part article: “Disasters and Mass Casualties: I. General Principles of Response and Management” (July 2007) and “Disasters and Mass Casualties: II. Explosive, Biologic, Chemical, and Nuclear Agents” (August 2007). Parts I and II of the article explore key concepts involved in managing disasters and treating the injuries resulting from natural disasters and terrorist attacks.
McKee: Which concepts of responding to mass casualty incidents are the most foreign to orthopaedic surgeons who aren’t trained in emergency response?
Dr. Born: The chaos of a disaster event is very foreign. We surgeons are accustomed to controlled circumstances, which don’t exist in a disaster. We are used to giving complete treatment and putting all of our resources toward every patient who comes into the trauma center. During a disaster, however, those resources are not available, so you have to make do with whatever you have, treat patients very quickly, and move on. That’s when triage becomes important.
Performing triage effectively can be difficult for surgeons who aren’t trained in emergency management because the concept of doing the greatest good for the greatest number of people goes against our precepts of doing the greatest good for every individual. Effective triage is critical to identify those people who are salvageable and require minimal care, and evacuate them to facilities away from the event site.
McKee: What qualities, experience, and skills should the person in charge of triage possess? Can an orthopaedic surgeon be the right person to fill that role?
Dr. Born: I think that the most effective triage officer is someone who has some experience responding to disasters. Orthopaedic surgeons, as a group, probably don’t have a lot of experience in this area. If necessary, they could help act as triage officers. People with military experience, particularly in the current military operations in Iraq, most likely have some experience in assessing patients quickly and making decisions about how to manage their care. In general, community orthopaedic surgeons and orthopaedic trauma surgeons are not as well equipped to do that as experienced emergency department physicians or general surgeon traumatologists, for example.
McKee: What problems can arise when triage isn’t done effectively?
Dr. Born: Triage accuracy depends on minimizing both overtriage and undertriage. In undertriage, critically injured casualties aren’t placed in the immediate care category fast enough. In overtriage, healthcare workers assign casualties who are not critically injured to immediate care, hospitalization, or evacuation, potentially displacing those who really need immediate care. Overtriage can overwhelm a facility with limited resources. Both triage problems can be equally life-threatening in a true mass casualty situation.
McKee: Why are flexible plans and effective communication such important parts of disaster response and management?
Dr. Born: In a disaster, all the agencies that are involved in mitigating or managing the disaster event need to know how to talk to one another. They also need to know what resources are available and must avoid conflicting agendas. One of the real take-home lessons from Hurricane Katrina was the general lack of coordination and communication. There were multiple agendas involved during that disaster, which made for a chaotic and uncoordinated response.
McKee: What should hospitals consider when they create a hospital emergency plan—and how can orthopaedic surgeons lend their expertise to help strengthen that plan?
Dr. Born: The first thing that orthopaedic surgeons can do is review their hospitals’ disaster plans to see what the plan for the orthopaedic surgery department might be. If no specific plan for orthopaedics exists, they might consider meeting to define what their roles might be and how they would respond if a declared disaster involved their hospital. They may consider having a spokesperson who interfaces with the hospital administration to communicate with those who are in charge of the disaster plan.
McKee: You identify the most significant barrier to disaster management as a lack of institutional commitment to preparing for an effective response to a large-scale, mass casualty incident. Why do you think this is so, and what needs to happen to solve this problem?
Dr. Born: It is difficult for hospitals to commit the time, energy, and funding to carry out biannual disaster drills, which are very important training elements. Training—having some idea of what to expect—is key to disaster management. If staff in the operating room, emergency department, cafeteria, housekeeping, or maintenance, for example, have no idea of what is expected of them or what managing a disaster is like, they’re not going to know what to do during an emergency. On-the-job training during a disaster can be counter-productive, so staff should be trained in advance or given an idea of what to expect and what they might be called upon to do during that kind of situation.
McKee: You point out that terrorist bombings are happening with increasing frequency and are the most commonly used weapon of mass destruction. With what principles of blast injury management should orthopaedic surgeons be familiar?
Dr. Born: Blast injuries in the civilian population are rare. Most trauma cases we see are caused by blunt objects, motor vehicle accidents, falls, shootings, or stabbings. So, unless they’ve had military experience, community orthopaedic surgeons and university-based orthopaedists are not going to be familiar with management of blast injuries.
Specific management issues need to be considered with blast injuries. Compressive blasts may cause unseen injuries that may take time to become apparent. The blast lung injury may be identified by radiograph as soon as 90 minutes after a blast occurs, but it could also evolve over 12 to 24 hours. Viscous injuries may not be identified immediately because the injury to the blood supply of the gut may take some time to cause necrosis of the bowel, and sequelae may take 24 hours to occur. Thus, there’s a clear mandate to hospitalize a patient who has been exposed to a significant blast, at least for observation.
McKee: How can orthopaedic surgeons become better prepared to provide care to disaster victims?
Dr. Born: I hope my co-authors and I have been able to outline some of the basics of mass casualty response and provide that information in the JAAOS articles.
Orthopaedic surgeons can also participate in continuing medical education courses on disaster management sponsored by organizations such as the Orthopaedic Trauma Association and the American Medical Association. In addition, they can volunteer with their local disaster management assistance team (DMAT). Participating in a DMAT is one of the most important ways orthopaedic surgeons can contribute to emergency response on a local and regional level.