MCI or Disaster?
Dilemmas and
traps
Kostas A. Papaioannou, MD, MSc
Plastic Surgeon
F. President of MSF-Greece
European Master in Disaster
Medicine
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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
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.
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unpredictable events
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
4
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
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Differences in Disasters
Routine Emergencies
Disasters
Interaction with familiar faces
Familiar tasks and procedures
Interaction with unfamiliar faces
Unfamiliar tasks and procedures
Intra-organizational coordination
needed
Roads, telephones, and facilities
intact
Communications frequencies
adequate for radio traffic
Intra- and inter-organizational
coordination needed
Roads may be blocked or
jammed, telephones jammed or
non- functional, facilities may be
damaged
Radio frequencies often
overloaded
Communications primarily intraorganizational
Need for inter-organizational
information sharing
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Differences in Disasters ( 2 )
Routine Emergencies
Disasters
Use of familiar terminology in
communicating
Communication with persons
who use different
terminology
Need to deal mainly with local
press
Management structure adequate
to coordinate the number of
resources involved
Hordes of national and
international reporters
Resources often exceed
management capacity
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Differences in Disasters (3)
Routine Emergencies
Disasters
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 hostagetaking 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.
8
9
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
Medical Severity Index = ( N xS )/ C
11
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
Empirical determination of the number of casualties
(N) in a disaster
immovable
immovables
Residential area b Per hectare Low - rise buildings 20-50
High - rise buildings 50-200
Business area
Per hectare
0-800
Industrial area
Per hectare
0-200
Leisure area
Per type
Stadium
-h
Shops
Per type
Discotheque
Camping site
Department store
Arcade
-h
- 13
Empirical determination of the number of casualties
(N) in a disaster
Mobile objects
Road transport
Per 100 M (length)‘
Pertype d
Rail transport e
Multiple collision
Coach
Single deck
Double deck
Air transport f
Inland shipping g
Pertype
Pertype
Small
5-50
10-100
5-400
10-800
10-30
Large
150-500
Ferry
10-1000
Cruise ship
200-300
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The Average Severity of Injuries
Triage: classification of casualties based on severity of injuries sustained
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.
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.
T4
ABC unstable victims who cannot be treated under the circumstances
given. This classification should be performed by experienced medical
personnel!
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Medical Severity Factor
S= (T1+T2) / T3.
J de Boer. Tools for evaluating disasters: Preliminary results of some hundreds of
disasters.Eur J Emerg Med 4:107–110, 1997
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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.
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Medical Rescue Capacity (MRC) =
Medical Transport Capacity (MTC) =
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
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
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CLASSIFICATION AND ASSESSMENT OF DISASTERS
Classification
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
Grade
Score
Simple
Compound
1
2
< 1 hour
1-24 hours
>24 hours
0
1
2
<1 km
1-10 km
>10 km
0
1
2
< 100
> 100
0
1
< 100
100-1000
> 1000
<1
1-2
>2
0
1
2
<6 hours
6-24 hours
> 24 hours
0
1
2
0
1
2
1-13
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the disaster severity scale (DSS)
Beaufort scale for wind speed
Mercalli scale for the intensity of an
earthquake
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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
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Required Medical Personnel (in Kobe University Hospital)
1 patient with severe trauma
2 emergency doctors (EMDs)
Operation or angiography required?
Yes
No
・Operation: 2EMDs+1Surgeon+1Anesthetist
Angiography: 2EMDs+1Radiologist
2 EMDs
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The average length of treatment time for the three types of
conditions in ER
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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)
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The estimated Formula for HTC (MRN) within H hours
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H.T.C
Ventilators
( available
3
Operating
Emerg. Op. rooms) χ 2.5 = Χ
rooms
+
+
2
For the 1st Hr
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Crucial questions/decisions for mass casualty
situations ( Dilemmas )
1. When to start in-hospital staff mobilization?
2. Is there a need for out-of-hospital staff recruitment?
thedemand
right information
regarding
: referring
3. Does theCollect
condition
stabilizing
the
patients
and
It depends on
them elsewhere?
4. Are treatment sites sufficient
or there
It depends
onis a need for opening new
magnitude of the event
treatment sites? thethe
type of incident,
The
type
of the event
5. Does the
condition
mandate
stopping
routine
hospital
It
refers
The magnitude and the type
of the
eventwork (OR,
Thetime
population
and theinvolved
location,
hospital clinics, …)?the
The severity of victims
6. PrioritizingThe
OR use
shifting
hours
of the
personnel
To
the
scene
(
dispersed
or
not victims,
The
weather
condition
Specific
morbidity
(
burns,
blast
injuries,
CBRN
cases
etc
)
7.
Shortening
OR
waiting
list
by
referring
patients
to
other
hospitals
Is there the only hospital to accept victims
High
number
of
T1 and
T2,
accessibility
of the
site..)
Thethe
distance
from
the
definite
treatment
services
8. Does
condition
mandate
opening
a
public
information
Is there
morning
or a night
shift?
the
number
of people
involved
etc
center?
9. AssessingFor
critical
shortagesservices
during conducting
the MCS (staff,
in hospital
( No of victims,
…
equipment,
supply…)
need for decontamination, isolation etc )
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ACCIDENT
NO
EXCEEDS EMERGENCY
RESPONSE CAPACITY YES
AFFECTED AREA
CALAMITY
NO
INCIDENT
CASUALTIES
YES
EXCEEDS MEDICAL
EMERG RESP CAPACITY
AFFECTED AREA
YES
DISASTER
NO
ACCIDENT
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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.
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THANK YOU
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