Mass casualty management

Mass casualty management
Basics of disaster medicine principles
Dr Patrick Guérisse
Emergency dept
CHU Brugmann - Brien

Why disaster medicine ?
Disaster, did you say ?
• « Titanic turn of mind » :
- sinking is unbelievable
- consequently, preparation is useless
•« Zero risk » does not exist :
– Technological accidents :
Seveso (1976), Bhopal (1984), Chernobyl (1986)
– Human accidents :
Football, music festivals, mass gatherings, riots,
terrorism, etc
• Preparedness :
– about management much more than medical aspects
– university curriculum open to non medical agencies
– common language

What is a disaster ?
versus a mass emergency or a mass casualty
• Sudden discrepancy between
- acute needs and
- locally available resources
• Failure for a community to cope with the
consequences of a damage
• Inability of a community to meet the
demand for health care
! Time sensitive definitions
« Disaster » : to be preferred when there is a major disruption
of the social and medical infrastructure

Specificities of a mass emergency
Different from day-to-day practice
Difference of kind and not only of size
Routine emergency
• Well-understood event
• Limited scale
• Easily manageable
• Quickly under control
• Rescuers familiar with
each other
• Well-accepted authority
• Clear-cut roles and
responsibilities
Mass emergency
• Enormous problems
• Breakdown of normal
arrangements
• Multiple procedures
• Large number of rescuers
• Unfamiliarity of the agencies
with each other
• Inadequate initiatives
• Conflicting roles and
responsibilities

Preparedness : disaster plan
• Specific plan = organizational framework
• Hazards identification
• Functional job descriptions & responsibilities
• Incident command system
• Tasks and means of action for each agency
• Inter-agency communication protocols
European Community Seveso directive (1982)

The case of Belgium
• Threshold for activation of the disaster plan
– 5 seriously injured
– 10 or more injured of unknown severity
– possibility or necessity of people evacuation
• Automatic response of the rescue-centre ‘100’
– 5 ambulances
– 3 medical teams (SMUR = MUG)
– warning of
• Director of medical rescue on duty (=medical incident officer)
• Red-cross
• Provincial Medical Inspector

On-site immediate organization
1. Giving alarm first
– Accident of unusual size or appearance
– Brief description of the overall conditions
– Asking for activation of the emergency plan
2. Assessment of the number of victims
3. Gathering the victims
4. Establishing a casualty-collection point
(PMA – VMP)

Casualty-collection area
( P.M.A. – V.M.P. )
• Mandatory channel for ALL the victims
• Identification
• Triage
• Minimal medical care
• Allocation to appropriate hospital
• Conditions of transport
• Listing

Medical management
Should victims be brought to hospitals ?
or
should hospitals be brought to the victims ?
• Depending from the day-to-day routine emergency
organization
• Evidence of research indicates that the better way
is to send mobile medical teams to the scene
• Comparison of London and Madrid terrorist
bombings

Why TRIAGE ?
• Conventional standards of medical care cannot
be delivered to all casualties.
As a consequence, medical resources and
personnel must be allotted to provide
the greatest good for the greatest number
( concept of minimal acceptable care )
• The goal is to identify the small number who will
benefit from early scene management
Consequently, before giving any care,
the first action must be a rapid examination of
ALL the victims one by one,
to identify the most severely injured.

TRIAGE
• Technique for assigning priorities for
treatment of the injured when the resources
are limited (Surgeon general D. Larrey, 1766-1842)
• START system : for first responders
– Binary sort : severely injured and the others
• Mettag tags : for medical teams
– Categorization into groups,
according with the emergency to treat,
i.e. to evacuate to the appropriate facility

Language-free
Serial number
Detachable corners
Name, address
Body diagram
Predominant injury
Vital signs chart
Detachable
priority tabs

Care on the scene
Medical care is limited to lifesaving actions :
B leeding control and
A irway control
S hock prevention
I mmobilization
C lassification

Hospital disaster plans
• Overcrowding of the nearest facility
by spontaneous uncontrolled flights
• Hospital admission capacity :
- different from the number of beds that
can be made available
- the actual bottleneck is the ER and its
capacity to recruit medical teams
• Efficient use of resources :
– appropriate distribution of the casualties from the scene
– only skilled personnel in the ER

The essential of Disaster Medicine,
in a few words …
• Preparedness
• Quickly recognition and warning
• Triage on site
• Minimal medical care = lifesaving actions
• Regulation :
controlled distribution of the injured to
the adequate hospital