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Preparedness the Key to Dealing with Mass Casualty

Physicians train to treat a variety of illnesses and injuries, but they are still challenged when headline-grabbing mass casualty situations occur in their own backyard and overwhelm their support systems. Dealing with great tragedy goes beyond training and knowledge and requires organizational skills, innovation, endurance, emotional stability and compassion, and experience.

Two seasoned healthcare professionals talked about the importance of those traits when they shared their experiences from dealing with two tragedies—the Fort Hood, Texas, shootings of 2009 and the Boston Marathon bombings of 2013. They spoke at the Society of Military Otolaryngologists and AAO-HNS Trauma Committee’s Symposium, “Terrorism on American Soil: Personal Reflections and Lessons Learned.”

U.S. Army Col. Melissa Givens, MD, is an emergency medicine physician who was stationed at Fort Hood when a staff psychiatrist at the base hospital opened fire in the tight quarters of a waiting room, killing 13 people and wounding 30 others.

“Nidal Hasan walked our halls and was considered a peer and colleague within our ranks,” said Dr. Givens, who raced from home to return to the hospital after being informed of the shooting. Beyond dealing with that many patients, an immediate problem was that staff members could not get to the hospital because of heightened security around the hospital.

Another challenge was that there was no distribution curve of injuries. “Every patient who came through the door was triaged as ‘immediate,’” she said. “Every single patient on the list needed massive amounts of care.”

“Every physician on the military base had experience dealing with battlefield trauma after serving in Afghanistan. However, this level of mass casualty was overwhelming for our civilian hospital staff, not technically overwhelming because they were doing their job, but emotionally overwhelming. They had no context in which to put this catastrophic situation,” Dr. Givens said.

“A lot of people work in military facilities that have not been trained for these circumstances. We have to remember our civilian providers and take care of them too,” she said.

She also noted the value of identifying your area of medical specialty to ensure your specific knowledge and skills are being administered to the appropriate patient needs.

“If you are ever involved with one of these events, please articulate what you bring to the table. Say ‘I can manage that airway.’”

Non-medical issues included the negative impact of telephone lines not working because of heavy call traffic and the positive influence of a food truck vendor coming in to feed people. Day care centers took care of the children of staff members who were working long hours.

“We got on Facebook and said ‘Stop calling; we need our phones.’ Social media was our friend. It relieved family members (when we said we are OK),” Dr. Givens said, adding that having a positive presence in the community paid off with the response of local citizens. “Those are the kinds of things you typically don’t think about.”

Meg Femino, HEM, has worked in several capacities in hospitals for more than 35 years, and she needed all of that experience when two pressure-cooker bombs exploded near the finish line of the 2013 Boston Marathon. In the blasts, three people were killed and another 280 people were treated for injuries. The trauma created days of impact when the city was also placed under a lockdown during a search for the suspects responsible for the bombings.

Amazingly, the incidents “never outstripped our resources” said Femino, the director of emergency management at Beth Israel Deaconess Medical Center in Boston. She also has chaired the Boston Preparedness Healthcare Coalition.

A key to coping was that Boston, a renowned healthcare hub, has six level 1 trauma centers within two miles of the bombing. Also nearby was a tent for treating runners, with a line of ambulances waiting.

“That was fortuitous. We did triage down there,” Femino said, adding that regular practice for catastrophes paid off quickly. The lessons learned were to always think about complexity and pattern recognition, allow staff to self-deploy to help, and prepare for psychosocial surprises.

Among the innovations that developed were a system to create one simple list of patients, injuries, and locations; decision-making was centralized; a large lounge dedicated to the families of victims was opened and an outpatient clinic operated in one room.

“It really is all about preparedness. Don’t wait for something to happen,” Femino said, adding that staff members were able to operate in the emergency using their “muscle memory” from practicing for catastrophes and mass casualty situations.

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