Introduction
All people are willing to live in a safe environment that gives them a wide range of opportunities and prevents from facing problems caused by different disasters. Still, considering recent events that happen all over the world, it turns out that such place can be hardly found. If there are no terrorist attacks, such as 9/11, one may face problems created by natural disasters, infections or technological catastrophes. Even though professionals tend to do their best to predict and prevent them, no one is really able to avoid all possible dangers. The population of the world increases greatly every year, which also means that more people can be at risk of mass casualties. Among the most vulnerable populations are those poor nations that live on insecure territories that are often influenced by hurricanes and floods.
As the number of incidents increases and more people become affected, there is a necessity to enhance the awareness of the representatives of the general public regarding the issues and ensure that the country is able to cope with possible disasters with mass casualties. This paper will focus on the management of actual or potential mass casualty events. It will be considered whether it is just a part of the normal activity of emergency services and community agencies or not. The attention will be paid to the role of the emergency health services, in particular. According to Australian emergency management glossary, medical emergency refers to mass casualties that are defined as “any event in which trained personnel are required to respond effectively to a medical crisis beyond the accepted routine of a health care facility” (Koob, 2012, p. 75).
Thus, it can be stated that such events exceed the normal activity of emergency health services, as there is a necessity to work with more patients than it is possible during routine procedures, prepare special arrangements and provide unusual assistance. Thus, this paper will disagree with the idea according to which it is enough to enhance normal activity to manage mass casualty events. The fact that emergency services and community agencies are challenged by actual and potential mass casualty events will be emphasised. To support this point of view, normal day practice activity in Saudi Arabia and Australia, triage in mass casualty, and a surge response will be thoroughly discussed on the basis of the information received from the authoritative literature sources and personal experience.
The representatives of the general public tend to perceive mass casualty events differently, which proves that they lack appropriate knowledge. Many treat them just as some ordinary emergency problems that are just a little bit more critical, as they cause more damage (Spencer, 2011). Thus, they believe that it is enough to expand the routine respond without the introduction of any new activities. In this way, they speak about the necessity to have more available personnel, equipment and space. Still, mass casualty events are not just large emergences, they “have the potential to rapidly overwhelm – or threaten to exceed – the local capacity available to respond, even with the implementation of major incident plans” (Ramesh & Kumar, 2010, p. 239).
Mass casualty events presuppose the occurrence of those problems that are not faced on the everyday basis that is why they require specially developed strategies and cannot be solved only with the help of additional resources of the same kind. Very often they are followed by immediate outspread of disease or chaos. The issues faced during mass casualty events are often of different nature, which means that multidisciplinary teams are needed to cope with all of them and just a grander scale of emergency services and community agencies is not likely to be enough (Wong, 2011). Among those teams that are generally involved in mass casualty events are medical teams that are represented not only by doctors but also by nurses. In Australia, as well as in other countries, they take an active part in the provision of emergency services (Bradt, Abraham, & Franks, 2003). To be able to deal with these duties, they all have disaster health training. In this way, professionals can cope with the most difficult issues and even treat more than one patient at a time as it is demanded by emergency medicine and nursing.
Normal Day Practice Activity of Emergency Service
Emergency services are maintained by agencies that ensure public safety. They are a part of normal duties for such organisations so that they do not cause any misunderstanding and operational issues. Depending on the situation, professionals provide different services that streamline normalising. In Saudi Arabia and Australia, emergency services focus on three critical functions. They provide law enforcement, which gives an opportunity to prevent crimes, respond to fire-related and medical emergencies.
The Emergency Medicine Department in Saudi Arabia is “able to provide rapid resuscitation, stabilisation and transfer of critically ill patients” (Ziegler, 2016, para. 2). In provides disaster management and trauma care. Treatment approaches differ depending on the problems that are to be resolved. Non-emergency patients wait for healthcare services longer than others but receive expedient treatment which cannot be provided to those patients that should be treated immediately (Al-Omari, Abdelwahed, & Alansari, 2015). All these services can be maintained on the everyday basis so that they do not cause many problems to the facilities and personnel because everyone knows how to act and effective guideline exists.
Still, sometimes emergency events are more critical. They can hardly be coped with special approaches and involvement of other professionals who concentrate on different tasks. According to the annual report of Australian ambulance Victoria, boosting the normal business of the organisation is not enough to deal with the mass casualty. Using the Victoria Bushfires tragedy as an example, professionals emphasise that the existing health management plan is not good enough and requires improvement. The epidemics that happened because of H1N1 influenza virus revealed that the Victorian Department of Health was not able to maintain and provide all those procedures, vaccines and vaccinations it promised (Smith, Burkle, Holman, Dunlop, & Archer, 2009). Thus, the World Health Organization developed regulations, according to which Australia’s aim is to “help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide” (World Health Organisation, 2005, para. 2).
The State Health Emergency Response Plan initially included the guideline for those issues that are treated in the framework of everyday work and do not affect the operations greatly (Department of Health, 2014). With the course of time, professionals realised that new system and infrastructure are needed for people to have an opportunity deal with mass casualty events. They undoubtfully require additional arrangements beyond normal activity. Mass casualty events refer to medical crisis that requires the involvement of multidisciplinary teams, which goes beyond the typical everyday practice of healthcare facilities and their staff. In this way, such different emergency services including the police, firemen and ambulance response can be needed. Various professionals cooperate to provide required assistance and improve the situation. For example, during such events as car accidents, healthcare workers (nurses, in particular) spend much time and afford to try to assist all victims and ensure decent cooperation and interaction among involved teams.
Emergency health services are typically used when some accidents happen, but they cannot be utilised separately with no other support when a mass causality event take place. World Health Organization develops guidelines that can serve as a helping tool for professionals (World Health Organisation, 2007). While focusing on day-to-day emergency events, healthcare facilities basically provide a particular range of services, which do not presuppose extensive usage of resources and streamlined procedures. In this way, it can be stated that mass casualty events occur rarely. That is why they are not discussed in the framework of routine activities. Emergency health services focus on day-to-day issues that are basically alike. Still, mass casualty events are solved with different approaches that need to be aligned with a particular situation. In some situations, both mass casualty and the ordinary operations of the emergency health service are maintained at the same time because hospital accepts new patients but also continue treating previous ones. The difference between the normal daily activity and mass causality can be found in the way patients are grouped and resources allocated.
Triage in Mass Casualty
Managing normal daily activity stops when an absolute necessity to resort to triage is faced. In the framework of a mass causality event, it is treated as the process of casualties categorising. According to it, professionals need to focus on medical care priorities and allocate treatment and evacuation on their basis (Roccaforte & Cushman, 2007). This procedure can be problematic because it exceeds usual tasks, and patients have unordinary injuries. Thus, professionals often lack experience in it, which affects their efficiency and effectiveness (Freishtat, Wright, & Holbrook, 2002).
Clinical urgency rating is managed in the framework of everyday triage. For example, the Australasian Triage Scale includes five categories (see Table 1) that are used in normal day practice by a nurse professional when one triages a patient. Still, in this way the attention is paid to the usage of resources when having a few patients. In case of a mass casualty event, such approach can lead to the unwise resources utilisation that will eventually prevent the professional from servicing all patients. If a nurse focuses only on one individual at the same time trying to provide the best services, he/she is likely to act not fast enough and to provide those clients who can wait with resources required by others (Sasser, 2006). Thus, it is significant to differentiate normal and mass casualty practices.
Table 1: The Australasian Triage Scale.
Disaster-specific triage objectives are needed when dealing with the mass casualty. For instance, Burkle’s SEIRV model can be used when having issues with the H1N1or other infections. According to it, patients can be divided so that the infectious and the vulnerable are treated separately. It can also help nurses to keep infectious patients out of the emergency department to ensure the safety of other people, which is not one of the everyday triage approaches (Bielajs, Burkle, & Archer, 2008).
In this way, sometimes nurses may face a necessity to alter triage and focus on the provision of help not to the most injured consumers but to the greatest number of them. In mass casualty, medical ethics principles still focus on good over harm, but it is considered that it is better to save more people (Weed & McKeown, 2001). Thus, while the usage of excessive resources in normal day practice can save the life of a patient, it can harm many other clients as they will not be able to receive expected treatment (Mitchell, 2008). As the number of mass casualty events tends to increase, it becomes even more critical to ensure that there is appropriate casualty triage plan that is familiar to all medical staff (Lerner et al., 2009).
The usage of triage scale can also cause difficulties because it is developed for healthcare professionals. When a mass casualty event happens, professionals from different spheres cooperate, not only medics. Thus, a special plan should be created to ensure effective interaction. Thus, it will be advantageous to use “a systematic approach to disaster-specific triage management that integrates care at all points of interaction” between patients and the emergency health services (Bostick et al., 2009, p. 35). As a result, triage turns into one of the main determinants for advantageous and appropriate disaster plans.
Thus, it can be concluded that it is not enough to use existing triage principles and categories if the event exceeds the concept of day-to-day practice. When using it, professionals may cause more harm than good because they focus only on one patient instead of taking into consideration issues that are peculiar for particular disasters.
Requiring a Surge Response
Hospital surge capacity is generally perceived as “the ability to provide acute care to both critical and non-critical mass casualties simultaneously, and is a marker of the ability to deliver emergency care in a disaster situation” (Traub, Bradt, & Joseph, 2007, p. 394). Even though this concept is discussed by the professionals, Australian hospitals do not have clear standards that can be used to determine physical and human preparedness goals. Still, epidemiological evidence reveals that the majority of the patients who were injured in a mass casualty event are taken to the closest hospital within an hour and a half after the accident. It is internationally accepted that such facility should be able to ensure x-rays and have enough operating rooms and intensive care unit beds but the benchmark for these is not indicated.
It is generally believed that the triage model ensures appropriate patient sorting, according to which they receive needed care. Still, everything is not so effective in practice, and not all casualties are responded in time. Thus, it is not surprising that these events overload medical facilities and make it more difficult for them to operate efficiently. For example, such issue occurred in the Ambulance Victoria when the H1N1 flu virus outbreak happened. The provider of emergency ambulance services emphasised the fact that even having and following pandemic preparedness plans, they were not able to guide the response adequately (Smith et al., 2009). What is more critical, professionals notice similar problems over and over. The amount of large-scale mass casualty events increases in winter, and lots of victims with different injuries create new challenges for healthcare facilities and their professionals, including nurses who need to work with each of them.
Recent research conducted by Traub, Bradt, and Joseph (2007) revealed that surge capacity in Australasian healthcare facilities requires improvement. Hospitals are normally operating close to capacity with access block, they lack personnel (especially nursing professionals due to high turnover rates) and have overloaded operating rooms. In this way, when a mass casualty event happens, hospitals will not be able to ensure appropriate services for all victims. Even though Robertson and Cooper (2007) claim that health authorities introduce arrangements and policies that are expected to improve the situation, it can be seen that this goal is not reached yet. Still, the fact that some steps for improvement are already discussed and implemented proves that authorities realise the existence of the problem.
Australian Health Protection Principal Committee (2011), for instance, developed AUSBURNPLAN, which focuses on the necessity to prepare hospitals for the patient surge. It is underlined that terrorist events happened in different countries all over the world. After the Bali bombing, Australia admitted several victims, which proved that even if it does not face such events personally, the country should be ready to respond to them in the framework of healthcare assistance. Back then more than 60 patients occupied adult burn beds, and hospitals had to provide them with the required care which affected normal activity greatly and proved that a response plan is undoubtfully needed. Similar views are supported by disaster initiatives connected with influenza and stockpile. In the framework of surge response, attention should be paid to antiviral treatment and personal protective equipment. While hospitals are normally able to ensure patient well-being in normal operations, problems are likely to occur when dealing with virulent virus strains (Robertson & Cooper, 2007).
Thus, day-to-day objectives and operations that are maintained by healthcare facilities are not good enough for dealing with surge capacity. It needs reconsideration of normal capacity and substantial enhancement of health services capability. As a mass casualty event happens, the need of patient care increases greatly. Such tension affects medical stuff greatly. It creates challenges for suppliers, space, management and infrastructure. The ability of emergency staff to cope with related issues is also taken into consideration (Hick, Koenig, Barbisch, & Bey, 2008). Those problems that are currently faced by medical facilities are likely to be caused by the lack of adequate mass casualty knowledge. Having a well-supplied base, professionals would enhance awareness and knowledge to be able to make better treatment decisions that can affect not only patient’s health outcomes but also facility operations (Milkhu et al., 2008).
In this way, it can be stated that normal day practice activity does not include all those arrangements that are to be discussed in hospital disaster plans that should include surge capacity that requires multidisciplinary response and additional involvement of management and authorities.
Conclusion
This paper focuses on the assumption that emergency health services that are provided by professionals who work in this sphere on the ordinary day-to-day basis can be used to cope with mass casualty issues. In fact, due to the information obtained from the authoritative sources, it turned out that such approach is not correct and true to life. Thus, this paper argues against such an idea and focuses on “or is it” view, which is quite the opposite. It is emphasised that mass casualty events do not coincide with normal activity because they are more complex and extensive. They are more severe and include more victims, which means that healthcare professionals should consider different approaches that can be utilised in this framework to improve the situation and use resources wisely.
Day-to-day triage that helps nurses to categorise their patients should be changed so that the patients receive the most benefit. Professionals should provide the good to the majority of their clients. If such idea is undertaken, it can be treated as the rational reason not to allocate all available resources to help one patient in the most severe condition. Realising the values in the framework of mass casualty event, professionals should focus on a surge response. To manage such an event, they need to create a guideline for each disaster and follow it. Taking everything mentioned into consideration, it can be concluded that emergency health services require special arrangements and extraordinary assistance that exceed the framework of normal day practices.
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