Mass Casualty Events and Emergency Health Services Essay

Introduction

Efforts to develop a centralized and all-consuming strategy to manage mass casualty incidents were made by the World Health Organization and all affiliated health bodies and associations ever since the early 1990s. There was a need for the development of standardized tools and planning instructions to deal with large-scale emergency situations (Auf der Heide, 2006).

Nowadays, instructions and guides related to pre-hospital management of mass casualties are included into the standardized training program of the medical schools in UK and the US (Mass casualty management systems, 2007). Australia developed a similar strategic plan in 2003 for the emergency response personnel. It provided all the necessary standards for nomenclature, practices, medical supplies and equipment that are necessary during a disaster (Bradt, Abraham, and Franks, 2003).

In Saudi Arabia, the threat of MCI is stronger than in Australia. Several MCIs that occurred in the Emirates in the last few years managed to highlight the flaws present in the country’s Emergency Medicine System. One of the major steps to improve the situation was the adoption of numerous recommendations provided by the Joint Royal Colleges Ambulance Liaison Committee. These recommendations are to be used to reform the EMS in Abu Dhabi (Fares et al., 2014).

In a normal situation, the local emergency services follow their standard schedule. There is no patient overflow, there is no issue with supplies, nurses and doctors have plenty of time to attend to all patients, and ambulances experience little trouble with reaching and transporting patients to the hospitals. Normal emergency health services are well-organized and are expected to perform their duties without hindrances (Disaster Readiness, 2008).

A mass casualty incident is commonly defined as an incident that ended in numerous casualties – far more numerous to handle within the parameters of a standard emergency response assignment (Thomas, 2016). These incidents include multiple vehicle collisions, building collapses, mass transportation incidents, CO Emergencies, incidents involving hazardous materials, weapons of mass destruction, multiple shootings and terrorist acts, and chemical exposure. MCIs are able to quickly exhaust the resources available for potential emergency response (Sprivulis et al., 2006). All hospitals are expected to have an emergency response plan in place. During the development of this plan, one must assume a worst-case scenario. (Rubinson et al., 2005). The logistical challenges presented to the medical personnel involve the capability to expand rapidly and efficiently in order to process a large number of civilian casualties through the system.

Nurses play a paramount role during mass casualty incidents. The international overall emergency preparedness plan expects all nurses worldwide to possess a minimum level of medical knowledge required to provide assistance during an MCI(Levi et al., 2002). Every nurse must know how to protect oneself and know what to do in order to provide immediate medical assistance. As skilled medical practitioners, nurses are very important, and thus must recognize when their own lives are in danger, as they are responsible not only for protecting those in need but also themselves (US Centers for Disease Control and Prevention, 2008).

Managing Mass Casualty incidents should not be equated with application of normal activity on a grander scale, as actions performed by emergency services during an MCI are incompatible with normal activity standards and involve nurses dealing with surges of patients and use triage methods to use the time and resources more efficiently. All of the information provided has a scope of supporting the paper’s thesis.

Normal Day Practice Activity in Australia and Saudi Arabia

Small-scale emergencies occur daily, and the Australian government has nine departments to handle them all. The jurisdiction of these departments ranges from assisting the people harmed in the events to dealing with the aftermath of the emergency, to the legal persecution of those responsible. Here is the list of organizations operating in Victoria, and a brief description of their normal activities (Emergency Risk Management Victoria, 2016). All these organizations are expected to do their part in the event of an emergency response.

• Department of Justice and Regulation. This department is responsible for delivering and monitoring of all the agencies within the justice portfolio. For the most part, it includes various public security organizations such as the MFESB, CFA, SES, and Police.
• Emergency management Department. It is a fairly new organization, which was established in Australia in 2014. Its responsibilities include setting and maintaining performance standards for other organizations, as well as analyzing and assembling data for the emergency response times of MFESB, SES, and CFA, in order for them to be included in the Budget papers according to the yearly justice portfolio.
• Department of Health and Human Services. The purpose of this department is watch over healthcare services. In addition, the department evaluates the speed and quality of the ambulance services provided to the population and makes sure they all adhere to the same minimal requirements. The Ambulance Services Act of 1986 bestowed these duties upon the department.
• Ambulance Subdivision. It works in close cooperation with the Department of Health and Human Services. Its duties include providing first aid, respond to medical emergencies and relocate patients from the site towards the medical facilities by road, sea, and air. The Ambulance service also refers information about an emergency to other healthcare institutions, should it be outside their area of competency.
• Fire authority. This service is responsible for combating fires and conflagrations, fire prevention efforts and fire safety inspection. Fire authorities are comprised of both career firefighters and volunteers.
• Metropolitan Fire and Emergency Services Board. This department oversees the Metropolitan District and deals with conflagrations, road accidents, accidents on water, and hazardous material emergencies. They are to provide limited resuscitation and life support measures until the arrival of the AV paramedics.
• Victoria State Emergency Service. Also known as SES, this agency serves as the control department for any natural disasters. It is also responsible for responding to rescue incidents and works closely with the CFA and the MFESB. The agency is comprised mostly of volunteers, who participate in all rescue operations.
• Police Department. The Victoria Police Department is a legal body that responds to emergency calls requesting assistance. It also is involved in prevention, detection, and investigation of various offenses and crimes, as well as supporting the judicial process and prosecution. During large-scale emergencies, the police department is expected to assist with the evacuation, rescue and crowd control.
• Emergency Services Telecommunications Authority. The ESTA is an agency responsible for consolidating all communication efforts in case of an emergency. They relay emergency calls to respective agencies and dispatch teams to deal with dangerous situations.

Saudi Arabia has departments that perform similar functions, as the emergency systems are universal around the world. Although it must be noted that instead of having nine departments like in the Australian state of Victoria, they only have four larger ones. These are:

• Police department – deals with crime and crime-related emergencies as well as legal matters.
• Civil Defense department – includes services and subdivisions that are capable of dealing with disasters and other events that may threaten the local populace. The Fire department is under their jurisdiction.
• Department of Health and Medical Emergencies – this department is responsible for dealing with all kinds of medical emergencies. It has authority over ambulance services, clinics, hospitals and emergency first-aid camps, and others.
• Coastguard – this department deals with all and any emergencies that occur on water (Dealing with Emergencies, 2016).

These structures encompass the entirety of possible emergencies that could happen during normal activity and are responsible of dealing with mass casualty events, should the need arise.

As it is possible to see, all organizations are meant to work in a specific order and tandem with one another, with clearly defined authorities and jurisdictions that they are not meant to overstep. However, in the event of a mass casualty situation, the differences between adjacent organizations often blur, as communications are overwhelmed and the supplies and personnel are exhausted. In these situations, the ability to work under stressful conditions, both in a team with other authorities or alone, as well as the ability to adapt to changing conditions is critical to every department presented on the list.

Triage in Mass Casualty Situations

The word “triage” came from the French language. It derives from the word “trier,” which stands for sorting and cutting corners. In medical practice, the term is used for processing and sorting out patients according to the priority of treatment and evacuation from the emergency location (Mitchell, 2008). The process takes many different forms and has numerous levels of operations. Its purpose is to provide the patients in need of assistance with the proper care at the right time and place. In critical situations, triage identifies the course of action that would allow saving more people.

Initially, the term was developed to describe the nature of medical activities in military conflicts and warzones. Nowadays, it is equally applicable to civilian emergencies and day-to-day operations (Arbon et al., 2007). Accurate triage plays a paramount role in dealing with victims of a mass casualty incident. It involves identifying those who are in need of urgent treatment and those who could wait for medical assistance to be administered. In a typical major incident, the latter tend to form the majority. Triage is also needed to understand which patients are beyond saving or would require too much time and resources best used on others.

Triage is not a static process – the patient’s condition tends to progress from bad to worse, thus changing the triage category and the priority of treatment. For these reasons, triage procedures must be carried out regularly, as every triage is a snapshot that reflects the patient’s condition at the time (Sasser, 2009). The demands of triage processes are simple: triage must be quick, easy-to-reproduce, and contain the bare minimum of required information. Proper triage forms the backbone of an emergency medical effort and greatly improves the effectiveness of patient care in a stressful environment (Bostick et al., 2008).

During massive casualty incidents, triage efforts show a relatively high percentage of accuracy and efficiency. According to dedicated studies, the accuracy percentage is around 70%; however, there is a tendency among the medical workers to underestimate how severe a patient’s condition really is (Policy on the Australasian Triage Scale, 2006). This tendency proves the importance of periodic reassessment of the patient’s situation until they receive wholesome and definitive care. One factor that severely interferes with the process of injury estimation is the emotional stress that comes with identifying survival probabilities. Medical personnel tasked with the screening assessments has trouble with branding the patient as “dying” and leaving them to their fate. Instead, it is common to brand them as in extreme need of urgent care, thus valuable time and resources. Triage accuracy is affected by altered perceptions of pain, psychological reactions among surviving casualties, and the high-stress environment (Ashkenazi, 2009).

In order to make the process of triage more streamlined, accurate, and comprehensible, numerous triage systems were developed over the years. They are characterized by different triage tag designs to document the severity of the conditions for the patients awaiting treatment. The difference between triage systems in different countries can prove detrimental to the group effort when more than one medical agency is involved. For example, during the aftermath of a Boeing Crash at Kegsworth, 1989, a situation occurred. The incident happened on the borders of three countries, whose respective ambulance services rushed to the rescue. All three used different systems of MCI triage which resulted in confusion (Phillips, 2006).

In order for the hospital staff to be effective during an MCI emergency, the routine of emergency care must not be too different from the daily routine. The procedures for the MCI emergencies should be kept simple and practical, bypassing the amount of bureaucracy and paperwork common to a hospital setting these days. Still, the triage system is supposed to maintain the skeleton structure of the standard daily operating procedure, in order to ensure that the specialists are doing what they are best at, and to prevent the organizational structure from collapse.

The Australian Senate Standing Committee on Industry, Science, Technology, Transport, Communications and Infrastructure has noted the clear benefits that come from simplification and standardization of disaster response practices within Australia (Caldicott & Edwards, 2002). It leads to the development of a national unified MCI triage system that would be used by both hospitals and ambulance services and include the common terminology that would ensure effective communications during an emergency situation.

The purpose of a triage system is to allow a medic to rapidly screen all patients, no matter their gender or age. It must be cost-effective and operable in adverse conditions, in order to remain relevant to practitioners operating alone in isolated areas. The labels must clearly identify the dead and the dying in order to prevent them from being transported to treatment areas, where they would needlessly occupy valuable space.

Around the world, many countries are using simple triage taxonomy with three or four active treatment levels. As practice showed, increasing the number of categories did not bring any improvement to the system. It only overcomplicated the procedure, resulting in additional time required for the screening operations. The Homebush triage Taxonomy systems employ this system to assess the priority of treatment for both pre-hospital and hospital treatments. The four core groups can be expanded if required. Providing a common color code for all health care providers serves as an effective tool for prevention of miscommunication and all problems associated with usage of different terminology. This is especially important for the military medical services, which are often integrated into the response effort to a large-scale MCI within a country or a state (Nocera & Garner, 1999).

Triage codes use phonetic markings and designation in order to avoid confusion during radio voice transmissions. Numbers see limited use, usually to identify the priority of patients or to highlight the exact number within a certain category.

The specific category reserved for patients who are dying is often used in case of an overwhelming situation, during which the medical personnel must make a difficult decision to withhold treatment from a particular patient or patients. The decision to brand a patient as such usually revolves around several factors, namely the definition of what constitutes a non-survivable injury, an individual’s probability of survival, and the capabilities of the current medical facility that are performing the treatment (McManus, Huebner, & Scheulen, 2007).

Giving dying patients appropriate labels allows the medical personnel and the assistant groups that deal with patients on site to properly plan and manage their efforts. These categories also identify patients with advanced medical treatment directives and chronic terminal illnesses that require an appropriate level of medical care (McCarthy, Aronsky, & Kelen, 2006).

Surge Response in Mass Casualty Situations

Hospitals and clinics must be able to accommodate the sudden influx of patients. It is crucial to the management effort in the event of a mass casualties incident (Hick, Koenig, Barbisch, & Bey, 2008). Providing additional accommodations for the patients and acquiring extra medical personnel is important. Alternative standards of medical care were considered numerous times.

Right now, the department of emergency medicine does not have any unified programs designed to deal with an overwhelming increase in demand (Fatovich and Hirsch, 2013). A practical and unified set of strategies is required for all and any medical care facilities, which could find themselves running at full capacity during the state of emergency. Problems such as overcrowding, inpatient boarding, fully occupied beds and ambulance diversion are also common (Derlet and Richards, 2000). In Australia, the Australasian Surge Strategy Working Group was assembled with the express purpose of compiling a list of strategies and recommendations that would be useful, should any facility find itself facing the challenge of being overcrowded, whether due to a singular MCI or from overwhelming demand. Here are some of the recommendations provided within the Surge Management Event Priority Actions program (Bradt, Aitken, Fitzgerald, Swift, O’Reilly, & Bartley, 2009):

As it is possible to see from the table presented above, the requirements and recommendations for hospitals to handle surges and influxes of patients introduce drastic changes in how the facilities and personnel are expected to work and operate, when compared to the normal activity schedule (Kaji, Koenig, & Bey, 2006). The quality of care drops considerably in favor of quantity, and cohort methods see massive use. The difference between modes of operation in normal and massive casualty settings are massive.

Conclusions

Managing potential and actual mass casualty events put all departments under great strain, with the main workload falling upon the shoulders of medical institutions, who have to deal with resource depletion, personnel understaffing, space constraints, and an overflow of patients. Nurses are forced to employ cohort care methods and extensive triage to save who they can, rather than strive to save everybody. This is very different from normal hospital settings, where doctors and nurses are expected to operate under high standards of hospital care and fight for every patient’s life. The medical personnel has to work under increasing amounts of physical and emotional stress, often beyond their call of duty.

The analysis of triage protocols and surge response recommendations highlights the major differences between normal and emergency activities of medical facilities as well as other government institutions. This paper concludes that managing actual or potential mass casualty events should not be equated with simple application of normal activity on a grander scale, as the differences in standards, practices and application methods are too great.

References

Arbon, P., Zeitz, K., Ranse, J., Wren, H., Elliot, R., & Driscoll, K. (2007). The reality of multiple casualty triage: putting triage theory into practice at the scene of multiple casualty vehicular accidents. Emergency Medicine Journal, 25(1), 230-234. Web.

Ashkenazi, I. (2009). Inadequate mass-casualty knowledge base adversely affects treatment decisions by trauma care providers: survey on hospital response following a terrorist bombing. Prehospital and Disaster Medicine. 24(4), 342-347.

Auf der Heide, E. (2006). The importance of evidence-based disaster planning. Annals of Emergency Medicine, 47(1), 34-49. Web.

Bostick, N.A., Subbarao, I., Burkle, F.M., Hsu, E.B., Armstrong, J.H., & James, J.J. (2008). Disaster triage systems for large-scale catastrophic events. Disaster Medicine and Public Health Preparedness, 3(1), 100-115.

Bradt, D.A., Abraham, K., & Franks R. (2003). A strategic plan for disaster medicine in Australasia. Emergency Medicine, 15(3), 271-282. Web.

Bradt, D.A., Aitken, P., Fitzgerald, G.J., Swift, R., O’Reilly, G., & Bartley, B. (2009). Emergency department surge capacity: Recommendations of the Australasian surge strategy working group. Academic Emergency Medicine, 16(12), 1350- 1358. Web.

Caldicott, D.G., & Edwards, N.A. (2002). The global threat of terrorism and its impact on Australia. Emergency Medicine, 14(3), 214-215. Web.

Dealing with Emergencies. (2016). Web.

Derlet, R.W., & Richards, J.R. (2000). Overcrowding in the nation’s Emergency Departments: Complex causes and disturbing effects. Annals of Emergency Medicine, 35(1), 63-68.

Disaster Readiness. (2008). Web.

Emergency Risk Management Victoria. (2016). Web.

Fares, S., Irfan, F.B., Corder, R.F., Marzouqi, M.A., Zaabi, A.H., Idrees, M.M., & Abbo, M. (2014). Emergency medicine in the United Arab Emirates. International Journal of Emergency Medicine, 7(4), 1-8. Web.

Fatovich, D.M., & Hirsch, R.L. (2013). Entry overload, emergency department overcrowding, and ambulance bypass. Emergency Medicine Journal, 20(1), 406-409.

Hick, J.L., Koenig, K.L., Barbisch, D., & Bey, T.A. (2008). Surge concepts for health care facilities: The CO-S-TR model for initial incident assessment. Disaster Medicine and Public Health Preparedness, 2(1), S51-S57. Web.

Kaji, K., Koenig K.L., & Bey T. (2006). Surge capacity for healthcare systems: a conceptual framework. Academic Emergency Medicine, 13(11), 1157-1159. Web.

Levi, L., Michaelson, M., Admi, H., Bregman, D., & Bar-Nahor, R. (2002). National strategy for mass casualty situations and its effects on the hospital. Prehospital & Disaster Medicine, 17(1), 12-16.

Mass casualty management systems: Strategies and guidelines for building health sector capacity. (2007). Web.

McCarthy, M.L., Aronsky, D., & Kelen, G.D. (2006). The measurement of daily surge and its relevance to disaster preparedness. Academic Emergency Medicine, 13(11), 1138-1141. Web.

McManus J., Huebner, K., & Scheulen, J. (2007). Science of surge: detection and situational awareness. Academy of Emergency Medicine, 13(1),1179-1182. Web.

Mitchell, G.W. (2008). A brief history of triage. Disaster Health and Public Health Preparedness, 2(1), S4-S7. Web.

Nocera, A., & Garner, A. (1999). An Australian mass casualty incident triage system for the future based on mistakes of the past: The Homebush triage standard. The Australian Journal of Emergency Management, 15(2), 41-46.

Phillips S. (2006). Current status of surge research. Academic Emergency Medicine, 13(11), 1103-1108. Web.

Policy on the Australasian Triage Scale. (2006). Web.

Rubinson, L., Nuzzo, J.B., Talmor, D.S., O’Toole, T., Kramer, B.R., & Inglesby, T.V. (2005). Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of the working group on emergency mass critical care. Critical Care Medicine, 33(10), E1-E13.

Sasser S. (2009). Field triage in disasters. Prehospital Emergency Care, 10(3), 322-323. Web.

Sprivulis, P.C, Da Silva, J.A., Jacobs, I.G, Frazer, A.R., & Jelinek, G.A. (2006). The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. The Medical Journal of Australia, 184(1), 208-212.

Thomas, J. (2016). Mass casualty Incident, an overview. Web.

US Centers for Disease Control and Prevention. Mass trauma casualty predictor. (2008). Web.