EDMG541

The Journal of Emergency Medicine, Vol. 48, No. 6, pp. 685–692, 2015 Copyright � 2015 Elsevier Inc.

Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2014.12.069

RECEIVED: 1 Jul ACCEPTED: 22 D

Selected Topics: Disaster Medicine

MASS CASUALTY DISASTERS: WHO SHOULD RUN THE SHOW?

Rachel M. Russo, MD, Joseph M. Galante, MD, Robert C. Jacoby, MD, and David V. Shatz, MD

Division of Trauma/Critical Care, University of California, Davis Medical Center, Sacramento, California Reprint Address:David V. Shatz, MD, Division of Trauma/Critical Care, University of California, Davis Medical Center, 2315 Stockton Boulevard,

Sacramento, CA 95817

, Abstract—Background: A clear command structure en- sures quality patient care despite overwhelmed resources during a mass casualty incident (MCI). The American Col- lege of Surgeons has stated that surgeons should strive to occupy these leadership roles. Objective: We sought to iden- tify whether surgeons, as compared to emergency physi- cians, are sufficiently prepared to assume command in the event of a mass disaster. Methods: We surveyed hospital- affiliated surgeons and emergency physicians to assess their knowledge of MCI response principles and to gauge opin- ions regarding who should be in charge during a disaster. Results: One hundred and forty-nine (58%) surveys were completed, 78 by surgeons and 71 by emergency physicians. Both groups demonstrated a critical lack of knowledge regarding fundamental principles and key logistical compo- nents of preparedness and MCI response. Surgeons as a group were even less prepared than emergency physicians. Of those surgeons who had reviewed their hospital’s disaster plan, half (50%) still did not know where to report for an MCI activation. Nonetheless, both groups believed they had sufficient training and both asserted they ought to occupy command positions during a disaster scenario. Conclusions: Errors in disaster triage have been known to increase mor- tality as well as the monetary cost of disaster response. Fund- ing exists to improve hospital preparedness, but surgeons are lagging behind emergency physicians in taking advantage of these opportunities. Overall, it is imperative that physicians improve their understanding of the MCI response protocols they will be tasked to implement should disaster strike. � 2015 Elsevier Inc.

, Keywords—mass casualty incident; disaster; disaster management; incident command; triage

y 2014; FINAL SUBMISSION RECEIVED: 12 Decemb ecember 2014

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INTRODUCTION

Hurricane Katrina, Hurricane Sandy, the earthquake in Haiti, tsunamis in Sri Lanka and Japan, and the outbreak of civil war in Syria are all recent examples of disasters requiring a coordinated response. These events were all well publicized and received international attention, but they are not common. Less publicized disasters occur every day: bus accidents, a bleacher collapse, or even a multi-car collision. These situations produce casualties that can overwhelm hospital resources and disrupt normal hospital function. In order to effectively respond to mega- disasters abroad, physicians must first be prepared to handle multi-casualty incidents within their own hospital.

When mass casualty incidents (MCIs) occur, a trans- formation takes place in which doing the greatest good for the greatest number of individuals takes precedence over doing the greatest good for a single individual. This shift in ideology requires a change in triage princi- ples, alterations in patient care, and revised prioritization of available resources. Successful disaster response re- quires well-defined leadership roles. Those in charge require clinical expertise to treat the injured, an under- standing of hospital triage principles, and experience in caring for patients when resources are scarce.

The American College of Surgeons (ACS) has stated that surgeons should lead disaster planning and manage- ment efforts especially when involving physical trauma (1). The skills required to successfully manage trauma- related disaster responses are an extension of the same skills surgeons use in everyday practice. Many sources

er 2014;

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agree with the ACS, i.e., an experienced surgeon is better equipped to be in charge during an MCI (2). Drawing on experiences from multiple terrorist events in Israel, Einav et al. has recommended that event managers and primary triage officers dealing with terror-related MCIs be attending surgeons (3). However, not all agree. Ashkenazi et al., of Hillel Yaffe Medical Center in Hadera, Israel, found that many health care providers, including physi- cians, nurses, and emergency medical technicians (EMT), feel a nonsurgeon would be an appropriate leader during a disaster (4). Britt et al. recommend that the person with the most relevant experience, regardless of specialty, should assume the role of triage leader in an MCI (5).

With disparate opinions in the literature regarding who should command an MCI, we sought to identify whether surgeons, when compared to emergency physicians in the same region, are better qualified to assume leadership po- sitions in the event of an MCI. We judged which group was best qualified to lead based on which ones most accu- rately identified correct MCI response protocols and disaster triage principles in sample scenarios.

METHODS

After InstitutionalReviewBoard approval, a two-page sur- vey with 16 questions pertaining to disaster protocols, triage principles, incident command structure, clinical ex- periences, andprofessional experience in treating common injuries encountered in mass casualty incidents, including exposure to nuclear; biological; or chemical agents (Figure 1), was distributed to regional surgeons and emer- gency medicine faculty at nine hospitals in California’s capital city of Sacramento and the surrounding area.

Physicians were identified through physician rosters on hospital websites under the department headings ‘‘Emergency Medicine’’ and ‘‘Surgery,’’ and surveys were mailed to the appropriate hospital or office ad- dresses. A repeat mailing to all participants 1 month after the first was done to increase response rates. Participants were reminded not to reply if they had already completed the survey. All surveys were answered anonymously and no physician was incentivized or forced to complete the survey. There were 11 additional demographic questions included that focused on fellowship training, practice setting, and military experience.

Responses were tabulated and entered into a database. The responses were divided between surgeons and emer- gency physicians. Descriptive statistics were used to cate- gorize the response from the surveys.

RESULTS

Fifty-eight percent (n = 149) of the 255 surveys were completed. The response rates were 73% for surgeons

and 48% for emergency physicians. Surgeons were older, more likely to have completed fellowship, in practice for longer, and more often had been involved in the military. More surgeon respondents (60%) than emergency physi- cian respondents (48%) were employed at a Level I or Level II trauma center. In both groups, many (50%– 60%) had at least some experience with MCIs (Table 1).

Few surgeons had reviewed their hospital’s disaster plan. This fact was highlighted when they were asked if they knew where to report in case of a disaster or MCI; 57% of surgeons reported to the wrong location. Of sur- geons that reviewed the disaster plan, 50% still did not know where to report in the event of a disaster. Twenty percent of emergency physicians, after reviewing their hospital’s MCI plan, made the same mistake. Fifteen percent of surgeons and 18% of emergency physicians from non–trauma centers believed they could not receive trauma patients, even in the event of anMCI. Two percent of surgeons were unclear of their hospital’s trauma desig- nation (Table 2).

Only 52% of surgeons knew the appropriate location to conduct casualty triage compared to 82% of emer- gency physicians. When asked about the specific color code used for triage, for example, green for walking wounded and black for expectant, only 24% of surgeons recognized the correct colors. Only one-third of surgeons compared to nearly two-thirds of emergency physicians answered the question about command structure correctly. Even with the broad deficiencies in knowledge, the majority of surgeons felt they should be designated as triage officer (51%) or incident commander (58%) in a mass casualty incident.

When trauma surgeons were analyzed separately, their responses mirrored emergency physicians. Trauma sur- geons had more experience than other surgeons with mul- tiple casualty situations (90% vs. 56%, respectively) and, thus, were more familiar with triage coding categories and correct triage areas than were non–trauma surgeons. Trauma surgeons, like other groups, believed that they should be in charge overall (91%) (Table 3). When lead- ership roles were broken down into specific scenarios, the trauma surgeons were more realistic than other surgeons, believing they should only be in charge if the situation fit into their areas of expertise. None of the trauma surgeons thought they should be triage officer or event commander for a hazardous material event (Table 4).

DISCUSSION

When mass disasters occur, effective management of re- sources greatly influences the success of the response. Gosselin emphasized that nearly two-thirds of surgeons who responded to the Haiti earthquake had no previous disaster training or experience (6). As a result of

Figure 1. Survey sent to regional surgeons and emergency physicians. MVA = motor vehicle accident, OR = operating room, ED = emergency department, ER = emergency room, TBSA = total body surface area.

Figure 1. (continued).

Leading Mass Casualty Disasters 687

disorganization, a lack of training, and inexperience, critics have questioned whether many of the amputations performed after the earthquake might have been unneces- sary or otherwise avoidable (7). For the critically injured, survival hinges on the practitioner’s ability to prioritize patients and optimize the rationing of scarce resources (8). There are many factors leading to inaccurate triage, making it difficult for even experienced triage officers to triage appropriately.

In the daily practice of medicine, resources are di- verted to the sickest patients first. In a disaster scenario, this egalitarian practice results in a vast amount of re- sources being expended on patients with nonsurvivable injuries (8). Clinicians who work directly with patients often have difficulty transitioning from care directed at extending life by every means possible to care requiring strict rationing of resources to the point of deeming some living casualties as triage-level black, nonsurviv- able, or expectant management (9). Undertriage is clearly dangerous, as severe but survivable injuries are over- looked and may go without treatment. Undertriage is minimized in nondisaster settings by protocols intended to purposely overtriage patients to higher levels of care than they may need (10). The intent is to catch patients with critical injuries who are delayed in presentation and may be missed during primary triage. The ACS rec- ommends that trauma centers maintain a 50% overtriage rate for the management of casualties sustained from routine trauma (11). However, this overtriage may also be dangerous by depleting resources, fatiguing staff, and impairing efficient flow of critically ill or injured pa- tients through the system to definitive care (8). As over- triage increases in a mass disaster so does critical mortal- ity. As noted by Roccaforte and Cushman, Frykberg illus- trated a direct linear correlation and demonstrated that after the attacks on September 11, 2001, overtriage rates reached an all-time high of 95% at New York University Downtown Hospital, resulting in devastating critical mor- tality approaching 45% for mass disaster casualties who initially survived the event (10). Unless a mechanism is

Table 1. Background and Disaster Experience of Survey Respondents

All Surgeons EM Physicians p Value

Total surveys sent, n 107 148 Total completed surveys, n (%) 78 (73) 71 (48) <0.01 Mean age (y) 50.1 43.7 <0.01 Mean years of practice 16.2 13.4 0.13 Have fellowship training, n (%) 44 (56) 10 (14) Subspecialty, n (%)

General surgery 34 (44) Trauma/critical care 11 (14) Surgical oncology 7 (9) Vascular 8 (10) Cardiothoracic 2 (3) Pediatrics 5 (6) Burn 3 (4) Transplantation 2 (3) Plastic 2 (3) Oral/maxillary 1 (1) EM 63 (89) Toxicology 2 (3) Internal medicine 2 (3) Pediatrics 2 (3) EMS 1 (1) Occupational medicine 1 (1)

Mass casualty incident experience, n (%) Have military experience 23 (29) 8 (11) <0.01 Have MCI training 46 (59) 62 (87) <0.01 Have mass casualty triage training 42 (54) 62 (87) <0.01 Have CBRNe training 31 (40) 62 (87) <0.01 Have MCI experience 44 (56) 44 (62) 0.05 Have MCI experience with >15 patients in a single incident 20 (26) 12 (17) 0.194

Type of mass casualty incident experience, n (%) Motor vehicle crash 25 (57) 29 (45) 0.265 Shooting 10 (23) 7 (11) 0.57 Explosion 9 (20) 5 (8) 0.335 Fire 6 (14) 3 (5) 0.375 Chemical/gas 1 (2) 16 (25) <0.01 Natural disaster 3 (7) 4 (6) 0.62 Terrorism 4 (9) 1 (2) 0.208 Other 4 (9) 0 (0) 0.053

CBRNe = chemical, biological, radiological, nuclear, and high-yield explosives; EM = emergency medicine; EMS = Emergency Medical Services; MCI = mass casualty incident. Percentage of respondents with a specific type of MCI experience has been calculated from the subgroup of those physicians with MCI experience, not from the total respondent pool.

688 R. M. Russo et al.

in place to limit critical interventions on an individual pa- tient in a disaster scenario, adhering to egalitarian proto- cols could lead to more harm than good in an MCI.

The Centers for Disease Control and Prevention has demonstrated that accurate triage in the prehospital setting saves lives and money (12). As much as a 25% reduction in deaths was seen when the accuracy of triage was improved for critically injured trauma patients (13). A significantly higher rate of death was seen in patients with similar injuries who were triaged inappropriately (14). Correct triage also resulted in a 12% cost savings, estimated to produce a national savings of $568,000,000 per year in the care of intensive care unit, trauma, and emergency department patients (15,16). If improving the accuracy of prehospital primary triage can have such an impact in routine trauma, it follows that improving the accuracy of triage in an MCI may have similarly beneficial effects.

Operating rooms and intensive care units are the pri- mary functional areas of surgeons. To preserve the func- tioning of these important hospital resources, it is essential that critical patients and casualties with opera- tive trauma are appropriately triaged to these areas and that overtriage of noncritical patients be limited. Howev- er, in their report on the orthopedic surgical response to the 2010 Haitian earthquake, Sonshine et al. reported that revision operations, guillotine amputations, fascioto- mies, and internal fixations—all suggestive of inappro- priate disaster care—were seen frequently (6). Similarly, Costello stated that many surgeons who volun- teered in Haiti lacked training in international emergency response and, as a result, lifesaving operations were de- layed (7).

In the United States (US), >5000 accredited hospitals have developed disaster plans modeled after the Hospital Incident Command System (HICS) (17,18). With this

Table 2. Knowledge of Hospital-Specific Disaster-Response Protocols for All Surgeons and Emergency Physicians

EM Physicians (n = 71), n (%)

All Surgeons (n = 78), n (%) p Value

Reported to wrong triage location 9 (12) 44 (57) <0.01 Reviewed hospital disaster plan 41 (58) 30 (38) 0.019 Reviewed plan and reported to wrong triage location 14 (20) 39 (50) <0.01 Believed hospital was exempt from receiving trauma in an MCI 13 (18) 12 (15) 0.633 Did not correctly identify hospital’s ACS trauma designation 0 (0) 2 (2) 0.174

ACS = American College of Surgeons; MCI = mass casualty incident; EM = emergency medicine.

Leading Mass Casualty Disasters 689

system in place since the late 1980s, and its emphasis following the disasters of the past decade, one might expect physicians to be more familiar with its contents. Nonetheless, most doctors were so unfamiliar with the terminology and titles used in HICS that we were forced to revise the survey questions to be generic characterizations of the principles upon which HICS is based. If surgeons are to be in charge of MCI response, including tertiary triage in definitive care areas, a mechanism must be in place to ensure a thorough understanding of necessary protocols and the nomenclature used therein. Given that these protocols are rarely used and most surgeons have never encountered a mass disaster, the importance of training, regular simulation exercises, and regular review of hospital disaster plans is paramount.

Frykberg has stated that trauma surgeons are uniquely qualified to lead the field of disaster response (19). How- ever, he also pointed out that the US trauma community has not taken the lead in the development of disaster plan- ning or education, which has largely defaulted to other medical specialties (19). Members of Medecins Sans Frontieres representing South Africa, Belgium, and Switzerland reported that the 2010 Haiti earthquake rep- resented the largest surgical deployment in the organiza- tion’s 40-year history, and perhaps the largest nonconflict humanitarian surgical deployment of all time. They refer- enced the ACS list of hundreds of surgeons ready for deployment to Haiti, but note that humanitarian agencies ‘‘were reluctant to use them because [of] inexperience in emergency settings’’ (20). Registrars of surgeons in the United Kingdom deemed qualified and ready to assist

Table 3. Effects of Respondent Specialty onMassCasualty Inciden Surgeons to Emergency Physicians with a Subgroup Ana

EM Physicians (n = 71), n (%)

All Su (n = 78

MCI training 66 (93) 48 MCI experience 45 (63) 44 Correct triage location 58 (82) 41 Correct triage category 30 (42) 19 Correct command structure 49 (69) 30 Believe they should be in charge 57 (80) 45

EM = emergency medicine; MCI = mass casuality incident.

during a disaster have attempted to address the training problem, but exactly what constitutes ‘‘qualified’’ is still debated (20). Multiple studies have demonstrated that surgeons with domestic disaster training are more comfortable in a disaster setting and demonstrate better clinical decision making (6,15,20). Lack of formal training has been implicated in preventable loss of life and limb for countless patients in post-earthquake Haiti and after terrorist attacks around the globe (3,4,6). Unfortunately, 10 years since Frykberg published his observation, and despite the ACS’s call to action, little has changed.

In September 2012, the results of a survey prepared by The Eastern Association for the Surgery of Trauma–Com- mittee on Disaster Preparedness were published, which attempted to assess the degree of preparedness training available for Emergency Medicine and General Surgery residents in the United States. The study found Emer- gency Medicine residents reported significantly more mass casualty and triage training sessions than did Gen- eral Surgery residents, with 21% of General Surgery res- idents reporting no training at all on any disaster- or mass casualty–related topic, including basic triage, a finding that was consistent with a study conducted by Galante et al. 6 years earlier (21,22). A review of hospital- and university-based disaster medicine fellowships shows that all of these fellowships are offered through Emer- gency Medicine departments, and none are offered through Departments of Surgery (23). Many nonfellow- ship higher-education degrees in mass disaster response are offered through other graduate schools and schools of public health (24). Of those offered through Emergency

t Training, Experience and Triage KnowledgeComparing All lysis of Trauma Surgeons to Emergency Medicine

rgeons ), n (%) p Value

Trauma Surgeons (n = 11), n (%) p Value

(62) <0.01 9 (81) 0.219 (56) 0.386 10 (90) 0.071 (52) <0.01 10 (90) 0.45 (24) 0.02 4 (36) 0.712 (38) 0.001 7 (64) 0.715 (58) 0.003 10 (90) 0.324

Table 4. Roles That Respondents Felt Should Be Occupied by a Member of Their Own Specialty During a Mass Casualty Incident, Overall and by Incident Type; Comparing All Surgeons to Emergency Physicians with a Subgroup Analysis of Trauma Surgeons to Emergency Medicine

EM Physicians (n = 71), n (%)

All Surgeons (n = 78), n (%) p Value

Trauma Surgeons (n = 11), n (%) p Value

Triage officer for bus accident 65 (91) 40 (51) <0.01 9 (81) 0.311 Chief Medical Officer for bus accident 55 (78) 48 (61) 0.05 10 (91) 0.306 Triage Officer for HAZMAT response 63 (88) 8 (10) <0.01 0 (0) <0.01 Chief Medical Officer for HAZMAT response 66 (93) 5 (6) <0.01 0 (0) <0.01 In charge in some form regardless of MCI type 57 (80) 45 (58) <0.01 10 (91) 0.396

EM = emergency medicine; HAZMAT = hazardous materials and items; MCI = mass casuality incident.

690 R. M. Russo et al.

Medicine departments, two are open to residents from other backgrounds, although none directly extend offers to surgery residents (23).Most trauma surgery and critical care fellowships include education in triage and disaster response, however, none of the 70 total programs actually meet the eligibility criteria of the American Board of Disaster Medicine for board certification (25,26).

The US government is increasingly interested in disaster response protocols and improving medical pre- paredness for MCIs, as it takes an increasingly proactive role in international disaster response (27). In the last decade, the United States has participated in more hu- manitarian and military-based mass casualty responses than ever before, led by organizations including the US Agency for International Development, the International Federation of Red Cross and Red Crescent Societies, North Atlantic Treaty Organization’s Euro-Atlantic Disaster Response Coordination Centre, and the United Nations Office for the Coordination of Humanitarian Af- fairs (21,28). In 2007, Homeland Security Presidential Directive 21 was released to address public health and medical preparedness. It declares the structure and operating principles of our day-to-day public health and medical systems cannot meet the needs created by a cata- strophic health event. Collectively, our nation must develop a disaster medical capability that can immedi- ately re-orient and coordinate existing resources within all sectors to satisfy the needs of the population during a catastrophic health event (29). The directive outlines federal support in the form of grants and the development of a National Center for Disaster Medicine, including the establishment of disaster health as a boarded discipline by the American Board of Disaster Medicine. Federal research grants are available to improve MCI training and hospital preparedness protocols. In 2011 alone, >$352 million in grant funding was awarded to hospitals and health care systems within every state (30). Despite these resources, lack of preparedness among surgeons was a frequent theme that resonated across national boundaries at the World Association for Disaster and EmergencyMedicine 4th Pan American Regional Confer- ence (2012).

Limitations

This article is based primarily on survey data obtained through self-reporting. As a result, the survey may inac- curately estimate how many physicians receive disaster response training or review their hospital’s Emergency Operations Plan. However, this inaccuracy may be of lit- tle consequence when interpreting the data to represent self-assessment of individual preparedness. The results could also be based on experience. For instance, cities and physicians that have experienced major disasters, such as Oklahoma City (Murrah Federal Building bombing), New York City (World Trade Center attacks), New Orleans (Hurricane Katrina), and Boston (Boston Marathon bombing), may produce results different from those that we found in Sacramento. Additionally, the sur- vey was conducted within a limited geographic area in an attempt to maximize responses within a representative cross section of Emergency Medicine and Surgery physi- cians. In an effort to reach a broad sample of Emergency Medicine and Surgery physicians that may be called upon to respond to a disaster, we did not specifically target HICS-trained personnel or designated disaster re- sponders. As a result many of the physicians surveyed, even if they had received some level of training in disaster response, were so unfamiliar with HICS and the language used therein that we had to revise the survey questions to be more generic. Thus, those who are very well versed in federal disaster response and the inner workings of the HICS may find questions about ‘‘who should be in charge’’ vague or debatable, depending on whether ‘‘in charge’’ refers to the Incident Commander or some other level of command staff. After revision, we were able to obtain a relatively high response rate, with nearly 60% of our surveys completed.

CONCLUSIONS

In summary, when a mass disaster arises, utilitarian values take precedence over egalitarianism emphasized in the daily practice of medicine. When this divergence is coupled with the inevitable confusion that is associated

Leading Mass Casualty Disasters 691

with a disaster, administering even basic medical care be- comes difficult. The greatest asset in these situations is a leader who remains calm, understands the principles of disaster medicine, and effectively leads those providing care. Our goal was to identify who, between surgeons and emergency physicians, was best prepared to assume that role. Unfortunately, despite a seemingly increased number of disasters facing medical providers over the last decade, most physicians (surgeons and emergency physicians) surveyed did not have a good grasp of the concepts of disaster response. More distressing, many from all groups lacked insight, asserting they should be in charge despite rampant misconceptions and a lack of experience. When compared to emergency physicians, surgeons on the whole were less prepared to lead disaster-response efforts and were more often incorrect in triage assessments. With a host of leaders unprepared for mass disaster response, one can expect a significant cost, both monetarily and in the potential additional loss of human lives, which could be avoided with appro- priate training. If physicians wish to become leaders in disaster response and MCI management, strides to improve understanding of MCI triage principles and disaster response protocols need to occur.

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ARTICLE SUMMARY

1. Why is this topic important? In the throes of a mass casualty response, it must be

abundantly clear who is in charge, as lack of this knowl- edgewill only lead to unwanted chaos.While many physi- cian specialties claim to have the necessary knowledge and experience to assume the leadership role, this is often based on opinion rather than fact. 2. What does this study attempt to show?

This study attempted to provide factual information regarding the necessary training, experience, and knowl- edge of those physicians most likely to be in a leadership role during a mass casualty response. The differences in training and knowledge between emergency physicians and surgeons, and, more specifically, trauma surgeons, was studied. 3. What are the key findings?

While both surgeons and emergency physicians claim to have the ability to properly lead the way during a mass casualty incident, that claim was not born out in this study. Surgeons were not as versed in incident com- mand structure, including basic triage management, as were their emergency medicine counterparts. For even the few surgeons who had knowledge of the hospital disaster plan, only half knew the proper reporting loca- tion. These differences were consistent over the base of knowledge questioned in the survey. Trauma surgeons, however, were equal to their emergency medicine col- leagues and would likely be equally capable of providing trauma-related leadership in a disaster response. 4. How is patient care impacted?

Proper management of the rapid inflow of multiple pa- tients during a disaster response requires experience and appropriate triage and treatment of those patients to avoid preventable deaths. While trauma surgeons and emer- gency physicians seem likely to be equally capable of managing an incident, surgeons without proper training may be better utilized elsewhere in the response plan.