Good afternoon. My name is Heather Finch. I'm the chair-elect of the Disaster Preparedness Committee. It's my pleasure to introduce John Hick, who is an emergency physician at Hennepin Healthcare in Minneapolis. He is the medical director for emergency preparedness and an EMS medical director there and a professor of emergency medicine at the University of Minnesota. He also serves as the lead editor for ASPR's Tracy Healthcare Preparedness website. Welcome, Dr. Hick. Thanks so much, Heather. I assume you guys can see the educational statement on the slide here. You just need to communicate that to everyone. By the way, the slides will be available afterwards, minus some of the pictures, but you'll be able to follow the links and things like that in a downloadable version of the presentation. With that, I wanted to just talk about, over the next hour here, some issues with mass casualty management and some paradigm shifts in triage, and in particular, some of the issues with secondary triage that we need to think about very carefully in our hospital disaster planning. I think we've covered the objectives already here, and we'll just go on to start talking about triage, historically, is thought of sorting, and that's used for different purposes. In the emergency department, we're basically triaging because we don't have enough rooms, and so it's prioritization on the order of being seen based on the acuity of the patient's condition. In battlefield triage, the goal, a lot of times, is to identify the soldiers that can be returned to battle as soon as possible, rather than necessarily identify the sickest ones. There's different sorting sometimes that occurs for different reasons, but most of the time when we think about triage, we think about primary triage, which is triage at the point of first contact. A lot of times, we see triage in relation to sorting the patients for transport or to be seen in, say, an emergency department environment. But in general, when we talk about triage, it's that you don't have enough resources, and it might be transportation or it might be room, but it might be a lot of different things. But the goal here is to do the greatest good for the greatest number based on the resources available, so kind of a relatively pure utilitarian goal. In conventional events, historically, they have followed a rule of 85-15, which is that for every 100 casualties that are injured, 85% will be minor injuries and 15% will be serious or critical injuries. So whether it's a bridge collapse like occurred here in Minneapolis, or it's a bus crash, or a building collapse, generally speaking, historical disasters have followed that rule. But that relies on blunt force injuries that are relatively static events. There's no secondary or ongoing threat, and it wasn't a terrorist event or an event geared to maximize the harm that was caused. So in a mass violence event, there's a couple of key differences. One is that there is a huge risk of secondary or ongoing threats, that a lot of times there are secondary devices, there are secondary attackers. That's very important from a security and safety standpoint at the hospital. And there's a very high incidence of surgical intervention. So in most mass violence events, whether it's bomb blast injuries in Israel or mass shootings here in the United States, at least 50% of the victims that are coming to the hospital require surgery of some kind, either orthopedic surgery or trauma, general trauma surgery like a damage control laparotomy. That really requires a whole different level of planning than for your conventional events. So we need to expect potential diversionary attacks, secondary attacks, including secondary attacks at the hospital. So secondary devices, secondary attackers, perpetrators dressed as police. A lot of perpetrators are wearing tactical gear now for ballistic protection, but certainly as in Norway, there have been cases where perpetrators have dressed up as police officers in order to get people to follow their directions and then increase the level of mortality. Fire has been used as a diversionary or sort of a forcing function to turn situations that might be able to be managed, you know, through a fairly prolonged negotiating process into an event that can't. So these events can be very, very dynamic. Mass shooting and blast events often unfold over a period of minutes, but they can continue on, depending on the number of secondary devices or the number of other shooters. Unfortunately, bullets and bombs are very cheap, and they're not hard to make, if we're talking about explosive devices, but they're just all too accessible. In particular, in the United States, we have a major, major problem with mass shootings. So we need to rethink triage processes and methods in terms of penetrating injury that has not historically been an approach. We want to make sure that we have active bystanders that are prepared to stop the bleed. And we want to make sure that public safety is using rescue task forces. So you can use models like 3ECHO, which I published on with some co-authors a few years ago. But whatever you choose to do, you need to make sure that public safety in your community is working to rapidly enter these scenes, control the threat, evaluate patients and evacuate them with rapid transport to an appropriate trauma center. So it's very much a military model of care under fire. And that, again, results in a very high volume of critical care in a short period of time at hospitals. So EMS triage in these circumstances really falls into much more of an alive or dead, you know, if they're alive, get them out of the area, get them transported. If there's an immediate life threat that can be addressed through airway positioning or a chest seal or a tourniquet, do those things. But there really isn't a whole lot as far as triage methodology as we historically have thought about it that fits with these circumstances. Choice of destination is really important as we'll talk about in Orlando in particular. Trauma centers got very much overwhelmed because the process in each community and the protocols relied on transporting all gunshot trauma to trauma centers. And when there's a mass casualty event, that can result in significant overloading of your major trauma centers. So your daily choices should parallel your disaster practices until they can't. And knowing what the threshold is and EMS understanding when they're going to start diverting certain patients away to other centers is really important. These incidents can happen anywhere. And for example, in northern Minnesota, in 2005, 10 people were killed and 17 patients resulted in total. And this occurred 40 minutes from the closest trauma center, which was a level four. So the trauma center in this case had to play a role in helping coach the local physician through some interventions, but also decide on who to prioritize for air transport, who to prioritize for ground transport, because the individual that was on that day in the Indian Health Services Hospital really hadn't seen much trauma ever and was not really prepared to make some of these decisions. So a trauma center physician providing support to that individual makes a big difference. Boston, in a very short period of time because of ground level detonation of these devices, an awful lot of extremities got shredded. We were fortunate that there weren't more lives lost because of a very quick and effective response by on scene personnel, as well as the proximity of major trauma centers. One thing I will say is that in these cases, tourniquets certainly saved lives. And yet at the same time, these kind of graphic injuries with shredded tissue to the extremities put us at risk of over triage. And that's something that when we receive patients at the hospital, we have to keep in mind. Frickberg first demonstrated that over triage contributed to critical mortality back in 2002. But those lessons continue on that graphic injuries often are prioritized by field personnel as well as hospital personnel over minor injuries that may actually turn out to be life threatening. And in particular, small torso injuries from shrapnel or from bullet trauma can be life threatening in a way that shredded extremities is not and needs to be prioritized accordingly. So we risk with over triage actually occupying resources with patients that don't immediately need them. And the more casualties, the more risk we run of having patients die of correctable causes. So let's just talk through a couple of recent incidents here and a few lessons learned that are in common and a few distinct. So in Aurora, Colorado, the midnight showing of Batman, unfortunately, was the target of the shooter in this case. This theater is actually very close to the medical center of Aurora and not far from the University of Colorado's trauma center. It also is very close to police and fire stations, which had advantages. But because of communication issues, you'll see here at University Hospital, this is their ambulance receiving area that night. And what do you notice about the ambulance deck? There's no ambulances. So the nine patients that came to the trauma center, all but one arrived by police vehicle because there were not EMS vehicles that were either available or because on scene communication had told EMS to stage away from the incident, there was a breakdown in communication about EMS knowing when the scene was safe. And at the medical center of Aurora, the same thing occurred that the majority of their patients that they received came by police vehicle and not by ambulance. So even when you have an event with some adequate transport available, you may not have EMS providers that are able to provide triage. In the Pulse nightclub shooting, Orlando Regional Medical Center is only a few blocks away from Pulse. They received 38 patients in 53 minutes. They had nine deaths in the emergency department. Half of those patients incidentally had no identification. On average, because this was a close range shooting exposure of 3.3 wounds per patient, so a very high degree of criticality and lethality, police transported nine of a total of the 46 individuals to ORMC. And you can see there were only 11 patients that didn't go to Orlando Regional. Interestingly, one ambulance accounted for 13 of those 46 transports because they just made continuous round trips between the hospital and the scene with very little intervention in route. As is usually the case, the triage for EMS was do they have a pulse? And that honestly is all that really counts in these situations. 28 surgeries in the first 24 hours, nine patients went directly to the OR from the ED. So again, if you're a level one trauma center and you're thinking about on the nighttime, how many patients can I get into operating rooms in a short period of time? And how many disposables and major procedure trays do I have? And how fast is that going to be able to be turned around? Those are all issues that need to be urgently addressed if you don't have a good plan for them. Because again, this could happen in any community. During the Orlando response, there was rapid communication throughout the ED that there was a shooter in the emergency department. The resuscitation area was barricaded. It turned out this was not true, but it certainly did impede operations for several minutes while this got sorted out. This certainly points out the necessity of having badge-controlled access into resuscitation and other areas that are critical during a response like this, as well as having a good communications and security plan. But this kind of information about additional perpetrators is just going to be common to these events. ORMC ran out of chest tubes and had to go procure some from the Children's Hospital. They did not make a lot of direct use of finger thoracostomies, which could have spared some chest tube use, but this was a common feature, as we'll also see with Las Vegas. And Orlando Regional went through 550 units of packed red cells that night. Fortunately, Bonfeast, their regional provider, proactively, and not according to any specific plan, but I think this is something to consider with your blood supplier, pushed units of blood both to TCMA and to University Hospital. I'm sorry, in Colorado, and in Orlando, they had to work with their regional supplier to get blood fairly quickly. In Las Vegas, because the shooting occurred from a long distance from the scene and from a height, any change in the muzzle orientation would result in injuries occurring to another person. So in this case, most of the injuries were shrapnel-related or direct bullet trauma from a high-powered rifle, but at a fairly long distance, but there were usually only single injuries per patient, so a little bit different just based on the characteristics of the scene. And this was a desperate scene. This was a very large concert venue with a limited number of on-site EMS personnel and ambulances, and occurring in an area where it became very, very difficult to, in any way, control the egress of these patients or control how the flow of patients was managed. So a lot of patients just jumped into cars or carried patients into cars, and then they would Google, where's the closest hospital? And so you can see here some of the issues that happened. Sunrise Hospital, which is a level two, received the most patients at 214, roughly, because they had patients walk out that never got registered with relatively smaller injuries, but they certainly saw more than this. But Desert Springs, which has no trauma designation and is a very fine hospital, but it doesn't do any trauma emergency services, happens to be the closest geographically to the location, received 93 patients with gunshot or shrapnel, and in some cases, trampling injuries, but they did a heroic job. But this brings up the issue of sometimes getting gunshot wound victims from hospitals where they self-present to a trauma center may be as important for EMS as getting patients from the scene to a trauma center in the first place. They were very fortunate from a timing standpoint in Las Vegas that this incident occurred across shift change, and so most hospitals were fortunate to have double staff available. But 21% of patients transported by EMS. So again, in Las Vegas, they did use a rescue task force model 19 times. This was mainly for calls that originated close to the event where there was a question about whether or not there was a shooter in that location. Triage was dead or alive, but most of the patients were gone before EMS could get there because as the EMS units approached, they would usually be approached by people on foot with victims, and as one battalion chief described it, they were drinking from a fire hose. Individuals stripped out the supplies from the ambulances to use. They didn't have nearly enough supplies for Stop the Bleed, and then people were generally gone and finding their own way to the hospital. So the EMS role for on-scene treatment was relatively short. There was also a communications issue that night. Because of police barricades that were put up around University Hospital to prevent non-essential traffic from getting into the ambulance drive, there was word passed around that University Hospital was closed, which unfortunately resulted in EMS units diverting a number of patients that should have gone to a major trauma center to other locations. So again, just the importance of communication and verifying information like that during an event. So when I think about triage, I'm really thinking about how much time are the interventions going to take that are needed to save this individual? What are the treater resources? So how much expertise? For instance, vascular surgery, cardiothoracic, et cetera, general trauma surgery, an emergency physician, a Boy Scout. And then what's the treatment? How many resources and what type do we need to put into this patient's care? And in some cases, what do we have available for transport? That's a concern for EMS, but also at hospitals, if we don't have enough definitive care available, is there a mechanism to get that patient to a trauma center to definitive care? So this would represent an optimal treater, treatment and time balance. Very little expertise required, very little for supplies and very little time to take to save a life here. So primary triage is usually what's conducted at the point where we first encounter the patients. And in EMS, historically, we've used triage tags. And I think wherever your jurisdiction is, or if you're in the hospital environment and you use them, we need to think about why. Is it priority for transport? And I would say only if you don't have transport available. Is it for patient tracking, in which case it's probably doomed to failure. Is the tag supposed to convey relevant information to the hospital? That would be nice, but in general, most of these tags never getting any writing on them. And a lot of times the patient condition changes. So most of the time these tags wind up being useless. Is there continuity with the hospital process? Doubtful. And honestly, if these tags remained on and could create confusion inside the hospital, that becomes problematic. So I would say the tags and other indicators on groups may be helpful when you don't have enough transport on scene. And certainly if you're going through quickly and marking individuals that are alive or dead, that's helpful. And marking the individuals that are dead is actually also important just because otherwise they're going to get reassessed and reassessed. So on the right-hand side here, after the 35W bridge collapse, we did have a patient collection area down at the base of a railroad yard. And we didn't have any way to get transport in across that rail yard. So eventually we commandeered some four-wheel drive pickups and were able to move these patients. But that's about the only time that I want to see a casualty collection location set up. So if you're on the left-hand side here, as is historically the idea that you would group patients at a scene once you understand how many casualties are there, and then load them into ambulances, I've told our EMS personnel I never want to see that. I never want to see ambulances waiting to transport people and have you sorting them by colors. When things get overwhelming, our principles are going to dictate that we concentrate less on definitive care and more on correction of immediate airway breathing and circulation issues in patients that are red or yellow. And the more critically injured they are, the more unstable they are, the more difficult their prognosis becomes, the more we need to shift our attention to those yellows that are relatively stable, that we probably have a good chance of salvaging a good outcome. There's a ton of triage methods out there. A lot of them, their validation comes against patient groups or in drill and exercise settings that don't really have any bearing on real life. And so there's very few of these that actually make a whole lot of sense to use, with the exception of if you have somebody who's GCS3 after a blast injury or penetrating injury to the head, and that's been persistent, that's fairly bankable. But most of these we've done a lot of training on, like START and SALT, really don't have a lot of actual validity. So START, we'll just review really quickly. Are respirations present? Are they over 30? That's completely arbitrary. That doesn't take into account respiratory distress. Is a radial pulse present? And then from a mental status standpoint, can they follow commands? Following commands is very, very helpful. And I think that is part of our ABCDE assessment for trauma life support. Other than that, there's not a whole lot of help in differentiating these. There are other examples out there, but when we looked at our level one trauma center, patients arriving to the resuscitation area, and we categorized them according to START triage, we wound up having to provide emergent intervention in 26% of the yellow patients. Not something that could wait 15 minutes, but emergency intervention. The under-triage rate overall in the yellow category was 24%, and there was very little over-triage in the red category. If you are red under START, you are in pretty dire shape. 70% of people that arrived without a radial pulse died, despite being already in a level one trauma center. So honestly, I think the best triage method, and we talked with our medics after the bridge collapsed, and none of them, despite weekly training on START, wound up using it. And yet, the patients arrived at our level one trauma center, which is blocks away from the scene, in almost the perfect order of severity, despite the fact that we had a structural collapse zone that was almost a mile wide. And why was that? It's because the medics understood the principles of trauma care. So your ABCDE of BTLS and ATLS is very important, and that part about exposure is really critical, because START and most of the other triage methodologies used do not take into account penetrating trauma. And so exposure and a search for truncal penetrating injury is absolutely critical in today's triage environment. And by the way, we actually do a pretty good job of just looking at patients and saying, that person's sick. And we like to think that a lot of experience helps with that, but when a Canadian study took untrained medical students who were in their second year or so untrained, that were working as phlebotomists in an emergency department, and they asked them to triage the patient as sick or not sick, based on the appearance of the patient and their interactions with the triage nurse. And they actually did a better job than the emergency severity index at predicting the need for critical interventions. So think carefully about how you tag and track individuals coming in the door, and how you perform. We'll talk more about secondary triage in a minute, but you have to be ready for hundreds of victims, just like Sunrise was, if you're a major trauma center especially. You need to have an unidentified naming convention that is not confusing, doesn't rely on numbers, doesn't rely on things that could easily get confused or lost. what we use at Hennepin on a daily basis as well as in disasters is a color unidentified as the middle name so we can search easily and then last name state. That allows us thousands of combinations because over time these unidentified patients get matched up with actual names and birthdates, et cetera. We refresh this every couple months in our system. So there's always, you know, a thousand patients you can draw from if you need to do immediate registrations. Immediate access to life-saving supplies. How many tourniquets do you have in the emergency department? How many major procedures do you have? How many disposable trauma packs, et cetera, chest tubes? Where do you send the walking wounded to get them out of your ED? Sunrise Children sent them all to the pediatric emergency department. So that's certainly one solution if you have them, but lobby areas, cafeteria areas, conference rooms, other places where you can send the walking wounded but that are still close enough to the emergency department that you can reassess is important. And make sure that somebody who's got some degree of experience and knows the system does the triage. That can be really, really helpful. We do use triage tags at Hennepin. That's primarily to say where the person should go. It also can document contamination or not, but I think more importantly on the backside of that, the disposition, where's that patient going to go to, you know, circled, and we'll talk more about the secondary triage groups, but we got to keep the flow going. We don't want patients to be in the emergency department for too long. So secondary triage is after we do some initial assessment and we can make some decisions based on prognosis about what we're going to do for the next step. And this is actually in the New Orleans airport after Hurricane Katrina. The reason I include this, it's the only time, sorry, it's the first time in history that our DMAT team members had to make decisions about secondary triage. But of the 30 patients roughly that they put in a category of comfort care only, the vast majority of those patients survived. And I think just a reminder that even when we do secondary triage or tertiary triage, we have to keep in mind that some people will exceed expectations or that our resource situation will change. And we've got to be prepared to reevaluate and recategorize. So this is an area of triage that is probably lacking in the majority of hospital plans that I look at. It's after the initial diagnostics are completed. So you're either through CT or you're in the resuscitation area and you've got an indication for operative interventions, then what? And who prioritizes those patients? So who does this? Ideally, you'd have a trauma surgeon that's quarterbacking these cases in the resuscitation area, but you might not be able to afford that. You might need all the surgeons in the operating rooms, in which case, is it emergency medicine that's going to decide? Is it anesthesia? Anesthesia certainly did some of this in Las Vegas in the pre-induction area. But is this part of your ICS? Is it part of your normal response? And how do you recognize and communicate with the individuals that are supposed to be doing these functions in the emergency department, as well as potentially in pre-induction? And how are they communicating with the surgery staff? Now in a smaller facility, and I know a number of you on the call today are from major trauma centers, but secondary triage for them is all about transport. Don't send me a GSW to the head that's had a low GCS as your first victim from a mass shooting. I want to take the abdominal injury that's got an ultrasound positive for abdominal free fluid that had some human dynamic instability, but now is stable after receiving some blood. So getting experienced trauma personality, their surgeons or emergency physicians on the phone with these referring facilities when there are questions about prioritization can be really helpful. So we've come to agreement at Hennepin and I did send this along. So if you're interested in it and want to modify it for your own uses, you'll have it, but this is up in poster form in our resuscitation area. So our first priority is to get patients up that are human and amicably unstable with more isolated injuries. The second is the more complicated stuff, the chest, the neurovascular cases, expanding mass lesions, but not GCS3, stable abdominal, but with known operative indications. And then third is our lower GCS penetrating injuries, other injuries that are likely to be fatal. And then, you know, if we've got ortho cases and things like that, those go to the floor essentially, or kept in the emergency department if capacity is available. But knowing where to put the patients who fall into each of these categories geographically in your facility and have somebody that is going to be receiving them and taking a look at them is super important. And this is a step again in triage that is often missed in planning. So in part, this process relies on rapid imaging turnover and monitoring of the imaging and not getting images confused, which is again, where making sure you've got a good system to tie the images to the proper patients is important. In one hospital that I'm aware of, the disaster numbers started with numbers that were easily confused with the room numbers of patients. And so that almost resulted in inadvertent taking somebody to the OR that didn't need to go. But in Aurora, for example, 150 radiologic studies in less than an hour. So making sure those are tied to the right patient, looked at by somebody that knows what they're doing and are acted on appropriately is key. Ultrasound can be a great tool, give you a ton of information, apart from CT, which is going to get jammed up pretty quickly. As we mentioned, having air traffic control or another triage officer in pre-induction or PACU areas is going to be important in deciding which cases do go into the OR next. So almost another secondary triage location that needs to be accounted for. And then we talked about blood, talked about tourniquets, talked a little bit about disposable surgical packs. It's really hard to assemble the component parts of these on the fly. So making sure you've got a large number of these available before you have an event and then major procedure trays. And some institutions, the nice thing about buying more major procedure trays, even though there's a pretty significant upfront investment, is that it does prolong the life of the surgical instruments on the other trays if you rotate these. Some institutions have opted for smaller surgical trays just designed for mass casualty use, and some have decided that it would be better during a disaster to keep their scrub nurses working with the usual trays. We talked about opening nine ORs potentially really quickly, and it's important to think about how you leverage other staff to do that. So for instance, in Las Vegas, OB staff was very helpful in helping with opening and closings of cases while the trauma surgeons basically went from room to room and did the damage control, in some cases, packing. But there were a lot of surgical subspecialties that could help the trauma surgeons in those first few hours get on top of things and do some of the things that could support them doing what only they could do. And then tertiary triage, we'll talk about briefly. That's when we are in the process of providing definitive care, and then we have to make decisions about what we're going to continue with or not. And I think we need to remember that there is potential here for a lot of bias, age being the most obvious, but also disability, other conditions such as obesity, drug use, you know, et cetera. So, you know, doing some education up front with your providers about the importance of being careful with, you know, attribution of prognosis to non-medical factors is important. At the same time, we know this is a SAFL burn triage table, which ties, you know, percent body surface area burns to age because there is a very good correlation with large burns and higher age and mortality. The same with if you have an individual who is elderly and has a high ISS, you know, versus a younger patient, you know their survival is going to be worse. Age is an independent predictor of poor outcomes in burn and trauma. So we do need to take, you know, certain things into account, but we've got to be careful that we're not acting on biased information. So tertiary triage, making sure that after we've sent these patients to the floor and other places around the hospital, that somebody else is taking another look at them and saying, how are things going? So maybe that's on the floor with a patient that looked pretty stable initially, but now is deteriorating. Maybe that's in the OR where we've gotten into an abdomen and now we realize we've got a lot of complex vascular injury. This is going to be a really protracted surgery with a very poor outcome. The patient's consuming blood products at a tremendous rate and we just decide that we can't continue to provide care given the other demands on the surgery team's time. So again, that's a dynamic process and we have to kind of reprioritize. I will say that if you're making a decision to abandon certain aspects of care, it's really good to make sure that your command team and command center are aware of those things because you want their support for any triage decisions that need to get made that are more systematic. And get a consultation, even get another surgeon, get somebody else to lean in and just say, yep, I totally agree. We can't continue to afford these resources. That helps a lot, not only in validating the decision, but also in reducing the moral injury that can accrue to providers when they have to make triage decisions that they might look back on later and say, what if? And then documenting the decisions were made based on the context. I don't expect you to read this diagram. This just basically says that the more consequential the decision about withdrawing resources, and a lot of this applies more to ongoing critical care than it does to an emergent surgical decision, but this is available at the web link below. It's a free full-text article from the Joint Commission's Journal of Quality and Patient Safety. And you can't really improvise plans in these situations. Cognitive loading when you are in a mass casualty situation is going to reduce your problem-solving capacity by up to 80 percent. So if there's not a policy, if there's not a plan, a lot of times the staff may either delay making decisions, delay reporting a situation, especially if they're not clear they've got the authority to do something. And then task lock is really common. In your most stressful moments, you tend to lock in on familiar rather than adaptive strategies. So unless people are trained on the strategies or you've got visual reminders or other things that from a system standpoint drive things in the right direction, you're going to wind up with a lot of people trying to just pedal faster and faster on the same bike, and sometimes that doesn't work. You also want to make sure that there's no delays in mobilizing additional resources, especially from outside the hospital. If you need additional transportation or staff called in or other resources, you don't want to get behind the curve on that. And so, you know, much better to have a written plan for the initial tier of activations, the subsequent tier of activations, notifications, et cetera, than to try to do that on a more individualized basis. There is liability for not planning for hazards that are known within the community. So making sure that your team is working with the emergency management directors on your hazard vulnerability analysis and making sure that mass trauma is prioritized in the planning and in the resourcing, you know, for these type of events. AstroTracy.hhs.gov, if you're not familiar with it, is a website where we have a wide range of collated resources. So in our technical resources collection, we've got a lot of different topics that we have annotated bibliographies of what we think are the most important works in different areas. So whether it's crisis standard of care or bomb and blast injuries, you'll find what we think are sort of the best of the best information within those collections. If you can't find the answer to a question or a specific resource that you need, get in touch with our assistance center. They're happy to help. They're available daytime hours, so it's not an emergency response group. It's a planning support group. So Tracy is really good to assist in the planning phase of these type of things. We've got a lot of really nice tip sheets from incidents like the Las Vegas incident that give you a lot of concrete information on what you can do to be better prepared as a hospital. And then our information exchange is peer-to-peer. So you keep us out of your business. You can ask for resources from other individuals and have dialogue in ways that we can't really do since we're essentially a government entity. So I mentioned the tip sheets. Those can be very helpful. We've got some good topic collections. And then the document that summarizes a national roundtable that we had involving TCAA, amongst other partners, pre-hospital and hospital, on some of these issues is called Mass Casualty Trauma Triage Paradigms and Pitfalls. That came out pre-pandemic. And so now that things are settling down a little bit, time to pick the threads back up on some of these initiatives and really try to do the best we can with EMS and with hospitals to plan for these incidents that really don't comply with our typical assumptions about mass casualty incidents. So with that, I will wrap up and open it up for questions. I hope that's been helpful to think a little bit about what your EMS systems and how your emergency department and surgical services function during a mass casualty event. And also think a little bit about what are some areas of policy and from a resources standpoint that we might need to do some work in order to be better prepared. So I think, Heather, we're putting questions in the webinar chat. Is that right? Yes, sir. Thank you, Dr. Hick. Yes, we'll open it up to questions from the group. And so if folks want to type your questions in, I'm happy to help facilitate the Q&A portion and read along. While we're waiting, Dr. Hick, I can kick us off for sure. I want to just ask for you, you touched on with the mass violence event that it doesn't follow that 85-15 rule. So just wondering with those high incidents of surgical interventions, do you recommend having an addendum to MCI plans that address a penetrating or mass violence event in particular? And what would be, in your opinion, a priority to include? Yeah, that's a great question, Heather. Honestly, I think mass casualty plans need to be driven by these mass trauma events, because if you can handle these mass penetrating injury events, you can handle the other stuff. So yes, you need a different plan for a specific hazmat event, a biologic event. But when it comes to a mass casualty incident, your plans honestly need to be geared around mass penetrating trauma, blast and bullet injuries. I think the main thing is just to make sure that your surgical and anesthesia and blood bank and laboratory and emergency department services are the primary ones that get their notifications. And just knowing how those staff get notified and doing that in a very rapid fashion that is independent of phone systems is super, super important. Getting those folks in and then just making sure, again, that the planning is in place, that they are adequately resourced. And good question from Deb about how does the trauma team assist in secondary triage? And that's very much part and parcel to, I think, each hospital's policies. What I'll say is that when something like this happens at our institution, the goal is for the backup trauma surgeon to assume the quarterback role in the resuscitation area for directing patients to the operating room. So they are known to the emergency department and they're our go-to as far as conduit to the OR. We have a direct line from the emergency department to the surgical desk in case there's need for rapid communication that's independent of the phone system. But if that fails, if that surgeon needs to go into the operating room urgently, then the emergency department physician will work off of the agreed upon poster conditions that we've set out in order to continue to send patients up to pre-induction and PACU. Go ahead. Dr. Hick, in follow-up to that, there's the trauma services work groups, the quality departments, essentially, that have critical care trained nurses that have had experience in ICU or ED that help run those trauma services departments. Do you see that there's a role for those members of the team, the registrars, the quality nurses, etc., to help in mass casualty response? Yeah, absolutely. I mean, this can be very much an all-hands-on-deck situation. What we have to be careful of is sending too many people to the emergency department because you need to be responding in an environment or with tasks that at least you have some preparedness to accommodate. Now, granted, there are situations that you can't plan for, like environmental services personnel. Sometimes we're holding pressure on bleeding wounds in Las Vegas. In the early moments after a mass casualty incident, you're going to be really short on help. But as help comes in, we've got to get the critical care docs to be doing the secondary triage upstairs. We've got to get all the surgical residents and staff to the ORs and covering PACU, pre-induction, the ORs, anesthesia, same thing, check-in and pre-induction. The pre-induction coordinator up there who's a nurse is basically the air traffic controller for that area of services. And so everybody is checking in with her and figuring out what to do and where to go. I see a question in the chat about, especially in time of staff shortages, how do we manage this? And that's a great question. You can't necessarily get everybody into the OR immediately that you want to, but trying to think about how we would leverage our colleagues in OB and ortho and others to help us with getting some of the cases started, thinking about whether there's an opportunity for temporization with like roboa, catheters, think about how you stretch your staff basically, and how could we be two places at one time or multiple places at one time if we had to. But that's unfortunately where triage starts to come in. In some cases, you're going to have to make decisions that we can only effectively staff four ORs or whatever it is. And this is the number of cases and these are the patients we're taking. But the goal then is to maximize your turnover. It's get in and get out. And so if you get into a surgical situation that you realize is going to take a whole lot more time and you have visibility on the number of patients that still need to get in there, you may have to make a decision to bail out or you're going to do a bunch of damage control and temporary packing and try to cycle those cases quickly, in which case it is incumbent to know that you have enough serial supplies and that also you've called in your central processing and sterile supply folks that they can start turning that stuff over again and gear up for orthopedic procedures in the subsequent hours and days. Thanks. I have a follow-up question regarding that surgical availability. Regionally, I know we've had a lot of discussions with our pre-hospital teams as there's been a request of, hey, we'd really like to know each facility's threshold, like their base threshold numbers so that when we're in event, we kind of know you can typically handle up to this many patients. From a hospital standpoint, we feel that that's pretty fluid depending on time of day and resources. Do you have any thoughts on stating a base number threshold for the pre-hospital team? That's a great question again. We do have default numbers. We have an EMS coordination point called Medical Resource Coordination Center in our area and during an MCI, basically, they're tracking which ambulances are going to which facilities and in some cases directing them to facilities. If they know that we've got a lot of walking wounded that came to HCMC, they're going to ask ambulances to avoid us unless they've got a really critical patient and we still have capacity. The default on EMS bringing patients to a level one trauma center for us would be 10 reds, 20 yellows, and 30 greens. That varies then if you're a non-trauma center, you're taking very few red casualties and a whole lot more yellows and greens. That's the default initial wave. Once that's hit, MRCC will then get in touch with the hospital and say, how are you doing? Can you take more or do we need to continue to move and have ambulances go to other hospitals? I think having a default number is really helpful for EMS. At the same time, just having EMS understand that in certain situations, they're going to have to make judgment calls. If they've got an extremity GSW, for example, that normally would come to a trauma center, if they know based on the incident that a lot of patients with truncal penetrating trauma are going to the trauma center, then take those patients somewhere else. Super helpful feedback for that question. Thank you so much. It looks like we don't have any more pending questions at this time. Looks like our webinar will be ending soon unless we have any questions. Happy to help and happy to stay engaged. I hope you make good use of the Tracy resources. I hope this will drive some good conversation with your trauma services and support services. It's much needed. Thanks so much. Good for taking the time. We will depart here soon. Thanks everybody for your comments. Thanks, Heather. Thanks, Deb. Stay safe and thanks for all the work you do.

Dr. John Hick

emergency physician

triage

disaster planning

mass casualty incidents

secondary triage

conventional events

mass violence events