My name is Carmen Flores, I am a trauma and burn surgeon over in Las Vegas at University Medical Center of Southern Nevada. I am a pupil of the prestigious Arizona Burn Center, we like to call it the world famous Arizona Burn Center. I was trained by Kevin Foster, Mark Matthews, Dan Caruso, and Mike Peck. And I am actually here representing Dr. Matthews as he could not be here today. We're going to be discussing largely burn disaster and the reaction to burn disaster. Some of the information here is a little redundant from my colleagues that have presented, but most of this is burn disaster. I thank you for the honor of the podium today. So what if the World Trade Center towers did not collapse? Here comes the boom. So what would happen or what would have happened if the World Trade Centers did not collapse? So I want you all to think about that. What impact did that have on this country? Disaster prevention, disaster response, not only for burns, but for mass casualty. What if the plane that hit the Pentagon hit somewhere that was not under construction? Could U.S. burn centers triage, treat, and transfer the thousands of patients to burn and trauma centers with a quote-unquote acceptable mortality? And what is an acceptable mortality? How is that defined? Where were you on 9-11, 2001? This is similar to the where were you when Kennedy got shot question. So we'll give you a little bit of time here, and then I'm going to date myself and then date Dr. Matthews, which is even more fun. All right, so it looks like most of us were at home and watching this on TV live as it happened. So as our poll showed, many of us were at home watching this unfold. And for many others, they weren't born yet. And this memory is not as burned in their conscious as those who watched it live or who were nearby or who were a part of this. So here's the dating of myself. I was actually in my post-baccalaureate program over in California and I had just finished an all-nighter, had an exam the next day, and I woke up, turned on the TV, and I saw the second plane hit the tower. And it just was immediate shock. It was an out-of-body experience. Did this really happen to our country? Dr. Matthews was in the operating room. He was a vascular fellow at the time and he had a resident, as he was doing a guillotine above knee amputation, run into the operating room and say, the World Trade Center just got attacked. And he continued to operate, came out, and they ran back into the operating room again and said the second tower was also hit. The response by the American Burn Association was within several hours of that attack. And oddly enough, or maybe not surprisingly, they found severe shortages of burn beds in this country. So less than 2,000 available burn beds to accommodate survivors or those who were impacted by mass casualty, which led to the current web-based National Burn Tracking System, which is essentially an interagency web-based command center. And what it does, it informs the public in a centralized area of where mass disasters are happening, whether that be a wildfire or any other mass casualty, a hurricane or tornado, et cetera. But what about today's threats? So while something as impactful as 9-11 has not struck our country, that doesn't mean to say that mass casualty can't happen on a local level. What about the California, Oregon, Colorado, Arizona wildfires? So some of this is a little bit close to home for me. I don't know if anyone in this room has ever watched Only the Brave. It was a movie that came out in 2017 about the Yarnell wildfires up in northern Arizona. I was in my training in general surgery and back then we did five years. We were five years in the burn center. And so I was actually a chief covering the burn center that day and the Yarnell fires hit and we got a patch that we would probably be getting multiple firefighters or hotshots that were fighting this blaze from the Granite Hills group of hotshots. And as we prepared, we got another patch that said 19 of those firefighters had succumbed. So 19 out of 20 of those guys fighting the blaze on the front lines had succumbed. What if a sporting event or a concert was affected by an incendiary device? This just happened a few months ago or early last month when a US traveler had an incendiary device on a Taiwan flight. What about nuclear accidents like Chernobyl and Fukushima where nuclear detonation occurred or was proposed to occur? Just a few months ago again, an Iranian terrorist was caught at the US Mexico border with a bomb. What about train tanker cars or accidental chemical explosions or disasters? This happened in East Palatine, Ohio a few months ago when five gas tankers that had derailed off of the train traveling there needed to be detonated and exploded because they had derailed. How many people would have been burned or injured and sustained burn injuries in addition to inhalation? Mass casualty incidents are defined as incidents that occur when the needs of the victims exceeds the abilities of available medical resources to manage each patient. And in the response to 9-11, you kind of understand what those burn resources are. Less than 2,000 beds with approximately 133 burn surgeons available to help these patients, it's not going to be enough. A disaster occurs when the imminent threat of widespread injury or loss of life results from terrorists or natural events exceeding the capacity of the local agency or agencies. And a burn mass casualty incident is a disaster that includes patients with burn injuries. It can be further defined, a burn mass casualty can be further defined as any catastrophic event in which the number of burn patients exceeds the capacity or the local resources of the burn center to provide optimal burn care. We've heard from some trauma centers and trauma surgeons that kind of know burn care and jump in when the need is emergent and can temporize these patients for transfer. And we'll talk about some of that shortly here. Burn injuries of any type require a large amount of resources, personnel, equipment, and time. Capability also includes the availability of burn beds, burn surgeons, burn nurses, support staff, operating rooms, equipment, supplies, and related resources. And capability varies from burn center to burn center. Some burn centers are as small as five beds. Some burn centers are larger. The BRCA network is probably the largest. Capability may be seasonal, week to week, day to day. During the summer in Las Vegas or Arizona, we are pummeled with contact burns from the pavement. You can't find an open bed in our burn unit in the summer and we're at overflow capacity on a regular basis at all times. Capability should not be confused with the willingness or the burn surgery capacity. And surge capacity is essentially flexing 1.5 times the number of available burn beds in each burn center, which is pretty standard, honestly. There are 133 burn centers as of July 2020. As explained before by my colleagues, approximately 72 are nationally verified burn centers. There is one military burn center at BAMC or SAMC, and approximately 2,000 burn beds with 300 burn surgeons to cover. As you can imagine, staffing issues can be impactful. If you recall the recent pandemic, there were many staffing issues and ICUs were pummeled. We were over capacity. All of our burn beds were used to accommodate COVID patients. Equipment issues and supply chains were impacted by the pandemic, which can impact our response to a mass casualty. Transfer issues, as we know, there are always transfer issues. And verified burn centers are usually linked to level one trauma centers for a reason, because there is a robust or a more robust set of responses and set of resources available at level one trauma centers. The real issue though, again, is of those identified burn beds, about 70 to 80% are already filled. And then there are other issues like geographic issues. So while we can say that 80% of the US population lives within two hours of a ground or rotary air transport of a verified burn center, there are geographic challenges to this. For example, Mississippi does not have a burn center. So where do those patients go? What if we hit the 72 hour rule where we have such an impactful disaster that air traffic is grounded for 72 hours? How do these patients get to where they need to be to get good care? Even more issues, a sudden surge of critically ill patients requiring immediate and prolonged care following a mass casualty incident places immense stress on our ready stressed healthcare system, including space supplies and experienced workers. So the response of the government and legislation to particularly burn mass casualties has been a little lax. So many regular disasters as they are identified, like fire, small disasters like tornadoes or big disasters like hurricanes, those can all impact burn care. Those all can have burn or blast injury. And this was not very well recognized by legislature until July, 2003, when burn centers were finally included in the legislation and were eligible for state and local funding for disaster preparedness. And as of 2019, funds are decreasing because now something like 9-11 is not in the national conscious. Our national consciousness has transferred to other big issues like the pandemic. And we're also the victims of our own success. So the US is rarely attacked and if so, we're attacked on a much more smaller scale than what happened in 9-11. And there are new issues brought to the forefront like the pandemic. Attacks by terrorists are now even referred to as quote-unquote man-made disasters. And today we are much more in tune with natural disasters or health-related disasters. And then politicians play to the grandstand, which as we all can understand, they're much more reactionary than proactive. City and statewide drills should take into consideration that a large number of BMCI casualties and review their disaster casualty plans. Now, I want to make clear that many disaster plans out there are based regionally. So several states, at least in the burn world, have gotten together and created regional disaster preparedness plans. But this is not to undermine or isolate the local disaster plans that everyone should have and small scale disaster plans. So some of these widespread disaster plans are broken up by region, western, southwestern, capital, and then individual states have their own disaster plans. One of these states is Arizona. So Arizona Burn Center is situated in Phoenix. And they set up in 2004, the Arizona Burn Disaster Network. And they sat down with 11 tertiary centers and said, we all need to be a team here. We all need to work with each other. We all need to have constant communication. We all need to be prepared in case there is a mass casualty. And burn disaster management was taught to staff and ancillary staff and stakeholders at all of these tertiary centers. And then stockpiles of burn supplies were placed around Arizona and the surrounding areas. But again, many of these disaster preparedness plans can occur on a smaller scale in a hospital, smaller hospitals, housing units, developments, churches, sports arenas, and can occur in response to other disasters as well. In creating the Arizona Burn Disaster Network, there was a needs assessment done. So as scientists, we do a needs assessment. What is the need out there? And identified several different areas where a potential mass casualty or a burn mass casualty can occur. And in the Arizona area, the first identified was near Yuma, which is the Palo Verde Nuclear Power Plant, which houses the largest nuclear reactor in the country. And it's always said that there can be a 747 that just crashes right into that reactor and causes a mass casualty incident. So that is down in Yuma and in the proximity of this Arizona Disaster Network, as are electrical substations and facilities, fuel pipeline and storage depots, methamphetamine labs. When I was training in Phoenix, we were the largest hub of methamphetamine traffic on the way to the Midwest. So we were a very big hotspot for methamphetamine labs and methamphetamine use on the way to Chicago in the transport of methamphetamine. Chemical plants, industrial plants were identified as well as airports and concert halls and big venues such as that. The Arizona Burn Disaster Network was part of the Southwest Regional Burn Mass Casualty Patient Plan that essentially empowers 23 burn centers in the Western region, which are capable of accepting transfers. Each site has capability by telemedicine, FaceTime. We talked about things going viral. Now we have FaceTime. Now we have to kind of harness all that social media to our advantage and communicate well among practitioners. And because of the 72-hour rule for terrorist events wherein things are grounded, we have to come up with a plan. How are we gonna transport these patients by ground, which is a very inevitable possibility. And once 72 hours are available or are over, how do we get these patients to the burn center for definitive care? Burn length of stay is typically one to two days of hospitalization per 1% TBSA, as we've seen in the previous presentations. And unlike burn injuries, trauma as compared to trauma patients, usually burn stay is longer. But truly definitive care should happen at a verified burn center. In the US, under normal conditions, most severe burn centers, most severe burns are immediately transferred to the nearest burn center. We saw the transfer criteria as published by the ABA. However, since a relatively small number of burn patients can quickly overwhelm any burn center, this referral paradigm may quickly overwhelm one small burn center, verified or not, in the setting of a disaster. And so this is where trauma centers come in. How can trauma centers stabilize these patients or even smaller centers, your level twos, your level threes, with simple burn care? Simple resuscitation, simple covering the burn with sheets, getting the patient warm, getting the patient maybe an early mechanical debridement if greater than 72 hours have passed, and then preparing them for definitive care. And this is where we all have to work as a team to come together in the case of a mass casualty. General hospitals and urgent cares usually don't have the bandwidth to treat these patients, or their providers and depth of resources are very shallow. And so the concept of any port in a storm is usually not sufficient and quite unreliable. As we've seen before, burn patients have a unique pathophysiology in response to injury. If you've ever seen a big total body surface area burn, you are very familiar with hypermetabolism and the immediate response to the burn. It's very different from your trauma shock. It's very different from your trauma hypermetabolism. The local burn center can assist in triage and decide who needs to be transported to another local or regional burn center and where to seek other provider care. Other burn centers can call other local burn centers, the burn directors can call within their network, et cetera. And so triage has to be done. So in the setting of a mass casualty, triage is very, very important. It essentially means sorting patients. It's the process of sorting them according to their immediate needs and taking into account the limited resources that are available and the limited burn expertise that is available. Hospital providers should have a working understanding of the pre-hospital system. Things can be very, very chaotic. And this is where pre-hospital staff have to be prepped and drilled and prepared for things of this nature because they can provide a sense of structured chaos or a calm in the storm, so to speak. Incident command is important. So incident command centralizes command and control. It establishes a coordination center for where patients are gonna go, how are they gonna be triaged, and the networking that happens in response to a mass casualty. And multiple agents are involved. Primary triage for a mass casualty starts at the scene. And when available, a master surgeon should be able to respond, meaning a burn surgeon that knows what they're looking at. So not everybody is trained in burn care. Not everyone knows what they're seeing. There's a lot of shock value to burns. We've talked a little bit about trauma trumping burn. Trauma trumps burn all day long, but burns can have very big shock value and injuries can be missed. I remember in a few months ago, we had a transfer of a patient, two patients that were burned in a candle wax factory. The candle wax factory blew up and blasted these two gentlemen that were working in the factory across the room. And they were sent to the nearby trauma center and they were noted each to have greater than 50% total body surface area burns and wax just stuck to their entire bodies. And the burn was so shocking to the staff that received these patients that the trauma workup wasn't done as well as it should be. There wasn't all of your ABCs and an axillary vein laceration was missed. So again, trauma trumps burn, but when available at these mass casualty incidences, a master surgeon should be able to look and see and identify what's going on with the burn. The scene incident commander can coordinate the local burn center response with triage, transport, and referral. And just a caveat, parceling out too much authority can quickly lose its effect. So outside agencies may not know where to go. They might not have the ability to understand the complexities of burn care. And again, burn center directors should reach out and use their networking ability. Local and regional transport should be a part of that response as well. ABA and the ABLS course recommendations are to triage major burns to a verified burn center within 72 hours or less. So the ABA and the ABLS have a very good kind of framework for disaster response and they're very good at that. They've published online. Secondary triage may occur from a verified burn center to a verified burn center or to a local trauma center. Transport may be across regions or nationally, but again, preferred to be at a verified burn center. Disaster scenes, as we stated, are hectic and they're out of control, which is where the first responders come in and kind of give a sense of control. PPE decisions are a big deal. As sterile as you can with the resources that you have. And then has everybody seen these color tags in their drills and such? So these are the color tags that go on the patient's feet and each one is tagged. So the basic principles are immediate or red patients are, they need immediate treatment to save a life, a limb or their sight, and they have a higher survival with immediate treatment. Whereas yellow tagged patients are still potential for life or limb issues, but not an immediate threat of cardiac or respiratory trauma and arrest. And care is temporarily delayed. Whereas your green patients are your walking wounded. They're usually alert. They usually do not need immediate care. And some of those, if not most of them, can go to outpatient management. Expectant patients are tagged with a black tag. These are poor prognostic patients, even with treatment at the lowest priority. So the essential concept is with an accurate or as accurate as you can be triage system, the greatest number of patients benefit from your limited care and your limited resources that are immediately available. So I think one thing to think about is standard of care in a mass casualty is essentially thrown out the window. You have to do and temporize patients to the best of your ability in the, with the limitations of your resources and staff. The box score is quite old. It is a score that determines or tries to determine the probability of death based on TBSA in a patient and age. So it is, the quick and dirty is age plus TBSA equals probability of death. So a 40 year old patient with 60% TBSA burns has 100% mortality according to the box score. Remember, this is no longer accurate anymore due to care that we have now, the intensive care that we have available and we are better at our jobs. We are better at what we do. We know more. Research has advanced to help our patients get early excision and grafting, get resuscitated and closed and critical care is better. This is the modified box score. There's three essential factors, TBSA greater than 40%. Always remember that inhalation injury impacts mortality directly for all of the reasons that we've heard. A patient with inhalation injury has a higher chance of mortality, especially if they have a higher TBSA burn. There are many kind of prognostic grids and prognostic formulas out there to determine the response or the way to triage patients and this is one of them. This is the TBSA start triage grid. It is essentially a grid that determines a patient's burn size and correlates that with their age and essentially gives you a way to triage them and how to triage them. It's never been quite proven and again, as you can imagine, in the setting of a mass casualty, you want your master surgeon there or somebody with experience to be able to triage these patients quick without relying on a grid. Burn size is the most readily identified factor in determining survival. Accurate assessment of the TBSA is super important to triage because it is a critical impact factor as is inhalation injury. You can calculate the percent burn either quick and dirty with the Palmar method or if a patient has areas of unburned skin, you can take that away from 100. Just quickly try to calculate it so that the patient gets the care that they need. Patients with burns don't immediately develop uncompensated shock, okay? So if they do develop uncompensated shock very quickly, then you gotta look for another injury. Is there a belly injury? Is there a splenic rupture? Is there a liver laceration that's actively bleeding? Is there a vascular injury? Patients between two and 60 years old will fare better. Patients with inhalational injury as we've described fare worse and definitive care must be delayed or withheld for expectant patients which can be very, very difficult, okay? So many, many times we see patients who are greater than 80% total body surface area burns. I can recall one of these patients, she was a grandmother. We had a set of grandchildren that she was taking care of. One of them was eight years old, the other was 11 and the eight-year-old was playing with matches on a mattress in the RV that they lived in and set the whole RV on fire and the grandmother dove in four different times into the RV to save both kids and she had 95% total body surface area burns by the time that happened. And these patients will come in, they are big shock value. They will lay in your trauma bay and they will be alert and oriented if they have not had a significant poisoning effect and they will ask you if they're going to survive and it is the most excruciating thing to see that and see that shock value in the setting of a mass casualty. Just understand that that is likely an expectant patient who you may not have enough resources to take care of. Think globally when it comes to burn disaster management. So think globally about associated traumatic injuries. So your blast, your C-spine injuries, your spine fractures, your belly fractures, your blunt cardiac injury and then think about pre-existing health issues. How are these patients impacted by coronary artery disease or chronic kidney disease, et cetera. Think about your personnel globally. So can you call somebody out of retirement? Who is around in the city? Have a loaded bench so that you can help take care of these patients. Have a global view of supplies and be creative. I always talk to the residents about MacGyver and they look at me like I'm like 80 years old and I'm like, you don't know MacGyver? Like I'm not that old, you guys. And so try to MacGyver things. Equipment, think globally about too and try to use what you have. Time from the incidents, think about that globally as well and think about that 72 hour mark of resuscitation. Weather and temperature are issues, okay? I come from a very extreme climate. I did residency in Phoenix and I thought the answer to the lightning question was Phoenix. I'm like, oh, that's Phoenix all day because we got so many lightning strikes. But think of weather and temperature extremes. If there's severe cold, remember that burns can happen in severe cold, wounds can happen in severe cold, trench foot, et cetera. So all of these can impact your mass casualty response. Survivability will depend on the previous factors and the magnitude of the event. Again, triage is important. Your incident commander must go through the director of the burn center. And then the state and federal systems can assist but should not supersede the expertise. That's hard to do, I know. This is the newer revised grid, which again, is not validated but can be used as a guide to the response. So we're gonna talk just very quickly since my colleagues kind of already went over these things. Airway breathing and ventilation. So your similar ATLS response, you're going to respond to your burn patient this way. Inhalation injury alone jeopardizes survival as we've talked at length about. After starting your IV fluids, airway edema increases significantly. Remember that the reaction in the airway to inhalation injury or to the burn itself or even flash burns that don't go past the glottis is to swell. Okay, so if you need to intubate or you think you need to intubate, if you're thinking about it, do it, especially if there's a long transport. We can always extubate the patient within 24 hours or 48 hours. Better safe than sorry. Ventilators should be tracked by each facility willing to partake in the care of burn mass casualty patients. Intubated patients require not only ventilators but remember the personnel that you need to run those ventilators. What if you don't have enough ventilators? How can you optimize or MacGyver your high flow oxygen? How can you use your nasal cannula? How can you optimize and get patients temporized? Does that mean no intubation for patients in your expecting category? It might. What about oxygen for comfort or to prevent air hunger? What about comfort care? All of these things should be in the back of your mind and you should have a global concept or global view of those. What about fluids? So ABLS and ATLS teach two large bore IVs in patients and LR, so LR because of the lactate that can help reverse or decrease the amount of metabolic acidosis which is why we love LR so much. Give IV fluids to priority people, those greater than 20%. I cannot echo Dr. Fagan enough by saying those with less than 10% TBSA and maybe in a pinch less than 20% TBSA, you may have to give them PO. Okay, PO and they can self-regulate, they can use electrolyte drinks, et cetera. In a pinch, you have to preserve and save your IV fluids for those most critical patients as well as RBCs. So as you can imagine in a mass casualty, we're short on blood. We're already short on blood as a country. So blood comes at a very high premium. And so hemoglobin less than seven or the trick trial trigger falls in here because of our national shortage especially in a burn mass casualty. IV access in the expectant category should be used for treatment of pain and anxiolytics and to keep these patients as comfortable as you can. Neurologic and gross deformities should be addressed and temporized at the scene. You should try to get any history that you can. All patients are trauma patients first which we've talked about already. In a pinch and in the setting of a mass casualty, exposure is key. Keeping your patients from progressing to hypothermia or into the trauma triad. Maintaining a warm environment is important. Use what you can, blankets, foil, plastic wrap, covering a child's head at all times. Burn dressing. So this is not the time during a mass casualty to tell the burn nurses to put everybody in Sylvadene and debride their blisters, right? This is your sterile low threshold burn dressings that are small, that are compact, that are cheap and that are easy to transport. Diapers for burns to the bottom. Clean cotton t-shirts also work. Plastic gloves for burn hands, socks for burn feet. And work on calling other centers to equip and be ready for your transfers. Burn pain is excruciating. Those of you who practice burn surgery know that maybe apart from the cancer ward, we pass out a lot of pain meds and patients eat right through them. Pain meds and sedatives. Hypermetabolism is real. These patients are in pain. So please treat them accordingly. If you don't have an IV, then use IM. Use PO if you need to. Telemedicine is important. We've already talked about that at length. When we first started telemedicine over in Arizona, and I'm gonna date my burn forefathers here, none of them knew how to work the damn machine. It was so hilarious. And they'd call the youngest resident that they thought was the most computer literate and they'd say, come and fix the telemedicine machine. Now technology is better. We have other ways, but optimize it. The only thing worse than having no plan is having two plans. So not a coordinated attack. And this was said by the great Alan Brunicini, who is a retired chief over in Phoenix Fire. Devising a master plan is key. So early triage, initial stabilization, and have a built-in redundancy. So having that wide bench of practitioners and experts as you can to care for these patients. Burn mass casualty incident creates a situation where the system operates under emergency rule that the standard of care can't be applied to all patients, and it's just something we've gotta expect. We're gonna go just really quick and dirty into inhalation injury. My colleagues have kind of already talked about this. 100% oxygen is the rule. So many places are not equipped with hyperbarics. 100% oxygen without touching the vent is okay. You should be able to identify the signs of inhalation injury. Obviously the two below are pretty drastic here. But progressive hypoxia should deem a tube. Vocal chord edema should deem a tube. Vocal character change should deem a tube. And remember, if you're thinking about putting a tube right when the patient gets there, you should think about what happens after you've got two liters in, or more than two liters in. That airway's gonna swell, and the patient's going to become an emergent airway, which is bad news. Remember your special populations, okay? We've talked about children and their special physiology for ET tubes. This also comes into play with your special populations like the elderly or patients with Down syndrome. I've seen patients with Down syndrome have the most acute response to any form, even exposure to small fires, and even brief exposure to smoke just makes their throat swell. So just keep that in mind, your special populations. Carbon monoxide poisoning we've talked a little bit about. We've talked a little bit about cyanide poisoning and hydroxycobalamin. In our rigs over in Vegas, every EMS is equipped with the cyanokit almost to the detriment of patients. So we'll get a call that says, oh, we have a 50-percenter, and somebody's really 10% and has the cyanokit, and it's going, and the urine's purple, et cetera. But all of the EMS have been trained to do that. Carbon monoxide, again, know the signs, and know that the signs of carbon monoxide poisoning, cyanide poisoning, and even hemoglobinemia can overlap. Don't depend on numbers. Look at the patient. Look at the patient, look at the signs, and if you think they need to be reversed, you think they need to be 100% oxygen, just pull the trigger. We've had a couple of patients who have had methemoglobinemia and have had iffy symptoms, and too much reliance was made on the numbers, and it wasn't well for the patient. So don't rely on numbers too much, rely on the patient. This was already said before, you may need to suture your ET tubes to the teeth or the gums, and the ET tube situation kind of brings us to this point, don't be a ball hog. Okay, this is in reference to a recent burn mass casualty response wherein one burn director kept all the patients instead of using their network and transferring patients. They ran out of ET tubes in size seven and 8.5, and they were highly criticized for doing this. So don't be a ball hog, use your resources and work as a team. In regards to fluid, what is the most preferred? All right, so LR, because it is the most physiologic, the osmolality is most close to our physiology and because of the lactate content. But in a pinch, if you need to use normal saline, then you use normal saline, you use what you got. And again, optimize your PO intake. Formulas are approximations only, okay? And sometimes, in a mass casualty, you may not have lab, you may not have numbers, you may not have an IV, you may not have lab, you may have blood drawn, but there's no lab text to interpret the lab. So urine output is the traditional gauge of response to fluid resuscitation. Base deficit is also helpful, although you're not gonna rely too much on labs early on in the mass casualty. And serum lactate is important. Base deficit and serum lactate, more so for trauma patients, but always think about the resources that you have. So in regards to dressing, what would you choose? Let's say that you had to do multiple dressings in a mass casualty situation to get patients out there. So what would you choose? All right, this one's a little tricky. And this is because if you don't know what Acticode or Keracontact is, then you can't really answer this. This is a Dr. Matthews question, he's very cerebral. So, the answer is Acticode or Keracontact. Now, this is because Acticode and Keracontact are thin, they are cloth-type dressings, they're portable, you don't need a big pallet of them in your warehouse like you do jars of Sylvadene, and they can be left on for 48 to 72 hours. So, all of those thin, portable, sterile dressings are preferred. Think dry dressings, all of these listed here, some of them have silver impregnated into them, but use a sheet if you need to, use a cotton t-shirt, something clean to keep the patient clean and to prevent hypothermia. Remember that those walking wounded maybe don't have to go to a burn center to follow up. Maybe they don't have to go to a trauma center to follow up. They can follow up at a plastic surgeon office or at a dermatology office, or at an ED, which is some feet or miles away. Stop the bleeding is important. Okay, so, this is just to reiterate, you may have multiple types of injuries. Tourniquets help, pressure helps. We just had a 17-year-old, I was on trauma call last week, 17-year-old shot right in the inguinal canal. Okay, so, right in that sweet groin spot, it took out his femoral vein, his common, his SFA, his profunda, just a big blast all at the same time, right at the frications. And a very quick-thinking Metro cop got to the scene, put a finger in the hole, and saved that kid's life. So, quick thinking, stopping the bleed. IOs have already been talked about, so has Combat Gauze. For those of you that don't know, Combat Gauze is helpful to keep pressure and stop the bleeding. Remember that in a burn mass casualty, this is kind of the map, okay? This is gonna help you triage. So, there's a hypocenter, a center of severe damage, a center of complete destruction, moderate, and light. Remember that those patients in the hypocenter or in the severe center are probably not going to make it. You will have nearly 100% death in that area. And so, sending EMS into that hypocenter or the severe center is not smart. Then you risk your staff, you risk your resources. So, wait till the center cools down, and then people can go in and recover. This is just another example of that. And this is actually the potential, this is how the Arizona Burn Disaster Network was kind of created. So, the needs assessment was, you see the airplane there? That's Luke Air Force Base where a plane crash can happen. The wildfires in Northern Arizona up in your right hand of your screen. Palo Verde nuclear reactor down by Yuma, and then our railway down below. And then Arizona Burn Center right in the center. So, assessing the needs in your area and having a plan. Having a plan to triage from, if there is a crash at Luke Air Force Base, where are these patients gonna go? To Tucson, to Yuma, to Arizona Burn Center, to Flagstaff. And then figuring out how many are gonna come back and how many need to come back. So, having a plan everywhere that your disaster can happen. This is the telemedicine. That's probably one of my former attendings not knowing how to use the computer. There are still many questions. Feds and local authorities, or local federal disaster plans. There are many, many, many questions still remaining. And again, our national conscience is not focused on this. And we just need to recalibrate and be prepared for these types of mass casualties, whether it be a local, a regional, or a national level. And I would like to thank Dr. Matthews, who put this presentation together. He is over at Banner University in Arizona, the Arizona Burn Center, and University Medical Center in Las Vegas.

Carmen Flores

burn disasters

mass casualty incident

triage

telemedicine

comprehensive disaster plans

9/11 attacks

burn centers