For the hospital management of mass casualties, the most basic principle is:

Mass Casualties

Mass casualty incidents may be caused by forces of nature or by accidental or intentional explosions and conflagrations. Interest in man-made mass casualties has been heightened by recent terrorist activities and the threat of future incidents. The incidence of severe burns in a mass casualty incident varies with the cause of the incident, the magnitude of the inciting agent, and the site of occurrence (indoors vs. outdoors). The terrorist attacks in which airplanes laden with aviation fuel crashed into the Pentagon and the World Trade Center on September 11, 2001, produced 10 and 39 patients with burns, respectively, for treatment at burn centers.82,83 Since then, many events have occurred throughout the world, with the most recent taking place at a festival in Taiwan in 2015, where 499 persons were burned who were between the ages of 12 and 38: 281 sustained burns over 40% TBSA. These patients were distributed between many hospitals, and the eventual mortality rate was 3%, akin to that normally seen in burn centers. The assembled response was massive, including thousands of providers, and was effectively coordinated at the federal level.84 Another prominent burn event occurred in Bali, in 2002, caused by an explosion and fire that killed more than 200 people and generated 60 burn patients who, after triage and emergency care, were transported by aircraft to Australia and treated at various hospitals.85 The casualties produced in terrorist attacks often have associated blast injury and mechanical trauma in addition to burns.

Recent nonterrorist mass casualty incidents have been of greater magnitude in terms of numbers of burn casualties. In the Station nightclub fire in Warwick, Rhode Island, in February 2003, 96 people died at the scene and 215 people were injured. Forty-seven of the 64 burned patients were evaluated at one burn center and admitted for definitive care.86 Additionally an explosion at a pharmaceutical plant in North Carolina in January 2003 killed 3 and injured more than 30 to an extent that necessitated admission to a hospital. Ten of the injured patients, all with inhalation injury and 6 with associated mechanical trauma, required admission to the regional burn center.87

To deal effectively and efficiently with a mass casualty situation burn treatment facilities must have an operational and tested mass casualty disaster plan and be prepared to provide burn care to a highly variable number of patients injured in either natural or man-made disasters.88 In reality, mass casualty events are likely to involve some form of burns, particularly in those with explosions. All regions should be prepared for such an event with established plans that are reviewed regularly and drilled.

MASS CASUALTY TRIAGE

Mass casualty incidents are distinguished from multiple casualty situations by available resources: with mass casualties, resources for each patient are limited, whereas with multiple casualties, full resources can be brought to bear on each individual patient. Mass casualty triage begins with recognition that an event has occurred that has generated casualties exceeding available resources.

Triage in a mass casualty incident seeks to put order into chaos by sifting out noncritically injured casualties in order to find those casualties who need acute attention. Triage begins at the scene, following scene risk assessment and implementation of first responder safety and security measures. The “second-hit” phenomenon, whether by secondary building collapse, chemical contamination, or intentional sequential explosives, is real. Failure to pay attention to scene safety can result in secondary casualties, which can include first responders, and the magnitude of the event increases.

The MASS technique is a useful method for limited first responders to separate acute and nonacute care casualties within a large casualty population: Move, Assess, Sort, Send. First, casualties who can walk are directed to move to an easily identified area with a visible care giver; these are the “walking wounded.” Next, the remaining casualties who cannot walk are instructed to raise an arm or leg, indicating that they have cerebral perfusion and anatomic injuries; these are “delayed” in priority. The remaining casualties then fall into one of three areas: those who require immediate attention, those who have injuries incompatible with survival, and those who are dead. Simple airway, breathing, and circulation assessments are conducted through this population using common field triage instruments to identify the primary casualties who need immediate/acute care.

Triage categories help to prioritize the care of casualties and guide the timing of intervention and evacuation. They include immediate, delayed, minimal, expectant, and dead. Following an intervention, the casualty is reassessed and re-triaged based on the result.

Immediate casualties have emergent, life-threatening consequences of injury and require rapid intervention for primary airway, breathing, and circulation issues. Airway compromise, tension pneumothorax, and uncontrolled external hemorrhage are classic examples in which relatively simple interventions can be life-saving. Delayed casualties have stable major wounds without uncontrolled hemorrhage, and include nonhemorrhagic penetrating torso injuries and long-bone fractures. Minimal casualties have non–life-threatening, nonurgent injuries, such as superficial soft tissue wounds and stress responses. Expectant casualties have injuries that are unsalvageable regardless of circumstances, or that are unsalvageable given resource limitations. Examples include severe head injury and high-percentage body surface area burns. This category has been largely unused in the American experience, and represents a potential siphon of resources in a bona fide mass casualty incident. “Dead” is listed as a triage category to prevent inappropriate use of resuscitation resources. External identifiers include missing body parts, open head wounds, and massive open torso wounds. The reality is that the mechanisms underlying mass casualty incidents carry a high scene mortality.

Triage occurs at every level of care and is designed to prevent missed casualties with life-threatening injuries. Transitions between care settings are ideal opportunities for reassessment and re-triage. At each care location, it is important that there is adequate space for casualty disposition, forward casualty flow without backtracking, separate places for expectant and dead, an identified place with care for minimal casualties, a decontamination area preceding the initial care area, and a control point.

Usually, a facility has a designated triage officer at the control point to make initial casualty disposition. This position should be preassigned in the facility's mass casualty plan. The essential characteristics of the triage officer are experience within the system, ability to make decisions, and ability to communicate. Although there is oneformal triage officer at point-of-facility entry, it bears emphasizing that across a system of triage, there are many caregivers performing triage, even within a facility.

Sequential triage as casualties move along the care pathway creates an efficient, error-tolerant system that minimizes the consequences of persistent undertriage and overtriage. Overtriage keeps “distracting” casualties within the care pathway and increases the critical mortality rate, a more appropriate measure of casualty population outcome than overall mortality (Figure 2). Adequate documentation is essential for casualty tracking and re-triage. As patients move across care levels, pertinent documentation provides the developing story to the next caregivers in line.

Pitfalls

A mass casualty incident involving multiple burn patients is likely to overwhelm local resources quickly, even in the event that there is a burn center in close proximity. As shown in a University of Michigan study in 2013 hospital utilization is constrained within the first 120 minutes due to the limited number of beds. The first bottleneck is attributable to exhausting critical care beds, followed by floor beds.19 In fact in the case of a large national disaster causing very large numbers of burn patients, it could be expected that even with national distribution of patients to verified and unverified burn centers, the surge would overwhelm available burn care beds very quickly. As of 2014 there are 128 burn care facilities in the United States. Of them, 64 are verified by the American Burn Association and the American College of Surgeons.20 Even fewer are verified as pediatric burn centers.

Unique considerations

1.

AS/MCI events present an active and presumed ongoing threat. Providers should expect ongoing shooting, multiple IEDs, and specific targeting of responders.

For first responders, situational awareness is paramount. There may be multiple shooters as was seen in Columbine and the Kenya Westgate Mall attack.36 Perpetrators may try to escape disguised as victims or choose to take hostages when confronted by LE.

ASE are not unique to the United States. Such attacks can occur anywhere firearms are available, as evidenced by the recent high-profile attacks in Kenya, Mumbai, and Norway. In fact, the deadliest mass shooting in history took place on the island of Utøya in 2011, with 69 killed and 110 injured.36,37

First responders must effectively transition from routine to high-threat operations: traditional EMS “stage and wait” protocols are being replaced by warm or indirect-threat-zone operations.

There is an increased requirement for dynamic interagency coordination in the prehospital setting.

The shooter(s) may end up as patients in your ambulance or ER, which may cause ethical and security concerns. Plan accordingly.

Hospital shootings do occur, but most are targeted, and not random acts of violence; a protocol to address this should be in place for the ER and hospital in general.38

Post-incident actions

Prehospital trauma life support (PHTLS) and mass casualty incident response are the mainstays of response to an RPG incident. The simple triage and rapid assessment (START) algorithm is an ideal method of triaging, caring for and appropriately dispositioning MCI patients including victims of RPG injuries.

Prehospital personnel should document injuries that occurred within an enclosed space to highlight the possibility of secondary and tertiary injuries when the casualty reaches the emergency department. Post-incident actions include notification of the trauma team in anticipation of requiring increasing hospital-based resources such as operating room personnel and blood. Plans should be in place for casualties who may have unexploded ordnance embedded in their bodies, may still be alive, and require care. These weapons can be handled relatively safely during removal from patients, but they will need ultimate disposal by appropriately trained personnel. Police bomb disposal personnel should be involved if there are any unexploded RPGs or EBWs retained in the patient’s body. Other considerations consist of mobilization of un-crossmatched blood and massive transfusion protocols. The police department and hospital security personnel should be used for crowd and media control.

Post-incident actions

Immediately after a conventional explosion in a high-rise building, there need to be individual and coordinated efforts between prehospital personnel, emergency department personnel, and personnel within the hospital who will be receiving these patients. While EMS personnel respond to the scene and prepare for the worst, hospital wards and emergency departments must prepare for an influx of patients. This includes the need to expedite patient movement out of the emergency department (ED) to clear the area for incoming patients. Such movements require significant preplanning and drilling by all hospital personnel at least annually. In addition, all personnel must be prepared for the possibility of secondary attack if the explosion is deemed to be of a possible terrorist etiology. Hospitals must go on “lock down,” ambulances should be inspected quickly before being allowed near the building, and security forces must be on heightened alert. This takes extreme coordination and familiarity with procedures and protocols.

Prehospital management starts with the notification of all local agencies that an event (mass casualty incident [MCI]) has occurred. A standardized message system will ensure efficient transfer of such alerts. The METHANE message as used in the UK Major Incident Medical Management and Support (MIMMS) system is an example of an easily taught and repeatable message structure:

M—Major incident/mass casualty incident declared

E—Exact location (grid reference if known or GPS)

T—Type of incident (fire, crash, explosion, etc.)

H—Potential hazards involved (smoke, oil, chemicals, fire, etc.)

A—Access roads to the scene from various directions

N—estimated number of casualties

E—Emergency services present and required

In addition, the CSCATTT tool used in MIMMS for prioritizing actions is a useful reminder for early on-scene first responders and this system is used widely by NATO services, ensuring that civilian and military responders are using the same terminology:

C—Command and control

S—Safety/security

C—Communications

A—Assessment

T—Triage

T—Treatment

T—Transport

If the event is anticipated to outstrip local resources, activation of other agencies must occur. This may include other outside local agencies as well as regional and state agencies. Some countries may have federal resources to respond in the event of a declared disaster. Knowing one’s local resources and protocols with regard to emergency management is of the utmost importance in advance of an event. “Scene Safety” is of the utmost importance, there exists significant potential for toxic chemicals, unstable structures, and hazardous materials. In addition, secondary explosive devices designed to explode on a delay, and directed at the personnel trying to rescue the victims, are unfortunately very common in terrorist attacks.17 At the scene, the safety of the remaining structure must always be assessed. Building collapse is a significant risk after any explosion, and it is not uncommon for rescuers to become victims when attempting to do their job. Once the building is secured, the rescuers must quickly triage victims according to standard protocols determining who has salvageable life-threatening injuries. Scene command must be determined, patient-staging areas must be designated, and appropriate transfer of patients to designated facilities must be coordinated so as to not overwhelm one facility.

Prehospital and ED staff must be prepared to triage patients appropriately. Every hospital and region should have a disaster plan in place ahead of time. Typically, the first round of patients are the less severe and can “self-extricate” and transport themselves to the hospital. The more severely injured patients are typically the second round of patients. If there is a collapse of the structure, the hospital should expect increased severity and delayed arrival of casualties. Centers for Disease Control (CDC) advice in the United States outlines that an ED should double the first hour’s casualties for a rough prediction of the total “first wave” of casualties.15

Prehospital personnel should expect to see familiar injuries, including blunt, penetrating, and thermal injuries. After an explosion, all medical personnel need to maintain a high index of suspicion for primary blast injury. Presence of a crater, injuries to closer victims, and building collapse are important observations regarding blast strength. Likewise, assessment of damaged objects near a casualty situation might yield a gross estimate of the pressures that existed in the vicinity. For example, shockwaves able to rupture a tympanic membrane are about the same as that needed to shatter automobile glass.18

It is also important to get a quick history. Phillips and Zajtchuk19 recommend the following questions when evaluating a bombing casualty:

What type of ordnance was used? How large was the explosion?

Where was the casualty located with respect to the blast?

Did the blast occur inside an enclosed space, such as a room or vehicle?

What was the casualty’s activity after exposure?

Were fires or fumes that might lead to an inhalation injury present?

What was the orientation of the casualty’s head and body in relation to the blast?

Prehospital medical personnel should be ready to perform lifesaving interventions including intubations, field amputations, and chest decompressions. The most common procedures performed include spinal immobilization, field dressings, and intravenous fluid administration.20 Prehospital personnel also should be trained and equipped for extrication of victims after complete or partial building collapse. Extricating these victims as quickly as possible greatly improves their chance of survival by reducing the occurrence of acute kidney injury from crush syndrome. The concept of “scene safety” with respect to rescuers cannot be overemphasized.

ED personnel should be involved in helping to direct prehospital personnel with respect to patient transfer to the appropriate facility. In some U.S. regions, this concept is known as “medical direction.” Designated trauma centers should be predesignated, and this concept should be used by all systems daily. EMS and hospitals should be considered a “continuum” of patient care, and thus ED personnel should consider themselves partners in EMS. Trauma centers should receive the most severely injured patients, even if they are not the closest hospital. It actually may be beneficial to take the more seriously injured to the further hospitals (if appropriate) because those less severely injured usually transport themselves to the more local hospitals. Upon arrival to the ED, staff must assess for the many types of injuries occurring as a result of a blast. Emergency staff must be prepared for victims, most of whom will have only minor injuries, to arrive by all modes of transportation. In the Oklahoma City Bombing, Hogan and colleagues report that 55% of victims came by private vehicle, whereas only 33% came by EMS transport. In addition, 80% were discharged that day.20

ED staff must activate the hospital disaster plan and mobilize the equipment necessary to treat mass casualty victims immediately upon notification of any MCI, including: wound care trays, tetanus immunizations, antibiotics, fracture care, endotracheal tubes, thoracostomy tubes, cricothyroidotomy trays, and all medications required for conscious sedation, rapid sequence induction, and advanced cardiac life support. Trauma teams must be notified, transport of admitted patients out of the ED must be expedited, and personnel from inside the hospital must be activated to the ED in anticipation of receiving injured patients requiring rapid assessment. This expedited “throughput” will create much needed ED space for incoming patients. The need for drills in preparation for this type of disaster by all hospital staff cannot be stressed enough. Communication between EMS and the ED is essential and can have positive or negative consequences with respect to morbidity and mortality associated with the disaster event.

Activation and Incident Assessment

Hospital emergency plans may vary, but common triggers to establish the ETA are mass casualty incidents, hazardous materials incidents, or sudden severe events that create casualties. Employees noticing television “breaking news” alerts may be one of your best notification triggers.

Obviously, the more warning time the facility has, the easier it will be to establish its ETA. Unfortunately, protocols should be based upon more realistic parameters—in the event of a disaster, it is likely the facility will literally only have minutes to establish perimeter security, mark traffic flow routes, and funnel incoming patients to a rapidly established ETA reception area. The only way to ensure that the ETA can be quickly and efficiently set up is through training. The ideal solution is to adopt triggers which are sensitive enough to allow for HERT activation to occur several times a year. This keeps interest amongst the team members and allows them to hone their skills.

If the determination is made to activate the HERT, it is important to collect as much information as possible on the nature of the event. It may be helpful to delegate an employee whose task is to establish contact with an on-scene liaison; monitor radio, TV and Internet reports; determine the size, scope, and nature of the event; and if possible, confirm early reports with on-scene responders. As critical information is received, it must be communicated to all team members. The more details ETA team members have, the better they will be able to select appropriate PPE, understand hazards that may be present, be prepared for anticipated injury patterns, prepare antidotes if available, and go into the operation with more confidence. Hospitals should always be prepared for a no-notice situation, as it is a realistic possibility, but as soon as pertinent information is collected and confirmed it should be disseminated to ETA team members. Effective and timely communication is a safety issue and must be addressed in pre-planning protocol development.

Once an initial event briefing is provided, more specific information needs to be collected. The actual location of the event can provide clues to substances that may be involved or injuries to anticipate, the capacity of workers or citizens that may be in that particular location, and the density of the surrounding population in relationship to any hazardous release. Your personnel need to know: Is the release on going? Was it a catastrophic container failure or a “puff event”? How many victims have already been assessed and what is their medical status and triage category?

Are decontamination operations ongoing in the field? Does the hospital have a memorandum of understanding (MOU) with the field response agencies that allows the hospital to accept patients who have undergone field decontamination as suitably clean to bypass the hospital decontamination corridor? Time spent cross-training with field personnel before an event to ensure confidence in decontamination thoroughness will be well worth the effort at this point. Decontamination operations will tax hospital personnel resources and hospitals should work with local response agencies to support each other in avoiding duplication of effort.

Continuous dissemination of collected information is a crucial task in establishing a prepared Emergency Treatment Area (ETA). A timely and concise briefing to the ETA members provides for a well-prepared and well-informed team. Throughout the pre-arrival time frame, information should be collected and disseminated. The utilization of outside technical assistance agencies (CDC, Poison Control, local HazMat Teams and ATSDR) and reference documents can only improve the facility's overall response.

The ETA has many components that must be set up and completed in order to be fully prepared to receive patients. Mobilization of these assets based on accurate incident information results in an efficient and effective ETA and plays a key role in ensuring protection of all team members, staff and the hospital itself. Practicing mobilization of personnel and equipment is the only sure way to measure the facility's ability to respond.

Perimeter control zones are designed to layer access to the hospital; they help ensure a safe and reliable environment for employees to function, allow for identifying persons who should not be within a secured area, and provide a positive image of organization and effectiveness in patient care. The seriousness of maintaining control during major events cannot be overstated, as an uncontrolled site will lend itself to chaos, which will ultimately compromise the hospital, your patients and your employees.

The perimeter can be separated into three areas: (1) controlled access to the grounds, parking and hospital buildings, (2) facility security from human intrusion and (3) decontamination corridor protection to prevent contamination intrusion into the facility. Many techniques can be used to create the control zones, from a simple barricade to electronic security access control. The number and type of systems utilized varies from facility to facility. A realistic review of a facility's campus layout, topography, natural barriers and capabilities can provide a blueprint for improving and enhancing the perimeter control aspects during worst case scenarios.

Current practice

Chemical disasters present unique challenges that can change the dynamic of scene response in a mass casualty incident. Chemical agents, whether inhaled or absorbed through the skin, can cause both immediate and delayed effects. Whereas biological and radiological exposures are more frequently characterized by delayed effects, such that definitive care can often await arrival at a hospital, many chemical exposures require lifesaving interventions at or near the scene of the event. This difference has significant implications for the pre-event planning and management of chemical disasters. In all mass casualty events, different teams of people need to organize quickly to provide effective care for patients while keeping health care workers safe. After a large mass casualty incident, it has been estimated that within the first hour of the event between 50% and 80% of acute casualties will arrive at the closest medical facility.11 Outlying hospitals are unlikely to receive a significant number of casualties; for this reason, significant pre-event planning and frequent training drills are important.12

Triage of victims in any disaster is based on the severity of injury. Classically, victims are triaged or “tagged” in one of four colors: black if they are not expected to live even if definitive care is achieved within a short time frame, red if immediate medical treatment is required for survival, yellow if a serious condition is suspected but the victim is not expected to deteriorate within the next several hours, and green for less severe conditions in medically stable patients. SALT (sort, assess, lifesaving interventions, treatment or transport) is a mass-casualty triage system recommended by the U.S. government.13 In the initial sorting, those who are motionless or have an obvious life-threatening condition are assessed first, followed by those who can wave and have purposeful movement; lastly, those who can walk are evaluated. Subsequently, individual assessments are made to determine severity of injury, and formal triage decisions are made to prioritize transport to hospitals. SALT and other triage systems were developed primarily to sort trauma casualties and may benefit from modifications for chemical disasters.

The initial triage, management, transport, and definitive care of victims exposed to toxic chemicals is limited by the risk of contamination of health care workers and other persons. Protection of and, if necessary, decontamination of health care providers are crucial. Hot, warm, and cold zones should be established immediately outside hospitals and at the scene of the event. Anyone entering the hot or warm zones where decontamination takes place must don personal protective equipment (PPE). However, these formal decontamination facilities do take time to erect; in an estimated 20% of cases, they can take up to 10 hours to finalize.14 Because many chemical agents begin penetrating skin and causing tissue damage within minutes, decontamination should take place at the scene of the event or at least be started by EMS. With chemical casualties, immediate spot decontamination of suspicious areas on the body becomes a priority equal to those of airway, breathing, and circulation. Along with timely administration of drugs or antidotes, the ABCDDs (Airway, Breathing, Circulation, immediate Decontamination, and Drugs) become the initial critical actions in caring for victims in a chemical disaster. Any clothing and shoes should be removed from victims to prevent ongoing contamination and absorption of the chemical. Any visible liquid should be blotted off, and then skin should be cleansed with soap and water. Commercial decontamination solutions such as Reactive Skin Decontamination Lotion (RSDL) do exist and are effective against many agents. In other circumstances, dilute bleach solutions, generally 1 part household bleach to 9 parts water, can be effective. However, because bleach has the potential to cause more tissue damage, as a general rule physical or mechanical decontamination should be emphasized over chemical decontamination. Showers with soap and water may be useful when large numbers of casualties arrive.

In addition, any hospital that may receive victims must limit entrance and egress to reduce the risk of wider contamination. Those with noncritical injuries and symptoms may attempt to leave the scene of the event quickly, and many will present for care outside of the EMS system. This complicates the triage system, as these patients will often arrive at hospitals before the most seriously injured and can delay care of the seriously ill. They also have the potential to contaminate unsecured areas of the hospital grounds. Ensuring that all victims must first pass through the decontamination center is essential.

A problem with all mass casualty incidents is that they result in a large simultaneous surge of patients into the medical system, disrupting the flow of patients in need of medical care for other reasons as well as those related to the disaster. Protocols for prehospital teams and the receiving facility should be in place before any event. Alternative sites of care should be identified, and prehospital diversion by EMS should be employed when possible. Plans should be in place at any hospital to manage a large influx of low-acuity patients and the “worried well” so that they can be seen and released expediently or reassessed at appropriate intervals. Although these events are rare, education, drills, and training exercises are essential because they can increase confidence in caring for victims exposed to toxic chemicals.

Physical properties of chemicals contribute to their effects. These include physical state at ambient temperature, volatility, environmental persistence, flammability, and other properties that help define the hazards associated with a particular chemical. Other important features of a chemical disaster include mode of dispersal, concentration of agent dispersed, amount disseminated, length of exposure, and the environment into which the agent was released. The CDC has divided toxic chemical agents into 13 main categories (Box 110-2).15 These groups are based on two primary factors: the physical properties of the chemical and the physiological effects induced in humans. Agents often have characteristic scents, physical properties in the environment, or specific recognizable physiological effects. Many produce very nonspecific symptoms including nausea, vomiting, shortness of breath, coughing, or dizziness; a more limited number of compounds or classes of compounds can result in characteristic constellations of signs and symptoms, or toxidromes. Some types of chemical exposures may require specific critical actions or specific antidotes, such as atropine and pralidoxime (2-PAM) for a nerve-agent exposure. It is essential that prehospital providers be able to recognize important toxidromes and report them to the receiving facility to allow clinicians to prepare the appropriate antidote if possible. The U.S. Department of Health & Human Services Chemical Hazards Emergency Medical Management (CHEMM) group is developing an online algorithm (CHEMM-IST) for use by EMS and first responders to help identify specific chemical toxidromes. By asking about specific clinical features unique to a toxidrome, such as level of consciousness, presence of seizure activity, pinpoint pupils, diaphoresis, wheezing, and other elements, CHEMM-IST aids in the potential recognition of a defined toxidrome.16 This algorithm, in prototype testing as of this writing, highlights the importance of early recognition of specific groups of signs and symptoms by first responders.

It is also incumbent on the physicians treating victims of these events to recognize common toxidromes, to understand the appropriate medical management, and include this treatment as part of the ABCDDs. In addition, it is essential for clinicians to have an understanding of the various toxicologic properties of the chemicals involved, including toxicokinetics, toxicodynamics (mechanisms of action), differences in physiological effect depending on routes of exposure (e.g., cutaneous versus inhalation), and immediate versus possible latent clinical effects. In the event of an industrial exposure, a material safety data sheet (MSDS) with information about the specific chemical involved may be available. Consultation with a medical toxicologist or the local poison control center is advised.17 Acronyms such as ASBESTOS, TOXICANT, and POISON can assist in a systematic assessment of chemical casualties and can help guide assessment and ensure that important toxicologic principles are not overlooked (Box 110-3). These acronyms may be printed and displayed in emergency departments.

Following triage, decontamination, transport, and treatment of victims in a chemical attack, many other issues will remain, including the future environmental effects (leaching of chemicals into soil, water table, nearby structures, etc.) and potential for future contamination of victims. In some circumstances, the location of the chemical release should be treated as a crime scene. Although this should not affect treatment of casualties, clothing and other items from the scene could potentially be important legal evidence. Lastly, all victims and providers involved in a chemical disaster should undergo a stress debriefing. The long-standing psychological effects of these events are often dramatic. The role of mental health providers and their ability to provide emotional support should not be underestimated.

After any mass casualty incident, the various providers involved in managing victims should debrief and plan for a future event. Whether the event was intentional or accidental, small or large, each event should be treated as a learning experience, with close examination of the pre-event planning process, as well as the decontamination and management of victims. The treatment of victims in a chemical release requires a highly coordinated effort and is dependent on the ability of first responders and first receivers, including hospital staff, to recognize the possibility of a chemical release and to implement the procedures necessary for an effective response. Through planning, appropriate training, and regular drills, both prehospital and hospital providers can be prepared and confident in caring for victims involved in the accidental or intentional release of toxic chemicals in a mass casualty incident.18

Practical Training Tips

Training for personnel involved with, or in support of, the decontamination corridor should be considered robust and may require meeting standards or regulations from agencies such as OSHA, EPA, Joint Commission, NFPA and other governmental agencies. Some basic training requirements and highlights are presented here to provide an overview. Be sure to research and the training requirements, regulations or standards for your area, as to cover every training requirement for every location is beyond the scope of this book.

From the “OSHA Best practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances” document, the following are excerpts on training personnel:

First Responder Operations Level training is required for employees (including security staff) who have a role in the Hospital Decontamination Zone, as well as the hospital's contamination cleanup crew. (OSHA HAZWOPER 29 CFR 1910.120q Standard)

First Responder Awareness Level Training is required for ED clerks and ED triage staff who might identify unannounced contaminated victims (then notify the proper authority) and security staff working outside the hospital Decontamination Zone.

A briefing at the time of the incident is required for employees whose roles in the Hospital Decontamination Zone could not be anticipated before the incident (“skilled support personnel”—e.g., healthcare specialist or a trade person, such as an electrician).

Information similar to hazard communication training is recommended for ED staff and other employees who work in the ED (Hospital Post-decontamination Zone), provided contaminated victims would not have access to them.

Examples of HAZWOPER First Responder Operations Level training curricula are available for hospitals preparing employees to conduct decontamination activities (HAZMT for Healthcare, 2003; CA EMSA, 2003a; VA, 2003; Sutter health, 2002). However, these curricula are not necessarily designed as 8-hour presentations (some are longer; others are shorter and intended for use when employees are able to demonstrate specific areas of competency).

Staff who might identify contaminated victims that arrive unannounced require specific instructions for handling the situation. Once ED clerks or staff suspects a patient is contaminated, they should be well trained in the following procedure:

Avoid physical contact with the patient.

Immediately notify supervisor and safety officer of possible hospital contamination.

Allow other properly trained and equipped staff to isolate and decontaminate the victim according to EMP (Emergency Management Plan).

Personnel (employees) whose participation in the Hospital Decontamination Zone was not previously anticipated shall be given an initial briefing at the site prior to their participation in any emergency response. OSHA also recommends some form of basic training for employees who work in the Hospital Post-decontamination Zone and who would not be expected to come in contact with unannounced victims, their belongings, equipment or waste.

Obviously training must meet certain regulations or standards, but the application of those standards should provide a sound basis for the practical aspects of each position as it relates to their tasks, equipment and skills.

Training options vary and may include an internal training program that allows for minimizing down time of employees, with no travel or incidental compensation. This frugal approach works well in accomplishing the task, but may not provide the advantages of external training programs that may be available, including free government support courses. Joint training programs or exercises with other healthcare facilities in your region may be an opportunity to provide a collaborative training environment along with reduced financial costs.

Wherever possible, training should be broken down into segments where individual team members can focus on details of the tasks they may have to perform during decontamination. As each segment is completed, cross-training of individuals can then occur, allowing for adaptive task cross-over of personnel when the need arises.

Practical training segments and practical exercises provide the best scenario for employees to gain skills and knowledge concerning the tasks they must perform. Although classroom presentation of the subject matter is a must to ensure team members are informed and knowledgeable, practical exercise and training provide the greatest opportunity to instill and refine skills and knowledge under realistic conditions.

What is the principle of mass casualty?

What are the main components of a mass casualty incident?

What is the initial goal of mass casualty triage?

What are the 4 categories of triage in a mass casualty situation?