Mass Casualty / Coordinated Incident Management

We had a gas leak at a local factory with 2 workers GCS 3 at the scene and 21 others exposed to the gas.

This gave us a chance to test our new Mass Casualty plan which had been developed largely by super ED nurse Michelle Batterbee. Tip for anyone else doing this work get a slightly OCD nurse to drive it not some ADHD ED doctor who won’t get deep enough into the detail.

A few Cordinated Incident Management System buzz words for exams: the 4 Rs: Reduction, Readiness, Response, Recovery

Reduction: what happens out in the real world by to prevent disasters
Readiness: planning and training to deal with a disaster
Response: what we do if a disaster happens
Recovery: getting back to normal, including lessons learned from the disaster.

We received a phone call from ambulance control at 5pm on Friday night “Major incident at the tannery. 2 stat 1 and 13 stat 3. No further information available.”

We rang ambulance control back to check this was correct and if there was any more information. It was and there wasn’t.

Probably going to be a chemical exposure with 2 sickies and a lot of minors with minor exposure.

Now I’m into the 5 Ps

People: I’m keen to call a mass casualty incident. My boss, the wise Athol Steward, says hang on till be get a bit more info – let’s see if they are “real” stat 1s. There are different systems for declaring a mass casualty incident. We use a 3 level system.

Level 1: we should be able to manage in ED with a bit of extra staff and maybe the ability to overflow.

Level 2: this is going to stretch the whole hospital.

Level 3 we are going to need help from other hospitals / military etc.

Which level is declared will depend on the current state of the department, time of day, size of hospital. A level 3 for a small hospital at 2am may be a level 1 for a big hospital, in the middle of a quite day. We are a 15 bed + 5 obs beds ED so 15 patients are going to swamp us.

Inform the team and assign roles. To start with one nurse, one consultant into 2 resuscitation rooms. Other staff doing what they can to clear ED.
We’d spoken to the on call anaesthetist who was just starting an operation.

Personal Protective Equipment

We have a recently obtained a HAZMAT suit – um – anyone know where it is? Who should wear them – just the guys doing the decontamination? We compromised with long-sleeved plastic gowns and some of us put on goggles and masks.

I’ll do a separate talk on the HAZMAT aspects of this case later.

Place: Clear some space: Get patients admitted, discharged or out to the waiting room or discharge lounge now. Clear the resus bays. Put a sign out in ED warning of a long wait. Alert the GP clinic next door that we are about to get slammed. Consider ambulance bypass if that is an option at your hospital.

Clear out all the crap that is being stored in the decontamination shower. Remind yourself how to turn it on

Plant (=equipment): What equipment and drugs to we need? Start setting up airways trolleys and drawing up anaesthetic drugs.

Plan: Start talking through plans, who will do what based on what you know.

First patient arrives, unresponsive, laboured breathing. The ambos just scooped and ran with him. He stinks of sulfur and we hear that sulphuric acid and sodium sulphate were involved. A quick wash in the decontamination shower trying to not to drown him. We hear the next patient is already intubated. The decision was made to call a Level 2 mass casualty incident and to call for 2 anaesthetists.

The beauty of this is that we make one phone call the telephonist who then goes through a list of all the people who need to be called and we can concentrate on what is happening in ED. And you get a lot of extra help. Physicians and surgeons appear in ED and admit or discharge patients. Beds are miraculously found on wards. Extra orderlies / porters appear, extra cleaners, the kitchen starts making sandwiches, the media liaison takes all the medial calls. Extra ED nurses come in (luckily it was early in the evening they were still sober). Extra bed managers come which is essential. Pharmacists turn up with drugs galore. Extra linen appears. We also called in off duty ED consultants (thanks Stuart). And in these situations people are keen to come in to play and to help.

The Mass Casualty box is opened

 

It contains lots of folders with “Unknown patient” labels (if needed), wrist bands, a paper based ED chart, lab forms, XRay forms. Patient tracking forms, signage, simple instruction cards. The patients had a ID label placed on their wrist and forehead with a hand written nickname “One”, “Two” added to it for ease of communication.

Staff wear vests to identify jobs to make it easier for newcomers to work out who is who.

Only ED staff get the vests. Staff from other wards that come to help wear their own uniforms.

If needed we make up teams of 1 ED doc, 1 ED nurse + a ward nurse and a ward doctor. During the big Christchurch earthquake 2 years ago the teams were ED doc, ED nurse, anaesthetist + another nurse + a medical student as a runner. This apparently worked very well. it is really important to have a doctor and nurse who are ED trained and know how ED works in each team. Everyone gets a job card telling them who they report to. So it states that the ward doctor reports to the ED doctor in their team. The ED doctor reports to the ED doctor in charge etc.

In our little department we assign a place for a nurse coordinator, an extra triage nurse, a transport nurse, an orderly.

When extra ED consultants arrived they joined the triage nurses at the ambulance door and at the waiting room triage area and worked with the triage nurses to triage and rapidly assess patients. For the minor chemical exposures this is a quick history, obs and listen to the chest. Many of the minors patients could be held in the waiting room to go directly to an obs ward for their 3-4 hours of observation.

As more senior help arrived our head of department stepped back from direct patient care and became Doctor in Charge of ED He coordinated the medical response and liaising with senior nursing and management.

Our patient assessment and management in a mass casualty situation is pretty much business as usual. We do the usual ED focused history and examination. Maybe a few less tests, less social history but otherwise do everything you would normally do. The main differences are in logistics – not in patient treatment Make sure everything is documented otherwise things turn to custard. Normally you will have enough people coming to help that you wont be short-staffed. Make sure the normal channels for patient tracking and admission are followed or patients will get lost.

The first patient was intubated and ventilated. The second one, who had had a respiratory but not cardiac arrest at the scene, arrived intubated and just had to be washed and tidied up a bit. We eventually found out the gas that had been created by the chemical spill was hydrogen sulfide and administered sodium nitrite and an antidote – causing profound hypotension with a bounding pulse in one of the patients.

And we had 19 minor patients including a whole shift of paramedics and a couple of firies who had been exposed to varying degrees to the gas.

The two sickies were flown out because our ventilators were already full of old crumblies. We had all but 3 of the others discharged within 4 hours – leaving us an almost empty department. It is amazing how the hospital could accommodate all our other patients. Then the recovery. Restocking, cleaning up and debriefing over pizza donated by a member of the public. Then more formal debriefs – how could things be improved – in days to come.

One lesson learned for me was that I didn’t consider the possibility of a blast. We weren’t told there was a blast but I didn’t specifically ask about one. When someone suggested it to me a few minutes later, the paramedics had already gone and I couldn’t get the necessary information from ambulance control. So we treated the 2 sickies as if there could have been a blast and did a panscan CT to be on the safe side.

In retrospect you could say that calling this a mass causality incident was an over call but
a) It’s better to over call than under call and you can always stand down the incident if it turns out it wasn’t as bad as you thought
b) With that volume of patients in our little ED it was good to have the extra staff.
c) It’s good to use the mass cas. plan every now and then so people are familiar with it – and so we can test and fine tune it.

Ours worked well. Thanks Michelle!