Injury (1990)21, 61-62 Printed rnGreat Britain
61
Are we ready for the next disaster? Brian J. Rowlands Professor of Surgery
Queen’s University
of Belfast, Belfast, Northern
Ireland, UK
The time, location and number of injuripssustained in major disasters are unpredictable. The medical response is usually swij? and appropriate, but manpower and resources may be quickly stretched to their limits. The hypothesis is advanced that optimal medical management of the victims of major disasters requires the development of a trauma system in the UK, adgreater emphasis on education and research in trauma and critical care.
Introduction In November 1988,a report of a working party of the Royal College of Surgeons of England entitled ‘The management of patients with major injuries’ ‘was published. This report considered that injury and its consequences ranks as one of the most important health problems of today and highlighted deficiencies in our present system of prehospital care, hospital care and rehabilitation, that lead to needless loss of life and failure of complete recovery for accident victims. A number of recommendations to improve the quality of care were made including the setting up of a network of Trauma Centres, better communication between ambulances and the receiving hospital, special training for ambulance personnel providing prehospital care, more emphasis on the problem and management of the injured in undergraduate and postgraduate medical curricula and greater consultant involvement in the management of victims of major trauma. These recommendations have not been implemented to date by the Department of Health.
Major Disaster Plans Since the publication of this report, several major disasters have occurred in the United Kingdom including those at Lockerbie, the MI plane disaster at Kegworth, the Clapham Junction train crash and the Hillsborough disaster. These incidents received widespread attention from the media, as did previous disasters such as the Enniskillen and Brighton bombings and the King’s Cross and Bradford fires. Central to all these reports was the widespread praise and commendation of the ambulance and fire services, the doctors and nurses and all the ancillary services that took part in the rescue and treatment of the victims. This symposium has highlighted some of the problems faced by medical personnel involved in these disasters and some deficiences in the Major Accident Plans of the receiving hospitals. There have also been reports of poor communication and coordination, lack of medical resources, such as intensive care unit beds 0 1990 Butterworth & Co (Publishers) Ltd 002&1383/90/01006142
and ventilators, and the psychological trauma not only to patients and relatives but to the professionals involved in rescue and treatment. There can be no doubt that communities and hospitals that have faced these unwelcome intrusions into their daily routine have coped admirably. They have mobilized manpower and resources to meet an unforeseen need in a manner not usually accorded to the single victim of accidental injury. If another major disaster happens tomorrow, a similar response will probably be forthcoming, and another Major Disaster Plan will be given its ultimate test. Thus, the response to the question ‘Are we ready for the next disaster?’ has to be No, but we shall cope if it happens’. A more appropriate response in the 1990s should be ‘Yes, because we have a trauma system capable of delivering high quality care to all trauma victims’. Unfortunately, in the United Kingdom we have a long way to go before such an answer becomes a reality.
Trauma systems A ‘Trauma System’ consists of four patient components (access to care, prehospital care, hospital care and rehabilitation) and four societal components (prevention, disaster care, education and research) (Trunkey, 1988). As an authority on trauma systems throughout the world and a leading trauma surgeon in the United States, Donald Trunkey has argued forcibly and persuasively that at least five of these components would need to be addressed to enable the UK to change a system that is currently providing suboptimal care. His recommendations on prehospital care, hospital care, rehabilitation, education and research are embodied in the Royal College of Surgeons of England Report. Thus, cornerstones of the establishment of a Trauma System in the UK would be better training for prehospital personnel in resuscitation and life support techniques and the creation of approximately 25 Regional Trauma Centres, staffed by senior medical personnel with special training in trauma and critical care. Such a system, based on USA experience and concepts (American College of Surgeons, 1986; Eastman et al., 1987), would ensure optimal care for individual victims of single major accidents and would reduce unnecessary mortality and morbidity. It would also provide a basis for the response to any major disaster in any region of the UK. The victims of major disasters will only receive optimal prehospital and hospital care if they are managed by personnel experienced in trauma because of their regular involvement with the victims of
62
Injury: the British Journal of Accident Surgery,(l%W)
Vol. Zl/No. 1
major accidents. Experience therefore needs to be concentrated in a small number of centres. Once such a trauma system was established, the coordinated national response to a major disaster could be mobilized quickly by cooperation between the network of Regional Trauma Centres. A National Coordinating Centre funded by Government or private enterprise would be essential to this effort to ensure that the necessary expertise, experience and equipment were made available as soon as possible to the community affected by the disaster (Edwards, 1989).
the accident and emergency resuscitation area and the surgical intensive care unit. This aspect of surgical training will be best obtained in a Trauma Centre and could lead to the development of specialist training schemes designed to produce trauma surgeons. This evolution would take time but is another essential component in the development of Trauma Centres in the UK. Their expertise, together with that of specialist anaesthetists and critical care physicians, would ensure optimal therapy for the victims of major disasters.
Trauma Research Centres
Conclusions
An essential component
of disaster management is to learn from the experience of those who have been involved in previous catastrophies. Medical personnel have a responsibility to publish the results of the medical management of their patients and the organizational components of their disaster plan, together with an appraisal of its successes or failures. In time a detailed analysis of the mechanisms of injury, causes of fatality and recommendations on prevention should also appear in the medical literature. Unfortunately this process is often hampered by insufficient documentation of injuries or post-mortem findings. Nationally agreed standardiition of triage procedures and documentation would be advantageous, and would ensure that important data were not lost or proved incapable of analysis. In addition, legal procedures, such as judicial enquiries, often place an embargo on full disclosure of all the medical facts in an effort to protect the interests of those responsible for safety or security, but this may not be in the best interests of futile potential victims of major disasters. Thorough research of the medical consequences of major disaster may be further hindered by lack of adequate funding. The generation of new knowledge as a result of major disasters would benefit from the creation of several Trauma Research Centres with adequate funding from government and the Medical Research Council. These Research Centres would have active programmes of basic and clinical research and could supply resources and expertise to analyse data derived from the management of each disaster.
Recent major disasters have focused public attention on the ‘adequacy’ of medical care following major injury, and few have found fault with the system for handling large numbers of casualties. The Royal College of Surgeons of England Working Party Report (1988) on ‘The management of patients with major injuries’ is critical of the trauma system in the United Kingdom and suggests that many trauma victims die unnecessarily. These two views appear contradictory but may be explained by the mobilization of all available medical, paramedical and ancillary personnel that occurs to cope with a disaster, while the single accident victim is very often triaged and treated by inexperienced trainees. Improvements in trauma care and disaster management should occur through the development of a trauma system, education and research. All doctors must receive adequate instruction in the care of the injured during training and must master the skills that may avert life-threatening complications. Medical audit of all accidents and their complications must be undertaken. More research funding should be available for studies of the pathophysiology and treatment of major injury. Trauma is the major cause of death between the ages of 15 and 45 years, but has received scant support from research funding agencies. We shall be ready for the next disaster only if trauma education and research are given much higher priority in the future, and provided that a new system of Regional Trauma Centres is developed to replace our present system of suboptimal care.
Training
References
At the present time, both our undergraduate and postgraduate medical curricula are deficient in the teaching of the basic concepts of trauma management (Trunkey, 1989). Few medical students are shown the critically injured patient in the accident and emergency department, intensive care unit or hospital wards. Postgraduate trainees in surgery, anaesthesis and accident and emergency medicine see during their training only a handful of patients who have been involved in major accidents. They may treat these patients without adequate supervision, and when they become consultants they will be responsible for the management of similar cases despite obvious deficiencies in their experience and training. It is little wonder that preventable deaths are estimated to be as high as 30 per cent in major trauma victims (Anderson et al., 1988) or that the Confidential Enquiry into Perioperative Deaths (1987) reported that hospital mortality following surgery or anaesthesia was often due to lack of adequate training, experience and supervision. Modification of our undergraduate curriculum to place more emphasis on care of the critically ill and injured is essential. Postgraduate surgical trainees should be more involved with the victims of trauma during their training, and should spend more time in both
American College of Surgeons (1986). Hostif@! and prehospifuf ResourcesfortheOpfimal Care qf the Injured Patient. The Committee on Trauma, American College of Surgeons, Chicago. Anderson I. D., Woodford M, De Dombal F. T. et al. (1988) Retrospective study of 1000 deaths from injury in England and Wales. Br. Med. J I, 1305. Eastman A. 8, Lewis F. R., Champion H. R. et al. (1987) Regional trauma systems design: critical concepts. 14m.J. Surg. 154, 79. Edwards J. D. (1989) Mass casualties. Br. 1. Hosp. Med. 42,99. Nuffield Provincial Hospital Trust (1987) The King’s Fund. ConfidentialEnquiry info PerioperafiveDeaths. Royal College of Surgeons of England (1988) Commission on the Provision of Surgical Services. Report of the Working Party on the Management of Patients with Major Injuries, London. Trunkey D. D. (1988) A time for decisions. Br. J. Strrg. 75,937. Trunkey D. D. (1989) Report to the council of the Association of Surgeons of Great Britain and Ireland. Br. Med. J 2,31. Requests fur reprink should be addressed fo: Professor Brian J. Rowlands, Department of Surgery, Institute of Clinical Science, Grosvenor Road, Belfast BT12 6BJ, Northern Ireland, UK.
61
Are we ready for the next disaster? Brian J. Rowlands Professor of Surgery
Queen’s University
of Belfast, Belfast, Northern
Ireland, UK
The time, location and number of injuripssustained in major disasters are unpredictable. The medical response is usually swij? and appropriate, but manpower and resources may be quickly stretched to their limits. The hypothesis is advanced that optimal medical management of the victims of major disasters requires the development of a trauma system in the UK, adgreater emphasis on education and research in trauma and critical care.
Introduction In November 1988,a report of a working party of the Royal College of Surgeons of England entitled ‘The management of patients with major injuries’ ‘was published. This report considered that injury and its consequences ranks as one of the most important health problems of today and highlighted deficiencies in our present system of prehospital care, hospital care and rehabilitation, that lead to needless loss of life and failure of complete recovery for accident victims. A number of recommendations to improve the quality of care were made including the setting up of a network of Trauma Centres, better communication between ambulances and the receiving hospital, special training for ambulance personnel providing prehospital care, more emphasis on the problem and management of the injured in undergraduate and postgraduate medical curricula and greater consultant involvement in the management of victims of major trauma. These recommendations have not been implemented to date by the Department of Health.
Major Disaster Plans Since the publication of this report, several major disasters have occurred in the United Kingdom including those at Lockerbie, the MI plane disaster at Kegworth, the Clapham Junction train crash and the Hillsborough disaster. These incidents received widespread attention from the media, as did previous disasters such as the Enniskillen and Brighton bombings and the King’s Cross and Bradford fires. Central to all these reports was the widespread praise and commendation of the ambulance and fire services, the doctors and nurses and all the ancillary services that took part in the rescue and treatment of the victims. This symposium has highlighted some of the problems faced by medical personnel involved in these disasters and some deficiences in the Major Accident Plans of the receiving hospitals. There have also been reports of poor communication and coordination, lack of medical resources, such as intensive care unit beds 0 1990 Butterworth & Co (Publishers) Ltd 002&1383/90/01006142
and ventilators, and the psychological trauma not only to patients and relatives but to the professionals involved in rescue and treatment. There can be no doubt that communities and hospitals that have faced these unwelcome intrusions into their daily routine have coped admirably. They have mobilized manpower and resources to meet an unforeseen need in a manner not usually accorded to the single victim of accidental injury. If another major disaster happens tomorrow, a similar response will probably be forthcoming, and another Major Disaster Plan will be given its ultimate test. Thus, the response to the question ‘Are we ready for the next disaster?’ has to be No, but we shall cope if it happens’. A more appropriate response in the 1990s should be ‘Yes, because we have a trauma system capable of delivering high quality care to all trauma victims’. Unfortunately, in the United Kingdom we have a long way to go before such an answer becomes a reality.
Trauma systems A ‘Trauma System’ consists of four patient components (access to care, prehospital care, hospital care and rehabilitation) and four societal components (prevention, disaster care, education and research) (Trunkey, 1988). As an authority on trauma systems throughout the world and a leading trauma surgeon in the United States, Donald Trunkey has argued forcibly and persuasively that at least five of these components would need to be addressed to enable the UK to change a system that is currently providing suboptimal care. His recommendations on prehospital care, hospital care, rehabilitation, education and research are embodied in the Royal College of Surgeons of England Report. Thus, cornerstones of the establishment of a Trauma System in the UK would be better training for prehospital personnel in resuscitation and life support techniques and the creation of approximately 25 Regional Trauma Centres, staffed by senior medical personnel with special training in trauma and critical care. Such a system, based on USA experience and concepts (American College of Surgeons, 1986; Eastman et al., 1987), would ensure optimal care for individual victims of single major accidents and would reduce unnecessary mortality and morbidity. It would also provide a basis for the response to any major disaster in any region of the UK. The victims of major disasters will only receive optimal prehospital and hospital care if they are managed by personnel experienced in trauma because of their regular involvement with the victims of
62
Injury: the British Journal of Accident Surgery,(l%W)
Vol. Zl/No. 1
major accidents. Experience therefore needs to be concentrated in a small number of centres. Once such a trauma system was established, the coordinated national response to a major disaster could be mobilized quickly by cooperation between the network of Regional Trauma Centres. A National Coordinating Centre funded by Government or private enterprise would be essential to this effort to ensure that the necessary expertise, experience and equipment were made available as soon as possible to the community affected by the disaster (Edwards, 1989).
the accident and emergency resuscitation area and the surgical intensive care unit. This aspect of surgical training will be best obtained in a Trauma Centre and could lead to the development of specialist training schemes designed to produce trauma surgeons. This evolution would take time but is another essential component in the development of Trauma Centres in the UK. Their expertise, together with that of specialist anaesthetists and critical care physicians, would ensure optimal therapy for the victims of major disasters.
Trauma Research Centres
Conclusions
An essential component
of disaster management is to learn from the experience of those who have been involved in previous catastrophies. Medical personnel have a responsibility to publish the results of the medical management of their patients and the organizational components of their disaster plan, together with an appraisal of its successes or failures. In time a detailed analysis of the mechanisms of injury, causes of fatality and recommendations on prevention should also appear in the medical literature. Unfortunately this process is often hampered by insufficient documentation of injuries or post-mortem findings. Nationally agreed standardiition of triage procedures and documentation would be advantageous, and would ensure that important data were not lost or proved incapable of analysis. In addition, legal procedures, such as judicial enquiries, often place an embargo on full disclosure of all the medical facts in an effort to protect the interests of those responsible for safety or security, but this may not be in the best interests of futile potential victims of major disasters. Thorough research of the medical consequences of major disaster may be further hindered by lack of adequate funding. The generation of new knowledge as a result of major disasters would benefit from the creation of several Trauma Research Centres with adequate funding from government and the Medical Research Council. These Research Centres would have active programmes of basic and clinical research and could supply resources and expertise to analyse data derived from the management of each disaster.
Recent major disasters have focused public attention on the ‘adequacy’ of medical care following major injury, and few have found fault with the system for handling large numbers of casualties. The Royal College of Surgeons of England Working Party Report (1988) on ‘The management of patients with major injuries’ is critical of the trauma system in the United Kingdom and suggests that many trauma victims die unnecessarily. These two views appear contradictory but may be explained by the mobilization of all available medical, paramedical and ancillary personnel that occurs to cope with a disaster, while the single accident victim is very often triaged and treated by inexperienced trainees. Improvements in trauma care and disaster management should occur through the development of a trauma system, education and research. All doctors must receive adequate instruction in the care of the injured during training and must master the skills that may avert life-threatening complications. Medical audit of all accidents and their complications must be undertaken. More research funding should be available for studies of the pathophysiology and treatment of major injury. Trauma is the major cause of death between the ages of 15 and 45 years, but has received scant support from research funding agencies. We shall be ready for the next disaster only if trauma education and research are given much higher priority in the future, and provided that a new system of Regional Trauma Centres is developed to replace our present system of suboptimal care.
Training
References
At the present time, both our undergraduate and postgraduate medical curricula are deficient in the teaching of the basic concepts of trauma management (Trunkey, 1989). Few medical students are shown the critically injured patient in the accident and emergency department, intensive care unit or hospital wards. Postgraduate trainees in surgery, anaesthesis and accident and emergency medicine see during their training only a handful of patients who have been involved in major accidents. They may treat these patients without adequate supervision, and when they become consultants they will be responsible for the management of similar cases despite obvious deficiencies in their experience and training. It is little wonder that preventable deaths are estimated to be as high as 30 per cent in major trauma victims (Anderson et al., 1988) or that the Confidential Enquiry into Perioperative Deaths (1987) reported that hospital mortality following surgery or anaesthesia was often due to lack of adequate training, experience and supervision. Modification of our undergraduate curriculum to place more emphasis on care of the critically ill and injured is essential. Postgraduate surgical trainees should be more involved with the victims of trauma during their training, and should spend more time in both
American College of Surgeons (1986). Hostif@! and prehospifuf ResourcesfortheOpfimal Care qf the Injured Patient. The Committee on Trauma, American College of Surgeons, Chicago. Anderson I. D., Woodford M, De Dombal F. T. et al. (1988) Retrospective study of 1000 deaths from injury in England and Wales. Br. Med. J I, 1305. Eastman A. 8, Lewis F. R., Champion H. R. et al. (1987) Regional trauma systems design: critical concepts. 14m.J. Surg. 154, 79. Edwards J. D. (1989) Mass casualties. Br. 1. Hosp. Med. 42,99. Nuffield Provincial Hospital Trust (1987) The King’s Fund. ConfidentialEnquiry info PerioperafiveDeaths. Royal College of Surgeons of England (1988) Commission on the Provision of Surgical Services. Report of the Working Party on the Management of Patients with Major Injuries, London. Trunkey D. D. (1988) A time for decisions. Br. J. Strrg. 75,937. Trunkey D. D. (1989) Report to the council of the Association of Surgeons of Great Britain and Ireland. Br. Med. J 2,31. Requests fur reprink should be addressed fo: Professor Brian J. Rowlands, Department of Surgery, Institute of Clinical Science, Grosvenor Road, Belfast BT12 6BJ, Northern Ireland, UK.
