The British Journal of Surgery Vol. 63 :No. 10 : October 1976 Br. J. Surg. Vol. 63 (1976) 731-734
ASSOCIATION OF SURGEONS OF GREAT BRITAIN AND IRELAND Y
The Annual Meeting of the Association took place in Birmingham on 7, 8 and 9 April 1976, with the President, Mr Alexander Innes, in the Chair. The papers in the Symposium and those in the subsequent sections of Short Papers for the Moynihan Prize and Short Papers are published in the order in which they were read.
BARBER’S COMPANY SYMPOSIUM ON ’OPERA TION CA TASTROPHE’
Major disasters : hospital admission procedures MILES I R V I N G * SUMMARY
Triage in the accident and emergency department and the admission of all patients needing further care t o one ward can form the basis of the successful hospital management of the victims of a major disaster.
UNTILrecently few surgeons would expect to be involved in the management of a major disaster. However, the spate of terrorist bombings has led to many hospitals throughout the country receiving, at short notice, large numbers of patients, many with severe injuries of a type normally only seen in wartime. Although most hospitals have a major accident plan devised for such a situation and one or two staff thoroughly familiar with the plan, such staff cannot be continuously available, and thus any medical practitioner in a hospital may be faced with the problem of coping with a major accident simply because he happens to be there at the time. This paper attempts 70
to provide simple guidelines which should help the doctor without special knowledge of disaster management to cope with the situation, should it arise.
Major disasters The term ‘major disaster’ can mean anything from a nuclear bomb explosion or earthquake to a bad traffic accident. Definitions vary but all include the common theme of disruption of normal working and the need for support of the emergency services. Zimmerman (1973) summed up the situation aptly as far as a hospital is concerned as ‘too much work for too few people with inadequate facilities’. Irrespective of the magnitude of a disaster the principles of management remain the same, though baselines such as the degree of medical care offered to the injured may have to be
* University of Manchester Department of Surgery, Hope Hospital, Salford. 731
Miles Irving altered when the number of patients is excessive. These aspects of disaster management, which are beyond the scope of this paper, are well reviewed by Zimmerman (1973). In any major disaster the hospital is the basic unit of medical care. It is important that it functions efficiently, dealing rapidly and skilfully with the patients it receives. It will fall down in this task if it is overwhelmed with work or if it fails to deal effectively with the workload. To try to avoid any one hospital being overwhelmed the police and ambulance staff at the scene of the disaster will attempt to distribute the patients equally between the various designated receiving hospitals in the area. This protection cannot, however, always be relied upon, especially if the incident occurs close to a hospital or even involves the hospital itself. Details of how a hospital intends to cope with the victims of a major accident are usually laid down in the hospital’s major accident plan. The details take into account the individual circumstances of the particular hospital but are not usually based upon practical experience. Although there is no doubt that every hospital should have such a contingency plan and that permanent staff should regularly familiarize themselves with its essential details, too much reliance should not be placed upon it. With the best will in the world it is unlikely that the constantly changingjunior staff will be familiar with its details, and, in a rigidly formulated plan, key personnel may not be present when it needs to be put into action. It is because of this now recognized tendency of rigidly laid plans to fail that experts in the field favour a more flexible organization. Thus, Savage (1972) has devised a system using ‘activity cards’ which is sufficiently flexible to cope with any situation using the staff available at the time. The recommendations made in this paper are based upon experience gained in dealing with the Old Bailey bomb explosion and were subsequently shown to be of value in dealing with the Tower of London bomb explosion (Tucker and Lettin, 1975). On 8 March 1973 at 2.50 p.m. a car bomb exploded outside the Old Bailey in the City of London. At the time the police, knowing that the device existed but not entirely sure in which car, were clearing the area. Unfortunately, the police activity attracted onlookers, many of whom were in a large glass-fronted office block overlooking the site. In consequence, when the bomb exploded a large number of people were injured. Within minutes the injured arrived in the Accident and Emergency Department of St Bartholomew’s Hospital some 100 yards away and close enough to have been damaged in the blast. In less than an hour 160 patients passed through the doors of the accident department with injuries of varying severity. Details of how this situation was handled have already been published (Caro and Irving, 1973) and there is little point in reiterating them. However, the problems posed by this incident which occurred in such a manner that the major accident plan could not be formally activated provide a useful basis 732
on which to discuss how a hospital should cope with large numbers of injured patients.
Problems of a hospital dealing with a major disaster 1. The management of the sudden intlux of patients who threaten to overwhelmthe accident and emergency department and its staff. 2. The recognition of patients who have severe injuries and who need immediate resuscitation and highly skilled assessment and management. 3. The control and rational deployment of medical, paramedical and non-medical staff. 4. The calm, orderly and rapid evacuation of the injured from the accident department to the wards and operating theatres, where they can receive definitive treatment in order of priority. I have attempted to summarize the management of the whole situation in Fig. 1. Needless to say, individual hospitals will vary their approach according to their layout and staffing but the general principles should be applicable in all hospitals. Triage It is generally agreed that the first two problems listed above can be dealt with by the process of triage. Triage is a military term for a process by which patients are classified according to the severity of their injuries at the time of their admission. By this means the seriously injured are directed to the major treatment areas, staffed by junior surgical, anaesthetic and casualty staff, supervised by a consultant, where they can be rapidly assessed and resuscitated prior to transfer to the admission ward. Similarly, patients with minor injuries can be directed to a previously designated ‘minor treatment area’ where they can be dealt with by non-specialist medical staff who have volunteered to help. Patients with minor injuries benefit from the company of non-medical volunteers who, by their presence, provide the reassurance of normality to those who will have been severely disturbed by involvement in a horrific experience. Triage should be undertaken by an experienced clinician of sufficient seniority to be able to shoulder criticism of any mistakes he might make. The triage area should be close to the entrance to the accident department and should be large enough to hold a few stretcher cases and the walking cases whilst the consultant makes his rapid assessment of their condition. All patients should pass through the triage area, and because of this it is necessary to ensure in a major accident situation that only one public entrance to the accident department is open. In really major disasters, where very large numbers of patients are injured and resources are limited, triage may include the necessity for deciding which patients, though still alive, do not warrant treatment because the severity of their injuries is such that they are unlikely to survive. The consultant undertaking triage should also watch carefully for signs that the hospital’s resources are being overwhelmed, indicating to the police in such circumstances that patients should be conveyed from the disaster site to other hospitals.
Admission procedures after major disasters
1 Senior Surgeon Triage
SEVERELY I N J U R E D
1
I
Junior Anaesthetic, A/E and Surgical Staff Consultant supervising RESUSCITATION
P
VOLUNTEERS
M I N O R INJURIES
\
ADJACENT DEPTS Any medical staff Consultant supervising
I
TREATMENT
I
X-RAY DEPT Consultant Radiologist and Staff Assessing urgently and reporting
I /
1
/
I
Final registration check
I Fig. 1. Suggested plan for managing the admission of the victims of a major disaster.
Management of the seriously injured after resuscitation The aim of the staff in the resuscitation area should be to clear patients from the area as soon as possible after they have been resuscitated in order to be ready for further admissions. In some hospitals, such as the Royal Victoria Hospital in Belfast, there is an admission ward adjacent to the accident department to which patients can be admitted without disrupting the working of the rest of the hospital. In most hospitals, however, special arrangements will have to be made for admitting the injured. Experience has shown the value of clearing a ward on the ground floor for this purpose and admitting to it all patients irrespective of their age, sex or injuries. Although this involves disruption of hospital routine, administrative nursing staff and porters can usually rapidly clear such a ward, distributing the patients to vacant beds throughout the hospital or sending them home. I believe this measure is the single most important factor in the successful management of the severely injured patients. Patients are not separated from their relatives, and all the staff know exactly where the injured are. Management of the admission ward is also crucially important. One consultant surgeon should be in charge of the ward and the operating theatres. One way of managing the problem is to allocate to each patient a team of a junior surgeon and anaesthetist who will carry out a detailed assessment of the injured person, reporting back to the consultant in charge on the situation as they see it. The surgeon in charge can then, in consultation with his colleagues, pronounce on the
treatment priorities and ensure an orderly flow of cases to and from the operating theatres, the patients being taken to theatre and dealt with by the team that assessed them. From the operating theatres patients can be returned to the admission wards or transferred to special units, such as intensive care units, ophthalmic wards, etc. Common sense dictates that occasionally patients may need to bypass these arrangements, e.g. in cases where torrential intra-abdominal bleeding demands urgent laparotomy, but such instances will be rare. Management of the minor treatment area By and large most patients in this area require little treatment, toilet and suture of lacerations being the most important task. Such treatment can be carried out by any medical practitioner who has served as a house surgeon. However, consultant supervision is still necessary in this area to detect the occasional injury that, though classified as minor, is of greater significance. The consultant can also supervise such matters as tetanus prophylaxis and can relieve pressure on the X-ray department by indicating which radiological investigations, though necessary, can be left until a later date.
The role of consultants At first consultants should assume a primarily administrative and supervisory role, for many of the tasks mentioned above require experience and judgement and carry a considerable responsibility. In the operating 733
Miles Irving theatres the temptation to get involved early on should be resisted. It is better for the consultants to supervise three or four junior surgeons, reminding them of easily forgotten principles, such as the importance of delayed primary suture. By adopting a supervisory role they can be readily available when exploration of an apparently straightforward lesion reveals a problem that requires the consultants’ skill and experience. Mobile teams In the past great emphasis was laid upon the importance of the mobile surgical teams. Whilst there is little doubt that a medical practitioner should be present at the scene of the disaster, he should be an administrator rather than a clinician. Highly trained casualty, surgical and anaesthetic staff function best doing their usual tasks in their usual surroundings. Sending them out is in most circumstances a waste of valuable resources and an embarrassment to the police and ambulance personnel, who feel inhibited by their presence. Mobile teams should only go to the disaster site if requested. Such requests should normally be for assistance with the management of patients who are trapped and injured and who need analgesia and resuscitation. Operative surgery should only rarely be carried out in such situations.
Discussion In a short paper it is impossible to cover all eventualities and how to deal with them, but the principles of triage and admission of all patients to one ward, associated with a voluntarily accepted command structure,
734
would appear to be basic to the successful management of all major disasters. Although rigidly laid plans will be doomed to failure because of the almost inevitable breakdown of communications that occurs in these situations, it does not mean that preparation is valueless. Prepared large placards that can be hung on pre-inserted hooks are of value in indicating particular areas, e.g. ‘Minor Treatment Area’, ‘Relatives Waiting Room’ and ‘Press’ are examples of the many assembly areas that can be usefully indicated in such situations. Similarly, the question of which documentation system should be used in the event of a major accident can be decided in advance. Involvement in the management of a major accident is a trying and depressing experience. Skilful handling of the situation in the admitting hospital will reduce morbidity and mortality and relieve a great deal of distress, and as such, brings its own reward to those handling the situation.
References CARO D. and IRVING M. H. (1973) The Old Bailey bomb explosion. Lancet 1, 1433-1434. SAVAGE P. E. (1972) Disaster planning: the use of action cards. Br. Med. J. 3, 4243. TUCKER K. and LETTIN A. (1975) The Tower of London bomb explosion. Br. Med. J . 3, 287-290. ZIMMERMAN J. M. (1973) Mass casualty management. I n : BALLINGER w. F., RUTHERFORD R. B. and ZUIDEMA G. D. fed.) The Management of Trauma, 2nd ed. Edinburgh, Churchill Livingstone.
ASSOCIATION OF SURGEONS OF GREAT BRITAIN AND IRELAND Y
The Annual Meeting of the Association took place in Birmingham on 7, 8 and 9 April 1976, with the President, Mr Alexander Innes, in the Chair. The papers in the Symposium and those in the subsequent sections of Short Papers for the Moynihan Prize and Short Papers are published in the order in which they were read.
BARBER’S COMPANY SYMPOSIUM ON ’OPERA TION CA TASTROPHE’
Major disasters : hospital admission procedures MILES I R V I N G * SUMMARY
Triage in the accident and emergency department and the admission of all patients needing further care t o one ward can form the basis of the successful hospital management of the victims of a major disaster.
UNTILrecently few surgeons would expect to be involved in the management of a major disaster. However, the spate of terrorist bombings has led to many hospitals throughout the country receiving, at short notice, large numbers of patients, many with severe injuries of a type normally only seen in wartime. Although most hospitals have a major accident plan devised for such a situation and one or two staff thoroughly familiar with the plan, such staff cannot be continuously available, and thus any medical practitioner in a hospital may be faced with the problem of coping with a major accident simply because he happens to be there at the time. This paper attempts 70
to provide simple guidelines which should help the doctor without special knowledge of disaster management to cope with the situation, should it arise.
Major disasters The term ‘major disaster’ can mean anything from a nuclear bomb explosion or earthquake to a bad traffic accident. Definitions vary but all include the common theme of disruption of normal working and the need for support of the emergency services. Zimmerman (1973) summed up the situation aptly as far as a hospital is concerned as ‘too much work for too few people with inadequate facilities’. Irrespective of the magnitude of a disaster the principles of management remain the same, though baselines such as the degree of medical care offered to the injured may have to be
* University of Manchester Department of Surgery, Hope Hospital, Salford. 731
Miles Irving altered when the number of patients is excessive. These aspects of disaster management, which are beyond the scope of this paper, are well reviewed by Zimmerman (1973). In any major disaster the hospital is the basic unit of medical care. It is important that it functions efficiently, dealing rapidly and skilfully with the patients it receives. It will fall down in this task if it is overwhelmed with work or if it fails to deal effectively with the workload. To try to avoid any one hospital being overwhelmed the police and ambulance staff at the scene of the disaster will attempt to distribute the patients equally between the various designated receiving hospitals in the area. This protection cannot, however, always be relied upon, especially if the incident occurs close to a hospital or even involves the hospital itself. Details of how a hospital intends to cope with the victims of a major accident are usually laid down in the hospital’s major accident plan. The details take into account the individual circumstances of the particular hospital but are not usually based upon practical experience. Although there is no doubt that every hospital should have such a contingency plan and that permanent staff should regularly familiarize themselves with its essential details, too much reliance should not be placed upon it. With the best will in the world it is unlikely that the constantly changingjunior staff will be familiar with its details, and, in a rigidly formulated plan, key personnel may not be present when it needs to be put into action. It is because of this now recognized tendency of rigidly laid plans to fail that experts in the field favour a more flexible organization. Thus, Savage (1972) has devised a system using ‘activity cards’ which is sufficiently flexible to cope with any situation using the staff available at the time. The recommendations made in this paper are based upon experience gained in dealing with the Old Bailey bomb explosion and were subsequently shown to be of value in dealing with the Tower of London bomb explosion (Tucker and Lettin, 1975). On 8 March 1973 at 2.50 p.m. a car bomb exploded outside the Old Bailey in the City of London. At the time the police, knowing that the device existed but not entirely sure in which car, were clearing the area. Unfortunately, the police activity attracted onlookers, many of whom were in a large glass-fronted office block overlooking the site. In consequence, when the bomb exploded a large number of people were injured. Within minutes the injured arrived in the Accident and Emergency Department of St Bartholomew’s Hospital some 100 yards away and close enough to have been damaged in the blast. In less than an hour 160 patients passed through the doors of the accident department with injuries of varying severity. Details of how this situation was handled have already been published (Caro and Irving, 1973) and there is little point in reiterating them. However, the problems posed by this incident which occurred in such a manner that the major accident plan could not be formally activated provide a useful basis 732
on which to discuss how a hospital should cope with large numbers of injured patients.
Problems of a hospital dealing with a major disaster 1. The management of the sudden intlux of patients who threaten to overwhelmthe accident and emergency department and its staff. 2. The recognition of patients who have severe injuries and who need immediate resuscitation and highly skilled assessment and management. 3. The control and rational deployment of medical, paramedical and non-medical staff. 4. The calm, orderly and rapid evacuation of the injured from the accident department to the wards and operating theatres, where they can receive definitive treatment in order of priority. I have attempted to summarize the management of the whole situation in Fig. 1. Needless to say, individual hospitals will vary their approach according to their layout and staffing but the general principles should be applicable in all hospitals. Triage It is generally agreed that the first two problems listed above can be dealt with by the process of triage. Triage is a military term for a process by which patients are classified according to the severity of their injuries at the time of their admission. By this means the seriously injured are directed to the major treatment areas, staffed by junior surgical, anaesthetic and casualty staff, supervised by a consultant, where they can be rapidly assessed and resuscitated prior to transfer to the admission ward. Similarly, patients with minor injuries can be directed to a previously designated ‘minor treatment area’ where they can be dealt with by non-specialist medical staff who have volunteered to help. Patients with minor injuries benefit from the company of non-medical volunteers who, by their presence, provide the reassurance of normality to those who will have been severely disturbed by involvement in a horrific experience. Triage should be undertaken by an experienced clinician of sufficient seniority to be able to shoulder criticism of any mistakes he might make. The triage area should be close to the entrance to the accident department and should be large enough to hold a few stretcher cases and the walking cases whilst the consultant makes his rapid assessment of their condition. All patients should pass through the triage area, and because of this it is necessary to ensure in a major accident situation that only one public entrance to the accident department is open. In really major disasters, where very large numbers of patients are injured and resources are limited, triage may include the necessity for deciding which patients, though still alive, do not warrant treatment because the severity of their injuries is such that they are unlikely to survive. The consultant undertaking triage should also watch carefully for signs that the hospital’s resources are being overwhelmed, indicating to the police in such circumstances that patients should be conveyed from the disaster site to other hospitals.
Admission procedures after major disasters
1 Senior Surgeon Triage
SEVERELY I N J U R E D
1
I
Junior Anaesthetic, A/E and Surgical Staff Consultant supervising RESUSCITATION
P
VOLUNTEERS
M I N O R INJURIES
\
ADJACENT DEPTS Any medical staff Consultant supervising
I
TREATMENT
I
X-RAY DEPT Consultant Radiologist and Staff Assessing urgently and reporting
I /
1
/
I
Final registration check
I Fig. 1. Suggested plan for managing the admission of the victims of a major disaster.
Management of the seriously injured after resuscitation The aim of the staff in the resuscitation area should be to clear patients from the area as soon as possible after they have been resuscitated in order to be ready for further admissions. In some hospitals, such as the Royal Victoria Hospital in Belfast, there is an admission ward adjacent to the accident department to which patients can be admitted without disrupting the working of the rest of the hospital. In most hospitals, however, special arrangements will have to be made for admitting the injured. Experience has shown the value of clearing a ward on the ground floor for this purpose and admitting to it all patients irrespective of their age, sex or injuries. Although this involves disruption of hospital routine, administrative nursing staff and porters can usually rapidly clear such a ward, distributing the patients to vacant beds throughout the hospital or sending them home. I believe this measure is the single most important factor in the successful management of the severely injured patients. Patients are not separated from their relatives, and all the staff know exactly where the injured are. Management of the admission ward is also crucially important. One consultant surgeon should be in charge of the ward and the operating theatres. One way of managing the problem is to allocate to each patient a team of a junior surgeon and anaesthetist who will carry out a detailed assessment of the injured person, reporting back to the consultant in charge on the situation as they see it. The surgeon in charge can then, in consultation with his colleagues, pronounce on the
treatment priorities and ensure an orderly flow of cases to and from the operating theatres, the patients being taken to theatre and dealt with by the team that assessed them. From the operating theatres patients can be returned to the admission wards or transferred to special units, such as intensive care units, ophthalmic wards, etc. Common sense dictates that occasionally patients may need to bypass these arrangements, e.g. in cases where torrential intra-abdominal bleeding demands urgent laparotomy, but such instances will be rare. Management of the minor treatment area By and large most patients in this area require little treatment, toilet and suture of lacerations being the most important task. Such treatment can be carried out by any medical practitioner who has served as a house surgeon. However, consultant supervision is still necessary in this area to detect the occasional injury that, though classified as minor, is of greater significance. The consultant can also supervise such matters as tetanus prophylaxis and can relieve pressure on the X-ray department by indicating which radiological investigations, though necessary, can be left until a later date.
The role of consultants At first consultants should assume a primarily administrative and supervisory role, for many of the tasks mentioned above require experience and judgement and carry a considerable responsibility. In the operating 733
Miles Irving theatres the temptation to get involved early on should be resisted. It is better for the consultants to supervise three or four junior surgeons, reminding them of easily forgotten principles, such as the importance of delayed primary suture. By adopting a supervisory role they can be readily available when exploration of an apparently straightforward lesion reveals a problem that requires the consultants’ skill and experience. Mobile teams In the past great emphasis was laid upon the importance of the mobile surgical teams. Whilst there is little doubt that a medical practitioner should be present at the scene of the disaster, he should be an administrator rather than a clinician. Highly trained casualty, surgical and anaesthetic staff function best doing their usual tasks in their usual surroundings. Sending them out is in most circumstances a waste of valuable resources and an embarrassment to the police and ambulance personnel, who feel inhibited by their presence. Mobile teams should only go to the disaster site if requested. Such requests should normally be for assistance with the management of patients who are trapped and injured and who need analgesia and resuscitation. Operative surgery should only rarely be carried out in such situations.
Discussion In a short paper it is impossible to cover all eventualities and how to deal with them, but the principles of triage and admission of all patients to one ward, associated with a voluntarily accepted command structure,
734
would appear to be basic to the successful management of all major disasters. Although rigidly laid plans will be doomed to failure because of the almost inevitable breakdown of communications that occurs in these situations, it does not mean that preparation is valueless. Prepared large placards that can be hung on pre-inserted hooks are of value in indicating particular areas, e.g. ‘Minor Treatment Area’, ‘Relatives Waiting Room’ and ‘Press’ are examples of the many assembly areas that can be usefully indicated in such situations. Similarly, the question of which documentation system should be used in the event of a major accident can be decided in advance. Involvement in the management of a major accident is a trying and depressing experience. Skilful handling of the situation in the admitting hospital will reduce morbidity and mortality and relieve a great deal of distress, and as such, brings its own reward to those handling the situation.
References CARO D. and IRVING M. H. (1973) The Old Bailey bomb explosion. Lancet 1, 1433-1434. SAVAGE P. E. (1972) Disaster planning: the use of action cards. Br. Med. J. 3, 4243. TUCKER K. and LETTIN A. (1975) The Tower of London bomb explosion. Br. Med. J . 3, 287-290. ZIMMERMAN J. M. (1973) Mass casualty management. I n : BALLINGER w. F., RUTHERFORD R. B. and ZUIDEMA G. D. fed.) The Management of Trauma, 2nd ed. Edinburgh, Churchill Livingstone.
