Increasingly, mass casualty incidents which were once unthinkable are becoming commonplace. Indeed, a day does not go by without a mass casualty event occurring someplace at home or in the world. The pediatric population is disproportionately affected by mass casualty incidents. Are you and your hospital ready to deal with one? I suspect not. On a daily basis, while providing anesthesia most of us hope for the best and prepare for the worst. Unfortunately, when dealing with mass casualties, hope is not a strategy…preparing, training and practice is. But how? The Board of Directors, the Education committee, and the Special Interest Group on Disaster Preparedness of the Society for Pediatric Anesthesia have planned an important and extraordinary workshop that will be offered at the Society’s Annual meeting in Austin (March 31-April 2,2023) to get you up to speed. I would urge all of you to register and attend this workshop. Because registration will be limited to only 24 people, I would urge you to register for the Friday (3 PM-6 PM) workshop entitled: Mass casualty incidents-Prepare and Practice as soon as possible. What are the workshop’s learning objectives?
1. List three actions they would immediately take to prepare the operating room in the event of a mass casualty;
2. Incorporate the guidelines in the American Society for Anesthesiology Manual for Anesthesia Department Organization and Management in mass casualty preparedness plans in their organizations;
3. Use tourniquets to effectively stop hemorrhage in trauma victims, as taught in the "stop the bleed" campaign;
4. Explain the principles of triage in mass casualty events including processes for immediate surge capacity in the event of large-scale public health emergencies;
5. Become leaders and advocates for children in mass casualty preparedness at their institutions
And remember how to be best prepared is the same as answer to the question: “How to you get to Carnegie Hall”?
In looking for an article on this topic for the PAAD readership, I was actually very surprised at how little published guidance exists. Fortunately, my good friend and former colleague, Dr. Deborah Schwengel of the Johns Hopkins Hospital sent this article to me1 and I’ve e asked her to assist me in writing today’s PAAD. I need to add that she was one of the article’s authors and is one of the organizers of the upcoming SPA workshop. Myron Yaster MD
Original article
Matthew Desmond, Deborah Schwengel, Kelly Chilson, Deborah Rusy, Kristyn Ingram, Aditee Ambardekar, Robert S Greenberg, Kumar Belani, Alison Perate, Meera Gangadharan; Society for Pediatric Anesthesia Disaster Preparedness Special Interest Group. Paediatric patients in mass casualty incidents: a comprehensive review and call to action. Br J Anaesth. 2022 Feb;128(2):e109-e119. PMID: 34862001
“War occurs increasingly in cities, with children being more affected and most vulnerable. Children may be intentionally targeted to maximize political or psychological effect. Further, children often take the backseat in terms of disaster preparedness and implementation of relief and treatment when mass casualty events occur”.1, 2
Why are children more vulnerable? Mechanical trauma: skeletal flexibility leads to internal damage (less rib fracture more pulmonary contusions), organ proximity increases polytrauma, large head size leads to more head injury. Explosive trauma: tendency to wander and play in areas with unexploded ordinance and improvised explosive devices which are often designed to look like toys. Thermoregulation and thermal trauma: less subcutaneous fat and thinner skin predispose to hypo- and hyperthermia. Chemical trauma: Less keratinization of skin increases transdermal absorption and vesicant injury, increased minute ventilation increases inhaled toxin dose. Biologic injury: proneness to dehydration from agents producing diarrhea and vomiting, lack of immunity to infectious diseases, increased minute ventilation increases inhaled doses. Radiologic injury: rapid cell turnover increases symptoms and future risks. Additionally, while pediatric patients account for approximately 25% of the population, many adult hospitals and emergency medical first responders lack appropriate staff, equipment, or protocols meant for children. Reunification with family members is also a complex problem, particularly when children or adults cannot identify themselves.
The sad truth about intraoperative mass casualty preparedness is that hospital teams are woefully underprepared. Errors in triage and initial treatment and use of resources lead potentially to increases in mortality and also have significant financial impact.3 We know that anesthesiologists feel underprepared and would like training in MCI preparedness. The keys to success include “education and rehearsals, policies and procedures must be updated and useable, and individuals must be empowered to prepare teams to deliver the best possible care in difficult circumstances”.1 Education and rehearsals can range from classroom-based teaching, such as lectures, workshops, game-based learning and table-top simulations, to small- and large-scale hospital simulations, and should include repeated combinations of those techniques to inform hospital systems and keep hospital staff nimble.1 Crisis standards of care are different and challenging and expose the vulnerabilities of hospital staff to depression, grieving and post-event stress.6 We cannot prevent mass casualty incidents but we can prepare.
The time to prepare is now! The ongoing pandemic does not preclude the next mass shooter, industrial accident, tornado, earth quake, or terrorist attack. We would urge all of you to consider registering and signing up for the SPA workshop to be held on Friday March 31 from 3-6 PM at the annual meeting in Austin. The number of spots in the workshop is limited so please do this now while you are thinking about it. https://www.pedsanesthesia.net/wp-content/uploads/2023/02/Workshop-Promo.mp4
References
1. Desmond M, Schwengel D, Chilson K, et al. Paediatric patients in mass casualty incidents: a comprehensive review and call to action. British journal of anaesthesia. Feb 2022;128(2):e109-e119. doi:10.1016/j.bja.2021.10.026
2. Markenson D, Reynolds S. The pediatrician and disaster preparedness. Pediatrics. Feb 2006;117(2):e340-62. doi:10.1542/peds.2005-2752