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Case Report: Mass Casualty Incident

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Prepared by: Michael Dingeldein, MD
Rainbow Babies and Children's Hospital, Cleveland, OH

Pre-Hospital:
Your city is hosting a National Special Security Event located near your medical center. There are a large group of demonstrators and counter-demonstrators including adolescents and children. At 9pm a large truck is driven intentionally into the crowd of demonstrators. EMS/fire/police are already on scene and quickly activate their MCI protocols. Given the proximity to the medical center, including your Level 1 Pediatric Trauma Center, walking wounded and patients transported by private vehicle start arriving within 10 min of the incident.

ED:
Your triage nurse is notified of the incident by the first of the walking wounded patients, stating "there are hundreds of people hurt." Within the first 20 min you have 6 identified adolescents with serious injuries needing likely operative intervention.

A disaster code is paged out and the hospital prepares for a large surge of patients. The Incident Command Center is activated.

Given the proximity of the medical center to the incident and reports of an "active shooter," the Medical Center is locked down and all major nearby roads are closed. Extra medical personnel are unable to quickly get into the medical center to assist with the patient surge. The administration officials that typically command the Command Center are unable to get into the medical center.

Per protocol the ED sets up Red, Yellow, and Green zones. A total of 20 pediatric patients are treated from the event with 6 needing operative intervention, 15 needing admission with 8 needing ICU beds. Available nurses for other units are able to help staff the ED. Pediatric hospitalists are able to staff the Green zone patients.

All patients were able to be identified within the first 6 hours.

Operative / Post Op:
With limited staffing you are able to run 2 operating rooms:

  • Patient A: 12yo fail chest, blunt cardiac injury. Required bilateral chest tubes and ICU monitoring with inotrope support due to chest crush including severe blunt cardiac injury. Progressed to severe respiratory failure requiring ECMO support.
  • Patient B: 14yo multiple long bone injuries, splenic lac. Splenic lac that was non-responsive to blood products thus requiring laparotomy. Long bone fracture requiring reduction.
  • Patient C: 15yo pelvic fracture. Hemodynamically unstable and IR team unable to reach hospital. Pre-peritoneal packing done and ex fix placed. Resuscitation in ICU.
  • Patient D: 10yo TBI, femur fracture. Epidural hematoma requiring craniotomy and femur fracture requiring reduction.
  • Patient E: 14yo abdominal crush, multiple bowel and solid organ injuries. Hemodynamically unstable requiring significant MTP use. Ex lap with bowel oversewn, liver packed, and spleen removed. Open abdomen with significant ongoing ICU needs.
  • Patient F: 15yo TBI, liver lac, pneumothorax. Hemodynamically unstable with ex lap, liver packing, open abdomen, chest tube, and hemicraniotomy for subdural.

Outcomes:
Your hospital unit leadership was able to quickly mobilize to create capacity by moving stable ICU patients to regular med/surg floor beds and also to rapidly discharge patients.

Hospital security and local law enforcement were able to secure the medical campus and allow for discharge of patients and influx of hospital personnel.

The ICU was able to handle the influx of 8 patients by doubling up in 2 rooms and utilizing meg/surg floor nurses to expand capabilities.

A secondary triage point was set up in the pre-op holding area for surgery and anesthesia to triage the surgical patients and set priorities for the operating room.

There were sufficient surgical attendings and residents to staff the cases but room turn over and preparation was an issue due to lack of personnel. Surgical staff were used to help augment the environmental services team.


All patients were able to be identified in a timely manner.

Learning points (i.e. things to discuss at your institution):

  • What is the mechanism at your institution for activating a "disaster" code? How do you preparing for treating a surge of patients?
  • How are you able to extend your institution capabilities and capacity with minimal help from the outside?
  • What is the mechanism for pediatric identification and tracking at your institution?
  • What is the mechanism for restocking ED, OR, and ICU supplies including case carts?
  • What is your hospital's recovery plan?
  • What is your hospital's alternate care site? Where would you see and treat a large influx of "walking wounded"? And how would treat these patients?
  • How does the COVID pandemic effect for MCI surge plan?

Resources:
The purpose of this case report is not to focus too much on the medical treatment of patients but more to serve as a starting point in discussing with your team and hospital about how you prepare and think about disaster management. Disaster preparation and management follows basic principles but is very individualized to your institution based on that facilities capabilities and capacity.


CME Opportunities

Presenters examine the evolution of post-disaster interventions since 9/11.

CME/CNE Link

Presenters describe how best to prepare our children for emergencies from the standpoint of community preparedness and resilience and of emergency preparedness within school settings.

CME/CNE Link

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