Optimizing Medical Care during a Nerve Agent Mass Casualty Incident Using Computer Simulation.

INTRODUCTION: Chemical mass casualty incidents (MCIs) pose a substantial threat to public health and safety, with the capacity to overwhelm healthcare infrastructure and create societal disorder. Computer simulation systems are becoming an established mechanism to validate these plans due to their versatility, cost-effectiveness and lower susceptibility to ethical problems. METHODS: We created a computer simulation model of an urban subway sarin attack analogous to the 1995 Tokyo sarin incident. We created and combined evacuation, dispersion and victim models with the SIMEDIS computer simulator. We analyzed the effect of several possible approaches such as evacuation policy ('Scoop and Run' vs. 'Stay and Play'), three strategies (on-site decontamination and stabilization, off-site decontamination and stabilization, and on-site stabilization with off-site decontamination), preliminary triage, victim distribution methods, transport supervision skill level, and the effect of search and rescue capacity. RESULTS: Only evacuation policy, strategy and preliminary triage show significant effects on mortality. The total average mortality ranges from 14.7 deaths in the combination of off-site decontamination and Scoop and Run policy with pretriage, to 24 in the combination of onsite decontamination with the Stay and Play and no pretriage. CONCLUSION: Our findings suggest that in a simulated urban chemical MCI, a Stay and Play approach with on-site decontamination will lead to worse outcomes than a Scoop and Run approach with hospital-based decontamination. Quick transport of victims in combination with on-site antidote administration has the potential to save the most lives, due to faster hospital arrival for definitive care.

Key performance indicators and benchmarks in MCI prehospital response using technological tools: a qualitative study assessing the perception of practitioners and tool developers.

PURPOSE: The aim of this study is to investigate the opinions and perspectives of The Novel Integrated Toolkit for Enhanced Prehospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE) end-users and tool developers regarding Key Performance Indicators (KPIs) and benchmarks that assess the prehospital response to Mass Casualty Incidents (MCIs) enhanced by the NIT-MR. METHODS: A qualitative study employing focus group discussions was conducted to collect opinions and perspectives of end-users and tool developers regarding KPIs and benchmarks in MCI response using the NIT-MR. The criteria considered for the selection and distribution of participants within the groups was the nature of their involvement within the NIGHTINGALE project and their familiarity with the tools to be discussed. RESULTS: Thirty-one participants from different countries were included. Four themes emerged during data analysis which are: definition/explanation is the personal understanding of participants of the term KPI, process of KPI development and relationship with User Requirements is the decision process for assigning KPIs to user requirements, benchmarking is the mental process of associating a benchmark to a KPI or for developing a benchmark, and technical/medical gap is the gap of understanding between each sides' fields. CONCLUSION: This study emphasized the need for a structured approach to using KPIs and bridging the gap between technological and medical worlds, taking the NIGHTINGALE project, funded by the European Union, which aims to develop a technological toolkit for first responders in mass casualty incidents as an example. These insights are crucial for enhancing disaster response.

Limitations of Triage in Military Mass Casualty Response: A Case Series.

INTRODUCTION: Mass casualty events (MASCALs) in the combat environment, which involve large numbers of casualties that overwhelm immediately available resources, are fundamentally chaotic and dynamic and inherently dangerous. Formal triage systems use diagnostic algorithms, colored markers, and four or more named categories. We hypothesized that formal triage systems are inadequately trained and practiced and too complex to successfully implement in true MASCAL events. This retrospective analysis evaluates the real-world application of triage systems in prehospital military MASCALs and other aspects of MASCAL management. METHODS: We surveyed Special Operations Forces (SOF) medics known to us who have participated in military prehospital MASCALs and analyzed them. Aggregated data describing the scope of the incidents, the use of formal triage algorithms and colored markers, the number of categories, and the interventions on scene were analyzed using descriptive statistics, and lessons learned were consolidated. RESULTS: From 1996 to 2022 we identified 29 MASCALs that were managed by military medics in the prehospital setting. There was a median of three providers (range 1-85) and 15 casualties (range 6-519) per event. Four or more formal triage categories were used in only one event. Colored markers and formal algorithms were not used. Life-saving interventions were performed in 27 of 29 (93%) missions and blood transfusions were performed in four (17%) MASCALs. The top lessons learned were: 1) security and accountability are cornerstones of MASCAL management; 2) casualty movement is a priority; 3) intuitive triage categories are the default; 4) life-saving interventions are performed as time and tactics permit. CONCLUSION: Formal triage systems requiring the use of diagnostic algorithms, colored tags, and four or five categories are seldom implemented in real-world military prehospital MASCAL management. The training of field triage should be simplified and pragmatic, as exemplified by these instances.

Don't forget the children-paediatric patients in mass casualty events and major incident planning.

Major incidents and mass casualty events can affect people of all ages. However, when planning the response to a major incident the focus is often on adult casualties rather than children. It is essential that the needs of paediatric patients are taken into account throughout major incident planning. Whether considering equipment, staffing or surgical and critical care capacity, hospitals should meet the needs of children as well as adults following a major incident and where possible, keep families together. The new Major Incident Triage Tool introduced in the National Health Service (NHS) in 2024 has a tendency to over triage paediatric casualties and so hospitals who may be receiving children following a UK major incident must be aware of this and plan for the potential implications. This article reviews the evidence and learning from previous mass casualty events and makes recommendations for hospitals to ensure that the needs of children will be met if a major incident occurs.

Key performance indicators in pre-hospital response to disasters and mass casualty incidents: a scoping review.

PURPOSE: The objective of this study was to offer a comprehensive synthesis of the existing Key performance indicators (KPIs) used in the evaluation of the pre-Hospital response to disasters and mass casualty incidents (MCIs). METHODS: At the end of December 2022 a scoping review has been performed on PubMed, Scopus, Embase, and Medline to identify articles describing the use of KPIs to assess the performance of first responders during the prehospital phase of an MCI (real or simulated). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, fourteen articles were included in the analysis. RESULTS: Eleven articles applied indicators in exercises and/or simulations. Two articles proposed new KPIs, and one used KPIs for developing a model for benchmarking pre-Hospital response. All articles analyzed quantitative indicators of time, whereas two studied indicators of structure, of process, and of outcome as well. CONCLUSION: The findings from this review emphasize the need for employing common terminology and using uniformed data collection tools, if obtaining standardized evaluation method is the goal to be achieved.

The Israeli Trauma system during wartime - policy and management.

On October 7, 2023, Hamas terrorists attacked people in their homes, fields, and at a music festival in Israeli communities near the border with Gaza. More than 1,145 men, women, and children were killed, about 1,800 wounded were evacuated to hospitals in the country, and 253 infants, children, women, elderly, and men were abducted. This mass casualty incident (MCI) was the start of a war that is still ongoing. The Israeli medical system, which faced an overwhelming first 24 h, continues to take care of casualties, including those who are injured by missiles that target Israeli residential areas.Israel has a well-established trauma system, and as a result of the experience gained in this war, the system merited review. This was the topic of a meeting of leaders of the Israeli healthcare system, and it forms the basis of this report. The meeting and report provide a platform for presenting the trauma system management during the war, highlighting the strengths of the system as well as its challenges and lessons learned. The participants also brainstormed and discussed possibilities for future improvements.

Designing a model of emergency medical services preparedness in response to mass casualty incidents: a mixed-method study.

BACKGROUND: Emergency medical services preparedness in mass casualty incidents is one of the most important concerns in emergency systems. A mass casualty incident is a sudden event with several injured individuals that overwhelms the local health care system. This study aimed to identify and validate the components of emergency medical services readiness in mass casualty incidents which ultimately led to designing a conceptual model. METHODS: This research was an explanatory mixed-method study conducted in five consecutive stages in Iran between November 2021 and September 2023. First, a systematic review was carried out to extract the components of emergency medical services preparedness in mass casualty incidents based on the PRISMA guideline. Second, a qualitative study was designed to explore the preparedness components through in-depth semi-structured interviews and analyzed using the content analysis approach. Third, the integration of the components extracted from the two stages of the systematic review and qualitative study was done by an expert panel. Fourth, the obtained components were validated using the Delphi technique. Two rounds were done in the Delphi phase. Finally, the conceptual model of emergency medical services preparedness in mass casualty incidents was designed by a panel of experts. RESULTS: 10 articles were included in the systematic review stage and sixteen main components were extracted and classified into four categories. In the second stage, thirteen components were extracted from the qualitative study and classified into five categories. Then, the components of the previous two phases were integrated into the panel of experts and 23 components were identified. After validation with the Delphi technique, 22 components were extracted. Lastly, the final components were examined by the panel of experts, and the conceptual schematic of the model was drawn. CONCLUSIONS: It is necessary to have an integrated framework and model of emergency medical service readiness in the planning and management of mass casualty incidents. The components and the final model of this research were obtained after the systematic scientific steps, which can be used as a scheme to improve emergency medical service preparedness in response to mass casualty incidents.

Effects of mass casualty incidents on anxiety, depression, and post-traumatic stress disorder among doctors and nurses: a systematic review.

OBJECTIVES: Doctors and nurses suffer different mental health conditions following traumatic incidents. We systematically synthesized existing evidence on the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) and their associated risk factors among doctors and nurses following mass casualty incidents (MCIs). STUDY DESIGN: Systematic review. METHODS: Seven databases were searched (2010-2022) with peer-reviewed articles in English using the predefined keywords. Two reviewers screened the titles, abstracts, and full texts using the eligibility criteria and extracted data independently. We used the National Institutes of Health Quality Assessment Tools (NIH-QAT) and the Critical Appraisal Skills Programme checklist (CASP) to measure the quality appraisal of the included studies. RESULTS: A total of 5170 articles were retrieved, and 2512 articles were assessed by title and abstract (53 were eligible for full-text review). Finally, we included 19 studies. Most were assessed as of fair quality with a considerable risk of bias. PTSD was the highest-reported mental health condition. Nurses reported higher mental conditions, particularly PTSD. Two sets of risk factors (personal and workplace) are associated with anxiety, depression, and PTSD were found. CONCLUSIONS: MCIs have a significant impact on the mental health outcomes of emergency health workers. Preventive measures should be designed considering the high-risk group, personal, and organizational risk factors of mental health outcomes.

Nurses under fire: Insights from testimonies of community nurses and midwives in nonhospital settings in the southern Israel conflict zone.

Nurses-with or without prehospital care training-may find themselves delivering immediate care to injured individuals outside a healthcare facility, sometimes even in situations where their own life is at risk. This study explores the experiences of community nurses and midwives who provided immediate care during the Hamas militant movement's attack in southern Israel. The researchers collected and analyzed eight nurse and midwife survivors' testimonies published in digital media to gain a deeper understanding of their perspectives. Through qualitative content analysis, common themes, patterns, and insights were identified. The study aimed to contribute valuable knowledge in this field and followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for methodological rigor. Two themes emerged from the testimonies, focusing on the nurses' swift realization of necessary action under fire and resilience and ingenuity in practice. Despite lacking training and resources, the nurses professionally assessed the situation and improvised creative solutions to care for the wounded. Although they had no prehospital emergency care background, community nurses and midwives were able to respond effectively, providing lifesaving care. The findings highlight the nurses' resilience, adaptability, and dedication in unprecedented situations. However, the study also emphasizes the importance of providing all nurses with baseline prehospital care training and structured planning of this care to empower them to deliver optimal patient care in uncertain and dangerous conditions, especially in and around conflict and disaster zones.

Use of Self-Efficacy Scale in Mass Casualty Incidents During Drill Exercises.

INTRODUCTION: Medical First Responders (MFRs) in the emergency department SUMMA 112 are tasked with handling the initial management of Mass Casualty Incidents (MCI) and building response capabilities. Training plays a crucial role in preparing these responders for effective disaster management. Yet, evaluating the impact of such training poses challenges since true competency can only be proven amid a major event. As a substitute gauge for training effectiveness, self-efficacy has been suggested. OBJECTIVE: The purpose of this study is to employ a pre- and post-test assessment of changes in perceived self-efficacy among MFRs following an intervention focused on the initial management of MCI. It also aimed to evaluate a self-efficacy instrument for its validity and reliability in this type of training. METHOD: In this study, we used a pretest (time 1 = T1) - post-test (time 2 = T2) design to evaluate how self-efficacy changed after a training intervention with 201 MFRs in initial MCI management. ANOVA within-subjects and between subjects analyses were used. RESULTS: The findings reveal a noteworthy change in self-efficacy before and after training among the 201 participants. This suggests that the training intervention positively affected participants' perceived capabilities to handle complex situations like MCI. CONCLUSION: The results allow us to recommend a training program with theory components together with practical workshops and live, large-scale simulation exercises for the training of medical first responders in MCI, as it significantly increases their perception of the level of self-efficacy for developing competencies associated with disaster response.

Developing emotional preparedness and mental resilience through high-fidelity simulation: a 'bridge too far' for institutions teaching major trauma management and mass-casualty medicine?

BACKGROUND: Clinical acumen represents only part of being adequately equipped to attend a major incident. The emotive sights, sounds and smells of these dynamic environments are all-encompassing experiences, and responders must also be armed with the emotional preparedness to perform their clinical or managerial duties effectively, as well as the mental resilience to facilitate professional continuance. Despite this, limited training and a sparsity of evidence exists to guide developments within this domain. Historically, major incident training has focused on clinical theory acquisition, but irrespective of how comprehensive the learning materials, they are of little consequence if tandem steps to cultivate mental resilience and emotional preparedness are absent. High-Fidelity Simulation (HFS) has a growing reputation as an effective means of bridging important gaps between theory and practice. This pilot study aimed to measure student's self-reported perception of their readiness to respond to a major incident following a large-scale HFS. METHODS: Quantitative data was obtained from a sample of 108 students undertaking paramedic science, physician associate studies and adult nursing degree programmes. A bespoke questionnaire was developed to measure self-reported clinical acumen, mental and emotional preparedness. RESULTS: 91% of students agreed the combination of theoretical training and HFS provided made them feel clinically prepared to attend a real major incident; 86% agreed this experience had developed their mental resilience and 90% agreed that they felt emotionally prepared to attend a major incident. CONCLUSION: Within this pilot study, the blend of theoretical training and HFS contributed to self-reported clinical acumen, mental and emotional preparation, in learners training to work in disaster environments or emergency medicine settings.

What If Nice Terrorist Attack Would Have Happened in Milan? Drawing a Disaster Plan for Mass Casualty Incidents Involving the Pediatric Population.

Terrorist attacks involving children raised concern regarding the preparedness to treat pediatric trauma patients during mass casualty incidents (MCIs). The purpose of this project was to assess the resources available in Milan to respond to MCIs as the 2016 Bastille Day attack in Nice. Literature and guidelines were reviewed and minimal standard requirements of care of pediatric trauma patients in MCIs were identified. The hospitals that took part in the study were asked to answer a survey regarding their resource availability. An overall surge capability of 40-44 pediatric trauma patients was identified, distributed based on age and severity, hospital resources, and expertise. The findings showed that adult and pediatric hospitals should work in synergy with pediatric trauma centers, or offer an alternative if there is none, and should be included in disaster plans for MCIs. Simulations exercises need to be carried out to evaluate and validate the results.

February 6th, Kahramanmaras earthquakes and the disaster management algorithm of adult emergency medicine in Turkey: An experience review.

This compilation covers emergency medical management lessons from the February 6th Kahramanmaras earthquakes. The objective is to review relevant literature on emergency services patient management, focusing on Koenig's 1996 Simple Triage and Rapid Treatment (START) and Secondary Assessment of Victim Endpoint (SAVE) frameworks. Establishing a comprehensive seismic and mass casualty incident (MCI) protocol chain is the goal. The prehospital phase of seismic MCIs treats hypovolemia and gets patients to the nearest hospital. START-A plans to expedite emergency patient triage and pain management. The SAVE algorithm is crucial for the emergency patient secondary assessment. It advises using Glasgow Coma Scale, Mangled Extremity Severity Score, Burn Triage Score, and Safe Quake Score for admission, surgery, transfer, discharge, and outcomes. This compilation emphasizes the importance of using diagnostic tools like bedside blood gas analyzers and ultrasound devices during the assessment process, drawing from 6 February earthquake research. The findings create a solid framework for improving emergency medical response strategies, making them applicable in similar situations.

Ethics in disaster, mass casualty care, and critical care.

The primary ethical principle guiding general medical practice is autonomy. However, in mass casualty (MASCAL) or disaster scenarios, the principles of beneficence and justice become of foremost concern. Despite multiple reviews, publications, and training courses available to prepare for a MASCAL incident, a minority of physicians and healthcare providers are abreast of these. In this review, we describe several MASCAL scenarios and their associated ethical, moral, and medicolegal quandaries in attempts to curb potential future misadventures.

Burn or trauma scoring: experience of the burn unit of the Queen Astrid Military Hospital during the terror attacks on 22 March 2016.

PURPOSE: On 22 March 2016, the burn unit (BU) of Queen Astrid Military Hospital assessed a surge in severely injured victims from terror attacks at the national airport and Maalbeek subway station according to the damage control resuscitation (DCR) and damage control surgery (DCS) principles. This study delves into its approach to identify a suitable triage scoring system and to determine if a BU can serve as buffer capacity for mass casualty incidents (MCIs). METHODS: The study reviewed retrospectively the origin of explosion, demographic data, sustained injuries, performed surgery, and length of stay of all admitted patients. Trauma scores (Injury Severity Score (ISS) and New Injury Severity Score (NISS)) and triage scores (Revised Trauma Score (RTS), New Trauma Score (NTS), and Trauma Score Injury Severity Score (TRISS)), were compared to burn mortality scores (Osler updated Baux Score and Tobiasen's Abbreviated Burn Severity Index (ABSI)). RESULTS: Of the 23 casualties admitted to the BU, the scores calculated on average 3.5 indications for a level 1 trauma center (ISS 4, NISS 6, RTS 0, T-NTS 4). Nevertheless, no deaths occurred during admission or the 1-year follow-up. CONCLUSION: MCIs create chaos and a high demand for care. Avoiding bottlenecks and adhering to the DCR/DCS principles are necessary to deliver the best care to the largest number of people. This study indicates that a BU can serve as buffer capacity for MCIs. Nevertheless, its integration into the medical resilience plan depends on accurate scoring, comprehensive care availability, and understanding of the DCR/DCS concept. NTS for triage seems the best fit for scoring polytrauma referrals to a BU during MCIs.

Burn mass casualty incident planning in Alberta: A case study.

Burn mass casualty incident (BMCI) preparedness is lacking across Canada. A focused exploration of the current policies, protocols and practices in Alberta that address the response to a BMCI was conducted. In this case study, data were gathered from documents outlining the health system response to a mass casualty incident and health care professionals directly involved. Interviews were conducted online, recorded and transcribed. Qualitative description was used to code common themes across documents and transcripts. Fifteen documents and nine participant interviews were included in this study. Overall, the current policies, protocols and practices in place were limited to all-hazards mass casualty incident planning and did not address the specialized needs of burn patients. Deficiencies included no burn-specific plan at each of the two burn centres, a lack of provincial-level recognition of the unique challenges associated with a BMCI and no established Canadian burn disaster communication plan. Suggestions of strategies for a burn plan included forward triage, patient movement, use of telemedicine, partnering skilled and non-skilled staff, and procuring additional supplies. For best patient outcomes the provincial health authority needs to provide dedicated time for burn care experts to develop BMCI response plans to better address this unique hazard.

Managing a Mega Mass Casualty Event by a Civilian Emergency Medical Services Agency: Lessons From the First Day of the 2023 Hamas-Israel War.

On 7 October 2023, Israel faced an unexpected attack by Hamas, causing over 1,200 deaths and injuring more than 9,000 individuals. This report delves into the rapid medical response spearheaded by Israel's civilian Emergency Medical Service, Magen David Adom (MDA), during this crisis. Utilizing data from MDA's electronic database, 4,097 dispatch records from the day were analyzed. Of these, 39.3% were directly related to the attack. EMS teams faced multiple challenges, including handling an overwhelming number of casualties and navigating active combat zones, which impeded safe access to victims, posed significant risks to teams' safety, and constrained patient evacuation strategies. This incident underscores the importance of reinforcing healthcare resilience, particularly emphasizing the need for centralizing various aspects of response efforts. These include streamlined communication, national coordination of pre-hospital resources, and systemic management of patient evacuations. Moreover, providing substantial support for EMS personnel, who operated in highly challenging conditions, is imperative.

Evaluating emergency response at a hospital near the Gaza border within 24 h of increased conflict.

BACKGROUND: Frontline hospitals near active hostilities face unique challenges in delivering emergency care amid threats to infrastructure and personnel safety. Existing literature focuses on individual aspects like mass casualty protocols or medical neutrality, with limited analysis of operating acute services directly under fire. OBJECTIVES: To describe the experience of a hospital situated meters from hostilities and analyze strategies implemented for triage, expanding surge capacity, and maintaining continuity of care during attacks with limited medical staff availability due to hazardous conditions. A focus will be placed on assessing how the hospital functioned and adapted care delivery models in the event of staffing limitations preventing all teams from arriving on site. METHODS: A retrospective case study was conducted of patient records from Barzilai University Medical Center at Ashkelon (BUMCA) Medical Center in Israel within the first 24 h after escalated conflict began on October 7, 2023. Data on 232 admissions were analyzed regarding demographics, treatment protocols, time to disposition, and mortality. Missile alert data correlated patient surges to attacks. Statistical and geospatial analyses were performed. RESULTS: Patients predominantly male soldiers exhibited blast/multisystem trauma. Patient surges at the hospital were found to be correlated with the detection of incoming missile attacks from Gaza within 60 min of launch. While 131 (56%) patients were discharged and 55 (24%) transferred within 24 h, probabilities of survival declined over time reflecting injury severity limitations. 31 deaths occurred from severe presentation. CONCLUSION: Insights gleaned provide a compelling case study on managing mass casualties at the true frontlines. By disseminating BUMCA's trauma response experience, strategies can strengthen frontline hospital protocols optimizing emergency care delivery during hazardous armed conflicts through dynamic surge capacity expansion, early intervention prioritization, and infrastructure/personnel protection measures informed by risks.

Development and evaluation of a mechanical ventilator-sharing system.

Background: During the COVID-19 pandemic surge in the hospitalization of critically ill patients and the global demand for mechanical ventilators, alternative strategies for device sharing were explored. We developed and assessed the performance of a system for shared ventilation that uses clinically available components to individualize tidal volumes under a variety of clinically relevant conditions. The feasibility of remote monitoring of ventilators was also assessed. Methods: By using existing resources and off-the-shelf components, a ventilator-sharing system (VSS) that ventilates 2 patients simultaneously with a single device, and a ventilator monitoring system (VMS) that remotely monitors pulmonary mechanics were developed. The feasibility and effectiveness of VSS and VMS were evaluated in benchtop testing using 2 test lungs on a single ventilator, and then performance was assessed in translational swine models of normal and impaired lung function. Results: In benchtop testing, VSS and VMS delivered the set individualized parameters with minimal % errors in test lungs under pressure- and volume-regulated ventilation modes, suggesting the highest precision and accuracy. In animal studies, the VSS and VMS successfully delivered the individualized mechanical ventilation parameters within clinically acceptable limits. Further, we found no statistically significant difference between the target and measured values. Conclusion: The VSS adequately ventilated 2 test lungs or animals with variable lung conditions. The VMS accurately displayed mechanical ventilation settings, parameters, and alarms. Both of these systems could be rapidly assembled for scaling up to ventilate several critically ill patients in a pandemic or mass casualty disaster situations by leveraging off-the-shelf and custom 3D printed components.