Lessons in planning from mass casualty events in UKBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4765 (Published 25 October 2017) Cite this as: BMJ 2017;359:j4765
All rapid responses
I wish to thank the authors Moran et al for their excellent article on mass casualty events.
However I would also like to draw attention of readers to the definition of what are considered to be Mass Casualties Incidents (MCI):
“a disastrous single or simultaneous event(s) or other circumstances where the normal major incident response of several NHS organisations must be augmented by extraordinary measures in order to maintain an effective, suitable and sustainable response”
"By definition, such events have the potential to rapidly overwhelm – or threaten to exceed – the local capacity available to respond, even with the implementation of Major Incident plans." (Ref 1)
It is important to note that there is no specific number or threshold in which to call a MCI, and the key is the potential/actuality to overwhelm local resources even if there is a plan in place.
Casual readers, including many doctors, may not understand the implication of this fact and often equate "lack of resources" simply to "get more staff, equipment or facilities".
In these MCIs, the lack of resources to cope is only one aspect of the conundrum, the other is limited time; thus the need to make a choice to provide care to the maximum number of people in a short period of time when it matters the most.
The unpalatable truth is when healthcare professionals have to make a choice to to provide urgent care via triaging, some patients may come to unintended harm, or even more regrettably, expected longer suffering (and even death) simply because of the fact that there are often insufficient skilled personnel on the ground. The reality is that choices have to be made to provide the most expedient care to the most people and this will result in less than ideal/adequate care in some cases and less time spent on attempts to revive terminal conditions.
A classic example of MCI triage is the use of theSimple triage and rapid treatment (START) method.
Despite multiple recent MCIs in UK, I suspect the proportion of those healthcare professionals exposed to these events are in the minority, much less those who had experienced more than one MCI event. While paramedics are more likely to have experience of low level MCIs, a significant fraction of their experience may be "scoop and run", given that most of these MCIs occur in metropolitan London where multiple major hospitals are only a few minutes away.
In the end, most doctors and nurses are ill-equipped and not ready for MCIs, including both senior and junior staff. As a result the START or other MCI triaging method may come as a huge shock to these people as their conventional experience and skills looking after individual patients with the best available care have to undergo a seismic change in mindset.
It is then no wonder, that there is a need to provide psychological support for staff; not just for survivor's guilt but also guilt from making life-changing/giving decision to allocate resources to one group of patients but not the other.
Even when doctors and nurses in the military undergo MCI training, and take part in simulations on the field as well as at the casualty collection station, it took several attempts for many to realise, that at the end of the day, that there is no right decision to be able to save everyone, and yet there are many potentially wrong decisions which will compromise their ability to save as many people as possible.
I urge all doctors and nurses to be proactive and take part in their MCI management program in their local facilities as I do not think the situation in the UK is going to be any better in the near future.
Competing interests: No competing interests
Well enumerated and narrated vital lessons obtained from mass casualty events . Emergency by description and definition is 'unanticipated and unexpected ' development in terms of timing , dimension , magnitude and nature ( primarily surgical or medical , or composite ). Therefore the planning , protocols and SOPs will have a primary response and sequential modules. In metropolitan cities across the world mass casualty events can be diverse--- plane crash , railway and road accidents , building collapses in monsoons ,flooding , poisonous gas release-- chlorine , ammonia from industrial establishments , earthquakes , fires , multiple serial bomb blasts , riots , overcrowding - stampede - asphyxia , firing to contain uncontrollable crowds , mass food poisoning...much can be added to the list that may turn endless. Crucial is the fact that the team dealing will have to be on alert , with a lasting physical and mental stamina (and reserve ) to emerge successful in salvaging lives and ensuring least morbidity by timely measures and steps. Astute clinical leadership on-site and coordinated multi departmental hospital back up are vital. Dr Murar E Yeolekar , Mumbai.
Competing interests: No competing interests