5/29/2014 SURGICAL RESPONSE TO DISASTERS Training Surgeons for Disasters “A MASS CASUALTY EVENT IS NOT JUST ANOTHER BUSY NIGHT IN AN URBAN TRAUMA CENTER!” ACS/COT M. Margaret Knudson MD, FACS Chief of Surgery, San Francisco General Hospital and Trauma Center Mass Casualty Management: A Weekly Event Propper et al: Annals of Surgery 2009 Elster et al: Implications of Combat Casualty Care for Mass Casualty Care, JAMA 2013 1
5/29/2014 4 Operating Rooms: 2 pts each Surgical Response in Boston • Amputations • Vascular Injuries Response in Haiti: ACS Operation Senior Visiting Surgeon Program Giving Back Massive Destruction US Naval Response 2
5/29/2014 Plane Crash Asiana Flight 214 • Departed from Incheon So. Korea for SFO • Boeing 777 aircraft • 307 passengers on board • 70 Chinese high school students en route to summer camp in So. CAL • 11:28 Crashed on final approach 3
5/29/2014 Fate of the Passengers Fate of the Plane • 181 injured passengers • 12 critical: 10 SFGH/2 Stanford • 2 deaths at the scene • Several victims ejected out back • Found on the runway still in seats • 9 hospitals admitted 182 pts. Boeing 777 Held up Well Saturday 11:30 AM @ SFGH • Trauma surgeon on-call for 24 hours • Just finished making rounds • Enjoying a “Breakfast of Champions” • Powerbar and a Latte • “Courtesy call” from ED: small plane crash 4
5/29/2014 JULY 6 TH 2013; 12:30 pm CRITICAL INJURIES: FIRST WAVE • First wave of injured patients arrive • Six critical condition PATIENT INJURIES • “Burns and Inhalation injuries”? • Severe blunt trauma • Two very unstable: taken to the OR within #1 TBI, Facial Burns, Inhalation*, Spine #2 Major intestinal, spine with paralysis; road minutes burns #3 Chest, intestinal, spine with paralysis, mandible, > 30% TBSA road burns #4 Extremity injury with compartment Sx #5 Severe TBI, spine, sternum, ribs #6 TBI, spine, sternum, extremity fractures Keeping track of patients/injuries 3 Waves of Patients Singular focus: Doing the right thing • Total seen at SFGH: 67 • 36 Adults • 31 Children • 36: Admitted 5
5/29/2014 OPERATING ROOM: FIRST 48 HOURS Other Unique Challenges • Blood bank supply: >100 U Crash Related Other emergencies Damage control laparotomy; burns Hand fracture • Judicious monitored use Reduction of fracture; fasciotomy Appendectomy Damage control laparotomy; burns Stab wound to the abdomen Laminectomy; spinal fusion Wrist fracture Spinal decompression Craniotomy Craniotomy Wound debridement Spinal fusion Wound debridement Take-back laparotomy Infection Take-back laparotomy Fracture Fracture Chance Fractures: A Rare Occurrence Chance Plus One • Combination of intestinal injuries and spine fractures • Most commonly seen with lap-belt use • Severe flexion over a fixed object • Most common injuries:spine;chest 6
5/29/2014 Hydrogen Fluoride Inhalation Injury: Potential Toxic Exposure Fire Suppression System • Strange metabolic picture: acidosis, • Fire suppression System: HFC-227/US military hypocalcemia; hypotension • Converts on heating to HF • Persisted for days among survivors • HF: devastating inhalation injury • Toxic exposure: jet fuels, foam, cargo? • Fluoride binds Ca++: liquifaction/cardiac arrthymias • 3/5 soldiers died: survivors treated with nebulized Ca++ Other Major Challenges Emotional Stress: Families • Damage control surgery/multiple take-backs • 2 deaths at the scene • “Road Burns”: wound care/skin grafts • Different Customs and Cultures and Languages • Cardiac arrhythmias, low Ca++, low platelets • Renal failure: CVVH • Intestinal Fistulas • Intra-abdominal infections 7
5/29/2014 Other Unique Problems Media • Children without parents • Accurate and regularly scheduled updates • Families separated by acuity • They will be there for days camped out • No one had been through customs! • One death in our hospital: Black Friday • Homeland security: set up in cafeteria The Tail Goes on for Days/Weeks and Decompression for the Team: July!! Months • Long after the press goes home….. • And the public almost forgets….. • There are still critically injured patients • Require multiple surgeries, rehabilitation 8
5/29/2014 China’s Zhejang Province 9
Recommend
More recommend
