Training Surgeons for Disasters A MASS CASUALTY EVENT IS NOT JUST - - PDF document

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Training Surgeons for Disasters A MASS CASUALTY EVENT IS NOT JUST - - PDF document

Sep 25, 2023 360 likes •460 views

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

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5/29/2014 1 SURGICAL RESPONSE TO DISASTERS

  • M. Margaret Knudson MD, FACS

Chief of Surgery, San Francisco General Hospital and Trauma Center

Training Surgeons for Disasters

“A MASS CASUALTY EVENT IS NOT JUST ANOTHER BUSY NIGHT IN AN URBAN TRAUMA CENTER!” ACS/COT

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

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5/29/2014 2

4 Operating Rooms: 2 pts each Surgical Response in Boston

  • Amputations
  • Vascular Injuries

Senior Visiting Surgeon Program

Response in Haiti: ACS Operation Giving Back

Massive Destruction US Naval Response

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5/29/2014 3

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

Plane Crash

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5/29/2014 4

Fate of the Passengers

  • 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.

Fate of the Plane 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
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5/29/2014 5

JULY 6TH 2013; 12:30 pm

  • First wave of injured patients arrive
  • Six critical condition
  • “Burns and Inhalation injuries”?
  • Severe blunt trauma
  • Two very unstable: taken to the OR within

minutes

CRITICAL INJURIES: FIRST WAVE

PATIENT INJURIES #1 TBI, Facial Burns, Inhalation*, Spine #2 Major intestinal, spine with paralysis; road 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

3 Waves of Patients

  • Total seen at SFGH: 67
  • 36 Adults
  • 31 Children
  • 36: Admitted

Keeping track of patients/injuries Singular focus: Doing the right thing

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5/29/2014 6 OPERATING ROOM: FIRST 48 HOURS

Crash Related Other emergencies Damage control laparotomy; burns Hand fracture 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

Other Unique Challenges

  • Blood bank supply: >100 U
  • Judicious monitored use

Chance Plus One

Chance Fractures: A Rare Occurrence

  • 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
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5/29/2014 7

Potential Toxic Exposure

  • Strange metabolic picture: acidosis,

hypocalcemia; hypotension

  • Persisted for days among survivors
  • Toxic exposure: jet fuels, foam, cargo?

Hydrogen Fluoride Inhalation Injury: Fire Suppression System

  • Fire suppression System: HFC-227/US military
  • Converts on heating to HF
  • HF: devastating inhalation injury
  • Fluoride binds Ca++: liquifaction/cardiac

arrthymias

  • 3/5 soldiers died: survivors treated with

nebulized Ca++

Other Major Challenges

  • Damage control surgery/multiple take-backs
  • “Road Burns”: wound care/skin grafts
  • Cardiac arrhythmias, low Ca++, low platelets
  • Renal failure: CVVH
  • Intestinal Fistulas
  • Intra-abdominal infections

Emotional Stress: Families

  • 2 deaths at the scene
  • Different Customs and Cultures and Languages
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5/29/2014 8

Other Unique Problems

  • Children without parents
  • Families separated by acuity
  • No one had been through customs!
  • Homeland security: set up in cafeteria

Media

  • Accurate and regularly scheduled updates
  • They will be there for days camped out
  • One death in our hospital: Black Friday

The Tail Goes on for Days/Weeks and Months

  • Long after the press goes home…..
  • And the public almost forgets…..
  • There are still critically injured patients
  • Require multiple surgeries, rehabilitation

Decompression for the Team: July!!

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5/29/2014 9

China’s Zhejang Province