European Journal of Trauma and Emergency Surgery

Focus on Disaster Medicine

Mass Casualty Event During a Musical Parade: Lessons Learned Michael Bemelman, Luke Leenen1

Abstract Objective: In the Netherlands, major incidents are sparse, and so there is a general feeling of a relatively low risk. Upon evaluating multiple casualty events (MCEs) in the Netherlands over the last 60 years, it is worth noting 39 major events. Our objective was to report the experiences from a mass casualty incident in an urban area, performing a critical evaluation of the response and outcome related to the scenario in order to learn from our past and to train for the future. Materials and Methods: In a retrospective patient record analysis we collected all of the data concerning an MCE we encountered in August 2006. Results: There were 21 casualties at the scene. Of our 19 patients, 12 were seen in the crash room. The average age of the patients was 30 years (range 22–53). In all, 87 X-rays, 1 ultrasound and 15 CT scans were performed. Four patients were admitted: ten patients received definitive wound treatment in the ED. Psychological support was given to all patients. One patient died three days later. Conclusion: Triage supported by one person and two trauma teams worked well. The amount of over- and undertriage was in line with the literature. Numbering the patients worked well but also caused enormous problems with the supporting facilities. Centralizing the trauma care yielded certain advantages; however, we must respect our surge capacity of 20 patients. When the number of patients surpasses 20, an alternative plan must be followed. This event has been an eye-opener for our organization; it has given us new tools to prepare for a potential new disaster. Key Words Mass casualty Æ Disaster Æ Managing

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Eur J Trauma Emerg Surg 2008;34:451–6 DOI 10.1007/s00068-008-8801-6

Introduction Depending on the amount of casualties arising from multiple casualty events (MCE), medical institutions are challenged to degrees ranging from a slight strain on the available resources to the complete depletion of medical assets. The most commonly used scheme for disaster evaluation is based on the scale of the resources needed to cope with the event. Level 1 is managed locally by expanding the existing resources. For level 2, resources are provided regionally and exceed the local supply. Level 3 are true MCEs – mostly caused by nature – and are dealt with using resources from the entire country or even from beyond the borders of the country [1]. The overall worldwide incidence of MCEs or disasters is increasing. This is mainly due to the increasing number of terrorist acts in recent years [2]. In the Netherlands, major incidents are sparse, and so there is a general feeling of relatively low risk; however, the three most deadly misconceptions in dealing with MCEs are: (1) ‘‘it will not happen here,’’ (2) ‘‘it will not happen to me,’’ and (3) ‘‘someone else will take care of the problem’’ [3]. Upon evaluating MCEs in the Netherlands over the last 60 years, it is worth noting that 39 major events have occurred (Table 1), with an average of 59 (0–947) wounded and 67 (2–1,836) fatal casualties. Statistically speaking, there is a chance of being confronted with an MCE every two years in the Netherlands.

Department of Surgery and Trauma, University Medical Centre Utrecht, The Netherlands.

Received: September 15, 2007; revision accepted: October 2, 2007; First Published on January 29, 2007. Doi 10.1080/15031430701688178 Published Online: September 26, 2008

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Bemelman M, Leenen L. Mass Casualty Event During a Musical Parade

Table 1. Overview of all recorded disasters in the Netherlands since 1946. Date

Event

No. wounded

No. fatal

7.10.1946 14.11.1946 17.1.1947 24.3.1947 12.2.1950 1.2.1953 23.8.1954 29.9.1954 2.4.1961 8.1.1962 15.6.1965 2.6.1966 25.6.1967 20.1.1968 12.12.1968 24.10.1970 2.2.1971 8.12.1972 28.9.1971 25.8.1972 7.11.1972 4.5.1976 9.5.1977 3.1.1980 6.11.1981 16.12.1983 6.11.1990 14.2.1991 8.7.1992 16.9.1992 4.10.1992 22.12.1993 30.1.1995 15.7.1996 25.9.1996 25.2.1999 13.5.2000 1.1.2001 26.10.2005

Airplane crash in school, Apeldoorn Airplane crash at Schiphol, Amsterdam Explosion at gunpowder factory, Muiden Mine disaster, Brunssum Shipwreck, Den Helder Flooding, Zeeland, South of Holland Airplane crash, North Sea, Bergen Bus accident, Valkenburg Tanker explosion, Rotterdam Train disaster, Harmelen Schipfire Ronastar, Botlek Explosion at gunpowder factory, Muiden Tornado, Chaam Explosion, Shell oil tank, Pernis Explosion, oil tanker Diana, Amsterdam Fire at psychiatric institute, Wagenborgen Fire at elderly home, Rolde Explosion at gunpowder factory, Muiden Hotel fire, Eindhoven Pile-up collision, Prinsenbeek Explosion, DSM, Geleen Train disaster, Schiedam Hotel fire, Amsterdam House fire, Rotterdam Airplane crash, Moerdijk Fire Casa Roso, Amsterdam Pile-up collision, Breda Explosion at a fireworks factory, Culemborg Explosion Cindu, Uithoorn House fire, Den Hage Bijlmer disaster, Amsterdam Flooding, Limburg Flooding, Gelderland Airplane crash, Eindhoven Airplane crash, Den Helder Legionella contamination, Bovenkarspel Fireworks explosion, Enschede Pub fire, Volendam Jail fire Schiphol, Haarlemmermeer

5 0 ? ? 0 ? 0 7 30 54 0 20 32 85 ? ? ? 18 19 14 109 50 57 ? 0 16 28 15 11 ? 25 – – 7 0 0 947 90

23 26 17 13 11 1,836 21 19 7 93 16 0 7 2 13 12 13 2 11 13 14 24 33 11 28 13 10 2 3 11 43 – – 34 32 32 23 14 11

The most disastrous incident was the flooding of Zeeland in 1953, with 1,836 deaths and an uncountable number of wounded. The floods of Limburg and Gelderland were solely environmental disasters. No fatal casualties were recorded

In general, the sudden surge of casualties in an MCE presents two challenges. The first is the logistic challenge: a large number of casualties need to be processed through the system. The second challenge is the medical challenge: how can we provide the greatest level of care for the greatest number of patients [4]? Preparation is essential to cope with these challenges. The only way to prepare for these events is to learn from our past and try to train for

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the future. Therefore, we analyzed our performance during the management of an MCE we encountered in August 2006.

Description of the Incident During the annual summer festival in the city of Utrecht, boats parade along the canals, accompanied by music.

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Bemelman M, Leenen L. Mass Casualty Event During a Musical Parade

Figure 1. 3D reconstruction of the CT scan of the first patient with facial injury. Most of the face was torn off and dislocated to the left.

On August 6, 2006 at 21:55 our emergency department was called and informed that a disaster had happened during the festival; the first report was that ‘‘a bridge had collapsed.’’ Dispatch requested the deployment of our Mobile Medical Team (MMT) for assistance with a patient with a serious facial injury. The total number of casualties was not known at that time. The on-call trauma surgeon was called in and the mobile team was dispatched within 10 min. However, due to the extent of the facial injury, the ambulance

Figure 2. Photograph taken shortly after the staircase collapsed (arrow). The staircase partially collapsed onto the boats, with spectators lying beneath the stairs.

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personnel decided not to wait for the MMT and performed a scoop and run. At 22:07, the first patient arrived at the emergency department at the same time as the trauma surgeon. The patient underwent a primary survey in the crash room where, due to his facial injury, he was intubated immediately and resuscitated (Figure 1). The patient remained hemodynamically stable and was sent for CT scan and afterwards to the ICU to wait for his operation. Due to the uncertainty regarding the other casualties, the operation was not started immediately. During the primary survey of this first patient, rumours that ‘‘a stadium or bridge had collapsed,’’ ‘‘bodies were floating in the canal’’ and that there were ‘‘more than one hundred casualties’’ started to reach the hospital. Based on these reports, all on-call surgical and anesthesiological staff were alerted and contact was made with the medical officer at the scene. At 22:15 the official report was that a staircase with spectators had collapsed onto a crowd (Figure 2). Two casualties were taken to other hospitals but there were still 14 casualties at the scene: three prio 1, five prio 2 and six prio 3 (see below for explanations of these categories). We were asked whether we could cope with all of the patients, which we confirmed. At this time the entire team consisted of three staff surgeons, two staff anesthesiologists, three surgery registrars, two anesthesiology registrars, two emergency department (ED) doctors, one neurologist, six nurses and one radiologist with two technicians. In anticipation of the large number of casualties coming our way, we devised a specific set-up (Figure 3). The trauma supervisor would perform triage at the entrance to the ambulance. The trauma supervisor was assisted by one registrar who marked the patient with a number on the chest and registered the injuries found. Two trauma teams were formed, each consisting of a registrar in anesthesiology, a registrar in surgery and two nurses. The first trauma team was meant to perform a fast primary survey in the crash room and a chest X-ray and leave the crash room as soon as possible to facilitate the care of the next patient. The second team evaluated the next patient, enabling the first team to stay with their patient before taking care of the third, and so forth. Two senior surgeons supervised both teams. The resident assisting the trauma supervisor screened all of the patients after the primary survey, recording all of the findings concerning diagnosis and investigations performed. Furthermore, psychological support was requested for the patients, and so a crisis team of three psychologists was called in.

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Bemelman M, Leenen L. Mass Casualty Event During a Musical Parade

Figure 3. A schematic representation of the emergency department with the available beds and patient flow. On the left side, the ambulance delivers the patient. Triage was performed here before sending the patient to the crash room, beds 3–5 with monitors, or the normal treatment rooms on the right.

Bed 2

5 Beds

10 Beds

Bed 1

Triage

Bed 4

In the period from 22:07 until 23:20, 19 patients were seen: 1 prio 1, 3 prio 2 and 15 prio 3. This, together with the two patients transported to the other hospital, made a total of 21 casualties at the scene. Of our 19 patients, seven T3 patients were primarily seen in normal treatment rooms by the ED doctors. Twelve patients underwent their primary survey in the crash room. At approximately 22:45, contact was made with the medical officer at the scene, who confirmed that the patient count remained at 21, and that the patients awaiting transportation consisted of only T2 or T3 patients. Because no additional critical patients were expected, and we still had three ORs standing by, the patient with the facial injury was sent for operation. After screening all patients, a short debriefing was held and the diagnosis and treatment plans were discussed. Further investigations and treatment were prioritized based on the injuries of every patient. Overview of Findings and Diagnostics The average age of the patients was 30 years (range 22–53). During the diagnostic procedure, 87 X-rays, 1 ultrasound and 15 CT scans were performed. Four patients were admitted: one patient with the facial injury, two patients with a spine fracture, and one patient with a skull fracture with an impression of a bone fragment. Ten patients received definitive wound treatment in the ED and were discharged. The psychological support team counseled all patients and most relatives and friends. Many received an appointment for the outpatient clinic for further follow-up.

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Bed 3

Crashroom

Bed 5

The last patient received treatment at 1:00 am in the ED. The first patient with serious facial injury underwent a 4 h reconstruction operation of his face. Unfortunately, the patient died three days later due to devastating cerebral injury.

Discussion The reported event appeared in a classic way: sudden, unexpected, unpredictable and random. Our response also corresponded to the four recognized phases [1]. First there was chaos: the mechanism contributing to the event was not clear and the amount of casualties was initially unknown. During this phase, the first reports of casualties were greatly overestimated – ‘‘more than one hundred.’’ This is a well-known phenomenon, especially in man-made disasters, showing that the initial estimation is higher than the true number of victims. After 20 min the paramedics at the scene had eventually obtained an adequate estimate of the number of victims. The second phase, response, is defined by the response of the emergency services: the deployment of the ambulances, MMT, police and fire brigade at the scene, and the installation of the trauma teams at the hospital. The third phase, recovery, is defined by the actions taken by these emergency services and trauma teams. However, this phase does embrace more than only taking care of the patients; it also means cleaning up at the scene, restoring infrastructure, and providing post-traumatic psychological support. The fourth and final phase, mitigation, is characterized by evaluating the event and taking precautions

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Bemelman M, Leenen L. Mass Casualty Event During a Musical Parade

for the future; for instance, in our case all staircases in the city were checked and were replaced as necessary. The initial field triage during this event had a considerable overtriage; this is a well-described problem. Overtriage rates of 8–80% have been reported in the literature [5, 6]. The danger of overtriage is that the limited resources will be exhausted for the wrong patients. The opposite problem, undertriage, leads to unnecessary deaths because critically ill patients are not recognized and are assigned to a less urgent scale. In order to reduce undertriage to almost zero, an overtriage of 50% is accepted [2]. In our case, we had an overtriage rate of 50%, and no undertriage. When the amount of casualties exceeds the medical resources, triage is the key to dealing with the incident successfully. The basic principles for triage are: the triage officer should be a senior traumatologist with a knowledge of the natural course of injuries, available medical resources, casualty volume and medical evacuation capabilities [7]. Although a five-scale triage has been described [5, 6, 8], the most widely used and accepted scale in the Netherlands is the four-scale triage [2, 9]. Prio 1 are patients with life-threatening injuries needing immediate treatment; prio 2 are patients with serious injuries who can tolerate some delay (6 h) in treatment; prio 3 are ambulant patients with minor injuries who, in general, can be treated by physician assistants; prio 4 are patients who have died or who are not expected to survive. By numbering the patients, we quickly created a simple system to identify our patients; keeping things simple is one of the main tools for dealing with disasters [10]. Nevertheless, this created considerable problems with the supporting facilities in our hospital, e.g., laboratory and radiology staff who could not cope with the numbers we were using. This problem was solved by calling IT personnel who came to the hospital to convert the data to the regular system. What seemed a very simple tool proved to be rather complex in the end. In the future, we will use predefined anonymous casualty numbers that are recognized by the other departments. The use of one person who registered all of the findings for the patients proved to be a very valuable and simple tool. The knowledge that all important data were collected by one person who had solely this purpose gave the triage officer a peace of mind that enabled him to concentrate more on distributing the patients correctly. Subsequently, the data could be presented in the debriefing, giving a quick and complete overview of all the casualties.

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The use of two teams who initially stayed with the patient after switching with the other team in the crash room worked well. It created just enough extra time to allow the analyses of the patient to be completed and to plan the diagnostic and therapeutic pathway. During the first communication with the field officer, we were asked if we could cope with all of the patients. It is generally accepted that casualties in an MCE are spread among the different hospitals. This is called leap-frogging [1], and is devised to prevent one facility from being overwhelmed. The trauma surgeon in charge made a controversial decision based on the amount of personnel at his disposal. The disaster happened during the shift change of the first aid personnel, which gave us double the amount of available nurses. Based on other disasters, it is accepted that approximately 10–15% of the total casualty count will have serious injuries requiring immediate treatment [6]. In retrospect, in our case and with 21 casualties, this means that we could have expected 2–3 patients requiring immediate treatment. This is exactly the number of emergency operation rooms that were available at short notice. Apart from pushing the resources of our ED to the limit, our controversial decision revealed some advantages. Our strategy partially relieved the police and fire department at the scene of having to obtain secure routes to multiple hospitals – they only had to secure one route. It also meant that the drivers became familiar with the route, which enabled fast transport. These aside, we encountered another unexpected advantage concerning the psychological aspects of the patients, families and friends. The fact that all patients were concentrated in one facility provided a situation in which the casualties could give each other support. This in turn resulted in a disciplined and well-controlled situation among the victims. Of course, we have to realize that this is only possible within the surge capacity of our first aid. If the number of casualties exceeds our capacity, it is obligatory to leap-frog. Based on the amount of room available in the ED, we can conclude that approximately 20 patients is the limit for our ED. During the diagnostic procedures, an impressive number of X-rays were carried out. In a disaster setting, it is essential to minimize the use of support resources, to prevent premature depletion of these resources [4, 10, 11]. The first impression may be that the amount of X-rays was too high; however, initially a chest X-ray was only done during the primary survey. The additional X-rays were done after completing the initial assessments of all patients.

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Conclusion In general, the set-up with a triage officer at the entrance, supported by one person for registration and two trauma teams, worked well. The amount of overand undertriage was acceptable and in line with the literature. The use of one person for the registration proved to be a valuable asset in keeping a complete overview of the situation and will be used in the future. Numbering the patients worked well for the trauma teams, but caused enormous problems with the supporting facilities; in the future predefined numbers will be used. Centralizing trauma care proved advantageous with respect to securing the route to the hospital and had a psychological advantage for the victims. We must, however, respect our surge capacity of 20 patients. When the number of patients surpasses 20, an alternative plan must be followed. In our hospital, a dormant major incident hospital is available, which can be opened if the number of prio 1 casualties is six or more. Because the limits were approached but not exceeded during this incident, this alternative was not initiated. This event has been a valuable lesson and eyeopener for our organization; it has given us new tools to work with in preparing for a potential new disaster. One should realize, however, that incidental experiences like this will not be enough to prepare for future events. Education and training are critical for adequate preparedness [10, 11]. In this respect, we must perform frequent drills and exercises. This does not always mean expensive and complex real-time exercises; in fact, recent developments make it possible to train medical staff for disasters with relatively simple computer models [10, 11]. Also, courses like hospital MIMMS and the Emergotrain system provide excellent means to prepare for exceptional events. With our historically calculated chance of an MCE every two

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years and the ever-increasing risk of terrorist acts, we are obliged to invest in such training facilities – failing to prepare is preparing for failure.

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Address for Correspondence Michael Bemelman, MD Department of Surgery and Trauma University Medical Centre Utrecht Heidelberglaan 100 3584 CX, Utrecht The Netherlands Fax (+31/30) -2505459 e-mail: [email protected]

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