Biomedical Engineering Reference
In-Depth Information
180 minutes to complete! A branching structure
can be completed much faster. Thought needs to be
given to distribution of personnel between multiple
institutions. Many physicians, especially, have
privileges at several hospitals. In a widespread
disaster, there must be an equitable distribution of
providers. Core and supplementary lists are one
possible solution.
In contrast to nursing and anesthesia staff,
surgeons are usually much more dispersed between
their offices, clinics, wards, and various ORs and
ambulatory surgery centers. The Surgical Chief
will need to have a means of tracking down
these physicians. Establishment of protocols that
include surgical office staff who usually know
where their surgeons are working is a prudent step
to rapidly increasing operative capacity. Likewise,
maintaining address lists that can be passed to
law enforcement or military personnel will allow
communication with surgeons event when the tele-
phone system is down.
Critical to good decision-making is accurate and
timely information. Sending a liaison to the Emer-
gency Department to act as the “eyes and ears” of
the Chief of the OR is highly recommended and has
proven effective during mass-casualty simulation
drills at Hartford Hospital. This individual should
be an experienced anesthesiologist. A critical care
trained anesthesiologist would be ideal. This physi-
cian's role is to provide timely information on the
situation, numbers of patients, and types of surgical
cases pending. Although he or she can render assis-
tance when needed, care should be taken not to get
tied-up, unable to perform the primary role. This
individual can also provide valuable feedback to
the Chief of the ED on OR availability, as well. A
dedicated means of communications between the
OR liaison and the Chief of the OR must be avail-
able for this system to work.
Coordination with intensive care units should
occur early to assess bed availability and begin
preparations for ICU expansion. Surgeons and
anesthesiologists trained in critical care are idea to
manage ICU overflow areas, but all anesthesiol-
ogists and many surgeons, while not subspecialty
trained, possess the ability to provide and
supervise critical care patients in an emergency.
CRNAs, most of whom are former critical care
nurses, are also qualified to serve in this role, if
necessary.
Consideration should be given to the establish-
ment of rapid response teams. Most hospitals have
a “code team” which responds to respiratory and
cardiac arrests as needed. These teams usually
consist of an anesthesia provider, a medical physi-
cian (MD or PA), a surgeon (MD or PA), a respi-
ratory therapist, and several nurses. During mass
casualties, it can be expected that there will be a
significantly higher need for these services than
normal. Extra contingency teams, either preposi-
tioned in the triage area and ICUs, or kept in
reserve in the OR, will ease the stress to find
needed personnel quickly.
Perhaps the most problematic aspect of surgical
mass casualty management is the distribution
and management of surgical subspecialists during
a crisis. In normal times, they function as
autonomous providers, either individually or as
parts of small groups. They usually manage their
own patients and cross-cover for their specialist
colleagues. A means of distribution of appropriate
specialists between functional areas of the hospital
(OR, Triage team, hospital wards) must be devel-
oped and tested beforehand by the department of
surgery. Furthermore, a means of assigning cases
must also be established. All surgeons possess
common skills which potentially allow them to
care for injured patients outside of their usual
surgical specialty. For example, a gynecological
surgeon could treat abdominal trauma; a plastic
surgeon could stabilize an open fracture with a
vascular injury in the absence of anyone with
more specific skills. Large numbers of less urgent
injuries can also be anticipated. Surgical teaching
clinics, private medical offices, and nearby ambu-
latory surgery centers can also be recruited to
handle the patient surge. Obviously, prior planning
is essential to success of this model.
It should not be forgotten that even during
mass-casualty events, routine surgical emergen-
cies continue to occur and will need to be
addressed (acute appendicitis, wound dehiscence
and infection, emergency caesarian section, etc.).
As a crisis prolongs, there will be an increasing
