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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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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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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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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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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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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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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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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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China’s Zhejang Province