Mass critical care

Earthquakes

Earthquakes are a model of a disaster that results in significant mortality, as can be seen in Fig. 168.1 . A homogeneous population well trained in both basic trauma and life support and the architectural design of the housing and public facilities of the stricken area are the two major determinants of outcomes for earthquake victims. The massive earthquakes in recent years in Turkey, Taiwan, Sumatra, Kashmir, Sichuan, and Haiti have shown us that a sound engineering design for earthquake resistance in civil structures such as schools and hospitals has a major impact on outcomes. In addition, urban earthquakes generate massive fiscal impact on the world in terms of reconstruction grants provided by wealthier countries for devastated urban areas. Moderately destructive earthquakes in the developing world usually cost up to $10 billion in reconstruction; the needs of developing countries with urban earthquakes may cost an order of magnitude more.

Despite extensive experience and published literature dealing with medical response to earthquakes, the earthquake in Haiti shows that we are frequently doomed to relearn the lessons forgotten.

The Haiti earthquake occurred on January 12, 2010, and was of magnitude 7.0 on the Richter scale, resulting in some 230,000 mortalities and 1.5 million homeless. Let us consider first the military medicine response delivered, especially in the face of continuous exposure of the military medicine establishment to mass-casualty management in the wars in the Middle East.

Responders from the very experienced Israel Defense Forces (IDF) were air-deployed within 48 hours of the Haiti earthquake. This team has had extensive experience over the years with international response and consists of 230 people. The team unpacked and built their portable hospital within 8 hours, and during 10 days of operation treated more than 1100 patients in a facility designed to provide 60 inpatient beds, including 4 intensive care beds and one operating room. Most of the first wave of casualties presented with crushed limbs with open infected wounds, and the later arrivals presented with sepsis and poor chance of outcome. Despite the repeated experience from prior earthquakes showing that victims of crush syndrome and acute renal failure require emergency dialysis to prevent death, this facility relied on other international teams for dialysis. Their major dilemmas were practical implementation of the triage algorithm by military personnel to a civilian population. The simple priorities were urgency, resources available, and probability of saving life. Patients with brain injury, paraplegia caused by spine injuries, or a low Glasgow Coma Scale score were immediately transferred to other facilities, because no neurosurgical capabilities were available. A triage panel of three senior physicians relieved individual physicians of personal accountability. Half of the intensive care capability was always dedicated to postoperative care, with the remaining two beds used for prolonged intensive care; only patients who were expected to stabilize within 24 hours were placed in these beds. The very early discharge policy permitted this facility to treat more than 100 patients per day.

Second, let us consider the response of the US military, which had a considerable portfolio on providing disaster relief in catastrophic events such as the Indonesian tsunami that devastated Sumatra. The US Naval Ship (USNS) Comfort, one of the hospital ships of the Military Sealift Command, was deployed as part of the mission termed Operation Unified Response . It started accepting casualties within 7 days of the earthquake. The ship is a 1000-bed facility that includes 75 ICU beds, blood bank, hemodialysis, pathology, physical therapy, morgue, and radiology with computed tomography and ultrasonography capability. It is staffed with 1000 active-duty US medical personnel, including three physician intensivists, and it was allocated to stay up to 6 months. ^, The first wave of casualties were critically ill trauma patients airlifted from field hospitals by US helicopters. Within 72 hours, the Comfort admitted 254 patients, and the census rapidly increased to 430, more than a third of them pediatric cases. A team of six internists provided 24/7 coverage. Dozens of patients underwent mechanical ventilation simultaneously; the open-bay design did not allow for isolation, and the nurse-to-patient ratio was about 7:1. A large volume of hemodialysis was provided to patients with crush syndrome, leading to rapid depletion of dialyzers and dual-lumen dialysis catheters. The discharges exceeded admissions in about 2 weeks, and after a total of 629 admissions, the ship completed its mission. Although the standard of care exceeded community expectations, the US Navy personnel followed naval protocol and standards.

Third, let us consider the relearning of the lessons of civil-military collaboration in disaster response. A volunteer medical team with civilian personnel under the auspices of the international medical corps flew to the Dominican Republic and reached the Hôpital de l’Université d’Etat d’Haïti in Port-au-Prince after a long bus ride on January 17, 2010. There were more than 800 injured in the partially destroyed facility, with the primary diagnoses being crush injuries, compartment syndrome, infected fractures, and hemorrhagic shock. One physician and one nurse were covering up to 80 critically ill patients in the wards. An aftershock of 5.9 magnitude resulted in an exodus of casualties and higher rates of heat stroke in dehydrated hypovolemic patients exposed to tropical temperatures. Destruction of the prison system released 4000 criminals into the community, and no security was available until the arrival of a US airborne infantry regiment. With the arrival of the USNS Comfort on January 20, evacuation of the most critically ill patients started, but a triage list developed rapidly, with ship facilities accepting preferentially complicated injuries, obstetric patients, and maxillofacial injuries. Patients with pelvic fractures, closed head injuries, complete spinal cord lesions, and mechanical ventilation cases were of too high acuity for the USNS Comfort . Family structures became fragmented, as separation of children from parents occurred. Yet the collaboration of civilian and military medical personnel was considered a success.

Next, let us consider the experiences of academic centers delivering care to victims of the Haitian earthquake onsite. The Miller School of Medicine of the University of Miami and Project Medishare had the advantage of long experience of collaboration with Haiti and close geographic proximity, and they were able to provide emergency relief within 20 hours. Within 8 days, they were able to establish a field hospital at the city airport, and by January 21, 140 patients were transferred into the upgrade facility. The well-organized command center with satellite links for telephone and Internet access was available. A joint adult-pediatric triage team accompanied by Creole-speaking medical staff of Haitian origin was used. Multiple surgeries were performed under local peripheral nerve blocks, with guillotine amputations being frequent. The highest-acuity patients were transferred to the IDF field hospital or the USNS Comfort . The command center eventually provided psychiatrists to manage the posttraumatic stress syndrome and a buddy system for the follow-up support.

Finally, one must consider the critical care response from New York City. Although many small teams and a large volume of supplies were dispatched, an organized response was delivered under the leadership of Dr. Ernest Benjamin, division chief of critical care in surgery at Mt. Sinai Hospital. Dr. Benjamin arrived in Port-au-Prince 3 days after the initial event, and after rapid assessment of needs and resources, organized the deployment of the 27-member critical care team to his home country, which arrived on January 20. The team remained onsite for 2 weeks and was responsible for postanesthesia and postoperative care delivery, with Dr. Benjamin being deputized as the director of critical care and recovery at the national hospital. The home institution effectively secured anonymous donations of private jets able to transport the team personnel and some 3000 pounds of medical supplies per flight. The team delivered intensive care with minimal technology but with kindness and dignity toward the suffering population. This was a truly integrated response with both language and cultural sensitivities and capabilities, which are very important in catastrophic situations that will take decades for the local population to recover from.

Experience in managing catastrophic international disasters continues to accumulate with unfortunate regularity. The preceding discussion suggests that combinations of dialysis, orthopedic surgery, pediatric trauma, security, transportation, posttraumatic stress treatment, and cultural and language sensitivities are crucial in earthquakes. Disasters produce well-defined syndromes with well-defined mortalities. It is the recovery phase that continues to require persistence and improvement. One of the most experienced managers and thought leaders in disaster management, Dr. Eric Noji, enumerated the most important factors in public health after disasters: environmental health, epidemic management, immunization, controlling the spread of human immunodeficiency virus/acquired immunodeficiency syndrome, management of dead bodies, nutrition, maternal and child health, medical services, and thorough public health surveillance. It is a common error to deliver a few weeks of heroic quality care and then abandon the population to the ravages of destroyed infrastructure, including public health organization.

Volcanic eruptions

A volcano is a hill or a mountain built around a vent that connects with reservoirs of molten rock below the earth’s surface. Different types of eruptive events occur, including pyroclastic explosions, hot ash releases, lava flows, gas emissions, and glowing avalanches (gas and ash releases). Lava flows tend not to result in high casualties because they are easily avoidable. The “composite” type of volcano is associated with a more violent eruption from within the chimney. These eruptions are associated with air shock waves, rock projectiles (some with high thermal energy), release of noxious gases, pyroclastic flows, and mud flows (lahars). Pyroclastic flows and lahars are often fast moving and are the main cause of damage and deaths from volcanoes, as evidenced by the small eruption of the Nevado del Ruiz in Colombia that killed more than 23,000 people. The release of ash and its subsequent rapid buildup on building structures can be substantial, causing them to collapse within hours. Ash is also responsible for the clogging of filters and machinery, causing electrical storms and fires, and interfering with communications. Ash is a main cause for respiratory-related syndromes and conjunctival and corneal injury. A variety of toxic gases (e.g., carbon dioxide, hydrogen sulfide, sulfur dioxide, hydrogen chloride, hydrogen fluoride, and carbon monoxide [CO]) are released during eruptions, causing bronchospasm, pulmonary edema, hypoxemia, cellular asphyxiation, topical irritation of skin and other mucosal surfaces, and death. Damage to health infrastructures and water systems can be severe. Problems related to communication (ashes cause serious interference) and transportation (poor visibility and slippery roads) are likely. On the basis of the initial assessment, various needs can be anticipated. Reducing the risk for vulnerable groups of being exposed to ash, raising awareness of the risk associated with ash (health and mechanical risk), and maintaining food security conditions over the long term (lava, ash, and acid rain cause damage to crops and livestock) can help limit suffering.

Hurricanes, cyclones, and typhoons

The large rotating weather systems that form seasonally over tropical oceans are variously named, depending on their geographic region of origin. They consist of a calm inner portion called the eye, surrounded by a wall of rain and high-velocity winds. On the basis of central pressure, wind speed, storm surge, and potential destruction, their severity is graded on a scale of 1–5 (Saffir-Simpson scale). They are among the most destructive natural phenomena. Cyclones during 1970 and 1991 in Bangladesh claimed 300,000 and 100,000 lives, respectively, because of flooding. The most devastating hurricane ever to hit the United States occurred in 1900 at Galveston, Texas. It claimed an estimated 8000–12,000 lives. The greatest damage to life and property is not from the wind but from secondary events such as storm surges, flooding, landslides, and tornadoes. Ninety percent of all hurricane-related deaths occur from storm surge–related drowning. The most common injury patterns include lacerations (during the cleanup phase), followed by blunt trauma and puncture wounds. Late morbidity can be the result of postdisaster cleanup accidents (e.g., electrocution), dehydration, wound infection, and outbreaks of communicable diseases. ^, Data from Hurricane Katrina confirmed data from previous meteorologic events. The leading mechanisms of injuries are fall, lacerations, and piercing injuries, with cleanup being the primary activity at the time of injury. Resources may have to be provided for an extended period after the initial inciting event, and significant resources may have to be provided for patients with chronic medical illnesses. ^,

Floods

There are three major types of floods: flash floods (caused by heavy rain and dam failures), coastal floods, and river floods. Together, they are the most common types of disasters and account for at least half of all disaster-related deaths. ^, The primary cause of death is drowning, followed by hypothermia and injury caused by floating debris. ^, The impact on the health infrastructures and lifeline systems can be massive and may result in food shortages. Interruption of basic public services (e.g., sanitation, drinking water, and electricity) may result in outbreaks of communicable diseases. ^, Another concern is the increase in both vector-borne diseases (e.g., malaria and St. Louis encephalitis) and displacement of wildlife (e.g., poisonous snakes and rodents). ^,

Landslides

Landslides are more widespread than any other geologic event. They are defined as downslope transport of soil and rock resulting from natural phenomena or man-made actions. Landslides can also occur secondary to heavy storms, volcanic eruptions, and earthquakes. Landslides cause high mortality and few injuries. Trauma and suffocation by entrapment are common. Pending an assessment, needs can be anticipated, such as search and rescue, mass-casualty management, and emergency shelter for the homeless. ^,

Pandemic 2009 H1N1 influenza A virus

Pandemic H1N1 2009 is a new strain of influenza A virus that was first identified in Mexico and the United States on March 18 and April 15, 2009, respectively. It originated from the quadruple reassortment swine influenza (H1N1) virus closely related to the North American and Eurasian swine lineage. However, this new virus circulated only in humans, with no evidence of transmission between humans and animals.

Within weeks, the virus quickly spread worldwide through human-to-human transmission. On April 26, 2009, the Strategic National Stockpile of the Centers for Disease Control and Prevention (CDC) began releasing 25% of the supplies in the stockpile for the treatment and protection from influenza. On June 11, 2009, the World Health Organization (WHO) declared the 2009 H1N1 influenza a global pandemic, generating the first influenza pandemic of the 21st century, with more than 70 countries reporting cases of H1N1 infection. By June 19, 2009, all 50 states in the United States, the District of Columbia, Puerto Rico, and the US Virgin Islands had reported cases of 2009 H1N1 infection. More strikingly, the CDC Emerging Infections Program estimated the number of hospitalizations and deaths in people aged 64 years and younger. The virus was most likely to strike children, young adults, and those with underlying pulmonary and cardiac disease. Pregnant women in their second and third trimester were also at high risk. Patients requiring intensive care had a remarkable prevalence of obesity.

Influenza vaccines are most effective not only to prevent but also to mitigate the severity of illness. The pandemic H1N1 influenza vaccine was promptly developed by the WHO and national authorities. A national influenza vaccination campaign was launched in the United States in October 2009, and the first H1N1 vaccine was made available at that time. Despite the rapid response of the authorities, developing countries in the Southern Hemisphere experienced delays and shortages of the vaccines. Thus research and developmental work have been encouraging for developing a “universal” influenza vaccine that could provide efficacious cross-reactive immunity and induce broad protection against different variants and subtypes of the influenza virus.

Data show that about 8% of H1N1 patients were hospitalized (23 per 100,000 population); 6.5%–25% of these required being in the ICU (28.7 per million inhabitants) for a median of 7–12 days, with a peak bed occupancy of 6.3–10.6 per million inhabitants; 65%–97% of ICU patients required mechanical ventilation, with a median ventilator duration in survivors of 7–15 days; 5%–22% required renal replacement therapy; and the 28-day ICU mortality was 14%–40%. Critical care capacity is a key element of hospital surge capacity planning. The proportion of ICU beds occupied by patients with H1N1 varied. In Australia and New Zealand, it peaked at 19%, whereas in Mexico, many patients required mechanical ventilation outside the ICUs. To match the surge capacity with increasing ICU demands during a pandemic is a difficult task, because uncertainty exists for many of these parameters. The disease brought a surge of not only critically ill patients but also patients who required prolonged mechanical ventilation and ICU management. Hospitals should maximize the number of ICU beds by expanding ICUs and other areas with appropriate beds and monitors. Elective procedures should be minimized when resources are limited, and critical care capacity should be augmented.

Safe practices and safe respiratory equipment are needed to minimize aerosol generation when caring for patients with influenza. These measures include handwashing and wearing gloves and gowns; using N95 respirators, which reduce the transmission of epidemic respiratory viruses; staff training in personal protective equipment (PPE); minimizing the use of bag-mask ventilation and disconnection of the ventilator circuit; and avoiding the use of heated humidifiers on ventilators, Venturi masks, and nebulized medications.

When the number of critically ill patients far exceeds a hospital’s traditional critical care capacity, modified standards of critical care to provide limited but high-yield critical care interventions should be the goal to accommodate far more patients. Triage criteria should be objective, transparent, and ethical and applied justifiably and publicly disclosed. The ICU triage protocols for pandemics should only be triggered when ICU resources across a broad geographic area are or will be overwhelmed despite all reasonable efforts to extend resources or obtain additional resources. The Sequential Organ Failure Assessment score, though not validated, has been proposed to determine qualification for ICU admission during mass critical care.

The major characteristics of 2009 H1N1 influenza A infection were the rapidly progressive lower respiratory tract disease leading to acute respiratory distress syndrome (ARDS) with refractory hypoxemia. A substantial number of H1N1 ICU patients required advanced ventilatory support (ranging from 1.7% to 11.9%) and rescue therapies, including high levels of inspired oxygen and positive end-expiratory pressure (PEEP), inverse ratio ventilation, airway pressure release ventilation, neuromuscular blockade, inhaled nitric oxide, high-frequency oscillatory ventilation, extracorporeal membrane oxygenation (ECMO), volumetric diffusive respiration, and prone-positioning ventilation. ^{, , ,} ECMO was successful in managing refractory hypoxemia in these patients in two studies. The median durations of therapy and survival rates to ICU discharge were 10 days and 15 days—71% and 67%, respectively. ^,

As of March 13, 2010, the CDC estimates of 2009 H1N1 influenza cases, hospitalizations, and deaths in the United States since April 2009 were 60 million cases, 270,000 hospitalizations, and 12,270 H1N1-related deaths, respectively. The virus did not mutate during the pandemic to a more lethal form. Widespread resistance to oseltamivir did not develop. The WHO declared an end to the H1N1 pandemic on August 10, 2010. The H1N1 virus is expected to take on the behavior of a seasonal influenza virus and to circulate for some years.

Ebola outbreak (2014–2016)

In late 2013, Ebola virus disease (EVD) became an international disaster of crisis proportion in West Africa, primarily in the countries of Liberia, Sierra Leone, and Guinea. This became the largest outbreak of EVD in history, greater than all previous epidemics combined, with a total number of 28,616 suspected cases and 11,310 deaths, all in the aforementioned countries; additionally, there were 36 suspected cases and 15 deaths outside of those countries. This point cannot be overemphasized: although the mortality of confirmed cases has been documented to be as high as 68% in the affected nations of West Africa, if patients are quickly recognized and given appropriate aggressive supportive care, the case fatality ratio drops dramatically. There are, to date, no specific approved pharmacotherapeutic interventions available to cure EVD; however, the VSV-EBOV Ebola vaccine has been shown to be safe and highly effective and was fast-tracked to use by the epidemic. The dramatically decreased case fatality ratio noted in developed nations is related to strict enforcement of isolation, hygiene, and use of supportive care.

With regard to the scope of the issue, the CDC predicted that the number of confirmed EVD cases would double approximately every 20 days, with estimated cases ranging as high as 1.4 million. From a mass-casualty perspective, it rapidly became clear that the aforementioned nations of West Africa did not have an adequate governmental infrastructure to create Ebola treatment units, nor were they able to strictly implement the necessary public health infrastructure of hygiene and isolation. At that point, important nongovernment organizations (NGOs) such as Médecins Sans Frontières, Red Cross, WHO, and worldwide military support intervened to create the lacking infrastructure. ^,

From the initial outbreak to December 2015 the WHO, with its partners, achieved unprecedented progress in combating the disease. From an environment of minimal diagnostic tools and scant medical personnel emerged 24 rapid diagnostic laboratories, a phase III trial of the VSV-EBOV vaccine, and a global network of thousands of healthcare professionals ready for rapid deployment in the Foreign Medical Teams (FMTs) Registry. These efforts were achieved through a three-phase approach. Phase 1 (August–December 2014) was of a rapid scale-up of the response. This consisted of increasing the number of treatment centers, rapidly hiring and training teams in safe dignified burials, empowering social mobilization, and launching the UN Mission for Ebola Emergency Response (UNMEER). Phase 2 (January–July 2015) emphasized increasing capacities for case finding, contact tracing, and community engagement. Phase 3 (August 2015–2016) focused on interrupting all chains of transmission. This was achieved by rapidly identifying all cases, contacts, and deaths; establishing safe facilities; developing multidisciplinary response teams; incentivizing local communities to comply with public health goals and local response; supporting survivors; and ending human-to-human transmission of the virus in the affected populations and countries.

When patients with EVD first started appearing in the United States, it required some fundamental reevaluation of the role of the CDC in such events. Normally the agency is tasked with providing information and guidance to both healthcare facilities and state and local health departments, but given the rapid, complex, and international nature of this particular epidemic, the routine approach of having state health departments manage these situations with oversight by the CDC was not particularly effective. The president created the role of “Ebola Response Coordinator” to help provide a coordinated federal oversight for the US approach to this disease. In addition, the CDC created Ebola “SWAT teams” that were sent in real time to appropriate locations to ensure appropriate resource allocation to hospitals, and, if necessary, transfer patients with suspected EVD to properly equipped regional centers. For example, in New York State, the governor mandated that eight medical centers (five in New York City alone) were to be designated centers for patients with suspected EVD and that all hospitals needed to develop strategic plans for initial management of patients with suspected EVD.

The CDC’s response to the Ebola virus epidemic was the largest in the agency’s history, in an area of the world with little operational experience. The CDC developed relationships with health ministries of local West African governments, US governmental agencies, and NGOs and developed a Global Rapid Response Team in June 2015.

Interestingly, despite the extremely low number of actual patients who were diagnosed with EVD in the United States, a challenging problem was media management; an initial lack of clear federal leadership rapidly led to confusion, fear, and misinformation being spread throughout the country. As an example, the PPE recommendations from the CDC were not aligned with the recommendations from the WHO. This left hospital officials confused about the best manner in which to protect their employees. Eventually, the recommended approach became more aggressive, and there was agreement between the CDC and WHO regarding PPE. ^,

In conclusion, major important lessons were learned during the outbreak of EVD, many of which have clear-cut implications for future epidemics. First, it became clear that for many developing nations, the existing governmental infrastructure is inadequate to provide appropriate containment, public health infrastructure, and treatment facilities; early aggressive intervention by a combination of NGOs and militaries is required to quell the spread. Second, the standard existing paradigm of local and state health agencies providing adequate resources, information, and guidance to health facilities may not be adequate; a rapid top-down federalized approach may be required. Clearly, more resources must be allocated to our federal and international health agencies to prepare for such possible events in the future.

Transportation disasters

Transportation accidents can produce injuries and death similar to those seen in major natural disasters. Some of the largest civilian disasters in North America have been related to the transportation of HazMat. Motor vehicle accidents, railway accidents, airplane crashes, and shipwrecks are some of the common transportation accidents. They cause a wide range of injuries, including multiple trauma, fractures, burns, chemical injuries, hypothermia, dehydration, asphyxiation, and CO inhalation. The hazard risk to a healthcare facility increases with its proximity to a chemical plant or highway, and such factors should be considered in the emergency preparedness plan of a hospital.

Weapons of mass destruction

Weapons of mass destruction (WMDs) are those nuclear, biological, chemical, incendiary, or conventional explosive agents that pose a potential threat to health, safety, food supply, property, or the environment. Since the terrorist attacks in September 2001 and intentional release of anthrax spores in the United States, there is growing concern around the world about the possible threat of chemical, biological, or nuclear weapons being used against a civilian population. The incidence of use of WMD to cause death and injury is rare. However, biological and chemical weapons are relatively accessible, and WMDs are thought to be available to most foreign states and terrorist groups. In response to a WMD incident, healthcare personnel will be called on to manage unprecedented numbers of casualties in an environment of panic, fear, and paranoia that accompanies terrorism. Because most attacks occur without warning, the local healthcare system will be the first and most critical interface for detection, notification, rapid diagnosis, and treatment. The best defense in reducing casualties will therefore rest on the ability of medical and public health personnel to recognize symptoms and provide rapid clinical and epidemiologic diagnosis of an event. This requires that healthcare providers be well informed of potential biological, chemical, and nuclear agents. They must have a heightened index of suspicion and be able to identify unusual disease patterns to determine whether WMDs are the etiologic agents of illness. Physicians will need to practice appropriate surveillance and reporting and develop knowledge of mass decontamination; use of proper PPE; and safety protocols related to a biological, chemical, or radiologic event. Salient characteristics and brief management strategies of different WMD are discussed here.