Case Writer: Nikita Joshi, MD
Keywords: Mass casualty incident, building bombing, disaster, triage, ethics
Educational Objectives
Medical
- Develop system of triage to optimize patient outcomes in prehospital disaster setting
- Effectively utilize color coded tagging method to assist in categorizing patients
- Develop treatment plans to address immediate emergency conditions per ATLS protocols
Communication
- Maintain team and personnel safety precautions
- Regularly provide updates to incident command center
Case Synopsis
A crowded 3-story commerce building within 4 blocks of the hospital was bombed from the lobby 10 minutes ago. An incident command center has opened and is directing the medical response. Police and fire volunteers have already rescued a few of the victims of the building and have laid them out on the sidewalk. The building is a commercial building with a daycare on the second floor for employees of the building. The victims range from toddlers to middle aged business workers. The medical team is responsible for triaging and formulating evacuation plan for victims. All pertinent information must be relayed to incident command center.
Prioritizes critical initial stabilization action and mobilizes hospital support services in the resuscitation of a critically ill or injured patient and reassesses after stabilizing intervention. | ||
Milestone Level | Milestone to be Assessed | Specific Behavior |
1 | Manages a single patient amidst distractions |
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2 | Task switches between different patients |
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5 | Employees task switching in an efficient and timely manner in order to manage multiple patients |
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8. ABEM Milestone: Multi-Tasking (Task-Switching) (PC8) |
Prioritizes critical initial stabilization action and mobilizes hospital support services in the resuscitation of a critically ill or injured patient and reassesses after stabilizing intervention. | ||
Milestone Level | Milestone to be Assessed | Specific Behavior |
1 | Participates as a member of patient care team |
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2 | Communicates pertinent information to emergency physicians and other healthcare colleagues |
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3 | Ensures transition of care are accurately and efficiently communicated |
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4 | Recommends changes in team performance as necessary for optimal efficiency |
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5 | Communicates with out-of-hospital and nonmedical personnel such as police, media, hospital administrators |
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19. ABEM Milestone: Team Management (ICS2) |
PDF of the case-specific ABEM Milestones (PC 8, ICS 2)
PDF of more detailed scenario description
Critical Actions
- Maintain team safety
- Perform triage based upon MASS and Color Coding system
- Perform lifesaving interventions on patients assigned a red color coding level
- Evacuation of victims based on triage
Learners
- ED residents
- EMS
- EMS students
- Nurses
- Nursing students
- Medical students
Location
Sidewalk outside of bombed building
Patients
- 3 yo girl
- Mother
- Man
- Nonresponsive Man
Special Equipment
- Triage Level Color Coding Cards
Standard Equipment
*Minimal emergency medical equipment will be made available given the pre-hospital location
- Non-rebreather O2 mask
- Oxygen tank
- Back board – spinal immobilization
- Cervical stabilizing collars
- IV fluid
- Scapels
- Syringes
Moulage
- 3 yo girl (manikin or confederate)– soot and dirt on child
- Woman (mother, confederate) – crush injury of lower extremity; using task trainer lower extremity
- Man (confederate) – singed off eyebrows, coughing black material
- Nonresponsive Man (manikin) – amputation of the upper extremity and structural material impaled through chest
Confederates
- Police Officer – gives history of finding mother and child; mentions how he helped the mother out of the building by assisting in the removal of heavy building material that trapped her lower extremity
- 3 yo girl – crying
- Mother – In extreme pain from the lower extremity
- Man – Coughing, complaining of ringing in the ears, insists on immediate medical attention
- Incident Command Center (voice) – asks team for regular updates, will bring resources if asked for by the team; asks the team to list the triage of the patients and discuss evacuation plan; informs team that there might be more bomb explosions
- EMS – arrives to transport victims in order designated by team
Supporting Files / Media
- None
Translation
BP | Blood Pressure |
HR | Heart Rate |
IV | Intravenous |
LOC | Loss of Consciousness |
neg | Negative |
RR | Respiratory Rate |
pt | Patient |
s/p | status post |
yo | year old |
Additional References
- ACEP Policy: Health Care System Surge Capacity Recognition, Preparedness, and Response. 2011.
- Asensio: Current Therapy of Trauma and Surgical Critical Care, 1st ed. Chapter 9 Triage. 2008. Mosby, Inc. affiliate of Elsevier.
- CDC Emergency Preparedness and Response: Mass Casualty Event Preparedness and Response. 2013
- DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med. 2005 Mar 31;352(13):1335-42. PMID: 15800229.
- Kleber C, Cwojdzinski D, Strehl M, Poloczek S, Haas NP. Results of in-hospital triage in 17 mass casualty trainings: underestimation of life-threatening injuries and need for re-triage. Am J Disaster Med. 2013 Winter;8(1):5-11. PMID: 23716369.
- Lee CH. Disaster and Mass Casualty Triage. Virtual Mentor. 2010. 12;6:466-470.