Americans have seen their share of devastating attacks and life-or-death catastrophes play out in the news with increasing frequency. Mass shootings at U.S. nightclubs, festivals, churches, schools, businesses; terror attacks in New York City, Boston, San Bernardino and at Ohio State University; a pedestrian bridge collapse; coast-to-coast hurricanes, floods and wildfires — they’ve all left destruction and heartbreak in their wakes.
Headlines remind us that random dangers lurk just about everywhere these days and that has people worried about what’s coming next. But concern is not enough. Level 1 trauma centers like MUSC must be prepared for countless contingencies, assuming at all times that a large-scale event could happen in this community. And while Charleston certainly has not been immune to tragedy, that doesn’t mean the city won’t see more in the future.
While doctors, nurses and administrators in New York, Orlando and Las Vegas never could have predicted that scores of critically injured victims would bombard their halls, chances are the Level 1 trauma centers were prepared to activate their mass casualty protocols.
Kathy Lehman-Huskamp, M.D., director of MUSC Health Emergency Preparedness, said it’s no longer a question of “if” a trauma center is going to be subjected to a mass casualty event, but when. In her experience, practice makes perfect. Specialized centers like MUSC Health are required to conduct preparedness drills regularly, and that tall order falls under her domain.
Drills help trauma centers prepare to respond to emergencies that could result in dozens or hundreds of casualties. MUSC Health, in partnership with entities such as Charleston County Emergency Medical Services, runs mass casualty drills throughout the year to prepare for the possibility of an influx of patients all requiring treatment at once. Friday saw one such drill at MUSC.
A realistic scenario
It’s every parent’s worst nightmare — hearing there’s been a bad accident and not knowing if your child is involved. Scant details surface about a school bus overturning on I-26, carrying 45 kids. There are injuries. EMS alerts MUSC Health. Finally, it’s reported that an SUV driver texting while driving crashed into another car. The school bus couldn’t brake in time and plowed into the collision, flipping on its side and critically injuring between 11 and 15 kids. The other students seem OK, but doctors will need to check them, too. One family had three sons on that bus. Parents’ anxiety was paralyzing.
While this is an all-too realistic scenario, fortunately, this time it was only a drill. The MUSC enterprise conducted the exercise with partners from Mount Pleasant, the Ralph H. Johnson VA Medical Center, City of Charleston Emergency Medical Services and Lowcountry Department of Health and Environmental Control.
Until the last moment when they received the alert, teams had no idea the type of mass event they would be dealing with. Lehman-Huskamp said the drill would test how effectively MUSC Health could execute its mass casualty preparedness plan.
“We need to be ready, able and practiced to receive victims from any numbers of mass casualty events, if God forbid, one like Las Vegas or Boston were to occur.”
On paper, MUSC emergency managers had every contingency accounted for. But how did it play out in real time, with ambulances delivering children on stretcher after stretcher to the MUSC Health Emergency Department?
Avoiding mass chaos during mass casualty
When it comes to avoiding chaos during a mass casualty event, clear protocols are key. The drill, Lehman-Huskamp said, triggers a particular sequence of protocols.
Commonly, she said, Emergency Medical Services is the first group to be involved, especially in larger events. EMS gives an immediate heads-up to the emergency department. The ED has its own paging process that it uses for normal trauma situations, but in a mass casualty event, the call center tacks on another group of people who are critical to this type of incident. She notifies the MUSC Health administrator on call, who gets a quick briefing and determines what next steps are most critical depending on the type of incident. Brenda Dorman, the administrator of the Anesthesia Integrated Center for Clinical Excellence at MUSC Health, was the administrator on call during this drill.
When Dorman got the call, she hit the ground running. First she set up the HEOC, or hospital emergency operation center. She called in additional staff to assist with the emergency response and designated special parking areas. Depending on the type and scope of the crisis, she can activate staging areas for organized operations, including:
A green patient care area in the Medical Library for the “walking well,” who are able to wait to be seen while critical patients are triaged immediately.
A reunification area in the College of Nursing’s Simulation Center for families who are searching for loved ones or information.
A safe area for uninjured, displaced or released children awaiting adult caregivers.
A media area in the Basic Science Building, so the institution can disseminate vital up-to-date information in a timely manner.
Nothing exemplifies MUSC’s ability and willingness to act an enterprise as does its plans for a mass casualty response, Lehman-Huskamp said. “Not only does the response involve the medical center, but it expands into areas of the university that have graciously agreed to help by providing space and personnel.”
The drill alert went out and prepared trauma staff awaited patients in the trauma lot. Registration personnel were present to get patient information quickly. Before the stretchers even arrived, teams had jumped into action. Much like an episode of the popular television show “Code Black,” people worked quickly to assess each patient, triaging multiple casualties at one time and quickly assigning patients to appropriate areas and services.
The trauma triage team fastened color-coded wristbands on patients to alert staff of their status. Green means the person can wait to be seen. Yellow means the patient needs medical help within an hour, possibly two. Red is the most critical, signaling that the patient may need surgery within 10 to 15 minutes. Finally, black bands are placed on the wrists of the people who didn’t survive the incident.
There was a large surgical presence on hand for the drill. Evert Eriksson, a surgical trauma specialist, said he mobilized 21 surgeons for the drill and an additional eight could be there within an hour.
The victims had injuries that ran the gamut from a liver laceration and spleen rupture to a child impaled with a metal pole. The 45-year-old bus driver had a significant brain injury, filling his head with blood. He and two children required immediate surgical care and went to the operating room. Others were sent to the pediatric intensive care unit or the imaging area.
While doctors further assessed victims in emergency department bays and hallways, teams discussed each patient and routed him or her appropriately.
Level 1 — best outcomes
Known as the gold standard of care, a Level 1 trauma center is a comprehensive regional resource capable of providing all aspects of care for life-threatening injuries. It has trauma specialists and 24-hour in-house surgeons, along with experts in neurosurgery, anesthesiology, emergency medicine, orthopedic surgery, radiology, internal medicine, plastic surgery, oral and maxillofacial surgery, pediatric critical care and adult critical care. It also has specialized equipment and quality improvement processes.
Patients with moderate to severe injuries taken to a Level 1 trauma center such as MUSC Health have a 25 to 30 percent better chance of survival compared to people taken to hospitals that don’t have trauma centers, according to the New England Journal of Medicine.
Lehman-Huskamp said MUSC doesn’t take this responsibility lightly. A lot of forethought and groundwork go into keeping a health care system of this size prepared. This drill involved teams across the enterprise, including:
University, MUSC Health and MUSC Physicians emergency management personnel.
The Department of Public Safety.
The Office of Public Affairs and Media Relations.
She explained that some teams were running live parts of the drill in real time — the emergency department, the hospital emergency operation center and emergency management services. Other teams did tabletop simulations.
Lehman-Huskamp was everywhere that morning, watching, directing and assessing readiness, efficiencies and performances. She gave the exercise a solid B.
“It’s better to know now where competencies can be improved then in the middle of a real event,” she said. “We have room for improvement. If an emergency manager ever says we performed at 100 percent, that we don’t need to improve, that would be nonsense. There are definite things we need to work on. For one thing, we are so used to our EMR. We have to be prepared that if we received an influx of patients so rapidly, we wouldn’t be able to use EPIC effectively.”
EMR stands for electronic medical records. Lehman-Huskamp said events such as the Las Vegas shootings showed electronic medical record systems can become quickly overwhelmed. Trauma centers, she said, need to be able to fall back on paper, phone calls, runners and fax machines.
Lehman-Huskamp said drills are critical to response improvement, pointing to the need to identify areas or processes that need strengthening or modifying. For instance, the radiology process is a known bottleneck in mass casualty events, as CT imagining and chest X-rays often determine life-saving actions. In preemptive response, she and Jeanne Hill, M.D., an MUSC radiologist, worked to effect solutions to avoid holdups or worse, chaos.
Lehman-Huskamp looks forward to the day's formal “hotwash.” This after-action discussion and evaluation of MUSC’s performance during this drill allows the at-large team to identify strengths and weaknesses during the crisis response and define the lessons learned to guide future responses and avoid repeating errors.
The kids had fun
Gage Hall, a 10-year-old participant in the drill, liked being on the stretcher. A fifth-grader at Jennie Moore Elementary School, he played the part of a child on the bus impaled in the accident.
“My guts started falling out,” he said laughing. “It was intense. It was really fun."
His brothers, Phinley, 8, and Gavin, 12, were also part of the simulation. Their dad, Greg Hall, is an emergency trauma care specialist.
Lehman-Huskamp’s son Ian also played a victim. All the kids involved, in fact, were children of MUSC Health care providers, spending the last days of summer getting a bird’s eye view of what their parents do on a day-to-day basis.
Each of the kids who played victims had student narrators from the MUSC Colleges of medicine, nursing and pharmacy by their side, explaining their conditions and serving as their clinical voices.
Nursing student Alexis Lanford called it extremely educational. “I thought it was great. The reason that I was interested in it was I just finished my population health course, and we did a mass casualty training exercise. It was nowhere near as realistic as this. This was a fascinating learning experience. I learned so much today.”
Rising second-year medical student Michael Troise said the drill went as well as any he saw during his seven years with the U.S. Air Force. “I think anytime someone can jump in on one of these, they should. It’s important, and it’s very educational. You see how everyone interacts on the team. There are always hiccups when it’s a training environment. It’s a great experience.”
In the next six months, MUSC will conduct a no-notice drill, Lehman-Huskamp said.