Health care approach to burn mass casualty incidents
SPMC J Health Care Serv. 2024:10(1):2. ARK: https://n2t.net/ark:/76951/jhcs3z8fh7
1Department of Emergency Medicine, Southern Philippines Medical Center, J.P. Laurel Avenue, Bajada, Davao City
Correspondence Benedict Edward P Valdez, rbenz628@gmail.com
Received 16 October 2023
Accepted 19 March 2024
Cite as Valdez BEP, Paderanga MAR, David JDM. Burn mass casualty incident management. SPMC J Health Care Serv. 2024;10(1):2. https://n2t.net/ark:/76951/jhcs3z8fh7
Burn mass casualty incidents
On July 4, 2021, a Philippine C-130 military plane carrying 104 personnel crashed in Patikul, Sulu after attempting to land at Jolo Airport, killing 53 individuals and injuring 50 others, both on board and on the ground. Some of the injured sustained multiple injuries, including fractures and burns. This incident triggered a swift response from various agencies. Mass casualty incidents, including those with multiple burn-injured patients, pose significant challenges to health care systems and can lead to high morbidity and mortality rates.1 2 3 Burn injuries, which account for at least 200,000 deaths annually, are a major global public health issue, particularly in low-resource settings, and can easily overwhelm the limited burn resources available.4 5 6 Efficient management of mass casualty incidents, proper triage decisions, and sound health care planning are crucial for optimizing patient outcomes and matching potential needs with available resources.7
Burn mass casualty incidents (BMCI) are incidents that involve at least three burn victims. These incidents, whether due to natural or human-caused accidents, can occur anywhere and anytime. The injuries are unpredictable and involve a large number of victims, requiring a significant consumption of logistics and medical attention. Medical response tasks in massive burn injuries are much more challenging than those required in separate burn incidents due to the unexpected nature of the events and the simultaneous involvement of a large number of patients. Such situations require the immediate mobilization of a significant number of personnel, resources, and facilities to address upcoming issues.
In this article, we describe the management of BMCIs based on our experiences in responding to the Patikul incident. We elucidate the strategies that are put into action and offer insights aimed at improving protocols for handling BMCIs in the future. Our goal is to contribute to the body of knowledge in this field and aid in the development of more effective responses to such critical situations.
Approach to BMCI based on the Patikul incident
A medical team from Southern Philippines Medical Center (SPMC) was deployed to Zamboanga 24 hours after the C-130 aircraft crash in Patikul, Sulu to assist the injured soldiers. The team coordinated with local authorities, assessed and treated patients at Camp Navarro General Hospital (CNGH), and updated interagency groups on their findings. The team also addressed patients' psychological distress from the crash. Five patients were identified for transport to SPMC's Burn Unit for further management.
Organizing a multidisciplinary team. Coordinating a team with diverse expertise to respond to BMCIs involves several key steps. The local government unit (LGU) where the occurrence took place would typically mobilize the nearest health facilities equipped with the necessary resources and expertise to orchestrate a comprehensive response to the situation.
The responding facility starts to identify the nature of the incident and plans for the necessary logistics and personnel who are equipped to adequately respond to the situation. A proactive approach would be liaising with the referring LGU to gather information on the actions taken so far in response to the incident. This helps in understanding the current situation and planning the next steps accordingly.
The SPMC Rizal Aportadera Burn Institute (RABI) in Davao City is recognized as the only facility in Mindanao capable of handling massive and severe burn cases, such as those from the mass burn incident in Patikul. The mayor of nearby Zamboanga City requested assistance from the mayor of Davao City, initially wanting to transfer all burn cases to the SPMC RABI. However, due to the influx of patients with COVID-19 at the time, the request was not immediately granted. Nevertheless, the head of the SPMC Trauma Team, following the directives of the Davao City mayor, alternately conducted consultative meetings and planning sessions with several health administrators. This resulted in the formation of a specialized team to be sent to Zamboanga to reassess and re-triage patients for proper distribution and definitive management.
The safety of the environment where the incident occurred is a critical factor that is taken into consideration. This includes assessing potential hazards that could pose risks to the response team or hinder the rescue operations. Cultural and language barriers are also identified to ensure effective communication and interaction with the affected community. This helps in procuring appropriate personnel and resources that can cater to these specific needs. Fortunately, the SPMC Trauma Team had two doctors who share the same religious faith as the majority of the affected locality. Their presence greatly helped in mitigating cultural barriers, thereby establishing the team’s integrity and rapport with the patients.
Initial approach. The clinical management of BMCIs requires a well-coordinated health care team. This team is responsible for the coordination and delegation of tasks, ensuring that each member of the team understands their roles and responsibilities. The team must also identify gaps in the delivery of critical care health services and work to address these gaps. This involves assessing the human resource capability of the team and the overall capability of the hospital to handle such incidents.
Logistics, transportation, and supplies. Logistics play a crucial role in managing BMCIs. This includes total incident control and tasking, and identifying directions of possible transport. The transportation of patients is based on their status, ensuring that each patient receives the appropriate level of care. The aircraft compatibility of equipment used is also a key consideration. Ideally, land vehicles, boats, and aircraft used in these operations should be GPS-tagged for efficient tracking and coordination. Handover systems must be simple, specific, yet comprehensive to ensure smooth transitions of care.
The SPMC Trauma Response Team identified five patients eligible for transport to the SPMC Burn Unit. These patients were presented to the SPMC Department Heads, LGUs, and CNGH delegates via an online conference. Patients in CNGH were transported from Zamboanga City to Davao City on a commercial airplane, accompanied by a doctor who monitored for any signs of distress, anxiety, and unstable vitals. The supplies on board, including a portable ultrasound machine, monitoring devices, and venous access devices were utilized by the accompanying Emergency Medicine physicians to stabilize the patients and address any in-flight health problems. Upon landing in Davao City, the patients were received by an Emergency Medicine resident physician, along with the staff and crew of the Davao City Central 911 Emergency Response Center. The patients were then directly transported to the SPMC RABI, where they received proper management and care.
The response team should have access to various equipment and supplies to effectively manage BMCIs. Essential equipment include a portable ultrasound machine for immediate diagnostic imaging, a multiparameter monitor for tracking vital signs, pulse oximeters for monitoring oxygen levels, tourniquets for controlling bleeding, and basic first aid kits for immediate wound care and other minor surgical procedures. The team should also bring intravenous (IV) cannulas, an intraosseous device, and adequate supplies of IV fluids that are appropriate for fluid resuscitation on-site and during patient transport to health care facilities. During their Zamboanga mission, the SPMC Team brought all the pre-hospital equipment they needed for triage, initial resuscitation and any surgical operation if indicated.
Assessment and management of patients. For the BMCI in Patikul, SPMC sent a team of six doctors and one nurse to Zamboanga City. The Emergency Medicine doctors were in charge of triaging and pre-hospital assessment. The Orthopedic team took charge of wound care, debridement, and management of burns with associated fractures, while General Surgery handled burns and wound care. For neuropsychological evaluation and head injuries, a Neurosurgery physician was also deployed. In anticipation of possible operations, an Anesthesiologist was also on board. Assisting them was one nurse from the SPMC Hospital Emergency Management (HEMS), trained and capable of prehospital management for trauma and medical conditions.
Triaging of patients during a BMCI is a critical step in ensuring good patient outcomes. The major challenge in triaging patients in a BMCI is identifying who needs to be immediately transferred to a specialized medical facility. This can be further complicated when patients have both thermal and polytraumatic injuries. An accurate assessment of the extent of the burn injury, as well as consideration of the patient’s age and the presence of a probable inhalation injury, could profoundly affect patient outcomes.8 Patients with severe burns can benefit from early wound care by performing life-saving procedures such as fasciotomy and escharotomy at a primary center or a first-receiving hospital.3 Concomitant trauma injuries should be identified at the first instance. First-receiving hospitals should support surge capacity in burns care,9 with COVID-19 precautions in place.
While triaging the victims of the BMCI in Patikul, the SPMC Team assessed airway, breathing, circulation, and disability. For patients who showed signs of instability, primary resuscitative measures were implemented. During the management of the victims, the SPMC Trauma Team assessed and diagnosed the patients' burn injuries. When a patient was not medically stable, resuscitation and stabilization of the patient were prioritized. When stable, patients were then evaluated for special burn management. Patients found to need special burn management were then referred to the SPMC Burn Unit.
Implementation of a referral system. Activation of the referral system is integral in the management of BMCIs. These incidents necessitate a multilevel and multisectoral action and participation from various groups of stakeholders. During the initial response, the team should undertake initial assessment of the actual situation in the field. In the Patikul incident, patients with more severe burns were admitted to either SPMC or the Victoriano Luna Medical Center. At both hospitals, surgeons skilled in burn care thoroughly discussed plans for excision and grafting. They took into account any concomitant trauma injuries and other life-threatening medical conditions, such as fractures, myocardial infarction, acute kidney injury, embolism, stroke, and acute respiratory distress syndrome. A constant flow of information was maintained among health care teams. Regular updates on the patients’ status and management plans were shared through a web-based social network, prioritizing discussions on patients with the most serious and complicated conditions.
Post-incident concerns. Burn injuries can have devastating sequelae that can cause substantial morbidity and mortality. Significant burn injuries can predispose patients to infection. Patients are also at risk of developing sepsis due to pneumonia, and they are also susceptible to ARDS, especially in cases of inhalation injury.10 At the time the Patikul incident occurred, which was at the height of the COVID-19 pandemic, elective surgery services at SPMC were reduced. Hence, scheduling surgical procedures at the operating room theaters turned out to be a significant challenge. The burn patients with severe injuries were admitted in the burn unit under critical care setup, since most of the intensive care unit beds were occupied by patients with COVID-19. Sufficient spare bed capacity and adequate staffing to accommodate these patients have also posed a challenge to the delivery of surgical care services.
| Table 1 General approach to the management of burn mass casualty incidents |
A. Organizing a multidisciplinary team
|
B. Assessing and managing patients
|
C. Implementing a referral system
|
D. Monitoring post-incident concerns
|
Gaps in the health care system experienced during the Patikul BMCI
The Patikul burn mass casualty incident revealed significant challenges in the healthcare system. The initial on-site triage and treatment were not conducted by a specialized and duly-trained burn rapid response team, indicating a lack of multidisciplinary response. The single burn-specialized institution in Mindanao, SPMC RABI, was unable to accommodate all victims due to the concurrent COVID-19 pandemic. Essential point-of-care gadgets were not readily available in nearby institutions, delaying critical care until the arrival of the SPMC team. The psychosocial needs of victims, many of whom experienced post-traumatic stress disorder, were only addressed two days after the incident, suggesting a delay in mental health care. The incident underscored the urgent need for coordinated first responders, advanced on-site medical triage posts, comprehensive land, air, and sea transport systems, and regular simulation training. Despite immediate decisions to airlift victims to other locations, survivability was not guaranteed, emphasizing the importance of on-site resuscitation and pre-hospital care.
Summary
Health care needs in BMCIs require a comprehensive and coordinated approach, which begins with organizing a multidisciplinary team. This team is responsible for providing appropriate and timely care for the injured, according to their severity and urgency. They also assess and prioritize communication and health care needs, and facilitate the optimal allocation and utilization of resources. The next step involves assessing and managing patients. For those with moderate-severe burn injuries, the health care team identifies any associated injuries, such as fractures, inhalation injuries, or shock, and considers resuscitating and stabilizing them. For those with minor burn injuries, the team re-triages them after the initial triage to prioritize the most urgent cases, checks for any missed injuries that may have been overlooked in the chaos, and monitors the progress of the injuries and manages them accordingly, such as dressing, cleaning, or debriding the wounds. Once the patients have been assessed and managed, it is crucial to put a referral system into action. Before transferring patients with moderate to severe burn injuries, to a facility that can provide definitive care, the specialized transport system considers the mode of transport, such as air or ground, and the capability of the transport team, such as paramedics or nurses. Dispatch decisions for critical care patients are based on the patient’s status, the availability and capacity of transport and receiving facilities, and the estimated time to definitive care. Lastly, monitoring post-incident concerns is essential. Handover and safety are ensured throughout the process, by transferring information, responsibility, and authority between health care providers or teams, and by preventing and mitigating harm to patients, staff, and the environment.
The comprehensive and coordinated approach to BMCIs not only ensures the immediate and appropriate response to the incident but also paves the way for long-term recovery and rehabilitation of the patients. This approach underscores the importance of preparedness, teamwork, and continuous learning in the dynamic and challenging field of burn mass casualty incident management.
Contributors
BEPV, MARP, and JDMD conceptualized the article. BEPV and MARP wrote the original draft. All authors performed the subsequent revisions. All authors have agreed to be accountable for all aspects of this report.
Article source
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Competing interests
None declared
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Copyright © 2024 BEP Valdez, et al.
Published
April 11, 2024
Issue
Volume 10 Issue 1 (2024)
Section
Health care focus
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