Apr 18

Mass Casualty Incident, What To Do?

Boston Marathon Mass CasualtyIn a perfect world a trauma patients are picked up by professionals at accident scenes and taken with much haste to a medical center where a staff of surgeons and other medical professionals await their arrival.  The patients are then afforded the best possible care in a sterile environment with every convenience of modern medicine at the fingertips of professionals who studied for years (or decades) in order to perfect their craft.  As the world watched the events in Boston unfold this week it became clear that optimal circumstances do not always exist during mass casualty incidents, and that lives often hang in the balance on a dirty street where civilians with no medical training whatsoever render lifesaving aid.  The bombing did occur near the finish line of the marathon, an area full of police and volunteer medical staff who were able to immediately rush to the aid of those in need.  Soldiers in uniform were seen tearing down the barriers and moving towards the blast site, undoubtedly veterans of conflicts overseas and trained in the art of “combat lifesaving.”

Here’s the point.  Even with all of those aforementioned professionals in the area cameras captured ordinary civilians doing what they could to help in the confusion.  Race runners and bystanders who were not casualties themselves assisted those in need by rendering aid or helping to evacuate them away from the scene.  They stood shoulder to shoulder with police and others, the situation being so fluid that anyone who could help was needed.  As you sit there reading this post you might be asking yourself, if faced with a similar circumstance what would you be willing to do?  What should you do and how should you go about it?

There is a great post over at the Doom and Bloom blog which discusses medical triage for mass casualty events.  It is very in depth and covers just about everything you could possibly imagine about the process.  While that is a great post, my methodology is somewhat different and caters to the average Joe who will not have all of the supplies or training at their disposal when something like this occurs.  Let’s say you are at the shopping mall, a sporting event, an outdoor festival and a loud explosion occurs.  You pick yourself up off the ground and try to take in what just happened, you see people running around and screaming but you hear none of it over the ringing in your ears.  The smoke starts to clear and you see the carnage.  Bodies, body parts, people in obvious shock and pain. You have the clothes on your back and your courage, that’s about it.  You decide that you need to help, so what now?

1- Establish Security.  Allow me to clarify this in that I understand that you will not have a police unit or military squad with you to secure the area. Here’s why this is important.  Even as we saw in Boston there might not always just one device.  There could be multiple devices or even a device followed by individuals armed with weapons.  When I refer to establishing security, I mean taking a brief moment to assess the situation before moving in blindly.  If you also become a casualty now there are more people to treat, so take a brief moment to scan the area to see if any other noticeable threats exist.  All of this can be done in seconds, or while moving to the site itself.  I am not advocating that you go into vigilante mode and “take out” anyone you deem suspicious, the situation will dictate what the appropriate response should be.  I’m simply stating that you need to take a few precious moments to ensure that no other threats exist before moving in.  There have been many instances overseas where a small device is detonated in order to bring in more first responders, and then a second device or even ambush is initiated.  The very fact that I am writing this for Americans who could have to deal with another event like this on our own soil is very troubling, but this is the state of the world in which we live.

2- Make sure someone is calling 911.  There is a high probability that someone in the area will immediately be on the phone with 911, but make it your duty to ensure that someone is.  Quite often people go into shock (even if they are not injured) and just lock up.  Make sure someone is on the phone with 911 and make sure they are able to give a good assessment of the situation so that the first responders will know how many resources are needed.  Are two people down with a few superficial wounds because a pipe bomb went off in a garbage can, or is it something more tragic like what occurred a few days ago?  That information has to get passed along quickly.

3- Tourniquets.  When someone has a limb torn off from an explosion (or if an artery is severed) they can bleed out very quickly.  The flow of blood has to be stopped, and simply covering up the wound with a towel or shirt isn’t going to do it.  You have to tie a tourniquet a few inches above the wound / severed limb in order to stop the flow of blood, the belt on your waist is the best way to accomplish this.  If you don’t have a belt find one, use the injured person’s belt if you have to.  There are various ways to secure a tourniquet, or to cinch it down so that the flow of blood is stopped, but you might not have the extra resources to make that happen.  Here’s what you need to know: put the belt on, cinch it down as tight as it will go and have someone else hold it in place with instructions NOT to loosen it up under any circumstance.  If you absolutely cannot find a belt, tear a T shirt into strips or use shoe laces.  Finally, elevate the limb so that it is above the heart.

4- Direct Pressure.  For puncture/shrapnel wounds that do not require tourniquets direct pressure needs to be applied.  This is not a dabbing of the wound, or a wiping away of the blood, or the setting of a shirt on the wound itself.  This is taking a shirt and wadding it up into a ball and pressing it against the wound (and not taking it off).      Have the casualty hold the shirt in place if they are able to, or have someone else do it while you move on to the next person who needs help.  Again it is important that once direct pressure is applied you do not continue to take it off to “check out” the wound, leave that for the medical professionals who will eventually arrive and take over.  As with the tourniquet  elevate the wounded limb above the heart.  If it is a stomach injury, lay the casualty on their back and bend their knees (do NOT attempt to push anything back into the body, i.e. intestines).

5- Interaction with the injured.  You’ve seen this done in war movies.  Those who are rendering aid often talk to the casualty (who is in shock).  What’s your name, where are you from, how many kids do you have, etc.  You have to keep them talking and under no circumstance should you let them view their wound or allude to how bad it truly is.  “I’ve got you, I’m taking care of you, help is on the way” is sure better that “wow, you are completely screwed.”  I think you get the point.

Right now about now EMTs, medical professionals, and other caregivers are probably jumping up and down at my generalization of everything with respect to lifesaving treatment.  You must take into account (and I’ll restate it) the purpose of this post.  This is for the average Joe with no medical expertise with no available resources who could be called into action to perform very basic lifesaving procedures on victims of attacks (like what happened in Boston) prior to medical professionals arriving on the scene.  I can think of no Doctor who would advocate that we who aren’t Doctors simply stand by and let people bleed out because we were never trained in trauma care.

On a final note I should acknowledge that every circumstance is different and every person is different in how they react to things.  I am not suggesting that every single person on the planet is wired in a way that would have them charging into the fray, searching out victims to render aid to.  Indeed even the most hardcore among us might have other responsibilities which eliminate the possibility of us participating at all.  Faced with a situation like Boston, my initial reaction would be to assist in any way possible.  But what if I was mentoring a group of small children, all under the age of 10?  My responsibility would be to get them out of the area and to safety versus leaving them stranded while I charged headfirst into the smoke.  The point is, it is impossible to throw a blanket over the entire scenario which covers every possible “what if.”  Faced with a mass casualty event, take a moment to assess the situation and do what you can.  Let’s just hope and pray for everyone’s sake  that we never have to put any of what I wrote about into practice ever again in this country.


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    • ParaB on April 18, 2013 at 11:14 AM
    • Reply

    PJ, good, simple article. No medical professional should be jumping up and down about anything you said. Because what you wrote is about all you can do. Ive been a full-time firefighter/paramedic for 14 years now, and also a “combat life-saver” in the army. First and foremost, you have to stop the bleeding and protect the airway. Without those being accomplished, nothing else matters. Here’s the thing, you cant do “paramagic” without your tools of the trade. And its always BLS before ALS. Also, you hit a point that a lot of newer medics dont seem to get. We in the gutters do as much for our patients by making them feel better mentally as anything we do physically. The mind is half the battle. Nice job buddy.

      • PJ on April 18, 2013 at 11:20 AM
      • Reply

      Thanks for the vote of confidence Para! I did leave out the airway portion, I contemplated that for a while but decided it was a bridge too far given the scope of the article. Given your expertise if you have anything else to add I’d appreciate it. Thanks for the comment.

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