The Orthopaedic Trauma Association (OTA) just launched a page on its website devoted to disaster-preparedness resources for surgeons and first responders.
Titled “Get Prepared,” the page includes:
- A 93-slide PowerPoint presentation on orthopaedic blast injuries
- Courses from the National Disaster Life Support Foundation and the American College of Surgeons’ Committee on Trauma
- A bibliography with links to the JBJS Reviews article “Disaster Response Management Protocol for Departments of Orthopaedic Surgery” and the JBJS/JOSPT Special Report It Takes a Team—The 2013 Boston Marathon.
Disaster Medicine and Mass Casualty management differ in principle and philosophy from conventional peace time medicine; it is not just the idea of “poly-trauma” medicine nor damage control surgery only.
Clinicians who have military medicine background or disaster management training know there is a significant foundation change in approach to multiple trauma patients presenting at the same time to a medical service, thus overwhelming the available resources and expertise. Ethical dilemmas occur particularly to those untrained or unfamiliar with this seismic change in fundamental management of multiple patients, from triaging care, prioritising patients with the most severe emergency conditions, to patients with the most severe emergency SURVIVABLE conditions, and in which basic manoeuvres are performed to maintain appropriate vital signs. In such situations personnel-intensive procedures are not always applied immediately to those patients who may have been managed differently in peacetime.
There are some important mindset changes in which senior experienced clinicians are best utilised at triaging rather than getting bogged down in personally managing those with complex injuries.
Major-incident management also has to involve safety of health care personnel themselves, even those located in established facilities as both the perpetrators, the victims and the helpers can unintentionally put those in these facilities at risk, particularly when crowd control is difficult and mass communication and situational awareness is at is poorest.
Except for a few orthopaedic emergencies, it is otherwise often acknowledged that there are many orthopaedic injuries that not immediately life or limb threatening, and definitive management can be delayed as long as appropriate first aid care is instituted, usually with splinting/immobilisation and analgesics and antibiotics as required. Orthopaedic surgeons need to realise this cultural shift in paradigm in order to assist in the implementation of major incident management protocols.
This would involve knowing the principles of MASS and SMART management. Earlier ATLS courses used to involve some instructions and discussion of mass casualty presentation, but recent incarnations appear to relegate these discussions to “optional” knowledge (in later sections of the ATLS course book, often unread).
It is time to reconsider what is important and reinvigorate the teaching of mass casualty knowledge in ATLS; ACS and OTA must lead in the return to the basics in this all-important course.