On April 15, 2013, at the finish line of the Boston Marathon, two improvised explosive devices (IEDs) – pressure cookers loaded with explosive material, nails and ball bearings – were detonated, killing three bystanders at the scene. Another 264 were injured and treated at 29 local hospitals, underscoring what has occurred in other mass disasters – victims do not preferentially go to level I trauma centers. (The greater Boston area has 11 adult and pediatric level I trauma centers.) At least 16 patients had traumatic amputations; their limbs were either severed during the explosion or sustained such severe damage that they required amputation at the hospital. Three of the 16 lost more than one limb. On April 22, 2013, Dzhokhar Tsarnaev was charged with use of a weapon of mass destruction and with malicious destruction of property resulting in death.
On April 17, 2013, only two days after the Boston bombing, the first of three recent chemical explosions occurred at a fertilizer storage and distribution facility in a small town close to Waco, Texas, while emergency personnel were responding to a fire at the facility. At least 15 people were killed, and more than 160 were injured. On June 14, 2013, two chemical-plant explosions in Louisiana killed two people and injured more than 100 at the Williams Olefins petrochemical plant in Geismar, Louisiana, and killed one and injured seven at the CF Industries nitrogen production plant in Donaldsonville, Louisiana, a small city on the Mississippi River 10 miles south of Geismar. Several of those injured had burns of sufficient degree that they were transferred to the burn unit in Baton Rouge, Louisiana.
On May 20, 2013, an EF5 tornado, with peak winds estimated at 210 mph, struck Moore, Oklahoma, and adjacent areas, killing 24 people and injuring 377 others. The Oklahoma Department of Emergency Management reported 1,150 homes destroyed and $2 billion in damages. Most areas in the path of the storm suffered catastrophic damage. Entire subdivisions were obliterated, and houses were flattened in a large swath of the city. Subsequent tornadoes have struck Oklahoma, and the associated weather systems have spawned thunderstorms as far south as San Antonio; on May 26, 2013, three people were killed in flash floods in San Antonio. Of course, the worst storm in the previous 12 months was hurricane Sandy, which struck the East Coast of the United States on October 29, 2012. Because Sandy came ashore during high tide, the storm surge was incredible: 285 people died, more than 5 million residents were left without electricity, and the cost of cleanup and restoration has reached the tens of billions of dollars.
To a military physician or one working in a level I trauma center, the concepts of surge capacity, emergency preparedness, and disaster management are readily appreciated, understood and often implemented – particularly for those working in the military. But what about those of us who do not work in a level I trauma center? Or who do not expect to be unable to get to work? Or who, if we do arrive at work, do not expect to find a hospital that is nonfunctional because of a lack of power or water or because of structural damage? How should a department of anesthesiology prepare for emergencies? And for what should it prepare? In terms of disaster management, does your facility have any surge capacity? Does it have enough personnel to run all the operating rooms for more than one shift?
We should all be prepared to deal with natural disasters – either weather-related or geologic – and industrial accidents. Where we live influences the kinds of natural disasters for which we should prepare, and the types of industrial plants or railroads that are in the vicinity of our hospitals likewise should help us anticipate the kinds of casualties we might see from an industrial accident. But how do we train to manage casualties from a terrorist’s use of an IED? Do we know what to expect from the type of IED used in Boston versus an IED used in a closed space? (The answer is that dismounted complex blast injuries [e.g., patients with more than one traumatic amputation] occur when IEDs explode in the open versus more thermal injuries when they explode in a closed space). And for those of us who work in a small rural hospital, how do we maintain our skills in caring for the patient with either a traumatic penetrating or crush injury? The data suggest that patients with traumatic injury do better in a level I trauma center as opposed to a level V facility.
ASA established the Committee on Trauma and Emergency Preparedness (COTEP) to assist its members in preparing for emergencies, in disaster management and in managing trauma patients. Trauma is the third-leading cause of death in the United States and the leading cause of death in adults younger than 45 years of age and in children. The COTEP has taken the approach that, for emergency preparedness, it will provide information on its website, and, when you are confronted with a natural disaster or an industrial accident, COTEP website is the place to go to find the information you need. In addition, COTEP has worked with the Fundamentals of Anesthesia Education Task Force to increase the number of trauma lectures at the ASA annual meeting, with the goal of allowing anesthesiologists the opportunity to obtain continuing medical education in the management of patients who have sustained traumatic injury. In addition, the COTEP is working with the Residency Review Committee to increase the amount of training that residents have in managing patients with traumatic injury so they will be prepared in the future to better manage patients with the kinds of traumatic injury described at the beginning of this article.
*The views expressed in this article are the personal views of COL Michael J. Murray. The information in no way represents the views of the Department of Defense, nor of the U.S. Army.