Emergent Phenomena during Mass Casualty Incidents
“Plans are Nothing, Planning is Everything”
In recent memory there have been three mass casualty incidents in New Zealand; the 2011 Christchurch Earthquake, followed by the Christchurch Mosque Shooting in 2019, and then in 2021 the White Island/Whakaari Eruption. In each case hospitals activated disaster plans and the organised team response saved countless lives. For anyone who has experienced a mass casualty incident (MCI) the gap between the written plan, and the chaotic reality is difficult to describe. This dissonance, where planning fails in the face of an unforeseen event, is a well-known if poorly understood reality. Military planners have long attempted to find ways to control the inevitable chaos of battle- Clausewitz, the military theorist writing in 1830, noted that “the enemy of a good plan is the dream of a perfect plan”. Eisenhower, the Supreme Commander of Allied Forces during World War II and 34th American President, knew the limits of planning when he said, “plans are worthless, but planning is essential”. This essay, based on my own and others personal experiences, is an attempt to shed light on this grey area, where the disaster plan has little utility and emergency responders must navigate an overwhelming and unpredictable event.
As background I’ll briefly describe New Zealand’s three recent mass casualty incidents.
The Christchurch Earthquake began at 1251 on Monday the 22nd February 2011. There had been a significant earthquake in the early hours of September 2010, but the February earthquake was far more lethal. This epicentre was located nearer the city and produced very high ground acceleration, so buildings weakened by the previous earthquake collapsed entirely. Unlike five months prior, it was lunchtime so many more people were in the city centre. Within Christchurch Hospital an MCI response was activated immediately, triage was set up, and 20 trauma teams formed. The first patients arrived in private cars within minutes. 231 casualties arrived in the first hour. Injuries were mostly blunt and crush, amputations were performed on scene so that patients could be extracted from collapsed buildings. The hospital backup generators failed leaving the Emergency Department (ED) in intermittent darkness, the basement flooded, and hospital telephone communications failed. Staff worked for the next 24 hours in a building that shook heavily, not knowing whether their family and friends were injured or worse. 185 people died, 6700 sustained injuries.
The second mass casualty incident to strike Christchurch took place at 1340 on 15th March 2019. A man armed with automatic weapons attacked the Al Noor and Linwood Mosques where hundreds of men, women and children were attending Friday prayers. Within half an hour the gunman was apprehended after his car was rammed by police. The speed of events meant that the hospital was unaware until a victim, having run from the Al Noor Mosque, arrived at the ED triage desk. Simultaneously, armed police in tactical gear appeared in the ED waiting room. The disaster plan was activated and resuscitation bays began to be cleared. Within seconds patients started arriving in private cars. 49 seriously wounded patients arrived within the hour. There was no time to retrieve the MCI plan and equipment, nor was there time for prehospital triage or adequate registration. The ED response was over as quickly as it had begun. By 1700 the ED was virtually empty and in lockdown (because a second shooter was thought to be still at large). Most patients had been transferred to theatre, ICU or to wards. In total 51 people died, and 40 were injured. There was 1 death in the ED.
The third incident occurred on White Island/Whakaari at 1411 on Monday the 9th December 2021. 47 tourists and guides were exploring the volcanic island when it erupted. The nearest hospital was in Whakataane, 50km away across water, the larger hospital at Tauranga, 90km away. Three tourist helicopters immediately flew to help and between the available helicopters and boat operators’ victims were transported to Whakataane, Tauranga and Waikato, each of which declared an MCI. Later that day patients were flown to plastics centres in Auckland, Lower Hutt, Christchurch, and Hamilton. The Australian army retrieved patients back to Australia in the ensuing days. Despite the relatively low numbers and rapid distribution of patients throughout New Zealand, the severity of both chemical and thermal burns required significant resource over the following weeks. Repeat visits to theatre for debridement and dressing changes combined with prolonged ICU stays meant that elective surgery and ICU capacity throughout New Zealand was impacted for weeks. 15 died at scene, 7 died over the coming days and weeks. Only 3 of the 25 survivors sustained minor injuries.
These are difficult events to recount and to read about. Instinctively, one wants to learn the hidden lesson that tells us how to stop disasters before they begin. Yet, despite natural disasters like earthquakes and volcanoes being planned for, particularly here in New Zealand, chaotic variables always interject. Time of day, mechanism of injury, distance to medical care, transport availability and how a hospital is functioning on the day are just some of the countless factors that no plan can fully account for. So, if planning only goes so far how can we manage, or at least mitigate unforeseen consequences?
Fortunately, mitigating phenomena do emerge during an MCI. Without training or prompting, individuals will identify and solve problems in the moment. For example, during the earthquake response, staff recognised that many of the crush injured patients were at risk of hyperkalemia, so suxamethonium was removed from intubation packs and hyperkalaemia treatment bags were made up. Blood bank staff arrived unannounced with as much universal blood as they could carry. When hospital communications failed medical students volunteered as runners between departments.
During the Mosque Shootings, before the first patient arrived, a senior nurse gathered a small team and rapidly transferred and discharged patients out of the ED making vital space for incoming victims. Another nurse distributed morphine and fentanyl to the trauma teams. A cardiologist with an ultrasound machine arrived and calmly went from bay to bay evaluating thoracic gunshot wounds. Chest drain bottles became scarce so a nurse fashioned a temporary underwater sealed drain. Vials of intravenous antibiotics and tetanus shots were brought to each patient by a pharmacist, and nursing students gave water to adrenalized staff.
In Whakataane, an off-duty nurse went to the local supermarket and bought all the cling-film she could carry, bringing it to the ED to dress burns victims. A pharmacist arrived with the hospital stock of propofol so patients could be sedated for wound management and escharotomies.
It appears that beneficial emergent phenomena during MCIs is universal. In the USA during the Las Vegas Shooting of 2017, the largest mass shooting in history, staff at Sunrise Hospital used endotracheal tubes when chest drains ran out, then created an assembly line system for intubating, and when ventilators ran out, used Y connectors to ventilate two patients with a single machine.
These spontaneous solutions are a consistent feature of mass casualty incidents. Witnessing individuals solving vital resource problems while under huge pressure is impressive to see. This behaviour can’t be planned or practiced, but it is reassuring to know that ad hoc ingenuity undoubtedly emerges during a disaster.
Another mitigating factor that quickly becomes apparent is frontline staffs’ ability to prioritise. Inevitably, with an overwhelming of resource, the ability to deliver normal care ceases and is replaced with austere emergency medicine. This means providing care that is sub-standard so that resources can be stretched and save as many lives as possible. Essentially, quantity becomes more important than quality. Prehospital and emergency department staff are experts at this, daily ED overcrowding and flexing of resource is something we are all used to. A mass incident requires a further drop in the standard of care. Knowing how to recognise and manage hypotension and hypoxia, with minimal resource (and potentially without monitoring), in order to maintain perfusion while definitive care can be arranged is vital. Using permissive hypotension, maintaining oxygenation with simple airway manoeuvres, diagnosing without CT scan, and staying away from time consuming procedures that add little value, like central and arterial lines, are skills most emergency staff are familiar with.
The deterioration of the usual standard of care affects responders differently. For those who are highly conscientious, or perfectionist, delivering substandard care produces stronger feelings of guilt at not having done enough. Having said that, guilt, along with other grief responses like anger, denial, bargaining and sadness are emotions felt by everyone in the wake of a mass casualty incident. Intrusive thoughts are inevitable in the weeks after but normalising of these emotions does occur, and most people carry on not unduly affected by bearing witness to mass trauma. Interestingly, the hours spent locked-down in the empty Christchurch ED after the Mosque Shooting meant there was time for staff to decompress in the same environment, to let the nerves settle, even to relax with colleagues before heading home to friends and families who could never fully understand what being part of a response was like. A similar effect occurred with the earthquake where, because the whole community had been affected and everyone had been through a similar experience, it became somewhat normalised and therefore more manageable psychologically. Another feature that Professor Karim Brohi, the medical lead for London MCIs (an unenviable role) points out is that a person who moves on from their colleagues to another job shortly after an MCI may struggle more with this normalisation process. So, doctors or nurses rotating frequently through short term jobs, or those who go on prolonged leave, may be at risk of a more prolonged psychological recovery.
Finally, there are two further issues that are not often recognised in disaster planning which may help prepare for an MCI.
Firstly, managing the medical record when tagging and registration fails to keep up, either because too many patients arrive at once (as in the Mosque Shooting), or when a computer system fails because of power failure or cyber-attack. A switch to a paper system should be part of any disaster plan but a simple temporary solution is to use mobile phone cameras. Being able to photograph the patient, the injuries, the portable X-ray and ultrasound image, and the drugs and fluids given (the vials themselves or the drug chart if available) means a coherent record can be passed on to successive teams. Patient privacy is forgone but for an unregistered gunshot victim who urgently needs to go to theatre these images provide vital information for surgeons, anaesthetists and ICU doctors who are taking over care.
Secondly, regarding crowd control and communication. Managing incoming relatives and bystanders is a well understood part of an incident plan yet controlling the large influx of medical staff is less well appreciated. In a large hospital, like here in Christchurch, one can expect fifty to a hundred staff arriving within minutes of notification. The solution is to corral staff in a central area, near the ED coordinator. Communication from the teams in individual resuscitation bays as to what type of specialist they need is passed to the leader who can then call out to the collected staff the person they need e.g. we need a general surgeon to bay one. In large EDs where mobile phones or voice activated communicators quickly become redundant because of so many calls being made, a loud voice or better, a tannoy system (which ideally shouldn’t be connected to the IT system) can be an old fashioned but vital tool in getting the right people to the right patient effectively, and for communicating to all teams the availability (or unavailability) of equipment.
So, if you work in the frontline and it has dawned on you that you may find yourself thrust into a disaster response, hopefully this essay alleviates some fears of the unknown that are inherent in mass casualty events. Knowing the plan and thinking about what you would actually do is vital. But do keep in mind Mike Tyson’s thoughts on managing the unpredictable, “everyone has a plan until they are punched in the face.”
For further reading
A stunning account of the response to the biggest mass shooting in US history by the ED staff of the Sunrise Hospital
ACEM disaster policy
And a literature review of emergent behaviour during disasters
Evan Cameron May 2022