surgical response to diasters - ucsf cme · •damage control surgery/multiple take-backs...
TRANSCRIPT
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SURGICAL RESPONSE TO DISASTERS
M. Margaret Knudson MD, FACS Chief of Surgery, San Francisco General Hospital and Trauma Center
Training Surgeons for Disasters
“A MASS CASUALTY EVENT IS NOT JUST ANOTHER
BUSY NIGHT IN AN URBAN TRAUMA CENTER!” ACS/COT
Mass Casualty Management: A Weekly Event
Propper et al: Annals of Surgery 2009
Elster et al: Implications of Combat Casualty Care for
Mass Casualty Care, JAMA 2013
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4 Operating Rooms: 2 pts each Surgical Response in Boston
• Amputations
• Vascular Injuries
Senior Visiting Surgeon Program Response in Haiti: ACS Operation
Giving Back
Massive Destruction US Naval Response
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Asiana Flight 214
• Departed from Incheon So. Korea for SFO
• Boeing 777 aircraft
• 307 passengers on board
• 70 Chinese high school students en route to summer camp in So. CAL
• 11:28 Crashed on final approach
Plane Crash
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Fate of the Passengers
• 181 injured passengers
• 12 critical: 10 SFGH/2 Stanford
• 2 deaths at the scene
• Several victims ejected out back
• Found on the runway still in seats
• 9 hospitals admitted 182 pts.
Fate of the Plane
Boeing 777 Held up Well
Saturday 11:30 AM @ SFGH
• Trauma surgeon on-call for 24 hours
• Just finished making rounds
• Enjoying a “Breakfast of Champions”
• Powerbar and a Latte
• “Courtesy call” from ED: small plane crash
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JULY 6TH 2013; 12:30 pm
• First wave of injured patients arrive
• Six critical condition
• “Burns and Inhalation injuries”?
• Severe blunt trauma
• Two very unstable: taken to the OR within minutes
CRITICAL INJURIES: FIRST WAVE
PATIENT INJURIES
#1 TBI, Facial Burns, Inhalation*, Spine
#2 Major intestinal, spine with paralysis; road burns
#3 Chest, intestinal, spine with paralysis, mandible, > 30% TBSA road burns
#4 Extremity injury with compartment Sx
#5 Severe TBI, spine, sternum, ribs
#6 TBI, spine, sternum, extremity fractures
3 Waves of Patients
• Total seen at SFGH: 67
• 36 Adults
• 31 Children
• 36: Admitted
Keeping track of patients/injuries Singular focus: Doing the right thing
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OPERATING ROOM: FIRST 48 HOURS
Crash Related Other emergencies
Damage control laparotomy; burns Hand fracture
Reduction of fracture; fasciotomy Appendectomy
Damage control laparotomy; burns Stab wound to the abdomen
Laminectomy; spinal fusion Wrist fracture
Spinal decompression Craniotomy
Craniotomy Wound debridement
Spinal fusion Wound debridement
Take-back laparotomy Infection
Take-back laparotomy Fracture
Fracture
Other Unique Challenges
• Blood bank supply: >100 U
• Judicious monitored use
Chance Plus One Chance Fractures: A Rare Occurrence
• Combination of intestinal injuries and spine fractures
• Most commonly seen with lap-belt use
• Severe flexion over a fixed object
• Most common injuries:spine;chest
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Potential Toxic Exposure
• Strange metabolic picture: acidosis, hypocalcemia; hypotension
• Persisted for days among survivors
• Toxic exposure: jet fuels, foam, cargo?
Hydrogen Fluoride Inhalation Injury: Fire Suppression System
• Fire suppression System: HFC-227/US military
• Converts on heating to HF
• HF: devastating inhalation injury
• Fluoride binds Ca++: liquifaction/cardiac arrthymias
• 3/5 soldiers died: survivors treated with nebulized Ca++
Other Major Challenges
• Damage control surgery/multiple take-backs
• “Road Burns”: wound care/skin grafts
• Cardiac arrhythmias, low Ca++, low platelets
• Renal failure: CVVH
• Intestinal Fistulas
• Intra-abdominal infections
Emotional Stress: Families
• 2 deaths at the scene
• Different Customs and Cultures and Languages
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Other Unique Problems
• Children without parents
• Families separated by acuity
• No one had been through customs!
• Homeland security: set up in cafeteria
Media
• Accurate and regularly scheduled updates
• They will be there for days camped out
• One death in our hospital: Black Friday
The Tail Goes on for Days/Weeks and Months
• Long after the press goes home…..
• And the public almost forgets…..
• There are still critically injured patients
• Require multiple surgeries, rehabilitation
Decompression for the Team: July!!
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China’s Zhejang Province