Haiti's Earthquake and the ABC's of Mass Casualty Management

All mass casualty scenes start out as chaos, but regardless of the scope of the incident, from a 5-car accident to a toxic gas leak affecting hundreds at a factory, or the earthquake in Haiti, they have steps in common. My HAZMAT training for industry and my OEC (Outdoor Emergency Care) training taught the same steps that I see the Haitian relief crews following now.

1 - Scene size-up asks the question, "WTF happened, and where"? Each kind of disaster has its typical injuries, each location has or doesn't have local resources to tap into and routes for incoming aid. You need to mobilize the right resources.

2 - Scene and rescuer safety asks the question, "Is it safe to go in there yet"? Has the dust settled and have the rocks stopped falling, if only for now? Can you find or create a safe place to start working?

It's hammered into us at training: Don't become part of the disaster. An injured rescuer is just another victim. If it gets too dangerous to stay, leave the area. If you decide to call in the police or the Marines before you send in your aid teams it doesn't mean you don't care that people are dying. It means you want your staff to stay alive and the supplies to reach the people who need them.

3 -Triage in a disaster is playing God. The rescue coordinators have to decide where to send help as it arrives, trying to help as many people as possible as soon as possible even though they know it's not going to be possible to save them all.

Inevitably the victims closest to the entrance point of the resources will get helped first. Distant victims may wait for days and die before help gets to them. In a multi-organization relief effort, inevitably one group's supplies will be delayed because it's impossible for everyone's supplies to arrive first.

At any part of the scene, victims are divided into three groups:
A - Those who are likely to live, regardless of what care they receive, or those who can wait for more resources. Move these people out of the area as soon as possible, if it is possible.
B - Those who are likely to die, regardless of what care they receive, and those who need care that isn't available to the rescuers. Leave these people to die.
C - Those who are likely to live if you provide immediate care with currently available resources. People in this group will live or die based on how you decide to allocate your resources. It sucks, but you may have to let one savable person die if it would free resources that could save 2 or more others.

In a disaster, you have to look for the "sure things", not try to pull off a miracle. When we set up multi-victim scenarios, the physicians are inevitably the ones who want to spend time on trying to save the victims that can't be saved with the supplies and staff at hand. Their training focuses them so intently on saving lives that they find it hard to say "we can't treat this one". Here's an example from Yahoo News of how not to do triage. That futile effort tied up eleven medics and doctors who could have been working on other patients, and consumed precious IV fluids and drugs. In the USA at a trauma center, it might have been possible to save him. In Haiti it wasn't, and arguably the effort should never have been started.

4 - Helping people. Finally casualty management gets around to the rescue operations. Here's one group from the awesome L.A. County Fire Department's Search and Rescue taking someone from a collapsed building. Notice their constant communication, the teamwork, and the scene control. It took hundreds of people working long hours to get those guys to a wrecked building.

So what does all this mean for Haiti? It's one of the worst possible scenarios I can think of - a huge earthquake in a poor island country with few medical resources. The mostly impoverished population on a good day might have enough stored food for the next day or two. People will die of minor wounds because normally preventable or treatable conditions, such as tetanus and septicemia, can't get treated soon enough. People will die of dehydration waiting for clean water, or of the dysentery they get from drinking dirty water. Recovery will take years, and the scars will be permanent.

Sources:
* Outdoor Emergency Care, 4th Edition, published by Jones and Bartlett
* Haitians die at hospital for lack of supplies By Alfred de Montesquiou, Associated Press Writer Wed Jan 20, 2010
* You Tube Video: Los Angeles Fire and Rescue Team
* http://en.wikipedia.org/wiki/2010_Haiti_earthquake