Clinical review: The role of the intensive care physician in mass casualty incidents: planning, organisation, and leadership

Initial intensive care unit physician response

Five senior intensive care doctors were in the hospital at the time the major incident was declared, and two more subsequently were able to attend. (Of this total, six were anaesthetists and one a physician.) None of these senior medical staff was notified via the paging system or mobile phone network that a major incident was declared. Runners were more effective in disseminating this information. As patients were triaged to the theatre, there was ICU consultant and registrar input in the resuscitation room and also in the operating theatre complex. Although this separated the staff, it did mean there was regular communication and early management regarding the progress of patients who were ultimately admitted to the ICU.

Intensive care unit command and control

The senior nursing office area in the ICU was set up as the ICU coordination centre, with the ICU matron taking a lead administrative role in organising and dispatching runners to get updates, particularly from the operating theatre. A local supermarket provided free food for the ICU staff during the afternoon of 7 July. As the day progressed, one ICU registrar was assigned as a dedicated clerk, working at a computer terminal producing an updateable worksheet on each individual patient with details of injury pattern, investigations, results, and completed and planned surgery. This was the singularly most useful effort and made the planning and organisation of subsequent care for each patient more streamlined.

Intensive care unit patient flow through the hospital

Of the seven patients who were admitted to the ICU, all were post-operative and sedated and ventilated, and their triage had taken place in the resuscitation room by a senior surgeon. As a result, no patient admitted to the ICU had fully completed secondary surveys and several had missing radiology. Three ventilated patients were identified as being fit for transfer and were taken to other hospitals in Northeast London with capacity expanded by the cancellation of major elective surgical procedures. Four non-ventilated patients were transferred to other hospital beds at the RLH. All HDU beds except one were cleared and patients moved to ward care. The five empty HDU beds were set up as emergency ICU beds, with an additional four satellite beds set up in the operating theatre recovery area. This work was done mainly by the critical care outreach team (CCOT), but during the event all of the intensive care patients were accommodated within the physical space of the ICU.

All of these patients required ongoing critical care support for an extended period of time (beyond the average ICU length of stay) and all required repeated surgery. Over 180 hours of additional theatre time were required over the following 3 weeks. Hospital length of stay was variable, and outpatient follow-up for physical, as well as psychological, support is still ongoing [3].

The successful outcome of the vast majority of patients admitted to the RLH ICU on 7 July was multi-factorial and included the relatively low number of seriously injured casualties and the ability to contain them all within the ICU. This enabled effective teamwork by clinicians from many specialties who already had extensive experience dealing with poly-trauma patients. At the time, however, this situation generated many organisational and clinical learning points, which have been incorporated into future training for medical and nursing staff in the ICU, particularly in relation to flu pandemic planning.

Most major incident planning concentrates on the first 6 hours, when most patients will not yet have reached the ICU. There is little emphasis on the impact of this phase of care from the ICU point of view or, in fact, on what is now termed 'the prolonged-care phase' following ICU admission.

Why should intensivists become involved in disaster planning?

It may seem to some that events on a large scale are the remit of someone else's planning responsibility. Beyond planning, many/most assume that the government and/or the military will provide the necessary response capabilities. These misconceptions can easily lead to three forms of denial: (a) it will not happen here, (b) it will not happen to me, or (c) someone else will take care of the problem.

Israeli physicians have shown that 4.7% of patients presenting to the emergency department after terrorist bombings require intensive care. In their experience, the greatest use of ICU personnel and equipment occurs during the resuscitation and resource allocation phases of the response to the incident; their presumption is that around 70% of the patients admitted to the ICU would require mechanical ventilation [4].

Often, while the initial emphasis is on expanding bed capacity, scant attention is paid to the longer-term critical care needs of these patients. Intensivists not only bring a multi-disciplinary approach to planning, but also have the day-to-day clinical experience in dealing with the sickest patients in hospital [5]. In addition, this care is often delivered with limited resources and stretched to capacity during 'normal' circumstances. Also, intensivists are able to predict where and why bottlenecks in patient management would occur since this is often a daily feature of their work. Finally, in the event that insufficient facility ICU resources are available, critical care will be provided in other non-ICU areas of the hospital. Who will provide this care? How will it be accomplished? What basic ICU skill sets should be taught to other hospital personnel? Deliberate planning around these issues must occur in hospitals and should be led by engaged critical care professionals.

Why should intensivists be involved in disaster planning, education, and training?

Disasters, whether natural or man-made, have always been part of human existence. Current evidence continues to support the threat of terrorism or of a man-made disaster occurring. Most emergency planning at the governmental level is on the basis of 'when' rather than 'if' and as such hospital planning must reflect this outlook [6].

A major incident plan should be based on local and regional facilities, incorporating experience gained from previous incidents and planning exercises. Planning in isolated 'silos' (as opposed to a more broadly considered systems-based approach) causes weaknesses that become all too apparent in the subsequent execution of a disaster response. Coordination of care as well as interoperability among the various work areas within the hospital will be hampered. And, unfortunately, most existing planning processes do not address necessary and essential critical care requirements.

We believe it essential that, in addition to involvement at the local level, all intensivists be acquainted with disaster response activation procedures as well as the roles and the responsibilities of various levels of command and control groups when disaster plans are activated.

Anaesthetists receive specific training in incident awareness which extends beyond clinical content, including the non-medical aspects of high-performance team behaviours. Similarly, intensive care physicians should look upon their unique role in the provision of major incident care as an opportunity to develop the same skill sets [7].

Increasing capacity

On 7 July, there was an initial expectation to have to provide intensive care to a large number of casualties and increasing bed capacity was initiated with this in mind. In addition to the transfer of stable longer-term patients to neighbouring hospitals, patients on the ICU and surgical HDU who did not require inotropic or invasive ventilatory support were transferred to general wards, their care supported by the CCOT. The CCOT also supervised setting up a six-bed satellite ICU in the HDU. In addition, one of the recovery rooms was identified as a holding bay for patients prior to admission to the operating theatres and could also be used as another intensive care area. General ward areas were cleared and patients discharged to the community under the care of the primary health care system. Elective operating was suspended at the RLH as well as two nearby hospitals. Fortunately, the number of severely injured casualties admitted to the hospital was limited and these facilities were not required.

District general hospitals in our network area saw their casualty attendance rise as non-incident-related casualties diverted spontaneously. In the first hour after the bombings, the hospital switchboard received 25,000 additional calls, which rendered the internal phone system non-functional for the remainder of the day. The mobile phone networks were blocked at an early stage of the disaster to facilitate emergency service communication. Flexibility was required to use other resources (runners and internal email) to overcome the loss of these contact facilities. During this phase, the ongoing care of other (pre-event) critically ill patients required dedicated staff provisions in order to prevent attention being diverted exclusively to the disaster casualties.

The difficulty in planning was the uncertainty of when the flow of seriously injured casualties would stop. It was noted in the Madrid bombings of 2004 that the hospitals closest to the incidents were quickly overwhelmed [9]. This was not encountered in our situation, although more patients were triaged to our location due to its identifiable association with trauma management and the London Helicopter Emergency Medical Service.

Much emphasis has been placed on the 'command and control physician' in trauma resuscitation and this has been shown to enhance the performance of the trauma team [10, 11]. In the intensive care setting, the intensivist should act as the conduit for all information flow regarding patient management decisions. This aspect of teamwork is liable to be put under pressure in disaster scenarios, especially highly emotionally charged situations, with the potential breakdown of the normal decision-making hierarchy.

On the day of the bombings, the senior nurse in the ICU became responsible for organising and dispatching runners to get updates, particularly from the operating theatre. A junior doctor was dedicated to compile work lists on a database as each patient was admitted, listing injuries, investigations, as well as current and planned treatment. This made planning subsequent care for each patient much clearer and smoother.

Multiple surgical teams were involved in patient care, and in subsequent days we found that teams made decisions without up-to-date knowledge regarding current patient status. The root cause of this shortcoming was the location of the handover meetings. We found it essential to centrally locate these multi-disciplinary meetings in the ICU itself rather than at a variety of distant locations.

Clinical triage

Of immediate concern on the day of the explosions was that the hospital triage aligned patient needs with available resources. If an explosive-type disaster yields low numbers of critically injured patients, over-triage is likely to be a problem, with the attendant risk of increasing overall mortality [12]. On the day of the bombings, patients were triaged directly to the operating theatre by a senior surgeon who assigned a surgical 'team' (anaesthetist, surgeon, and operating department practitioner) to each of the patients to follow them from admission to the hospital through to the operating theatre and ultimately delivery into the ICU.

One of the early problems encountered was the identification of casualties. The standard triage system (casualty numbers assigned at the scene) did not 'dovetail' with our hospital's existing patient numbering system. Assigning additional hospital identifiers complicated cross-matching blood products, obtaining laboratory results, and requesting radiological imaging. The numbers assigned at the scene were not site-specific and caused initial problems in identifying victims. This experience is not unique and it has been suggested that separate documentation in such incidents be abandoned in favour of standard day-to-day paperwork [13].

The concept of 'damage control' resuscitation and surgery is not limited the operating theatre [14]. It is incumbent upon the ICU physician to become involved in a patient's care at the earliest opportunity. This means a presence in the resuscitation room. On the day of the bombings, there were three ICU physicians present in the emergency department who were directly involved in the resuscitation phase of the most seriously injured casualties.

Ongoing care

While the casualty surge proved to be relatively brief and the hospital resources were able to accommodate all patients in a timely and appropriate fashion [12], this initial 24-hour burst of activity was just the start of a prolonged-care phase that greatly increased the surgical, anaesthetic, and intensive care workload.

As soon as the emergency department was cleared of casualties (within a few hours following the event), the major incident response was stood down. Within 5 hours of the start of the incident, the emergency department was reopened to major trauma casualties without necessarily considering the potential impact on the operating theatres (all working to maximal capacity). It is vitally important that these sorts of decisions be communicated and acknowledged at the managerial level and incorporated into the incident plan. (The seven patients admitted to the ICU arrived hours after the hospital major incident had been stood down.)

The haematology department at the RLH was one of the last to be informed that a major incident had occurred; this was identified as a weakness in the response to the incident at the time. In Israel, reliable access to blood for transfusion as part of the response to terrorist acts is seen as vital. This can ensure the blood supply in times of disasters and minimise outdating and wastage [15].

The timing of subsequent surgical intervention requires a combined surgical, anaesthetic, and intensive care approach. Recent evidence suggests that the inflammatory response to multiple trauma can be exacerbated by surgery that extends beyond the remit of damage control in the early stages [16].

To facilitate the number of complex admissions, we increased the number of senior staff working the 24 hours, with a rotational system of senior staff to spread the workload. It proved difficult for all concerned to retain focus on the care of the other ICU patients and we formally divided duties to maintain consistent patient care to all.

Beyond the initial crisis, there is a need for longer-term planning as recovery from critical care can take weeks and months. Where extensive physical injuries are involved, multiple surgical procedures often are followed by intensive and sometimes prolonged rehabilitation. The lessons learned in Australia and Israel can prove useful in guiding requirements in this phase of care [17, 18].

Reflection and debriefing

The problems we faced following the events of July 2005 were not unique and are seen on an ongoing basis in other parts of the world, including settings of insurgency warfare, such as in Iraq and Afghanistan [19, 20]. Even with a comprehensive major incident plan and daily experience of multi-trauma patient management, there still were some obvious deficiencies in our system. The ethical dilemma of 'non-clinical' transfers is an uncomfortable aspect of increasing capacity which needs to be considered and agreed upon in advance. Not all of these were initially apparent and it took more than 6 months to collate data. A dedicated hospital-wide audit also brought the various teams together to get a broad base of learning points. Intensive care services have an important position in relation to these types of casualties and our major incident plan had to be revised and extended to include bioterrorism and infectious disease strategies [21, 22]. The detonations occurred in the relative confines of underground train carriages and tunnels and in a bus. The initial management focused on the basics of intensive care, achieving optimal oxygenation and perfusion, with a shift in individual patient management dependent on the injury profile [23, 24]. Bedside toxicology and chemical agent monitors should be available in the ICU setting to screen for the possibility of exposure. The extent of our normal daily emergency workload as a major trauma receiving centre, combined with a reasonable major incident plan and the flexibility of all members of staff, were also major contributory factors. The ability to provide best-practice care without compromise probably contributed to our low mortality. The long-term psychological impact of a terrorist act should not be underestimated. Communication with psychological support staff at an early stage is essential to ensure that patients, relatives, and staff can be advised of how to access these services, should they be required [25].