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Fri Aug 31 21:32:30 BST 2007

I too agree with you, Pret. One of my favorite things to do, is review risk
management in the journals and at M&M. Truth of the matter is, we will all
be held to ridicule 100 years from now when things are done totally
differently. Look at the "new" resuscitation, utilizing cooling and
electricity..

Remember, the Queda bomber the the US/Canadian border was captured on a
feeling the guard had-- and perhaps the behavior of the individual. These
things are all so subjective and if we truly learned the lessons, would the
reviews be necessary?!

On to the long weekend and 12 hour shifts.

C M Morris

On 8/31/07, Moore, Rick <Rick.Moore at triadhospitals.com> wrote:
>
> Pret,
> Believe it or not, I agree with you. My response is very likely more due
> to the CNN version of the report, rather than the actual report. However
> I do maintain that the very public albeit over simplified version of the
> report will undoubtedly result in numerous fairly baseless and
> unnecessary lawsuits. You are right these reports are necessary for
> improvement, but I feel like they should be protected from general
> public release, which always winds up with a very negative (CNN) type of
> spin on it.
> Thanks for presenting a rational version.
> REM
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Bjorn, Pret
> Sent: Friday, August 31, 2007 9:55 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Va Tech disaster recommendations
>
> Lady and Gentleman,
>
> Consider for a moment that you might be oversensitive.
>
> There is much to be proud of in the local trauma and disaster responses,
> which the report makes abundantly clear.  The mission of the authors was
> to point out potential improvements of the system.  Don't confuse
> responsible process improvement with thoughtless nitpicking.
>
> Plug your ears if you wish; but the recommendations are for the most
> part rational and reasonable, and my guess is that most local providers
> will not spend much time taking offense.  Indeed, I suspect they are
> fast on their way to implementing what recommendations they can.
>
> The mistakes which permitted and ignored Cho's descent into homicidal
> insanity had next to nothing to do with either HIPAA or his civil
> rights.  These were much more a function of insufficient, underfunded
> and disorganized mental health resources, amplified by confusion among
> laypeople forced by circumstance to be surrogate caseworkers.
>
> And let's not get started on gun control.
>
> Pret
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Moore, Rick
> Sent: Friday, August 31, 2007 10:05 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Va Tech disaster recommendations
>
> That is what irks me about these type of reports too. They have all the
> time in the world to review the situation after it happened and find
> fault with the responders and the institution for not being completely
> prepared to handle a situation that has never happened to them before.
> They also keep making a big deal out of the fact that the shooter was
> known to have psych problems but the world hadn't been warned about him.
> This is a glaring example of the great things that civil rights and
> HIPAA has done for us.
> REM
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Charlene M Morris
> Sent: Friday, August 31, 2007 8:53 AM
> To: Trauma &amp, Critical Care mailing list
> Cc: ccm-l at ccm-l.org
> Subject: Re: Va Tech disaster recommendations
>
> I read this account yesterday and was furious that it was reported
> "things could have been done better".
>
> As it is said, hindsight is 20/15 (NOT 20/20, IMO!!) and yes-- as in all
> bad results, there are a series of problems. Let's not buy into
> culpability when all are punished. Perhaps with this sentinel event,
> things will change. THAT is the true test.
>
> C M Morris
>
> On 8/31/07, Jeffrey Hammond <hammond at umdnj.edu> wrote:
> >
> > The formal report from the State of Virginal on the shooting at
> > Virginia Tech has been released. At 260 pages it is a bit much to read
>
> > but the EMS, Hospital, and Emergency Management responses were
> > investigated and outlined from page 100 to page 122. I've copied the
> > key findings and recommendations below.
> > The report should be commended for not concentrating solely on EMS and
>
> > pre-hospital issues. There are a few gaps (e.g. what role did the
> > surgeons gaining emergency credentialing play at other hospitlas; what
>
> > pre-event training did the hospitalists have, etc), and some of the
> > operational details are sparse, but in general I found the report
> > sound and a good example of what we should endeavor to do in future
> events. "Lessons learned"
> > are still those we haven't learned yet from previous events, i.e.
> > communications disconnects, failure to effectively use HICS, delays in
>
> > opening an EOC, questionable value of triage tags, obstacles to
> > patient tracking and dissonance between healthcare and police disaster
>
> > plans for example. Nevertheless, it seems clear that pre-event
> > coordination, planning and exercises paid handsome dividends.
> >
> >  Two "medical" aspects of the report bear special attention I think:
> > 1) The discussion of post-event psychological support for healthcare
> > personnel is directed at pre-hospitl providers and ignores the needs
> > of hospital staff; 2) The recommendation to include hospitalists more
> > prominantly in a disaster response plan is a good one. Hospitalist and
>
> > house physician staff are not generally target groups for disaster
> > training or involved in disaster drills (especially at facilities
> > which are resident heavy), and in my experience an often overlooked
> resource.
> >
> > I suspect this report will be the subject of discussion and debate in
> > the near future as new aspects and insights emerge.
> >
> > The full report can also be seen at:
> > http://www.governor.Virginia.gov/TempContent/techPanelReport.cfm<http:
> > //www.governor.virginia.gov/TempContent/techPanelReport.cfm>
> >
> > *
> >
> > KEY FINDINGS
> >
> > Positive Lessons
> > *
> > The EMS responses to the West Ambler Johnston residence hall and
> > Norris Hall occurred in a timely manner. Initial triage by the two
> > tactical medics accompanying the police was appropriate in identifying
>
> > patient viability.
> >
> > The application of a tourniquet to control a severe femoral artery
> > bleed was likely a lifesaving event.
> >
> > Patients were correctly triaged and transported to appropriate medical
>
> > facilities.
> >
> > The incident was managed in a safe manner, with no rescuer injuries
> > reported.
> >
> > Local hospitals were ready for the patient surge and employed their
> > NIMS ICS plans and managed patients well.
> >
> > All of the patients who were alive after the Norris Hall shooting
> > survived through discharge from the hospitals.
> >
> > Quick assessment by a hospitalist of emergency department patients
> > waiting for disposition helped with preparedness and patient flow at
> one hospital.
> >
> > The overall EMS response was excellent, and the lives of many were
> saved.
> >
> > EMS agencies demonstrated an exceptional working relationship, likely
> > an outcome of interagency training and drills.
> >
> > *Areas for Improvement*
> > **
> > All EMS units were initially dispatched by the Montgomery County
> > Communications Center to respond to the scene; this was contrary to
> > the request.
> >
> > There was a 4-minute delay between VTRS monitoring the incident (9:42
> > a.m.) on the police radio and its being dispatched by police (9:46
> > a.m.).
> >
> > Virginia Tech police and the Montgomery County Communications Center
> > issued separate dispatches. This can lead to confusion in an EMS
> response.
> >
> > BVRS was initially unaware that VTRS had already set up an EMS command
>
> > post. This could have caused a duplication of efforts and further
> > organizational challenges. Participants interviewed noted that once a
> > BVRS officer reported to the EMS command post, communications between
> > EMS providers on the scene improved.
> >
> > Because BVRS and VTRS are on separate primary radio frequencies, BVRS
> > reportedly did not know where to stage their units. In addition, BVRS
> > units were reportedly unaware of when the police cleared the building
> > for entry.
> >
> > Standard triage tags were used on some patients but not on all. The
> > tags are part of the Western Virginia EMS Trauma Triage Protocol.
> > Their use could have assisted the hospitals with patient tracking and
> > record management. Some patients were identified by room number in the
>
> > emergency department and their records became difficult to track.
> >
> > The police order to transport the deceased under emergency conditions
> > from Norris Hall to the medical examiners office in Roanoke was
> inappropriate.
> >
> > The lack of a local EOC and fully functioning RHCC may lead to
> > communications and operational issues such as hospital liaisons being
> > sent to the scene. If each hospital sent a liaison to the scene, the
> > command post would have been overcrowded.
> >
> > A unified command post should have been established and operated based
>
> > on the NIMS ICS model.
> >
> > Failure to open an EOC immediately led to communications and
> > coordination issues during the incident.
> >
> > Communications issues and barriers appeared to be frustrating during
> > the incident.
> >
> > *RECOMMENDATIONS*
> >
> > *IX-1 Montgomery County, VA should* *develop a countywide emergency
> > medical **services, fire, and law enforcement communications **center
> > to address the issues of **interoperability and economies of scale.*
> > *IX-2 A unified command post should be established and operated based
> > on
> > the** **National Incident Management System **Incident Command System
> > model. *For this incident, law enforcement would have been the lead
> > agency.
> > **
> > *IX-3 Emergency personnel should use the **National Incident
> > Management System **procedures for nomenclature, resource typing **and
>
> > utilization, communications, **interoperability, and unified command.*
> > **
> > *IX-4 An emergency operations center must **be activated early during
> > a mass casualty **incident.*
> > **
> > *IX-5 Regional disaster drills should be **held on an annual basis.
> > *The drills should include hospitals, the Regional Hospital
> > Coordinating Center, all appropriate public safety and state agencies,
>
> > and the medical examiner's office. They should be followed by a formal
>
> > postincident evaluation.
> > **
> > *IX-6 To improve multi-casualty incident **management, the Western
> > Virginia Emergency **Medical Services Council should **review/revise
> > the Multi-Casualty Incident **Medical Control and the Regional
> > Hospital **Coordinating Center functions. *
> > **
> > *IX-7 Triage tags, patient care reports, or standardized Incident
> > Command System forms must be completed accurately and retained after a
>
> > multi-casualty incident.* They are instrumental in evaluating each
> > component of a multi-casualty incident.
> >
> > *IX-8 Hospitalists, when available, should **assist with emergency
> > department patient **dispositions in preparing for a multicasualty*
> > *incident patient surge.*
> > **
> > *IX-9 Under no circumstances should the **deceased be transported
> > under emergency **conditions. *It benefits no one and increases the
> > likelihood of hurting others.
> > **
> > *IX-10 Critical incident stress management **and psychological
> > services should continue **to be available to EMS providers as
> > needed.*
> >
> > **
> > **
> > * Jeffrey Hammond MD, MPH
> > Chief, Trauma/Surgical Critical Care
> > Robert Wood Johnson Medical School
> > New Brunswick, NJ
> > *
> >
> > * *
> >
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