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Fri Nov 28 13:57:05 GMT 2008

The inclusion of hospitals on the target list can't shock anyone.  We've fretted over the possibility several times  on the Trauma-List.  But in the real world, large emergency preparedness systems persist in a woeful vacuum of imagination.  Regrettably, Mumbai may serve as an opportunity by way of an object lesson.

Even in our own highly detailed and sophisticated regional plans here in the bucolic reaches of Maine, protecting the hospitals remains almost exclusively the HOSPITALS' responsibility.  Realistically, we're told, law enforcement and the national guard will be absorbed in defending the smoldering rubble of ground zero.  Healthcare facilities are thus instructed to initiate lockdown procedures, under the assumption that an internal hospital lockdown of this scale -- and under these conditions -- can somehow be effective.

Of course, such is hilariously outside of the healthcare skill set, and American hospitals are security nightmares on the quietest days.  As if to punctuate the irony, secondary attacks are actually built into our training scenarios (among a short list of "internal" or "paralytic" disasters), silently asserting that they're inevitable.  The organizational, community, and regional plans ANTICIPATE these attacks, but devote no functional systematic resources to PREVENTING them.  

Especially in this context, we are imperiled by our organizational and philosophical silos.  Shamefully, our response is not to abandon the silos, but to INTERCONNECT them, on the fly, literally while the bombs are going off.  It's abjectly oxymoronic; a Rube Goldberg solution which serves mostly to defend and perpetuate dangerously restrictive paradigms.

Until we can project and protect the needs of civilian healthcare under combat conditions, we must expect the collapse of civilization at the local level.  If it comes to that, the most prudent disaster response for healthcare workers will be to run like hell.  

With any luck, events of recent days will convince us that hospitals are uniquely important, alarmingly vulnerable, and inherently incapable of protecting themselves.  The larger the assault, the more imperative it will be to circle the tanks around our hospitals.

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of John Annen
Sent: Friday, November 28, 2008 3:41 AM
To: Trauma &amp; Critical Care mailing list
Subject: Re: Mumbai & other event observations

According to media reports, at least one and possibly two hospitals in Mumbai came under attack during the current incident. This represents a terrible aspect of caring for the sick and injured victims of disasters. The safety and security of the hospitals and other institutions providing the care should perhaps receive greater attention. Certainly this issue has been addressed to some extent, but how many of you believe that your own facilities are prepared, should they come under direct attack as part of a terrorist incident? Granted, the chances that any given institution would be attacked are small, which argues against putting substantial resources into the protection of individual hospitals, but when it does happen, I expect the effects can be devistating both for the hospital itself, and for the community and health care system which it serves.

Does anyone have more information about the attacks against the hospitals in Mumbai? Has any research been done into the systematic provision of health care in a civian setting while "under fire"?

Regards,
John Annen
Zurich, Switzerland

________________________________
From: "KMATTOX at aol.com" <KMATTOX at aol.com>
To: trauma-list at trauma.org
Sent: Friday, November 28, 2008 1:22:43 AM
Subject: Mumbai & other event observations

1.    Every since Allison, Katrina, and Ike, I have been  pondering the 
issues of (TRAUMA) surgeon's role in disasters, particularly one  like we have just 
witnessed in Mumbai.  I have watched disasters the  past 5 years have 4-5 
doctors and an additional 4-5 nurses per patient with more  than 85% of the 
disaster causalities at the trauma center having extremely minor  conditions.  

2.    I do believe that the issue of SURGE has been both  UNDER and OVER 
emphasized.    It is poorly  understood.    I am very curious as to what the real 
surge was at  Charity in New Orleans, at the major hospital in Minneapolis, 
at the designated  trauma centers in Washington DC and NYC during 911, during 
the fires in  California, at Parkland during Katrina,  In San Antonio,  etc.  
  In the USA, except for a stressful Friday night in  the ER, we have not 
really experienced Disaster Surge.  

3.  Despite the rhetoric, we in the USA have more lectures  about SURGE, 
than we have had experience.  

4.  In Mumbai, the very few trauma centers certainly has  significant SURGE 
with their more than 300 blast and GSW victim, although, I  calculate the 24 
hr surge there to be less than 25 patients, making the CITY  WIDE surge only 
1/hr if my calculations are correct.    

5.  I would like to chat off line with the few persons in the USA (and  
outside if really experienced and interested) who have had experience with large  
simultaneous experience with penetrating trauma, other than the "busy Friday 
and  Saturday night".  I would request that interested persons contact me  
(_Kmattox at aol.com_ (mailto:Kmattox at aol.com)  )  or Dr. Norman  McSwain  (  
_nmcswai at tulane.edu_ (mailto:nmcswai at tulane.edu) ) of your interest and  experience.  
  I have a couple of hypotheses I would like  to discuss with those who have 
really really been there.  

6.    Recall that ALL TRAUMA DISASTERS are  LOCAL.    This is a time for the 
kind of interactive  collaborative networks that we see in Connecticut, 
Texas, and  elsewhere.  It is the kind of network which was headed by Dr. Ron  
Stewart for the 5 state ACS Region VI during Katrina and Ike.  That  worked like 
a charm.    

7.    After a great deal of reflection and analysis, I am  also about ready 
to give strong recommendation that the entire OUTSIDE Physician  assistance 
response for TRAUMA disasters be totally reanalyzed, rethought, and  reorganized. 
  This includes:  DMAT, NDMS,  Rangers,  etc.  There are a significant 
number of problems with these concepts  and a number of areas that did not work 
during the recent disasters in the  USA.  I would call upon the Disaster 
Committees of the AMA, AHA, ACS,  ACEP, and others to seriously honestly look hard at 
what we all have learned  together the past 10 years about real time MEDICAL 
DISASTER.  I am  not talking about evacuations, shelters, public health, etc. 
    I'm talking about the first 24-36 hours.      

I look forward to hearing from a few good men and women who have been there  
and done that.  I want to exercise your  brain.      

Kenneth L. Mattox, MD

PS    Norm McSwain and I have already  chatted.    We do not have solutions, 
we do have some questions  and observations.  

k
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