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Wed Aug 5 17:08:04 BST 2009

I have been following this story since last evening.    This  time it 
occurred in Pittsburgh, and involved a community at the periphery of  Pittsburgh, 
not downtown.    It is tragic as to what happened,  and the victims ranged 
from minor to critical.   They were taken to  three hospitals.       This is 
just a peripheral  observation as ANY community in the world could and will 
face a SYSTEM mass  casualty or disaster situation.    In this instance, it 
appears  that this was no greater than a busy Friday night in anyone's ER, 
but it gained  national attention because it was a single shooter in an 
exercise  gym.      Now for some editorial comments relating to  trauma care, 
disaster systems etc.

1.    Pennsylvania trauma system is governed by the  Pennsylvania Trauma 
Foundation.   I do not know if the disaster  systems response or mass casualty 
systems approaches are under the PTF or  not.   I do know that with most 
instances such as this, there are many  silos that want to be the boss and get 
the credit.   When this occurs,  the system care is often jeopardized.  My 
comments here are not  directed at Pittsburgh, but in general.   I would 
plea that every  community have a system approach for such an event which 
involves law  enforcement, the trauma system, the EMS system, public health, and 
Critical  Care.   I only know of ONE state where this is occurring and all 
work  together in an integrated manner and that is Connecticut.    Such  an 
integration must be in place AHEAD of time or mass confusion and posturing  
breaks out among the many silos.     I saw just a bit of  that happening here 
on the very very late news last night.  

2.    During most disasters, and mass casualty situations,  after one 
eliminates the dead, and obviously those who will soon be dead and  have non 
survivable injury etc, the 10% rule exists.   That is only  10% or less of those 
involved need to go to a hospital, and of that group only  10% have 
immediate life threatening conditions (1% of the original  group).    From my 
calculations of the very little data I  obtained from the Internet and news 
reports from last night and this morning,  these statistics seemed to hold true 
again.   

3.    Even though the 10% rule and statistical papers  regarding surge 
capacity have been widely published, the ERs of the receiving  facilities are 
often massively over loaded with far too many people.    I am currently 
attempting to get data from the Internet reports about the  numbers of providers 
in the three hospitals to which the victims were  taken.   I would suspect 
that at least 2 of the hospitals activated  their disaster plans and had far 
too many doctors, nurses , etc. when the  immediately available data did not 
support disaster plans activation, and the  SURGE limitations are not in the 
location where the patients arrived (EC), but  the ORs and ICUs.    That is 
why pre-planning for a system  approach with OR and ICU persons on the 
planning committee is  essential.    We have learned these lessons over and over 
 again.  

4.    This now brings up my last point.    It  is key that the system find 
the 1% of critical patients very early and send them  to the right place 
quickly.    As one examines the disasters  which have occurred in the United 
States during the last 20 years, including  911, this often did not happen.    
In the Washington DC area  following the Pentagon being hit, not one 
patient was taken to a local or  regional verified Level I Trauma Center.   Very  
interesting.    In Pittsburgh last night, it seems that perhaps  two 
patients were CRITICAL.   Those individuals optimally would be  taken immediately 
to a facility that routinely during everyday operations would  have received 
such critical patients, and that most often is NOT the closest  facility.    
I have not yet determined just who went where, but I  suspect there was an 
element of secondary triage and transfer.   This  kind of delay is often the 
case during disaster and mass casualty, when it is  not for just another 
busy Friday night.   That is because when a  disaster is declared, there is 
often a group of people calling the EMS and  distribution shots that are not 
involved in every day EMS  operations.   This gets us back to the issue of 
pre planning using all  of the right people in a community

The purpose of this post is for all of us to optimally learn positive and  
negative lessons from sad events such as this.   I am point no fingers  at 
all, unless I am pointing at myself and my own city and  state.    Let us all 
build on the lessons of the past.  

Kenneth L. Mattox, MD
Houston

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