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Wed Aug 5 17:13:09 BST 2009

Dr. Mattox:

You might want to contact Dave Crippen, MD direct as he probably has  
contacts at the facilities and could give you more information directly.

Also, I'm betting that this will be a hot topic on the Critical Care  
Mailing List (CCM-L.org), which Dr. Crippen also heads.

ck
Charles S. Krin

In a message dated 8/5/2009 10:09:42 Central Standard Time, KMATTOX at aol.com 
 writes:

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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