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Wed Aug 5 17:17:39 BST 2009

Thx. I will but since this did occur in Pittsburgh, and we are  discussing 
Disaster System Principles to apply to our own communities, it is  best if 
those OUTSIDE of Pittsburgh at this time be the discussants.  

k

In a message dated 8/5/2009 11:14:34 A.M. Central Standard Time,  
Krin135 at aol.com writes:

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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