Is Australia’s health system prepared to respond quickly and efficiently in the event of a mass casualty event? Anthony Bergin and Paul Barnes write that it’s time to test the country’s readiness.
This week an improvised explosive device detonated as thousands of fans left a concert by US singer Ariana Grande in Manchester killed 22 people and left 59 wounded. It was the biggest terrorist attack in the UK in the last decade. But it’s only the most recent incident in a series of mass casualty events across Europe.
On 14 July, 2016 a 19-ton cargo truck was deliberately driven into crowds celebrating Bastille Day on the Promenade des Anglais in Nice, resulting in 86 people killed and 434 injured. On 19 December, 2016 a truck was deliberately driven into the Christmas market next to the Kaiser Wilhelm Memorial Church at Breitscheidplatz in Berlin in an incident that resulted in 12 deaths and 56 people left injured. In Stockholm on 7 April, 2017 a truck was driven into pedestrians and then rammed it into a department store resulting in four lives lost and 15 people injured.
Australia isn’t immune to this type of event. Bourke Street in Melbourne on 20 January this year was the scene of a motor vehicle attack resulting in the deaths of six people and injuring 36.
We need to get better at responding to such events.
Emergency response exercises are often used to test response capabilities. One such exercise was SydEx 2016, a large-scale field test held on Sunday 28 August 2016 and billed as a Central Business District (CBD) Emergency Management Field Exercise. The event scenario focused on the crash of large airliner near Sydney airport.
SydEx developed out of findings from the Central Metropolitan Region 2015 CBD emergency management exercise that had highlighted the need for emergency management arrangements to ensure familiarity with existing plans and protocols across a multi-agency environment. Importantly, that exercise highlighted the need to test responses to a mass casualty incident.
Key objectives of SydEx 2016 were to test triage, movement of casualties, disaster victim registration in an urban environment and the capabilities of ambulance and health services when faced with a mass casualty scenario.
But if a key aim of the exercise was to test how well we’re doing in providing the best care in the pre-hospital environment after a mass casualty event and ensuring the right patients are transported to the right hospitals, then we’d judge that the exercise didn’t really test the ability of our healthcare system to respond to a mass casualty event.
This conclusion is based on several reasons. The mass casualty component was based entirely at the simulated ground zero of the crash – the Barangaroo site – where a casualty clearing station was established without the actual transportation of ‘patients’ to hospital. A manual system tracking the notional transportation of patients was used.
In the scenario, the disaster victims consisted of 500 Corflute ‘persons’ that were each tagged with health and injury indicators, covering triage categories red, yellow and green or deceased. But using plastic cutouts of victims to represent many types of injuries and deceased people undermined the ability to assess how effectively the emergency services could co-ordinate and effectively manage large scale disasters, including mass casualty terrorism attacks.
In the exercise, individual firefighters could ‘carry’ multiple critical patients because they were cardboard cutouts. And that wasn’t the only unrealistic aspect: New South Wales Ambulance had huge numbers of university paramedic students, something that wouldn’t occur in an actual event.
No real people acted as simulated patients in the exercise. No effort appeared to be made by the exercise planners to draw in the professional medical bodies like the Australasian Trauma Society. While emergency services were getting drilled, the hospital system and in particular the Emergency Department (ED) and Intensive Care Unit (ICU) operating theatre surge capacity wasn’t tested.
Neither did the exercise test the logistics of transport through gridlocked panicked city (note it was undertaken on a Sunday), overcrowded EDs, or movement of cases through Sydney hospitals.
Disaster management exercises should be realistic encounters for emergency service workers and our healthcare system in responding to mass casualty events.
A true multi-agency response should include actual movement through the city in real-time and under realistic emergency response conditions to actual hospitals. In the Sydney exercise only one part of the health system was tested: the ambulance service. But even then it seems this was staffed mostly by student paramedics.
Here, too, it’s worth noting the Improvised Explosive Device Guidelines for Places of Mass Gathering issued last year by the Australia-New Zealand Counter-Terrorism Committee.
The guidelines refer to ‘injuries’ and ‘people hurt’ but not that we’re likely to see multiple fatalities and a correspondingly larger number of casualties in a terrorist bombing in one of our major cities. There’s also no discussion in the document of longer-term health issues: not all casualties will be immediately apparent and there’ll be a need to record those who felt the blast effects for medical observation and monitoring.
We need to examine the full emergency medical cycle and this includes activating hospitals for full participation in exercises. We need to focus more on consequence management by factoring in the complete disaster response.
This requires a ‘whole-of-service chain’ activation: hot zone and tactical emergency medical response, pre-hospital care, retrieval, emergency department, and intensive care theatre.
A major study undertaken ten years ago on surge capacities during emergencies in our hospitals, the SCOPE study, predicted that our hospitals would be quickly overwhelmed in the event of mass casualty events, in terms of numbers of seriously injured patients needing immediate access to operating theatres, with a similar lack of access to ICU beds for the critically injured and x-ray facilities for less critically injured patients.
A 2017 assessment of efficiencies in public hospital emergency departments suggests that if tested with a real disaster victim load current emergency department capacities might be rapidly overwhelmed.
The 2007 SCOPE study should be refreshed to see what, if anything, has improved in recent years. This update should factor in the more recent terrorist incidents and the types of injury patterns we’re seeing: more injuries perhaps and fewer immediate deaths, the use of vehicles, and intent to harm first responders/rescuers with secondary explosive devices. Such a study may find that while we’re now able to save the lives of more casualties in such events, our healthcare system will need increased resources and capacity to cope with longer response activation and mass casualty presentations.
But whatever the findings, it should be recognised that hospital surge capacity remains one of the most serious challenges for national emergency preparedness.