Sample questions from the questionnaire. Overall, more than 200 questions with their individual response categories were included. Only a small sample of the questions is presented. Respondents were first asked to provide relevant responses within the response categories provided for each question and then encouraged to comment on the issue at hand. ED indicates emergency department; OR, operating room; and TMCE, terrorist-related multiple-casualty event.
The respondents' opinions regarding the quality of data (eg, the scale of the event and the impending arrival of severely injured patients) obtained via the various communication channels during terrorist-related multiple-casualty events. EMS indicates emergency medical services.
The respondents' preferences for the decision to proceed with an operation in a patient who had been anesthetized immediately prior to a terrorist-related multiple-casualty event. PACU indicates postanesthesia care unit.
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Einav S, Spira RM, Hersch M, Reissman P, Schecter W. Surgeon and Hospital Leadership During Terrorist-Related Multiple-Casualty Events: A Coup d'état. Arch Surg. 2006;141(8):815–822. doi:10.1001/archsurg.141.8.815
During terrorist-related multiple-casualty events (TMCEs), the role of the surgeon expands beyond providing traditional trauma care.
Survey and expert opinion poll.
Interviews (structured, open/closed questions) conducted in 14 Israeli hospitals.
Sixty hospital physicians selected for their experience in TMCEs.
Main Outcome Measures
Identification of key staff members and their roles during TMCEs and development of recommendations for hospital management.
During TMCEs, hospitals are comanaged by a physician hospital administrator and a clinical medical director (usually a surgeon) responsible for prioritization of patient care. Primary triage is often performed by a general surgeon experienced in trauma. Trauma specialists supervise other physicians providing patient care. Key staff members to recruit to the hospital at event onset include the chiefs of surgery and anesthesiology, attending surgeons and anesthesiologists, critical care physicians, and radiologists. Paramedics stationed in-hospital as emergency medical services liaisons improve communication between the field and the hospital. Operating room and intensive care unit (ICU) management remain unchanged. Controversies exist regarding continuation of planned and ongoing elective surgery and ICU triage despite use of the postanesthesia care unit as an extension of the ICU.
During TMCEs, surgeons fill pivotal roles in hospital command and control and hands-on clinical care. Anesthesiology services and ICUs are relied on heavily for provision of patient care and should be included in information flow and decision making. Operating room and ICU management should remain unchanged since the care of patients who are already in these locations at the time disaster strikes is a subject of controversy with ethical implications.
Civilian populations increasingly constitute the front line in modern warfare as the prevalence of terrorist-related multiple-casualty events (TMCEs) and state-sponsored bombing rises worldwide. During TMCEs, any hospital adjacent to the location of the incident may be called on to function as an evacuation hospital, thus becoming pivotal in patient treatment during the event.1 Proximity to the event rather than trauma accreditation will often determine the role of a given hospital in response to a TMCE.
Optimal trauma care of a single patient requires multidisciplinary coordination. Treatment of multiple patients simultaneously demands excellent managerial decisions and teamwork and never more so than during TMCEs, when hospital capacity may be overwhelmed despite full resource mobilization. Yet at these crucial times, this demand may be imposed on the hospital least prepared to provide the necessary care.
Strategies for medical management of TMCEs are currently undergoing rapid evolution. Major discrepancies may occur between estimated and actual resource requirements because the response to a TMCE is a dynamic process. Both the disaster plan and the key decision makers must be flexible enough to make course corrections in real time to provide the optimal response. Surgeons have traditionally functioned as leaders in trauma care of the single patient, but the strategies for overall hospital organization and the specific roles of the surgeon in hospital management and teamwork during TMCEs are yet to be clarified.
The current study was designed to identify key staff members for hospital organization during TMCEs and to obtain information regarding the strategies that have been developed and implemented by Israeli hospitals for efficient overall hospital organization during TMCEs. Investigated categories include (1) overall organization (event management and staff recruitment), (2) emergency department (ED) management, (3) operating room (OR) management and scheduling, (4) intensive care unit (ICU) management (eg, admissions and transfers), and (5) use of postanesthesia care unit (PACU) resources. The specific role of the surgeon was studied within each of the investigated categories.
This report reviews our current level of understanding regarding each of the examined categories based on the expert opinions of 60 hospital physicians selected for their TMCE experience. We hypothesized that the role of the surgeon during TMCEs is greatly expanded beyond providing traditional trauma care. If supported, this finding would have major implications for both disaster planning and surgical training.
Following waiver of consent from the institutional review board, semistructured, in-depth, individual interviews were conducted with 60 attending physicians working in various hospitals throughout Israel and selected for their broad professional experience with in-hospital patient care during TMCEs. A third of the interviewees were also advanced trauma life support instructors. The sample size of the focus group was based on the principle of theoretical saturation in qualitative research.2
The interviews were performed by 2 of the researchers (S.E. and W.S.). Prior to beginning the interview, the interviewee received an explanation that the questionnaire relates primarily to bombings in public locations since this mode of operation is common in Israel. A structured questionnaire, created for the purpose of this study, was used to guide the interview and provide a common denominator for the interview. The questionnaire included more than 200 open as well as closed questions, and interviewees were encouraged to provide comments during the interview. Issues addressed in the questionnaires were management of primary triage, staff recruitment, command and control, patient care (in ORs, EDs, PACUs, and critical care units), communications, and transport. Within each subheading the questions addressed not only current practice but also the interviewees' opinions regarding this practice (eg, who performs primary triage during TMCEs and who should perform primary triage during TMCEs). Sample questions from the questionnaire are presented in Figure 1.
Two databases were constructed for the purpose of data collection. The responses to the structured questionnaire were collected using SPSS version 10 (SPSS Inc, Chicago, Ill), and interviewees' comments were listed using Microsoft Office Excel 2003 (Microsoft Corp, Redwood, Wash). The contents of comments made by the interviewees were analyzed by 2 independent researchers who assigned them to relevant subheadings. Each researcher described the comment to the best of their understanding and listed it within the relevant subheading separately. Comments were considered adequately understood when they were assigned similar meaning and categorized within the same subheading by both researchers. The number of interviewees repeating each comment was documented.3 Statistical analysis was performed using SPSS version 10. Descriptive statistics used included counts and proportions.
Sixty respondents (30 general surgeons [50%], 25 anesthesiologists and critical-care physicians [42%], and 5 physicians [8%] from other related disciplines) from 14 hospitals were interviewed. Most (72%) had participated in more than 10 TMCEs. When pooled, their interviews provided more than 450 cumulative TMCE experiences.
Validation of these events as multiple-casualty incidents was performed by questioning the respondents regarding the availability of staff and equipment at the time of the event in relation to the number of arriving casualties.
Terrorist-related multiple-casualty events are usually managed by a clinical coordinator and an administrative coordinator (a physician member of the hospital administration). The clinical coordinator, usually an attending surgeon, is responsible for minute-by-minute decisions regarding priorities in distribution of resources for patient treatment. The administrative coordinator is responsible for recruitment of staff and resources. A representative of the hospital administration (together with the hospital public relations division) is responsible for communication with the media.
Tight security measures are implemented by the on-duty hospital security officer immediately on notification of TMCEs. These include limitation of access of nonauthorized vehicles to the hospital, closure of key hospital locations to the media and the general public, and searching the various hospital locations and the personal possessions of new arrivals (visitors and patients) for weapons or ordinance.
Most respondents (75%) agreed that an in-hospital paging system should be used to recruit relevant in-hospital personnel, particularly to staff the ED immediately on notification of an event. Respondents from all of the hospitals in the study mentioned that staff already present in the hospital at the time of a TMCE had reported occasional recruitment by this method.
Conventional communication systems have been known to collapse during TMCEs, highlighting the importance of correct prioritization of staff recruitment from outside the hospital. In Israel, several attending surgeons and anesthesiologists regularly receive pages directly from the national emergency services. When a TMCE occurs, they are notified immediately. Hospital calling systems that were intended to recruit staff from outside the hospital (particularly cellular phones) were considered effective by only 53% of the respondents, and 58% noted that their arrival at the hospital usually did not result from such calls. Almost half of the respondents noted that the collapse (planned or otherwise) of conventional communication systems during TMCEs impedes staff recruitment and emphasized that priority should be given to resolution of this issue.
When requested to define priorities for staff recruitment, respondents unanimously demanded the immediate presence of the chief of surgery, attending surgeons, and surgical residents (Table 1). The respondents based this demand on the multiple roles filled by surgeons in the surveyed hospitals during TMCEs (Table 2). Respondents were also unanimous in their demand for attending anesthesiologists, the director of anesthesiology, and anesthesiology residents (Table 1). Specialists in orthopedic surgery, emergency medicine, and critical care were called in immediately by more than 90% of respondents. All respondents considered in-hospital security staff crucial for event management and efficient crowd control in the ED. The proportion of respondents demanding immediate recruitment of the hospital chief of security (85%) was similar to the proportion of respondents demanding specialists in thoracic surgery, vascular surgery, and radiology. The hospital director was placed in the first priority call of only 51.7% of the respondents.
Once the occurrence of a TMCE has been circulated by the media, large numbers of hospital staff members (not necessarily trained in trauma care) flock to the hospital to offer assistance. Most respondents noted that the presence of too many staff members had interfered with their work in the ED (83%), ORs (7%), and PACU (10%). Surgeons felt that their work as team leaders was hampered by the presence of bystanders particularly in the ED (93%) and OR (16%). Superfluous staff members were primarily physicians (78%), administrative staff (57%), and nurses (27%). One method implemented to overcome this issue is isolation of critical treatment areas (ie, ED, OR, PACU, and ICU) by closure of all entry points by hospital security and allowance of entry solely by tag identification. Several respondents suggested that rather than turning away additional staff members, these individuals should be directed to a standby location from where their assistance may be requested as needed.
Since ED inundation is the rule during the initial phase of a TMCE, all respondents agreed that as many as possible of the patients who are already in the ED when the disaster occurs should be transferred to an alternative location immediately on notification of a TMCE.
Only 45% of the respondents felt that the quality of data provided to hospital staff regarding the situation in the field was satisfactory. Satisfaction with the quality of the information received from the field was more common among surgeons (57%) than among anesthesiologists (31%). Respondents often felt that important information such as the scale of the event and the impending arrival of severely injured patients was not provided to the correct people. The respondents' views regarding the potential benefit and reliability of various sources of information are presented in Figure 2.
Most respondents concurred that primary triage should be performed by an attending general surgeon (73%) outside the entrance to the ED (82%). Eighty percent of the respondents who were attending surgeons (n = 30) concurred that ideally the triage officer should be a surgeon experienced in trauma rather than the person designated as the trauma specialist of that hospital.
In Israel, there is no official trauma fellowship training program. Some hospitals designate a surgeon who has received trauma training abroad as their trauma specialist. Others designate a surgeon who has not received formal trauma training other than army and advanced trauma life support courses but has been nominated by the director of surgery to serve as the trauma specialist based on his or her experience and interest in trauma. This person directs the planning and training of the entire hospital preparedness and response program. When a TMCE occurs, the trauma specialist serves as the hospital incident commander who is in charge of hospital management. This surgeon often circulates among hospital locations to monitor events occurring at the multiple treatment sites and at the same time acts as supervisor/consultant to other physicians providing patient care in these locations.
According to 72% of the respondents, primary triage is often performed by a surgeon experienced in trauma who is not the hospital trauma specialist. In 12 of the 14 participating hospitals, the respondents stated that an attending surgeon performs the primary triage during a TMCE. Terrorist-related multiple-casualty events do not necessarily occur during office hours. No Israeli hospital maintains an in-house trauma specialist, and on-duty teams often consist of younger surgeons or even residents. Thus, respondents from only 3 hospitals stated that the triage officer was commonly a trauma specialist. Primary triage is usually performed in the first stage of the event by the most experienced surgeon present in the hospital at the time and later (on their arrival to hospital), by a senior surgeon with experience in trauma surgery.
Operating room management during TMCEs remains a source of contention. Operating room administration hierarchy usually remained unchanged from the routine practiced in times of calm, and a large number of respondents noted the importance of maintaining this routine. However, respondents from 8 hospitals stated that anesthesiologists participate in OR management, and respondents from 10 hospitals stated that surgeons participate in OR management. Notably, there were differences of opinion regarding actual management even among respondents from the same hospital. One third (11 of 30) of the interviewed surgeons thought that OR management during TMCEs should not be performed by an anesthesiologist, even if this does occur on a daily basis.
The respondents concurred that initiation of elective surgery had been and should be suspended until the scale of the event is clarified (in all 14 hospitals). Patients already in the OR holding area either remained there until more information became available (in 13 hospitals) or were sent back to the floor (in 9 hospitals). The decision to proceed with an operation in a patient who had been anesthetized immediately prior to a TMCE was controversial (Figure 3). Searching for options to shorten ongoing surgery was considered a real option by a total of 17% of the respondents and by 13.3% (4/30) of the surgeons.
The PACU had been used for at least 1 of the following 3 functions in all but 1 hospital: as an extension of the ICU (12 of 14 hospitals), as an extension of the ED for severely injured patients (9 of 14 hospitals), and as a temporary location for patients waiting to enter the OR (13 of 14 hospitals). Although patients already in the PACU prior to the TMCE were often evacuated (13 of 14 hospitals), such practice was controversial: 10% of the respondents said all patients should be transferred, 23% thought patients should be transferred only if their care would not be seriously compromised, and 12% hinged the number of patients to be transferred on ED demand and 7%, on ICU demand. Surgeons participate in the selection of patients to be evacuated from the PACU in 4 of 14 hospitals. Most of the surgeon respondents considered it preferable that these decisions be made by the anesthesiologists.
Intensive care unit bed availability was a concern raised by several respondents. In these unique circumstances, pressure is often placed on ICUs to evacuate patients already in the ICU at the time of the TMCE. Most respondents (75%) claimed that patients were routinely evacuated from the ICU in their hospitals (13 of 14 hospitals) to admit TMCE casualties. A quarter (25%) of the respondents knew of an ICU patient whose condition had deteriorated secondary to being transferred from the ICU.
Table 3 summarizes the authors' recommendations for hospital management during conventional TMCEs.
The current study demonstrates that surgeons and anesthesiologists constitute the foundation of trauma care in TMCEs and details the relative importance of key staff members essential to overall hospital management and individual patient care during TMCEs; priority is given to physicians who are instrumental to immediate hands-on patient care rather than administrators. Surgeons spearhead not only the trauma care of individual patients but also function in most TMCEs as clinical coordinators (attending surgeons) and supervisors/consultants (trauma specialists) and are responsible for primary triage (attending surgeons with trauma experience). Anesthesiologists are responsible for OR scheduling and intensive care regardless of location (ED, ICU, or PACU).
To our knowledge, this study summarizes the largest pool of experience in hospital management of TMCEs to date. Evaluation of hospital disaster plans by activation during actual TMCEs is rare. Even simulation is not a common occurrence. In a survey conducted in the United States, the existence of a statewide disaster plan was reported by most states (94%), but few (48%) reported testing by activation.4 Alternatively, studies suggesting principles for hospital management during TMCEs based on previous experience usually describe the experience of a single medical center and do not use qualitative methods to support their recommendations.5-7
Hospital management during TMCEs resembles a military hierarchy. Early and efficient implementation of security measures enables uninterrupted provision of professional medical treatment despite a potentially disruptive environment (eg, ED inundation with patients8,9 and excess nonsurgical staff10). Division of authority between the clinical and administrative coordinators allows the clinical coordinator to focus on patient treatment and flow and the administrative coordinator to concentrate on recruitment of resources and personnel, both major issues in the chaotic TMCE environment.11 The decision-making process must be rapid and therefore depends on a few, select key decision makers, often replacing normal managerial decision processes. The prerogatives of the clinical coordinator temporarily overrule those of the normal management hierarchy. During this “coup d'état,” the role of each physician (foot soldier to commanding officer) hinges solely on the degree of their understanding of the disease process. As a foot soldier, the role of the physician is to treat and advocate for individual patients. As a commanding officer, the role of the physician is to use both clinical expertise and organizations skill to command the care of a large number of patients. Surgeons are the natural leaders in this scenario not only because of their traditional commitment to trauma care and their technical expertise but also because of their understanding of the management of the multiply injured patient and their training in rapid screening; selection of surgical options and decision making are also crucial.
Communication capabilities and skills are vital for management of TMCEs. Previous studies have shown that most national communication systems are fragmented.4 The Israeli Magan David Adom (MDA) prehospital care service is a nationwide network with a central command allowing for centralized organization and communication with the TMCE site. Previous experience has led to deployment of MDA–emergency medical services liaison officers to all hospitals in the vicinity of TMCEs. The liaison officer, who is usually an experienced paramedic, communicates directly with the emergency medical services–MDA triage officer on scene and with the emergency medical services communication center managing the event. This arrangement provides quality information under difficult circumstances. Major disruptions of conventional communication systems have been reported to occur following large-scale disasters12 and may occur following TMCEs. The window of opportunity prior to collapse of the communication systems must therefore be effectively used for recruitment of key hospital personnel.
The current study supports the suggestions of Kluger et al6 regarding both assignments and functions of key personnel and principles and definitions during TMCEs. Effective division of administrative and medical responsibilities at St Vincent's Hospital during the events of September 11, 2001, was also reported by Kirschenbaum et al.7 The respondents' preferences for staff recruitment during the first few minutes of the event also coincide with the findings of previous studies regarding the times of arrival of patients with various injury types and their surgical priority.13
The current study suggests that to minimize the ethical dilemmas arising during TMCEs, several management issues that have remained unresolved thus far should be addressed in the future. These dilemmas include the treatment of patients who are already anesthetized but in whom surgery has not yet commenced at the time of the TMCE, the option of shortening operative procedures already under way, guidelines for patient transfer from the PACU and the ICU to evacuate beds for arriving injured patients, and recommendations for continued monitoring and treatment of these patients. None of these issues can be resolved in real time in an ethical manner because of the duress caused by a TMCE. We advise that anesthetized patients who are not considered high risk for anesthesia and are about to undergo elective procedures should emerge from anesthesia and be extubated until it is possible to proceed with elective surgery without endangering patients who may lose life or limb because of insufficient resources. Surgery for anesthetized patients who are considered high anesthesia risk or who are scheduled for semiemergent procedures should proceed. Patients already undergoing surgery at the time of a TMCE should not undergo a truncated procedure but rather the procedure that is considered optimal for the patient by the operating surgeon regardless of the TMCE. Intensive care unit facilities should be expanded into the PACU and even into the OR if necessary, rather than transferring critically ill patients from a monitored to an unsafe environment. Hospitalized patients should compete equally with TMCE patients for resources, and all triage decisions should be based on patient acuity and expected outcomes.
The issue of OR management merits special mention; on a day-to-day basis, the administrator is often an anesthesiologist and maintenance of normal OR administration hierarchy to maximize efficacy is probably ideal. However, the role assignments and functions of key anesthesia personnel should be brought before the TMCE administration hierarchy and clarified prior to TMCE occurrence to decrease friction. The fact that a third of the interviewed surgeons thought that OR management during TMCEs should not be performed by an anesthesiologist reflects the degree of pressure placed on the clinical coordinator and the department of anesthesia. On a daily basis, demand for anesthesiologists is counterbalanced by predesignation of ORs. During TMCEs, the relative availability of anesthesiologists for OR schedules decreases because of the “forward deployment” of anesthesiologists practiced in many hospitals14; a large number of anesthesiologists may be tied up in the treatment of patients outside of the ORs (ie, in the ED, PACU, and ICUs). Evidence of the high demand for anesthesiologists outside the OR may be found in their high priority on the call list, in their responsibility for decisions regarding evacuation of PACU and ICU beds, and in the relatively high ICU admission rate during TMCEs13,15 in a country where anesthesiologists constitute the majority of ICU physicians.
This study describes the experience in hospital management during TMCEs in Israel. These incidents all resulted from conventional terrorism. Differences in management concepts may be required for biological and/or chemical terror as well as for TMCEs resulting from modes of operation that are different from those commonly experienced in Israel. Because of the qualitative nature of the questionnaire, data do not exist regarding the exact nature of the events referred to by the interviewees. Another potential weakness of the study is the inability to control for observer bias in qualitative research. The applicability of these findings to other countries may be limited by potential differences in professional training and experience among physicians trained in different countries. For example, almost all physicians in Israel have extensive military training and experience (which has been shown to affect preparedness16), which may not be true in other countries. Although these issues are pertinent, the results of this study can be extrapolated to hospitals outside Israel because of the large variety of experiences they represent.
The current article provides recommendations for the structure of hospital management during conventional TMCEs based on testing by activation in true incidents. It describes the shift in hospital leadership and management responsibilities and the pivotal roles of surgeons and anesthesiologists in this system. Surgeons are involved in hospital command and control and provide clinical care and should therefore be highly involved in hospital TMCE planning and training. Anesthesiologists are vital for OR management and critical care and should be trained to participate in the clinical decision-making process during TMCEs. This article also highlights still unresolved ethical dilemmas and provides a framework of requirements for future policy decisions.
Correspondence: Sharon Einav, MD, Intensive Care Unit, Shaare Zedek Medical Center, POB 3235, Jerusalem 91031, Israel (email@example.com).
Accepted for Publication: April 7, 2006.
Previous Presentations: This study was presented as a poster at the 77th Annual Meeting of the Pacific Coast Surgical Association; February 18, 2006; San Francisco, Calif.