Reconsidering the Resources Needed for Multiple Casualty Events: Lessons Learned From the Crash of Asiana Airlines Flight 214 | Nursing | JAMA Surgery | JAMA Network
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Table 1.  Imaging Studies Obtained in Initial Evaluation of Patients Within 48 Hours
Imaging Studies Obtained in Initial Evaluation of Patients Within 48 Hours
Table 2.  Patients With Each Type of Major Injury
Patients With Each Type of Major Injury
Table 3.  Consultant Specialists Required
Consultant Specialists Required
Table 4.  Nursing Overtime Hours on Day of Event
Nursing Overtime Hours on Day of Event
1.
National Transportation Safety Board.  Aircraft Accident Report: Descent Below Visual Glidepath and Impact with Seawall, Asiana Airlines Flight 214, Boeing 777-200ER, HL7742, San Francisco, California, July 6, 2013. Washington, DC: National Transportation Safety Board; 2014.
2.
National Transportation Safety Board. Aviation accident database and synopses. http://www.ntsb.gov/_layouts/ntsb.aviation/index.aspx. Accessed December 10, 2015.
3.
Caterson  EJ, Carty  MJ, Weaver  MJ, Holt  EF.  Boston bombings: a surgical view of lessons learned from combat casualty care and the applicability to Boston’s terrorist attack.  J Craniofac Surg. 2013;24(4):1061-1067.PubMedGoogle ScholarCrossref
4.
Gates  JD, Arabian  S, Biddinger  P,  et al.  The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.  Ann Surg. 2014;260(6):960-966.PubMedGoogle ScholarCrossref
5.
Schecter  W, Lim  R, Sheldon  G, Christensen  N, Blaisdell  W.  The History of the Surgical Service at San Francisco General Hospital. Wilmington, NC: Broadfoot; 2008.
6.
Soffer  D, Klausner  J, Bar-Zohar  D,  et al.  Usage of blood products in multiple-casualty incidents: the experience of a level I trauma center in Israel.  Arch Surg. 2008;143(10):983-989.PubMedGoogle ScholarCrossref
7.
Beekley  AC, Martin  MJ, Spinella  PC, Telian  SP, Holcomb  JB.  Predicting resource needs for multiple and mass casualty events in combat: lessons learned from combat support hospital experience in Operation Iraqi Freedom.  J Trauma. 2009;66(4)(suppl):S129-S137.PubMedGoogle ScholarCrossref
8.
Kutcher  ME, Kornblith  LZ, Narayan  R,  et al.  A paradigm shift in trauma resuscitation: evaluation of evolving massive transfusion practices.  JAMA Surg. 2013;148(9):834-840.PubMedGoogle ScholarCrossref
9.
Holcomb  JB, Jenkins  D, Rhee  P,  et al.  Damage control resuscitation: directly addressing the early coagulopathy of trauma.  J Trauma. 2007;62(2):307-310.PubMedGoogle ScholarCrossref
10.
Little  M, Cooper  J, Gope  M,  et al.  “Lessons learned”: a comparative case study analysis of an emergency department response to two burns disasters.  Emerg Med Australas. 2012;24(4):420-429.PubMedGoogle ScholarCrossref
11.
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.PubMedGoogle ScholarCrossref
12.
Aylwin  CJ, König  TC, Brennan  NW,  et al.  Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005.  Lancet. 2006;368(9554):2219-2225.PubMedGoogle ScholarCrossref
13.
McConachie  NS, Wilson  FM, Preston  BJ,  et al.  The impact of the M1 air crash on the radiological services at the Queen’s Medical Centre, Nottingham.  Clin Radiol. 1990;42(5):317-320.PubMedGoogle ScholarCrossref
14.
Brunner  J, Rocha  TC, Chudgar  AA,  et al.  The Boston Marathon bombing: after-action review of the Brigham and Women’s Hospital emergency radiology response.  Radiology. 2014;273(1):78-87.PubMedGoogle ScholarCrossref
15.
Einav  S, Aharonson-Daniel  L, Weissman  C, Freund  HR, Peleg  K; Israel Trauma Group.  In-hospital resource utilization during multiple casualty incidents.  Ann Surg. 2006;243(4):533-540.PubMedGoogle ScholarCrossref
16.
Hirshberg  A, Stein  M, Walden  R.  Surgical resource utilization in urban terrorist bombing: a computer simulation.  J Trauma. 1999;47(3):545-550.PubMedGoogle ScholarCrossref
17.
Baker  SP, Brady  JE, Shanahan  DF, Li  G.  Aviation-related injury morbidity and mortality: data from US health information systems.  Aviat Space Environ Med. 2009;80(12):1001-1005.PubMedGoogle ScholarCrossref
18.
Postma  IL, Winkelhagen  J, Bijlsma  TS, Bloemers  FW, Heetveld  MJ, Goslings  JC.  Delayed diagnosis of injury in survivors of the February 2009 crash of flight TK 1951.  Injury. 2012;43(12):2012-2017.PubMedGoogle ScholarCrossref
19.
Postma  IL, Oner  FC, Bijlsma  TS, Heetveld  MJ, Goslings  JC, Bloemers  FW.  Spinal injuries in an airplane crash: a description of incidence, morphology, and injury mechanism.  Spine (Phila Pa 1976). 2015;40(8):530-536.PubMedGoogle ScholarCrossref
20.
Reid  AB, Letts  RM, Black  GB.  Pediatric Chance fractures: association with intra-abdominal injuries and seatbelt use.  J Trauma. 1990;30(4):384-391.PubMedGoogle ScholarCrossref
21.
Rowles  JM, Robertson  CS, Roberts  SN; Nottingham, Leicester, Derby, Belfast Study Group.  General surgical injuries in survivors of the M1 Kegworth air crash.  Ann R Coll Surg Engl. 1990;72(6):378-381.PubMedGoogle Scholar
22.
Rotondo  MF, Schwab  CW, McGonigal  MD,  et al.  “Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury.  J Trauma. 1993;35(3):375-382.PubMedGoogle ScholarCrossref
23.
Kautza  BC, Cohen  MJ, Cuschieri  J,  et al; Inflammation and the Host Response to Injury Investigators.  Changes in massive transfusion over time: an early shift in the right direction?  J Trauma Acute Care Surg. 2012;72(1):106-111.PubMedGoogle ScholarCrossref
24.
Propper  BW, Rasmussen  TE, Davidson  SB,  et al.  Surgical response to multiple casualty incidents following single explosive events.  Ann Surg. 2009;250(2):311-315.PubMedGoogle ScholarCrossref
Original Investigation
June 2016

Reconsidering the Resources Needed for Multiple Casualty Events: Lessons Learned From the Crash of Asiana Airlines Flight 214

Author Affiliations
  • 1University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
JAMA Surg. 2016;151(6):512-517. doi:10.1001/jamasurg.2015.5107
Abstract

Importance  To date, a substantial portion of multiple casualty incident literature has focused exclusively on prehospital and emergency department resources needed for optimal disaster response. Thus, inpatient resources required to care for individuals injured in multiple casualty events are not well described.

Objective  To highlight the resources beyond initial emergency department triage needed for multiple casualty events, using one of the largest commercial aviation disasters in modern US history as a case study.

Design, Setting, and Participants  Prospective case series of injured individuals treated at an urban level I trauma center following the crash of Asiana Airlines flight 214 on July 6, 2013. This analysis was conducted between June 1, 2014, and December 1, 2015.

Exposure  Commercial jetliner crash.

Main Outcomes and Measures  Medical records, imaging data, nursing overtime, blood bank records, and trauma registry data were analyzed. Disaster logs, patient injuries, and blood product data were prospectively collected during the incident.

Results  Among 307 people aboard the flight, 192 were injured; 63 of the injured patients were initially evaluated at San Francisco General Hospital and Trauma Center (the highest number at any of the receiving medical facilities; age range, 4-74 years [23 were aged <17 years and 3 were aged >60 years]; median injury severity score of 19 admitted patients, 9 [range, 9-45]), including the highest number of critically injured patients (10 of 12). Despite the high impact of the crash, only 3 persons (<1%) died, including 1 in-hospital death. Among the 63 patients, 32 (50.8%) underwent a computed tomographic imaging study, with imaging of the abdomen and pelvis being the most common. Sixteen of the 32 patients undergoing computed tomography (50.0%) had a positive finding on at least 1 scan. Nineteen patients had major injuries and required admission, with 5 taken directly from the emergency department to the operating room. The most frequent injury was spinal fracture (13 patients). In the first 48 hours, 15 operations were performed and 117 total units of blood products were transfused. A total of 370 nursing overtime hours were required to treat the injured patients on the day of the event.

Conclusions and Relevance  Proper disaster preparedness requires attention to hospital-level needs beyond initial emergency department triage. The Asiana Airlines flight 214 crash highlights the need to plan for high use of advanced imaging, blood products, operating room availability, nursing resources, and management of inpatient hospital beds.

Introduction

On July 6, 2013, Asiana Airlines flight 214 departed from South Korea carrying 291 passengers and 16 crewmembers bound for San Francisco International Airport. At 11:28 am, the plane crashed short of the runway, with the landing gear and tail striking the seawall that projects into the San Francisco Bay. The impact separated both engines and the tail from the aircraft. The remainder of the fuselage and wings rotated approximately 330°, coming to rest on the runway.1 In all, 192 patients were injured, 49 seriously.1 Twelve hospitals received patients, with the largest total (63 patients), including 10 of 12 in critical condition, transported to San Francisco General Hospital and Trauma Center (SFGH). Two died at the scene and 1 died 5 days later. The crash was the first commercial airline crash to result in fatalities in more than 4.5 years in the United States.2 According to the National Transportation Safety Board, more than 400 transportation-related deaths each year in the United States can be attributed to aviation crashes.2 Most crashes involve small private airplanes; thus, few trauma centers have experience caring for people injured in major commercial airline disasters. Owing to the historically high mortality associated with major aviation disasters, little information is available on injuries sustained by survivors.

Proper disaster planning requires an understanding of the resources necessary to effectively care for patients in larger multiple casualty incidents (MCIs). Lessons learned from other modern disasters have all enhanced our ability as a medical community to prepare for MCIs of varying sizes.3,4 Most of the MCI literature has focused exclusively on prehospital and emergency department (ED) resources. In prior airline crashes described in the literature, either all plane occupants were completely noninjured due to relatively low impact or there were no survivors due to high impact. In contrast, the crash of Asiana Airlines flight 214 represents one of the largest major aviation disasters to result in a high number of survivors despite an intense ground impact. This event generated an opportunity to explore aspects of MCI preparedness extending beyond initial ED triage, including blood products, nursing, and inpatient resources.

Methods
Study Setting

San Francisco General Hospital and Trauma Center is an American College of Surgeons–verified level I trauma facility treating more than 4000 trauma patients annually, including both adults and children. It is the only trauma center for the city and county of San Francisco and has a catchment area of approximately 1.5 million people. It is the closest level I trauma center to the airport, 11 miles away. It has an illustrious history of pioneering trauma care and was one of the first hospitals in the nation to have a dedicated trauma surgical team.5

Data Collection

A prospective disaster log of all patients arriving from the scene was generated at the time of the event. A retrospective review was then performed between June 1, 2014, and December 1, 2015, on all patients in the disaster log sheets. Data on injuries, operations, and physiological parameters were extracted from patient records. Blood product data at our institution are prospectively collected in real time in a master blood bank database. Units of packed red blood cells (PRBCs), fresh frozen plasma, and platelets during the initial 48 hours were analyzed. The PRBCs per patient index (PPI) was calculated by dividing the total number of PRBCs used divided by the total number of patients for the first 24 hours.6,7 Additional overtime nursing work hours were supplied by the time card system. Admission location was recorded. Type and number of initial imaging studies recorded in the first 48 hours were analyzed. All data analysis was performed using Stata version 13.1 statistical software (SAS Institute, Inc). This study was approved by both the University of California, San Francisco Institutional Review Board and SFGH and was conducted under waiver of consent.

Results

The manifest of Asiana Airlines flight 214 included 307 people. Despite the intense force at which the plane hit the runway, only 3 persons died, including 2 at the scene. The majority of those on the plane (192 of 307 [62.5%]) were field triaged as injured and were transported to a medical facility for evaluation.1 Twelve were triaged as critically injured. The overall in-hospital mortality rate was 0.52% (1 of 192 patients transported to a medical facility).

San Francisco General Hospital and Trauma Center evaluated the highest number of injured patients of any of the receiving medical facilities and treated 63, including 10 of the 12 critically injured patients. The initial evaluation of the patients was done by a team of 5 emergency medicine attending physicians and 3 trauma surgeons. On a typical shift, 3 emergency medicine attending physicians and 1 trauma surgeon are present. Thirty-six of the 63 patients (57.1%) required either admission to the hospital (n = 19) or a prolonged (>6 hour) observation period (n = 17). The patient age range was 4 to 74 years. Among the 63 patients treated at SFGH, 23 (36.5%) were younger than 17 years and 3 (4.8%) were older than 60 years. The median injury severity score of the 19 admitted patients was 9 (range, 9-45).

Radiology Studies

Forty-three patients (68.3%) required at least 1 radiographic imaging study during their initial evaluation, including 32 patients (50.8% of the 63 patients evaluated) who required a computed tomographic (CT) scan (Table 1). The most commonly acquired CT scans were abdomen and pelvis (24 of 63 patients [38.1%]) and cervical spine (22 of 63 patients [34.9%]), followed by chest (20 of 63 patients [31.7%]) and head (15 of 63 patients [23.8%]). Of the 76 CT scans obtained from the 32 patients, 28 scans (36.8%) had 1 or more positive finding for injury; 16 of the 32 patients who underwent CT (50.0%) had a positive finding on at least 1 scan. Four attending radiologists were mobilized immediately to expedite scan interpretation.

Injuries

Nineteen patients had major injuries and required admission. Four of these 19 patients were treated for inhalation injury, including 3 requiring intubation for their inhalation injury. Table 2 details the number of patients with each type of major injury. Of the 19 admitted patients, 8 (42.1%) had multisystem injury. The most frequent injury was spinal fracture, occurring in 13 patients (20.6%), with thoracic fractures being the most common. Those with sternal fractures described being crushed by the impact of the seats collapsing backward onto them. In patients with any spinal fracture, a median of 4 separate vertebrae were fractured. Two patients had the classic Chance fracture pattern of spinal fracture along with bowel injuries consistent with hyperflexion over a lap belt. The wide variety of injuries required a number of specialty consultants (Table 3). Spine coverage was provided by neurosurgery.

Operating Room Resources

Although it was a Saturday morning, the operating room (OR) was already busy with 2 other emergent trauma cases when the first patients from the crash arrived. Fifty-two operations were performed, including 9 in the first 24 hours and 15 during the initial 48 hours. These initial operations included damage control laparotomies, emergent intracranial interventions, major wound debridements, and orthopedic operations. Five dedicated anesthesia teams were mobilized on the day of the event.

Blood Bank Needs

One of the often overlooked aspects of multiple casualty disasters is the need for blood bank resources. Patients required 117 total units of blood products during the initial 48 hours following the crash: 52 units of PRBCs, 53 units of plasma, 8 pooled units of platelets, and 4 units of cryoprecipitate. San Francisco General Hospital and Trauma Center uses a massive transfusion protocol and aims for a balanced resuscitation of blood products (ratio of plasma to PRBCs to platelets) in our trauma patients.8,9 Our achieved ratio approached 1:1:1 (53 plasma units, 52 units of PRBCs, and 48 units of platelets) when accounting for each pack of platelets representing a pooled 6-pack of platelets. Three of the 63 patients treated at SFGH (4.8%) required more than 10 units of blood products in the first 6 hours and required 45 units of PRBCs in the first 24 hours. The PPI for the first 24 hours was 0.7 and the median plasma to PRBC ratio of patients who received a transfusion was 1:1 (range, 0.8-1.1).

Inpatient and Nursing Resources

Inpatient admission was needed in 19 patients (30.2%). Among the 44 patients discharged without inpatient admission, 17 required extended observation periods (6-23 hours). Five patients were taken directly to the OR. Three of these patients were admitted to the intensive care unit (ICU) postoperatively, resulting in a total of 6 of 63 evaluated patients (9.5%) requiring ICU admission and another 6 patients (9.5%) requiring step-down admission. The median hospital stay for admitted patients was 3 days (range, 1-108 days). Six patients required inpatient care beyond 5 days. Four required intubation, with 3 patients requiring ventilator support longer than 5 days (range, 3-48 days). A total of 370 total nursing overtime hours were required on the day of the crash, which is equivalent to 5.9 hours per patient (Table 4). In addition, our incident command center was fully staffed for the immediate 12 hours after the disaster.

Discussion

The Asiana Airlines flight 214 crash represented the single largest MCI in the history of our center. Preparation was initiated as word spread initially in social media. Many staff responded from home to assist. Triage tents were erected outside the ED to facilitate additional space for the anticipated large number of incoming patients. Rapid discharges of patients awaiting nursing or rehabilitation facilities were expedited with the assistance of our community partners. Low-acuity patients in the ICU were transferred to the ward.

The event took place in a secured environment of the airport and patients were transported often in large groups. All arrived via ambulance and complete scene triage took several hours. The first patients arrived approximately 45 minutes after the event. Within 30 minutes of the first patient arrivals, the 10 critically injured patients arrived. Three of these 10 went to the OR within minutes. Ultimately, 6 of the 10 were admitted with critical injuries.

An emergency medicine attending physician assumed control of the initial triage in the ambulance bay. Following triage, an attending trauma surgeon supervised the workup and disposition in conjunction with ED staff. This dual command structure allowed patient flow to be managed efficiently as many arrived simultaneously. The importance of senior surgical staff present in the ED to facilitate care during disasters has shown benefit in 2 large burn incidents10 and in terrorism events.11,12 By maintaining a constant senior trauma surgery presence in the ED, our patient disposition was expedited and communication enhanced.

Radiology requirements during large-scale disasters are not well studied. The radiology resources used in a previous airplane crash from 1989 were reported with use of a large number of plain radiographs and relatively few CT scans.13 A recent study of the Boston Marathon bombing reported that 78% of patients seen at one of the hospitals required radiographic imaging, but only 7 of 40 (17.5%) required CT imaging.14 A study of bombing events in Israel showed that 40% of patients admitted to the hospital received a CT scan in the ED.15

With this event, an early and deliberate decision was made to perform thorough evaluations with liberal use of CT imaging, given the force of the crash and the severity of injuries of the initial patients. Forty-three patients (68.3%) received an imaging study, including 32 (50.8%) who underwent a CT scan. The differing use of advanced imaging likely reflects the clinicians’ pretest assessment of injury probability given the mechanism.

It is imperative that a thoughtful approach be systematically adopted for evaluation of MCI patients based on the mechanism of injury to avoid overuse of radiologic studies while minimizing missed or delayed diagnosis of injures. Although eFAST (Extended Focused Assessment With Sonography for Trauma) is liberally used at our institution, images and findings were not stored during the disaster. Therefore, we cannot comment on how ultrasonography affected the rate of plain radiographs obtained. There were no new diagnoses made on tertiary survey, no known missed diagnoses, and a high positivity rate of obtained imaging studies in our patients.

Hirshberg et al16 performed a computer simulation of large-scale hospital disaster management based on bombing events and found that CT imaging was a significant bottleneck in patient flow. To reduce this bottleneck, our senior trauma surgeon in charge determined who received CT scans and in what order. As hospitals prepare for future disasters, it is important to consider the need for a sizable amount of advanced imaging.

Injury data sustained by airline crash survivors are scarce. Baker et al17 searched the Nationwide Inpatient Sample and found that 27% had lower extremity fractures, 11% had head injury, 9% had internal injury, and 2% died in the hospital. However, these data are misleading, as one-third of these injuries occurred in parachutists. In contrast, in a review of recent European data, head injuries and spinal fractures were common, with in-hospital mortality rates between 7% and 34%.18 Despite the extreme force in our crash, there were only 3 total deaths (mortality <1%) and an in-hospital mortality rate of 0.56%. This is a remarkable statistic considering the National Transportation Safety Board concluded that 6 persons were ejected out of the plane.

Although few died in this crash, the survivors sustained severe blunt force trauma. The most common injury was major vertebral fracture, followed by extremity, chest, and traumatic brain injuries. Of the 63 patients treated at SFGH, 13 (20.6%) were noted to have a spinal fracture; if a spinal fracture was identified, a median of 4 vertebrae were injured. This is consistent with data from the 2009 airplane crash in Amsterdam in which 18.3% of patients presenting to the hospital sustained spinal fractures.19 In this uniquely high-force trauma, health care professionals should be quite vigilant in looking for spinal fractures. The Chance fracture injury pattern was noted in 2 patients, with concomitant spinal fractures and bowel injuries consistent with hyperflexion over a lap belt.20 This injury pattern was seen in automobile accidents before mandatory 3-point restraints were put into use. Unlike other airline crashes, inhalation injury was infrequent as the aircraft caught fire after all but 6 persons were evacuated. However, some patients sustained major soft-tissue injuries from presumably being dragged on the runway.

Fifty-two operations were performed, including 9 in the first 24 hours and 15 in the first 48 hours. Only 2 patients had intra-abdominal injuries, and the low rate of abdominal injury is consistent with a British report of an airplane crash in which 2 patients had significant abdominal injuries among 87 survivors.21 An emphasis was placed on damage control surgery.22 The goal is to facilitate rapid control of hemorrhage and peritoneal contamination while leaving complex reconstruction for subsequent operation, so as to allow resuscitation and correction of deranged physiology.

In disaster surgery, damage control serves 2 purposes. Not only does it allow for the rapid correction of physiology, but also it allows surgical teams to maximize their efficiency to treat as many patients as possible. This practice has been used in bombing incidents and has become a standard in the military during the wars in Iraq and Afghanistan.4,15 These principles were instituted during this event to keep as many ORs and surgical teams as possible available as patients arrived. In addition, SFGH continued to perform in its role as the city’s sole trauma center, performing several unrelated emergency operations as well.

Blood products are a precious resource in any trauma center. Our trauma center uses a hemostatic resuscitation strategy emphasizing a balanced resuscitation ratio when performing transfusions in critically injured patients. This strategy has been suggested to decrease overall blood use but requires significant blood resources up front.23 During the Asiana Airlines flight 214 disaster, the blood bank and the attending trauma surgeons were in frequent contact monitoring our in-hospital blood supply. The injured individuals would receive more than 100 units of blood in the first 48 hours after the crash.

The volume of blood required is of great interest to disaster planners, and efforts have been made to determine blood product requirements based on the number of evacuated patients. Most published data on blood requirements from MCIs involve explosives. Our PPI was 0.7. This is in line with published data showing a PPI between 0 and 3.6 per incident with an average PPI near 1.0 to 1.5.6,7,24 The injury mechanism differences from prior literature compared with the Asiana Airlines flight 214 crash as well as overtriage may explain why our blood product needs were somewhat less than in previous events. Based on our results and others, it would be prudent for civilian trauma centers to expect to require 1 unit of blood per injured patient in an MCI.

Virtually no data exist on what nursing resources are required during major disasters. We found that 370 nursing overtime hours were required in the first 18 hours following the crash, equaling an average of nearly 6 overtime hours per patient evaluated. The nursing resources were split relatively evenly between the ED, ICU, hospital wards, and OR, underscoring the need to plan for inpatient responses to MCIs.

Like many other urban centers, SFGH runs constantly near capacity. To accommodate a large number of casualties, patient discharges to surrounding facilities were expedited. Patients in the ICU who were potentially suitable for transfer to regular ward beds were moved. The rapid disposition and transfer of patients were made possible by effective intervention by hospital administration working with administrators of the regional nursing and rehabilitation facilities. This level of cooperation was essential in allowing us to handle the surge of patients from the crash. In the modern era of medical care with most trauma centers functioning near capacity, bed availability threatens to hinder care during MCIs. Trauma centers should consider working with their local nursing and rehabilitation facilities to arrange preplanned expedited discharges in the setting of disaster. This will ensure adequate bed availability for the patients injured in an MCI.

Conclusions

The crash of Asiana Airlines flight 214 was one of the most challenging incidents SFGH has had to face. It tested our trauma center’s resources and provided many lessons for future disaster preparedness. While each incident brings its own unique set of circumstances, many different factors are shared between MCIs. Needs for rapid radiographic studies, blood products, OR availability, and strategies to manage inpatient hospital beds are common themes for which all hospitals should plan. Sharing experiences from each MCI is critically important, as each individual health care professional may only experience 1 such incident in his or her career but it is essential that the lessons learned from each incident are not lost.

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Article Information

Corresponding Author: Rachael A. Callcut, MD, MSPH, University of California, San Francisco, San Francisco General Hospital and Trauma Center, 1001 Potrero Ave, Ward 3A, San Francisco, CA 94110 (rachael.callcut@ucsf.edu).

Accepted for Publication: October 5, 2015.

Published Online: January 13, 2016. doi:10.1001/jamasurg.2015.5107.

Author Contributions: Dr Callcut had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Campion, Juillard, Knudson, Cohen, Campbell, Callcut.

Acquisition, analysis, or interpretation of data: Campion, Juillard, Knudson, Dicker, Cohen, Mackersie, Callcut.

Drafting of the manuscript: Campion, Knudson, Campbell, Callcut.

Critical revision of the manuscript for important intellectual content: Campion, Juillard, Knudson, Dicker, Cohen, Mackersie, Callcut.

Statistical analysis: Campion, Callcut.

Administrative, technical, or material support: Campion, Juillard, Cohen, Campbell, Callcut.

Study supervision: Knudson, Dicker, Callcut.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Callcut is supported by career development award 8KL2TR000143-09 from the National Center for Advancing Translational Sciences, National Institutes of Health, via the University of California, San Francisco Clinical and Translational Institute.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We acknowledge the trainee resident staff, our colleagues in emergency medicine, neurosurgery, orthopedics, radiology, pediatrics, anesthesiology, and critical care, and the staff of San Francisco General Hospital and Trauma Center who contributed invaluable expertise, compassion, and care to the individuals injured in the Asiana Airlines flight 214 crash.

References
1.
National Transportation Safety Board.  Aircraft Accident Report: Descent Below Visual Glidepath and Impact with Seawall, Asiana Airlines Flight 214, Boeing 777-200ER, HL7742, San Francisco, California, July 6, 2013. Washington, DC: National Transportation Safety Board; 2014.
2.
National Transportation Safety Board. Aviation accident database and synopses. http://www.ntsb.gov/_layouts/ntsb.aviation/index.aspx. Accessed December 10, 2015.
3.
Caterson  EJ, Carty  MJ, Weaver  MJ, Holt  EF.  Boston bombings: a surgical view of lessons learned from combat casualty care and the applicability to Boston’s terrorist attack.  J Craniofac Surg. 2013;24(4):1061-1067.PubMedGoogle ScholarCrossref
4.
Gates  JD, Arabian  S, Biddinger  P,  et al.  The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.  Ann Surg. 2014;260(6):960-966.PubMedGoogle ScholarCrossref
5.
Schecter  W, Lim  R, Sheldon  G, Christensen  N, Blaisdell  W.  The History of the Surgical Service at San Francisco General Hospital. Wilmington, NC: Broadfoot; 2008.
6.
Soffer  D, Klausner  J, Bar-Zohar  D,  et al.  Usage of blood products in multiple-casualty incidents: the experience of a level I trauma center in Israel.  Arch Surg. 2008;143(10):983-989.PubMedGoogle ScholarCrossref
7.
Beekley  AC, Martin  MJ, Spinella  PC, Telian  SP, Holcomb  JB.  Predicting resource needs for multiple and mass casualty events in combat: lessons learned from combat support hospital experience in Operation Iraqi Freedom.  J Trauma. 2009;66(4)(suppl):S129-S137.PubMedGoogle ScholarCrossref
8.
Kutcher  ME, Kornblith  LZ, Narayan  R,  et al.  A paradigm shift in trauma resuscitation: evaluation of evolving massive transfusion practices.  JAMA Surg. 2013;148(9):834-840.PubMedGoogle ScholarCrossref
9.
Holcomb  JB, Jenkins  D, Rhee  P,  et al.  Damage control resuscitation: directly addressing the early coagulopathy of trauma.  J Trauma. 2007;62(2):307-310.PubMedGoogle ScholarCrossref
10.
Little  M, Cooper  J, Gope  M,  et al.  “Lessons learned”: a comparative case study analysis of an emergency department response to two burns disasters.  Emerg Med Australas. 2012;24(4):420-429.PubMedGoogle ScholarCrossref
11.
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.PubMedGoogle ScholarCrossref
12.
Aylwin  CJ, König  TC, Brennan  NW,  et al.  Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005.  Lancet. 2006;368(9554):2219-2225.PubMedGoogle ScholarCrossref
13.
McConachie  NS, Wilson  FM, Preston  BJ,  et al.  The impact of the M1 air crash on the radiological services at the Queen’s Medical Centre, Nottingham.  Clin Radiol. 1990;42(5):317-320.PubMedGoogle ScholarCrossref
14.
Brunner  J, Rocha  TC, Chudgar  AA,  et al.  The Boston Marathon bombing: after-action review of the Brigham and Women’s Hospital emergency radiology response.  Radiology. 2014;273(1):78-87.PubMedGoogle ScholarCrossref
15.
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