Recap of Day One Event

1. Based on your work looking at objective measures of success for MCI/Terrorist response - what do you believe are the key indicators to follow to understand how successful response is?

   • Key point is patient flow, the quicker they are evacuated from scene and brought to hospitals and get casualty care in hospitals is one key indicator, other is zoning and interaction between police forces and rescue forces (these two are the most important)

2. Thank you Dr. Wurmb - you mentioned there were plans for MCI but not for terrorism attacks. What would you say was the main lack you identified? Thank you.

   • Main lack was staff, materials (equipment), we staffed ambulances with special devices to treat more penetrating injuries like blast injures, second thing is zoning and interaction with police, triage is a big issue, triage should be made different as compared to MASCAL from his point of view

3. Can you speak to any challenges/limitations to joint law enforcement/Fire-EMS exercises as well as joint training between public safety and local hospitals?

   • Local hospitals and public safety is important topic and we have to go deeper into that area in the future, saw it with the COVID-19 pandemic, when you think of large scale conflict, this becomes more important, long lasting missions/actions like war, we definitely depend on good interactions between these two

4. What equipment beyond tourniquets are they carrying on their person with the tactical gear? Do the medical team have radio's, and if so, are they taking to law enforcement or are they talking to other clinicians in the green zone?

   • Coordination very difficult, normally in exercises it is common post 'common tactical post' have Tactical Director within team (Casualty Extraction/Collecting Point), communication in hot zone and green zone are organized only on common post because in hot zone you do not have time to speak to emergency team outside. First CCP was 200 meters, but communication was complicated.

5. Are your teams carrying freeze-dried plasma?

   • No, because our objective was only to make basic life saving acts, the situation could change very quickly (explosives, etc.), no place for life saving techniques, this can be done outside at Casualty Collecting Point. If coordination is good, best to apply life saving techniques outside of hot zone.

6. Do the teams carry weapons?

   • Always want physicians to not be armed, due to rescue and tactical emergency and not to the security aspect. Protected by Red Team and not by ourselvesd , ensures audio and visuals are working properly in virtual environment, mutes hot mics; 

1. When an mass casualty event occurs, how do your organizations get activated?

   • Macintyre- Through the state. Requests go out and teams for four hours to assemble and dispatch, typically via ground transport. 

2. How do organizations prepare for multidisciplinary responses?

   • "Garret- Maintaining readiness is a perpetual effort because resources are not always available for training when response efforts are not activated. Many team members are consistently working to maintain/grow skills and seeking out individual trainings until groups can get together to actually exercise and practice for disaster/emergency events. It's also helpful that we often rely on emergency responders that do this type of work regularly for guidance/leadership when activated.

   • Macintyre- Its very important to define roles, both within teams and with other assets on the ground. Another solution is regular communications when activated.

   • FitzGerald- One method to prepare is to utilize just in time training, especially for national security events. We also benefit from that fact that many teams include providers that are very well-prepared to provide care, so trainings should focus on dealing with environments which are adverse to providing care."

3. Can we do/develop more electronic trainings on equipment?

   • "FitzGerald- There are ongoing efforts to develop simulation trainings to convene teams in virtual spaces to conduct trainings and increase training opportunities. 

   • Garret- Yes it's very important to find deficiencies and areas of improvement for training, but it's important to regularly seek out additional funding. Virtual trainings only reduce costs of travel, which are often the most affordable part of large trainings."

4. How is NDMS approaching civilian bed space given current climate related to limited capacity?

   • FitzGerald- NDMS is actively engaged with a network of hospitals as well as non-NDMS hospitals to build regional preparedness and seek out/find beds if needed. We're also actively trying to get a better picture of where and how we can locate additional beds. 

5. Are we good at communication between local, state, and federal agencies when responding?

   • "Macintrye- Communications is always a challenge but has gotten much better. The evolution of federal response and how it supports states and local response has changed including technology advancements but also improvements in dissemination. This will continue to be a challenge but there are active efforts to help.

   • Garret- Current technology has made communication a lot better but so has coordination at the federal level. Regarding the comment, as we professionalize EMS we need to ensure we are considering rural regions and not just large cities."

6. Do current models take staffing into bed capacity determinations? Follow-up: States face a lot of challenges deciding whether someone will serve best in civilian or reserves role.

   • "FitzGerald- During COVID it was a significant lesson-learned that we can create space but not staff. Within NDMS we face the same space challenges as the healthcare industry at large- recruitment, retention, etc. We also have to consider regional challenges and role flexibilities. On a federal-level we have to consider different situations that result in a lack of beds and focus on developing guidance/solutions for instances that can be improved vs. ones that are beyond our control. We've deployed healthcare assessment teams for preposition into an impacted area to report back to the state a good strategy regarding what various systems/hospitals need to get them back up and running. We also developed small teams to go into hospitals to facilitate low-regret decision-making, allowing for better staff movement. It's important to focus on local and regional improvements that can make federal level work easier/better as well. 

   • Follow-up response from Fitzgerald- Yes that's a problem with no perfect solution, one thing we currently do is actively avoid pulling response teams from impacted areas but rather pulling from surrounding non-impacted areas."

7. Northern US regions are currently facing challenges with transport and coordination over the Canadian border. Is this a consideration in federal response planning? Follow-up: There are a lot of operational limitations that cannot be/are not currently addressed on-paper. 

   • "Macintyre- There are many federal, state, and local coordinating efforts and agreements with Canada. Federal agencies are incorporating lessons learned from COVID into efforts related to coordination across borders.

   • Garret- Good point, we do need to take actual operational limitations into consideration on the federal level."

8. What are you thoughts on differences between the US and France in regarding to physician training and availability for emergency response?

   • The US systems tends to be faster than the French in terms of response. In the hospital, it seems better for physicians to be making decisions rather than paramedics, however, physicians do need to be trained for emergency response on the ground. There is research supporting the fact that paramedics are preferred for decision-making on the ground during these events.

9. Is there any training that focuses on intuitive response during mass casualty events?

   • Training exercises focus on triage and getting everyone out as soon as possible during these events. 

10. "How can we do better in filling the gaps between ESF 6 & ESF8, to meet the health maintenance needs of people with disabilities who do not need hospital level care without pressing them into acute medical settings and skilled nursing facilities where they often deteriorate and lose their community living resources.

    • "McIntyre: At risk populations are a big focus, spending a lot of time ensuring we are meeting the needs of everyone affected by disaster, recovery efforts with American Red Cross, and others in USPHS to manage displaced populations who do not require acute medical needs but have another life safety needs to ensure they get what they need. Folks on acute and medical side to provide support services to those who need it.

    • Garrett: Can't solve probably of fed government, hospital probably worst place to have child or person in disabilities if you aren't sick, chances of getting ill are high. Battery charging or medication needs can be addressed, preparedness has been hiuge challenge to keep ppl out ofd medical facilities or go somewhere they can go safely without having to rely on others; need to change mandate on preparedness. Think of NDMS, ESF-6/8 as a safety net

    • McIntyre: Work with state teams to identify at risk (dialysis, in patient folks), program in conjunction with Medicare/Medicaid to identify folks in community who have variety of needs so fed gov has SA before incident, to provide targeted support, ensure they don't have access issues/delays

    • Garrett: Empower crossed over databases CMS, Medicaid, lens of preparedness to better identify folks who need that assistance before rather than ESF shelters, building process where other stakeholders may not be able to meet that goal"

11. What collaboration and coordination tools/platforms/processes do you use? What do you like about them, and what is one gap that you wish could be solved?

    • "Response from Nicholas Kman: Mischa, I am a Medical Team Manager for Ohio Task Force 1, FEMA US&R. Deployed almost every year since Harvey in 2017. We use What's App or Telegram to have a chat with all the Medical and Safety teams.  Great way to share documents and medical plans/thoughts.  Also great way to interface with IST doctors. It does rely on having an active phone/internet connection.  I use First Net.

    • Response from Panel: Fitzgerald: CMS (FEMA) platform that can handle several challenges in terms of tracking of situation, training goes into it, it functional and gets interagency together to move things out. LCIMAS (logistic platform)

    • MacIntyre: Technology platform to provide common operating picture, broadly key coordinating role/function lot of interagency collaboration/coordination in place between folks inside/outside organization, ESF side, engage with partners in space weekly even during steady state times to ensure we have those lines of communications to ensure situational awareness on people involved, successful missions have been set up on good collaboration and navigating gaps and IT systems by maintaining those relationships. Joint Operation spaces (especially medical people), interoperable centers work on interstates local or fed, have regional personnel involved in those

    • Garrett: Ability to speak apples to apples to walk into office and say 'You are Ops, I know what you do"", transcends technology because you can still do the work on paper"

12. Regarding integration of public safety (LE, Fire, EMS) and hospitals into preparedness planning and training, What is being done well and what needs attention?

    • "Fitzgerald: Evolution of healthcare coalitions, one person who is the lead author on program doc, Dr. Joe Barbarra, put down solid concepts in how healthcare could integrate into HCC, competitve business antagonists, but also with state/actors/response sector municipalities. Have a collective that all needs same information, provide situation assessment to other response agencies, implemented in various response fashions, some implemented at better success than others, at the end of the day they help promote promotion

    • Garrett: Traditional roles of EMS/firefighters/first responders, a lot more crossover, blurring those lines to better serve the community we all want the same thing, community health. What processes are bearing fruit in terms of saving lives? "

13. Hospitals struggle to maintain decontamination capabilities.  We all have traditional roles that make it difficult for us to be decon trained and experienced. It is very expensive for non profit organizations to maintain. This is a huge issue that does not seem to be addressed. The HPP grant funding has been very helpful for hospitals to be able to buy PPE and contract the annual training required by OSHA but staffing and maintaining competency is a challenge?

    • Garrett - "Fully agree with you- this is a heavy lift that is oftentimes under or unfunded. Also, there is no question that the ability to effectively decon your "whole community" members goes far beyond what the OSHA regulations require.  Maintaining competency is a huge challenge, not to mention ensuring that your facility has the equipment to support decon. While some communities have developed an arrangement for their local Fire Department to do or assist their emergency decon, this remains a challenging approach due to double-hatting- there are many scenarios in my mind where the fire department may have a lot of top priorities at the same time and the hospital's decon mission could potentially be deprioritized.  For a healthcare facility, decon is mission-critical so you don't risk the asset of the hospital or put the staff at-risk with contamination. This is akin to evacuation drills, fire drills, and other aspects of disaster and emergency preparedness in my mind- it truly does have to be done by whatever means necessary.  As you mention it's not just about the funding for equipment, it's finding a team that can become and stay proficient at this skill.  There are lots of best practices, data, and strategies out there (see the HHS ASPR TRACIE website at https://asprtracie.hhs.gov/) and maybe there are some out-of-the-box ways your facility could approach decon by training non-clinical hospital personnel or volunteers, or via a partnership with other healthcare assets nearby who may need the same thing.  Of course, work with your local emergency management as you work through this challenge."

1. The use of triage tags is critical, but their use was not reported during the Boston event. Do we use triage tags or ribbons?

   • "The use of red tags is essential. In our training and mass casualty response, we often focus solely on triage tags. They play a crucial role, yet we've become so entrenched in our training doctrine that we've lost sight of the environment around us. The tags facilitate preventative care and enable us to track patients from the point of injury, which is currently our ultimate goal.  Let's consider the principles involved. Right now, there is a significant challenge regarding the reasons the red tags were not used as intended. Once we can implement mass categorization effectively, we can address this issue more effectively."

   • Mentioned that in some instances,  the used red tags or ribbons not used but rather the use of landscapers tape or gloves seems to be easier and are being used more often. 

2. How important did the civilian bystander or what we would call the immediate responder play in stopping the bleed with improvised tourniquets. This happened prior to the Hartford Consensus?

   • Biddinger - "The civilian bystander efforts, including assistance with moving patients to medical areas/care, direct pressure for bleeding, and others, were extraordinary and likely saved multiple lives.  The medical evidence for improvised tourniquets is less strong, but the proper tourniquets carried and used by Boston EMS and others clearly helped save lives also.  Since 2013, there are many more publicly-available stop the bleed kits and more public training which are very helpful."   

   • Kue - "Agree with Dr. Biddinger.  I would say a surprising element on the bystander response was that most did not do what we artificially do in so many MCI exercises, maniacal people running up to responders to create artificial "stress inoculation."  Many wanted to help despite the potential for threats and would have benefited from guidance.  There were plenty of anecdotal reports of bystanders fashioning improvised tourniquets from T-shirts, belts and clothing.  We should strive to use commercially available TQs.  Increased availability of public-access hemorrhage kits w AEDs, Stop-the-bleed training all help, but the reality is that unless we are all mandated to carry a CAT TQ in the US, there will be times when improvised tourniquets that are effectively made can make a difference.  Effectively training rather than only focusing on products is important to ensure that IF an improvised tourniquet is used, it is effective.  I have seen plenty of commercial TQs placed by first responders, nurses, physicians, etc. that are ineffective and causing harm, due to inadequate TRAINING.  Another planning consideration is for first response agencies to consider having MCI kits that can be distributed to the public, especially in areas where security is an issue.  For example, tactical teams entering into venues before EMS, or rescue task forces having bleeding control kits that can be passed to the public, increasing available hemorrhage control kits at areas of potential targeting - airports, schools, public venues, stadiums, concert halls, etc.  Mandate with AEDs in public locations.  Attached is a thoughtful article that discusses the issue of by-stander hemorrhage control training and the need to focus on concepts rather than just an item (TQs)."

   • Stewart SK, Duchesne JC, Khan MA. Improvised tourniquets: Obsolete or obligatory? J Trauma Acute Care Surg. 2015 Jan;78(1):178-83. doi: 10.1097/TA.0000000000000485. PMID: 25539219

3. What large MCI event has successfully used triage tags? All I'm hearing from events described at NAEMSP & Eagles they've not been used?

   • Kue -  I have not seen or heard of many large-scale MCIs that have successfully or effectively utilized triage tags are part of the initial triage process.  Where I think we have to do better is determining when exactly formal triage makes sense.  At the incident of point of injury, as many speakers have mentioned, focus really should be on clearing the scene to an appropriate area where casualties can be organized for select life-saving injuries and then transport in the appropriate priority.  For Boston, we took each ambulance and tried to optimally load - 1 red, w a couple of greens, etc.  1 pt=1 ambulance is a waste of resources.  The reality is that current triage tags ask too much of our task-saturated EMTs and medics who are trying to manage a chaotic scene while maintaining situational awareness for any change in the security or threat situation.  Most incidents have shown that hospitals have been able to effectively respond to mass casualty arrivals in the absence of adequate triage tag usage.  So, are we holding first responders to some artificial standard that has not shown effectiveness?  Should we recalibrate hospital expectations that EMS transported patients will always have formal triage tags on casualties properly filled out on arrival?  I leave this for everyone to reflect on.  Here are some publications that can offer some more insight on this topic.

   •  Kamler JJ, Taube S, Koch EJ, Lauria MJ, Kue RC, Rush SC. Effectiveness of and Adherence to Triage Algorithms  During Prehospital Response to Mass Casualty Incidents. J Spec Oper Med. 2023 Mar 15;23(1):59-66. doi:10.55460/73Y0-FSLB. PMID: 36853853.

   • Ryan K, George D, Liu J, Mitchell P, Nelson K, Kue R. The Use of Field Triage in Disaster and Mass Casualty Incidents: A Survey of Current Practices by EMS Personnel. Prehosp Emerg Care. 2018 Jul-Aug;22(4):520-526. doi:10.1080/10903127.2017.1419323. Epub 2018 Feb 9. PMID: 29425472.

   • Rush SC, Lauria MJ, DeSoucy ES, Koch EJ, Kamler JJ, Remley MA, Alway N, Brodie F, Foudrait A, Barendregt P, Atkins M, Miller K, Hines R, Champagne M, Paladino L, Shackelford SA, Miles EA, Obiajulu J, Dorlac WC, Gurney JM, Robb D, Kue RC. Limitations of Triage in Military Mass Casualty Response: A Case Series. J Spec Oper Med. 2024 Oct 2;24(3):62-66. doi: 10.55460/0GO5-QW03. PMID: 39172917.                                                                                                                                                                    

   • Gill -  "I have found the tags to be more useful when there are less critical patients and a delay in transport assets."

4. How many table top exercises or simulations of this sort were utilized prior to the event?

   • Biddinger - "There are multiple tabletops that occur at the city, state, and other levels each year for the Marathon and they continue each year.  Before 2013, there were multiple among the hospitals, public health, and EMS each year for others."

5. Would you share your protocols or make them available?

   • Biddinger - "We have a redacted version of the MGH MCI protocol that we are happy to share.  In addition, we are happy to share a recent article describing our buffer zone MCI plan that is a response to severe hospital crowding."

6. How do we incentivize hospitals to put the money into preparedness, and to do so consistently over time?

   • Biddinger - "The best arguments that we have found so far are 1) preparedness programs pay dividends for other operational disruptions (supply chain, IT system failures, severe weather) beyond preparedness for MCI events.  Keeping the hospitals open and functional no matter what the threat has been a compelling financial and operational argument for some of our c-suite leaders."

7. Because Marathon Monday is like a holiday in Boston, there were fewer scheduled surgeries, so there were more open surgical theatres. Furthermore, the bombing happened around the time of a shift change, so there were more clinical staff on hand at the hospitals. What sort of analysis has been done to identify if these factors helped in the low mortality? And how do you delicately communicate to your staff: you did amazing, but it could have been worse?

   • Biddinger - "Although Marathon Monday is a holiday in MA, most hospitals maintain a nearly full procedural schedule.  Nonetheless, the points about how it could have been a worse event (farther from the trauma centers, indoors, not at shift change, etc.), is an important one.  The hospitals have tried to acknowledge this in our internal and external reviews. In addition, given the worsened state of hospital and ED crowding as compared with 2013, we are vocal that there is still much more work to do in planning and training."                                                                                                                                                                       

   • Gill -  "Our preparedness funding has been predominantly Department of Homeland Security grant programs, to include UASI, Port Security and Metropolitan Medical Response System to name a couple."

Additional answer from questions from the audience are being received and will be posted as soon as possible.

1. How do we manage a 1K casualty a day?

   • "The Federal government has some lessons learned to identify and fill-in the gap"

2. How do you use specialty units for beds?

   • "The trauma surgeon took the lead in identifying critical care needs. They then triaged the patients according to their units, bypassing the Emergency Department (ED). They really understood one approach: when handling day-to-day surgeries, patients go to the unit first and then back to the ED."

3. What does HCA think the optimum rate for time is? 

   • "It's hard to manage, depending on whether or not you have the staffing for care."

4. How does HCA plan for accommodating families and patients with disabilities in MCIs?

   • "The family call center helps medical staff identify patients with disabilities who are being treated during a mass casualty event, but whose disabilities were not initially known to the medical team."

5. What if you were encouraged to use a wireless interface? What what would that have looked like?

   • "Implementing a mass alert early on proved to be effective. The messages were tailored specifically for employees and then organized by units. Having preassigned leads is critical for effective messaging."

6. What is the chance, in terms of a patient in foreign settings, of redistributing resources, especially where centers are not accustomed to sending out patients but rather receiving them? How do you see this being leveraged?

   • "I don't think it matters whether it's for-profit or non-profit; during these types of events, the focus shifts. The Memorandums of Understanding (MOCs) during COVID were issued at that time because there was no opportunity to do so at any other time. Having a centralized hub that contains data and can check the availability of beds across every hospital is essential."