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Mass Casualty Incidents

April 27, 2013 — 1 Comment

In the wake of the 2013 Boston Marathon bombings, I feel it is helpful to reflect, as many have already done, on the situation. Atul Gawande, for example, has already provided an excellent review of the preparedness of Boston’s hospitals. The city was prepared due to extensive and flexible training, along with the assistance of myriad bystanders. With three deaths and over 260 casualties, this left a mortality rate of about 1%. This is remarkable, and numerous factors may have played a role in addition to any disaster plan.

What could have led this mortality rate to be so low? First, consider the location. This was a major public event, with medical personnel readily available. Additionally, the timing of the bombings was unique. The attack occurred not only on a holiday when operating rooms may not be at capacity, but they took place shortly before the 3:00 p.m. shift change that occurred at nearby hospitals. This created a situation where space was available, and twice the number of medical teams were available at this time. The location itself was beneficial, too. Boston is home to world-renowned hospitals with seven trauma centers. In other words, capacity and quality peak at this location. Even the location of the bomb was beneficial. Indoor attacks tend to produce greater injuries due to concentrated blast waves. The shoddy pressure-cooker bombs in this open venue reduced primary blast injuries compared with a situation indoors. Finally, we can see the effects of medical knowledge from military personnel making its way through trauma centers in the United States.  For example, Boston’s EMS chief hosted a conference to discuss the effects of blast injuries and terrorist attacks across the globe, taking advantage of this military knowledge. Taken together, a combination of superb disaster preparedness with key factors unique to this situation may have played a role in the reduction of the mortality in this attack.

This is not intended to detract from the severity of the Boston Marathon bombings. Like all attacks, this was a national tragedy that struck a chord with many of us. Numerous media outlets reporting on the attack described mass casualties. It is this term that I would like to clarify in this blog post. What does mass casualty mean? Having spoken with numerous colleagues and friends, I find that this term needs some clarification.

First, one must define casualty. This term has both military and civilian usages. A military casualty is any person that is deemed unfit for war, typically due to death, injury, illness, or capture. A civilian casualty, in the broadest sense, refers to both injuries and deaths in some incident. I bring this up because the term casualty is oftentimes incorrectly used synonymously with fatality, with the latter referring to only to deaths, and casualties including both fatal and non-fatal injuries.

But what is a mass casualty? The New York Post may want you to believe that this refers to a large number of fatalities, but we already know that a casualty is not a fatality. Is it then a large number of people injured or killed? The answer is more nuanced than that. A mass casualty incident is a term used by emergency medical services, not referring solely to the number of people injured or killed. It is better to consider this as a protocol that one must follow in a situation where the number of casualties (or potential casualties) outweighs the resources available. A mass casualty incident could thus include both a major explosion with hundreds injured to one building with a carbon monoxide leak where there are not yet any injuries. It comes down to the difference between the number of people that must be triaged versus the supplies available. This term may be related to total casualties, but it is not a measure of them.

In a mass casualty incident, a protocol of triage, treatment, and transport is followed. First, all persons in the vicinity are triaged. This means that medical personnel look at each person to see who requires the most immediate medical attention. Then, triaged patients (color coded) are taken to appropriate treatment areas. In extreme cases, an on-site morgue is set up to handle the worst cases. This happened in Boston, where an EMS tent acted as the morgue. Finally, after initial treatment, patients are transported to hospitals for care. This protocol has specific guidelines for each member of the team, creating a situation for efficient triage, treatment, and transport.

It is then disheartening to hear screams of mass casualties used loosely in the media, often implying a large number of civilian mortalities. This creates an air of panic and fear. While we must report cases like this with severity, we must also do it accurately, and the misuse of this term is just one of many mistakes the media made in this scenario. Precision in language is important. More importantly, we must also remain accurate and vigilant in both reporting and understanding of breaking news reports.

Though I only focused on one term, I hope this provides a general lesson to all. Misuse of terms in national media misinforms. We must take it upon ourselves to remain educated, promote vigilance in the reading of such reports, and educate others on what we learned.