Preparedness for Mass Casualty Events

The blackout of the Eastern United States and Canada in August 2003. Hurricane Sandy in October 2012. The horrific events of the Boston Marathon in April 2013.

What do all of these events have in common?

These mass casualty events affected numerous individuals, and institutions in these affected areas had to suddenly respond to patients impacted by these events in addition to handling patients who had already been hospitalized at the time that these events happened. Most patients affected by such events usually went to the most ideal place of the hospital in order to receive prompt care- the emergency department.

Unfortunately, across the globe, these events are seemingly becoming an everyday occurrence.

In my very first post on this blog, I discussed the concept that pharmacists practicing in the emergency department need to be able to anticipate care for patients in a such a manner that even being a few steps ahead of the physicians and ready to hand off medications that were likely to be needed for patients was the most ideal. I also made the point that after having seen something occur so frequently, it becomes somewhat of a rote process, and almost second nature. This skill does not necessarily develop overnight, but does take time to cultivate as practice becomes more and more refined.

In some ways, I think trauma resuscitations are beautiful. Now, I know that may sound a bit unusual, but hear me out on this one. Yes, the situation in and of itself for the patient is indeed awful, but everyone responding to the trauma- the trauma surgeon, residents, nurses, critical care technicians, pharmacists, and other ancillary support- know exactly what their role is. So much so that even the locations around the bed or stretcher of the patient in which the responders position themselves is well-defined. Several articles have addressed the role of the pharmacist in trauma resuscitations, and even when it comes time for us to hand off medications that the patient may need in such a situation, we may have already drawn everything up and have it prepared and ready to go before it is requested. It is almost as if we have simulated the situation so many times that in the midst of all the chaos, it is organized. And there is beauty in that.

No doubt that there is literature published on mass casualty events that fall under the categories of chemical, biological, radiological, and nuclear (CBRN) disasters. We are aware of the importance of decontamination and maintaining a “chempack” of antidotes and antimicrobial agents in the event of such disasters, and some of us may be involved in ensuring that adequate supply of these agents are maintained.

However, here is my question: What about events that do not fall under the categories of CBRN? That is, is there literature out there to guide pharmacists on how to respond to mass casualty events such as those listed in the examples above? What do we do then?

To put it quite simply, there is little to guide us, which is somewhat disheartening, as the likelihood of events outside of CBRN occurring is a bit higher than those that fall under CBRN. More and more tragic situations are impacting us, some occurring in our own backyards, but we are ill-equipped with guidance from national organizations on how to prepare for such events. For any guidance that is provided, the oft-made statement of “refer to your local emergency preparedness plan” may be seen with any of the reference manuals that you may flip through in your research. And yes, that reference manual may be in a remote location on your institutional Intranet that you may not be able to access in such a situation.

When it comes to situations like this, an “all hands on deck” approach is an absolute must. However, in such disasters, it is also important to consider practical questions that may arise; preferably, those questions should be addressed before such an event.

For example, how will you be able to assemble, organize, and delegate tasks to personnel in providing medications to victims during such events? Is your staff trained to respond to such events? How will you relay and communicate information to the staff in the setting of such an event?

What sorts of medications and quantities need to be maintained in stock in the event of such a disaster? We need to think beyond medications that are in chempacks, and begin to think about those medications that we commonly use in trauma resuscitations. Especially as drug shortages plague our day-to-day activities, is there a mechanism in place for alternative medications to be retrieved in a timely fashion? How will you ensure that your supply is adequate to not only treat patients directly impacted by such events, but also inpatients and members of the community?

More importantly, how will you mobilize medications to those patients? Say that the electricity is out, and your employee badge to access the area of medications is not functioning, and you cannot access patient care areas nor the automated dispensing cabinets within the institution. What happens then?
These are just some questions that may arise, and I am sure there are many more. As this may be the tip of the iceberg and this may be considered to be an “alligator sky” to some, concerted efforts need to take place with support from both governmental agencies and national pharmacy organizations to ensure that pharmacy personnel are prepared to respond to such events.

Related links to Preparedness for Mass Casualty Events:

Bringing the OR to the ER: Administration of Nicardipine as an IV Bolus

Preparedness for Mass Casualty Events
Selected References:
Pedersen CA, Canaday BR, Ellis WM, et al. Pharmacists’ opinions regarding level of involvement in emergency preparedness and response. J Am Pharm Assoc 2003; 43:694-701.
Austin Z, Martin JC, Gregory PA. Pharmacy practice in times of civil crisis: The experience of SARS and the blackout in Ontario, Canada. Res Social Adm Pharm 2007; 3:320-335.
Hogue MD, Hogue HB, Lander RD, et al. The nontraditional role of pharmacists after hurricane Katrina: process description and lessons learned. Public Health Rep 2009; 124:217-223.
Erickson K. An emergency department pharmacist’s experience at the Boston Marathon. Am J Health Syst Pharm 2013; 70:1652,1654.
Duncan EA, Colver K, Dougall N, et al. Consensus on items and quantities of clinical equipment required to deal with a mass casualties big bang incident: a national Delphi study. BMC Emerg Med 2014; 14:5.

“Where was I when the rockets came to life,
And carried you away into the alligator sky?
Even though I’ll never know what’s up ahead;
I’m never letting go, I’m never letting go.”
–“Alligator Sky” by Owl City