ALiEM Sim Case Series: Mass Casualty Building Bombing

Posted by Nikita Joshi, MD on Jul 05, 2013

Case Writer: Nikita Joshi, MD

Keywords: Mass casualty incident, building bombing, disaster, triage, ethics

Educational Objectives

Medical

Develop system of triage to optimize patient outcomes in prehospital disaster setting
Effectively utilize color coded tagging method to assist in categorizing patients
Develop treatment plans to address immediate emergency conditions per ATLS protocols

Communication

Maintain team and personnel safety precautions
Regularly provide updates to incident command center

Case Synopsis

Download Building Bombing Flowchart (PDF)

A crowded 3-story commerce building within 4 blocks of the hospital was bombed from the lobby 10 minutes ago. An incident command center has opened and is directing the medical response. Police and fire volunteers have already rescued a few of the victims of the building and have laid them out on the sidewalk. The building is a commercial building with a daycare on the second floor for employees of the building. The victims range from toddlers to middle aged business workers. The medical team is responsible for triaging and formulating evacuation plan for victims. All pertinent information must be relayed to incident command center.

Prioritizes critical initial stabilization action and mobilizes hospital support services in the resuscitation of a critically ill or injured patient and reassesses after stabilizing intervention.
Milestone Level	Milestone to be Assessed	Specific Behavior
1	Manages a single patient amidst distractions	Takes a brief history and physical from every victim Examines and assigns a specific triage color level to all four victims
2	Task switches between different patients	Reassesses patients who have change in physical exam Verbalizes different procedures that each patient will require based on injury
5	Employees task switching in an efficient and timely manner in order to manage multiple patients	Does not delegate a significant amount of time resuscitating victims triaged to Black nor to the walking wounded
8. ABEM Milestone: Multi-Tasking (Task-Switching) (PC8)

Prioritizes critical initial stabilization action and mobilizes hospital support services in the resuscitation of a critically ill or injured patient and reassesses after stabilizing intervention.
Milestone Level	Milestone to be Assessed	Specific Behavior
1	Participates as a member of patient care team	Takes orders from team leader and executes orders
2	Communicates pertinent information to emergency physicians and other healthcare colleagues	Obtains bombing history from police in order to understand the potential injury patterns Contacts Incident Command Center upon arrival on the bomb scene to obtain information Contacts Incident Command Center after triaging victims to communicate the order of evacuation Communicates resources needed for patient such as advanced airway equipment for man with developing respiratory distress
3	Ensures transition of care are accurately and efficiently communicated	Communicates with Incident Command Center each of the following: Four victims triage colors, resources needed to evacuate each victim, method of how victims need to be transported Tells EMS the importance to obtain advanced airway on man with respiratory distress immediately upon arrival of EMS
4	Recommends changes in team performance as necessary for optimal efficiency	Reassigns team tasks and roles when man with respiratory distress begins to deteriorate
5	Communicates with out-of-hospital and nonmedical personnel such as police, media, hospital administrators	Communicates with police and obtains understanding of bombing Communicates with EMS and gives sign out on all victims Communicates with Incident Command Center
19. ABEM Milestone: Team Management (ICS2)

PDF of the case-specific ABEM Milestones (PC 8, ICS 2)
PDF of more detailed scenario description

Critical Actions

Maintain team safety
Perform triage based upon MASS and Color Coding system
Perform lifesaving interventions on patients assigned a red color coding level
Evacuation of victims based on triage

Learners

ED residents
EMS
EMS students
Nurses
Nursing students
Medical students

Location

Sidewalk outside of bombed building

Patients

3 yo girl
Mother
Man
Nonresponsive Man

Special Equipment

Triage Level Color Coding Cards

Standard Equipment

*Minimal emergency medical equipment will be made available given the pre-hospital location

Non-rebreather O2 mask
Oxygen tank
Back board – spinal immobilization
Cervical stabilizing collars
IV fluid
Scapels
Syringes

Moulage

3 yo girl (manikin or confederate)– soot and dirt on child
Woman (mother, confederate) – crush injury of lower extremity; using task trainer lower extremity
Man (confederate) – singed off eyebrows, coughing black material
Nonresponsive Man (manikin) – amputation of the upper extremity and structural material impaled through chest

Confederates

Police Officer – gives history of finding mother and child; mentions how he helped the mother out of the building by assisting in the removal of heavy building material that trapped her lower extremity
3 yo girl – crying
Mother – In extreme pain from the lower extremity
Man – Coughing, complaining of ringing in the ears, insists on immediate medical attention
Incident Command Center (voice) – asks team for regular updates, will bring resources if asked for by the team; asks the team to list the triage of the patients and discuss evacuation plan; informs team that there might be more bomb explosions
EMS – arrives to transport victims in order designated by team

Supporting Files / Media

None

Translation

BP	Blood Pressure
HR	Heart Rate
IV	Intravenous
LOC	Loss of Consciousness
neg	Negative
RR	Respiratory Rate
pt	Patient
s/p	status post
yo	year old

Additional References

ACEP Policy: Health Care System Surge Capacity Recognition, Preparedness, and Response. 2011.
Asensio: Current Therapy of Trauma and Surgical Critical Care, 1^st ed. Chapter 9 Triage. 2008. Mosby, Inc. affiliate of Elsevier.
CDC Emergency Preparedness and Response: Mass Casualty Event Preparedness and Response. 2013
DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med. 2005 Mar 31;352(13):1335-42. PMID: 15800229.
Kleber C, Cwojdzinski D, Strehl M, Poloczek S, Haas NP. Results of in-hospital triage in 17 mass casualty trainings: underestimation of life-threatening injuries and need for re-triage. Am J Disaster Med. 2013 Winter;8(1):5-11. PMID: 23716369.
Lee CH. Disaster and Mass Casualty Triage. Virtual Mentor. 2010. 12;6:466-470.

Author information

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University

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Tags: prehospital, Simulation, simulation series