Keywords

16.1 Overview

Whenever a major incident occurs, an integrated and efficient response is necessary in order to make an impact on mortality and morbidity. This can only come about if the personnel involved are educated and trained in the unique procedures forethought to be necessary in the response to these events. The aim of this chapter is to discuss the challenges and different problems that may be encountered when educating and training medical personnel in this scenario. The focus is on events that may lead to a mass influx of patients suffering from injuries, whether following a terror attack (bombing, mass shooting, truck stampeding into a crowd), mass gathering disaster, mass transport accident, or an industrial disaster without an overt toxicologic component.

The main challenge facing the health system is how to achieve preparedness for an event for which the circumstances and scope are not fully known. Risk assessment is carried out in order to determine possible consequences of realistic threats [1]. Contingency plans should be developed for possible scenarios. These should identify potential responders, potential procedures, and potential tools necessary to carry out the plan. No matter which component of the response is being planned for, there is no alternative to prior education and training of those responders who will be responsible for carrying out the task once the calamity strikes [2].

Major incidents lead not only to injuries and to deaths, but also to disruptions in infrastructure and logistics all of which may affect the response. The response to these events will involve not only the health system, but also other sectors, such as security forces, other rescue services, and different government agencies. Different organizations need to learn how to work together in order not to interfere with one another during a real event. This can only be done if the aims of the different sectors involved are made known and prioritized before the event occurs. Members of the health system, for example, need to learn how to cooperate with the police and firefighters [3]. Simulations should be instituted in order to assess whether different organizations have indeed implemented the necessary tools to allow a coordinated response [4,5,6].

The medical response to major incidents in itself is also complex. Members of the health system that need to be educated and trained include medical first responders, hospital first receivers such as physicians and nurses, and health care institution support personnel such as janitors, hospital administrators, laboratory personnel, radiology technicians, and security personnel [7]. Members of each of these sectors have different responsibilities within the medical chain of response during a crisis. The educational content and intensity of training for each sector will be different. Identifying response components that can be incorporated into daily professional practices together with just-in-time training is one strategy to create a sustainable mechanism allowing members of the health care delivery system the ability to respond properly during the crisis [7]. Furthermore, identifying those critical components that are not part of the daily professional practices foretells which components will probably fail during the event [8]. These should be the elements most emphasized during simulation sessions.

While the need to educate and train for a possible event is clear, there are still many deficiencies to overcome. It is not uncommon to encounter hospitals without detailed disaster plans and without active disaster committees [9, 10]. Challenges to education and training include lack of time and lack of staff devoted to training. Training is not prioritized due to absence of ubiquitous support, incentives, or requirements among health professions [11]. Most of the education and training done is fragmentized by the different professions involved and even within each profession, the teaching and training of the different proficiencies are fragmentized. Infrequent exercises lead to personnel’s uncertainty concerning their role during a real event [8, 12]. These problems are further complicated by myriad of solutions that exist for similar problems creating a chaos between similar training systems, for example, triage [13,14,15]. Seldom are all the components of the chain of response trained together [2]. Current available options for training are limited by lack of realism, prohibitive expense, and lack of assessment tools [16].

16.2 Types of Education, Simulation, and Training

Extensive literature exists on different techniques employed in educating and training possible responders in their role of action during a mass casualty incident (Table 16.1). These may be technologically simple such as paper-based exercises and didactic lessons or technologically complex such as interactive virtual simulations and high fidelity human patient simulators [18,19,20,21,22]. Didactic lessons, large-scale exercises, and pilot demonstration projects enable education and training of a large number of people at the same time [23]. Other techniques such as virtual simulators may be more limited in the number of people who can participate in any one session.

Table 16.1 Training tools and possibilities
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The different techniques are usually targeted at specific sectors of responders such as medical first responders and other health care personnel. Some efforts are less selective and involve medical students who may find themselves in the future, during their professional life, responding to a mass casualty incident [23, 24]. Training courses have been developed to teach non-medical personnel-specific skill, such as triage skills course for non-medical members of other rescue services [25, 26]. Courses have been developed even for the lay public in order to make these ready to assist if in case a mass casualty event occurs [27]. Some of the skills needed in order to respond may need refreshment. For this purpose, some of the courses include a short-term “last minute” training session [28]. Alternatively, aide memoirs may be used as last minute reminders [22].

Many of these educational courses and training sessions include an element of evaluation. Many base their evaluation on Likert charts, where student participants evaluate their perceived competencies before and after the course [3, 29,30,31]. Other tools used for evaluation include surveys, pretests, and post-tests [8, 32]. Responders’ knowledge and confidence can be reevaluated several months later [26, 31]. Some forms of training allow quantifiable data to be collected, such as triage accuracy [25, 26, 33]. Virtual reality scenarios allow recording errors, delays and completion of action, as well as assessment of non-technical skills [16].

More important is the content of most of these educational efforts. Depending on the specific training course, these include, among others, basic disaster life support techniques, prehospital trauma life support, advanced trauma life support, different triage techniques, and different procedures that might be needed, such as proper tourniquet placement [30, 34]. It is clear that the myriad courses that exist, each based on the education of specific skills and aimed at specific sectors, raise doubt about the real value of these courses in training the system to be prepared for a mass casualty incident. Many of these present themselves as educational initiatives meant to improve response to mass casualty incidents. Whether this is true is questionable.

Once the risks are realized and the contingency plans thought out, it is necessary to evaluate who should be educated and trained to respond for these events. Splitting the plan into different areas of responsibility and allocating key personnel from each area to propose the most appropriate strategies to fulfill the tasks under their responsibility is key in producing a plan that is feasible. This approach also serves the purpose of education since collaborating with key personnel to produce parts of the plan will enhance their own performance when the need arises. Collaborating with key personnel will also help identify other human resources and procedures needed to carry out the role within each of the areas of responsibility. Any of the methods mentioned above is legitimate in training potential responders. Familiarity with the area of responsibility will help key personnel define which responders need more training and which tasks or skills are not employed routinely and therefore need strengthening.

While the model proposed above has many benefits, it should be emphasized that fragmentation of preparedness needs to be complemented by a process that examines how the different components of the system work together. Educational and training sessions of specific skills may be common. However, training of larger parts of the system is infrequent, becoming less common as the number of potential sector participants increases. In Israel, for example, the prehospital emergency system trains alone and different hospitals each train individually for mass casualty incidents. Over the last two decades, only few exercises were dedicated to test both the hospital and prehospital systems together. Joint training of the medical system with other rescue agencies and security forces is rare and usually limited to table-top exercises involving managerial positions.

A different approach is taken by the developers of the Medical Response to Major Incidents (MRMI) postgraduate course (Fig. 16.1) [5, 35]. The main idea behind the course is to introduce students to the whole chain of medical response: prehospital system, hospital system, and regional medical command. The students learn the theory and practice of the main sites and functions within the system. Two large table-top exercises constitute the backbone of the course where the students need to treat multiple victims following a major event. The injured victims are based on a real scenario. The real consumption of time and resources for every decision made is clearly illustrated, and also the consequences of the decisions with regard to mortality and complications, giving the trainees proper feedback with regard to the accuracy of the decisions on all levels in the chain of response.

Fig. 16.1
figure 1

Students training in primary and secondary triage in a mass casualty incident table-top exercise held in Karolinska Institute, Stockholm 2013 (courtesy of International MRMID-Association)

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Though the emphasis of the course is medical response, members of other rescue agencies and security forces participate. The students who work in the different stations learn to communicate their needs with other stations, whether these are medical or pertaining to the other non-medical agencies responding to the event. Since the injured victims represent patients with specific injuries and specific needs, the medical system response can be measured. Impact of different approaches adopted by one component of the system may raise problems that will be experienced downstream within the chain. For example, minimal or no treatment on a scene with prolonged transport times will lead to increased mortality of patients with airway problems during transport. On the other extreme, an over-cautious policy of intubation on the scene will negatively affect the workup possibilities of multiple patients once these are admitted to the hospital. The course lectures are supplemented by manuals and the Medical Response to Major Incidents and Disasters textbook that serves as a guidebook for this course [36]. The accuracy of the course for its purpose has been scientifically validated on a large number of trainees from many different countries [32].

Large-scale exercises enable training large numbers of staff in their role usually within their natural environment. Apart from testing decision-making, large-scale exercises have an added benefit of testing certain logistical issues that cannot be otherwise reproduced within other training formats. For example, large-scale exercises help identify obstacles in patient flow both in the scene and in the hospitals. In the setup of the hospital, problems with simultaneous inflow of a number of ambulances with patients can be appreciated as well as mobilization of patients between the different sites within the hospital itself. The efficacy of the method for rapid patient registration can also be assessed. This is crucial since different aspects of vital treatment of severely injured patients rely on proper patient identification.

Though allowing to train simultaneously the staff within their natural environment, large-scale exercises do not offer a comprehensive solution for MCI education and training. Patient flow may be assessed in the hospitals’ emergency departments or radiology departments, but cannot be reproduced in the intensive care units and within the operating rooms. Furthermore, the role of large-scale exercises should be re-examined in a reality where the medical system, though expected to be prepared to respond to a calamity, is mainly judged by its ability to maintain economic viability. In order to be effective, most, if not all those involved in the response, should be relieved from other tasks during the large-scale exercise itself. Large-scale exercises demand from hospitals to limit economic activities such as outpatient clinics and routine operations on the day of the exercise. The economic losses entailed by large-scale exercises transform these into an unattractive solution for hospital administrations.

Table-top exercises may reproduce most of the components trained in large-scale exercises. Those activities in major incident response that have to be tested and trained “live” to secure function can be done in small-scale exercises involving selected individual units. Planning and integration of both table-top exercises and small-scale exercises are essential in order to produce an effective system for education and training that can be repeated as necessary with minimal constraints on the medical system.

Recent involvement of the coalition forces in conflicts in Iraq and Afghanistan has created a new dimension for education and training [37]. The experience in treatment of war-like injuries within the civilian sector is limited. Nevertheless, use of bombs and high-velocity automatic guns are commonly used by perpetrators aiming at causing incidents with as many casualties as possible. New courses are being created with the aim to introduce civilian physicians with this type of injuries. The realization that the types of injuries that may be encountered following terror attacks will be different from those commonly encountered in everyday trauma scenarios should be emphasized if we wish to make an impact on survival.

16.3 A Rationale Approach to MCI Education and Training

It is time to reevaluate the current approach to MCI education and training that has created a chaotic environment of multiple endeavors that vary in their aims and contents across geographical regions and rescue systems within the same region. Realization that the medical response to major incidents demands a synchronized approach across the medical system as well as effective collaboration with other rescue services, security forces, and government agencies should be emphasized. Current efforts should be maintained, but prioritized according to their contribution to preparedness according to the regional plan. We therefore suggest:

  1. 1.

    Link the educational effort with the regional plan.

    As explained above, involving responders in the planning phase contributes not only to the feasibility of the plan, but also to the education of those who will lead the response to the event.

  2. 2.

    Education and training should target the whole chain of response. This should be supplemented by education of specific skills needed by specific responders.

    While effective planning demands fragmentation of the plan into its components, effective execution demands the plan to be evaluated as a whole. Training the whole chain of response will identify the gaps in the plan, many of which tend to occur in between components executed by different sectors of the response.

  3. 3.

    Identify the components of the plan that rely on procedures done on routine basis and those which are not.

    The plan is as good as its weakest link. Procedures that are not in common use will fail if responders are not acquainted with these. Involving the responders in the planning phase is one strategy to increase acquaintance of responders with their role. Identifying those uncommon procedures helps identify which procedures need frequent training.

  4. 4.

    Define for each education and training undertaking a set of learning objectives that corresponds to objective of the plan.

    Evaluation of regional readiness demands periodic review of the plan against the learning objectives of available educational and training efforts. Gaps identified should be fixed with most appropriate method of education and training.