• Rob Orman

58. Lessons Learned in Blood with Mike Shertz, MD

Mass casualty events are rare and thus the mistakes made and lessons learned are often repeated, over and over. In this episode, emergency physician and former Special Forces medic Mike Shertz, MD walks us through the steps on how to be an effective first receiver of mass casualty victims and shares the 'lessons written in blood' from previous events.

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Guest Bio: Mike Shertz MD is an emergency physician who spent 13 years as a Green Beret and a Special Forces medic. He is the founder and purveyor of Crisis Medicine which teaches and trains first responders in tactical casualty care. Check out this video that we did together in 2019 on how to place and remove a tourniquet and this one on how to pack a gunshot wound with combat gauze.

This episode is in support of the I AM ALS. I AM ALS was founded by Brian Wallach and his wife Sandra shortly after his diagnosis at the age of 37. He was given 6 months to live, and now 4 years later he is leading a revolution to find a cure. People often refer to ALS as rare, which is not really so. The lifetime risk is around 1 in 300. Since Lou Gehrig was diagnosed 80 years ago, available treatments have been shown to extend life a mere 3 months. I AM ALS supports research, legislation to fast track therapies, and provides critical resources to patients and caregivers. ALS is relentless, and so are they. The question is no longer if we'll find a cure for ALS, but when. This is an underfunded disease and every little bit makes a difference. We will match donations to I AM ALS up to $5000 -- get started here on our Stimulus Donation Page. And for your daily dose of positivity, follow Brian on Twitter.

Bonus content.

Below is a walk through of the 2017 Las Vegas Mass casualty event from Essentials of Emergency Medicine.

We discuss:

The First Receiver who is in a singularly unique position as it applies to a mass casualty [03:55];

  • The term was coined in 2003 describing chemically contaminated casualties being taken to non-specialized hospitals (aka. first receiving hospitals).

  • The Committee for Tactical Emergency Casualty Care also uses the term to indicate non-trauma hospitals that will receive trauma patients in the event of a mass casualty incident where there's too many patients for the trauma centers.

  • This term is in contrast to the more common term “First Responders.” Most First Responders act at the site of an incident, as opposed to in the Emergency Department.

The difference between a hospital’s surge capacity and mass casualty preparedness [05:30];

  • Surge capacity is generally defined as a hospital having the ability to hospitalize more than 20 percent over their licensed bed capacity.

  • Mass casualty preparedness refers to no notice or limited notice events where you potentially have hundreds of casualties. Your big concern is throughput and saving lives.

  • The CDC calculator estimates that if you look at the number of patients that present to your facility in the first hour of a mass casualty and double it, that's a fairly accurate estimate of the total casualty count that you'll receive.

What you might expect from EMS during a mass casualty as compared with a normal day [08:20];

  • During a mass casualty, EMS will focus on life saving interventions. This includes aggressive use of tourniquets, more surgical airways and fewer rapid sequence endotracheal intubations, aggressive decompression of tension pneumothoraces, limited intravenous access, and limited triage.

The mindset of the medical provider after receiving a patient from EMS [10:32];

  • Your job is to figure out what is killing the patient at that moment and fix it.

  • You need to understand that you’re not going to be able to fix everything. You need to fix the patient enough to get them to somebody else (eg. the surgeon, another facility).

  • The military’s mnemonic MARCH can help you focus on what’s important: massive hemorrhage, airway, respiration, circulation, and hypothermia.

  • Patients who have a pulse and are talking generally are not dying. You can be more sophisticated in your evaluation -- unclothing the patient, looking for wounds, downgrading unnecessary tourniquets,

The value of a field triage score which is a simple way to stratify casualties [12:50];

  • A 2010 study looked at a database of approximately 5000 military casualties and subdivided them into 3 groups based not on the anatomic location of their injuries, but instead on how sick they were at that moment.

  • They found that those with a radial pulse who could follow simple commands (thus having a normal motor GCS) had a 2% death rate.

  • On the other extreme, casualties who had no radial pulse and couldn't follow a simple command had about a 40% death rate

  • This method of stratification can be very helpful for training people with little medical training (such as law enforcement) who may be the first on scene.

How the success of a mass casualty event for the first receiver has to do with organization, throughput, and saving lives [16:15];

  • It is easy for a level 1 trauma center to be overwhelmed; it can take as few as 5 simultaneous trauma patients to result in chaos in an emergency department.

  • The first step in preparation for a mass casualty is to empty the ED. Get patients admitted and discharged quickly to generate space.

  • Step 2 is to designate care areas. Where are you going to put the most seriously injured? Find another area for the walking wounded.

  • Step 3 is to assign people to the triage area and organize vehicle throughput to keep the ambulance area clear so patients can be easily offloaded.

  • Get security involved in the planning process (to block off the ambulance area, assist with moving wheelchairs/stretchers, ensure safety of staff, etc).

  • Within the hospital system you need to cancel all non-critical surgeries, call in additional staff, have hospitalists clear inpatient beds, create a temporary morgue, and put the entire hospital in lock-down for security purposes.

Lessons learned from the Christchurch, New Zealand mass shooter incident [29:45];

  • In 2019, an individual went into two mosques and shot numerous people. Christchurch Hospital received 41 casualties in 45 minutes.

  • Vehicles that brought victims often carried wounded, uninjured, and dead in the same car, so the Field Triage Score was particularly helpful in giving a snapshot of each person’s physiologic state.

  • One lesson was that ED resources are too limited to perform an ED thoracotomy. They take too much time and the survival rate is too low. Treatment should focus on stopping hemorrhage, securing airways, placing chest tubes, and giving blood.

  • Another lesson was of the importance of managing hypothermia as best you can. 9.3% of civilian trauma patients arrive at a trauma hospital with a body temperature <36℃.

How your response to a mass casualty differs if you’re unsure about the safety of your facility (as was the case in the 2020 Beirut explosion) [41:15];

  • The first thing you'd have to decide is whether you have enough concern about the building that you need to physically exit (and take as many casualties with you as possible).

  • The reality is that even if you question the safety of your infrastructure, you may not know if it’s safer outside it. Also, enough casualties will present near simultaneously that you’ll probably get stuck there caring for people.

  • Sending people away who are not severely injured and whose care can be deferred (such as lacerations or fractures) can help you make the problem smaller.

“We need to make the problem of the mass casualty small enough that we can get some control of it.”

One of the sayings of the Special Forces: ‘All lessons are written in blood’ [43:27];

  • This means that we don’t want to re-learn the lessons from the blood of our casualties.

  • While in Nairobi in 1998, Shertz learned that the only helpful x-ray in a mass casualty was a portable chest. Extremity x-rays looking for fractures were unnecessary and, therefore, discouraged. Many years later in more recent tragedies, physicians are still re-learning this piece of advice.

  • While the literature is not robust when it comes to mass casualties, lessons learned in the military are incredibly valuable.

One thing medicine does not do well is learn lessons from these big events. That’s in large part because they aren't studied well.”

The question Shertz thinks people should ask of their hospital disaster planners [45:45];

  • “What is the existing plan?” Hospitals that have a generic disaster plan may not have considered some of those nuances of active violence incidents. For instance, does your hospital have a plan if the morgue is at capacity?

  • The challenges faced by those managing mass casualties are “predictable, foreseeable, and, therefore, should be planned for.”

  • What is your plan if you need to place a chest tube? The military special forces community uses the PACE mnemonic for such a scenario. What is the Primary plan? (Use the appropriately sized chest tube.) What is the Alternate plan? (Use a smaller tube.) What is the Contingency plan? (If there are no chest tubes, do a finger thoracostomy.) What is the Emergency plan? (This is your alternative when everything else has failed.)

“When you plan ahead for your primary plan, your alternate plan, and your next plan, that’s lessons learned in blood.”

And more.

Shownotes by Melissa Orman, MD

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