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Lessons identified from the 2017 Manchester and London terrorism incidents. Part two: the reception and definitive care (hospital) phases
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  1. Paul Hunt1,2
  1. 1 Emergency Department, South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
  2. 2 ADMEM, Royal Centre for Defence Medicine, Birmingham, UK
  1. Correspondence to Paul Hunt, Emergency Department, South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough TS4 3BW, UK; paul.hunt1{at}nhs.net

Abstract

The provision of medical care during the reception and definitive care phases of a terrorist incident will likely take place in designated receiving hospitals such as Major Trauma Centres. There is a need for an enhanced capability in such units to receive, initially manage and hold casualties with more serious injuries. Also, even less severely injured casualties may require significant time and clinical input such as risk management in potential bloodborne viruses.

The distribution of casualties from the incident scene requires advance consideration of the injury pattern and regional network organisation of specialist services, such as maxillofacial, neurosurgery or severe burns care. Paediatric centres are also more sparsely distributed and often only in large city networks which represents a significant challenge for planners and responders in other regions. An effective response relies on a coordinated multidisciplinary approach including emergency and front-of-house teams, surgical, medical and clinical support services.

  • major incidents
  • terrorism
  • EPRR
  • reception phase
  • definitive care phase

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Key messages

  • This article summarises key lessons from the national multidisciplinary debrief process, which followed the three UK terrorist incidents in 2017.

  • The lessons identified cover all phases of the medical response and outline the main challenges, and examples of good practice, applicable to future incidents.

  • The military context and potential applications of this knowledge are also summarised.

Introduction

The first article in this series1 detailing the lessons identified during the NHS England clinical debrief meetings which followed the response to the 2017 Manchester and London terrorist incidents described feedback from the prehospital phase and relevant responders. Key lessons common to all three incidents were highlighted such as the importance of effective communication and ensuring situational awareness in the prehospital phase in order to provide an effective and timely medical response. Importantly, the process of enhanced casualty triage and transport decision-making demonstrated effective casualty distribution to receiving hospitals.

This, the second article in the series, discusses the reception and definitive care phases including reception in the emergency department (ED) with observations from Major Trauma Centres (MTCs) and Trauma Units (TUs) as well as reflections from surgical teams with reference to a variety of injury patterns including blast and ballistic trauma. Other important components of hospital management covered include specialist and clinical support services, radiology, the NHS Blood and Transplant (NHSBT) organisation and bloodborne virus (BBV) risk management.

The reception phase

MTCs represented the key receiving hospital capability and capacity during each of the incident responses with preferential transport to such centres in the case of critical or serious multiple injuries. The network configuration in Manchester required a highly selective transfer approach, with specialist capability restricted to certain hospitals. TUs were also required to provide urgent life-saving care for critical patients and to ensure casualty loading was appropriately distributed and avoid overwhelming any one site. In some cases, TUs were required to deal with certain injury patterns that would normally bypass due to network policy. This highlighted the need for TUs to have a greater level of ‘hold’ capability in the case of a major incident.

Figure 1 shows an example of the overall injury burden as identified during the Westminster Bridge incident; demonstrating the high proportion of thoracic and soft tissue trauma injuries.

Figure 1

Injury and site by percentage of total caseload.

Timings between the incident occurring and major incident declaration, arrival of first patient and stand-down are likely to vary due to variation in receiving hospital protocol, readiness state, capacity or the method and accuracy of the communication. For example, relevant timings for the London Bridge incident are shown in table 1.

Table 1

Timings from incident to major incident standby, declaration, arrival of first patient and stand-down for each receiving hospital during London Bridge incident

A summary of further observations for MTCs and TUs from all three incidents are listed in box 1 and box 2, respectively.

Box 1

Major Trauma Centres observations

  • The key to the reception phase in the emergency department (ED) was the rapid and effective generation of capacity. This relied heavily on an effective acute medical team response to move an existing patient caseload from the ED.

  • Ensuring that a minimum reception capacity is planned for and regularly exercised. This would take the form of a ‘quota’ for the hospital response from a network/regional framework perspective.

  • From a clinical point of view, the emphasis was on Damage Control Resuscitation techniques and a progressive, one-way resuscitation approach throughout the pathway of care including radiology where necessary.

  • Sequential severe blunt trauma cases required rapid team reconfiguration and restocking/cubicle reset.

  • A freeware and cross-platform instant messaging service (‘WhatsApp’) was used for internal communications and information sharing.

  • Increased number of clinical staff in the survivor/relative support areas.

  • Increased blood bank staff to support resupply and help prethaw stocks, and deploy team forward to ED to support department and improve communication and governance/safety.

  • Increasing radiology personnel for ‘hot’ reporting as well as ‘double-reporting’, eg, within 24 hours, especially with penetrating trauma with soft tissue FB.

  • An agreed, structured debrief process is essential; carried out at individual, group and organisational levels.

  • Early and open access to psychological support and staff welfare services is vital.

  • Creating capacity on surgical wards proved more straightforward than expected with discharge and welfare support in place and appropriate, safe after-care arrangements for continuity.

  • Concerns about hospitals as a secondary target or as part of a coordinated terrorist attack.

  • Requirement for clear lockdown guidance for hospital and departments with regular rehearsals.

  • Flexibility across sites for effective utilisation of specialty resources and capacity (‘hyperacute transfers’).

  • Intensive care unit (level 3) bed capacity creation from a mixture of internal and external resource utilisation: transfers to secondary sites by prearranged teams (third-party hospital or regionally).

  • The importance of Trauma Unit liaison and information sharing for situational awareness.

Box 2

Trauma Unit (TU) observations

  • TUs received casualties with severe polytrauma for which they are conceptually unprepared for in terms of the usual major trauma response—many of whom went straight to operating theatre.

  • Suggested need for ‘hardening’ of TU capability to withstand similar incidents safely and sustainably.

  • The need for framework response for ‘scoop and run’ casualties who may be brought directly to nearest hospital by public or other non-medical responders; which may be before formal declaration and hospital major incident responses are active.

  • Effective cross-site working and sharing of expertise; clinical mentoring and provision of advice between disciplines and hospitals; clear communication and case conferencing.

  • Similar challenges to Major Trauma Centres with capacity generation in the emergency department, theatres, critical care and wards; elective caseload similarly suspended and requirement for interunit cooperation and organisational mutual support.

  • Creating a resilient communications and information-sharing ‘portal’ through use of messenger services; patchy signal and blackspots reduced regular mobile network function. Switchboard services were felt to be undercapacity and capability for rapid and effective cascade.

  • Benefit of tactical-level plans for other specialties—such as ophthalmology or maxillofacial surgery.

  • ‘Smaller’ hospitals may not have great staffing levels for security and associated support staff to facilitate lock-down.

  • Primary care needs of relatives and other members of the public not otherwise directly involved in the incident—who will deliver? How to ensure continuity on return home?

  • Importance of retriage to recognise more severely injured, apparently ambulant casualties.

  • ‘P3’ cases often need more clinical care than expected.

  • For paediatric casualties to consider dropping the age threshold to 12 years.

During the Manchester incident response, several District General Hospitals (DGHs) were used as receiving hospitals, particularly for ambulant (P3) casualties. Reflection from these units raised similar learning points including the need for standardised documentation at a regional or network level and the benefit of clear, simple and reproducible action cards for operational and tactical level teams. Teams from DGHs also recognised the need for robust arrangements for access to acute care needs for stroke and acute myocardial infarction during the response to a major incident. Effective communications was again highlighted as a key factor and most hospitals identified a need for reviewing the current process and improving information sharing.

The definitive care phase

Reflections from surgical teams

The case-mix for the Manchester incident represented a typical military ballistic pattern of injury with multiple and often complex open orthopaedic and plastic surgical needs. In some cases, neurosurgical, spinal injury or cardiothoracic intervention was also required. The surgical ‘tail’ continued for 2 weeks or more with 26 hours of operating on day 1, 9 hours on day 2, 12 hours on day 3 and several hours daily subsequently. Approximately 400 hours of surgery were undertaken over this time and a total of 392 units of blood products (334 Packed Red Cells,PRC and 58 Fresh Frozen Plasma, FFP) during the initial management of casualties. It can be estimated that each serious casualty requiring hospital treatment and surgical care would need up to 8 units of blood product during initial management and up to 8 hours of surgery throughout their hospital stay. The requirement of an average 6–8 units of blood product per casualty is consistent with reports from other major incidents.2 These figures could therefore act as a future planning guide to assist in long-term resource allocation and business continuity management.

For the Westminster and London Bridge incidents, the patterns of injuries were consistent with a more common road traffic collision mechanism and penetrating trauma as a result of sharp-edged weapons. Immediately following the London Bridge incident, 30% (n=14) of casualties required operating theatre management and 41% (n=19) required critical care management in the four main receiving hospitals.

A summary of observations are listed in box 3.

Box 3

Surgical team observations

  • Operating theatre teams recommended creation of relevant plans and action cards for elective list management and rescheduling which may continue for several weeks.

  • The main impact was on increasing the trauma list capacity for a prolonged period; often necessitating a reduction in elective surgical and outpatient activity.

  • A vital role was suggested of the ‘Surgeon Commander’ for coordination and prioritisation of surgical cases; working beside the hospital coordination team, especially representation and liaison in the emergency department.

  • The paradigm of Damage Control Surgery (DCS) was emphasised as the most appropriate approach, although a hybrid model of DCS and definitive management was also considered effective, where resources made it possible. It should be trained for and regularly practised.

  • Management of blunt polytrauma was recognised as being well within an existing surgical skill set and capability, although the blast and ballistic injury pattern was much less familiar—the use of simulated (tissue model, virtual or augmented reality) environments for training were suggested.

  • Step-down of the emergency theatre capacity and activity was sequential in nature.

  • A systematic, reproducible triage system for surgical prioritisation was felt to be lacking—a military development team are currently investigating this.

  • Providing clear information to inform at a strategic level, and for public and other external agencies: proactive and dynamic situational reports.

  • Having a clear escalation plan and information cascade that is robust and rehearsed for any time or day of week.

  • Development of a clear haemostatic therapeutic ‘ladder’ including effective recognition and hand-over when escalated measures such as limb tourniquet are used.

  • ‘Double-operating’ for increased resilience and mutual support and reduce task-focus issues.

  • Clear clinical leadership for prolonged care planning.

  • Front-of-house CT scanner capability provides considerable benefit to aiding surgical prioritisation.

Blast and ballistic injury patterns

A significant area of learning for NHS personnel was regarding blast and ballistic trauma. Key points included how to identify and most effectively document limb tourniquet use at scene, ballistic wound evolution and staged surgical care, whether or not to chase every fragment or apparent foreign body and the concept of ‘biological shrapnel’. It was broadly accepted that, at best, each surgical stage will remove around 90% of contaminating material from the wound. The main challenges for services included the need for multiple ‘take-backs’ and the planning required for cohesion with ongoing critical care treatment. For NHS personnel, the idea of peripheral pulmonary emboli following blast was new and, as recognised from military experience, were safely managed conservatively without necessarily the need for prolonged anticoagulation therapy. Also, in the case of indwelling metallic bodies from intentional energised fragments, it was important to recognise the potential for toxicity from elements such as lead and copper.

Specialist services

Timely involvement of specialist services is essential during the reception phase of the response and beyond. The key to successful integration of specialist assistance, particularly from external expertise, was in effective leadership and good communication. The role of a ‘specialist service coordinator’ was also suggested in order to support multidisciplinary coordination and ensure continuity.

Examples of key surgical specialities that may be required during a major incident includes ophthalmology, maxillofacial surgery, cardiothoracics and neurosurgery in addition to the general and vascular, trauma and orthopaedics, plastics and reconstructive surgical teams. Depending on the circumstances of the incident, further teams that are likely to be required are paediatric surgery and obstetrics and gynaecology. Certain mechanisms may also yield complex injuries requiring urological surgical input—this was certainly the case during the UK military experience in Afghanistan.

Ophthalmology services were vital in ensuring timely identification of ocular injuries and, as such, diagnoses were delayed in very few cases. Changes to emergency ophthalmology outpatient services was required to free clinical personnel to support the response. Most of the injuries managed involved relatively minor corneal abrasions and foreign bodies. It was suggested that penetrating injury will usually require intravitreal injection to manage potential infection. In many cases, systemic antibiotics were also used, although the evidence basis for this was not clarified.

In terms of medical specialties, the early involvement of acute and general medicine teams was vital in facilitating the clearance of the ED, assisting safe discharge from inpatient wards and ongoing provision of medical expertise for relevant conditions that may still present during an emergency. In the event of an incident involving chemical, biological or radiological hazards, certain specialist services may be required in addition. Infectious disease expertise may also be used in the event of blast or ballistic trauma and the possibility of BBV inoculation from ‘biological shrapnel’.

Clinical support services

Key clinical support services, including laboratories and blood transfusion, must have plans in place to establish extra resource and enhance delivery in the event of surge or escalation in response to a major incident. Feedback from the UK terrorism incidents of 2017 demonstrated the importance of placing liaison from clinical support services into front-of-house areas. An increase in capacity of these services will generally only be required during the initial reception phase. Following this, routine capacity is likely to be sufficient.

Blood transfusion is discussed in more detail in the 'NHS blood and transplant' section. Clinical photography resources were also noted to be extremely useful for documenting injuries and for specialty service support. Radiology services are discussed specifically in the next section.

Radiology

Radiology services often represent a ‘bottleneck’ for multiple trauma cases. Significant benefit was noted from having radiologists directly supporting the reception phase at front-of-house to assist the prioritisation of surgical cases. Victims of blast and ballistic trauma generally underwent whole body CT (WBCT) scanning and was considered essential in both adults and children. WBCT provided a detailed assessment of the extent of tissue damage from penetrating injury and three-dimensional location of ballistic material, shrapnel or other fragments including biological foreign bodies. Double-reporting of CT scans was also recommended, with a second ‘reader’ reviewing the images within 24 hours.

NHS blood and transplant

Both local and national aspects of the NHSBT service were considered during feedback from the three incidents. NHSBT covers blood and skin tissues. Resilient stocks held by NHSBT include over 3000 units of O− red cell. A summary of key observations are listed in box 4.

Box 4

Key observations from the NHS blood and transplant (NHSBT)

  • NHSBT observed instances of overstocking with unnecessary requests from hospitals involved in the response due to the assumption of requiring an 8-hour supply at all times.

  • A need for a national standard and uniformity of the casualty identification system during major incidents as significant variation was noted between hospitals and networks.

  • Ensuring age and gender information is included on blood requests will facilitate best use of available blood products, for instance, by using O+ blood where appropriate.

  • Major Haemorrhage Protocols (MHP) must be written to account for major incidents—rather than supplying multiple ‘packs’ the emphasis should be on a ‘front-loaded’ stock, supported by laboratory staff for governance and safety reasons.

  • Road fleet and cold stores must be sufficient to match supply and demand with plans in place to take into account potential disruption from infrastructure damage to travel routes.

  • It was noted that there is no legal precedent to preventing the donation of tissues from victims of a mass casualty, major incident or terrorist incident.

Bloodborne virus risk management

Human tissue projectile implantation from blast, and other mechanisms of penetrating trauma such as stabbing injuries, have the potential risk of transmission of BBV such as hepatitis B (HBV), hepatitis C and HIV. In the UK, HBV is considered the main threat, although the overall prevalence for all BBV is still considered low. Comparative BBV prevalence and risk of transmission is shown in table 2.

Table 2

Comparison of BBV risk in the UK4

Overall, the undiagnosed rate of HIV is believed to be very low in the UK. The effective therapeutic suppression of viral load also significantly reduces transmissibility.

The ideal BBV risk management strategy must be clear and consistent. A dedicated microbiologist or virologist should be appointed to provide support and guidance locally following incidents where there is risk of BBV transmission. Following the Manchester incident, requests for communal testing were generally responded to very positively and very few cases of active HBV infection were identified in those tested. A key challenge will be ensuring a robust and reliable follow-up with local public health teams, maintenance of an effective casualty registry and providing out-of-area liaison for victims after returning home. The most up-to-date guidance for BBV risk management following blast injury is summarised in box 5.

Box 5

Summary of latest bloodborne virus (BBV) risk management guidance4

  • Victims within 2 m of a blast are most likely to suffer significant human tissue projectile injuries.

  • All human foreign body implantations should be urgently removed and specimens taken from scene, post-mortems and survivors at risk of BBV infection.

  • Blood specimens from victims should be taken and stored prior to specific postexposure treatment.

  • Any victims with relevant injuries that have breached skin must receive hepatitis B virus (HBV) vaccination schedule.

  • The accelerated course of HBV vaccination consists of injections at either 0, 1 and 2 months or 0, 7 and 21 days and 12 months.

  • Postexposure prophylaxis using HBV rapid schedule immunisation is highly effective within 48 hours, and may still be considered up to 1 week after exposure.

  • Hepatitis C  virus (HCV) has no evidence-based method for postexposure management.

  • HIV Post Exposure Prophylaxis (PEP) is well-described and is effective subject to compliance and if commenced within 72 hours.

  • All patients should be followed up at 3 and 6 months to determine HCV and HIV status.

Conclusions

The provision of medical care during the reception and definitive care phases will, in most cases, take place in designated receiving hospitals and usually these will be MTCs. However, one of the main lessons identified was the need for an enhanced capability in TUs to receive, initially manage and hold casualties with more serious injuries. Also, even less severely injured casualties may require significant time and clinical input such as BBV risk management.

The distribution of casualties from the incident scene requires advance consideration of the injury pattern and regional network organisation of specialist services, such as neurosurgery or severe burns care. Paediatric centres are also more sparsely distributed and often only in large city networks,which represents a significant challenge for planners and responders in other regions. An effective response relies on a coordinated multidisciplinary approach including emergency and front-of-house teams, surgical, medical and clinical support services. The next paper in this series3 follows on from the reception and definitive care phase with a discussion of the lessons identified relevant to the postincident and recovery phase.

References

Footnotes

  • Contributors As per previous submission.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.