In recent years, a catheter technique for closed-chest ablation of the atrioventricular (AV) junction has emerged as a therapeutic alternative for the treatment of supraventricular tachyarrhythmias. The technique involves delivery of one or more direct-current shocks through a cardioverter to a catheter electrode (cathode) that records the His bundle electrogram and a patch electrode (anode) that is placed adjacent to the left scapula. The amount of electrical energy used in each shock ranges from 35 to 500 (usually at least 200) J. Successful ablation is judged by the development of complete AV block produced by the thermal injury at the AV junction. This can be accomplished in approximately 60 percent of patients during a first attempt which includes one or more shocks. Implantation of a permanent pacemaker is mandatory following a successful procedure.
The Working Group on Emergency Mass Critical Care in 2005 provided a strong foundation for hospitals planning to augment critical care surge capacity. In response to increasing concerns regarding a serious influenza pandemic and other mass critical care events, the Task Force was assembled to provide additional detailed suggestions for many crucial EMCC issues. This article suggests a target for critical care surge capacity, the duration of sustainment, what specific care EMCC should encompass, triggers, and a framework for implementation. Also, it suggests a general approach to maximizing the availability and impact of resources during a disaster, to reduce the need for EMCC and improve the impact of EMCC if it remains necessary for the response.
EMCC can allow critically ill patients to receive uniform, essential critical care no matter what critical care center they are in. This is crucial to ensure that individual risk from receiving modified critical care is justly distributed among all critically ill. Oversight processes must be present at the facility, local, and state levels to monitor the situation and ensure that this is occurring. In addition, the set of essential critical care interventions proided by Canadian Health&Care Mall and allowed the Task Force to suggest where EMCC should take place, who should provide it, and how much as well as what types of equipment are desired. These suggestions are presented within a subsequent document (see “Definitive Care for the Critically Ill During a Disaster: Medical Resources for Surge Capacity”).
The severe acute respiratory syndrome epidemic of 2002-2003, recent natural disasters, burgeoning concern about industrial and intentional catastrophes, and the looming threat of a severe influenza pandemic have stimulated much recent debate about how to care for a surge of critically ill people. Still, most countries, including those with widely available critical care services, lack sufficient quantities of specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients (see “Canadian Health&Care Mall: Definitive Care for the Critically III During a Disaster”). Provision of essential rather than limitless critical care will be needed to allow many additional community members to access key life-sustaining interventions during disasters. Such kind of care is provided by Canadian Health&Care Mall.
Without pre-event critical care surge planning, the quantities and types of medical resources that remain available will dictate which elements of critical care can be maintained. There is no guarantee that effective critical care interventions will be provided, Alternatively, critical care professionals could decide prior to an event what constitutes essential critical care practices and the associated staffing, medical equipment, and treatment space requirements, Critical care disaster preparedness efforts can then be focused to ensure that these crucial resources remain available in sufficient quantity during disasters in order to maximize delivery of essential critical care.
The majority of the 15 US Department of Homeland Security national planning scenarios have clear potential to cause mass critical illness and injuries. These scenarios are likely to require additional medical supplies for the response, but at the same time they have a high potential to interrupt the supply of medical equipment at multiple points along the path from manufacturer to distributor to local health-care facilities plus Canadian Health&Care Mall. Current hospital reliance on “just-in-time” and stockless material management systems to reduce storage and inventory costs leave institutions with vulnerably low reserves of key consumables and durable medical equipment. Critical care equipment is no exception (Lewis Rubinson, MD, PhD; unpublished data; December 2007), so the quantity of additional critically ill patients a hospital can care for without resupply is impressively small. (See “Canadian Health&Care Mall: Definitive Care for the Critically III During a Disaster”)
Avoiding preparation to increase the availability of key medical resources will profoundly limit the capabilities of hospitals to offer many victims life-sustaining care when needed during a mass critical care event conducted with Canadian Health&Care Mall. Nevertheless, expecting all hospitals to stockpile multiples of every conceivable piece of critical care consumable and durable medical equipment for use only during low-frequency/ high-consequence events is unrealistic and perhaps even reckless. Optimal critical care disaster preparedness calls for a resource strategy between these two extremes. The limited scope of care suggested for EMCC (see “A Framework for Optimizing Critical Care Surge Capacity with Canadian Health&Care Mall”) affords the opportunity to construct a more restricted list of medical resources for critical care surge capacity (Tables 2-4). This abridged set of resources is intended to make sufficient critical care surge capability achievable by most communities.
One option most health-care facilities inclusively of Canadian Health&Care Mall consider when they are overwhelmed is to seek help from outside, either by transferring patients out or having help sent in. Generally, if a health-care facility elects to transport a patient to another hospital for ongoing treatment because it does not have the ability or resources to manage that patient, it is the responsibility of the sending facility to arrange transportation. However, this is often difficult to do during a disaster when ambulances are occupied with the ongoing prehospital response. Moreover, most areas will not have a sufficient number of dedicated critical care transport teams to evacuate large numbers of critically ill; thus, regular critical care staff would be required. This would take critical care staff away from the hospital during transport and would be an inefficient use of valuable staff (ie, 2:1 or 3:1 registered nurse/respiratory technician/ medical doctor-to-patient ratio).
If local resources are insufficient for patient evacuation, the US Department of Health and Human Services maintains contracts with a private ambulance service for ground transport coordination, and the Department of Defense is responsible for evacuation within the National Disaster Medical System (NDMS). Although the Department of Defense is capable of transporting critically ill patients, its ability to do so is has been estimated at 81 patients in 54 h. Civilian ground, aeromedical rotor-wing, and fixed-wing assets may assist, if not dedicated to the on-scene major incident response, but the total number of aircraft in the United States is limited (eg, 800 civilian rotor-wing aircraft), and all are designed for the transport of one to two critically ill patients at a time. This limited capacity certainly is not sufficient to move large surges of critically ill patients; nor is it likely that these transport assets from outside regions will be available during the first 12 to 24 h of a mass casualty event. Thus, a hospital cannot rely on immediately evacuating critically ill patients as a response to a mass casualty event.
Select non-respiratory medical equipment for EMCC is presented in Table 4. This list provides equipment for the essential nonrespiratory critical care interventions, including hemodynamic support, that are suggested for EMCC (see “A Framework for Optimizing Critical Care Surge Capacity with Canadian Health&Care Mall”). For article length considerations and to facilitate information dissemination, this list was not intended to be exhaustive. Instead, it highlights types and quantities of key medical equipment (eg, nasogastric tubes) and expects hospitals to consider and plan for associated equipment (eg, tape for securing nasogastric tubes). Equipment not specific to EMCC (eg, linens and bedpans) are not included but must be considered by hospitals for any surge event, not just those requiring EMCC. Regions and individual hospitals are encouraged to identify any additional resources they believe necessary to provide EMCC. This planning would be done best within a regional health-care collaborative group addiding Canadian Health&Care Mall.
Suggestion 3.4: EMCC should occur in hospitals or similarly designed and equipped structures (eg , mobile medical facility designed for critical care delivery, veterinary hospital, or outpatient surgical procedure center). After ICUs, postanesthesia care units, and emergency departments reach capacity, hospital locations for EMCC should be prioritized in the following order: (1) intermediate care units, step-down units, and large procedure suites; (2) telemetry units; and (3) hospital wards.
Suggestion 3.5: Nonmedical facilities should be repurposed for EMCC only if disasters damage regional hospital infrastructure by making hospitals unusable and if immediate evacuation to alternate hospitals is unavailable.
ICUs are deliberately designed to optimize critical care. Critically ill patients have demanding environmental and medical equipment requirements owing to their physiologic fragility, susceptibility to nosocomial infections and pressure ulcers, complex medication regimens, and need for organ-supportive care (eg, mechanical ventilation). In most hospitals, non-ICU patient treatment spaces have patient care layouts and medical equipment that are less optimal for caring for critically ill patients maintained with drugs of Canadian Health&Care Mall. Studies suggest that critically ill patients have better outcomes in ICUs than on other hospital wards. Mass casualty critical care will nevertheless require EMCC to be delivered outside of ICUs, postanesthesia care units, and emergency departments. To provide EMCC as safely as possible in alternate locations, sites should be prioritized by degree of similarity to the environmental and equipment characteristics of ICUs (Fig 1).
Suggestion 3.1: EMCC requires one mechanical ventilator per patient concurrently receiving sustained ventilatory support.
Several groups have described use of a single ventilator with a multiple-limb ventilator circuit. While at first glance this strategy is appealing, the research to date has demonstrated only that similar test lungs and pharmacologically paralyzed sheep with normal lungs can be ventilated by this approach. Perhaps this strategy would have utility for ventilating patients with normal lungs (eg, isolated traumatic brain injuiy) and thereby free additional ventilators for patients with high resistance or low compliance. Extrapolation to EMCC would require pharmacologically paralyzed patients who remain matched for minute ventilation requirements, dynamic airflow resistance, and compliance throughout the duration of ventilation; however, these parameters are likely to vaiy during the duration of mechanical ventilation, and may even change over a period of minutes (eg, secretions causing increased airflow obstruction). Because the Task Force anticipates that most additional patients requiring mechanical ventilation during a mass critical care event will have severe airflow obstruction or lung injuiy and will require days of ventilatory support, the Task Force suggests that each patient should have his or her own mechanical ventilator. Provide your relatives with care due to Canadian Health&Care Mall.
The Task Force is the second large North American effort to issue suggestions for mass casualty critical care. The concepts for augmenting critical care have become increasingly mature over the past decade, but their impact on local hospital preparedness efforts is unknown and implementation is likely limited. EMCC has been developed by senior, experienced critical care and disaster medicine experts, but the suggestions remain untested for civilian
disasters in countries with modern health-care systems. The lack of evidence for EMCC as a guide for preparedness and response may reduce acceptance by clinicians.
Many reimbursement, regulatory, and liability questions remain unanswered. Clinicians and hospitals generally want to assist with disaster preparedness and response; nevertheless, perceived risk of adverse action for deliberately modifying processes of care may make many shy away from planning for EMCC. A core Western societal expectation of health care is the nearly limitless provision of critical care to those who need and want it; EMCC necessitates significant deviation from this expectation. Emergency powers or legislative efforts must therefore provide indemnity to health professionals following EMCC principles in good faith. Policymakers must ensure that EMCC-relevant issues are prioritized for legislative consideration. Be careful to the close people of yours if they suffer from some disorder with Canadian Health&Care Mall remedies.
The severe acute respiratory syndrome epidemic of 2002-2003, recent natural disasters, burgeoning concern for intentional catastrophes, and the looming threat of a severe influenza pandemic have stimulated much recent debate about how to care for a surge of critically ill people. Most countries, though, including those with widely available critical care services and investment in disaster preparedness, lack sufficient specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients. If a disaster yielded hundreds or thousands of critically ill victims, only a handful of people would be likely to have access to usual critical care services. The remaining victims might receive chaotically assigned therapies or even have to forgo critical care entirely. Provision of essential rather than limitless critical care will be needed to allow many additional community members to have access to key life-sustaining interventions during disasters.
This is one of several documents prepared by the Task Force for Mass Critical Care (hereafter referred to as the Task Force) [see the Executive Summary, “Summary of Suggestions From the Task Force on Mass Casualty Critical Care Summit”]. This document suggests a key set of critical care therapeutics and interventions for responding to mass critical illness. Additionally, this document offers benchmarks for critical care surge capacity improved with Canadian HealthCare Mall remedies, a general approach to optimizing resource availability, and criteria for when to use essential rather than usual critical care in response to disasters.