Mass Casualty Plan

Tomas the surgeon disscusses the events of a mass causalty plan

Tomáš wrote this post in April 2015.

Put him here! I need an infusion! Where is the new torch for laryngoscope*? How many patients are we still expecting and where are they coming from? How is your breathing? Can you hear me? Yes, insert the cannula here. He is suffocating! Are we going to intubate** him here or in the operating room? I need someone to put their finger instead of mine in the hole in his neck; I’ll need my hands to be free in the operating room.

8:35 am. We are finally doing quite a calm round in the ward of the intensive care unit. I have been in the hospital since 4:00 am, because of an abdominal surgery caused by shooting, which is a new standard at night, but I feel quite fresh.

I am looking forward to the afternoon’s rest to compensate for another endless night, but I first need to finish everything. 

“Pupils respond symmetrically, he is starting to move his right hand…” I am listening to a local doctor at the intensive care unit when someone shouts “MCP!” - Mass Casualty Plan. They are announcing a mass emergency. Everyone gets a text message with first brief information saying from where, when and how many people we are expecting. A hospital siren starts to roar…

Nobody panics, least of all the Afghans. The staff put on the corresponding color of vest for the triage zone where they will work.

Everybody has a card in their pocket, which says what kind of post we occupy in the team and what function we have in the whole plan. It is more important than ID here. I take it out of my pocket, even though I know exactly where my place is.

I am supposed to be in the operating room (OR) and at the same time I am supposed to be helping in the “red zone”, which is the place where most critical patients are located. I have already experienced a mass emergency, this is actually my fourth.

When I arrive at the red emergency zone, I see a man with a hole on the right side of his neck lying next to the wall. Bright red blood is spattering from that hole and he is spitting out the same amount of blood on the ground under him. Otherwise, he seems to be stable.

I decide to dedicate my time to the patient next to him. This is a clear abdominal injury, so we write damage control on the board next to the OR. Another guy has got his jawbone shot off. There are many people around him again and it seems that they have the situation under control. When I go to check on the fourth, the hospital director is pulling my hand and is shouting: "Tom, come! That one is still breathing!"

There is a man lying in the “black zone”, half of his brain is gone. And yes, he is still breathing. Mr. Director, he was correctly labeled as dead in triage, I am explaining him. They are giving him painkillers. If the patient perceives what is going on, somebody usually stays with him. Psychologist Helena is in charge of the black zone in our hospital giving good words for the final journey… I confirm that resuscitation is not possible, he has zero life prognosis.

I am going back to the red zone; we are going to operate on the abdomen. I do the whole procedure within 20 minutes in the operating room. And then return to the red zone, as it is written on my card.

The guys are not very successful in handling the bleeding from the neck. They are speculating about something, probably for quite a long time, because the blood is not spattering that much. So I put on a sterile glove and I stick my fingers into the wound. I take the bag valve mask with my free hand and I am ventilating it to the intubation tube so that I can free my colleague Clemens’s hands.

This is how we get him to the third OR, where a Cameroonian woman Gilberta puts on the sterile gloves and puts her finger into the wound instead of me. I wait in there with him till the moment when the surgeons get to the source of bleeding and surgically repair it. I have thus my hands free again and I can go on to deal with the next abdomen.

When I am about to finish suturing [surgical sewing], our anesthesiologist Hans is tugging at my sleeve. Come. Right now. There is no surgeon at the emergency room; all of them are in the ORs.

Doctors at the emergency room have not been able to take control over the bleeding from the jawbone. I am turning the bandage into the clamp and I get him to the intensive unit care till there is space for him in the OR. Back to the OR. I am going to see how far they are with the bleeding from the neck. There are tens of instruments in the wound and it doesn’t seem very well under them.

I remember a crucial passage from the Top Knife, the reference book for surgeons: "The more peans (vascular clamps) in the wound, which is bleeding, the more evidences that you are screwed right now, surgeon.” After a moment of impatience, I make my colleague Sebastian move so that I can hand over to him a clear surgical field without tools and bleeding, because I still have to suture another trachea and esophagus.

It’s like MASH. As surgeons, we are moving from one to the other, we are just quickly changing our sterile cloths.

Three hours later, the fight is over. It was just a small MCP, a total of eight people. For me, this means that everything I planned for today is moving to tomorrow and I am pushing a vehicle full of patients and tasks ahead into the next morning.

And I still have to finish today’s tasks. Oh no. Damn bombs! When I went to the intensive care unit to check on the patient with broken jawbone, the guy was unconscious. When I loosened the clamp from the bandage, he started to move again. But I’d rather he stays still, the more he fought back, the more it could worsen his conditions.

This morning I am lying on the ground on the tiles behind the door. So that I am not cold, my colleague Pavel Rolda Rolleček brought me a towel. There is something good inside. Not in the towel, in Rolda. He admits it but claims that it’s somewhere very deep. I’m just exhausted. I feel dizzy. When I’m closing the abdomen, I feel physically sick. It’s still the same. I don’t eat and I don’t sleep. I never manage to finish everything and every day there are more and more things to do!

At the 32nd day of my stay I have done 34 major abdominal surgeries.

19 of them need only one procedure, the rest were more complicated when I had to open the abdomen for an operation for the second or the third time.

Two of them were damage control surgeries that saved their life, but even during the first surgery, we plan to open up the patient again for a more permanent repair.

Abdominal surgeries after shooting are difficult. In most of the cases, one of the parenchymal organs (liver, spleen, and kidney) is injured and small or large intestine, bladder, stomach, pancreas suffer from it. What’s more, it is necessary to urgently solve bleeding. I don’t count anymore how many meters of intestine I have cut out in total and how many connections I have made. Two of my patients died of postoperative complications.

Then I performed eight head surgeries, so called craniotomies. Nobody died. Seven of them are fully recovered, one of them is still in the hospital. I did one thoracotomy – a thoracic surgery of a shot-through lung. He is doing fine. I don’t count the vessels I have sutured, bleedings I have stopped, nor plastic and facial surgeries and various kinds of lobes I have done, one external fixation of the tibia and one pelvis clamp, traction of long bones, kidney surgery and urinary bladder surgery, tracheostomy, tendon sutures… On average, it’s two major surgeries per day, including weekends.

Holy crap, you don’t get bored here at all. What I do here in two months is something I do at home during two years, taking into account the number and complexity of surgeries.

Today, 6 of April 2015 at 12 am, I finally did couple of surgeries I had been putting off. As things have started getting fast recently, there is not enough time to find a moment to look into someone’s abdomen for the second or the third time.

I’m sitting in a room where we have morning report. It’s afternoon, finally nothing to do and I need not to be disturbed for one hour, before our car gets here. Orthopedist Miloš accompanies me. He calmly lies on pillows on the left side, while our local referent for nosocomial infections (infections caused by a stay in the hospital) comes to pray on the carpet on the right side.

While I’m writing these lines, I’m lying on pillows between them. I like this mixing of cultures. A Muslim doesn’t mind that there are two persons lying on the floor next to him while he prays. And we don’t mind at all that he is calmly whispering his prayers. Each according to his beliefs.

* - an instrument for examining the larynx
** - insertion of a tube into the trachea (windpipe) to keep the airway open