Trauma Resuscitation, Mass Casualty Incident Management and COVID 19: Experience from a South African Trauma Unit

Abstract

The COVID 19 pandemic has spanned 2 years and is still ongoing with many questions arising. We attempt to answer some pertinent questions with literature as well as anecdotal evidence from our facility. To describe any changes to the resuscitation of trauma patients during the COVID 19 pandemic if any. During the COVID 19 pandemic, Johannesburg a city in the Gauteng Province of South Africa experienced civil unrest and a fire at one of its trauma units, this resulted in a mass casualty incident (MCI) at the only functional trauma unit in the public sector. Results of this observational study will be elucidated. Focus is placed on PPE protocols, trauma resuscitations, MCI management, triage principles and the changing surgeon’s role within the pandemic.

1. Introduction

The COVID 19 pandemic has spanned 2 years and is still ongoing, this pandemic has had significant impact on all healthcare professionals. The spectrum of its effect is vast ranging from PPE protocols for infectious diseases, training of healthcare professionals, research, burn out and the response to a never- ending global mass casualty incident (MCI). Reviewing the literature brings about many questions, some of which are answered by anecdotal evidence within our setting and some that have been published. The literature in the past 2 years with regards to covid and its effect in different settings is extensive and ever changing. We attempt to answer some pertinent questions with literature as well as anecdotal evidence from our facility. Focus is placed on PPE protocols, trauma resuscitations, MCI management, triage principles and the changing surgeon’s role within the pandemic.

2. PPE and trauma

PPE has been an integral part of the ATLS principles of a trauma resuscitation and has been taught globally [1]. With the advent of the Covid 19 pandemic, more focus has been placed on PPE protocols for not only resuscitation but for all patient interaction due to the infectious nature of the virus and the unknown state of the patient at first interaction. These PPE protocols have evolved over the last 2 years with the ongoing research into the spread of COVID 19 and all its variants from full PPE and fomite transmission to no fomite transmission and basic PPE such as a plastic apron, visor and N95 for all patient interaction, whereas the vast public is encouraged with social distancing, hand sanitizing and either surgical or cloth face masks [2, 3]. These evolving protocols have no effect on the trauma resuscitation, as the basis here is healthcare professionals safety from all bodily fluids in a high risk, life threatening situation. Could this be the reason for a low positivity rate among healthcare professionals in the trauma surgical discipline? In an attempt to answer this question, I provide you with unpublished data from our facility due to a lack of appropriate literature available to answer this question.

Our facility was faced with a MCI due to civil unrest in the week of 9–16 July 2021. At the same time we were experiencing the 3rd COVID wave, with an adjusted level 4 lockdown, this entailed a curfew from 9 pm to 4 am, and no alcohol sales. Our neighboring hospital (18 km away) with the only other functional trauma unit in our Metropolitan was shut down due to a fire and with the civil unrest, all patients were seen in the only functional trauma facility. Although the numbers of patients and procedures done increased, patient positivity rate was 9% below the national average of 29.1% at the time [4]. Only two doctors of a total of forty tested positive during this time (5%). This was with the adherence to standard PPE protocols according to ATLS principles with the inclusion of a N95 masks (unpublished data).

Similarly In Nigeria full PPE was used when intubating patients, and when performing an emergency room thoracotomy while standard precautions were used for ICD insertions [5]. Globally we have seen many doctors and healthcare professionals testing positive for covid and in the infancy of the pandemic, many had succumbed to the virus. Most of which were involved in patient care of COVID positive patients with the adherence of PPE protocols [6]. Again, one would question why this is the case? Is it due to the combination of the burden of COVID positive patients seen by the individual and the burn out experienced by many which ultimately weaken the immune system? A meta-analysis done in 2021 has failed to answer this question [6]. However the changing PPE protocols and COVID infections of healthcare personnel, community acquired or nosocomial, did not change how we would resuscitate a trauma patient with an unknown covid status, we adhered to basic principles, which was guided by ATLS principles [1].

3. Trauma resuscitation, patient management and covid

One cannot comment on a trauma resuscitation without mentioning the ATLS resuscitation principles [1]. As part of any trauma resuscitation, there are many life- saving procedure that need to be done with urgency under aseptic techniques, as a result trauma resus bays are well stocked with all the equipment within arm’s reach [1]. Due to the concern for fomite transmission, some trauma departments changed the layout of their resuscitation area and removing equipment to a different area that is remote from the patient interaction [7]. Livingstone et al. removed all equipment from their trauma resuscitation bays. They designated hot, warm, and cold zones around the patient, where a hot zone involved direct patient contact, a cold zone was a significant distance from patient interaction, where equipment was kept, and the warm zone was the zone in between hot and cold where equipment was transferred on a table. This was in keeping with the EPA guidelines [7]. Logistically, this would hamper an efficient resuscitation and it can now be seen that it was not necessary due to the lack of fomite transmission [3].

In an effort to conserve PPE, only the staff in the hot zone donned and doffed full PPE, in our setting we also experienced a shortage of PPE and therefore one gown with an N95 and a visor was issued per shift to each healthcare practitioner (shifts lasted either 12 or 24 hours) [7]. However, this can be adapted to the ever-changing PPE protocols [2].

I would like to bring your attention back to our MCI with the low positivity rates. We have a 15- bay resuscitation area with each bay having its own monitors and life- saving equipment. We did not change our resus area at all and again we had low positivity rates (unpublished data). This adds to the evidence for non- fomite transmission [3].

The first focus of the ATLS resuscitation is airway management with its inherent risk for transmission during intubation as an aerosolizing generating event [8]. At the beginning of the pandemic, the use of intubating boxes was advocated. However practically they were not feasible and seemed to hamper airway management [9]. What worked well for us was a video laryngoscope, equipment that was previously not available in our trauma resuscitation area and was reserved for the use by anesthetists [10]. This has also been substantiated in the literature with a meta-analysis [11]. Thus the pandemic benefitted us in that we could hone in on this new skill and gain confidence in the use of it.

COVID positivity or screening never became part of our trauma resuscitation protocols. All patients were treated as PUIs (patients under investigation) meaning their covid status was unknown and all patients that were admitted or required a surgical procedure were tested. If the status of the patient was unknown, they were again operated on a PUIs. We had no dedicated PUIs theater as most acute care surgical and trauma patients were operated on with their covid results being unknown. This was largely due to PCR results turnaround time of about 12 hours if tested after 4 pm and 2 hours if before 4 pm. Surgeons used disposable gowns (a change in the usual theater attire), visors, and masks, which were a N95 instead of a surgical mask. Anesthetic staff occasionally used half-face elastomeric respirator with P100 filters if they were intubating the patient, of note, these were not supplied by the hospital but instead purchased on the own accord of the anesthetist.

Post operatively patients went to the ward which was also a PUI area and only once covid status was known would they be transferred to the covid wards or ICU if a positive result was found. The main nine bed Trauma ICU required a COVID negative result before admission of the patient and therefore a patient would be housed within the ward ventilated and ongoing resus was continued until a result was known and the patient was accepted for admission to the Trauma ICU.

Again, I would like to mention that although our ward was considered a PUI ward, as well as a COVID negative ward as only the COVID positive patients would be moved out once their result was known. We still only had a 9% positivity rate within the unit during our MCI (unpublished data).

In Nigeria, their trauma protocols were adjusted. Patients were screened in their triage area for fever and flu like symptoms not related to their traumatic injury, contact and travel history. Suspected cases were moved to a designated area to be seen by the hospital COVID 19 team (review and testing) while the trauma team continued the resus. Suspected patients were given a surgical mask [5]. This change in protocols places more emphasis on COVID instead of the traumatic injury. Due to social distancing their resus area capacity decreased from twelve beds to eight beds. The most senior person managed the airway in full PPE. With regards to surgical procedures an N95 and face shield was added to their PPE protocol in theater and the most experienced personnel operated to decrease operative time, hampering training [5]. They again focused on COVID by adding signs and symptoms of covid and travel history to the AMPLE history changing the acronym to SAMPLET. Surgical protocols were also changed, with the focus shifting to COVID, if a patient was covid positive, non- operative or delayed repairs were encouraged [5]. These decisions should be based on the patient’s trauma burden and physiology. We made neither of these changes to our protocols, our focus remained on trauma, the only difference covid made was changing the location of the patient. However, we need to do a formal audit to quantify if our covid positive patients’ outcomes were significantly different to their covid negative counterparts. In some areas the trauma burden has decreased with the increase of covid thereby providing us with an ongoing MCI and an approach to this needs to be defined [12].

4. Mass casualty incidents (MCIs)

MCIs are defined as events where the number of patients exceed the local resources (human or equipment). These events can occur remotely to the health facility or within the health facility. All the literature on mass casualties come from the trauma surgical discipline [13]. The questions we now need to ask is, combined with COVID, do trauma protocols and triage principles need to change? Is there more that we can learn from this? In an attempt to answer these questions, we revert to the literature. One must be cognizant of the fact that with the covid pandemic all patients essentially have a breathing problem, if one must consider ATLS principles, some of which may require invasive ventilation [1].

Tankel and Einov defined specific objectives that need to be planned for in a MCI, namely equipment and consumables, transport, hospital capacity, training, education, and debriefing, command and control and communication [13]. These are the same principles in disaster management, some of which will be highlighted in this text. These concepts are echoed by the WHO guidelines which involves a multisectoral planning which include national governments and healthcare personnel, starting at facility level to international level [14].

Data from the US stems from terrorism attacks and mass shooting events and have influenced MCI protocols [13]. The major difference between a MCI in a trauma setting and a pandemic is the length of the mass casualty. Most MCIs last 24–48 hours and thereafter there is a return to normal duties, which allows for a period of debriefing. But this MCI has lasted 2 years and there has been no return to ‘normalcy’ [15]. So, can we truly extrapolate from MCI in the trauma setting to a pandemic? When do we return to pre pandemic triage/MCI principles when the MCI is prolonged?

Planning ahead, stock piling of equipment and consumables are integral to a response to a MCI [13, 14]. However, consumables are a limiting factor in MCIs as well as in a pandemic as evidenced by the global oxygen supply shortage and ventilator shortage [16]. Tankel and Einov suggest that regional instead of local (individual hospital) stock piling is more cost effective, however maintenance of the consumables is questionable and therefore may not be functional when needed. One also needs to define MCI specific equipment for example during the pandemic this translated to oxygen and ventilators but in a trauma, setting could be theater capacity, availability of trauma surgeons and blood and blood products [13].

4.1 What happens when the supply of global resources outweighs the demand be it oxygen or human resources?

Our healthcare professionals have lost their lives from being on the frontline and burn out has become more evident than before [6, 17]. Training of new healthcare professionals have also been hampered in the past 2 years of the pandemic because all they now know is how to manage a COVID patient. Airway skills have become a selective skill reserved for anesthetist and the most senior personnel at the expense of the junior doctors that have started out [5, 8].

To confound matters while experiencing the COVID pandemic we needed to deal with a disaster (mass evacuation of a hospital due to a fire), this resulted in the hospital closure and the majority of patients being redirected to our facility. This was even further confounded by enduring a MCI when civil unrest led to a flood of patients in our trauma unit.

The evacuation of a hospital due to a fire was largely driven by healthcare professionals selflessly moving patients (immobile patients, in their beds) to evacuations points in smoke covered corridors with no oxygen supplies while emergency fire personnel battled the blaze. The loss of a health facility compounded the effects of a pandemic on the loco regional facilities.

With this said the loco regional functional hospitals can change their triage processes and therefore certain hospitals can only accept P1 and other hospitals can accept P2 and P3 patients thereby distributing the load [13]. Prehospital services and healthcare facilities (receiving and disaster area) should have effective communication for this to be feasible, disaster committees should be established in the sending and receiving facilities. Efficient communication is integral to the management of any disaster or MCI [15].

Our facility was on the receiving end of the fire, 150 patients were evacuated to our facility without communication to the team onsite. Both the on- call trauma and acute care surgical units had to manage current acute patients in their respective areas as well as the patients evacuated to their facility. The discrepancy here was that a disaster team should have been established at the receiving hospital to manage evacuated patients. This should not have been the responsibility of the on-call trauma and acute care surgical units. Emergency services that transported patients to our facility were also used to transport patients to the relevant wards as we did not have the capacity (porters) available to do this, therefore the need for non-healthcare personnel should also be considered e.g. cleaners, porters etc. [13].

The burden on the facility was significant as bed capacity was reduced due to reallocations for COVID patients. Unique to South Africa is that a large percentage of our population lives below the poverty line in informal settlements, which are quite densely populated, you could have at least ten people living in a 1-bedroom shack (informal dwelling) [18]. Therefore, our patients could not self- isolate at home and a facility was opened for this specific reason NASREC, previously an events area. This was specific for patients not requiring hospital admission and no oxygen requirements. It was purely for patients that were unable to self- isolate safely at home. This was an attempt to lessen the load on secondary and tertiary level institutes.

Going back to the MCI specific to trauma the riots from the civil unrest. This event was not anticipated and therefore could not be planned for especially during a covid pandemic and with the neighboring hospital trauma unit closed due to a fire. We experienced many bottle necks for example CT scanners availability and theater capacity despite more staff being mobilized to respond to the disaster. We were also unable to mobilize staff from outside the hospital as it was not safe to travel to the hospital. Therefore, disaster committees should focus on training, education and debriefing, treatment protocols that are disease or injury specific and should be aim at a level appropriate for all heath care specialist not just trauma surgeons or infectious disease specialists [13, 15].

Due to the sheer burden of P3 patients, we developed a strategy for quick reference as to the patient’s condition and progress of management. Labels were placed on patients and were used to indicate injuries, results of investigations and what the patients were awaiting as a quick reference with no need to go locate the patient file. This is planning whilst one is in the midst of a MCI but was successful and will be used for planning of future MCI within our institution. Therefore, a response to a MCI is an ongoing process.

With regards to training over the last 2 years. Interns have mostly been exposed to the management of covid patients which has largely been protocol based. They have missed opportunities related to procedures specifically that of airway management which many have reserved for the most senior staff [5, 10]. In the surgical spectrum, elective procedures have been stopped thus decreasing exposure of surgical trainees. Despite discrepancies in training and being reallocated to manage patients that is not within your field of expertise, burnout has come to the fore [17, 19, 20]. Many healthcare personnel have experienced burnout largely due to the pandemic/mass casualty spanning 2 years currently and leaving no time to debrief or recuperate after each wave [17]. Human resources are a scarce commodity as well as being constraints by a budget for monetary compensation, as seen by healthcare professionals working long hours risking their lives as well as that of the household [15].

Command and control of a mass casualty or disaster must consist of healthcare professionals that are clinically active, to know what is happening on the floor as well as management and politicians and policy makers. These committees should be established locally, regionally, nationally, and even internationally depending on the nature of the MCI [13, 14]. Elective theaters, emergency theaters, ICU, physicians, surgeons, allieds, nursing staff, porters, radiographers, and radiology form integral components of the response team to these events. Special types of patients should also be considered especially those that are time dependent such as cancer patients [13]. Once a SOP (standard operating procedure) was established for the covid response and the relocation of patients due to the fire. Chemotherapy and radiotherapy as well as surgical procedures for patients with malignancies were prioritized. Oncological services such as chemo- and radiotherapy were halted transiently as they were only available at the hospital that was closed due to the fire, however rapid communication with other hospitals and the fast tracking of the establishment of a chemotherapy service at our hospital assisted with this issue. Transport for these patients were also arranged to these facilities, not to impede these patients from receiving oncological services. Communication needs to be bi-directional top down and bottom up, so that protocols are practical and feasible with real-time feedback [13].

Coccolini et al. defined four phases in disaster management namely mitigation, planning, response, and recovery. Mitigation, this is the preemptive planning stage to reduce the effect of MCIs however the protocols of COVID was ever changing (PPE, isolation days, lockdown periods, economics changing policy) and therefore the planning stage is an evolving stage [2, 3, 8]. Planning requires practice of protocols for feasibility however there was no time with the pandemic to practice, it’s been an ongoing practice session for the past 2 years as such good communication (local, regional, national, international, NPOs) has become imperative [15]. The response phase entails activation, notification, and initial response. Therefore, the need to identify a state of disaster and activation of the relevant teams, and a central Command structure (local, regional, or national) [15]. The major issues with the covid pandemic and its associated disaster management is the ever-changing protocols resulting in the planning, practice and response phases never ending. You also need buy in from all stake holders, however medical personnel have also become hesitant in accepting these ever-changing protocols. As healthcare providers we have lost the trust of the global population by changing protocols largely due to the lack of understanding of the research process [2, 8, 10, 15]. The final stage is recovery, which entails staff debriefing, however with the many waves of the pandemic we have not reached this phase in 2 years, resulting in burn out and significant strain on the mental health of many healthcare professionals [15, 17]. With these ever-changing protocols of covid and a prolonged MCI, do we still utilize triage principles as before, or do we adapt them to the current pandemic?

5. Triage principles

The Federal healthcare resilience task force kept the trauma triage principles unchanged, with just the addition of the awareness of COVID 19 and the prehospital use of PPE [21]. This was also the case within our facility. A common theme prehospital and within hospital resus is the decreased number of healthcare personnel involved in the resus and airway management was by the most senior first responder [7, 21]. With specific reference to the covid pandemic and MCIs, crowd control becomes important [21].

It has been stated that during the current pandemic, it is unable to “discern the likelihood of survival of trauma patients relative to the potential for having concomitant COVID 19 is not possible [21]. One would disagree with this statement, there are many trauma scores that relate burden of injury to mortality and therefore concomitant COVID or the suspicion of covid played no role in our triage process. The burden of injury and the survivability of the injury enabled our triage process according to trauma principles.

Supportive and palliative care is an ethical principle that forms part of any MCIs [13, 15]. During this pandemic this has come to the fore due to shortages of ICU beds, ventilators and even Oxygen and the overwhelming demand [16]. Palliative care has become integral to triage during this longstanding MCIs that is the COVID Pandemic [22].

At our facility, most of our trauma patients are young males and were incidental or asymptomatic covid positive results. During the pandemic in a trauma setting, we still focused on the principles of triage according to the trauma burden and was more focused on the survivability of the injuries sustained and not the patients covid status [1]. Their covid status may have complicated their surgical course and lead to unexpected deaths or morbidities but it did not hamper their treatment. If at all, it might have given them resources which would not have been otherwise available. Our unit only has a nine bed Trauma ICU, but with the COVID pandemic a general ward was converted to a thirty seven bed COVID ICU, so if not for their COVID status some patients may not have received the critical care that they needed. We have discussed the covid pandemic with regards to PPE, MCIs and resuscitation, extrapolating principles from surgery, but what has been the surgeon’s role in the pandemic?

6. The surgeon and COVID

Elster et al. commented that surgeons responded by postponing elective surgery, however this was a misnomer. Most electives are time sensitive malignant cases [23]. At our facility we instituted the Covid scoring system (NDOH technical working group on COVID 19) as well as a vetting committee and as a result our oncological procedures and services continued.

With regards to COVID positive elective cases they were postponed to either when the patient was asymptomatic for 72 hours and two negative covid tests 24 hours apart [23]. At our facility we initially postponed to 2 weeks post covid infection and as evidence become available our protocols change to 8 weeks post covid, in keeping with the current literature [24]. No repeat covid tested were requested on patients previously tested positive.

In order to protect staff members from a prolonged MCI Elster et al., implemented a few protocols, namely, Screening of outpatients, testing patients before entering the hospital, limiting OPD and seeing only the medically needed and time sensitive cases, avoiding burnout and unprotected exposure to infected patients, encouraging telemedicine and all meetings to be done virtually [23]. These protocols have also been implemented within our facility except for the avoidance of burn out. Surgeons and interns were mobilized to work in COVID units. Critical care training is included in the curriculum for surgical residents as well as having experience with critical care in the wards due to the shortage of critical care beds within specialized units. These covid duties were in addition to their surgical responsibilities and therefore impossible to avoid burnout. Surgeons have skills that are geared towards dealing with the COVID pandemic, these skills arise from their experiences in MCIs in the combat and trauma setting as well as their critical care experiences [23].

Literature is populated with the surgeon’s role in the pandemic [25, 26]. Acute care surgeons assisted by converting post operative recovery areas into ICUs to increase critical care capacity, which were managed by critical care trained surgeons. The less severe covid patients were managed by surgeons with no critical care experience as well as taking on acute care surgical responsibilities of themselves and the critically trained surgeons. Non critically trained surgeons were prepared for their covid responsibilities by undergoing a 1 week catch up course involving antibiotic and ventilatory strategies as well as specific covid protocols. There were times when they were teamed up with physician intensivists or small teams consisting of members from all specialties with one team leader [25, 26]. All electives and research activities were stopped to increase human resources [25]. The strategy of Giogola et al. involved weekly virtual meetings for updates, a tiered approach adapted from the SCCM which resulted in intensivist burn out as it was top heavy [25].

In a London Trauma unit, they anticipated a staff illness rate of 30%, to negate this they allowed high risk personnel to provide off site support virtually or telephonically which translated to a staff illness rate of 10%. Again, surgical responsibilities were decreased by stopping electives and the application of lock downs decreased the trauma burden [26]. OPD were done telephonically or virtually. With the covid pandemic social media played an important role, however there were concerns with patient confidentiality and therefore social media was sanctioned nationally and only allowed within a hospital. These platforms were used to disseminate the latest peer reviewed information but at times humor and outburst were also shared, which can be expected from staff experiencing a prolonged MCI resulting in burnout with no time to debrief [26]. Social media may have assisted with information dissemination within a hospital, but difficulties were seen with communication from a central command to those on the frontline [26].

Due to the re-deployment of anesthetic and surgical staff to covid units, non-operative management was favored, and theaters were transformed to ICUs, impacting training of fellows and residents negatively. To compensate for this deficit, many extended their training time [26]. In our setting surgical management remained according to surgical principles and protocols pre covid and not dictated by the patient’s covid status.

To assist with healthcare professional well-being, which was affected by loss job opportunities, uncertainty, no training and redeployment to unknown areas, wellness programmes were initiated [26]. These included free wellbeing classes yoga, Pilates or meditation, free food donations and greater awareness on media – seeking mental health services were thus more accessible as it was not seen as a weakness [26]. This depicts the benefits of social media.

7. Conclusions

The covid 19 pandemic thought us many lessons but we also used lessons from the past. Previous experience with MCIs assisted during the many different waves and variants. Ever changing PPE protocols and transmissibility of the virus showed us that we had more to learn and adapt. Globally we were not well prepared for this MCI as evidenced by Oxygen and ventilator shortages as well as the strain on our human resources by health care personnel burn out. The greatest lesson learnt is the versatility of the medical professional, assisting in areas they are not specialized in (surgeons in infectious disease wards and critical care settings of intensivist), redistributing resources with ever changing protocols. Although there was a global response to the front line to treat patients of a MCI, the amount of research and literature churned out by clinicians is impressive. This will serve as the foundation for future pandemics/MCIs, and one would hope that it will not be as prolonged as the current pandemic.

Conflict of interest

The author declare no conflict of interest.