A tale of two crises

In November 2009, a tour bus rolled over in southeastern Minnesota, killing two people and injuring 21 others. The driver, in critical condition, was airlifted to Saint Marys, one of Mayo Clinic's hospitals in Rochester, Minn. The rest of the injured — a total of 20 passengers — were transported to hospitals in Austin and Albert Lea.

Bradley J. Niebuhr, emergency department (ED) director at Mayo Clinic Health System in Albert Lea, says several factors helped his Level IV facility manage the six-patient influx. One was timing — same-day surgeries were over and a new staff was coming on at shift change.

Another was the hospital-owned Emergency Medical Services (EMS) system. "We always had a close working relationship with that group — we worked elbow to elbow in the ED — and so we had more integration there than in most communities," Niebuhr says.

He also credits a large part of the hospital's effective response to the American College of Surgeons Rural Trauma Team Development Course (RTTDC), which helps rural hospitals develop a standardized team approach to trauma care.

"In those days, the state trauma system was relatively new. The RTTDC folks came out and presented courses at both sites — Austin and Albert Lea — which reinforced the team aspect of recognizing critically ill patients early and facilitating their rapid transfer to tertiary centers," Niebuhr explains. "Another key aspect of the RTTDC program is learning to recognize the potential for serious events and having all resources readily available. (With the bus accident), by the time the first casualties arrived, we had assembled the full spectrum of providers — surgeons, anesthesiologists, radiologists."

He says the trauma program has cemented what a lot of people tried to do on their own or in their own service areas.

"It's so much more beneficial to be part of a larger system and to have patient management guidelines that are uniform and looked upon as current best practices. You gain by sharing and get power from collaboration," he notes.

One day, 48 tornados

On June 17, 2010, less than a year after the bus accident, 48 tornados touched down in Minnesota — the second most active tornado day on record. Albert Lea sustained some of the heaviest damage. One person died and 14 were injured, some severely.

Niebuhr says, "We were more organized for the tornado after working through the bus accident, and we had moved further along in regionalization of the health system."

Still, the situation was challenging. Because air service was down, critically ill patients were transferred by ambulance to Rochester — less than 30 minutes away by air but an hour by ground transport.

"Everybody recognizes that people with life-threatening injuries have the best outcomes with rapid intervention, and helicopters really do limit the time between buildings, which is when things can go wrong," Niebuhr says.

The RTTDC course also helps hospitals develop transport guidelines in accordance with state trauma criteria, including standards for activating air medical and advanced life support. Niebuhr says one result has been automatic activation of Mayo One for all automobile crashes.

"Before, EMS would make the call from the field, but a lot of time was lost. This way, we can get people to tertiary care sooner."

Pediatric trauma is another evolving area. No children were seriously injured in the tornado, but Niebuhr points out that kids may be emotionally affected by traumatic events, even if they're not personally harmed.

"Pediatric trauma adds a different wrinkle. You have to think about and treat children differently; they can stay healthy looking even when badly injured and because they're so compact, traumatic injuries really affect the whole body. But beyond that, kids carry traumatic events with them even if they're not the ones injured. The care the family receives makes a lasting impression on them. They remember a lot more than we give them credit for."

On the receiving side

John B. Osborn, M.Sc., is operations manager for trauma, critical care and general surgery at Mayo Clinic in Rochester. He says Saint Marys has a mass casualty protocol, developed over six years, that is continually updated and adjusted.

He explains, "We have two levels of response — one for five to 10 severely injured people and another for mass casualties of between 10 and 20 patients. In the first case, we bring in as many surgeons as we can. We make sure we have enough ED beds available, we try to keep one OR open for every potential victim, and we open up ICU beds. In an event like the tornado, which resulted in multiple casualties, we take the same approach — augment staff, rapidly discharge patients who are at the end of their hospital stay or don't have acute needs to another location, and hold all surgical cases to make sure we have the capacity to take people to the OR. And we take steps to ensure we have enough supplies and medications to handle a surge of acutely injured people."

Osborn says the threshold is lower for pediatric trauma. Because there are fewer pediatric-specific resources, the presence in the ED of three or more severely injured children calls for a first-tier response.

Of the overall continuum of crisis care, Osborn says, "We try to stay in normal-operation mode as long as possible. That's followed by contingency operations — rapid discharge and canceling elective cases so we can absorb the influx of acutely injured patients. The final stage is when the health care system is too overwhelmed for normal operations to take place. In that case, it comes down to triage. Patients that under other circumstances would go to the OR might be stabilized and held. We have to triage the most severely injured and treat those most likely to benefit from immediate care."

He points out, "The same guidelines and triage and transfer protocols apply even as casualties increase. We deal with severely injured people on a daily basis, so aside from the greater number of resources and patients involved with mass casualties, we really just do what we do every day."