Summertime is known to emergency response teams and hospitals nationwide as “trauma season.” Like clockwork, diving-board concussions and grilling burns abound, and boats, bikes, and lawn mowers become common sources of injury. As August came to a close this year, though, the trauma team at Penn Presbyterian received a call that could be jarring even for staff trained to expect the unexpected.
Around 12:15 a.m. on August 22, a train arriving at the 69th Street terminal collided with a stationary, unoccupied train. Thankfully, neither derailed, but the impact buckled the floors and sent the train operator and the 41 passengers on board ricocheting about the car. The source of the crash has yet to be determined by the National Transportation Safety Board, but it left 32 injured. In an interview with CBS Philly, one passenger recounted how his head slammed into a wall and described the scene as “super bloody.”
EMS, police, and fire officials from Upper Darby were mobilized as a part of a mass casualty response, and the injured were rushed to eight local hospitals. PPMC’s Level I Trauma Center received two passengers and the train operator, while HUP admitted two additional passengers. In an interview with 6ABC, Patrick Kim, MD, director of the trauma program, noted the passengers transported to PPMC luckily did not suffer any internal bleeding or head or spinal injuries.
“We saw injuries that were fortunately very minor – musculoskeletal injuries and facial fractures,” Kim said. “In the trauma bay, we mobilize resources from within the hospital, and if the incident had been worse, we could have mobilized resources from outside the hospital as well. We were able to prepare in time and really render the best possible care given the circumstances.”
How is Presby’s trauma team able to prepare so quickly when these incidents strike? Disaster movies and hospital dramas depict mass casualty incidents (MCIs) as utter chaos, but in fact, the response within Level I trauma centers like PPMC is a well-orchestrated system. While FEMA has guidelines for preparing for and responding to large-scale emergencies (terror attacks, natural disasters, etc.), and EMS teams and hospitals routinely practice effective coordination techniques, preparing for MCIs at PPMC entails much more than simulations and lectures about hypothetical scenarios.
Every two weeks, one of the seven units in the Trauma Center receives a call to immediately attend to a patient with an acute traumatic injury, such as a burn or a stab wound. The page sounds exactly like a normal trauma page, so staff members believe they are rushing to a real patient – until they spot the simulator smuggled in by staff from the Penn Medicine Clinical Simulation Center.
“The simulations are meant to be realistic, so in addition to the physicians using their own equipment, space, the wireless mannequins we use are very lifelike,” said Gretchen Kolb, MS, CGC, director of Learning Innovation at Penn Medicine. “They appear to breathe and have pulses; their eyes can blink and their pupils are reactive to light; and with colored fluids and patches, we can simulate bleeding, wounds, and even exposed bones.”
Simulations last 20 to 30 minutes and are recorded for educational purposes, and while some preliminary information is given to the team so they understand how the mannequins work, these are generally surprise exercises. The only person given advance notice is the head of the unit so they can cover clinical duties. Though the simulations typically involve one patient, they require surgeons, nurses, anesthesiologists, emergency medicine staff, and residents to assess the damage and work together. This improves response time and adds another experience to the physicians’ trauma care “muscle memory” so they can react confidently in a real situation, whether there is one patient or five.
“These simulations should make you sweat a bit,” said Jose Pascual, MD, PhD, an associate professor of Traumatology. “Everyone needs to be comfortable with the system in place for an MCI, and they have to be ready to spring to action. That sense of urgency doesn’t exist with traditional simulation exercises at the Simulation Center where providers can show up in jeans with a coffee and an idea of what to expect.”
“We like to emphasize that we’re not ‘testing’ them – we’re preparing the teams to react and communicate effectively during high-risk events,” Kolb said.
For genuine MCIs, PPMC’s trauma team has a system in place to rapidly increase hospital resources. An old-school phone tree ensures efficient communication; one surgeon alerts two others, each of them alerts two more, and so on. The message is clear: get to the hospital now. Had an injured passenger been stuck in the train, a surgeon would also have been deployed to the scene with an always-ready, in-field care bag. Clear communication also spans the health system. In the case of the SEPTA crash, the attending trauma surgeons working at PPMC and HUP were in contact to discuss how to best triage injured patients to each hospital.
Though mass casualty events are fortunately infrequent, Pascual is proud that Presby’s dedication to preparation has earned acclaim, noting, “Our simulation plan was novel and is still novel even though it’s been in place here for three years. We’ve even been asked to speak nationally about it. In the end, it’s just about us making sure that we’re ready for anything so we can improve the outcomes of our patients, no matter the situation.”