Dr. Andy

Reflections on medicine and biology among other things

Thursday, September 08, 2005

Medical response to the London bombings

is the subject of several articles in the August 11 NEJM (all free full text!). These are all excellent, well written articles, with expected British understatement and modesty and together give good insight into what the medical response to an attack like this entails

Ryan and Montgomery
give us an overview of the emergency response and also detail just what happens to the victims of a bomb attack:
When an explosive device detonates, a small volume of explosive is rapidly transformed into a large volume of gas. A high-pressure blast wave expands outward at the speed of sound and, in interacting with the body, causes primary injuries (mainly at air interfaces such as the lung, ear, and bowel). The resultant blast wind propels solid matter into the patient (secondary injury) or the patient into solid matter (causing tertiary injury). Quaternary injury is caused by heat, flames, or the inhalation of smoke and hot gases. Confined spaces exacerbate such effects: surface reflections amplify and prolong the blast wave, the blast wind is channeled, and heat and gases are contained. The severity of injuries and the resultant mortality are thus greater. The total number of persons endangered is increased by detonation within a rush-hour commuter environment.
Bolden, who was at the British Medical Association building immediately adjacent to where one of the bombs detonated, helped organize his colleagues, some of whom hadn't practiced clinical medicine in years (and even fewer had recent experience with trauma) into an immediate response team"
I have trained for such a situation for 20 years — but on the assumption that I would be part of a rescue team, properly dressed, properly equipped, and moving with semimilitary precision. Instead, I am in shirtsleeves and a pinstripe suit, with no pen and no paper, and I am technically an uninjured victim. All I have is my ID card, surgical gloves, and my colleagues' expectation that I will lead them though this crisis.
Of course, they were able to effectively triage and stabilize patients until help arrives and the wounded can be evacuated to hospitals.

Redhead, Ward, and Batrick describe their experiences at one of the hospitals that received many of the casualties, despite not being a level I trauma center

Patients were triaged on arrival by senior teams and assigned to one of three areas of the emergency department, depending on priority. When the condition of two patients deteriorated during their initial assessment, their priority was adjusted accordingly. After initial assessment and management, critically injured patients requiring surgery were transferred to the operating rooms, where teams of orthopedic, vascular, and general surgeons would work on into the night.

The repeated reassessment of all casualties was important. A senior surgical consultant reviewed all casualties, ensuring that a thorough secondary survey was performed. Orthopedic surgical expertise was fundamental in assessing patients with complex compound injuries and prioritizing cases for surgery. Ear, nose, and throat surgeons evaluated and arranged outpatient follow-up for all patients with audiologic consequences of the blast. Radiologists interpreted trauma x-rays and performed ultrasonography in the emergency department, as well as performing computed tomography. Chaplains, patient-liaison teams, and the mental health staff provided support to distressed patients and their relatives. Medical students acted as "runners" between key areas of the hospital and helped with supplies and blood samples.
Things got even worse when they found out an unexploded device might be located next door, requiring evacuation of parts of the hospital. I'm concerned terrorists may eventually decide to start secondarily targeting EDs and hospitals that care for the wounded in bombings.

Finally Wessely, a psychiatrist, reviews some of the challenges faced by survivors. He notes that immediate psychological intervention is at best useless and may actually be harmful:

There have now been more than a dozen controlled trials in which people who have been involved in accidents and other traumatic events have been randomly assigned to receive or not to receive such counseling. The results have shown conclusively that such immediate psychological debriefing does not work. Those who received it were no better off emotionally than those who did not. Worse, the better studies with the longer follow-up periods showed that receiving such counseling actually increased the likelihood of later psychological problems. In fact, the people who seemed to be harmed by this intervention were those who had been especially upset at the time — precisely those who one might think ought to be treated.1 So whereas immediate post-trauma counseling may reassure the rest of us that something is being done, it does not actually help those who receive it.

Why it doesn't work is less clear, but probably trauma survivors need help from those they are already close to, not a therapist they've never met before. They also probably need to work through their shock and grief on their own.

He describes the media driven culture of everyone as victim

There is a danger that our stoicism, professionalism, and pride may become diluted over time. Almost immediately, reporters began carelessly describing London as "a city in trauma." Only 24 hours after the bombings, BBC Breakfast News was asking whether people who had only watched the scenes unfold on television would require counseling, and others demanded that counseling services be offered to all Londoners to enable them to "cope with the trauma." Such voices, however, were muted, and the messages coming from most mental health professionals were consistent, balanced, and less dramatic.
and concludes with an admonition we should all heed:

We must be careful to avoid shifting from the language of courage, resilience, and well-earned pride into the language of trauma and victimhood. The bombs made more than enough victims; it is important that we do not inadvertently create more.
Finally, I think the ultimate goal of these terrorists is to breakdown our society by pulling us away from each other. Bolden notes it doesn't seem to be working:
Many soon come to believe that the bombs were the work of religious extremists. I had counted at least eight different nationalities among the victims. My team consisted of Jews, Muslims, Christians, humanists, and agnostics, who all served humanity irrespective of race, color, or creed and regardless of personal danger.

7 Comments:

At 2:57 PM, Blogger ollie said...

Great article, Andy.

I have a question though: has there been studies which show whether counciling helps those who have, say, been displaced and are trying to "start over" again (I am thinking of what the Red Cross is doing with those displaced by Katrina)

 
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