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A Coup d’état

Sharon Einav, MD; Ram M. Spira, MD; Moshe Hersch, MSc, MD; Petachia Reissman, MD; William Schecter, MD

Arch Surg. 2006;141:815-822.

Hypothesis  During terrorist-related multiple-casualty events (TMCEs), the role of the surgeon expands beyond providing traditional trauma care.

Design  Survey and expert opinion poll.

Setting  Interviews (structured, open/closed questions) conducted in 14 Israeli hospitals.

Participants  Sixty hospital physicians selected for their experience in TMCEs.

Main Outcome Measures  Identification of key staff members and their roles during TMCEs and development of recommendations for hospital management.

Results  During TMCEs, hospitals are comanaged by a physician hospital administrator and a clinical medical director (usually a surgeon) responsible for prioritization of patient care. Primary triage is often performed by a general surgeon experienced in trauma. Trauma specialists supervise other physicians providing patient care. Key staff members to recruit to the hospital at event onset include the chiefs of surgery and anesthesiology, attending surgeons and anesthesiologists, critical care physicians, and radiologists. Paramedics stationed in-hospital as emergency medical services liaisons improve communication between the field and the hospital. Operating room and intensive care unit (ICU) management remain unchanged. Controversies exist regarding continuation of planned and ongoing elective surgery and ICU triage despite use of the postanesthesia care unit as an extension of the ICU.

Conclusions  During TMCEs, surgeons fill pivotal roles in hospital command and control and hands-on clinical care. Anesthesiology services and ICUs are relied on heavily for provision of patient care and should be included in information flow and decision making. Operating room and ICU management should remain unchanged since the care of patients who are already in these locations at the time disaster strikes is a subject of controversy with ethical implications.

Author Affiliations: Intensive Care Unit and Department of General Surgery, the Shaare Zedek Medical Center, the Faculty of Health Sciences of the Ben Gurion University, Jerusalem, Israel (Drs Einav, Spira, Reissman, and Hersch); and Department of Surgery, University of California and San Francisco General Hospital, San Francisco (Dr Schecter).