Articles

www.thelancet.com Vol 368 December 23/30, 2006 2219

Reduction in critical mortality in urban mass casualty
incidents: analysis of triage, surge, and resource use after the
London bombings on July 7, 2005
Christopher J Aylwin, Thomas C Knig, Nora W Brennan, Peter J Shirley, Gareth Davies, Michael S Walsh, Karim Brohi
Summary
Background The terrorist bombings in London on July 7, 2005, produced the largest mass casualty event in the UK
since World War 2. The aim of this study was to analyse the prehospital and in-hospital response to the incident and
identify system processes that optimise resource use and reduce critical mortality.
Methods This study was a retrospective analysis of the London-wide prehospital response and the in-hospital response
of one academic trauma centre. Data for injuries, outcome, triage, patient ow, and resource use were obtained by the
review of emergency services and hospital records.
Findings There were 775 casualties and 56 deaths, 53 at scene. 55 patients were triaged to priority dispatch and
20 patients were critically injured. Critical mortality was low at 15% and not due to poor availability of resources.
Over-triage rates were reduced where advanced prehospital teams did initial scene triage. The Royal London Hospital
received 194 casualties, 27 arrived as seriously injured. Maximum surge rate was 18 seriously injured patients per
hour and resuscitation room capacity was reached within 15 min. 17 patients needed surgery and 264 units of blood
products were used in the rst 15 h, close to the hospitals routine daily blood use.
Interpretation Critical mortality was reduced by rapid advanced major incident management and seems unrelated to
over-triage. Hospital surge capacity can be maintained by repeated eective triage and implementing a hospital-wide
damage control philosophy, keeping investigations to a minimum, and transferring patients rapidly to denitive
care.
Introduction
The multiple bomb explosions in London on July 7, 2005,
resulted in the largest mass casualty event in the UK
since World War 2. By contrast with multiple casualty
incidents, a mass casualty event taxes emergency systems,
hospitals, and community infrastructure, and exceeds
the capability of available resources to provide optimum
trauma care.
1
Mass casualty events such as the New York
World Trade Center attack in 2001
2
and the Madrid
commuter train bombings in 2004
3
have high numbers
of injured casualties and test disaster contingency plans
to the full.
As modern warfare shifts towards civilian arenas,
millions of people are now living with the threat of
terrorism, while around the world the number of natural
and man-made disasters continues to rise.
4
Emergency
service, hospital, local, and regional disaster plans are
being revised to respond to these new and increasingly
likely events. Much of this planning is done in a relative
vacuum of information detailing how and when dierent
parts of a trauma system are tested by the resource
consumption of casualty surge.
The two fundamental aims of a disaster response are
rapid evacuation of all casualties from a hazardous
incident scene and to reduce the mortality of critically
injured patients.
1
Rapid evacuation of all casualties is vital
where there is the potential for structural collapse or
secondary explosive devices. However, reducing critical
injury mortality needs careful assessment to identify the
severely injured patients among the large numbers of
non-critical casualties. Overtriageassigning non-
critically injured casualties to a high priority for early
evacuation and treatmentinappropriately assigns
constrained resources and impairs the management of
the critically injured.
5
Studies of previous terrorist
bombing incidents have identied a linear relation
between the over-triage rate and critical mortality.
6
Thus
there are conicting priorities between the requirements
for rapid scene clearance and reducing overtriage. Scene
clearance should therefore be highly organised and
e cient to optimise casualty triage and survival.
Rapid scene clearance creates a surge in the rate that
casualties arrive at receiving institutions. A fundamental
issue in mass casualty care is not simply the number of
patients that need treatment, but also the rate at which
they arrive and use available resources. The ability to
maintain standards of trauma care is reduced by this
casualty surge, and the ability to provide high-level trauma
care under these circumstances is the surge capacity.
7
We describe how critical mortality in mass casualty
events can be reduced, despite a high scene over-triage
rate, by the e cient management of surge at every stage
of a disaster response. This study therefore analyses the
prehospital and in-hospital response to this mass casualty
event to identify the critical mortality and the over-triage
rate. We then analyse surge by describing patient ow
Lancet 2006; 368: 221925
See Comment page 2188
Department of Trauma
Surgery (C J Aylwin MRCS,
T C Knig MRCS,
N W Brennan MRCS,
M S Walsh FRCS, K Brohi FRCS),
Department of Intensive Care
Medicine (P J Shirley FRCA),
and Emergency Medicine and
Prehospital Care
(G Davies FFAEM), Royal
London Hospital, London
E1 1BB, UK
Correspondence to:
Dr Karim Brohi
karim@trauma.org
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2220 www.thelancet.com Vol 368 December 23/30, 2006
and resource use at key stages in the disaster response.
Specically, we examined the emergency department,
radiology, blood bank, operating rooms, and critical care
areas. We then identify system processes that optimise
use of resources and reduce critical mortality in the face
of maximum surge and high over-triage rates.
Methods
Londons major incident plan is developed and organised
by the London Emergency Services Liaison Panel.
8
A
major incident can be declared by any member of the
emergency services, either on-scene or in the control
room. Response command and control is organised
around a Gold (strategic), Silver (tactical), and Bronze
(operational) structure.
9
Inter-agency discussions at Gold
level escalate a local incident to London-wide status,
coordinated from a dedicated Gold control operations
centre. Gold control is responsible for activating major
incident response plans for hospitals and health
authorities across London, although hospitals can self-
activate their response when necessary. The London
major incident plan requires the presence of a doctor at
scene to tactically manage the incident from a medical
perspective. Medical commanders were provided by the
Royal Londons Helicopter Emergency Medical Service
(London-HEMS).
10
Support for the medical role was later
provided by on-call volunteers from the London Medical
Commander pool.
In-hospital analysis was done of the Royal London
Hospitals experience of the London-wide major incident.
The Royal London Hospital is a 675-bed university
hospital geographically close to the Aldgate and Kings
Cross incident scenes and is the primary trauma receiving
hospital for London. The emergency department sees
around 120 000 patients per year, and the trauma team is
activated (assembled in the emergency department via an
emergency paging system) 800 times per year. The
resuscitation room is equipped with ve trauma bays, an
overhead x-ray gantry, dedicated ultrasound, and two
helical CT scanners. There are 11 general operating rooms
and an 18-bed intensive care unit (ICU) of which 16 are
open and staed. 95% of admissions to intensive care are
for trauma or emergency cases and bed occupancy is
routinely at, or close to, maximum.
Data for the number and triage categorisation of
casualties at each incident scene were obtained by
reviewing records kept by London-HEMS and the London
Ambulance Service as well as transcriptions of emergency
communications made during the incident. Data for
injuries and mortality were obtained directly from the
trauma registry of the Royal London Hospital and from a
Government Home O ce database of casualties for the
other receiving hospitals. The Injury Severity Score (ISS)
11

was calculated and critical patients were dened as those
with an injury severity score greater than 15 or with
proximal traumatic amputations.
5
Critical mortality is
dened as the number of deaths in critically injured
survivors.
5
In-hospital data were obtained on patient
arrival and dispatch times for the emergency department,
operating room, and critical care areas. Resource use data
were also obtained on radiology use, blood product
administration, and operative procedures.
Role of the funding source
There was no funding received for this study. The
corresponding author had full access to all data in the
study and had nal responsibility for the decision to
submit for publication.
Results
At 0850 h on Thursday July 7, 2005, three bombs exploded
on trains at three dierent locations on the London
Underground system. A fourth bomb exploded on a
double-decker bus at 0947 h. Edgware Road station was
the rst site to be declared a major incident at 0912 h
followed by Kings Cross station at 0919 h, Aldgate station
at 0924 h, and Tavistock Square at 0957 h. Initial reports
were confused as to the nature and number of explosions,
not least because of casualties emerging from stations at
either end of a tunnel, and in total there were eight
separate incident scenes declared, all requiring a full
emergency response. A London-wide major incident was
declared at 0923 h.
Overall, 775 people were injured and 56 people died,
53 at scene (table 1). Casualties were triaged by injury
type and physiology with a simplied Priority 14 tagging
system into 55 severely injured (equivalent to P1 and P2)
and 667 walking wounded (P3) patients (table 1).
1
Two
patients were assigned to a P4 Expectant category and
died at scene. 349 P3 casualties were treated in local eld
units and transferred to hospitals after the critical patients
had been dispatched.
20 of the P1 and P2 patients were critically injured,
giving a scene over-triage rate of 64% (table 1). Initial
triage at both Edgware Road and Tavistock Square was
done by the ambulance service and medically-trained
bystanders, which might in part explain the high over-
triage rates at these sites (82%) compared with 33% at
the Aldgate and Kings Cross incidents where medical
incident control and triage was done mainly by London-
HEMS sta.
Three patients died in hospital, giving a critical
mortality rate of 15%. Two patients died at the Royal
Aldgate Kings Cross Edgware Road Tavistock Square Total
Dead at scene 7 25 7 14 53 (7%)*
Priority 1 or 2 11 10 17 17 55 (8%)
Critically injured 8 6 2 4 20 (3%)
Overtriage, n (%) 3 (27%) 4 (40%) 15 (88%) 13 (77%) 35 (64%)
Critical mortality 1 2 0 0 3 (15%)
*Of 775 total casualties. Of 722 immediate survivors. Of 20 critically injured patients.
Table 1: Prehospital response, triage categories, and mortality
Articles
www.thelancet.com Vol 368 December 23/30, 2006 2221
London, one of massive torso haemorrhage in the
operating room and one had repeated episodes of
hypovolaemic traumatic arrest en-route to hospital and
was subsequently declared brain dead 6 days later. On
peer review of the management of these two patients,
neither death was deemed preventable, nor was care
compromised by the volume of other casualties in the
hospital. The third in-hospital death was at another
institution and was the result of severe traumatic brain
injury.
The rate of casualty clearance from the incident scenes
was 27 P1 and P2 patients per hour for 2 h (gure, A,
table 1). In total, 19 prehospital doctors and eight
paramedics from London-HEMS and 101 ambulances
and 25 fast response units from the London Ambulance
Service were deployed. The primary factor limiting the
surge rate at this stage was di culty in underground
scene access and patient extrication, although there were
some di culties with ambulance provision for casualty
evacuation because of the number of multiple active
incidents.
Initially, all emergency departments in London were
put on major incident standby by Gold control. 12 inner-
London hospitals instituted their major incident plans
and casualties were distributed between six London
university hospitals on the basis of their proximity to the
incident and their known capacity and capability.
Overall, the Royal London Hospital received 27 seriously
injured (P1 and P2) and 167 walking wounded (P3)
casualties. P3 casualties were managed in hospital areas
close to, but separate from, the emergency department
and most arrived around 2.5 h after the major incident
was declared. Over-triage rate to the Royal London was
1 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Edgeware
Road
Aldgate
Kings
Cross
Tavistock
Square
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14
12
10
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6
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2
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C2
C3
C4
C5
C6
C7
C8
N1
N2
N3
N4
N5
N6
N7
N8
N9
N10
N11
N12
N13
N14
N15
N16
N17
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Critically injured
Hours after rst explosion
Majors area
Resuscitation room
Time in resuscitation room
Time in majors area
Major incident patients
Other patients
Beds available
Beds used
Ward
Operating room
Hours after rst explosion
Total P1/P2 patients
Figure: Patient ow and surge analysis
Dierent stages of major incident response. All graphs have time in hours as the
abscissa, starting at time zero as the time of the initial bomb explosions on the
underground system. (A) Prehospital. Solid bars=emergency service arrival and
scene clearance times for each site (Edgware Road: 81 min; Aldgate: 64 min;
Kings Cross: 108 min; Tavistock Square: 81 min). Red triangles=time of arrival of
London-HEMS teams (Aldgate 0930 h; Kings Cross: 0940 h; Edgware Road:
1015 h; Tavistock Square: 1020 h). Height of bars=relative number of P1 and P2
patients evacuated from each site (table 1). Red bars=casualties subsequently
identied as critically injured (table 1). (B) Number of casualties in emergency
department (ED) at 15-min intervals. Red=patientstriaged to trauma bays.
Purple=triaged to majors areas. (C) Patient ow through emergency department
and operating rooms. C1C8=patients triaged to the resuscitation room.
N1N19=patients triaged to majors area. Resuscitation bays re-used by rapid
dispatch of patients obviously requiring immediate surgery to operating rooms
(patients C1, C3, C5, C6, and C8). Two non-critical patients (N2, N10) moved to
the operating room before clearance of the resuscitation room and stand-down
of major incident were identied as having substantial traumatic brain injuries.
(D) Operating room use. Red bars above the abscissa=operating room occupancy
for casualties from the bombing incidents. Grey bars below abscissa=other
operations running during the incident. Six elective cases were already running
at start of the day. Two further emergency procedures on patients already in
hospital were done during course of major incident. (E) Intensive care bed
capacity and use. Blue bars=available ICU-capable beds. Red bars=major incident
patient ICU bed use.
Time points: (a) 0850 h: First three bomb explosions on London Underground.
(b) 0926 h: Royal London Hospital major incident declared. (c) 0947 h: Bomb
explodes on bus in Tavistock Square. (d) 1240 h: Royal London Hospital major
incident stood down. (e) 1330 h: Emergency Department re-opens.
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2222 www.thelancet.com Vol 368 December 23/30, 2006
63% with ten of the 27 P1 and P2 patients having critical
injuries. Casualties were re-triaged on arrival into eight
patients to be managed by a full trauma team in the
resuscitation room and 19 by one doctor-nurse team in
the majors area (a 16-cubicle area where patients are
managed on trolleys) of the emergency department. Two
of these patients were under-triaged and subsequently
identied as critically injured with evolving traumatic
brain injuries, one of which needed a craniotomy for
evacuation of an extra-axial collection. Table 2 shows the
injuries sustained by P1 and P2 patients admitted to the
Royal London Hospital.
The rst priority (P1 or P2) patient arrived at 1005 h.
Maximum surge was seven resuscitation room patients
and 11 majors area patients per hour during the rst
hour of the emergency department response (gure, B).
Resuscitation room capacity was reached within 15 min
of the rst patients arrival. Since all communications
with the scene had failed and without any information
about the total number of expected casualties, emphasis
was placed on rapid assessment and movement of
patients to denitive care (gure, C). The Director of
Trauma oversaw management of all trauma teams,
directed use of radiology, and prioritised dispatch to the
operating rooms together with the lead trauma ortho-
paedic surgeon and lead trauma anaesthetist. At no time
was resuscitation room capacity exceeded.
Radiological assessment in the emergency department
was directed only at the identication of life-threatening
injuries. Table 3 shows the radiological examinations
done immediately during the casualty-receiving phase
of the major incident, compared with the total number
of radiological investigations done over the next 24 h.
Initially, only six patients had CT scans, all for
assessment of traumatic brain injury. CT use was
limited by the liberal use of ultrasound in the
resuscitation room as a screening method, and con-
current diagnostic laparotomy for patients needing
other emergent surgery.
17 patients needed operations, which were done over
14 h, with a maximum operating room surge of four
patients per hour. Figure, D, shows room use during the
rst 15 h of the major incident. Six rooms had already
started their elective operating lists at the time of major
incident activation. All were available within 2 h of
declaration of the major incident. The rst operation of
the major incident began at 1045 h and maximum use
was reached 75 min later, at which time eight rooms
were running concurrently. Operating room use and
sta deployment were coordinated by a senior ana-
esthetist and senior operating-room nurse working as a
Critically injured
(n=8)
Non-critically injured
(n=19)
Head
Cerebral contusion 3 1
Extra-axial haematoma 3 2
Base of skull fracture 1 0
Skull vault fracture 1 1
Face
Facial fractures 4 2
Tympanic perforations 8 19
Eye injuries 3 2
Chest
Rib fractures 2 0
Lung contusion 3 0
Pneumothorax 1 0
Haemothorax 2 0
Mediastinal injury 2 0
Smoke inhalation 3 5
Abdominal 0 0
Spine 2 0
Soft tissue wounds
Head/neck 6 13
Trunk 4 2
Extremities 5 8
Extremity
Upper limb amputation 1 0
Lower limb amputation 2 0
Long bone fractures 4 0
Metacarpal fractures 2 1
Metatarsal fractures 1 0
External
Burns 2 3
Head/neck soft tissue 6 13
Trunk soft tissue 4 2
Extremity soft tissue 5 8
Table 2: Injuries sustained by seriously injured trauma patients admitted
to the Royal London Hospital
Immediate Total
Plain lms
Chest 14 21
Pelvis 3 8
Spine 1 2
Extremities 12 27
Ultrasound
FAST 8 8
CT
Brain 6 10
Face 3 4
Abdomen 1 3
Chest 0 3
Pelvis 0 2
Spine 0 8
FAST=Focused assessment with sonography for trauma. Immediate=during
major incidence activation. Initial face CT scans done with brain imaging on a
multidetector CT scanner.
Table 3: Radiological investigations during rst 24 h at the Royal
London Hospital
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team. Table 4 shows the list of operations during the
major incident. All operations were managed by
consultant surgeons, although not all of these surgeons
routinely manage trauma patients. Operations were done
in a damage control
12
mode until no further casualties
were expected. At this point, several patients remained in
the operating rooms for denitive care procedures.
264 units of blood products were used in the rst 15 h
of the major incident including a total of 130 units of
packed red blood cells, 46 units of fresh frozen plasma,
70 units of cryoprecipitate, and 11 pools of platelets.
Typical blood product usage runs at around 240 units of
all blood products per day. The volume of blood products
available was augmented by the regional blood trans-
fusion service, but the primary issue again was surge in
demand rather than resource availability. Haem atology
sta were diverted from other areas to support the usual
two transfusion technicians and all non-urgent requests
for blood cross-matching and typing were postponed.
In total, seven major incident patients were admitted to
the intensive care unit, and the maximum surge rate for
the intensive care unit was two patients per hour (gure,
E). On declaration of the major incident the two unstaed
beds were opened, ve self-ventilating patients on the
intensive care unit were discharged to the ward under
the care of the ICU outreach team, and three ventilated
patients were transferred to other hospitals within the
Trust by the Surrey Ambulance Service. One of these
patients subsequently died at the receiving institution,
although whether the transfer adversely aected this
outcome is not clear. The high dependency unit was
cleared and upgraded to intensive care capability and
four post-anaesthesia care units were also available for
intensive care use. Thus ICU bed capacity was increased
from one available bed at the time the major incident was
declared to a total of 11 ICU beds and seven ICU-capable
satellite beds. For the operating room and the intensive
care unit, the major incident persisted for the next
14 days. During this period the 27 patients needed 183 h
of operating time, and extra surgical, anaesthetic, and
critical care sta were needed throughout to manage the
extra workload. Median ICU stay was 12 days with a
maximum of 22 days.
Discussion
This study presents a detailed analysis of critical mortality,
casualty ow, and the medical response to an urban mass
casualty event. We identied a relatively low critical
mortality and showed how triage errors and surge can be
reduced by trained, experienced decision-makers working
in their usual environments. Finally, we showed how
damage-control principles can be applied to a mass
casualty response to reduce resource use and optimse
surge capacity.
In assessing the eectiveness of a disaster response
plan, we need to distinguish between the immediate
deaths due to the explosion and the potentially preventable
subsequent deaths in patients who receive medical care.
Immediate mortality of the London bombings was 7%,
similar to the 9% experienced in the Madrid commuter
train bombings (177 immediate deaths of 2062 total
casualties).
3
Conned space explosions are usually
associated with higher mortality rates, and a study of four
suicide bomb attacks in Israel in 1996 revealed a 46%
immediate mortality in conned space explosions
compared with 7% in open-air incidents.
13
Several factors
could eect the immediate death rate, including type of
explosive and positioning. Undoubtedly mortality would
have been much higher if the Victorian tunnels of the
London Underground system had not held, since
structural collapse is associated with signicantly higher
immediate mortality rates, as seen in the 1995 Oklahoma
City bomb (21%),
14
the 1994 bombing of the Argentine
Mutual Insurance Agency in Buenos Aires (29%),
15
the
1983 Beirut barracks bomb (68%),
16
and the 2001 World
Trade Center attacks (91%).
2

A major incident response can only have a minimum
eect on the numbers of deaths at scene, but some
reduction in immediate mortality could be achieved with
rapid casualty access, assessment, and evacuation by an
eective prehospital trauma system.
The overall mortality rate of mass casualty events is
skewed by the large number of walking wounded, and
the critical mortality rate is more indicative of the
eectiveness of the trauma system and disaster response.
5

Although the number of people killed at scene varies
widely, the number of critically injured survivors is
relatively small and remarkably consistent (Buenos Aires
14; New York 20; Madrid 29; Beirut 37; Oklahoma
City 53).
2,3,1416
At 15%, the critical mortality rate of the
London bombings is lower than that of most previous
terrorist mass casualty events (Buenos Aires

29%, Beirut

37%, New York

38%)
2,15,16
and is closer to that of isolated
Number of operations
Laparotomy 5
Thoracotomy 1
Intracranial monitor 1
Craniotomy 2
Upper limb amputation 1
Lower limb amputation 11
Above knee 6
Through knee 2
Below knee 3
External xation of fracture 3
Internal xation of fracture 1
Limb fasciotomy 5
Wound debridement 15
Globe repair and xation of facial fractures 1
Finger debridement and tendon repair 1
Table 4: Operations on day of major incident at the Royal London
Hospital
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2224 www.thelancet.com Vol 368 December 23/30, 2006
conned-space multiple-casualty events such as the
Israeli suicide bombings, which had a critical mortality
of 18%.
13
Reduced critical mortality rates are seen where
there is immediate access to medical care, such as in the
Oklahoma City bomb where the 83 survivors were
evacuated to a hospital only two blocks away from the
scene of the explosions and there were ve deaths in
52 critically injured casualties (10%).
14

Compared with previous incidents, the average scene
over-triage rate of 67% would be expected to have a critical
mortality of 2530%.
5
However, the critical mortality rate
of 15% in the London incident seems unrelated to
overtriage but rather to the deployment of trained, skilled
medical and paramedical sta working within their
normal environment and scope of practice, providing
rapid scene assessment and clearance while still
providing eective triage.
London-HEMS sta achieved low over-triage rates
(average 35%) compared with the other sites and to
previous events (Buenos Aires 56%, New York 70%,
Beirut 80%,

Madrid 89%).
2,3,15,16
Improved triage might
also be because of the simplied triage system classifying
patients as seriously injured (P1 and P2) or walking
wounded (P3). The standard P14 triage system is slow to
eect and does not take account of subsequent injury
evolution and physiological deterioration (especially with
rapid casualty access and assessment). We recommend
that local pre-hospital guidelines be reviewed to see
whether simplication of their triage system is
appropriate. Subsequent triage into P1 and P2 categories
is more eective and appropriate when casualties arrive
at an emergency department.
In the initial chaos of a mass casualty situation, triage
errors will happen. A disaster response plan must identify
and reduce the consequence of these errors. Under-triage
will take place with rapid scene assessment and
evacuation because of the evolving nature of many of
these injuries, and patients assigned to delayed care must
be closely monitored for any deterioration. Over-triage
rates will rise when casualty clearance from a hazardous
scene is the priority and this situation must be
compensated for by reducing surge and increasing surge
capacity at other stages of disaster response. The gure
viewed as a whole shows how dierent parts of the
trauma system experienced the major incident surge at
dierent times and how each part of the trauma system
reduced surge for the next stage of the process. Surge,
overtriage, and under-triage can be reduced in a step-wise
fashion by systematic reassessment, reprioritisation, and
redirection of patients at every stage, and should happen
anywhere in the system where resources are constrained.
Again, the use of trained and experienced medical sta
in controlling access to the resuscitation room, radiology,
blood bank, operating room, and critical care areas
reduced the eects of overtriage, protected against and
corrected under-triage, and optimised resource use.
These core control positions should be explicitly
designated in a disaster response plan and are central to
the organisation of an error-tolerant system of casualty
management.
Surge capacity can be improved by increasing resource
availability or by reducing resource use. Although disaster
plans usually focus on increasing the availability of
resources, this approach has only a small eect on surge
capacity.
6
To eectively reduce resource use every section
of the trauma system must move to a damage control
mode of operation. Damage control is most commonly
understood to apply to surgical procedures, where a
limited resource (the patients physiological reserve) is
conserved by abbreviating an operation to the minimum
procedure that will save life. The principle of damage
control can be applied to all aspects of the major incident
response. For example, London-HEMS teams did few
advanced on-scene interventions, but instead focused on
identication and extrication of the most severely injured
patients. Similarly, access to the CT scanner was reduced
by delaying all non-urgent scans and avoiding abdominal
CT for blast injury in favour of mini-laparotomy when
patients needed other emergency surgery. Requests for
blood typing and cross-match were restricted only to the
most severely injured and no other laboratory tests were
ordered.
The amount of blood used during the rst 24 h of major
incident response was easily matched by the hospital
with some supplementation from the regional blood
transfusion service. This situation is typical of civilian
and natural disasters, despite the perception of the media
and the public that massive amounts of blood are needed
during these events. There have only been ve disasters
in the USA since 1975 where more than 100 units of
blood were transfused, with a maximum of 224 units
used in New York City during the terrorist events of
Sept 11, 2001.
17
However, the New York Blood Center
obtained 5000 units of blood in the rst 12 h of the
response and more than 475 000 units were donated in
total. In Madrid, more than 1725 extra blood donors were
mobilised on the day of the bombings, but only 145 units
were transfused.
3
Across London 1400 units of blood
products were issued by the National Blood Transfusion
service on July 7, all from existing stocks. No appeal for
donors was made, although 10 000 calls were received
from members of the public wishing to donate blood.
The natural desire of people to help and the media drives
that fuel this only result in futile resource consumption
as communications systems and transfusion sta are
overloaded by a well-intentioned, but counter-productive
public response.
Although mortality and injuries sustained in major
incidents are commonly reported, there is little published
data for casualty ow that can be directly applied to
disaster planning. Various methods of disaster simulation
such as table-top exercises, war-gaming,
18
and computer
modelling
6,19,20
all rely on estimates of casualty arrival
rates and subsequent ow through the trauma system.
Articles
www.thelancet.com Vol 368 December 23/30, 2006 2225
The gure, AE, shows how surge is not uniform and
estimates of surge by averaging patient numbers over the
duration of the incident will underestimate the actual
maximum surge rate. For example, the average surge
experienced by the emergency department was one
resuscitation room and six majors area patients per hour,
but the maximum surge rate was nine resuscitation
room and nine majors admissions per hour. Disaster
plans that are based on estimates of average surge will
fail with the early arrival of larger numbers of critically ill
patients. We believe this data will be valuable in future
disaster planning and we would encourage other groups
to publish in a similar format.
A disaster response system must manage the competing
priorities of safe evacuation of all casualties from an
incident scene and reduction in mortality of the critically
injured. Rapid scene clearance will lead to high over-
triage rates and a surge in casualty numbers, which
might be substantially larger than predicted. The eects
of scene overtriage and casualty surge can be reduced by
staged triage with explicit control of patient ow and
resource use. Surge capacity can be most eectively
increased by applying damage control principles to all
aspects of the system response. Implementation of these
processes in a mass casualty response will allow optimum
trauma care for the critically injured, despite the casualty
surge that results from the e cient scene management
of modern advanced pre-hospital systems.
Acknowledgments
We would like to thank Graham Chalk and Anita West for their
assistance with data collection, and Eric Frykberg and Asher Hirshberg
for their helpful discussions of the manuscript.
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