Purpose: To examine the relationship between overtriage and critical mortality after a mass casualty incident (MCI) using a simulation model of trauma system response.

Methods: We created a discrete event simulation model of trauma system management of MCIs involving individual patient triage and treatment. Model variables include triage performance, treatment capability, treatment time, and time-dependent mortality of critically injured patients. We model triage as a variable selection process applied to a hypothetical population of critically and noncritically injured patients. Treatment capability is represented by staffed emergency department trauma bays with associated staffed operating rooms that are recycled after each use. We estimated critical and noncritical patient treatment times and time-dependent mortality rates from the trauma literature.

Results: In this simulation model, overtriage, the proportion of noncritical patients among all of those labeled as critical, has a positive, negative, or variable association with critical mortality depending on its etiology (ie, related to changes in triage sensitivity or to changes in the prevalence and total number of critical patients). In all of the modeled scenarios, the ratio of critical patients to treatment capability has a greater impact on critical mortality than overtriage level or time-dependent mortality assumption.

Conclusions: Increasing overtriage may have positive, negative, or mixed effects on critical mortality in this trauma system simulation model. These results, which contrast with prior analyses describing a positive linear relationship between overtriage and mortality, highlight the need for alternative metrics to describe trauma system response after MCIs. We explore using the relative number of critical patients to available and staffed treatment units, or the critical surge to capability ratio, which exhibits a consistent and nonlinear association with critical mortality in this model. (Disaster Med Public Health Preparedness. 2007;1(Suppl 1):S14–S24)

Background: Seung-Hui Cho, a student at Virginia Polytechnic Institute and State University (Virginia Tech), shot and killed 33 students and faculty, including himself, on the morning of April 16, 2007.

Methods: A retrospective review of the medical examiner system response to this multiple fatality event was undertaken to identify which procedures were and were not effective. Case records, spreadsheets, telephone call logs, notes, and after-action interviews of staff were reviewed and analyzed. Recommendations were developed to improve the management of the multiple components of a high-profile multiple fatality event.

Results: One autopsy took place on Monday, April 16, 12 on Tuesday, April 17, and 20 on Wednesday, April 18. Pathologists archived the biopsies of major organs in formalin. Slides were made of entrance wounds that exhibited residues. Blood for alcohols was collected from victims. Blood for alcohols, acid, base, and neutral drugs was collected from Cho for analysis.

Conclusions: Standard forensic pathology procedures worked and timely postmortem examinations were completed. The victim identification component of the family assistance center must be established and staffed at the time of the initial response. Public information officers need training in morgue and medicolegal death management and in ways to effectively communicate with different audiences about multiple fatality management procedures. (Disaster Med Public Health Preparedness. 2007;1(Suppl1):S25–S30)

Incidents of school and workplace violence are rare but devastating events that can result in significant psychological consequences in communities. The majority of people in the United States will experience some type of traumatic event in their lifetime, but most of them will have no disruption or only transient disruption in functioning. They are either resistant to the development of symptoms or resilient, able to bounce back quickly. By enhancing resistance and promoting resilience, even fewer individuals may develop mental disorders. This article takes a closer look at the concepts of resistance, resilience, and recovery and the need for research on interventions that promote them, in the hope of applying the concepts and interventions to schools and the workplace. (Disaster Med Public Health Preparedness. 2007;1(Suppl 1):S33–S37)

Background: Government reports have persistently indicated the intent of terrorists and hostile nations to acquire and “weaponize” nuclear materials for deliberate attack on a major US metropolitan city.

Methods: A modeling analysis of the effects of 20- and 550-kiloton nuclear detonations on the 2 major metropolitan centers of Los Angeles and Houston is presented with a focus on thermal casualties. Brode’s work as modified by Binninger was used to calculate thermal fluence, using thermal fractions. The EM-1 and WE programs were used to calculate blast effects. Fallout radiation was calculated using the Defense Threat Reduction Agency’s Hazard Prediction and Assessment Capability V404SP4 with “urban effects” turned on. The ESRI ArcView program calculated affected populations from 2000 US Census block-level data for areas affected by thermal effects.

Results: The population affected by a 550-kiloton nuclear weapon detonated in Los Angeles and Houston is staggering: surviving thermal casualties are estimated at 185,000 and 59,000, respectively. Even the 20-kiloton detonations in Los Angeles and Houston are significant: the numbers of surviving thermal casualties requiring care exceed 28,000 and 10,000, respectively.

Conclusions: The surviving health care community postdetonation would be faced with an unprecedented burden of care for thermal casualties. A great expansion of personnel involved in emergency burn care response is critical. Bold, new approaches such as regionalization and predetermined medical air transport need to be considered. (Disaster Med Public Health Preparedness. 2007;1:80–89)

The recent shootings at Virginia Polytechnic Institute and State University (Virginia Tech) suggest that an increased reliance upon the medical community to support public health violence prevention efforts may be warranted. As physicians are called upon to support these efforts, they must effectively balance their obligations to promote public safety with their traditional obligations to promote the best interests of their individual patients. To meet these concurrent ethical obligations, physicians' participation in public health violence prevention should seek to improve public safety without compromising the care of patients or exposing individuals to undue harm. Physicians should, therefore, report to the appropriate authorities those patients who are at risk of committing violent acts toward the public, but should only disclose the minimal amount of information that is necessary to protect the public. Moreover, physicians should also recommend the separation of violent individuals from the community at large when necessary to improve public safety while advocating for the provision of appropriate treatment measures to improve the patients' well-being. (Disaster Med Public Health Preparedness. 2007;1(Suppl 1):S38–S42)

Assessing legal responsibility in the aftermath of the April 2007 tragedy at Virginia Polytechnic Institute and State University (Virginia Tech) is inevitable. Beyond assigning blame, law- and policymakers should examine ways to protect the public from future incidences of gun violence on campuses and other settings. Although no combination of legal responses may fully deter individuals who are intent on causing significant harm, select legal reforms have the potential to prevent future acts of gun violence. These reforms include considering more restrictive gun laws nationally, reporting individuals with known mental impairments that may endanger themselves or others to federal or state databases, and refining laws that limit institutions from acting in advance to address prospectively dangerous people. Each of these reforms has the potential to reduce acts of gun violence to improve the public's health, but also implicates individual rights and interests. (Disaster Med Public Health Preparedness. 2007;1(Suppl 1):S43–S46)

Background: On May 4, 2007 an EF5 tornado hit the rural community of Greensburg, KS, destroying 95% of the town and resulting in 12 fatalities.

Methods: Data was requested from the emergency medical services units that initially responded and the regional hospitals that received people injured in the tornado within 24 hours following the tornado. Requested data included patient age and sex, and injury severity score or ICD-9 codes. Critical mortality, or the number of deaths of critically injured patients, was also calculated.

Results: The extensive damage caused by the tornado effectively destroyed the infrastructure of the community and created enormous challenges for emergency medical services responders, who were unable to record any triage data. Area hospitals treated 90 patients, who had an average injury severity score of 6.4. Age was found to be related to injury severity, but no relationship between sex and injury severity was found. Critical mortality was found to be 18% for this event.

Conclusions: Injury severity score has seldom been used to analyze natural disasters, especially tornadoes, although such analysis is helpful for understanding the magnitude of the disaster, comparing to other disasters, and preparing for future incidents. Advanced warning and personal preparedness are important factors in reducing tornado-related injuries and deaths. (Disaster Med Public Health Preparedness. 2007;1:90–95)