A little while ago I reported from the American Association for the Surgery of Trauma’s meeting – specifically covering the management of major – or mass casualty – incidents (MCI). Many similar themes stood out despite these occurring in various locations – in high-income, developed countries.
Low- and middle-income countries (LMIC) are unfortunately no strangers to these types of events, whether they are from natural disasters or terrorist attacks. Our colleagues in these countries strive hard, often with unique challenges and barriers but with no less zeal to achieve the best outcomes for their patients.
While we sometimes focus all our attention on research and clinical experience gained from “the West,” we should remember that just as our global colleagues learn from information we put out, they are putting in a huge amount of work to study problems to improve the education and medical care delivery in their own environments. We can (and should) learn and adapt lessons from the rest of the world. These can provide lessons for all of us.
To this end, the inclusion of abstracts and article summaries in our major emergency medicine publications like the EMJ and Annals of Emergency Medicine has been a nice step towards this inclusive learning, as has been the increasing globalization that #FOAMed has made possible.
In my own continuous quest for expanding my knowledge (and in particular keeping a patriotic eye out for initiatives and advances from back home), I came across this amazing video from my own home city of Karachi, Pakistan.
I thought this to be a fantastic effort to apply principles of both medical education and multidisciplinary training to the local environment. I had a chance to catch up with the doctor leading this training – Dr. Rashid Aqeel – and ask him a few questions:
ZQ: Tell me a little about yourself – where did you train and what is your current role?
RA: I am an Emergency Medicine physician. I completed my training in emergency medicine at Aga Khan University Hospital, Karachi, Pakistan. I currently work as a Clinical Instructor in the same department. I am in the process of pursuing the Fellowship of Royal College of Emergency Medicine (FRCEM).
ZQ: Can you describe the current state of emergency medicine in Pakistan, and in particular Karachi?
RA: Emergency Medicine is a developing field in Pakistan. The College of Physicians and Surgeons Pakistan recognized Emergency Medicine as a primary specialty in 2011 but up until 2014, only two teaching hospitals in Pakistan, one in Islamabad and one in Karachi, were offering Emergency Medicine training to medical trainees. Currently, four hospitals in Karachi offer residency training in Emergency Medicine. Overall, there is critical shortage of Emergency Medicine-trained physicians in Pakistan.
ZQ: You’ve put together what looks like a fantastic simulation course. What event prompted this to happen? Can you talk about the current effect and response to mass casualty incidents in a city like Karachi?
RA: Well, when I was a medical student, I worked as a volunteer in the aftermath of the 2005 Kashmir earthquake – that was the time I developed interest in this field. The loss that could have been prevented or minimized hurt me the most. I wanted the people of my country who had suffered so much pain and loss both on a personal and national level to never have to go through anything similar ever again.
It is clear that the incidence of mass casualty incidents has increased significantly in Pakistan. Not only this, but the floods and earthquakes in Pakistan are among the worst the world has seen. To cope with these kinds of situations, it is not enough that medical staff do their ordinary job and continue to do it as efficiently as possible. They need additional knowledge and skills of a different kind to be able to respond to mass casualty incidents. Unfortunately, there is not a single Disaster Medicine specialist in Pakistan. This further drove me to develop a special interest in this field.
Therefore, immediately after joining the training in emergency medicine, I started teaching and training medical students, healthcare professionals and ambulance crews about trauma and mass casualty management on a voluntary basis. So, whenever I get time between my Emergency Department shifts, I visit different hospitals and universities and provide them trauma and mass casualty management training. From 2011, I have been an instructor on the Primary Trauma Care (PTC-UK) course as well as, from 2013, an instructor on the Basic Assessment and Support in Intensive Care (BASIC) course, both held in Pakistan.
The basic problem in Pakistan is that there is no well-developed trauma system. There is almost no concept of a pre-hospital trauma care system in Pakistan. In particular, there is no awareness of a “mass casualty management system” among first responders. Most of the ambulances operating currently have a driver without any trained emergency responder. These drivers are not even BLS-certified and do not have knowledge about the airway, cervical spine, or hemorrhage control. In addition, these ambulances lack vital monitors, medications and first aid equipment. Their primary role is to shift the patient from accident scene to the nearest hospital, regardless of that hospital’s capacity and ability to manage a trauma victim – largely due to lack of formal communication or pre-notification system.
As a result, the trauma patients are mostly managed by non-trauma trained physicians. This has multiple reasons, but importantly there is a critical shortage of formal emergency medicine-trained physicians to appropriately manage the initial resuscitation and casualty triage phase, and a lack of surgeons with specific training in trauma surgery. As a result, the surgery is often carried out by general surgeons with a variable experience of traumatic injuries. The post-surgical management of these patients, including rehabilitation is also lacking. A lack of funding also affects the general healthcare infrastructure in Pakistan.
In essence, I found a gap in our system where the front-line doctors and staff are not being trained adequately related to the mass casualty plan and management. For example, they did not know about their own hospital’s mass casualty plan (if there even was one), how to activate emergency system, what to do after receiving the alarm, what the hospital incident command system (HICS) was, how to prepare and perform triage during an MCI, how to prepare their hospital and organize emergency department to receive mass casualties, and so forth. The purpose of this course was to teach and train healthcare professionals regarding how to build hospital emergency plan and how to deal with real mass casualties.
In conclusion, we need to work hard and concentrate in establishing a well-developed trauma system.
ZQ: What are the resources you used to develop this course?
RA: As I mentioned, I have extensive experience in managing MCIs over the last 8 years from both terrorist incidents (bomb blasts and mass shootings) as well as environmental issues such as major heat waves. I have also been actively involved in teaching and training on MCI management for quite some time, however this teaching was without simulation exercise. For a long time, I was working to develop an innovative mass casualty course which included a simulation exercise and which is easy to understand for the multiprofessional healthcare staff.
In order to achieve this goal, I completed different disaster/mass casualty management courses like those provided through the Harvard Humanitarian Initiative, Johns Hopkins Bloomberg School of Public Health, the International Committee of the Red Cross (ICRC), and several online courses in this field. I used knowledge from these courses plus additional guidelines from various international resources, especially the World Health Organization’s guidelines. In addition, I read different disaster medicine textbooks (like those authored by Ciottone as well as Koenig and Schultz) and other resources like the Major Incident Medical Management and Support (MIMMS) course manual.
In short, I used knowledge from a number of different resources to develop this course and adapt it to our situation in Pakistan.
ZQ: Can you tell me about the specifics of how you put the course together? What kind of challenges did you face and what did you learn in terms of logistical issues
RA: This course is comprised of two main components; the first part includes interactive lectures, discussions and tabletop exercises covering every single aspect of mass casualty management in our healthcare system. The second component was the simulation-based exercise in a virtual emergency department. The main aim for this hands-on simulation exercise is to increase knowledge, skills and confidence of the multiprofessional healthcare team in dealing with mass casualties in real life under stressful conditions.
As I mentioned earlier, I used knowledge from different resources and later compiled all the knowledge from my own personal notes to make a simple yet easy to understand mass casualty course as per our local needs. Local acceptance is very important aspect of such courses because you have to work along your own team using your own available resources. However, I made sure that all the content of this course met international standards.
The simulation part was not an easy task. It took a lot of time because I designed this simulation part mostly from my own past experiences. After finalizing the total 16 different cases for this simulation exercise, the next part was to teach and train all facilitators and volunteers, individually. This was very time consuming and took a lot of effort. I had to train all of them alongside my full-time hospital duties.
During the preparatory phase, I taught and trained all volunteers individually about their specific role, individual injuries, and the way they should be acting during the simulation exercise specific to their injuries. Therefore, all volunteers who took part acted like real patients, able to reproduce specific clinical signs and wearing realistic makeup.
Similarly, I trained all facilitators individually during this phase to make sure they were all on the same page as the volunteers. They had to know about different type of injuries and how to manage them as per current guidelines. The training of the volunteers and facilitators was the real challenge, as I had to teach and train them all myself. Once I was satisfied from individual trainings, we did multiple rehearsals of this exercise all together to correct mistakes and polish their performance before the course began.
For the makeup effects, I learned from various internet resources how to create realistic appearing wounds. It was also a good learning experience for me to create fake blood. Fortunately, during the early preparation phase, I found a small moulage kit in our Medical Education building which had never been used before- in fact nobody knew its purpose and how to use it. It was such a great feeling for me when I informed the leadership that I found a kit in building that could be used for our simulation. Through these efforts, I was able to create very realistic patients.
The result was that, during final exercise, all course participants had an equal opportunity to assess and manage all 16 different patients who had a wide variety of injuries. With the help of the facilitators, they all had the chance to learn and provide hands-on emergency management up to an international standard but utilizing locally available resources. Importantly, they were given enough time to discuss each case with their facilitators.
ZQ: In your mind, what lessons can other countries around the world learn from your experience with dealing with mass casualty incidents in Pakistan and other LMIC countries?
RA: It was simply an amazing experience for me as this was first of its kind and innovative “Mass Casualty Management” course in Pakistan with a simulation-based exercise in a virtual emergency department for healthcare professionals as per international standards.
I would suggest that healthcare professionals from other LMICs can learn from my own experience and the way I designed our own mass casualty course for Pakistan, as per our local needs. They should first try to find the gaps in their healthcare system and then do their best to fill that gap. The can use various resources available online or even through some effort on their own part to learn from people around the world. Those lessons however need to both maintain the international standard but and be adapted to your own resources.
These incidents can happen worldwide as we see every day in the news, and it is of course a huge challenge to bring about change. I think if you are really enthusiastic and persistent about something then along with your passion and hard work, you can achieve anything you want.
I am very thankful to you for appreciating my efforts and giving me the opportunity to share my thoughts – I hope they can be helpful for others.
The final word
I thank Dr. Aqeel for all his efforts in improving the care for the people of Pakistan, and showing the world that through the work of dedicated individuals like him, systems of care can be maneuvered towards change. We are a global community dedicated to our patients, and it is imperative that we continue to learn from one another and share lessons we learn beyond our own four walls.
- Maqsood R, Rasikh A, Abbasi T, Shukr I. Pattern of injuries seen in mass casualties in terrorist attacks in Baluchistan: a three years experience. J Ayub Med Coll Abbottabad 2015;27(4):858-860 PMID: 27004339
- Zafar H, Jawad A, Shamim MS et al. Terrorist bombings: medical response in a developing country. J Pak Med Assoc 2011;61(6):561-566 PMID: 22204211
- Shahzad H, Irfanullah, Shafqat U et al. Disaster management preparedness: attitudes and previous experience of emergency physicians of Peshawar, Pakistan. South Asian Journal of Emergency Medicine 2018;1(1):9-15. https://www.ejmanager.com/mnstemps/184/184-1541331346.pdf
- Shah AA, Rehma A, Sayyed RH et al. Impact of a predefined hospital mass casualty response plan in a limited resource setting with no pre-hospital care system. Injury 2015;46(1):156-161 PMID: 25225172
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