Plane Crash

I was in the hospital rounding on pain service patients when I got a page: "Code Triage - Major." I hadn't seen this code before, but the page followed with an explanation: "Mass casualties. Plane crash at SFO." I hurried over to the OR, switched into scrubs, and set up an operating room. Anesthesiologists rushed in. Many were in house - ICU, cardiac, pediatric, liver, and obstetric teams - and others came in from home.

We got the story in bits and pieces. A Boeing 777 passenger jet flying from South Korea crashed on landing at San Francisco International Airport. Two people were killed, over 180 injured. Most were going to SFGH and other hospitals, but many were coming to Stanford. I was astounded by the rapid spread of information; Twitter feeds chattered, and I even saw a Youtube video of the plane billowing smoke. We heard the tail ripped off, an engine was destroyed, fire engulfed the plane, and even that the plane rolled over.

As I was setting up, our first patient rolled into the operating room. With burns on the arms and legs, a large bleeding scalp laceration, and little time to prepare, I had to make quick decisions about the anesthetic. After asking the patient some basic questions, I prepared a rapid sequence induction and intubated the patient. On intubation, I saw soot and erythema suggesting inhalation of smoke and hot gases. The rest of the anesthetic was resuscitation, warming, and access. Burn injuries cause rapid loss of heat and water, and falling behind can have severe consequences. We also kept the patient intubated post-operatively because inhalation injuries can have severe airway swelling.

I learned a lot from this incident. In a mass casualty situation, call all your resources early. Even though I wasn't supposed to be in the OR, my skills were needed and I had no hesitation to take care of someone sick and injured. Plan as much as you can early but expect that you will not anticipate everything. Anything could have come in, from burns to chest trauma to arterial bleeding to children. At this time, my place is at the front line, taking care of the individual patient, but I am starting to get a sense of what it's like to coordinate a potential multiple patient disaster. Communicate in the operating room; too much commotion or too little discussion, and no one knows what's happening. The surgeon knows the injuries and what he wants to do. The anesthesiologist knows the access, airway, blood pressure, temperature, and fluid management. The nurses handle the equipment, the post-operative disposition, and the medications from pharmacy. The front desk knows how many more people may be coming up and how much time we have before a critically ill patient sucks away resources. And debrief at the end. I made some anesthetic decisions that worked, but were they optimal?

Image shown under Fair Use, from New York Times.