<BODY><SPAN class=124275700-31082007><FONT face=Arial><SPAN class=890571901-31082007>The </SPAN>formal report from the State of Virginal on the shooting at Virginia Tech<SPAN class=890571901-31082007> has been released</SPAN>. At 260 pages it is a bit much to read but the EMS, Hospital, and Emergency Management responses were investigated and outlined from page 100 to page 122. I've copied the key findings and recommendations below. </FONT></SPAN>
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<DIV><SPAN class=124275700-31082007><FONT face=Arial>The report should be commended for not concentrating solely on EMS and pre-hospital issues. There are a few gaps (e.g. what role did the surgeons gaining emergency credentialing play at other hospitlas; what pre-event training did the hospitalists have, etc), and some of the operational details are sparse, but in general I found the report sound and a good example of what we should endeavor to do in future events. "Lessons learned" are still those we haven't learned yet from previous events, i.e. communications disconnects, failure to effectively use HICS, delays in opening an EOC, questionable value of triage tags, obstacles to patient tracking and dissonance between healthcare and police disaster plans for example. Nevertheless, it seems clear that pre-event coordination, planning and exercises paid handsome dividends. </FONT></SPAN></DIV>
<DIV><SPAN class=124275700-31082007><FONT face=Arial></FONT></SPAN> </DIV>
<DIV><SPAN class=124275700-31082007><FONT face=Arial> Two "medical" aspects of the report bear special attention I think: 1) The discussion of post-event psychological support for healthcare personnel is directed at pre-hospitl providers and ignores the needs of hospital staff; 2) The recommendation to include hospitalists more prominantly in a disaster response plan is a good one. Hospitalist and house physician staff are not generally target groups for disaster training or involved in disaster drills (especially at facilities which are resident heavy), and in my experience an often overlooked resource. </FONT></SPAN></DIV>
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<DIV><SPAN class=124275700-31082007><FONT face=Arial><SPAN class=124275700-31082007><FONT face=Arial>I suspect this report will be the subject of discussion and debate in the near future as new aspects and insights emerge.</FONT></SPAN></FONT></SPAN></DIV>
<DIV><SPAN class=124275700-31082007><FONT face=Arial></FONT></SPAN><SPAN class=124275700-31082007><FONT face=Arial></FONT></SPAN> </DIV>
<DIV><SPAN class=124275700-31082007><FONT face=Arial>The full report can also be seen at: </FONT><A href="http://www.governor.Virginia.gov/TempContent/techPanelReport.cfm" target=1><FONT face=Arial>http://www.governor.Virginia.gov/TempContent/techPanelReport.cfm</FONT></A></SPAN></DIV>
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<DIV><SPAN class=124275700-31082007><B><FONT face=Arial color=#003365>
<P align=left>KEY FINDINGS</P></FONT>
<P align=left><FONT face=Arial>Positive Lessons</FONT></P></B></DIV>
<DIV align=left><FONT face=Arial>The EMS responses to the West Ambler Johnston<SPAN class=124275700-31082007> </SPAN>residence hall and Norris Hall occurred in a<SPAN class=124275700-31082007> </SPAN>timely manner.<SPAN class=124275700-31082007> </SPAN>Initial triage by the two tactical medics accompanying</FONT></DIV>
<DIV align=left><FONT face=Arial>the police was appropriate in identifying<SPAN class=124275700-31082007> </SPAN>patient viability.</FONT></DIV>
<DIV align=left><FONT face=Arial></FONT> </DIV>
<DIV align=left><FONT face=Arial>The application of a tourniquet to control a<SPAN class=124275700-31082007> </SPAN>severe femoral artery bleed was likely a lifesaving<SPAN class=124275700-31082007> </SPAN>event.</FONT></DIV>
<DIV align=left><FONT face=Arial></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>Patients were correctly triaged and transported<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>to appropriate medical facilities.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>The incident was managed in a safe manner,<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>with no rescuer injuries reported.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>Local hospitals were ready for the patient surge<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>and employed their NIMS ICS plans and managed<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>patients well.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>All of the patients who were alive after the<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>Norris Hall shooting survived through discharge<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>from the hospitals.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>Quick assessment by a hospitalist of emergency<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>department patients waiting for disposition<SPAN class=124275700-31082007> </SPAN>helped with preparedness and patient flow at<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>one hospital.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>The overall EMS response was excellent, and<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>the lives of many were saved.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>EMS agencies demonstrated an exceptional<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>working relationship, likely an outcome of<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>interagency training and drills.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV><FONT size=2>
<DIV align=left><STRONG><FONT face=Arial>Areas for Improvement</FONT></STRONG></DIV>
<DIV align=left><STRONG><FONT face=Arial></FONT></STRONG> </DIV></FONT>
<DIV align=left><FONT face=Arial><FONT size=2>All EMS units were initially dispatched by the<SPAN class=124275700-31082007> </SPAN>Montgomery County Communications Center to<SPAN class=124275700-31082007> </SPAN>respond to the scene; this was contrary to the<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>request.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>There was a 4-minute delay between VTRS<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>monitoring the incident (9:42 a.m.) on the police<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>radio and its being dispatched by police (9:46</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2>a.m.).</FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>Virginia Tech police and the Montgomery<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>County Communications Center issued separate<SPAN class=124275700-31082007> </SPAN>dispatches. This can lead to confusion in an<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>EMS response.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><FONT size=+0><FONT size=2>BVRS was initially unaware that VTRS had<SPAN class=124275700-31082007> </SPAN></FONT></FONT><FONT size=2>already set up an EMS command post. This<SPAN class=124275700-31082007> </SPAN>could have caused a duplication of efforts and<SPAN class=124275700-31082007> </SPAN>further organizational challenges. Participants<SPAN class=124275700-31082007> </SPAN>interviewed noted that once a BVRS officer<SPAN class=124275700-31082007> </SPAN>reported to the EMS command post, communications between EMS providers on the scene<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>improved.</FONT> </FONT>
<P align=left><FONT face=Arial><FONT size=2>Because BVRS and VTRS are on separate primary<SPAN class=124275700-31082007> </SPAN>radio frequencies, BVRS reportedly did<SPAN class=124275700-31082007> </SPAN>not know where to stage their units. In addition,<SPAN class=124275700-31082007> </SPAN>BVRS units were reportedly unaware of when<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>the police cleared the building for entry.</FONT></FONT></P>
<P align=left><FONT face=Arial><FONT size=2>Standard triage tags were used on some<SPAN class=124275700-31082007> </SPAN>patients but not on all. The tags are part of the<SPAN class=124275700-31082007> </SPAN>Western Virginia EMS Trauma Triage Protocol.<SPAN class=124275700-31082007> </SPAN>Their use could have assisted the hospitals with<SPAN class=124275700-31082007> </SPAN>patient tracking and record management. Some<SPAN class=124275700-31082007> </SPAN>patients were identified by room number in the<SPAN class=124275700-31082007> </SPAN>emergency department and their records<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>became difficult to track.</FONT></FONT></P>
<P align=left><FONT face=Arial><FONT size=2>The police order to transport the deceased under<SPAN class=124275700-31082007> </SPAN>emergency conditions from Norris Hall to the<SPAN class=124275700-31082007> </SPAN>medical examiners office in Roanoke was<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>inappropriate.</FONT></FONT></P>
<P align=left><FONT face=Arial><FONT size=2>The lack of a local EOC and fully functioning<SPAN class=124275700-31082007> </SPAN>RHCC may lead to communications and operational<SPAN class=124275700-31082007> </SPAN>issues such as hospital liaisons being sent<SPAN class=124275700-31082007> </SPAN>to the scene. If each hospital sent a liaison to<SPAN class=124275700-31082007> </SPAN>the scene, the command post would have been<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>overcrowded.</FONT></FONT></P>
<P align=left><FONT face=Arial><FONT size=2>A unified command post should have been<SPAN class=124275700-31082007> </SPAN>established and operated based on the NIMS<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>ICS model.</FONT></FONT></P>
<P align=left><FONT face=Arial><FONT size=2>Failure to open an EOC immediately led to<SPAN class=124275700-31082007> </SPAN>communications and coordination issues during<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>the incident.</FONT></FONT></P>
<P align=left><FONT face=Arial><FONT size=2>Communications issues and barriers appeared<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>to be frustrating during the incident.</FONT></FONT></P>
<P align=left><FONT color=#003365><STRONG><FONT face=Arial size=2>RECOMMENDATIONS</FONT></STRONG></FONT></P>
<P align=left><FONT face=Arial><FONT size=2><STRONG><EM><SPAN class=124275700-31082007>IX-1</SPAN> Montgomery County, VA should</EM></STRONG><SPAN class=124275700-31082007> </SPAN><STRONG><EM>develop a countywide emergency medical<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>services, fire, and law enforcement communications<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>center to address the issues of<SPAN class=124275700-31082007> </SPAN></EM></STRONG></FONT><STRONG><EM><FONT size=2>interoperability and economies of scale.</FONT></EM></STRONG></FONT></P></DIV>
<DIV align=left><FONT size=2><FONT face=Arial><STRONG><EM>IX-2 A unified command post should be<SPAN class=124275700-31082007> </SPAN>established and operated based on the</EM></STRONG><SPAN class=124275700-31082007><STRONG><EM> </EM></STRONG><FONT size=2><STRONG><EM>National Incident Management System </EM></STRONG><STRONG><EM>Incident Command System model. </EM></STRONG></FONT><FONT size=2>For this incident, law enforcement would have been the lead agency.</FONT></SPAN></FONT></FONT></DIV>
<DIV align=left><FONT size=+0><SPAN class=124275700-31082007><STRONG><EM><FONT face=Arial></FONT></EM></STRONG> </DIV>
<DIV align=left><FONT face=Arial><FONT size=2><STRONG><EM>IX-3 Emergency personnel should use the<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>National Incident Management System<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>procedures for nomenclature, resource typing<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>and utilization, communications,<SPAN class=124275700-31082007> </SPAN></EM></STRONG></FONT><STRONG><EM><FONT size=2>interoperability, and unified command.</FONT></EM></STRONG></FONT></DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2></FONT></EM></STRONG> </DIV>
<DIV align=left><FONT face=Arial><FONT size=2><STRONG><EM>IX-4 An emergency operations center must<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>be activated early during a mass casualty<SPAN class=124275700-31082007> </SPAN></EM></STRONG></FONT><STRONG><EM><FONT size=2>incident.</FONT></EM></STRONG></FONT></DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2></FONT></EM></STRONG> </DIV>
<DIV align=left><FONT face=Arial><STRONG><EM><FONT size=+0><FONT size=2>IX-5 Regional disaster drills should be<SPAN class=124275700-31082007> </SPAN></FONT></FONT></EM></STRONG><FONT size=2><STRONG><EM>held on an annual basis. </EM></STRONG>The drills should<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>include hospitals, the Regional Hospital Coordinating</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial><FONT size=2>Center, all appropriate public safety and<SPAN class=124275700-31082007> </SPAN>state agencies, and the medical examiner’s<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>office. They should be followed by a formal postincident</FONT></FONT></DIV>
<DIV align=left><FONT size=2><FONT face=Arial>evaluation.<SPAN class=124275700-31082007> </SPAN></FONT></FONT></DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2><SPAN class=124275700-31082007></SPAN></FONT></EM></STRONG> </DIV>
<DIV align=left><FONT size=2><FONT face=Arial><STRONG><EM>IX-6 To improve multi-casualty incident<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>management, the Western Virginia Emergency<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>Medical Services Council should<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>review/revise the Multi-Casualty Incident<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>Medical Control and the Regional Hospital<SPAN class=124275700-31082007> </SPAN></EM></STRONG><STRONG><EM>Coordinating Center functions.<SPAN class=124275700-31082007> </SPAN></EM></STRONG></FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2><STRONG><EM><SPAN class=124275700-31082007></SPAN></EM></STRONG></FONT> </DIV>
<DIV align=left><FONT size=+0><FONT size=2><SPAN class=124275700-31082007></SPAN></FONT></FONT><FONT face=Arial><FONT size=2><STRONG><EM>IX-7 Triage tags, patient care reports, or<SPAN class=124275700-31082007> </SPAN>standardized Incident Command System<SPAN class=124275700-31082007> </SPAN>forms must be completed accurately and<SPAN class=124275700-31082007> </SPAN>retained after a multi-casualty incident.</EM></STRONG><SPAN class=124275700-31082007> </SPAN>They are instrumental in evaluating each component<SPAN class=124275700-31082007> </SPAN></FONT><FONT size=2>of a multi-casualty incident.</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2></FONT> </DIV>
<DIV align=left><FONT face=Arial><STRONG><EM><FONT size=+0><FONT size=2>IX-8 Hospitalists, when available, should<SPAN class=124275700-31082007> </SPAN></FONT></FONT></EM></STRONG><STRONG><EM><FONT size=2>assist with emergency department patient<SPAN class=124275700-31082007> </SPAN></FONT></EM></STRONG><STRONG><EM><FONT size=2>dispositions in preparing for a multicasualty</FONT></EM></STRONG></FONT></DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2>incident patient surge.</FONT></EM></STRONG></DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2></FONT></EM></STRONG> </DIV>
<DIV align=left><FONT face=Arial><STRONG><EM><FONT size=+0><FONT size=2>IX-9 Under no circumstances should the<SPAN class=124275700-31082007> </SPAN></FONT></FONT></EM></STRONG><STRONG><EM><FONT size=2>deceased be transported under emergency<SPAN class=124275700-31082007> </SPAN></FONT></EM></STRONG><FONT size=2><STRONG><EM>conditions. </EM></STRONG>It benefits no one and increases the</FONT></FONT></DIV>
<DIV align=left><FONT face=Arial size=2>likelihood of hurting others.</FONT></DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2></FONT></EM></STRONG> </DIV>
<DIV align=left><FONT face=Arial><STRONG><EM><FONT size=+0><FONT size=2>IX-10 Critical incident stress management<SPAN class=124275700-31082007> </SPAN></FONT></FONT></EM></STRONG><STRONG><EM><FONT size=2>and psychological services should continue<SPAN class=124275700-31082007> </SPAN></FONT></EM></STRONG><STRONG><EM><FONT size=2>to be available to EMS providers as needed.</FONT></EM></STRONG></FONT></DIV>
<DIV align=left> </DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2></FONT></EM></STRONG> </DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2></FONT></EM></STRONG> </DIV>
<DIV align=left><STRONG><EM><FONT face=Arial size=2>
<DIV><SPAN class=124275700-31082007><FONT face=Helvetica size=3>Jeffrey Hammond MD, MPH</FONT></SPAN></DIV>
<DIV><SPAN class=124275700-31082007><FONT face=Helvetica size=3>Chief, Trauma/Surgical Critical Care</FONT></SPAN></DIV>
<DIV><SPAN class=124275700-31082007><FONT face=Helvetica size=3>Robert Wood Johnson Medical School</FONT></SPAN></DIV>
<DIV><SPAN class=124275700-31082007><FONT face=Helvetica size=3>New Brunswick, NJ</FONT></SPAN></DIV></FONT></EM></STRONG></DIV>
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