Mass casualty influx: triage, hospital capacity and neutrality of care

Total: 5 red (P2, P5, P6, P8, P12), 3 yellow (P4, P9, P11), 3 green (P1, P7, P10), 1 black (P3).

Vigilance: P9: penetrating abdominal wound, risk of internal bleeding, to be reassessed very frequently and placed at the top of the yellow list for theatre; P10: blast injury with difficulty breathing, suspected blast lung injury, to be monitored and reassessed (may become red); P11: 32-week pregnancy, obstetric assessment and fetal monitoring, risk of placental abruption; P7: extent and depth of the burns, airway if there are facial burns. Triage is a repeated process: every patient is reassessed.

Occupancy: surgery 846 / (30 × 30) = 94%; medicine 690 / (25 × 30) = 92%; paediatrics 720 / 750 = 96%. Average length of stay: surgery 846 / 141 = 6.0 days; medicine 690 / 115 = 6.0 days; paediatrics 720 / 180 = 4.0 days. Average beds occupied: surgery 28.2 (1.8 free), medicine 23 (2 free), paediatrics 24 (1 free): about 5 free beds.

Projection for 30 casualties: red 30 × 5/12 = 12.5, i.e. 13; yellow 30 × 3/12 = 7.5, i.e. 8; green 7.5; dead 2.5. Beds: red and yellow patients to be admitted: about 20 to 21, for 5 free beds: about 16 beds short. Theatre: 0.7 × 12.5 + 0.4 × 7.5 = 8.75 + 3 = 11.75, i.e. 12 operations, × 1.5 h = 18 h of theatre time for a single theatre and a single surgeon. Blood: 0.7 × 12.5 × 2 = 17.5, i.e. 18 units for 14 in stock: a shortfall of at least 4 units, with no reserve.

Decisions: (1) erect the 20-bed tent immediately and place stable patients or monitored yellow patients there, with dedicated staff; (2) early discharge of stable patients and transfer of chronic cases; (3) cancel the scheduled operations at 16:00; (4) damage control surgery (short life-saving procedures, delayed definitive surgery) to reduce theatre time; prioritisation for theatre by a single decision-maker; (5) call in off-duty staff (call-back plan) and organise teams in shifts, as the surgeon cannot operate for 18 h in a row; request surgical support and organise transfers to other facilities if access allows; (6) mobilise the volunteer donors now (testing and collection) for at least 10 units; rational use of blood.

Command: activate the mass casualty plan; an incident coordinator (yourself or the medical director) in a command post, separate from the triage doctor; situation updates every hour; one person responsible for each function (triage, red zone, theatre, inpatient care, logistics, security, communication).

Zones: a single entrance with triage outside; red zone in the resuscitation room; yellow zone; green zone set apart (with a nurse, reassessment); an area for the dead, dignified and out of sight; one-way flow towards the theatre and the wards.

Security and families: keep the crowd away from the entrance with the help of community leaders and, if necessary, the authorities; family information point outside, with a dedicated staff member and updated lists; access control; no-weapons rule inside the hospital.

Registration: wristband and number for each patient, including unidentified ones; single register (category, time, destination); list of the dead and identification.

Communication: ask the journalist to stop filming patients in the corridor (dignity, consent, security); a single spokesperson; regular information for staff; report to coordination. Logistics: tent, equipment, water, meals for staff; planning for staff relief and psychological support for staff after the influx.

Sample answer: "Situation report no. 1, 19:00. 14:10: explosion at Malakal market. Influx of casualties since 14:35; 12 patients received by 15:30 (5 red, 3 yellow, 3 green, 1 dead on arrival), about 30 expected according to the authorities. Mass casualty plan activated; scheduled operations cancelled; 20-bed tent erected. Capacity: 1 theatre and 1 surgeon for an estimated need of 12 operations (18 h of theatre time); 14 units of blood for an estimated need of 18: collection from volunteer donors under way. Needs: surgical and anaesthesia support, trauma kits, transfer options. Security: crowd at the entrance, under control. Next report: tomorrow 08:00, with final figures." The actual figures (total number received, deaths, operations performed) replace the estimates at the time of sending.

Principles: the order of care is determined solely by medical need (impartiality, medical ethics): the commander is treated like any other casualty, according to his category, without discrimination in either direction. Weapons must not enter the hospital, to protect patients, staff and the neutral nature of the facility.

Conduct: the safety of staff and patients comes first: no physical confrontation. The coordinator, or the designated trained person, speaks calmly to the group's leader, away from the patients: explains that his commander is stable, that he is being cared for (examination, pain relief, dressing immediately, regular reassessment) and that he will be operated on as soon as the casualties in danger of death have been; reminds him that the hospital treats everyone, including their wounded, thanks to this rule; asks that weapons be left outside or that the armed men wait outside the compound. If the threat becomes direct and immediate, people's lives come before the principle: the decision is documented, reported and analysed.

Afterwards: immediate security incident report to coordination; reporting according to internal procedures and, if relevant, to the WHO Surveillance System for Attacks on Health Care; subsequent dialogue with the group's hierarchy on respect for health facilities; support for staff.