Unfortunately, in many large cities—and even smaller ones—medical emergencies involving a large number of casualties have become a fact of life in America. What is also emerging as these tragedies unfold year after year is the increasingly critical role radiology is playing in managing the medical care needed following such traumatic incidents.
“Radiology plays such an integral role in the work up and treatment of trauma patients,” said Mark Wilson, M.D., professor and chief of radiology at San Francisco General Hospital, who was on duty in the aftermath of the Asiana Airlines disaster at San Francisco International Airport on July 6, 2013. “That really came to light here.”
That day, Dr. Wilson was visiting friends in Lake Tahoe and decided to make a 3 ½- hour dash back to San Francisco after learning of the crash. By the time he got to the hospital, the first wave of victims had already gone through the emergency department (ED). Along with Dr. Wilson, four other attending radiologists were on-site along with three residents and a number of radiologic supervisors and technologists, making it possible for the department to scale up to handle the initial wave of 53 passengers and crew brought to the hospital’s trauma center that day.
The big questions, Dr. Wilson said, became, “What do we do with the patients after they are imaged? How do we triage them? How do we decide what kind of treatment they need?” Those decisions were complicated by the fact that trauma physicians were chasing down radiologists to review imaging findings in person.
That’s when inspiration hit: Why not make the radiology reading room the nerve center for reviewing patient imaging and clinical data? So, at around 5 p.m. that day, radiologists, trauma team physicians representing the ED, trauma surgery, neurosurgery, neurology, pediatrics and orthopedics, as well as several high-level nurses, gathered around a PACS station and began reviewing imaging and clinical data for each patient. Every imaging study on every patient was reviewed by one of the radiology attendings at that time.
“We then decided how to triage the patient,” Dr. Wilson said. “Would the patient go to the operating room, be admitted to the hospital or be discharged?” The team faced other decisions including whether a parent(s) was available to make a decision in case a child needed to undergo surgery.
“All those decisions were made at that one moment and it was very impressive to see everyone working together,” Dr. Wilson said. “At our trauma center, essentially every patient has to come through radiology for something, so it made sense for radiology to be the nexus for all this activity.”
The approach was so successful it will be codified as an ongoing procedure at San Francisco General in times of disaster. Hopefully, the new process won’t be necessary any time soon, but as Dr. Wilson pointed out, “this is earthquake country, so anything can happen at anytime.”
At 3 a.m. on July 20, 2012, James P. Borgstede, M.D., professor of radiology and vice-chair for professional services, clinical operations and quality at the University of Colorado School of Medicine, Denver, was awakened by a phone call informing him that the ED was about to receive casualties from a mass shooting at an Aurora movie theater showing of the “The Dark Knight Rises.”
A number of victims made their way to the ED, some by ambulance and some loaded into police cars. In one case, Dr. Borgstede said, a man ran from the movie theater all the way to the hospital with what turned out to be a relatively minor bullet wound. In all, the radiology department ended up imaging 23 victims in the aftermath of the shooting.
The event re-emphasized something physicians there already knew, Dr. Borgstede said. “Radiology plays such an integral role in decision making,” he said. “To a large extent the ED was waiting for our reads on these patients so they could decide how to triage them.”
While it was certainly a trying time, “everyone in the ED and radiology worked very efficiently,” Dr. Borgstede said. In all, the radiology department performed a large volume of CT and radiographs, but was able to keep up with the workload. Still, Dr. Borgstede said, there were lessons learned.
For example, in those early morning hours when it became clear that he and another attending radiologist could handle the workload, Dr. Borgstede refrained from calling in any more staff.
“I knew that some of these patients were going into the operating room and that when they came out they were going to need further imaging,” Dr. Borgstede recalled. “I wanted to keep my staff fresh and elected not to call in anyone else. Sure enough, around 7 a.m., patients started coming back from the OR for more imaging and I had fresh staff ready. It’s important to have a measured response.”
All in all, everything went very well, Dr. Borgstede said. “Every patient who made it to the ED survived—we didn’t lose anyone.” And even though medical professionals are trained to handle such calamities, “You can always learn a lesson from an actual disaster,” Dr. Borgstede added.
As a Level 1 verified facility, the trauma center at MedStar Washington Hospital Center is a primary patient destination for medical emergencies involving mass casualties.
Those incidents include the crash of American Airlines Flight 77 into the Pentagon on 9/11 and the Washington Metro train collision in 2009 that killed nine people and injured more than 80. Most recently, the hospital treated the victims of the September 16, 2013, shooting spree at the Washington Navy Yard that ended in the deaths of 12 people and the wounding of eight others, including three by gunfire.
The three gunshot victims were brought to MedStar Washington Hospital Center, which is equipped with a Lodox Statscan Critical Imaging System—one of only a handful in the U.S.—capable of taking head-to-toe X-ray images in 13 seconds. James Jelinek, M.D., chairman of the hospital center’s Department of Radiology, said the scanner is particularly useful for victims who have been sprayed with gunfire or suffered shrapnel wounds from explosive devices like improvised explosive devices (IEDs). Medstar Washington Hospital Center is the only adult Level 1 facility verified by the American College of Surgeons, Dr. Jelinek said.
The scanner gives the trauma team a maximum diagnosis as quickly as possible, allowing physicians to treat patients in the “golden hour”—the time in which there is the greatest likelihood that treatment can prevent death.
“That first hour is critical,” Dr. Jelinek said. “It’s all about speed. In a large hospital any one patient could need a general surgeon, a neurosurgeon, a thoracic surgeon and an orthopedic surgeon. When you have that whole body X-ray within 15 seconds, you’re able to make those images available immediately.”
Although the hospital treated just three victims from the Naval Yard shootings, the facility did implement some new emergency procedures. For example, depending on the number of expected casualties, the trauma center can cancel routine imaging procedures to ensure that scanners are readily available. In this case, Dr. Jelinek said, some patients were diverted away from CT scanners near the trauma center to free up capacity.
“We were expecting more,” he said. “But, as our chief medical officer, Dr. Janis Orlowski, said, we’ve become the experts when it comes to this, and we’d like to see someone put us out of business.”
While catastrophes can demonstrate the key role radiology plays in emergencies, disasters can also end up damaging radiology departments. That happened last October in New York when the impact of Hurricane Sandy caused NYU Langone Medical Center’s imaging department to lose access to millions of dollars in imaging equipment and supplies.
The first order of business was to get imaging services back up and running as quickly as possible, so in the days after the hurricane, staff worked feverishly to recover and move imaging equipment and supplies into temporary spaces, said Michael Recht, M.D., chair of the medical center’s radiology department.
Within days, outpatient ultrasound services were available in a building four blocks from the main hospital previously used for offices and research. Radiologists were also able to use MR scanners reserved for dedicated research for clinical purposes. “Our first response was to get imaging services back up and running so we could serve patients,” Dr. Recht said.
While it was apparent that NYU Langone would need a new imaging center and equipment, the damage gave the hospital a unique chance to reinvent its processes. “What we need to do now is build the best imaging center we can,” he said. “Our goal is to utilize all of the advantages of IT infrastructure that have been developed over the last several years and make this center incredibly patient- and employee-centric.” Improvements include an electronic “grease board” that allows technologists to view the department in real time and to triage patients in such a way that improves department efficiency. The hospital is also performing imaging utilization studies.
There is already evidence that the new approach is working. Before the hurricane, NYU Langone had three CT scanners available for outpatient imaging, but lost one in the storm. “Even down one machine we’re doing more CTs now than before the hurricane,” Dr. Recht said. “And we’re doing it significantly more efficiently.”
The team that previously used the lost CT scanner has now been incorporated into the two other teams, allowing staff to provide better, more efficient service. Radiology is moving patients through CT exams so quickly, Dr. Recht said, that the department has increased its on-time performance rate to nearly 95 percent—“significantly better than our previous rate.”
Other efficiencies are also being achieved. For example, the department—using the electronic grease board—can track how much time has lapsed since a patient had ingested contrast material, allowing radiology staff to plan more efficiently and scan patients faster.
The disaster also prompted a renewed perspective among hospital staff, Dr. Recht said.
“We came to the realization that people are more important than machines,” Dr. Recht said. “That’s the most important lesson we learned.”
View a video covering the impact, evacuation and recovery of NYU Langone Medical Center in New York in the wake of Hurricane Sandy at http://bit.ly/1hDBQqi.
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