Outcome quality in the management of multiple casualty incidents

Sir, In a recent study, Kuisma et al. (1) described the outcome of 263 patients involved in small multiple casualty incidents in Helsinki. Their distribution of trauma deaths seems to approximate Trunkey’s trimodal distribution (3). This trimodal distribution has been used to audit the outcome quality of major incident management (4): The first mode (immediate death, seconds to minutes after the impact) is not influenced by the emergency medical system, while the second (early death, minutes to hours after the accident) and third modes (late deaths, days to weeks after the event) can be reduced by good trauma care. The high quality of a trauma system is indicated by a low number of (potentially preventable) early and late deaths compared with immediate mortality (preventable, e.g. by seatbelt use, but not salvageable by emergency care). Table 1 compares the results of different trauma systems. The Ramstein air show incident and the ICE high-speed train derailment (Eschede, Germany) are generally considered examples of poor and excellent major incident management. The outcome achieved by the Emergency Medical Service of Helsinki is in between the German and American results. This reflects the composition of the Helsinki service: many incidents are dealt with by paramedics alone at an advanced life support level, as in the USA, but there is also some medical involvement (mobile intensive care units, trauma helicopter) along the German/French model. The international comparison strengthens Kuisma et al.0s conclusion of the beneficial effect of medical leadership in pre-hospital care.