On December 2, 2015, a terror attack in the city of San Bernardino, California killed 14 Americans and injured 22 in the deadliest attack on U.S. soil since September 11, 2001. Although emergency personnel and law enforcement officials frequently deal with multi-casualty incidents (MCIs), what occurred that day required an unprecedented response. Most of the severely injured victims were transported to either Loma Linda University Medical Center (LLUMC) or Arrowhead Regional Medical Center (ARMC). These two hospitals operate two designated trauma centers in the region and played crucial roles during the massive response that followed this attack. In an effort to shed a light on our response to others, we provide an account of how these two teaching hospitals prepared for and coordinated the medical care of these victims.

In general, both centers were able to quickly mobilize large number of staff and resources. Prior disaster drills proved to be invaluable. Both centers witnessed excellent teamwork and coordination involving first responders, law enforcement, administration, and medical personnel from multiple specialty services. Those of us working that day felt safe and protected. Although we did identify areas we could have improved upon, including patchy communication and crowd-control, they were minor in nature and did not affect patient care.

MCIs pose major challenges to emergency departments and trauma centers across the country. Responding to such incidents requires an ever-evolving approach as no two incidents will present exactly alike. It is our hope that this article will foster discussion and lead to improvements in  management of future MCIs.

Introduction: Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in grossmorbidity and mortality if not treated in its early stages. The Laboratory Risk Indicator for Necrotizing Fasciitis(LRINEC) score is used to distinguish NF from other soft tissue infections such as cellulitis or abscess. Thisstudy analyzed the ability of the LRINEC score to accurately rule out NF in patients who were confirmed tohave cellulitis, as well as the capability to differentiate cellulitis from NF.

Methods: This was a 10-year retrospective chart-review study that included emergency department (ED)patients ≥18 years old with a diagnosis of cellulitis or NF. We calculated a LRINEC score ranging from0-13 for each patient with all pertinent laboratory values. Three categories were developed per the originalLRINEC score guidelines denoting NF risk stratification: high risk (LRINEC score ≥8), moderate risk (LRINECscore 6-7), and low risk (LRINEC score ≤5). All cases missing laboratory values were due to the absence ofa C-reactive protein (CRP) value. Since the score for a negative or positive CRP value for the LRINEC scorewas 0 or 4 respectively, a LRINEC score of 0 or 1 without a CRP value would have placed the patient in the“low risk” group and a LRINEC score of 8 or greater without CRP value would have placed the patient in the“high risk” group. These patients missing CRP values were added to these respective groups.

Results: Among the 948 ED patients with cellulitis, more than one-tenth (10.7%, n=102 of 948) weremoderate or high risk for NF based on LRINEC score. Of the 135 ED patients with a diagnosis of NF, 22patients had valid CRP laboratory values and LRINEC scores were calculated. Among the other 113 patientswithout CRP values, six patients had a LRINEC score ≥ 8, and 19 patients had a LRINEC score ≤ 1. Thus, atotal of 47 patients were further classified based on LRINEC score without a CRP value. More than half of theNF group (63.8%, n=30 of 47) had a low risk based on LRINEC ≤5. Moreover, LRINEC appeared to performbetter in the diabetes population than in the non-diabetes population.

Conclusion: The LRINEC score may not be an accurate tool for NF risk stratification and differentiationbetween cellulitis and NF in the ED setting. This decision instrument demonstrated a high false positive ratewhen determining NF risk stratification in confirmed cases of celulitis and a high false negative rate in casesof confirmed NF.