**4.1 What happens when the supply of global resources outweighs the demand be it oxygen or human resources?**

Our healthcare professionals have lost their lives from being on the frontline and burn out has become more evident than before [6, 17]. Training of new healthcare professionals have also been hampered in the past 2 years of the pandemic because all they now know is how to manage a COVID patient. Airway skills have become a selective skill reserved for anesthetist and the most senior personnel at the expense of the junior doctors that have started out [5, 8].

To confound matters while experiencing the COVID pandemic we needed to deal with a disaster (mass evacuation of a hospital due to a fire), this resulted in the hospital closure and the majority of patients being redirected to our facility. This was even further confounded by enduring a MCI when civil unrest led to a flood of patients in our trauma unit.

The evacuation of a hospital due to a fire was largely driven by healthcare professionals selflessly moving patients (immobile patients, in their beds) to evacuations points in smoke covered corridors with no oxygen supplies while emergency fire personnel battled the blaze. The loss of a health facility compounded the effects of a pandemic on the loco regional facilities.

With this said the loco regional functional hospitals can change their triage processes and therefore certain hospitals can only accept P1 and other hospitals can accept P2 and P3 patients thereby distributing the load [13]. Prehospital services and healthcare facilities (receiving and disaster area) should have effective communication for this to be feasible, disaster committees should be established in the sending and receiving facilities. Efficient communication is integral to the management of any disaster or MCI [15].

Our facility was on the receiving end of the fire, 150 patients were evacuated to our facility without communication to the team onsite. Both the on- call trauma and acute care surgical units had to manage current acute patients in their respective areas as well as the patients evacuated to their facility. The discrepancy here was that a disaster team should have been established at the receiving hospital to manage evacuated patients. This should not have been the responsibility of the on-call trauma and acute care surgical units. Emergency services that transported patients to our facility were also used to transport patients to the relevant wards as we did not have the capacity (porters) available to do this, therefore the need for non-healthcare personnel should also be considered e.g. cleaners, porters etc. [13].

The burden on the facility was significant as bed capacity was reduced due to reallocations for COVID patients. Unique to South Africa is that a large percentage of our population lives below the poverty line in informal settlements, which are quite densely populated, you could have at least ten people living in a 1-bedroom shack (informal dwelling) [18]. Therefore, our patients could not self- isolate at home and a facility was opened for this specific reason NASREC, previously an events area. This was specific for patients not requiring hospital admission and no oxygen requirements. It was purely for patients that were unable to self- isolate safely at home. This was an attempt to lessen the load on secondary and tertiary level institutes.

Going back to the MCI specific to trauma the riots from the civil unrest. This event was not anticipated and therefore could not be planned for especially during a covid pandemic and with the neighboring hospital trauma unit closed due to a fire. We experienced many bottle necks for example CT scanners availability and theater capacity despite more staff being mobilized to respond to the disaster. We were also unable to mobilize staff from outside the hospital as it was not safe to travel to the hospital. Therefore, disaster committees should focus on training, education and debriefing, treatment protocols that are disease or injury specific and should be aim at a level appropriate for all heath care specialist not just trauma surgeons or infectious disease specialists [13, 15].

Due to the sheer burden of P3 patients, we developed a strategy for quick reference as to the patient's condition and progress of management. Labels were placed on patients and were used to indicate injuries, results of investigations and what the patients were awaiting as a quick reference with no need to go locate the patient file. This is planning whilst one is in the midst of a MCI but was successful and will be used for planning of future MCI within our institution. Therefore, a response to a MCI is an ongoing process.

With regards to training over the last 2 years. Interns have mostly been exposed to the management of covid patients which has largely been protocol based. They have missed opportunities related to procedures specifically that of airway management which many have reserved for the most senior staff [5, 10]. In the surgical spectrum, elective procedures have been stopped thus decreasing exposure of surgical trainees. Despite discrepancies in training and being reallocated to manage patients that is not within your field of expertise, burnout has come to the fore [17, 19, 20]. Many healthcare personnel have experienced burnout largely due to the pandemic/mass casualty spanning 2 years currently and leaving no time to debrief or recuperate after each wave [17]. Human resources are a scarce commodity as well as being constraints by a budget for monetary compensation, as seen by healthcare professionals working long hours risking their lives as well as that of the household [15].

Command and control of a mass casualty or disaster must consist of healthcare professionals that are clinically active, to know what is happening on the floor as well as management and politicians and policy makers. These committees should be established locally, regionally, nationally, and even internationally depending on the nature of the MCI [13, 14]. Elective theaters, emergency theaters, ICU, physicians, surgeons, allieds, nursing staff, porters, radiographers, and radiology form integral components of the response team to these events. Special types of patients should also be considered especially those that are time dependent such as cancer patients [13]. Once a SOP (standard operating procedure) was established for the covid response and the relocation of patients due to the fire. Chemotherapy and radiotherapy as well as surgical procedures for patients with malignancies were prioritized. Oncological services such as chemo- and radiotherapy were halted transiently as they were only available at the hospital that was closed due to the fire, however rapid communication with other hospitals and the fast tracking of the establishment of a chemotherapy service at our hospital assisted with this issue. Transport for these patients were also arranged to these facilities, not to impede these patients from receiving oncological services. Communication needs to be bi-directional top down and bottom up, so that protocols are practical and feasible with real-time feedback [13].

Coccolini et al. defined four phases in disaster management namely mitigation, planning, response, and recovery. Mitigation, this is the preemptive planning stage to reduce the effect of MCIs however the protocols of COVID was ever changing (PPE, isolation days, lockdown periods, economics changing policy) and therefore the planning stage is an evolving stage [2, 3, 8]. Planning requires practice of

*DOI: http://dx.doi.org/10.5772/intechopen.103971 Trauma Resuscitation, Mass Casualty Incident Management and COVID 19…*

protocols for feasibility however there was no time with the pandemic to practice, it's been an ongoing practice session for the past 2 years as such good communication (local, regional, national, international, NPOs) has become imperative [15]. The response phase entails activation, notification, and initial response. Therefore, the need to identify a state of disaster and activation of the relevant teams, and a central Command structure (local, regional, or national) [15]. The major issues with the covid pandemic and its associated disaster management is the ever-changing protocols resulting in the planning, practice and response phases never ending. You also need buy in from all stake holders, however medical personnel have also become hesitant in accepting these ever-changing protocols. As healthcare providers we have lost the trust of the global population by changing protocols largely due to the lack of understanding of the research process [2, 8, 10, 15]. The final stage is recovery, which entails staff debriefing, however with the many waves of the pandemic we have not reached this phase in 2 years, resulting in burn out and significant strain on the mental health of many healthcare professionals [15, 17]. With these everchanging protocols of covid and a prolonged MCI, **do we still utilize triage principles as before, or do we adapt them to the current pandemic?**
