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Disaster management
- 1. Disaster Dr Stephanie Schlueter 19th December 2013 SCGH
- 2. Outline • General Principles Definitions & Classifications Epidemiology • Emergency Department Process- Code BROWN • Pre-Hospital Management • Specific injuries Blast Crush Compartment syndrome Burns
- 3. Case 2245h Phone Call from SJA • 20 y/o male head injury, GCS 3, HR 120, sBP 100 • Major incident at a dance festival • Collapse of scaffolding and suspended speaker system into Mosh Pit • ETA- 15 minutes Outline your approach
- 4. Disasters in 2013 • November 2013 Typhoon “Yolanda” > 6000 deaths > 25.000 injured • September 2013 Westgate Shopping Mall- Mass Shooting 72 deaths > 200 injured • August 2013 Ghouta Chemical Attack- Syrian civil war 1729 deaths 3600 presentations to 3 surrounding hospitals within 3 hours • April 2013 Boston Marathon Bombings 3 deaths 264 injured
- 5. General Principles Definitions Disaster …”a serious disruption of the functioning of society, causing widespread human, material or environmental losses that exceed the ability of the affected society to cope using only its own resources” ACEM Policy Document Medical Disaster “ …when the number of casualties far exceed the normal operating capacity of that part of the health system that would be expected to deal with them.” Major incident/ Mass casualty incident …”an event causing illness or injury in multiple patients simultaneously through a similar mechanism e.g. major crash, explosion Mild: >25 injured or 10 requiring admission Moderate: >100 injured or 50 requiring admission Major: > 1000 injured or 250 requiring admission
- 6. General Principles Classification Slow Onset vs. Epidemics, droughts Trauma Sudden Onset acute weather events building collapse, transport crashes vs. Medical infectious disease outbreak, CBR incident Natural disasters vs. Cyclone, earthquake etc. Simple Industrial accidents Transportation/Crashes Terrorism vs. Community infrastructure intact Compensated Human generated Complex essential infrastructure disrupted vs. Disaster capacity sufficient Complex humanitarian emergencies Mass refugees from conflict or natural disaster Uncompensated exceeds planned disaster capacity
- 7. General Principles Epidemiology • Within 90 minutes- 50-80% of acute casualties closest medical facility • 1st wave • Less injured • Leave scene by themselves or with help of 1st aiders • May arrive before the most seriously injured • 2nd wave • Most severely injured • ~50% of all casualties will arrive within 1 hour • Average time in ED 3-6h • Blast/explosion • ~1/3 serious- needing OT • ~10% ICU • ~ 2/3 non-critical
- 8. General Principles Concepts • All hazards response • All agencies response • Tiered/ Graduated response • Command & Control
- 9. General Principles “The greatest good for the greatest number”
- 10. General Principles Disaster Planning - Four main areas 1. Prevention/Mitigation 1. Preparation 2. Response a. Alert b. Initiation c. Execution d. Resolution 3. Recovery
- 11. Emergency Department ProcessCode BROWN “ A disaster or major incident in which the number or type of casualties exceed the normal working capacity of the Emergency Department or Hospital” Objectives: • Modify workflow and resources • Provide the greatest benefit for the most number of casualties • To provide a Hospital Response Team (HRT) +/- Health Commander if requested • To return to a normal working environment as soon as possible • To attend to welfare of relatives of patients and staff
- 12. Emergency Department ProcessCode BROWN Phases: 1. Notification 2. Preparation 3. Receival 1. Recovery
- 13. Emergency Department ProcessCode BROWN Phase 1- Notification • Official phone call • Name, Title and telephone number of caller • Major incident declared or only potential • Exact location of the incident • Type of incident • Hazards • Access to site • Number & type of casualties & expected arrival times • Emergency services (present & required) • Confirmation • Activation • Dial “55”- activate Code Brown • Request to speak to Hospital Health Coordinator • Switch will activate Emergency Response Team (ERT) and Emergency Control Group (ECG) • Code Brown announced over PA system
- 14. Emergency Department ProcessCode BROWN Phase 2- Preparation • Meet with Emergency Response Team • Review Code Brown Plans & Equipment • Brief ED staff • Command and Communication • Action Cards • Prepare space • Decanting ED safely • Rearrangement of geographic function • Expand Resources • Staff • Hospital • Equipment • Prepare to send a Hospital Response Team
- 15. Emergency Department ProcessCode BROWN Phase 3- Receival • Disaster Triage • Immediate care needs • Early identification of medical futility • Streamline approach • Minimising time in ED • Liaison with OT, ICU, wards etc. • Documentation • Rapidly & reliably • • • • Liaison with ECG +/- ICU/OT/Radiology Security Relatives Media
- 16. Emergency Department ProcessCode BROWN Phase- 4 Recovery “ when presentations return to pre-disaster conditions” • Stand Down • DPMU ECG • Announced over PA ED Duty Consultant • Defusing • Return to normal roster & procedures • Restock department • Debriefing • Review Disaster Planes • Q/A
- 17. Pre- Hospital Management MIMMS Principles- Major Incident Medical Management and Support Emergency Management Act 2005 Four main areas Concepts: 1. Prevention/Mitigation • All hazards response 2. Preparation 3. Response a. Alert b. Initiation c. Execution d. Resolution 4. Recovery • All agencies response • Tiered/ Graduated response • Local/District/ State/ Federal • Command & Control
- 18. Pre- Hospital Management Response- CSCATTT • Command & Control • Safety • Communication • Assessment • Triage • Treatment • Transport
- 19. Pre- Hospital Management Major operational structure
- 20. Pre- Hospital Management Bronze Zone- aka “Hot Zone”
- 21. Pre- Hospital Management Silver Zone- aka- “Warm Zone”
- 22. Pre- Hospital Management Hospital Response Teams Campus 6 month rostercommences 0800hrs 3rd Monday in January 6 month roster commences 0800hrs 3rd Monday in July RPH A B SCGH B A FH A B Team A Team B Team C Team D Health Commander Senior Doctor Doctor x2 Doctor x1 Triage Nurse Senior Nurse Nurse x3 Nurse x2 Transport Nurse Triage Nurse Doctors x2 Doctor x1 Nurse x 2 Nurse x2 Communications Officer
- 23. Pre- Hospital Management What is our role out there???
- 25. Pre- Hospital Management Phase- 4 Recovery • Stand Down • Diffuse • Restock • Debrief • Q/A
- 26. Difficulties of clinical care outside the hospital • Unfamiliar environment • Exposed to elements (cold, hot, rain, wind) • Variable light • Noisy • Terrain rough and uneven, dirty • Working on casualties on the ground • Hazards of incident may still seem apparent • Site appears disorganized • Information unavailable, inconsistent or incorrect • Inadequate health staff, equipment & supplies • Feeling of being overwhelmed • High expectations on health workers • Lack of transport and stretchers • Different hierarchical system; less autonomy to delegate PANIC
- 27. Paediatrics • Main differences in management are • Anatomical • Physiological • Psychological • Children should stay with their parents/guardians/ siblings • Children may be transported to adult hospitals and vice-versa • Reasonable to give higher priority due to psychological impact
- 28. Questions
- 29. Summary • Challenging & overwhelming situation • Two main components • Pre- Hospital • Emergency Department & Hospital Response • Knowledge of key elements • Prevention • Preparation • Response • Recovery The greatest good for the greatest number
- 30. References 1. 2. 3. 4. 5. MIMMS Handbook, 2nd Edition SCGH – CODE BROWN, Emergency Procedures Manual- Version 4.0, June 2013 SCGH- Operational Directive, 19th December 2008 WA Health Disaster Hospital Response Team Subplan, May 2012 Cameron, Adult Emergency Medicine 3rd Edition Very special thanks for supplying materials, experience & support • Dr Swift • Dr Vlad • Dr Yaman
- 31. Specific Injuries Blast Injuries • Primary • Lung • Signs usually present at evaluation, may be delayed for 48h • Suspect if dyspnoea, cough, hemoptysis, chest pain • At risk of air embolism (MI, CVA, acute abdomen, blindness, deafness ect) • Mx: high O2, NIPPV, intubation, ICC • Abdomen • Gas filled structures most vulnerable • Bowel perforation, mesenteric injuries, solid organ injury, testicular rupture • Clinical signs can be subtle until acute abdomen and sepsis evolved • Ear • TM rupture- most common injury • Hearing loss, tinnitus, otalgia,bleeding, otorrhoea • Other • Traumatic amputation • Concussion • Contaminated wounds • Eye injuries
- 32. Specific Injuries • Secondary • Injury from projectiles e.g. bomb fragments or flying debris • Penetrating and blunt trauma • FB’s follow unpredictable paths • Tertiary • injuries from displacement of the victim by the blast or structural collapse • Quaternary • All other injuries or illnesses from the blast • Disposition • no definitive guidelines • d/c depends on associated injuries • Ensure f/u for wounds • Written instructions for patients with deafness & tinnitus
- 33. Specific Injuries Crush Injury • Regional & systemic effects Crush Syndrome • Systemic effects of a crush injury after reperfusion of the affected body part(s) • Prolonged (>4h) or extensive crush • Rhabdomyolysis • arrhythmias, hypotension - early • renal failure, DIC- later • Mx: IV fluid resus, diuresis, correct E’lytes, analgesia, dialysis Compartment Syndrome • High index of suspicion • Measuring compartment pressures is difficult & of equivocal accuracy • Faciotomies
- 34. Specific Injuries Burns • Early intubation • O2 • Identify circumferential torso & limb burns • Escharotomy • OGT/NGT • Nausea, vomiting, distension • BSA % >20% • Estimate TBSA % • Rule of Nines • Palmar surface (including fingers) of pt’s hand (1%) • IV replacement- time starts from the time the burn occurred !!! • > 10% BSA children; >15% BSA adults • 2-4ml/kg/TBSA % Hartmans • ½ in first 8h • ½ in next 16h • Infusion rate guided by U/O ( 0.5ml/kg/h adult; 1ml/kg/h child • Aggressive analgesia • Sterile soaked saline gauzes/ Glad wrap • Escharotomy • Timely input from Burns specialist
Editor's Notes
- Typhoon YolandaExtremely powerful tropical cyclone crossed SE Asia>6000 fatalities in the Philippines aloneWestgate Shopping Center21st September, Nairobi, KenyaUnidentified gunmen attack in upmarket areaGhouta21 AugustDisputed suburbs of Capital DamaskusHit by rockets containing SARINHighest death toll estimateDoctors without borders report : 3600 presentations with neurotoxic symptoms within 3 hours6 medics died according to Free Syrian Army reports
- Multitude of definitions- no uniform internationally accepted oneDisaster- Australian Emergency Manual= extraordinary circumstance that requires extraordinary resources - need to be coordinated in such a manner to ensure long-term management of mass casualtiesOperating capacity varies from region to region- Southern Cross Bus CrashExtraordinary resources would be required to minimise morbidity & mortality- resources drawn from within local organisation or from outsideMass casualtyTerm to describe sudden, discrete disastersNumbers again relitve- Southern Cross Bus crash
- Several ways of classifying disasters- Diverse number of incidents- classified as disastersComplex humanitarian – humanitarian crises characterised by political instability, food shortages, collapse of infrastructure
- 1st waveLess injuredLeave scene by themselves or with help of 1st aidersMay arrive before the most seriously injured1 hour window begins when 1st casualty arrives at the hospitalTotal expected casualties ~number of casualties arriving in 1hour x 2
- All hazards response- being able to react to any incident or event planned or unplannedAll agencies response- being able to respond in cooperation with all other emergency services to achieve the best outcomeTiered or graduated response: in the event of a defined number of casualties the ED and hospital executive group may exercise discretion in the extend of activation of ED and hospital areas and call-in staff- response may be scaled up or down
- Instead of…
- Prevention & Mitigation- Regional/ State or national levelInvolves identification of hazards & risksAssessment of risk with actions taken to remove or reduce theses hazards or lessen their impactEquipmentTraining (education and exercise)Implies formulation of policies, legislation, regulatory measures and risk reduction programsPreparationPlans and training to deal with an emergency/major incidentRegular review and checking of functionability of equipmentResponse
- - Circumstances that are purely external orCircumstances of external disaster threatening hospitals capacity to function normally- e/g cycloneLocalised or involving a number of campusesAim- to be able to deal with multiple or mass casualties from a disaster in a timely and effective manner
- Code Brown- response or activation occurs in stagesStage 1: NotificationOfficial phone call: Which phone, Who, sources- where- BAT phonesources: SJA, FESA, Disaster & Preparedness Management Unit (DPMU), State Health Coordinator, Metropolitan Hospital Medical Coordinator- ED DC/ Senior Reg/ Duty Reg or Shift CoordinatorFill in CODE BROWN notification form & contact DC immediatelyALWAYS confirm !!!Unofficial calls MUST be confirmed by phoning the Hospital Health Coordinator On Call Duty officer, DPMU on 9328 0553 or Ambulance control center
- ??? What do you want to prepare???Emergency Response Team:SRN & Area WardenShift EngineerSecurityHAS SupervisorReview Code Brown Plans- Activate and enact ED plansDisaster cupboard- contains all equipment required for a Disaster response in ED and for HRTBrief staff: Med, Nursing and auxillary staff are under the direction of the ED Consultant and ED nursing supervisor- should not take direction form any other hospital staffAction Cards:Easiest and most efficient way to organise individual staff to enact a plan they have never executed before= ALLOCATION OF ROLESStaff should be given roles they are familiar withClearing ED - Expediting admission- all admitted patients immediately to the ward - Discharges: Senior Registrar or Consultant to r/v all patients in WR- admit, other medical facility, GP or homeRearrangement of geographic function- Tiered response- as staff arrive areas areas can be expanded - Area file in Disaster Response Cupboard - Triage: ED Cons or Sen Reg, Senior ED nurses x2 - Resus 1-7, C 8,9 – ATS 1 & 2 - C 10-18- ATS 1,2,3 - C 19-28 & FT- ATS 3&4 - Obs: ATS 3 &4 once 19-28 full - Pain Clinic- ATS 3,4,5 - Plastics dressing clinic- Treatment areas for 4&5Resources- Call in staff but ensure adequate reserve to maintain 24/7
- Disaster Triage:Fundamental difference is the number of casualties +/- injuriesDamage control careShould also reflect likely prognosis, urgency and take into account co- morbidities and general healthStreamline approachAim is to SORT patientsGreatest good for the greatest numberRapid and objective triage assessmentDynamic process repeatedly performed- can be triaged up or down anywhere in the processSingle card & colour system- immediate, urgent, delayed, expectant, deadCards easy attached info- Name, gender etc.Rules of thumbdon’t hold for further treatment if OT etc availableSalvage life over limbdon’’t over triage- usually we overtriage- err on side of caution- this changes in disaster triageControversies:Altered standards of care- withholding treatment or delaying investigations that would be done under normal circumstances e.g. CT scans for injurySecurityRelativesMediaBetter to actively involve them- usually via PR hospital systemUse them to disseminate messages to publicDiscourage staff from engaging with the media
- Stand Down:When advised that no more disaster casualties will be sent to SCGH and the work level both within the ED and other clinical areas has returned to a manageable levelDefusingInformal “defusing” session immediately afterDebriefing- Formal within 7 days
- Emergency Management ActPassed in 2005- established individual services and legislative protectionDefines Hazard Management agencies (HMA’s) – responsible for developing WESTPLANS = State Emergency Management Plans for Managing Hazards)WESTPLAN Health details public, private and allied health responsibilities in a disasterIn a nutshell:Hospitals with ED’s to be prepared to send HRTs to incident areaGP division of Australia to be prepared to assist with the medical care of the walking woundedSJA & RFDS to be prepared to provide triage/treatment/transportPreparation - Planning- Regional/State/ National level- includes plans for mass gatherings and hospital response plans - Equipment - Training- education & exercises
- Command & Control: ALL HAZARDS approach- same approach regardless of the hazardcommand= difficult concept for doctorsDoctors are not the boss!Incident controller controls other agencies Usually the police except in e.g. epidemic the control lies with HEALTHCommand refers to vertical control within each serviceMajor bodies involved:Police creating inner and outer cordonAmbulanceFESASAS/ Military/ Volunteers/CoastguardFirst doctor is the Medical Incident Officer = An AdministratorYour Boss- if deployed as member of HRT= Health Commander- Should not be directly involved in patient care- As more doctors arrive a chain of command is establishedIt is vital that information move up the chain of command to allow a coordinated overall responseSafetyYourselfThe SceneCasualtiesCommunicationVitalUse METHANE to communicate informationMethods of communication: radios, mobiles, face-to-face, sat phone, Reliable information-brief & relevantUpdates as situation changesChanneled resources into single systemMinimise parties accessing communication linesMinimise repetitive enquiriesAssessmentRapid assessment of scene to determine initial response is dynamicTriageprimary= triage Sieve- designed to get people to safetySecondary triage Sort- designed for treatment and transportDynamic processTreatmentEnough to allow patients to get to hospital safelyhaemorrhage control, splinting, airway control, breathing controlTransport- By appropriate or available means to the destinations most likely to be able to manage the casualties- requires central coordinationambulance- usually by triage score, other factors sometimes involved e.g. can take low priority if can sitPublic bus
- -Site of hazard- Inner Cordon AKA HOT ZONEUsually non-hospital emergency services onlyNo role for hospital medical or nursing staff in this zoneUrban Search and rescue team- specifically trained to go in & sieveResponsibility of incident controller- usually police/ FESA- forward commanders
- In incident area but outer cordonOn site but far away from the hazardRestricted access, police will zone off this zoneID & logging of access at incident control pointLocation of Casualty Clearing Post,TriageTreatmentTransportThis is where the HRT operateUnder the Command of Health CommanderGOLD ZONE aka “ Cold Zone”Usually completely different predetermined location to sceneAway from site where emergency services command and coordinate the response ususally State Health Emergency Coordination Center- DoH- Royal Street, Perth
- Senior StaffMIMMS trainedTraining or experience in prehospital care of patientsFamiliar with prehospital disaster equipment & PPEBalance the nedd to send staff to the site versus staffing needs in EDHealth CommanderCommands from Silver Zone and operates from Forward Command postAssists in providing resources to the CCPLiaises with Senior Medical OfficerLiaises with other agency commanderCommunicates to DoH Coordination centreMay activate use of 4th (expectant) catgory!! Members of one agency have NO authority to dirrectly command those from another agency- requests MUST go through the HC- this maintains hierachy of command and controlSenior doctor/Nurse-Commands CCPWith SJA selsct site for CCP if not already done soMonitors resources and makes requests to HCProvides direction to what extend ALS can be given to casualtiesAssists in difficult clinical decisionsKeeps trach of casualty numbers through CCPResponsible for Safety and welfare of clinical staff at the CCPCommunications officerCommunication link between Senior Doctor and HCTriage NursesWorks with SJATriages sort and sequentially allocates Casualty ID number maintaing a log sheet anf tally Team doctor & nursePrimary survey ( with SJA)Teams originating form same hospital will generally operate in one triage areaFirst come, first seen basisRe-prioritise casualties for transportTransport OfficerWorks with SJA ambulance officerIdentify casualty transport prioritiesLiaise with HC via radio to establish transfer destinationMaintain a log
- What is our role? Establish Casualty Clearing PostLocation chosen in collaboration with SJA and hazard management agency- may have been set up prior to arrival of HRTIt should be:Accessible from the site and as near as possible to primary triage area to alleviate long distance carrying- but outside BronzeLarge enough to accommodate staff & casualtiesEasy to access and egress ( evacuation)As protected from the elements as possibleAs well lit as possibleProtectedUpwind from the site2. Triage Sort- evaluate the severity and urgencies of the casualties injuries for prioritization of evacuationTriage LabellingGeographic3. Treatmentdo the most for the mostdefinitive care is not a priorityTop priorities AIRWAY, HAEMORRHAGE CONTROLAnalgesia IM, spinal immobilisation, splinting of limbsGENERALLY NO PLACE FOR CPR- except exacrabtion of chronic IHD who are minorly injured and sustain a VF arrest and responding immediately to defibrillationPreserve life or limbVaries due to available resources, number and type of casualties and time to transport4. Coordinate retrieval and transport- Movement in one directionAmbulance holding pointAmbulance loading pointHelicopter landing zoneCommunications with health commander, transport nurse, ambulance reg. injuries so that equitable distribution is made between hospitals
- Triage ‘Sieve”- designed to get casualties to safetyTriage ‘Sort’- for treatment and transportAccording to revised triage trauma score- physiological scores, Colour coded:RED- 1st priority- immediate: life threatening shock or airway compromise present, but patient likely to survive if stabilisedYELLOW- 2nd priority- urgent: injuries have systemic implications but not yet life threatening- if given appropriate care should survive 45-60 min without immediate riskGREEN- - walking wounded- injuries unlikely to deteriorateBLACK- DEAD- any patient with no spontaneous circulation or ventilation is classified dead- Expectant= Consideration of placement of catastrophically injured patients in this category; goals should be adequate pain management!!! OVER zealous efforts on these patients likely to have deleterious effects on other casualties
- What are some of the difficulties you may encounter?
- Management follows the same rules as single trauma patientResources may be limited- therefore management in vertical rather than concurrent mannerBlast:Most injuries involve multiple penetrating wounds and blunt traumaConfined space explosions and explosions resulting in structural collapse lead to greater morbidity and mortalityPrimary:Usually result from confined space explosionsLungPt with normal CXR and ABG who have no complaints can be considered for d/c after ~6h observationTM ruptureisolated- not a marker for morbidityTraumatic amputation of a limb= marker for multisystem injuries and deathCompartment, rhabdo- from long extraction, burns
- Secondary:Most common- head, neck, chest abdomen- penetrating or blunt, fractures, amputations, soft tissue, shrapnelTertiary:Head injury, spinalSkull ##Quaternary-BurnsAsthmaAnginaHTNHyperglycemiacrush
- Crush syndrome-major cause of early mortality after crush injuryGreatest initial danger after release of the crushed limb from entrapment with restoration of circulationCannot determine actual tissue damage based on area of affected body partHyperK, hypoCa, myoglobinemia, hypovolemia, hypoxemia, IV fluid resus- preferably prior to release of crushing force 1 L Saline bolus, 1-1.5 L/h infusion, consider alkalinisationCompartment syndromePain out of proportionTense compartmentsLimitation of active and passive movements or muscles of affected limbPallor, paraesthesia and absent pulses are LATE !!!