disaster management
DESCRIPTION
Disaster managementTRANSCRIPT
Disaster
Dr Stephanie Schlueter
19th December 2013
SCGH
Outline
• General PrinciplesDefinitions & ClassificationsEpidemiology
• Emergency Department Process- Code BROWN
• Pre-Hospital Management
• Specific injuriesBlastCrushCompartment syndromeBurns
Case2245hPhone 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
Disasters in 2013• November 2013
Typhoon “Yolanda” > 6000 deaths> 25.000 injured
• September 2013Westgate Shopping Mall- Mass Shooting72 deaths> 200 injured
• August 2013Ghouta Chemical Attack- Syrian civil war 1729 deaths3600 presentations to 3 surrounding hospitals within 3
hours
• April 2013Boston Marathon Bombings3 deaths264 injured
General PrinciplesDefinitions
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 admissionModerate: >100 injured or 50 requiring admissionMajor: > 1000 injured or 250 requiring admission
General PrinciplesClassification
Slow Onset vs. Sudden OnsetEpidemics, droughts acute weather events building collapse, transport crashes
Trauma vs. Medical infectious disease outbreak, CBR incident
Natural disasters vs. Human generatedCyclone, earthquake etc. Industrial accidents Transportation/Crashes Terrorism
Simple vs. ComplexCommunity infrastructure intact essential infrastructure disrupted
Compensated vs. UncompensatedDisaster capacity sufficient exceeds planned disaster capacity
Complex humanitarian emergenciesMass refugees from conflict or natural disaster
General PrinciplesEpidemiology
• 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
General Principles
• All hazards response
• All agencies response
• Tiered/ Graduated response
• Command & Control
Concepts
General Principles
“The greatest good for the greatest number”
General Principles
Disaster Planning - Four main areas
1. Prevention/Mitigation
2. Preparation
3. Response
a. Alert
b. Initiation
c. Execution
d. Resolution
4. Recovery
Emergency Department Process-Code 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
Emergency Department Process-Code BROWN
Phases:1. Notification
2. Preparation
3. Receival
4. Recovery
Emergency Department Process-Code 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
Emergency Department Process-Code 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
Emergency Department Process-Code 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
Emergency Department Process-Code BROWN
Phase- 4 Recovery
“ when presentations return to pre-disaster conditions”
• Stand Down• DPMU ECG ED Duty Consultant• Announced over PA
• Defusing
• Return to normal roster & procedures
• Restock department
• Debriefing
• Review Disaster Planes
• Q/A
Pre- Hospital Management
MIMMS Principles- Major Incident Medical Management and SupportEmergency Management Act 2005
Four main areas1. Prevention/Mitigation
2. Preparation
3. Responsea. Alertb. Initiationc. Executiond. Resolution
4. Recovery
Concepts:• All hazards response
• All agencies response
• Tiered/ Graduated response• Local/District/ State/
Federal
• Command & Control
Pre- Hospital Management
Response- CSCATTT
• Command & Control
• Safety
• Communication
• Assessment
• Triage
• Treatment
• Transport
The main failing of major incident managementis poor communication
Pre- Hospital ManagementMajor operational structure
Pre- Hospital ManagementBronze Zone- aka “Hot Zone”
Pre- Hospital Management
Silver Zone- aka- “Warm Zone”
Pre- Hospital ManagementHospital Response Teams
Campus 6 month roster-commences 0800hrs 3rd Monday in January
6 month rostercommences 0800hrs 3rd Monday in July
RPH A B
SCGH B A
FH A BTeam 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
CommunicationsOfficer
Pre- Hospital Management
What is our role out there???
Pre- Hospital Management
Pre- Hospital Management
Phase- 4 Recovery
• Stand Down
• Diffuse
• Restock
• Debrief
• Q/A
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
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
Questions
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
References1. MIMMS Handbook, 2nd Edition2. SCGH – CODE BROWN, Emergency Procedures Manual- Version 4.0, June 20133. SCGH- Operational Directive, 19th December 20084. WA Health Disaster Hospital Response Team Subplan, May 20125. Cameron, Adult Emergency Medicine 3rd Edition
Very special thanks for supplying materials, experience & support• Dr Swift
• Dr Vlad
• Dr Yaman
Specific InjuriesBlast 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
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
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
Specific InjuriesBurns
• 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