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Disaster management

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Disaster management

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Disaster management

  1. 1. Disaster Dr Stephanie Schlueter 19th December 2013 SCGH
  2. 2. Outline • General Principles Definitions & Classifications Epidemiology • Emergency Department Process- Code BROWN • Pre-Hospital Management • Specific injuries Blast Crush Compartment syndrome Burns
  3. 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. 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. 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. 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. 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. 8. General Principles Concepts • All hazards response • All agencies response • Tiered/ Graduated response • Command & Control
  9. 9. General Principles “The greatest good for the greatest number”
  10. 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. 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. 12. Emergency Department ProcessCode BROWN Phases: 1. Notification 2. Preparation 3. Receival 1. Recovery
  13. 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. 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. 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. 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. 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. 18. Pre- Hospital Management Response- CSCATTT • Command & Control • Safety • Communication • Assessment • Triage • Treatment • Transport
  19. 19. Pre- Hospital Management Major operational structure
  20. 20. Pre- Hospital Management Bronze Zone- aka “Hot Zone”
  21. 21. Pre- Hospital Management Silver Zone- aka- “Warm Zone”
  22. 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. 23. Pre- Hospital Management What is our role out there???
  24. 24. Pre- Hospital Management
  25. 25. Pre- Hospital Management Phase- 4 Recovery • Stand Down • Diffuse • Restock • Debrief • Q/A
  26. 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. 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. 28. Questions
  29. 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. 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. 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. 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. 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. 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

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