Disaster management

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


Phases:1. Notification

2. Preparation

3. Receival

4. Recovery


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


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


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


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



Response- CSCATTT


• 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”


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


What is our role out there???


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

Disaster management

Health & Medicine

Transcript of Disaster management