Disaster and Prehospital

Disaster and Prehospital

Disaster – On scene management Receive the call – – – – – – – ETHANE Exact location Type of incident Hazards at site Access Number of casualties Emergency services required and present

Initial response AADME Activate major incident plan Alert other hospitals Dress appropriately safety gear Medical equipment, staff, drugs Ensure good communications

At Scene CSCATT Command and control – go there first Safety – self, scene, patients Communication Assess scene, patients, hazards Triage Treat Transport

Triage Greatest good for the greatest number Walking – yes – green Airway – no – black Breathing – RR 10, 29 – red Circulation –cap 2sec,PR 110– red Yellow

Disaster – Hospital Preparation Mass casualty incident Potential to overwhelm resourses May require response from outside agencies (regional, state, international) Aim greatest good for greatest number

Principles Confirm (ETHANE) Activate disaster plan Establish control centre Hospital level preparation ED preparation / medical issues – – – – – Areas (red, yellow, green, black, morgue) Staff Equipment and drugs Education Documentation Debrief CQI

Biological / Chemical Warfare Personnel material resource protection Decontamination Triage – Different, expect large numbers worried well, anthrax – pt w any symptom poor prognosis Treatment – Reduce routine demand while inc health supply – Specific – anthrax, plague, organophosphates, botulism Disposition – Fatalities, contaminated remains – Victim ID and tracking Continuing Quality Improvement

Interhospital transport Aimed at improved patient care Management during transport should be equal to or better than point of referral

Transport depends on: Nature illness Urgency Location patient Distances Road transport times and conditions Weather Aircraft landing facilities Range and speed of vehicle

Problems Loading and unloading Altitude Low PiO2 Dysbaria – Boyle’s law – press x vol K – Skull fractures, gut, mediastinal emphysema, pneumothorax, penetrating eye injury, decompression illness Limb swelling Low temperature Noise Vibration, acceleration, deceleration, turbulence Danger agitated patients Space and lighting Electromagnetic interference

Transport Communication Patient Staff Equipment Drugs Mode Documentation

SAQ 1 You are working in an urban district hospital with no obstetric or neonatal service. A 28 week pregnant woman presents in premature labour. Examination reveals an absence of bleeding and a closed cervical os. Outline your initial management in the emergency department (50%) Outline the arrangements required for transfer to a tertiary centre (50%) (2011/2)

Key issues 2 patients, viable pregnancy, high risk prematurity, closed os – not an imminent delivery Aims of initial management – Early consultation with obstetrics team – Confirm foetal wellbeing – Slow labour if no contraindications – Steroids for lung maturity – Treat mother – Seek and treat underlying cause – Arrange safe disposition – Back up preparations for delivery

Arrangements for transfer – Safest is in utero with retrieval team from tertiary hospital, avoid delivery in transit if possible – Preparations should include all of the below to ensure expertise and facilities for safe transport and anticipation of delivery in transit Communication, Staff, Equipment, Drugs, Mode, Documentation

Exam Report Overall pass rate 57/81(71.6%) On the information provided the patient was considered to be in premature labour, however with a closed cervical os this was an urgent rather than an emergency issue with respect to delivery. As a minimum, candidats were expected to cover the following in their initial management: Consultation with an obstetric service Slow or cease premature labour if appropriate with a tocolytic (nifedipine, magnesium or B2 agonists were deemed acceptable) Administration of corticosteriods for foetal lung maturation Better answers would provide: specific info on contraindications (maternal and foetal) to slowing/ceasing labour with tocolytics; specific drug dosing regimes for tocolysis; dosing of corticosteroids (betamethasone); use of antibiotics (penicillin) for gorup B strep prophylaxis, monitoring of foetal well being; and supportive cares for the mother (analgesia). Examiners accepted variable management algorithms with respect for tocolytics and steroids

With respect to the arrangements for transfer to a tertiary centre, the examiners were flexible in terms of whether this was to occur as a transfer with ED staff or via a retrieval team collecting the patient. As a minimum, candidates were expected to cover the following with their transfer arrangements: Appropriate communication (eg. With patient / staff / and the recevigin unit at the tertiary centre) Staffing – to escort the patient during transfer (number, type, experience, skills etc) or use of a retrieval team Preparedness for potential delivery during transfer Better answers would provide: a comments on the over-riding principle of the benefit of in-utero transfer and avoidance of delivery in transit; more detailed information concerning the above minimum criteria; consideration of mode of transport (likely road given the urban district setting); information on the drugs and equipment they would arrange to take; documentation; and monitoring arrangements during transfer

Features of Unsuccessful Answers Main features was no consultation with obstetric servicein part A and no preparation for delivery during transfer in part B Didn’t answer questions Failed to adequately prepare for transfer with regard to specific problem. Generic transfer answer not helpful Fatal errors Dangerous drugs Drug doses or combinations of drugs eg 20mg IV salbutamol stat!!

SAQ 2 (2004/2) You are working in a large regional emergency department. You receive a telephone call from a doctor at a small community hospital two hours away by road. This doctor is a general practitioner with limited emergency experience. He asks for advice regarding an 18 month old boy who presented with fever, pallor and stridor. Despite intramuscular and nebulised steroid the child has severe respiratory distress with stridor. (a) Outline your advice to the referring doctor. (50%) (b) Outline the arrangements you would undertake to transfer this child. (50%)

Key issues Immediate airway threat, possible epiglottis or severe croup – Confirm situation and resources – Advise temporising measures – adrenaline, antibiotics, IV steroids – Safe intubation if available and appropriate Transport – Safest will be a retrieval team – Low threshold for intubation prior to transport – Communication – Staff skilled in paediatric airway emergencies and surgical airway if required – Equipment/monitoring for intubation and re-intubation en route if required – Drugs – Mode – Documentation

Exam report The overall pass rate for this question was 50 / 64 (78.1%). Examiners considered this to be a “core business” aspect of FACEM training but found that many candidates showed no insight into arranging a transport in a rural setting (for instance sending a team including a paediatric anaesthetist and an ENT surgeon). It was expected a substantial part of the answer would cover guidance for the GP on appropriate treatment for the important differentials (especially croup and epiglottitis), summoning local resources and other preparation in readiness for transfer. In terms of the transfer it was expected that issues to cover would include mode of transport, team composition, communication, documentation and a low threshold for definitive airway management prior to transfer. Failing answers did not deal with these issues.

SAQ 3 (2006/1) You are the consultant in charge of the emergency department in a tertiary hospital. The ambulance service calls at 1000 hours on a weekday warning that they are at the scene of a major motor vehicle crash. They have 6 patients – 5 adults and a 12-month-old infant, all in a serious condition. They will be arriving at your department in 10 minutes. Describe your response to this situation. (100%)

Potential to overwhelm resources Confirm incident Activate disaster plan Consider diversion of some cases Hospital level preparation ED preparation – – – – – Areas/other patients Staff/trauma teams Equipment Drugs Paediatric Debrief Contiued Quality improvement

Exam Report The overall pass rate for this question was 29/40 (72.5%). Examiners considered that being able to deal with such a situation is an important skill for an emergency physician. The question was broad but the expected answer focused on the managerial issues of recognizing and using available resources to cope with a disaster rather than the specifics of trauma care. The elements of a comprehensive answer were: confirm and recognize the potential disaster, liaise with the EMS, consider diversion of some cases (eg paediatric), constitute trauma teams, clear the ED as possible, hospital wide notification/involvement (eg trauma call, internal disaster), manage relatives/media and plans for some sort of standdown/debrief. Failing answers neglected issues such as team constitution/allocation, did not notify widely (including other ED staff) and did not liaise with the EMS.

SAQ 4 (2008/2) You have been advised by Emergency Medical Services of a bus versus petrol tanker accident with mass casualties. Describe how you would configure and deploy a medical team to the accident scene. (100%)

Disaster with potential to overwhelm resources Deploying medical team – Confirm site, type of incidents and hazards at site – Access – Number of casualties – Number of emergency services already present and required – Anticipate multi-trauma and burns

Team itself – – – – – – Staff Equipment Drugs Dress and safety gear Ensure good communications Mode of transport Hospital disaster plan and other hospital communications Consider impact on your department

Pass rate 61/81 (75.3%) One examiner felt that this was a poor question as it allowed a variety of interpretations depending on local/regional practices. Despite this, the examiner was able to identify a series of core knowledge points that seemed extrapolatable to any geographical region Good answers addressed the team composition and expertise, clarification of special needs, configuration within the confines of the local Displan, equipment needs, briefing, transport, communication and impact on the Emergency Dept