Transcript Week 4 - GCS 16

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