Transcript emergency medical care and emergency room in msf settings

EMERGENCY MEDICAL CARE
AND
EMERGENCY ROOM
IN MSF SETTINGS
EMERGENCY ROOMS
No emergency medical care referent in MSF F
before September 2010.
We are now 1 year and 2 months old!
Let’s see what we have done or not done yet.
EMERGENCY ROOMS
MSF emergency rooms in regular missions:
• Drouillard hospital / HAITI --- 300/sem
• Teme Hospital / NIGERIA --- 150/sem
• Hangu Hospital / PAKISTAN --- 400/sem
• Rutshuru Hospital / CONGO DR --- 275/sem
• +/- Khameer & Althal Hospitals / YEMEN
• Mullaitivu Hospital / SRI LANKA --- 50/sem
• Awil Hospital / SOUTH SUDAN
• Pawa Hospital / CAR
EMERGENCY ROOMS
MSF ER in emergency missions:
• Ivory Coast
• Libya
• Syria
• Egypt?
• Yemen?
EMERGENCY ROOMS
Common strategy for
• Organization
• Protocols
• Medical material and drugs
• Human resources
EMERGENCY ROOMS
ORGANIZATION: Triage area
TARGETS:
– To attend in priority patients with life-threatening
conditions or higher risk of complication.
– To improve medical care.
– To manage patients flow and decrease
overcrowding.
– To improve patient satisfaction and decrease overall length
of stay.
ESSENTIAL IN ANY EMERGENCY ROOM
EMERGENCY ROOMS
ORGANISATION: Triage area
• Routine triage :
– syndromic approach or vital signs approach (depends of
skills, patients flow, material…)
– Triage area at ER entrance
• Massive influx:
– Large area prepared at ER entrance (empty and closed in
routine activity)
– Mass casualty incident guide line
ROUTINE:
SYNDROMIC APPROACH
RED PATIENTS
PATIENT TO BE SEEN BY DOCTOR IMMEDIATELY: patients are critical and need immediate
treatment
Direct to resuscitation room. Inform doctor and other nurses.
Registration is done after ni itial treatment.
 Any patient with shock or signs of early onset of shock (tachycardia, low blood pressure, poor
capillary refill, cool peripheries)
 Polytrauma (traum a with multiple injuries)
 High energy trauma
 Any bleeding (trauma or non-trauma) with impending shock
 Severe burns: Large area, burns to face or perineum, electrical or chemical burn, smoke inhalation
 Fracture or dislocation with neurovascular compromise
 Altered level of consciousness / coma
 Ongoing seizures
 Respiratory rate <9 or >20 in adult and/or cyanosis
 Severe chest pain
 Hypothermia < 35°C
 Envenomation
 Suspicion of meningitis
ADULT TRIAGE SCORE
3
2
1
Mobility
ADULT TRIAGE / SYNDROMIC COMPLEMENT
3
COLOR /
CATEGORY
SCORE
TARGET TIME
TO TREAT
MECHANISM
OF INJURY
0
1
2
Walking
With help
Stretcher
immobile
9 - 14
15 - 20
21 - 29
> 29
RR
101-110
111-129
> 129
HR
BREATH SHORTNESS - ACUTE
Mobility
RR
<9
HR
< 41
41 - 50
51 - 100
71 - 80
81 - 100
101-199
> 199
SBP
RED
YELLOW
GREEN
5 OR MORE
3-4
0-2
IMMEDIATE
< 1 HOUR
< 4 HOURS
HIGH ENERGY TRANSFER
temp
< 35
35 - 38,4
> 38,4
temp
AVPU
Confused
Alert
Reacts to Reacts to Unresponsi
voice
pain
ve
AVPU
COUGHING BLOOD
CHEST PAIN
SEIZURE - CURRENT
SEIZURE - POST ICTAL
HAEMORRHAGE UNCONTROLLED
Trauma
FOCAL NEUROLOGY - ACUTE
Trauma
< 71
NO
YES
DISLOCATION OTHER JOINT
ROUTINE:
VITAL SIGNS APPROACH
HAEMORRHAGE CONTROLED
REDUCED LEVEL OF
CONSCIOUSNESS
THREATENED LIMB
age > 12 years / taller > 150 cm
PRESENTATION
SBP
FRACTURE - COMPOUND
DISLOCATION FINGER OR
TOE
FRACTURE - CLOSED
BURN - FACE / INHALATION
BURN > 20%
BURN - ELECTRICAL
ALL OTHER PATIENTS
BURN : OTHERS
BURN - CIRCUMFERENTIAL
BURN - CHEMICAL
POISONNING / OVERDOSE
PAIN
HYPOGLYCAEMIA glu<3mmol/l or 0,6g/l
PSYCHOSIS / AGRESSION
DIABETIC - glu>11mmol/l
or2g/l WITH KETNONURIA
DIABETIC - glu>17mmol/l
or3g/l NO KETNONURIA
VOMITING - FRESH BLOOD
VOMITING - PERSISTENT
PREGNANCY & ABDOMINAL
TRAUMA
PREGNANCY & ABDOMINAL
PAIN
SEVERE
PREGNANCY & TRAUMA
PREGNANCY & PV BLOOD
MODERATE
RED
COLO UR
Mass casualties incident
PATIENTS
IMMEDIATE (ABS OLUTELY URG ENT)
Patients who need IMMEDI ATE surgical or medical treatment; their condition
is life-threat ening in the short term, but they have a reasonabl e chance of
survival .

Airway obstruction: neck or facial injuries, chest wound s, etc.

Respiratory distress: tension pneumothorax, hemothorax , cardiac
tamponna de, flail chest, etc.

Active
bleeding
with
hemorrhagi c
shock: extremity wound s,
abdo minal wounds, etc.

Hypovole mic shock/dehydration: e.g., cholera epidemic.
YELLOW
This lis t is not ex haustive
DEL AY ED (RELATIVELY UR GENT )
Patients who need surgical or medic al treatment, but whose condition is not
immediately life-threatening, and who are stable enough to wait.

Chest or abdominal wounds or trauma without respira tory distress

Wounds or tra uma without hemorrha gic shock; hemodynamically
stable.

Head trauma with good prognosi s (Glasgow Coma score >8)

Open fractures or traumatic amputations, suspected pelvic o r
femora l fracture.

Large w ounds with no active bleeding.
This lis t is not ex haustive
GREEN
MINOR (NOT URGENT)
Patients who need non-urge nt care, with no short- or medi um-term lifethreatening conditions.
Conscious patients.
Patients who do not need hospitalisation, but just outpatient treatment.

Superficial wounds

Closed fractures
This lis t is not ex haustive
BLACK
DEAD OR DYING
Patients who have died, or whose condition is life-threatening and who have
very little chance of surviva l, with or without medical or surgical care.

Sever e multiple trauma

Severe head trauma (Glasgow Coma score <8), or penetrating head
trauma

Trau matic quadriplegia

Burns over more than 50 % of the body (unless 1
This lis t is not ex haustive
st
degree)
EMERGENCY ROOMS
ORGANISATION: Medical care area
ER = severe patients management (trauma++)
ER = ADAPTED RESOURCES NEEDED
(++ considering good quality of surgery / anaesthesia)
– Resuscitation zone / red zone :
• Specific material: automatic BP, vacuum, electrical syringe driver…
• Resuscitation material and drugs
• Dedicated HR?
–
–
–
–
Yellow zone: acute patients / no needs of resuscitation
Green zone: non seriously sick patients
Plaster and suture: dedicated room or trolley.
Isolation room?
Link +++ with OT, radiology, ICU, lab, wards : central position
ORGANISATION: Observation room
EMERGENCY ROOMS
MEDICAL PROTOCOLS
• Long process ! Very long!
• Evidence based protocols
• Problem: validation and
implementation (training)
TARGET: same severe
patients management in
all MSF settings.
Problem: different levels in
terms of material, skills,
logistics…
• Achieved:
– Triage in routine
– Triage in mass casualty
incident
– Intra-osseous catheter
ADULT
AND
PAEDIATRICS
• Almost achieved or in
process:
– Trauma
– Shocks
– Asthma
– Convulsions…
EMERGENCY ROOMS
EQUIPMENTS
•
•
MONITORS / AUTO BP: no unstable patient management without adapted tools !
SYRINGES DRIVERS: essential for dopamine, adrenaline
• FAST echo EXCELLENT ALTERNATIVE / scanner = dream
• INTRA OSSEOUS KT / ELECTRICAL DEVICE: central IV = dangerous
and difficult / excellent alternative urgent IV access
• ECG: pb for ECG diagnosis AND pb for treatment even if
diagnosis is well done
=====> ADAPTATION to new tools = TRAININGS
EMERGENCY ROOMS
DRUGS / MEDICATIONS:
• Implementing new protocols (evidence based), we’ll have
to implement new drugs
• Worldwilde health changes (thanks to mondialisation).
We have to face more and more western pathologies
– Diabetes
– Cardiac and vascular
– Old and multi pathologies patients
====> ADAPTATION ++++ to new health problems and new
treatments
EMERGENCY ROOMS
HUMAN RESOURCES:
• TRAININGS : how to train our national staff to EM?
– Most countries: no concept of emergency med speciality.
– Most expat volunteers : different back-grounds in EM.
• SOLUTIONS / ISSUES?
–
–
–
–
–
–
ATLS
Impact?
FAST ECHO
Value?
Certification?
BASIC
ACLS? PALS, ASLO?
“MSF made” trainings?
Qualified Expat emergency doctor: senior doctor.
EMERGENCY ROOMS
REAL CHALLENGE TO HAVE EFFICIENT EMERGENCY ROOMS
• TRAININGS
• NEW MATERIAL
• NEW ADAPTED PROTOCOLS AND DRUGS
• EXPAT EMERGENCY DOCTORS / SENIORS
• …..
Step by step we achieve interesting progresses !
EMERGENCY ROOMS
TARGETS IN THE FUTURE : SEVERE TRAUMA WILL NEED
• surgeon + anaesthetist/intensivist + ER physicians
commitment
• Patient pathways
• Development of technologies as we began (Ultrasound,
Intra osseous cath.)
• Training in specific fields : ultrasound, trauma
management (ATLS, BASIC)
• Dedicated protocols (hemodynamic and fluids
management, ...)
EMERGENCY ROOMS
HAITI / Hôpital Drouillard
 Implementation of FAST Echo in emergency
Room
 Experienced and qualified EM doctor expat, for
6 months (+ 3 months)