Presentation on theme: "Mass Casualty Management for the Doctor, Nurse & Paramedic -Formerly ATLS Mass Casualty Management By Dr S. T. Boyd, BSc(Hons), MBChB, DA(SA), FCEM(SA),"— Presentation transcript:
Mass Casualty Management for the Doctor, Nurse & Paramedic -Formerly ATLS Mass Casualty Management By Dr S. T. Boyd, BSc(Hons), MBChB, DA(SA), FCEM(SA), Dip.PEC(SA)
Mass Casualty Management Goal: To apply trauma triage principles in multiple patient scenarios Objectives: –Brief local / international history with mass casualties –Define triage –Understand and identify factors –Apply principles of triage with scenarios –Conclude with an example which is still today RSA’s biggest train accident
You've carefully thought out all the angles. You've done it a thousand times before. It comes naturally to you. You know what you're doing, its what you've been trained to do your whole life. Nothing could possibly go wrong, right ?
Natal & Durban Floods September 1987 Largest floods in living memory, Cyclone Demonia 1986 excluded
Similar to September 1987 Problems created in Sept 1987? Loss of road, rail & almost all air communications (Durban International under water & Virginia nearly so) Loss of telephone & radio comms Washaways in informal settlement areas (>400 people washed away when rivers came down in flood) Mudslides with entrapments
Mass casualties - why train accidents in India have so many injured
Mass Casualty Management Interactive scenario session
Disaster Management - Triage French = “to sort or select” (“Sorting of differing grades of wool & later coffee beans”) Napoleon’s surgeon Baron Larrey, applied the principle to the assessment & treatment of the injured To sort into categories based on an assessment of: –A B C D E’s –Resources available RSA System: Red (P1), Yellow (P2), Green (P3) & Blue (P4)
TRIAGE CATEGORIES: RED (P1) = 1-5% YELLOW (P2) = 5-10% GREEN (P3) = 80% BLUE (P4) = 1-5%
Triage "YELLOW CODE" (“P2”) = The horizontal but ABC intact patient who is demanding: –An injury which requires complex care but is not an immediate threat to life : Fracture of a long bone Spinal lesion Abdominal injuries without shock Vascular injuries Large burns 20-60% BSA
Triage "GREEN CODE" (“P3”) = The walking talking but very demanding in terms of resources: –Patients with minor injuries requiring first aid or outpatient treatment : Small lacerations Burns <20% BSA Musculoskeletal injuries without shock
Triage "BLUE CODE" (“P4”) = The gasping / agonal or obviously dead: (sometimes called black or grey codes): –Patients who are obviously dead or who have apparently mortal injuries.
Triage - Fine Tuning based on Vital Signs = Green / P3 = Blue / Black / P4 = Red / P1 = Yellow / P2 = Green / P3
Triage - Reality Check - KISS!!!! To summarise - Keep it simple stupid!! : –remove the walking ABCD intact green codes = +/- 80% –the +/-20% left behind are all horizontal - horizontal and gurgling with ABCD compromised = red codes = 1st priority horizontal with intact ABC so are able to cry for help = yellow codes = 2nd priority and the horizontal with ABCD foo-baa and dead or dying = blue codes = leave alone
Disaster Management Triage tags applied to patients, make one’s task of sorting much easier USA MILTAGS Front Back
Disaster Management Triage tags come in all shapes & sizes
P1 Urgent A B C P2 Semi-Urgent D P3 Walking wounded P4 Dead or Dying Name___________Dept__________ Time____:____ Date___/__/____ BP___/___ P________ R________ IV____@__:__ ______________ Triage Tag - fold to show appropriate colour on outside
Triage Note Triage is on going / repeated: –T1 on scene –T2 at CCS/FAP –T3 on route / at hospital –T4 in the trauma unit
Scenario I-Bank Hold-up Customer involved in a bank hold-up. 5 shot - 3 bank patrons & 2 bank employees. Robbers hold you & 12 individuals in the bank as hostages while they negotiate with the police negotiators.
Scenario I-Bank Hold-up You are allowed to examine the victims and evacuate them one at a time, to an ambulance in exchange for cool-drinks, food, beers, whisky & sodas, etc (wheels & firearms are not permitted). The shootings occurred at noon - it is now 14:00 The five injured are:
Scenario I-Bank Hold-up –A - 45yr man with 2xGSW - 1st entered below the right nipple & exited through the right scapula while 2nd is a thro’ & thro’ injury to the palm of the right hand. Awake & alert. The hand & chest is wrapped with a torn shirt. Neither wound is bleeding. VS: P=90, RR=25 –B - 68yr diabetic man with a thro’ & thro’ GSW injury to the left thigh. C/O left leg & foot pain. A very large haematoma of the left thigh is noted & the distal foot is cool & pulseless. VS: P=110, RR=30
Scenario I-Bank Hold-up –C - 50yr obese woman with a GSW to the right buttock - entry wound visible but no exit. She is lethargic, but responds to verbal stimuli. Her skin is cool & moist to the touch. VS: P=120, RR=35 –D - 25yr man with a thro’ & thro’ GSW to the left chest - entry wound 4th ICS midaxillary line & exited at the xiphoid. He is awake & alert, & C/O abdominal & chest pain. There is no obvious bleeding. VS: P=140, RR=25
Scenario I-Bank Hold-up –E - 22yr woman was standing near a window & showered with glass from ricocheting bullets. She sustained multiple lacerations of the face & arms, including the right eyelid & globe. VS: P=90, RR=25 Who goes 1st, 2nd, 3rd, 4th & 5th in terms of evacuation - A, B, C, D, or E? (press right arrow for answer) Answer: Evacuate patients in the following order C, D, A, B & E.
Scenario I-Bank Hold-up How to triage: 1.ABCDE - boring, boring, boring but it works 2.MOI = Mechanism Of Injury - whose is the more severe 3.Who has the more deranged vital signs! SIMPLE STUFF ESPECIALLY IF THE CROCODILES ARE BITING
Scenario II-CarCrash You are the only doc on a rural scene of a motor vehicle accident - MOI = rollover with ejections You have available to assist you one paramedic student and AEA of 2 years standing You have 5 patients who were occupants of the car travelling at 96kph before it crashed The injured patients are:
Scenario II-CarCrash A- 45yr unrestrained male driver who was thrown against the windscreen. On arrival, he was in severe respiratory distress. Injuries include severe maxillofacial trauma with bleeding from the mouth & nose, an angulated deformity of the left forearm & multiple abrasions over the anterior chest - VS: BP= 150/80, HR= 120, RR= 40, GCS= 8
Scenario II-CarCrash B- 38yr woman front seat passenger who was thrown from the car & found 9meters from the car. On arrival she is awake, alert & C/O abdominal & chest pain. On palpating her hips, she complains of pain & fracture related crepitus is felt. - VS: BP= 110/90, HR= 140, RR= 25.
Scenario II-CarCrash C- 48yr male passenger was found under the car. He is confused & responds slowly to verbal stimuli. Injuries - multiple abrasions to his face, chest & abdomen. Breath sounds are absent on the left & abdomen is tender on palpation - VS: BP= 90/50, HR= 140, RR= 35, GCS= 10.
Scenario II-CarCrash D- 25yr hysterical woman extricated from the back seat of the vehicle. She informs you that she is 6/12 pregnant & C/O abdominal pain. Injuries include multiple abrasions to face & anterior abdominal wall - abdomen is tender to palpation & she is in active labour - VS: BP= 120/80, HR= 100, RR= 25.
Scenario II-CarCrash E- 6yr boy extricated from floor of rear seat who prior to your arrival was alert & talking. He now responds to painful stimuli by only crying out. Injuries include multiple abrasions & an an angulated deformity of right lower leg. There is dry blood around his nose & mouth - VS: BP= 110/70, HR= 180, RR= 35.
Scenario II-CarCrash Triage these patients as to who you would treat first, second, third, fourth & fifth (press right arrow for answer) Answer: A, C, B, E & D
Scenario III-Disaster Planning It is 14:00hrs on a Sunday afternoon - “snooze time”. You are in charge of a 100 bed rural community hospital. Your available staff in the casualty include an ER physician, 2 nurses & four paramedics who are on clinical rotation as part of their clinical training. Your rural hospital has three ground ambulances & availability of a helicopter from the EMS. Surgical services are also available at your facility on a callout basis afterhours.
Scenario III-Disaster Planning The nearest definitive care center is 160km away A trucker calling on his radio, notifies the hospital that an overloaded minibus has run off the highway & rolled over. He states the minibus has approximately 25 passengers, some of whom are children who are in various degrees of panic & injury. The incident is approximately 10 minutes away from the hospital by ground ambulance.
Scenario III-Disaster Planning What calls need to be made & who should make them? What areas in the hospital need to be designated or set up for this condition? Who should go to scene? What equipment & agencies should be deployed to scene?
Scenario III-Disaster Planning What categories of triage should you anticipate using, & how should they be employed? What communications would you have available at the: –Scene? –Hospital?
Scenario III-Disaster Planning How would you manage the following: –Crowd control? –News media? –Ground ambulances? –Helicopter? –Traffic? –Patient indentification?
Scenario III-Disaster Planning Having considered all of the above: –Are you involved in disaster planning at your hospital? –Is the plan adequate for the hospital? –Is the plan adequate for the community? –What are the key elements to the successful management of a disaster plan?
Concepts in Mass Casualty Management – Pre-Hospital FCP IC OC FAPCCS Incident CHA : Toys Wheels/Wings People Access routeEgress route COMMS Metro Control Primary & Secondary Hospitals Principles: FCP IC / OC FAP CCS CHA Access Egress Comms Hospitals
Marionhill Train Accident 8th March 1994 Emergency Medical Services Disaster Management of the Scene - Summary: >380 injured >68 dead
Marionhill Train Accident Early morning commuter train / rural Durban bound railway line ? Train speeding excessively & the passenger coaches jumped the railway line while negotiating a curve near Marionhill station. Accident occurred @ 05:00hrs Driver went into the tunnel & contacted Spoornet Control & then ESCAPED the crowds wrath by going through the tunnel
Marionhill Train Accident First emergency units arrived 10 - 15min later Info relayed to Metro Control & additional units dispatched 05:30hrs - FCP created and attempts at creating a CCS for red and yellow code patients was already in progress. Initially, great difficulty was experienced in clearing the highly emotional crowd of spectators away from the designated CCS
Marionhill Train Accident The CCS was eventually achieved utilising "reverse psychology" + local chief, who requested his community to assist in acting as stretcher bearers – this dissipated the not unexpected, high emotion present when EMS first arrived on scene. Often this emotion is unreasonable & directed at anyone representing some authority - use the emotion wisely - give people something to do!
Aerial view into the valley : 11 coaches involved, 2 separated & 9 derailed Tunnel + 2x coaches 200m away Durban bound
Note effectiveness of cordons in keeping spectators back
Marionhill Train Accident Acute shortages of stretchers in the early phase of the response, required that patients brought to the CCS were moved off the stretcher or board onto the ground, so that the stretcher could be reused for another patient
Marionhill Train Accident To CCS / FAP Empty stretchers going back
Marionhill Train Accident At this point & despite every effort, it had become obvious that the small dirt track winding down to the railway line, was completely blocked by numerous vehicles preventing ambulances shuttling patients up to the top of the hill. Other options had to be explored: –hand carrying the stretchers up the hill –SAAF 15 Sqdrn heli assets airlift ????
Marionhill Train Accident SAAF Oryx helicopters arrived overhead -> circled & the first came in hovering under the high tension Eskom power lines to land -> unloaded sorely needed 20 fold up stretchers -> before loading 7 - 8 red code patients on the floor of the aircraft + 1x paramedic Additionally a pilot joined the FCP with a ground- to-air radio to act as a local ATC & relay designated hospitals to the aircraft
Overview of Marionhill Accident Site Tunnel & Durban FCP CCS Yellow Code CCS + Buses + Bulk Supply Green code FAP + Buses Communications unit placed on hill top H2O Food Railway line in valley floor Heli LZ2 Eskom HT power lines across the valley Egress route to Durban Footpath through valley Heli LZ3 Main tarred road on hilltop 2 1 3 Heli LZ1
Marionhill Train Accident By 09:00hrs (4 hours after the accident), >380 patients moved by ambulance, disaster bus & helicopter (>60) to 12 different hospitals The patient loads were determined by the capabilities of the respective hospitals e.g. Marianhill Hospital accepted 50 green codes No hospital was sent more than 50 patients to prevent hospital overload
IT AINT FINISHED UNTIL THE FAT LADY SINGS! So true! 5/2/2002 Charlottedale Station near Stanger - Dead = 26 (>16 children) & Injured = 100
Concepts in Mass Casualty Management - In-Hospital FCP IC OC FAPCCS Incident CHA : Toys Wheels/Wings People Access routeEgress route COMMS Metro Control Primary & Secondary Hospitals Principles: FCP IC / OC FAP CCS CHA Access Egress Comms Hospitals
Triage- Comrades Marathon Medical Tent - A Planned Annual Disaster Medical Tent Triage Tent First Aid Tent Entry
Triage- Comrades Marathon Medical Tent - A Planned Disaster for 14,000 masochistic runners 1.Dr John Godlington 2.Dr Jeremy Bolton 3.? Where are the articles?? Mobile walking talking FCP
Simple & cleanable Burn pack Thomas bag ALS Spine broad Bulk stretchers Bulk C’ collars
Triage ER Resus OR/OT Wards ICU <- Power Sewerage Heli access Road access Water Lab / blood bank Containerised bulk supplies Wings + wheels egress Access into & Egress route out of FCP + Comms Staff accomadation Security cordon FAP Air Con Units Pharmacy
ER Triage / Resus Area - Waiting for the choppers – tents are sealed positive pressure units in case of biochem warfare
1 423 6 5 10 87 11 9 15 14 16 13 12 20 1918 17 1. OP entrance 2. Expat Dr Room 3. National Dr Room 4. Dental Room 5. Pharmacy 6. OP waiting area 7. Admin 8. Holding room 9. Tea Room 10. Toilet 11. Toilet 12. Lab 13. X-Ray 14. Shower 15. Janitor 16. Receiving / Triage Area 17. Foyer 18. ER Holding 19. Scrub 20. ER Original Point A Clinic floor plan (Not to Scale)
1 423 6 5 10 87 11 15 14 16 13 12 17 1. OP entrance 2. Expat Dr Room 3. National Dr Room 4. Dental Room 5. Pharmacy 6. OP waiting area 7. Admin 8. Holding room 10. Toilet 11. Toilet 12. Lab 13. X-Ray 14. Shower 15. Janitor 16. Receiving / Triage Area 17. Foyer New Point A Clinic floor plan (Not to Scale) ER / Treatment Room
1 4235 10 7 11 15 14 16 13 12 Triage Area Communications Centre KEEP CLEAR RADIO - BASE STATION RADIO H/HELD PHONE FAX H/PHONE Links: ERC / APO Security Jakarta Medical Medan / Sing Evac Aviation SLS / NSO Ambulances
1 423 6 5 10 87 11 15 14 16 13 12 Triage Area Access Clear outpatients and non- essential personnel Egress On notification of Incident Ambulance Holding Area A Establish Cordon SECURITY OFFICER ER / Treatment Room Open disaster stock Check communications Assemble & brief staff including all & additional ambulance drivers Check all ambulance radios communicating with base station Put out trestles & NATO stretchers for overflow Open pharmacy
1 423 6 5 10 87 11 15 14 16 13 12 Triage Area Access Clear outpatients and non- essential personnel Egress Arrival of Casualties Ambulance Holding Area A Establish Cordon SECURITY OFFICER ER / Treatment Room Monitor communications Place staff appropriately Monitor ambulance radios for ETA Assess triage on trestles & NATO stretchers Pharmacy to assist with supplies
Admin Lab 15 X-ray Triage Area KEEP CLEAR RADIO DESIGNATED HOLDING AREA HOLDING AREAS (MASS STOCKS) GREEN CODE PATIENTS YELLOW CODE PATIENTS COMMUNICATIONS RED CODE PATIENTS BLUE CODE PATIENTS Clinic – Mass Casualty Plan ACCESS EGRESS Resuscitation Area Mortuary Area + Security
Have SOMEONE engage politicians & media when they arrive, otherwise you will be chowed!
No cordon = chaos = Gauteng petrol tanker rollover 2008 – KISS for the idiots of this world
WHEN YOU ARE UP TO YOUR EARS IN CROCODILES - REMEMBER THE FACE!! I FCP IC OC FAPCCS CHA : Toys Wheels People Access routeEgress route COMMS Metro Control Primary & Secondary Hospitals THANK YOU With acknowledgement to Mr Alan White, FRCS & J.P.Keenan, FRCS, Chief AEMS 1981-1986 & 1986- 91 respectively