Disaster & Emergency Medicine Project

The Project establishes an Internet Presence

28th February, 1997-- To aid in the dissemination of information about the Project, a Website has been established and goes "online" on the 28th February, 1997.

We are indebted to Dr Tony Lembke of Medicine Australia, the Online Medical Journal, for providing the Web space and assitance in setting up the Site.

Link to Medicine Australia on the Internet : http://www.MedicineAu.net.au/

DISPLAN MODEL :

DISASTER AND EMERGENCY MEDICINE PROJECT

 

MEDICAL DISASTER PLAN

A Proposal for the Integration

of General Practitioners into local Displan

 

 

 

Produced by Dr. George Somers (General Practitioner Project Manager)

Ms Nicolette Torcello (Project Officer)

Dr. E. John Drinkwater (Webmaster)

and Mrs Kay Auden (Administrator).

 

INDEX

 

Introduction

Background to the Project

Rationale

Medical Displan Victoria

Model for the Integration of General Practitioners into Displan

Method of Callout

Roles & Responsibilities

Division Key Contact Person

Field Medical Team

General Practitioner Team Leader

General Practitioner Team Members

Identification of General Practitioner Team

Medical Supplies & Safety Equipment

Debriefing after a Disaster

Future Directions

Training and Liaison

Regionalisation

Benefits for General Practitioners

References

Acknowledgments

 

 

DISASTER AND EMERGENCY MEDICINE PROJECT

(Formerly Emergency Medicine Project)

Proposal for the Integration of General Practitioners into local Displan

Introduction

The Disaster and Emergency Medicine Project is funded through the Federal Government and is an initiative of the Sherbrooke and Pakenham Division of General Practice. The project looks at the desirability to involve General Practitioners in disaster management and to provide them with the necessary infrastructure, skills and equipment to respond to a disaster. The term 'disaster medicine' has been incorporated into the name to include emergency management and medical procedures performed at a disaster site. 'Displan' is used as the term to describe a disaster plan.

This proposal puts forward a model for the integration of General Practitioners into a local Emergency Response for Displan, and considers future coordination into larger teams, statewide and nationally.

Excellent work by Dr. George Corones of the Brisbane North Division of General Practice¹ improved the preparedness of GPs for a response to a disaster by collating information about General Practitioner facilities in his Division. He passed this on to the local and state Displan coordinators. He also collated the available Displan documents, and passed these on to the interested GPs. There are plans to spread this project throughout Queensland.

Our proposal looks at protocols for initiating a local medical response, at the organisational, educational, safety, and medical equipment needed by GPs and at the roles of key medical personnel. Nurse Practitioners have also been integrated into the plan, as has liaison with the other emergency services. The relationship between local, regional and State Medical Displan and other issues such as, debriefing are discussed. This proposal is designed as a guide for other rural Divisions of General Practice, initially in Victoria. It has been implemented locally² and has been considered favorably by the Victorian State Displan and National Displan.

Background

In January 1994, Dr. George Somers, a local General Practitioner, was invited to attend a mock disaster as a medical observer. The "Mock Disaster" was organized by the regional Country Fire Authority. The mock disaster involved the local Country Fire Authority, State Emergency Services, the St Johns Ambulance Service and Police..

The "disaster" occurred at Menzies Creek in the Dandenong Ranges, Victoria, Australia, and involved the collision of the Puffing Billy tourist train and a petrol tanker. The accident resulted in forty volunteers sustaining injuries of varying severity.

This is not an unlikely scenario as the Puffing Billy is a popular tourist attraction and the narrow, rough and winding roads of the Dandenong Ranges make driving particularly hazardous. Furthermore apart from the Emerald Ambulance Station and local general practices, the area lacks medical facilities. The nearest hospitals are each 25 to 30 minutes away, accessible only by narrow winding roads. Due to the magnitude of the "disaster" and the problem of transporting victims to hospitals, many of the injured were still in need of medical attention two hours after the incident.

It was apparent, and has been reported elsewhere^3-11, that if the injured had received immediate medical care, more lives could have been saved. Currently, this supply of medical personnel should come from either either a large distant hospital, or by a smaller more local one. With rationalisation of medical services throughout Australia, major hospitals are becoming less capable of mobilising appropriate Field Medical Teams rapidly, and staff in local hospitals would be required to treat the victims when they arrived there¹².

This mock disaster experience provided the impetus for the Sherbrooke and Pakenham Division of General Practice to seek funding for a project to train General Practitioners in disaster and emergency medicine and integrate them into the local Displan Emergency Response Team.

Rationale

Emerald, Victoria, is central to a population of 20,000 people and like many rural townships is geographically isolated from major services. In the event of a disaster, injured persons requiring immediate medical attention would need to be transported to the nearest Hospital, normally a 25 minute ambulance drive distant. As Ambulance Officers would need to negotiate the crowded, narrow, winding roads which in most places do not allow overtaking or speeding, even with sirens and lights, this time is likely to be greater rather than less. Although some advocate a ‘scoop and run’ policy when the incident is near a large medical facility, most would agree that, in the case of considerable time delay, adequate resuscitation is essential prior to and during transport.^7,9,13-18.

In a disaster, the need to administer immediate medical care is vital for the short and long term survival of victims^{3,6,9,10,17-20.}. Deaths from trauma typically occur in one of three distinguishable time periods^3,13,21.. The first peak occurs within seconds/minutes of the injury where only prevention of the accident could have avoided deaths. The second peak occurs within the first one to four hours of injury, described as the ‘golden hour’ resulting in 35% of deaths. The third peak occurs several days/weeks after the initial injury where death results from sepsis or multiple organ failure. Not only are increased survival rates likely to result from early and appropriate medical efforts (i.e. in the ‘Golden Hour’), but the costly treatment offered in Intensive Care Units would be significantly reduced.^3,20,22,23.

Local General Practitioners are currently called upon sporadically to render medical assistance^1,24-26 in Australian disasters. This is despite a call to utilise local community resources by several agencies^24,27-29.

Overseas, GPs are increasingly involved in Emergency Medicine. The United Kingdom has seen a massive return of General Practitioners into the emergency medicine field of road accidents^30-35 although some "flying squads" are Specialist based.^36,37 Canada seems to have a mixture of Specialist and General Practitioners involved in Emergency Medicine³⁸ The United States of America has built its local Emergency Medicine Services around the paramedics, and have regional centres which supplement and support local response to disasters^39-42.

Australian GPs have long had an interest in Emergency Medicine, and there have been some attempts to focus this into an organised response.^{43, 44} General Practitioners seem, however, reluctant to become involved^{10, 16} and are not encouraged to do so, as they are not often considered part of the emergency team.^8,20,45 Despite this, their desirability at a disaster site is well recognised.^5,46

Morale and self-esteem among Australian GPs are currently at a low ebb. In part this is caused by political, social, professional and financial manoueverings around them, over which they feel powerless. In the chaos of a disaster one needs self confidence, in order not only to make the right decisions, but to make any decision at all. It would therefore be reasonable to expect General Practitioners to be reluctant to respond to a disaster. Nevertheless, GPs generally do accept it as their duty to respond to an emergency, and indeed, do so when called upon.

It has been shown by Tolhurst et al⁴⁷., that 8.4% of emergency attendances of rural GPs involve very urgent or life threatening problems, yet "deskilling" of these GPs is as widespread as the closure of rural hospitals.

GPs do not always see this deskilling as a problem, however, because they feel they will cope when called upon, as the skills required are merely an extension of their everyday activities. This may be the case in most emergencies, but we can no longer rely on goodwill and good intentions to manage mass casualties in a disaster⁴⁸.

The many obstacles discussed above need to be addressed before General Practitioners can be expected to accept an appropriate role as first responders to medical emergencies. A structure to address these is proposed by this Project.

Throughout Australia, but especially in rural areas, GPs are usually the closest and most available doctors to a disaster site. A rapid, well coordinated response to a disaster by local General Practitioners would save lives and reduce both morbidity and its associated cost to the health budget and to the community.^3,14,33,42 Local Nurse Practitioners should be included in this local Field Medical Team. It is therefore important that General Practitioners have an understanding of disaster management and are appropriately trained to respond to a disaster situation.^{13’19’24’25’30’44’49.} Liaison, networking and integration with the other emergency services should be a high priority. Local GPs and Nurse Practitioners should be participants in Displan rather than be expected to render an ad hoc response at the time of need. It is obvious that the contribution of local health practitioners is maximised by appropriate planning and liaison.^24,50

Medical Displan, Victoria¹²

Displan (established under the Emergency Management Act 1986) provides the legislative framework for all organisations to respond to emergencies in Victoria.

Dr. Andrew Bacon, the chairman of the Health Subcommittee of Displan, coordinates all health related activities. He is also the Chief Medical Commander (CMC) of the Area Medical Coordinators (AMC) squad.

The AMC Squad coordinates first aid, ambulance, hospital admissions, specialized resources required at a disaster and those aspects of mental and public health which are appropriate in a disaster situation. The AMC Squad consists of eleven metropolitan AMC’s and thirty five rural AMC’s.

In the event of a disaster in the Dandenong Ranges, the Chief Medical Commander(CMC) would activate the two nearest Area Medical Coordinators. One would be appointed as the Forward Medical Coordinator (FMC) and placed at the disaster site, whilst the other would be placed in a central location to act with or for the Chief Medical Coordinator^12,24-26,46..

The Field Medical team response would be initiated by the CMC and would be responsible to the Forward Medical Coordinator (FMC)at the disaster site. Currently the Field Medical Team, "often made up of relatively junior members of staff, inexperienced in on-site emergency treatment" would be flown in by helicopter from a major hospital, with possible significant delays²².

Local immediate care doctors who are familiar with the pre-hospital environment, may be more appropriate than hospital consultants⁵¹ It is our contention that a trained, coordinated local GP Field Medical Team could be on site within minutes, well before the conclusion of the all-important "Golden Hour".

Model for the Integration of General Practitioners into Displan

A model for the integration of General Practitioners into Displan has been prepared in accordance with the protocols of the State and National Displan^7,8. The diagrams below illustrate a coordinated approach to General Practitioner involvement in response to a call-out by the CMC.

There would be three groups of General Practitioners, Stream A, B and C, each with designated roles. Medical procedures at the site will always be under the control of the most senior medical or paramedical staff, (i.e. Site Medical Coordinator), who may be the Area Medical Coordinator, the Medical Team Leader or the senior Ambulance Officer^24-26. When present the Area Medical Coordinator will be in overall command of total patient care on site.

Diag. 1. A schematic diagram of an idealised response from a General Practitioner Field Medical Team.

Diagram 1. represents a slowly evolving situation (e.g. bushfire²⁶), with adequate time to put the individual steps into process consecutively. Diagram 2. is often more realistic, showing that the first three steps often occur concurrently (e.g. major transport incident), and that Streams A and B +/- C, are activated together. It is only later, when the disaster site has been stabilised somewhat, that they are separated into "local" and "distant" groups.

Diag. 2. A schematic diagram of a realistic response from a General Practitioner Field Medical Team.

Stream A (GPs from local surgeries) represents a team of local General Practitioners who, being closest, would be the first GPs to respond to the disaster site. The team's responsibility is to provide immediate medical attention to the victims at the disaster site (the most good to the most victims). These GPs would then be joined by the Stream B (Potential Field Medical Team) and would triage^3,52,53, treat, resuscitate^3,54-56 and stabilize casualties at a patient treatment post in preparation for evacuation. When appropriate, Stream A (local General Practitioners) would return to their nearby surgeries to treat the 'walking wounded' as well as their regular patients. The treatment of the 'walking wounded' by local General Practitioners will relieve the demand on local hospitals to treat minor casualties and will enable them to concentrate on treating major injuries.

Stream B - (GPs Distant 1) represents General Practitioners from the potential Field Medical team who would come from nearby unaffected areas. The team’s responsibility would be to work with and eventually replace the local General Practitioners from Stream A, and provide on going assessment and emergency treatment of casualties at a designated patient treatment post prior to the transfer of injured persons to a hospital. In the case of "adequate" medical personnel at the scene, it may be appropriate for some to accompany the most severely injured to hospital⁵⁷.

Stream C (GPs Distant 2) represents 'distant' GPs not in Stream B who would act as ‘reserves’ should Stream A and B GPs need more personnel and/or equipment. In the case of a protracted disaster such as a bushfire Stream C would relieve Stream A and B after a period of time. Stream A General Practitioners may well be involved personally in the disaster and require relief at the outset.

Activation.

In the event of a disaster General Practitioners need to have a rehearsed protocol for initiating a coordinated medical disaster response.

After a single contact from the Area Medical Coordinator (AMC), the Division Key Contact (DKC - see later for details) person takes the prime responsibility for contacting the General Practitioners. This will generally be done from a predetermined hospital or major Surgery, which will form the headquarters of the General Practitioner response (GPHQ). Administrative support staff will also be called in. The DKC will contact GPs in order of proximity to the Disaster Site and/or expertise and will nominate the most experienced GP to be the Field Medical Team Leader. They will attend post haste, until a desired number of General Practitioners are in attendance at the disaster site.

The DKC in conjunction with the AMC will meanwhile allocate some local Surgeries and/or Hospitals to be opened and staffed to receive the "Walking Wounded." Some excess GPs from the Site and Streams A and C will support the staff of these. The DKC will contact remaining GPs of the Division to ascertain the reserve capacity of the Division.

Division Key Contact Person (DKC)

The role of the Division Key Contact person is crucial in implementing an expedient and effective disaster response. This person is responsible to the Area Medical Coordinator and activates the model only at the request of the AMC. The DKC enables the AMC to activate the model with a single telephone call. The DKC will normally be organised through the relevant General Practice Division.

Responsibilities

Attend regular local Displan meetings and liaise with State Displan representatives where appropriate

Maintain updated records of local General Practitioners, their contact numbers which will include home and practice phone numbers, facsimile, pager numbers and mobile phone numbers.

Have available a current detailed regional map of the Division which includes detailed road routes, the location of General Practitioners’ Practices and residential addresses, and details of resources available.

Be available to the Area Medical Coordinator and be prepared to call-out and coordinate General Practitioners of the Division.

Provide General Practitioners and Surgeries with information on the nature of the disaster, types of casualties expected, any special requirements, options for transportation and transportation routes.

Coordinate relief for the General Practitioner Teams.

Ensure adequate immediate and long-term debriefing for all involved staff.

Field Medical Team

It is essential that when the medical team (Stream A local GPs) arrive at the disaster site they report initially to the Site Medical Coordinator/Ambulance Coordinator or to the Command Post when established. This is important for the Site Medical Coordinator who needs to be aware of available resources in order to allocate tasks and to establish order within the controlled Medical Area. In particular the medical team should remain in areas allocated for duty and move from these areas only under direction of the Site Medical Coordinator. A GP Team Leader (preferably with Early Management of Severe Trauma (EMST) training) should also be appointed by the DKC to coordinate and direct the team.

General Practitioner Team Leader

The GP Team Leader will be responsible to the Site Medical Coordinator.(SMC)

Responsibilities

Report to Command Post and see Site Medical Coordinator for orders/liaise with Ambulance Coordinator.

Ensure that team members are suitably attired and have with them the Action cards and necessary disaster kits.

Assemble the team to discuss likely risks, injuries, priorities, plan of action, check medical supplies and use of triage labels.

Divide team into working pairs (doctors/nurse) and ask team members to revise action cards. (card listing responsibilities)

Triage and label victims, decide priorities both in terms of treatment and transport, allocate team members to deal with problems and assist with resuscitation once all patients are triaged.

Report yellow and red triaged victims to Site Medical Coordinator who will arrange disposal through Senior Ambulance Coordinator.

Ensure that team members attend a general debriefing.

Disaster kit equipment and supplies are to be recovered where possible and restocked.

Forward a written report of activities to the Chief Medical Coordinator and Health Authorities.

General Practitioner Team Members

GP team members will work in pairs (ideally with a Nurse Practitioner) and be responsible to the Site Medical Coordinator and/or the GP Team Leader.

Responsibilities

On arrival to disaster site report to Command Post for briefing .

Be prepared to work in pairs to triage, resuscitate and stabilize the victims and in addition prepare victims for transport and if necessary commence treatment.

Ensure that the appropriate attire and disaster kits are on hand.

Attend the debriefing sessions for medical personnel.

Team members need to remember to work with a team, watch for dangers, beware of neck and spine injuries, coma positions for unconscious patients and avoid unnecessary movement of victims. Provide only quick and simple treatment if possible and ensure that unstable patients are constantly monitored by medical/first aid personnel. At the appropriate time after the designated Field Medical Team arrives local General Practitioners can be relieved to assume the responsibility of treating the 'walking wounded' in local surgeries. All General Practitioners should assist the Red Cross to keep lists of all victims (including bystanders).

Identification of General Practitioner Teams

It is important that General Practitioners are provided with appropriate equipment both for the purpose of safety and to distinguish medical response teams from other personnel. Green tabards with fluorescent 'Doctor' written both front and back should be supplied. These are best kept at local Ambulance Stations, and delivered to the site by them. In addition GP s should be issued with photograph name tags with a color code indicating skill level.

Medical Supplies and Safety Equipment

To ensure that General Practitioners are appropriately equipped they need the necessary medical supplies and safety equipment. Recommendations for safety equipment include fire resistant overalls, fluorescent tabards, helmets and safety boots

A 'typical' doctors kit might include (as well as the ‘usual’ contents of the ‘Doctor’s Bag’) a set of Guedel airways, endotracheal tubes, linen tape, laryngoscope, self inflating bag, bandages, safety glasses and rubber gloves.

Major supplies would be transported to the site with the first returning ambulances. These have been described elsewhere.^24,34.

Debriefing after a Disaster

Disasters have a tremendous emotional and psychological impact on victims and responders. All disaster response personnel should have the opportunity to debrief after a traumatic incident. Debriefing allows people to describe their experiences and emotions. This process increases the rate of recovery from the initial stress and allows victims to resume to a normal level of functioning. Ideally the debriefing of individuals should occur within 72 hours of the trauma, longer delays make debriefing less effective. Those who are not debriefed after a traumatic incident are at an increased risk of depression and post traumatic stress disorder. In addition to short term debriefing, responders and victims should be offered long term counseling. Currently there are two sources of this counseling: Public psychiatry units, and Church groups who have been trained to State regulated standards. General Practitioners are ideally placed to work with both, adding their own expertise to the team.^58,62.

Future Directions

The most cost effective and realistic way to overcome the triple requirements of retraining, liaison and involvement, is through local, integrated, multidisciplinary, modular, education.⁴⁹

Most General Practitioners are likely to be involved in very few disasters. In order to utilise the expertise and equipment most efficiently, it has been found that regional structures work best^{51, 60,61.}

Training and Liaison

In order for General Practitioner to be effective members of a medical response team they need to be appropriately trained. Such training opportunities need to be created at the local level to involve all emergency service organisations, where there is sometimes a deficiency in Acute Trauma Life Support (ATLS). This opportunity for networking and liaison is invaluable⁵⁰.

In addition to local training, General Practitioners should be afforded the opportunity to gain disaster and emergency medicine skills through a comprehensive education program. A survey of local General Practitioners carried out by this Project, showed that whilst 98% felt that they should be involved in disaster planning, only 32% felt confident attending a disaster. Only 35% had skills adequate for a disaster.

This project is currently exploring funding options for the development of a distance education package. This should be comprehensive, national and accredited by the Colleges. A modular system has been proposed, for ease of attendance, and a certificate of completion is envisaged. This could best be delivered to rural areas by a mobile teaching unit in the form of a "travelling circus" which would travel from Division to Division. In terms of cost, it has been suggested by Snook⁴⁹ that this unit could combine its role with that of flying squad, chemical incident unit and major accident vehicle, although this might be less easily achieved in Australia than the U.K. It could also provide administrational assistance to the maintenance of this project, once implemented.

The education package would be developed by the Monash University Centre for Rural Health, Moe, Victoria, in conjunction with the RACGP and be available to both rural and urban General Practitioners. It is intended that the package would cover all aspects of disaster medicine including an overview of disaster management, site safety, State and National Displan, chain of command, the roles of General Practitioners and the emergency services, medical and triage procedures, debriefing, recovery, and medicolegal issues. It would also cover all aspects of emergency medicine, and would highlight their application in a disaster setting. It would have a significant "hands-on" component.

The RACGP is considering its use as a core component of the Rural Registrar Training Scheme. It is not seen as an alternative to the EMST Course run by the Royal Australian College of Surgeons, but complementary, as those interested in advanced training would also attend the EMST course.

Skills achieved would need to be maintained. As General Practitioners are unlikely to be involved in more than one or two disasters in a medical lifetime, regular practice would need to be provided. This could be in local or larger hospitals (Accident and Emergency or Anaesthetics Departments) or through the Ambulance Service. Another method for interested General Practitioners would be to attend roadside accidents again. This would be of great benefit to the General Practitioner, other emergency services personnel, and the community.

Regionalisation.

Throughout the world it is recognised that Emergency Medical Services perform better if they are regionalised, and indeed have a national basis.^41,42 The U.K. has its "flying squads" and GP Accident Services, which have come under the umbrella of the British Association of Immediate Care Schemes (BASICS)⁵⁹ The USA bases its regional response on specialist trauma centres, but the Disaster Medical Assistant Teams (DMAT) consisting of about five physicians (often GPs.) and support staff, assist when local services are overwhelmed^39,41,60,61. There is a National Disaster Medical System (NDMS) which can muster several large aeroplanes, and 100,000 hospital beds! Both the "Flying Squads" and the DMATs are voluntary, but have a system of remuneration for responders.

Each State in Australia has its own unique "Displan"/Emergency Response plan, and there are regional and local sub-plans. These are supported by committees with active members. Until now, there has been very limited use of General Practitioners as first responders and this is usually as individuals, not teams.

Prior to the introduction of Divisions of General Practice, General Practitioners in Australia have not been geographically grouped. The vast majority of General Practitioners admit they would respond to a local disaster. It is now possible to form General Practitioner based first response teams (Field Medical Teams) within the existing Displan and could define ‘local’ as the Division.

As disasters know no boundaries, it is imperative that this project be expanded over the whole of Victoria, and Australia. Members of Urban Divisions (where such a scheme may, or may not be necessary) could train and form DMAT-type support teams. A national approach will be necessary to enable a uniform application of this project. As each state has unique requirements the project should proceed one State at a time.

Benefits To General Practitioners

This scheme allows for the development of mutual support, which may be carried over into day-to-day practice. Skills gained in preparing for a disaster would be transferable to day to day general practice, as Tolhurst et al. showed⁴⁷. Skill maintenance could be achieved by attending roadside accidents, again. Liaison with other EMS personnel (especially ambulance) would improve our working relationships and professional standing in the community. Education programs for the public (schools and newspapers) would highlight the roles of the General Practitioner in the community. The current low morale amongst General Practitioners could be improved by reclaiming the GP's position within the broader community.

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ACKNOWLEDGEMENTS

Dr. Andrew Bacon Chief Medical Commander State Displan

Mr. Rob Birch Group Manager, Victorian Ambulance Service

Mr. Michael Burgess Metropolitan Ambulance Service, Emerald.

Mr. David Cleater Country Fire Authority, Emerald

Dr. Paul Flood Monash University, Centre for Rural Health.

Mr. Richard Gilhome Director, EMST, RACS.

Dr. Hugh Grantham Medical Director, SA Ambulance

Dr. John Gruner Local General Practitioner

Dr. Rob Hall, Monash University, Centre for Rural Health.

Sgt. Gary Huntington Emerald Police Station

Dr. Peter Noonan, Director, A&E, The Angliss Hospital.

Prof. Roger Strasser, Monash University, Centre for Rural Health.

Dr. Sarah Strasser, Director of Rural Training, RACGP.

Dr. David Vissenga Area Medical Commander Dandenong Ranges

Dr. Rod Wellard, Director of Education, RACGP.

Dr. Johannes Wenzel Director, A&E, Dandenong and District Hospital.

Mr. Don Withers, Emergency Management Australia.

For More Information Contact:

Disaster & Emergency Medicine Project
c/- Emerald Medical Centre, Murphy's Way, Emerald, Vic Australia 3782
Tel: +61 (0)359 684 622
FAX: +61 (0)359 685 750
Internet: john_drinkwater@onaustralia.com.au

Send mail to john_drinkwater@onaustralia.com.au with questions or comments about this web site.
Copyright © 1997 Disaster & Emergency Medicine Project
Last modified: February 14, 1998