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The General Practitioner as First Responder in a Major Medical Emergency.
Authors: Dr. George T. Somers (MB. BS., B.Med.Sci., Dip.RACOG.) General Practitioner, Emerald Medical Centre, Murphys Way, Emerald. Victoria. Project Manager, Disaster and Emergency Medicine Project(DEMP), Sherbrooke and Pakenham Division of General Practice.
Dr. E. John Drinkwater (M.B.,B.S. FRACGP) Solo General Practitioner, Mount Dandenong Whole Health Centre, Mount Dandenong. Victoria. Webmaster, DEMP.
Nicolette Torcello (B.A. Grad.Dip.Health Ed.), Project Officer (DEMP).
Responsible Author: Dr. George T. Somers, Emerald Medical Centre, Murphys Way, Emerald. Victoria. Ph. (03) 5968 4622. FAX (03) 59685 750
Email : g.someres@r150.aone.net.au
ABSTRACT:
Our research reveals that rural and semi-rural General Practitioners feel they should be involved with disaster planning (87%) and should respond to a disaster (81%). However, only 36% felt confident in responding to a disaster and 75% felt they should know more about emergency medicine. These figures clearly show the need of rural General Practitioners for a better understanding of their role in medical disasters.
The Australian Emergency Manual - Disaster Medicine (1) briefly mentions General Practitioners as a resource but fails to outline their role or responsibilities. The Victoria State Medical Emergency Response Plan (March 1997) (2) has included General Practitioners as first responders, and more detail of their involvement is being developed.
Whilst there have been many articles and seminars on the Ash Wednesday Bushfire and Port Arthur Shooting disasters, the role, responsibility and support structure of GPs and the effect of the disasters on them, have received little attention.
Whilst it is beyond the scope of this paper to address the effects of a disaster on GPs in depth, it looks at the role of the General Practitioner as a First Responder in a Disaster in rural and semi rural Australia. Hopefully, a structured involvement, with adequate preparation and recovery, will minimise harm to these respondents.
It is written after a Local-GP-Response to disasters has been incorporated into the local Displan of one region (3). This response was successfully activated by Victoria State Displan during the Dandenong Ranges Bushfire disaster of January, 1997.
SPOT CHECKS:
- Whilst in some areas, some General Practitioners play an important role in Medical Displan, General Practitioners are an underutilised resource in the management of Medical Disasters.
- We have found that General Practitioners are willing and available to respond to a Medical Disaster in rural and semi rural Australia, but most lack the confidence, training and organisational framework to do so.
- General Practitioners as first responders, are at risk of the same if not more, psychological trauma as the other Emergency Services, but usually lack the organisational support to deal with it.
- Divisions of General Practice are seen by GPs to be the appropriate link between them, the other Emergency Services, and Medical Displan.
- Whilst the concept of GP as First Responder is largely limited to the country, committed urban GPs could provide a valuable reserve force in a large or protracted Disaster (2).
DEFINITIONS:
A Disaster is said to have occurred when normal community and organisational arrangements are overwhelmed by an event, and extraordinary responses need to be instituted.(1)
First Responder has become the generic term for those who arrive at the scene during the early phases of the response, i.e., before centralised coordination is in place.
Displan is the abbreviation for the State Emergency Response Plan.
The Phases of Emergency Management consist of Prevention, Preparation, Response and Recovery.
INTRODUCTION
In January 1994, a 'Mock Disaster' exercise took place at Menzies Creek (near Emerald) in the Dandenong Ranges, Victoria, Australia, and involved the collision of a petrol tanker with the Puffing Billy tourist train. The accident resulted in forty 'victims' sustaining injuries of varying severity, many with spinal, femur and pelvis fractures. The two nearest hospitals are each 25 to 30 minutes away, and, apart from the Emerald Ambulance Station and local general practices, the area lacks medical facilities. Due to the magnitude of the 'disaster', problems extricating victims with spinal injuries from the rough terrain, and the problems of access and transporting victims to hospitals, many of the injured 'died' unnecessarily and many more had not been evacuated from the site two hours after the incident. This is not an unlikely scenario as the Puffing Billy is a popular tourist attraction and the busy, narrow, rough and winding roads of the Dandenong Ranges make driving particularly hazardous.
Local authorities agreed at the formal debriefing that these conditions, and worse, could have applied in a real situation.
It was apparent here, and has been reported elsewhere (4-6), that if the injured had received immediate medical care, more lives could have been saved. Indeed, Hogan and Grantham (6) reported in a study of 183 road trauma victims, that '6 lives were definitely saved and morbidity was reduced in many other instances' through local General Practitioner attendance at the accident scene. This led us to the hypothesis that the early involvement of a team of well-trained local General Practitioners and Nurses at a Disaster, could also result in improved outcomes.
THE NEED FOR 'IMMEDIATE CARE'
Deaths from trauma typically occur in one of three distinguishable time periods (4,7).. The first peak occurs within seconds/minutes of the injury, where only prevention of the accident could have avoided deaths. The second peak occurs in the second to fourth hours of injury, (described as the 'golden hour') resulting in 35% of deaths from trauma in motorised countries with advanced trauma services. 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, but the costly treatment offered in Intensive Care Units would be significantly reduced.(4)
Preventable deaths occur due to a failure to make fast and appropriate clinical assessments and rapidly to institute the appropriate resuscitative measures which should be within the capability of all medical graduates (4). The Golden Rule of disaster medicine is to 'do the best for the most', and not to perform 'heroics for the hopeless' (8). This is at odds with the General Practitioner's usual modus operandi in 'one-on-one' care. (9) Triage, (and this Golden Rule in particular), requires particular attention in the training of GPs for disasters, and in debriefing afterwards.
Although some would advocate a 'scoop and run' policy when an 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, to increase the chances of the patient arriving at the hospital alive and in a reasonable condition for definitive surgical care. (7) A General Practitioner medical team, therefore, needs to be able to institute appropriate resuscitative measures.
MEDICAL PERSONNEL AT THE DISASTER SITE
A source of medical personnel which until now seems overlooked in disaster planning throughout Australia (1) is the General Practitioner workforce. It is ubiquitous and therefore local to the Disaster site, having local knowledge of resources and obstacles; yet it is multifocal, so unlikely to be immobilised by the disaster itself. It is generally 'on-call' 24 hours of the day, especially in the country, and can be rapidly mobilised. Our research has shown that rural General Practitioners themselves feel they should be involved in disaster planning (87%), and 64% think most GPs (urban and rural) will one day be obliged to attend a disaster.
Despite having several senior Australian GPs on the National Consultative Committee on Disaster Medicine, The Australian Emergency Manual (1) discusses the role of local General Practitioners in two paragraphs. The first admits their ability to assist, and the second states that their contribution is maximised by appropriate planning and liaison. Far greater detail is needed, and this paper seeks to start this process.
Currently, the source of medical personnel for a major medical incident would be a large distant hospital. (8). It seems inappropriate to deplete the response capability of the local hospital by sending its doctors and nurses to the scene. In rural areas with nearby hospitals, however, this may provide the most rapid initial response. Hospital staff could be relieved to return to the local hospital as soon as more of the local General Practitioners/Nurses are mobilised.
Towns without hospitals are becoming increasingly prevalent, and General Practitioners/Nurses in these towns would more likely be first responders. The absence of a local hospital means that these GPs will need to have better emergency training and equipment availability, as patients are more likely to present directly to their surgeries. They have been identified as requiring special consideration in the provision of equipment and ongoing training, both for the day to day emergencies and disasters (9).
Medical Displan Victoria (1997) (2) now introduces GPs at the First Responder and possibly, at Field Medical Team levels. Whilst their role is not yet fully explained, there is, we believe, a framework in that document for the integration of GPs as first responders to disasters.
One of the most significant reasons GPs have not hitherto been called upon to give more than an ad hoc response to a disaster is that there has been no widespread regionalisation of Australian General Practitioners prior to the introduction of Divisions of General Practice.
Hence it was difficult to organise GPs into groups and potential teams could not easily be identified. Our research has shown that General Practitioners see their Divisions as the appropriate organisations to facilitate their integration into Displan.
It is appropriate that local Nurse Practitioner volunteers should be included in this local Field Medical Team (3,8). During the implementation of our project, we have found that local nurses are at least as keen to be involved in Displan as the General Practitioners.
GP OR NOT GP
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 (10). Canada seems to have a mixture of Specialist and General Practitioners involved in Emergency Medicine (12). The United States of America has built its local Emergency Medicine Services around the paramedics, and have regional centres which supplement and support the local response to disasters (13,14).
In Australian disasters, local General Practitioners/Nurses are currently called upon only sporadically, to render medical assistance (15). This is in spite of a call to utilise local community resources by several agencies (1,16-18). Their desirability at a disaster site is well recognised. (6,7,15,20) Australian GPs have long had an interest in Emergency Medicine, and there have been attempts to focus this into an organised response as much as twenty-five years ago.
THE RISKS OF AN ad hoc RESPONSE:
It has been shown by Tolhurst et al (21), that 8.4% of emergency attendances of rural GPs involve 'very urgent' or 'life threatening' problems. GPs feel they will cope when called upon in a disaster, as they believe the skills required are merely an extension of their everyday activities (22). This is open to some dispute, and some areas of contention (triage, one-on-one management, debriefing) have already been mentioned.
Our experience has identified two factors in a disaster which may compromise the General Practitioner, which are not present in an emergency in the surgery. The first is the effect of the disaster itself on the community in general. As a member of the community, the GP will suffer the same overwhelming feelings of loss and hopelessness as everyone else, i.e. will be a victim of the disaster. This may affect his/her ability to respond unless he/she understands the "bigger picture" and feels a part of it. Hence the need for the GP to be officially integrated into Displan and trained as a part of the 'team', with all the involvement in the Preparation Phase that this entails, and currently seems lacking.
It is almost inevitable that the rural General Practitioner would become involved in any major emergency within his/her community. Initially this will be as a respondent to the emergency itself, however, from the moment of involvement, the GP will, consciously or unconsciously, be assisting the community towards recovery. As the General Practitioner is seen as a stable, responsible, influential and helpful leader in the community, he/she is in an ideal position to lead recovery from within the community. Indeed, it is one of the basic tenets of Emergency Recovery that the community should be supported to manage its own recovery (27).
Whilst being seen to be involved in the response phase will set the scene for a more effective role in the recovery phase, this is the second factor which marks the General Practitioner as a victim of the Disaster. Harm minimisation and the recovery of General Practitioners can best be effected through recognition of their special needs. Perhaps the most important of these is the inclusion into a General Practitioner team to help inter alia mitigate the effect on the GP of having to be seen as a stable, responsible, influential and helpful leader whilst, in reality, feeling as lost as the next victim. The formal team structure would enable appropriate preparation, help ensure the best possible response and the safest recovery.
His/her ability to function during the response phase may be affected by the degree to which he/she has become a victim of the Emergency per se. We believe that his/her ability to function during the recovery phase and beyond is more likely to be affected by the degree to which he/she has become a victim of the response. This latter effect may not declare itself until much later.
Proposed Call-out Procedures
Medical Displan Victoria (1997) describes two avenues of involvement for General Practitioners in the Response Phase of a Disaster. The first is as Volunteers arriving on-site individually, and the second is as the Field Medical Team. Our proposal, modified since the published plan (23), is to utilise both of these. The importance of the General Practitioner as the cornerstone of community recovery will not be further discussed in this paper.
Local rural General Practitioners would attend the site upon notification by their own local networks (usually local ambulance, local police or patients) after first alerting the Divisional GP Key Contact Person (GPKCP), with whom they would remain in telephone (mobile) contact. The GPKCP, who has a close working relationship with the local Area Medical Coordinator, will notify the AMC of the activities of the Division members. After consultation with the GPs and the AMC, the GPKCP will mobilise more Volunteer GPs, Nurses, and/or a GP FMT as appropriate. These local Volunteers will naturally be responsible to the AMC, but the most experienced may need to act as SMC until the arrival of the AMC.
The CMC would activate the GP Field Medical Team by ringing the Division's GPKPC, who would notify the GPs of the incident and conditions and coordinate deployment of the GP FMT. It is likely that this GP FMT will be made up of more distant GPs, who would relieve the local first responder General Practitioners, so that they can return to their surgeries or local hospitals where they would be more appropriately deployed. Additional reserves of equipment and personnel could be sourced from within the Division, or from other urban or rural Divisions as appropriate. Such a structure has been implemented in the Emerald local Displan (3,23)
EXPERIENCE OF THE PLAN
The Plan, as outlined above, has been activated once in a mock disaster, and once in a real disaster (the Bushfires of January, 1997).
The mock disaster consisted of a telephone call-out of the GPs of the Sherbrooke and Pakenham Division of General Practice in response to a fictitious bus crash at 5 p.m. on a Saturday afternoon. Participants had had no pre-warning and were not expected to actually attend the site, but to state whether they would have done so in a real situation, and how long they expected it would take to arrive. Our Nursing Team had not been fully established at this time and was not involved. The result of the exercise was that ten General Practitioners could have been 'on-site' within an hour of call-out, the first within 5 minutes.
During the Bushfire Disaster in the Dandenongs on 21st January, 1997, the Division was put on standby by the CMC. There was concern that a Supportive Residential Care Home may have been at risk. The GPKCP had the first two GPs on standby within 4 minutes and seven more on alert within an hour. The first Nurse Practitioner was present at the GP Headquarters (GPHQ) within 35 minutes, and another five within 90 minutes of activation.
The CMC had been informed that it was not possible to evacuate the SRC Home, but with our local knowledge and support from the local services, we were able to coordinate this evacuation to the GPHQ, which by this time had 6 Nurses and 3 GPs in attendance. Together with the CMC and the Department of Human Services, we arranged transport and overnight accommodation for the 36 elderly and debilitated residents.
Meanwhile, the CMC requested the GPKCP to provide a GP presence in each of four Evacuation Centres. Within an hour (as this did not require urgent deployment) there was a GP and a Nurse at each of the Centres.
Whilst the General Practitioners and Nurses involved were not required to save lives or attend the scene of a major incident they did all that the CMC asked of them, and more. This event highlighted the effectiveness and flexibility of the Plan, and the usefulness of local General Practitioner involvement in the management of Displan.
SUMMARY
In many rural areas, the General Practitioner is usually involved in major emergencies through an involvement with the local hospital. Most Area Medical Coordinators in Victoria are, in fact, GPs. However, an organised response by teams of GPs per se has not hitherto been recognised.
The role of the General Practitioner in a disaster has been discussed, and a local General Practitioner based disaster response plan has been described. Whilst this Plan has been developed based on the needs of the region, we believe that similar Plans, varied according to local conditions, could easily be set up throughout the whole of rural Australia.
Based on our research of General Practitioner attitudes to Disasters, we believe that they consider that involvement in a disaster is inevitable, and that the majority of GPs are not comfortable with their competence to respond. These GPs want their Divisions of General Practice to address the problems of Emergency Management training, liaison and planning.
This Project was not expensive to set up at a local level, and maintenance of the plan as described is relatively simple. The challenge is out for all Divisions to take an interest in this exciting and rewarding area of General Practice.
REFERENCES
1. Australian Emergency Manual - Disaster Medicine. Emergency Management Australia. Commonwealth Department of Human Services and Health, National Consultative Committee on Disaster Medicine, National Disaster Relief Committee (1995) Chapter 1 Paragraph 1.01: Chapter 13 Paragraph 13.06, 13.07.
2. Victoria State Medical Emergency Response Plan. Medical Displan Victoria. March, 1997.
3. Huntington G. Local Emergency Plan-The Initial Response. Relative to the Emerald, Clematis Menzies Creek Areas. Standing Plan. Revised Copy: 1996-97.
4. Royal Australian College of Surgeons. 'Early Management of Severe Trauma' 1992 Capitol Press Pty Ltd Box Hill Victoria.
5. Skinner, D. Fisher, J. The multiply-injured patient and the GP. The Practitioner 1988 232 870-873
6. Hogan, C. Grantham, H. The role of the GP at the roadside. MJAust. 1994 161: 175-176.
7. Evans, R.C. Evans, R.J. Accident and emergency medicine-I. Postgrad. Med. J 1992 68, 714-734.
8. 'Medical Displan Victoria - Hospital Medical Team Sub Plan & Disaster Site Procedures Revised 1995.
9. Campbell, D. Strasser, R. Kirkbright, S. Survey of Victorian rural General Practitioners in towns without hospitals. Monash University, Moe Campus. December, 1996.
10. Silverston, P.P. Physicians at the roadside: Pre-hospital emergency care in the United Kingdom. Amer. J. of Emer. Med. 1985 3:561-564.
11. Fulde, G. Help! A disaster with multiple casualties. Modern Medicine Aust. 1997 40, 104-109
12. Cohen, L. Federal disaster-planning exercise brings 30 emergency MDs together fo week-long course.Can. Med. Assoc. J 1991. 145 871-872
13. Roth, P.B. Status of a national disaster medical response. JAMA 1991 266:1266
14. Pretto, E.A. Safar, P. National medical response to mass disasters in the United States: Are we prepared? JAMA 1991 266:1259-1262.
15. Bacon, A. Medical Displan-What happens in Victoria when there is a major disaster? "In Concert No. 5" Sept 1995, Dept. Health & Community Services Newsletter Victoria.
16. "Disaster Management" Report of the Senate Standing Committee on Industry, Science, Technology, Communications and Infrastructure, June 1994.
17. "A Healthy Disaster" A total health involvement in disaster management. Report of the Medical and Health Disaster Workshop held at the Australia Emergency Management Institute from 23-27 March 1994.
18. "No More Ambulances?"An Australian medical and health disaster perspective. Report of the Medical and Health Disaster Workshop held at the Australian Counter Disaster College from 5-9 November 1990.
19. Pacy, H. Rescue and first aid for our highways.MJAust.1972 1:704-707
20. Ashby, R. Emergency Medicine in the 90s-the changing role of the General Practitioner. Current Therapeutics April 1995. 17-18
21. Tolhurst, H. Dickinson, J.M. Ireland, M.C. Severs emergencies in rural General Practice. Aust. J. Rural Health 1995 3: 25-33.
22. Klein, J.S. Weigelt, J.A. Disaster management-Lessons learned. Surg. Clin. Of N. America. 1991 71 257-267.
23. Somers, G.T. Torcello, N. Auden, K. The Medical Disaster Plan-A proposal for the integration of General Practitioners into local Displan. Published by the Sherbrooke and Pakenham Division of General Practice. (distributed to all GP Divisions in Australia.)
24. Grantham, H. The General Practitioner's guide to emergency services. Aust. Fam. Phys. 1994 23:129-133.
25. Nocera, A. and Dalton, A.M. Disaster Alert! The role of physician-staffed helicopter emergency medical services. M.J.A. 1994. 161. 689-692
26. Cooke, M. W. Arrangement for on scene care at major incidents. BMJ 1992 305: 748.
27. Harper, J. Emergency Recovery response to the Port Arthur shootings: an operational management perspective. Aust, J.E.M. 1997 Vol.12 No.1: 2-4.
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