1. Emergency Medical Service (EMS) Planning David Alexander University College London

2. The emergency medical challenge a critical part of critical infrastructure rationing of essential medical and health services bringing medical response into the field rationalising medical transportation preparing for emergencies inside and outside the medical centre. 3. Medical effects of disaster 4. The phases of a medical emergency: (1) Impact damage to health facilities, lifelines damage to communications channels loss of some medical personnel (2) Emergency - isolation medical aid administered with manpower, equipment, supplies immediately available in disaster area (3) Rehabilitation local resources augmented by those from outside the area 5. DISASTER VICTIM Search and rescue NOT INJUREDINJUREDMedical assistancePublic health measuresHEALTHYWORSENING OF PATIENT'S CONDITIONINFECTED Medical assistanceIMPROVEMENT OF PATIENT'S CONDITIONRECOVERS IMPROVEMENT OF PATIENT'S CONDITIONDISEASESWORSENING OF PATIENT'S CONDITIONMortuary DEATH and funeral servicesINJURIES 6. Earthquakes: expected pattern of injuries dead serious multiple injuries simple fractures minor injuries: bruises, lacerations, etc. Ratio of serious to slight injuries: from 1:9 to 1:30 7. Percentage of people brought out alive from under collapsed builings 100500 0.5 1 Hours 3 1 2 3 4 5 7 10 15 Days Survival time 12 8. Rescue loopINCIDENT WITH VICTIMSFirst aid medical postIncident command postMortuary areaTriage areaAmbulance loading areaHelicopterMain cordonMedical post for rescuersPrimary assembly areaSecondary assembly area Minor injuries treatmentRoad block Mass media post 9. Pattern of hospital admissions after a sudden impact disaster 10. Estimation of structures damaged Estimation of casualtiesEvaluation of hospitals in region (emergency function)Evaluation of regional medical potential 11. Medical centres (especially highlevel trauma centres) need to: remain functional during crises adapt to dynamic circumstances know when to move into emergency mode have interoperability have autonomy of fuel & other supplies. 12. Emergency health service planning 13. HOSPITAL AND HEALTH SYSTEM EMERGENCY PLANMUTUAL ASSISTANCE PACTSMUNICIPAL EMERGENCY PLANINDUSTRIAL AND COMMERCIAL EMERGENCY PLANSAIRPORT AND TRANSPORT EMERGENCY PLANSREGIONAL AND COUNTY OR PROVINCIAL EMERGENCY PLANSNATIONAL EMERGENCY PLANCULTURAL HERITAGE EMERGENCY PLAN 14. Hospital emergency planning framework Internal: emergency in the medical centre fire contamination External: emergency outside medical centre general mass-casualty influx specific mass-casualty influx (e.g. burns) External emergency affects medical centre structural damage inoperability. 15. Disaster in the medical centreDisaster in the system of medical centresDisaster in the external environmentCoordinated EMS Disaster plansDisaster planning for the medical centreDisaster planning for the medical systemDisaster planning for the external environment 16. Plan for the following medical aid: rescue: medical assistance during SAR first aid: advance medical post hospital: main or prolonged treatment transfer: inter-hospital movement [HEMS / road ambulance interaction]. 17. Mass-casualty logistics after disaster search, rescue and care of the injured recovery and disposal of the dead monitoring and control of communicable disease organisation of shelter, health care, sanitation and food supply for survivors special care for neonates, the sick, the elderly, people with disabilities. 18. Triage 19. Triage - 14th century French - an act of choosing; in use in English since 1728, in medicine since 1930 20. Triage: the classification of injuries on the basis of who would gain the greatest benefit from the most immediate attention. A form of rationing scarce medical resources in times of excessive demand for them. 21. Highest priority to patients: whose prognosis would increase dramatically with some rapid and simple medical care Lower priority to patients: with simple or light injuries, or who are moribund and would need intensive care for limited or uncertain benefit. 22. Triage is carried out on patients at the scene of the disaster to determine priorities for immediate stabilising treatment at the ambulance loading loop to determine priorities for transport to medical centres in the reception area of the receiving hospital - to determine priorities for immediate medical treatment. 23. Incident: Incident casualty generator commander Rescue and Communications link Hold patients recovery loop until functionality Medical director T1 Staging post and capacity of hospitals is Communications assessed link Ambulance Advance Mortuary circuit and Hospital T2 aerial equivalent direction medical post Hospitals Assess structural damage, available personnel, number of beds 24. Helicopter routesAmbulance routesTelecommunications linesT1Secondary transport routesT2Primary triage pointsSecondary triage pointsPulmonary specialists Hospital I Hospital IIWaiting areaT2T2 T1Major burns unitDisasterSecondary treatment centreT2Incident command post Incident commander MortuaryEmergency operations commanderOperations centreCoronerRelatives of victims 25. First-wave protocol: ambulances not to load patients until last red-code patient has been triaged and full transportation priority has been established. 26. Triage categories: Ivital functions compromised, life in danger, rapid assistance urgently needed - REDIIserious injuries that can wait a few hours for treatment - YELLOWIII light injuries that can wait some hours before being treated - GREENIVmoribund or dead patients - BLACK 27. Categorisation of patients is somewhat subjective 28. The French method: AU - absolutely urgent (red)RU - relatively urgent (yellow, green) UD - mortuary case (black) (urgences dpasses) NU - case not urgent 29. Injury severity scoring employs anatomical or physiological methods abbreviated injury scale (divides body into 7 anatomical zones) respiration, pulse, verbal response (RPV) method (physiological) 30. Triage at medical evacuation centre: EU - extremely urgent (red) U1 - first-level urgency (red)U2 - second-level urgency (yellow) U3 - third-level urgency (green) 31. Trauma index: A - ambulatory (0-1) MS - moderately serious (2-4)CR - critical but will recover (5-7) CRU - critical, not likely to recover (>7) 32. Triage data patient's personal details field triage data (colour, scores) hospital triage determination details of patient's clinical condition details of treatments applied results of any diagnostic tests final treatment to be given to patient. 33. Advance medical post 34. Advance medical post (first aid post) at a safe location near the crisis scene must be accessible and autonomous must be deployable in two hours needs enough doctors and nurses stabilises patients for transport to hospital. 35. Yellow: to the relatively urgent cases area as necessaryRelatively urgent cases Green: non-urgent evacuationField triageFIELD MEDICAL POSTMedical evacuationRed: to the absolutely urgent cases area as necessaryAbsolutely urgent cases Black: to the mortuary or other site 36. Field medical post zones patient assessment and triage area first aid and patient stabilisation area ambulance loading area waiting area for ambulatory patients temporary morgue. 37. The congestion problem 38. The instantly deployable "mini-AMP" 39. Typical emergency medical work respiratory function recovery, intubation, assisted breathing thoracostamy with drainage tube recovery of circulation, haemostasis analgesia, anaesthetics first-aid burns treatment emergency amputation general treatment of injuries. 40. Field hospital 41. Field hospital: an autonomous, usually portable structure with clinical, diagnostic and general medical capabilities slow to deploy, expensive to run, often underutilised more useful for general medicine than disaster medicine can substitute for damaged permanent hospitals needs to be well equipped and staffed can be modular, can be containerised. 42. Field hospitals - typical problems in the wrong place; inaccessible set up too late to treat the injured lacks interoperability with local services runs out of supplies lacks patient medical records other solutions may be cheaper. 43. Mass Fatalities 44. The dead:- plan for body recovery identification of bodies labelling and photography death certification uncontaminated preservation of evidence collection and storage of personal effects organising an area for examination of bodies. 45. The dead: organising a temporary mortuary finding a suitable building organising logistical and administrative support health and safety at work role of the chief pathologist. 46. The dead: identification commission directed by the chief pathologist orthodontic specialist expert on biometry (fingerprints, etc.) forensic anthropolist? recording and preserving evidence of positive identification police and social services contact near relatives. 47. The dead: organise identification visits to bodies in a separate area of the mortuary, with controlled access organise and direct services to receive relatives and friends of the deceased the need to preserve dignity religious and cultural needs of relatives minimise the stress on relatives exclude the mass media. 48. When an inquest is needed violent or unnatural death cause of death not known other specific circumstances. 49. The coroner must establish: the identity of the deceased how and of what he or she died when and where he or she died the registration of death, which depends on these factors. 50. No one owns a body, but there are "rights of possession"To avoid confusion, and to avoid overburdening hospitals, the bodies must be taken to a temporary mortuary located at a distance and in an area protected against public intrusion. 51. The temporary mortuary is used for: identifying the bodies establishing the cause of death preserving the body (if necessary) cosmetology (if requested) preparing the body for the funeral. 52. RETRIEVAL OF BODIES SceneBody Holding Area Temporary MortuaryMortuary 53. A temporary mortuary at its worst.Photos courtesy of Prof Erik Dykes 54. Good. 55. An effective emergency mortuary plan was important part of London response to 7/7The London temporary mortuary 56. The London prefabricated mortuary 57. Requirements for a temporary mortuary ("dry area"): access for ambulances and parking area security and privacy lights, heating, ventilation hot and cold running water, drainage telephones. 58. Requirements for a temporary mortuary ("dry area"): a room for body identification an office for the coroner an x-ray room [+ developing facilities] showers and toilets area for stockpiling coffins screens for the mortuary entrance. 59. Requirements for a temporary mortuary ("wet area"): tables for autopsies area for washing bodies area for examining teeth area for embalming. 60. Requirements for a temporary mortuary ("wet area"):- refrigerators overall dimensions: 200 sq. metres - 30 x 2 m for managing 200 bodies - a larger work area for pathologists. 61. Identification of disaster victims needs information on the deceased to be collected from relatives or medical, dental or criminal record data needs sufficient post mortem data. 62. Means of identifying bodiesUsing only one criterion: visual recognition by relatives or close friends of the deceased fingerprints (only for people with a police record). 63. Means of identifying bodies Using at least two criteria together:- fingerprints (taken at victim's home and compared with those of the body) dental records surgical scars, skin blemishes, tattoos, piercings, etc. 64. Means of identifying bodies Using at least two criteria together: clothes and personal effects (money, documents, telephone, jewellery, etc.) estimate of the age of the subject exclusion and elimination criteria. 65. An example of religious requirements bodies of practising muslims: identification is urgent because of need to ascertain identity as a muslim keep bodies of muslims together bodies laid out on clean surfaces and covered with simple white sheets head turned towards right shoulder face turned towards Mecca bodies always buried, never cremated. 66. Conclusions 67. Health systemEmergency medical responseEmergency communicationsContingency planningEmergency responseSearch and rescueEmergency management 68. Section 6.1 pp. 189-216