This document discusses emergency medical service planning for disasters. It covers triage, which involves classifying patients based on who would benefit most from immediate medical attention. An advance medical post provides initial stabilization near the disaster site. Field hospitals can substitute for damaged hospitals but have challenges. Mass casualty management involves search and rescue, medical care, disease monitoring, and mortuary services. Temporary morgues are needed to identify victims and determine causes of death. Overall, effective EMS planning requires coordination across various emergency response plans and medical facilities.
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.
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 INJURED
INJURED
Medical assistance
Public health measures
HEALTHY
WORSENING
OF PATIENT'S
CONDITION
INFECTED
Medical assistance
IMPROVEMENT
OF PATIENT'S
CONDITION
RECOVERS
IMPROVEMENT
OF PATIENT'S
CONDITION
DISEASES
WORSENING
OF PATIENT'S
CONDITION
Mortuary
DEATH and funeral
services
INJURIES
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.
8. Percentage of people brought out
alive from under collapsed builings
100
50
0
0.5
1
Hours
3
1
2 3 4 5 7 10 15
Days
Survival time
12
9.
10.
11. Rescue
loop
INCIDENT
WITH VICTIMS
First aid
medical post
Incident
command
post
Mortuary
area
Triage
area
Ambulance
loading area
Helicopter
Main cordon
Medical post
for rescuers
Primary
assembly
area
Secondary
assembly
area
Minor
injuries
treatment
Road block
Mass
media
post
15. 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.
18. 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.
19. Disaster in
the medical
centre
Disaster
in the system
of medical
centres
Disaster in
the external
environment
Coordinated
EMS Disaster
plans
Disaster
planning for
the medical
centre
Disaster
planning for
the medical
system
Disaster
planning for
the external
environment
20. 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].
21. 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.
23. Triage - 14th century French
- an act of choosing; in use in English
since 1728, in medicine since 1930
24. 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.
25. 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.
26. 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.
27. 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
28. Helicopter routes
Ambulance routes
Telecommunications lines
T1
Secondary transport routes
T2
Primary triage points
Secondary triage points
Pulmonary
specialists
Hospital I
Hospital II
Waiting
area
T2
T2
T1
Major
burns
unit
Disaster
Secondary
treatment
centre
T2
Incident
command
post
Incident
commander
Mortuary
Emergency
operations
commander
Operations
centre
Coroner
Relatives
of victims
29. First-wave protocol: ambulances not to
load patients until last red-code patient
has been triaged and full transportation
priority has been established.
30. Triage categories:
I
vital functions compromised, life in
danger, rapid assistance urgently
needed - RED
II
serious injuries that can wait a few
hours for treatment - YELLOW
III light injuries that can wait some
hours before being treated - GREEN
IV
moribund or dead patients - BLACK
35. The French method:
AU - absolutely urgent (red)
RU - relatively urgent (yellow,
green)
UD - mortuary case (black)
(urgences dépassées)
NU - case not urgent
36. Injury severity scoring employs
anatomical or physiological methods
• abbreviated injury scale
(divides body into 7 anatomical zones)
• respiration, pulse, verbal response
(RPV) method (physiological)
37. Triage at medical evacuation centre:
EU - extremely urgent (red)
U1 - first-level urgency (red)
U2 - second-level urgency (yellow)
U3 - third-level urgency (green)
38. 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)
39. 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.
41. 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.
42. Yellow: to
the relatively
urgent cases
area as
necessary
Relatively
urgent cases
Green:
non-urgent
evacuation
Field
triage
FIELD
MEDICAL
POST
Medical
evacuation
Red: to
the absolutely
urgent cases
area as
necessary
Absolutely
urgent cases
Black: to
the mortuary
or other site
43.
44. 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.
49. 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.
50. 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.
52. 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.
53. 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.
54. 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.
55. 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.
56. When an inquest is needed
• violent or unnatural death
• cause of death not known
• other specific circumstances.
57. 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.
58. 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.
59. 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.
65. 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.
66. 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.
67. Requirements for a temporary mortuary
("wet area"):• tables for autopsies
• area for washing bodies
• area for examining teeth
• area for embalming.
68. 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.
69. 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.
70. Means of identifying bodies
Using only one criterion:• visual recognition by relatives
or close friends of the deceased
• fingerprints (only for people
with a police record).
71. 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.
72. 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.
73. 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.