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Malaysian Trauma Life Support (MTLS) Penang 2013MAJOR INCIDENT MANAGEMENT

EMERGENCY MEDICAL SERVICE RESPONSE

ONLY A FOOL LEARNS FROM EXPERIENCE.I LEARN FROM THE EXPERIENCE OF OTHERS.Otto Von Bismarck 1815-1898

Definition & TypesDirective 20, N.S.CComponent of ManagementContingency Planning & ProtectiveHospital Activation PhaseIncident Site Management Recovery & Rehabilitation MAJOR INCIDENT MANAGEMENT Emergency Preparedness-prevention planning, research and response in connection with emergencies in peace and war time.

DEFINITION(Referring Directive 20, N.S.C)A regional event that involves a large number of casualties in a large geographical area that overwhelms the available local resources & service.MAJOR INCIDENT MANAGEMENT DEFINITIONSMass Casualty Incidents (MCIs)Disaster in which patient care resources are overextended but not overwhelmed, focus on most life threatening injuries

Mass Casualty Events (MCEs)Disaster in which patient care resources are overwhelmed and cannot be immediately supplemented, focus on identifying those patients with the greatest possibility of survival.

DARK SIDE OF MODERNITY

More complex, widespread & with a larger scale of losses due to:

Increased technologyIntensive urban developmentGreater area of habitationSophisticated transportationIncreased motorisationDISASTER

An interface between an extreme physical event & vulnerable human populationSusman et al

1. NATURAL DISASTERSEarthquakes, hurricane, volcano eruption etc.2. TECHNOLOGY & HUMAN RELATEDCollapsed building, war, air crash, transport accidents.3. HYBRID CIVIL EMERGENCIESWhen both components are involved eg. Flood with collapsed building. TYPE OF DISASTER OR MCI

ANATOMY OF A DISASTERThe physical happening which is determined by the geographical area, physical structures, infrastructure of the area, number of lives and the exact nature of destruction

PHYSIOLOGY OF A DISASTERThe social occasion and mechanism of the process of disruption which will determine the consequence and impact of the event.

Human and Technology Related IncidentStructural CollapseMass Transportation e.g. Plane crashTerrorismWarWeapon of Mass DestructionPetrochemical Industry

HYBRIDEcological Balance DisruptionLandslideFloodingUrban Oriented Flash FloodStorm and Typhoons El Nino

Weapon of Mass Destruction (WMD)DefinitionVery High Yield Conventional Explosive

Dispersal of an AgentChemical, Biological or RadiologicalUnknown by Kind, Method, qualityCauses Casualties and or Damage to Property

OutcomeMass CasualtiesPsychologicalLoss of Public Trust in AuthoritiesEconomical

TYPES OF W.M.D.RadiologicalBiologicalChemicalExplosive and Incendiary Devices

W.M.D.Similar to Hazardous Materials eventsChemical, Biological, Radiological has the potential for mass casualtiesChemical, Biological, Radiological event is a crime sceneWidespread psychological impactEmergency Medical Service and hospitals and overwhelmed

W.M.D.Psychogenic casualties predominateResponding personnel are at risk for personal injuryCriminal event - need for evidence preservationNumber of victims and dead are greater.

CHEMICAL TERRORISMCopycat attacks in Japan using cyanide, phosgene, and pepper sprayPossible sarin attack in Disneyland1997 Sydney, Australia chlorine bombs in shopping centers injure 14-500 evacuated.

DIRECTIVE 20, NATIONAL SECURITY COUNCIL( N.S.C.)

DIRECTIVE 20 NATIONAL SECURITY COUNCILDISASTER:An event that occurs suddenly.Complex in nature.Loss of lives.Destruction of property and/or environment.Disruption of the community daily activities.Divided into 3 main level of categories depending on the management capability and capacity

DIRECTIVE 20 NATIONAL SECURITY COUNCIL (NSC)LEVEL 1Localized major incidentunder controlnot complexsmall no. of casualties and property loss minor disruption of daily community activitiesmanageable by the local authorities not requiring multi sectoral involvement.e.g. bus accident, train derailment, landslide.

Directive 20 NSC Level 1:

Bencana Tahap 1

LEVEL 2 Widespread over a large area but under controlComplicated and complexLarge no. of casualties and property loss.Affecting daily community activitiesNot manageable by the local authorities requiring assistance from other states or National AuthoritiesSupport required, Regional or National Support e.g.: Highland Towers Collapse, Greg Storm Sabah, Bright Sparklers.

National Security CouncilPrime Ministers Dept.Chairman : DPM/ MinistersMember : All Director General and Sec. Gen. of all MAJOR Relevant MinistryConsultant/Expert/Core TeamSecretariat: National Security Unit

LEVEL 3Involves a very large area.Loss of many lives.Total Destruction of infrastructure and public facility.Complicated and complex.High risk to rescue workers.Complete disruption of daily community activities.Major destruction of resources.All local resources destroyed and assistance from external resources required.e.g. Earthquake, typhoons, volcanoes, war.

MAJOR INCIDENT MANAGEMENT1. Depend on the severity of conditions2. Depend on the resources available3. Geographical location4. Political situation

APPROACHPRINCIPLE OF DISASTER MANAGEMENT

DO THE GREATEST GOOD FOR THE GREATEST NUMBERPhases of Disaster Management1.Preparation2.Mitigation3.Response4.RecoveryCONTINGENCY PLANNING

CONTINGENCY PLANNINGForward Planning ProcessProcess rather than documentationConsensus buildingDefining actionsPutting systems in placePrevent damage control and limit consequences

CONTINGENCY PLANNINGRisk analysis and assessmentResource matrix preparationObligation of allDirector, HOD, Community LeaderDynamicInter agency and multi sectoredERP and alert system

Contingency PlanningCOMMITTEEGeneral CommitteeJKKD/ JKKN / MKNSpecific CommitteeRadiation, Disease Outbreak, Petrochem, FloodHigh Profile MembershipGOVT, CORPORATE, NGOS

Contingency PlannersPolitical willExpert groupStrategistFinancierTechnical groupResearcherAnalystPolicy makers

Contingency PlanLaw & EnforcementFire & RescuePolice

SURVEILLANCE AND DETECTION Natural Disaster:Seismological, Forecasting, Remote Sensing & Warning SystemAlert System e.g. Satellite Radar SystemG.I.S. & Remote Sensing ( N.R.S.A. ) Hazard MappingTracking e.g. Cyclone Tracking

INCIDENT SITE MANAGEMENT

1. Zoning and coding2. Work matrix3. Medical Base Station Layout4. Role & responsibilities5. Human resource management6. Triage- Primary- Secondary7. Forensic activities8. Public Health9. Psychological Management

INCIDENT SITE MANAGEMENT

Incident AreaHigh Risk ZonePolice Base StationFire Base StationMedical BaseCOMMAND CENTRE(TACTICS ZONE)PRESSFamily & RelativeAmbulance HQ TransportationSTRATEGY ZONEOn Scene Commander POLICE ( OSC )On Site Medical Commander ( OMC )Forward Field Commander BOMBA (FFC)ZONING CONCEPT AT THE INCIDENT SITE:

Incident Site ManagementZONING

RED ZONEInner ZoneHigh Risk ZoneApprox. - 50 to 100 mFor Rescue workers, marshal, fire unitRapid response team (Medical Team)

INSIDENT SITE MANAGEMENTTake a genuine inventory of current capabilitiesInstruct personnel about disaster plan using realistic scenariosPlan must address triage, decontamination, and treatmentRectify deficiencies in training, equipment, and supplies

INSIDENT SITE MANAGEMENTDevelop strategies to overcome resistance to preparednessIncorporate responsible people in the planning process Keep the plan cost effectivePlan for problems that are likely to occurCommunication and sharing of informationSecurity, traffic control, hospital accessStaff identification, triage, decontamination, information management

INSIDENT SITE MANAGEMENTParticipate in joint planning-Work together with emergency medical service, law enforcement, fire-Integrate plan into community-wide disaster planDevelop mutual aid agreementsDevelop policies and procedures

Effect on First Responder - Need for Protective Gear - Constraints on Movement and Communications - Limitations on Duty Time - Coordination Challenges - Psychological Incident Characteristics

Universal Protection SystemBehaviour and Culture of practice:-Hand wash.Handling patient.Handling specimen.Handling of contaminated item.Barrier nursing.

Personnel Protection SuitSuitGloveBootsOxygen respirator Suit cooling systemSealed containerGogglesWork Discipline and Culture

Decontamination of the Victim

Decontamination Process

Decontamination process of Environment

Sealing of Contaminant

Decontamination of Personnel

PITFALLSRequires increased awareness and training of Emergency Medical Service personnelDetection equipment is not availableEmergency Medical Service personnel must depend on clues to identify a Biological Warfare attackReport concerns to officials

Rescue, Evaluation & Treatment DetectionDetection is difficult since Biological Warfare have no immediate warning propertiesStark contrast to chemical agentsDetection equipment not readily available

Mobile Decontamination Cargo

Protection Suite

Public EducationHelps alleviate public fearsMechanism to teach protective measuresMust include media and public officials (centralize)Educate the publicKEY POINTS

Large numbers of dead expected in an Chemical, Biological, Radiological terrorist eventConsider special decontamination proceduresTemporary morgue are requiredHandling the Dead

Hospital Activation Phase

HOSPITAL ACTIVATION PHASEA Hospital Response NOT Emergency Dept. ResponseA Hospital StrategyHandled by Hospital AuthorityA Mandatory requirement by Ministry of Health, MalaysiaALL Hospital personnel must be AWARE of the Response Plan.

HOSPITAL ACTIVATION PHASE1. Activation Of the Alert System

2. Establishment of specific zones/centers

HOSPITAL ACTIVATION PHASEMust contain specific measures relating to:1. Assessment of the hospitals capacity2. Activation of the plan3. Establishment of chain of command4. Communication5. Logistics aspects/treatment areas

INCIDENT CALLER999 PoliceNGOsMRCSSt.JohnFire & RescueCivil DefenseHospital OperatorEmergency Dept. Registrar Head of Dept. Emergency Services Director of HospitalYellow AlertPolice ConfirmationConfirmationFalse AlarmStand DownDeclare Red AlertHOSPITAL ACTIVATION PHASE ALERT PHASE

Establishment of Chain of CommandInterhospitalPrimary responding hospitalSecondary responding hospitalIntrahospital

Primary Responding HospitalThe main hospital leading the managementCoordinating RoleClosest and most well equipped hospital

Role Of Primary Responding HospitalCoordination with other agencies e.g. Police, FireDispatching Search and Rescue TeamProviding On Line supervision and assistance to the incident site.Coordination with other support hospitalsCoordination with Communication and Dispatching Center

Secondary Responding HospitalSupporting HospitalAssist in the followingReceiving patientSuppliesPersonnelEquipmentActivate on request of the Primary responding Hospital

HAP CoordinatorHosp DirectorAdmin CoordinatorDep. Director of HospClinical CoordinatorSenior ClinicianSupervisorPharmacistSecurityDieticianMatronHODSMA of EDPharmacistED SisterCHAIN OF COMMANDOrganizational Aspect:

Role of Hosp Coordinator

Administrative CoordinatorAdmin CoordinatorDep. Director of HospMA SupervisorPharmacistSecurityDieticianMatronWardRelative Mx AreaOTTrafficTotal SecurityTransportLogisticsControl Centre

1. Control Center/ Operation RoomNerve center where all decisions and strategies are discussed / issued.Coordination of all activitiesAct as main communication center & sources of all information / press statements

Manpower For The Centera. Members of Major Incident Mx Committeeb. Medical Director c. Administrative Coordinator and his team of supervisors d. Other members identified by the medical directorESTABLISHMENT OF SPECIFIC ZONES/CENTERS

2. Non Clinical Areas/Zones

a) Hospital Information Center- center to provide information and queries of relatives of victims- provides counseling and assistance to relatives when needed- can also serve as the information center for the press- should be away from the clinical areas eg lobby- manned by social worker, PRO and non-critical staffb) Relative Management area- functions as waiting room for relatives- best placed beside the information centerc) Bereavement room- close to body holding area - staff trained in grief management and counseling

3. Clinical Zones

- At the Emergency Department (ED)- At designated treatment areas

a) Patient reception and triage areab) Treatment areac) Body holding aread) Emergency department control center

a) Patient Reception & Triage Area:Designated for triaging & sorting and of patientsUsually located at the front entrance of the dept.Serves as a crowd controlling areaDirect relatives to appropriate zonesManaged by Doctors, Paramedics Tight security area

Triage Zone In Hospital:Strategically locatedManned by senor and experience staffNot a registration ZoneSmooth triaging prevent congestionChannel patient to the appropriate zone

b) Treatment areasDepartment Divided Into Zones:

RED ZONE CriticalStabilized, resuscitated and managedimmediatelyYELLOW ZONETrolley area (semi critical)Expand the existing areaMove patients up to the ward rapidlyOpen up wards for the trolley patientGREEN ZONEWalk - in area (non-critical)Away from the Emergency Dept.Do not congest the deptRecord and Document ALL Discharges

c) Body holding areaplaced away from the clinical area

d) Emergency Department Control Centersituated in the EDkeeps tract of patients movementthe link and support for the ED and incident siteclose communication with the hospital operations center and relay and update information to the centermanned by ED supervisor and matron

BE PREPARED!CONCLUSION

THANK YOU!

Malaysian Trauma Life Support (MTLS) Penang 2013