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Overview Of The Basic
Principlesin the Management of
Disaster/Mass-CasualtyIncidents
Dr Nik Ahmad Shaiffudin Bin Nik HimEmergency Physician
Hospital Sultanah Nur Zahirah
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Presentation Outlines1. Definitions2. Our Experiences3. The guidance 4. Emergency Medical Response5. Summary/Conclusions
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Definitions
When the destructive effects of natural or man-made forcesoverwhelm the ability of a given area or community to meet the
demand for health care. ~American College of Emergency Physicians~
A sudden ecologic phenomenon of sufficient magnitude torequire external assistance .
~World Health Organization~
An Interface between an extreme physical event & vulnerablehuman population
~ Susman et al ~
Generally defined by the effect on people and infrastructure resulting in the
loss of the ability to respond independently
Disaster.....
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Definitions cont. MCI: Large number of victims .enough to
overextend/disrupt the normal course of emergency andhealth care services not overwhelm your facility s capabilities.
Mass Casualty Event The number of casualties overwhelmshospital capabilities (usually >20 patients). MCM: management of victims of a mass casualty event,
aimed at minimizing loss of life and disabilities.
The magnitude 1 - 99 casualties: Mild 100 - 999 casualties: Moderate
=>1000 casualties: Major ~American College of Emergency Physicians~
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TYPE OF DISASTER/MCI1. NATURAL DISASTERS
eg. Earthquakes, hurricane, volcano eruption etc.
2. TECHNOLOGY & HUMAN RELATED
eg. Collapsed building, war, air crash, transport accidents.
3. HYBRID CIVIL EMERGENCIES e.g. When both components are involved eg. Flood withcollapsed building.
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People killed and affected by type of disaster in the world(Period 1994-2003)
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Source: ADRC, Japan based on CRED EM-DAT database, 2003
Summary of Natural Disasters
(1975-2002) Number of Disasters
Number of Killed
Number of TotallyAffected People
Amount of Damage(1,000 US$)
World 7,104 2,063,633 4,797,950,112 982,894,232
Asia 2,676 (38%) 1,182,637 (57%) 4,269,422,754 (89%) 480,536,348 (49%)
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Malaysian Experience
Date Disaster/Major Incident/MCI Dead Injured
19 Oct 1968 Collapse of 4 storey building, KL 7 11
Jan 1971 Monsoon flood spilled over to West
Coast of W. Malaysia
24 National
EmergencyDeclared
31 July 1988 Collapse of Sultan Abdul HalimJetty, Butterworth, Penang
32 1674
22 Sept 1989 Fire at Sek. Agama RakyatTaufiqiah Khairiah Al Halimiah, Yan,Kedah
27 6
7 May 1991 Fire & Explosion of Bright SparklesFireworks Factory, Sg BuluhSelangor
22 103
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Date Disaster/Major Incident/MCI Dead
Injured
15 July 1996 Tourist Bus Accident,Landslides at KM 15, Genting
Highlands, Pahang
20 23 injured
29 Aug 1996 Mudslides at the Aborigines;Village in Pos Dipang,Kampar, Perak.
50 12 injured250 homeless
26 Dec 1996 Tropical Storm GREG(Typhoon) Keningau WestCoast Of Sabah.
270 26 injured3,000 homeless1,150 affected
1 30 Apr1997
Enteroviral Outbreak SibuSarawak
25 Many affected
Malaysian Experience
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Date Disaster/Major Incident/MCI Dead Injured
July Oct1997
Country wide haze in Malaysiaand haza emergency inSarawak
Enviroment Damage,Health Problems &Economic Losses.
24 Dec 1997 Fire and Explosion Shell SMDSBintulu Sarawak.
12
Feb May
1998
Forest and peat fires
throughtout the country
3000 hectares of
forest burnt
Mac Sept1998
Water supply crisis in KlangValley
1.8 Million residentsaffected
4 Feb 1999 Kg Gelam Landslides 17
Malaysian Experience
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Date Disaster/Major Incident/MCI Dead InjuredOct 98 June 99
Japanese Encephalitis (JE) OutbreakIn Perak, Negeri Sembilan andMelaka.
101
28 Jan 2002 Ruan Changkul Simunjan, SarawakLandslide
16
2003 SARS Anthrax Scare
2004 Avian Flu26 Dis 2004 Tsunami 64 69
28 Mac2005
Earthquake Nil
Malaysian Experience
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POS DIPANG 30 AUGUST 1996
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HIGHLAND TOWERS 11 December 1993
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GREG TYPHOON 26 DECEMBER 1996
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PENANG FERRY BRIDGE 31 DECEMBER 1988
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Powders, Powders Everywhere
Anthrax Scare Threatens Malaysia
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Yearly monsoon reminder in the
East Coast of Malaysia
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Kg. Sungai Muda, Kedah
Pictures fr om KEDAH & L ANGKAWI
Kuala Chenang, Langkawi
Kuala Muda KedahChenang Beach, Langkawi
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Bagan Jermal, Penang
Pictures from Penang..
Gurney Drive, Penang
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Terengganu Experience ???
Flood at Setiu, Terengganu on 18 December 2005.Source: NST
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Date Disaster/Major Incident/MCI Dead Injured2002 5 kereta MVA Sg Ular 15
2003 Bas sekolah Vs Lori , Sg Ular 5 16
2003 Bas sekolah terbalik di Jln Air Putih 20
2003 MVA 4 wheel Vs Car Vs Van Pekerja,Kemaman
11
2007 Bas sekolah MVA 1 33
2008 Car VS Van Pelancong, Cherating 1 8
9/7/08 MVA Trak tentera Vs Van, Cherating 1 20
15/7/09 Fire Engine slide, Manir 9
Terengganu Experience1.Motor vehicle accident
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MEMBERS OF NSC
Chairman : Prime MinisterDeputy Chairman : Deputy Prime Minister
Members : Minister of Defense
Minister of Home AffairsMinister of Foreign AffairsMinister of InformationChief Secretary to The Government
Chief of The Armed ForcesInspector General of Police
Secretary : Director General
National Security Division
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Directive 20 of the NationalSecurity Council.
Disaster
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
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LEVEL 1
Localized major incident
under control
not complex small no. of casualties and property loss
minor disruption of daily community activities
manageable by the local authorities notrequiring multi sectoral involvement.
e.g. bus accident, train derailment, landslide.
DIRECTIVE 2 NATIONAL SECURITY
COUNCIL
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LEVEL 2 Widespread over a large area but under control Complicated and complex Large no. of casualties and property loss. Affecting daily community activities Not manageable by the local authorities
requiring assistance from other states orNational Authorities
Support required, Regional or National Support
e.g. Highland Towers Collapse, Greg StormSabah, Bright Sparklers.
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LEVEL 3 Involves 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 fromexternal resources required.
e.g. Earthquake, typhoons, volcanoes, war
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ORGANISASI PENGURUSAN BENCANA
SEKRETARIAT /URUSETIA
OPERASI
PDRM JBPM SMART JPA3 ATM RELA Perkhidmatan
Perubatankecemasan
Lembaa PelesenanAtom
PDRM JBPM SMART JPA3 ATM RELA Perkhidmatan
Perubatankecemasan
Lembaa PelesenanAtom
SOKONGAN /LOGISTIK PERUBATAN
ATM PDRM JKR Majlis Daerah
Tempatan Pejabat Daerah TNB Telekom
PerkhidmatanPerubatanKecemasan
ATM PBSM St. John
Ambulance
KEBAJIKANKAWALAN
KESELAMATAN
PDRM RELA
JabatanKebajikanMasyarakat
PerkhidmatanPerubatanKecemasan
PBSM St. John
Ambulance RELA
MEDIA
Jabatan Penerangan
Jabatan Penyiaran
INSIDEN /BENCANA
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INCIDENT SITE
SMART
PDRM
EmergencyMedical Services
JBPM
PKTK
PertahananAwam
ATM
YELLOW ZONE
RED ZONE
Access Road
Guard Post Operating zone for SpecialisedSearch And Rescue Units
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SMART
PDRM
EmergencyMedical Services
JBPM
PKTK
PertahananAwam
ATM
YELLOW ZONE
RED ZONE
Access Road
Guard Post Guard Post Operating zone for SpecialisedSearch And Rescue Units
GREEN ZONE
Aid Agencies and NGOs
FamilyBereavementCentre
CounselingCentre
TemporaryMortuary
MediaCentre
Rest Area
Food Store
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Safety First !
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Emergency Medical responseMass Casualty Management System
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Disasters/MCI
Survival skills is the key element for victims Elemental needs of the human person Aim to survive until help arrives (days / weeks / never) Community Resilience
Principle for responders doing the most for the most Limited resources requires responders to provide
assistance to those with a good chance of survival Best available treatment may not be sending the patient
to the hospital Elemental care is vital
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Save life Prevent escalation of the incident Relieve suffering
Protect the environment Protect property Rapidly restore normality Assist any criminal investigation @ enquiry
Perform the above in a coordinated, and safe way
Recovery and lessons learnt
Emergency Medical response
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Rescuing the rescue team ??
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A Multi-sector Rescue Chain
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INAPPROPRIATE APPROACH
SCOOP & RUN - competition & no coordination CLASSICAL CARE APPROACH - basic triage
& field before evacuation but no coordination between the field organization & the receivinghealthcare organization.
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MCM APPROACH
Pre-established procedures for resource mobilization,field management & hospital reception.
Approach is adapted according to specific situational problems (topography, infrastructure, communication,health facilities)
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Triage Triage,Immediate
Evacuation
FIELD ORGANIZATION
EVACUATIONSCENARIOS
1
3
2
Advance Medical PostTriageStabilization
Controlled Evacuation
Non-TriageImmediate
Evacuation
TriageTriageStabilizationImmediate
Evacuation
4
TriageTriageStabilizationImmediate &
Delayed Evacuation
5
Scoop & Run
Stay & Play
Mass CasualtyManagement System
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The Impact of a Mass-Casualty / DisasterEvent on the Hospital service
Disruption of on-going and routine services Overwhelming of ED resources Mobilisation of staff and resources
Unaccustomed working environment Event stress leading to post-traumatic stress Adverse effect on quality of care Control of situations with patients, relatives, press, other
hospital staff Information control Event disrupts ability of hospital to respond or mobilise
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Always-be-ready concept Anytime anywhere Activation and Response phases
In any mass casualty or disaster, the role of the
medical team deployed includes.... Primary ambulance response Disaster triage Control of Medical Operations at site of incident On-scene/site management
Transfer decisions Hospital activation Receiving of in-coming patients
Disaster/MCI Preparedness
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Disaster Plan
2 main phases
Emergency Dept activation phase
Hospital Activation phase
3-stage Alert system
Yellow Alert Red Alert Green stand-down
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ALERTING PROCESS
Notification & verification. To evaluate the extent of the problem. To ensure that appropriate resources are informed &
mobilized. MOBILE/FLYING/ASSESSMENT TEAM COMMUNICATIONS!!!!!
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Phases of Medical Response
Activation event is first discovered Scene assessed
Command established
Implementation Search and rescue Triage
Stabilization Transport Definitive management of
patients and scene
Recovery Withdrawal from scene Resume normal operations
Debriefing Analysis of event
Mitigation Lessons learnt
Risk Mapping Contingency Planning
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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
Management of the Event itself is as important as themanagement of the individual patient
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Principles of FIELD MCM
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SAFETY MEASURES
IMPACT ZONE (red): strictly restricted to professional rescuers.
SECONDARY AREA (yellow): restricted toauthorized staff involved in the rescue operation
TERTIARY AREA (green): restricted to pressofficials & public
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Action for 1 st team on-site
1. Report to PKTK Introduce yourself Ask for brief situational report Safety hazards
2. Situation evaluation3. Inform Hospital
Actual situation Estimated number of casualties Type of casualties
Back-up required
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1st team. (cont)
4. Set-up Base Station5. Communication6. Temporary Zoning7. Temporary morgue
8. Logistics9. Head count duty 10. Get other agencies to aid if/ when reqd11. Operative until stand down declared by OSC
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S-S-S-S-S
S Safety
S Scene Size-Up S Send Information
S Set-up S START
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ADVANCE MEDICAL POST
AREA-Medical Base Station Location: safe area, direct access to the evacuation road,
short distance from the Command Post, clear
communication zone. Good triage capacity. Specifically trained medical teams.
Good communications between the field & the hospital. Good coordination of all involved sectors.
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Design of Basic AMP-Medical
Base Station
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PRINCIPLE OF INJURY
MANAGEMENT 3 T principle TRIAGE/TAG TREAT TRANSFER/TRANSPORT
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SEARCH & RESCUE
Safety first Locate & remove victims from
unsafe locations to collecting point, if necessary On site triage First aid, if necessary Transfer victims to the AMP,
if necessary
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TRIAGE SYSTEM-Disaster Field Triage
1. Basic Aim : To do the most good for the most people
2. Transport priority for the most salvageable withthe most urgent problems3. Transport those who are treatable in hospitals but
fatal in the field first4. Sieve and Sort using the START system
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Disaster Triage Tags
Most effective Internationally recognized Color codes Defines severity of injury and also defines urgency of
transport Useful to incorporate ID codes here
Red : critically injured (need immediate specialty care)
Yellow : less critically injured Green : no life/ limb threatening injury White/Black : fatal injuries or dead
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RULES OF EVACUATION
NO VICTIM MAY BE REMOVED FROM AMP TO THEHOSPITAL BEFORE:
the victim is in the most stable possible condition the victim is adequately equipped for the transfer the hospital is correctly informed & ready to receive the victim the best possible vehicle & escort are available
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THE NORIA PRINCIPLE
Victim movement - one way direction, withoutcrossings.
Victim movement - organized as conveyor belt(from basic first aid care level to sophisticated levels)
each transport level will have to use its own limitedresources in a rotating system.
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Emergency Dept Activation
Notification and Activation sequences
Chain of Command
Setting up the Emergency Operations Centre
Initiation of Field Operations
Mobilising resources and staging area
Triage and patient flow systems
Control of area and traffic flow Re-designated treatment areas
Specialized areas for family, media, mortuary, forensics
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Hospital Activation
Preplanned Response
Documented & accessible
Tested & analysed User challenged
Dynamic
Table top exercise
Disaster drill
H i l A i i Ph
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Hospital Activation Phase
A Hospital Response NOT Emergency Dept.Response
A Hospital Strategy
Handled by Hospital Authority A Mandatory requirement by Ministry ofHealth, Malaysia
ALL Hospital personnel must be AWARE of
the Response Plan.
INFORMATION FLOW: PRESENT MALAYSIAN SCENARIO
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INFORMATION FLOW: PRESENT MALAYSIAN SCENARIO
INCIDENT SITE
Informer/Caller : Provide the following Info:Identification of CallerTime of IncidentType of IncidentLocation
999
999
999
Red Crescent Police
Fire & Rescue
Civil DefenceHospital
Deployment ofRescue Team
Deployment ofRescue TeamAnalysis of Information
Stand Downon YellowAlert
YellowAlertStandby
Red AlertDeclaration ofDisaster
ActivateHospitalAlertSystem
Deployment of Search &
Rescue Team
INCIDENT SITE
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MANAGEMENT OF MAJOR INCIDENT IN MALAYSIAHOSPITAL ACTIVATION PHASE
PRIMARY RESPONDING HOSPITAL
The Main Hospital Leading The Management
Fulfill Criteria Of A Leading HospitalCoordinating Role
Closest & Most Well Equipped Hospital
Identified & Selected By Authorities
Resource Development
Skill Training
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SECONDARY RESPONDING HOSPITAL
- Other Hospitals Involved In The Management Of
Victims
- Activated Only When Called By Primay RespondingHospital
ROLE:
1.Provide logistic support , Eg. Manpower, Equipment, Wards For Admission
2. Managed & Accommodate Victims etc
MANAGEMENT OF MAJOR INCIDENT IN MALAYSIAHOSPITAL ACTIVATION PHASE
HOSPITAL ACTIVATION PHASE
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ORGANISATIONAL ASPECT
COORDINATOR
HOSP. DIRECTOR
ADMIN.COORDINATOR
DEP. DIRECTOR OFHOSP.
MATRON SECURITY SUPERVISOR
DIETICIAN
ADMIN
PERSONNEL
PHARMACIST
CLINICALCOORDINATOR
SENIORCLINICIAN
HOD s Senior AMOOF ED
SISTER ED
PHARMACIST
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ADMINISTRATIVE COORDINATOR
Resource & Logistic Management Resource & Logistic Deployment Continous Requirement Assessment Patient Accomodation Inventory Management Transport Requirement SETTING UP OF VARIOUS Mx AREAS
Relative Areas
Control Centre
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CLINICAL COORDINATOR
Organize Clinical Teamo Critical, S. Critical, Non Critical
Deploy On Site Management Team Deploy Sar Team
Set Up Clinical Management Area Set Up & Manage Triage Centre Coordinate The Forensic Service Team
o Pathologist & Maxillofacial
Coordinate Psychiatrist & Counselor Service Liaise With Admin Coordinator For Bed
Requirement, Pharmacist In Close Liaison With OMC
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Summary1. Understand how disaster affect us. 2. Alerting Process3. Situation Assessment & Field Area Identification
4. Safety measures5. Command Post6. Communication Tools7. Search & Rescue8. Triage & Stabilization9. Controlled Evacuation10. Hospital disaster preparedness plan !!!
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CONCLUSIONS
1. Coordination
2. Familiarization3. Abide By The Directive From The National
Security Council Of Pm Dept., MALAYSIA( Arahan 20, MKN )
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Th k 1
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Thank you.. 1 Malaysia Boleh