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Module 10 A

OPERATIONS MANAGEMENT

CHAIN OF MEDICAL CARE

ON SITE ACTIVITIES

PRE-HOSPITAL ACTIVITIES

8th regional training coursePublic Health and Emergency Management in Asia and the Pacific

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Learning Objectives

By the end of this module, the participant should be able to:

•Describe the organization of on site activities, especially medical activities•Describe the main reasons for having special arrangements on scene such as Advanced Medical Post and specific procedures such as sectorisation and triage•Discuss the various links of the medical chain and the needs for policy, planning and training•Discuss the roles of the HEM in developing the various elements of pre-hospital medical capacity

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Q&A

• What are the main components of on site activities and pre-hospital activities and how are they organized in your country?

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PoliceFire - RescueMedicalVolunteers

Medical TeamTriageLife savingStabilization

EMSDispatchingMEC

Triage

Emergency Dept

Treatment

OPD

Information

Pre-hospital activities and on-site activities

A multi-sectoral organization

Site: ICP EOC - local or provincial

ECC – national or provincial

AMP sectors MEC

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public health in emergencies

Three closely organized systems

First transferof patients

Advanced Medical PostEvacuations

process

HOSPITAL

Continuum : C C C

Activation of plans

Inter-sectoral /inter-agency

RECOVERY

site

time

1 2

3

Pre-hospital medical chain

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chain of medical care HDCA Geneva

CHAIN OF MEDICAL CARE : Large scale disaster

sector sector sectorsector sector

AMP /MEC AMP /MEC

ICP(s)Ambulances

/helicopters…Ambulances

/helicopters…

EOC(s)

hospitals

ECC

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TS Allison Hits Houston

How EWS??? How Surge Capacity??

5 days

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Ensuring access to quality health care in disaster situations

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South Asia Earthquake

Slide 11

Logistics

© Edward Parsons / IRIN

A bridge near Karoll lies in ruins, as

does a truck unlucky enough to be

caught on it when the quake hit.

Pakistani soldiers help carry boxes of

high energy biscuits from a UN

helicopter for families in the remote

village of Nauseri, in the Neelum Valley.

© Evan Schneider / UN

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Canine team

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Questions?

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AMP ISA CONCEPT

NOT A BUILDING ORANOTHERFORMALSTRUCTURE

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S Lennquist 2001

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S Lennquist 2001

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S Lennquist 2001

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COUNTRYPOLICY

PATIENTCHART

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LOCALCONTEXT

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public health in emergencies

TIME AND SPACE…………..

Pre-hospital chain of medical care extends :

• in space:from the site (sector level) to the final hospital

triage area/ reception area• in time :

from the alarm (pre-alert, early warning) until the admission of the last casualty

• strategy : emergency operational plans• tactic : activation of response plans

/contingency plans• logistics : human & material resources /

systems for command, coordination and control/ communication/ Advance Medical Post/ triage/ evacuations of patients/ dispatching/ management of information/ management of the dead and the missing

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THE STEPS OF THE CHAIN

The chain of medical care has 7 components :

1. alert (in some situations : warning) : activation of plans

2. Reconnaissance activities (of the site)3. setting up front medical organization4. triage and emergency care5. medical care during relief and rescue

operations, AMP6. medicalized evacuations7. hospital reception (triage and care)

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Field Working Areas

• Impact Zone

• Restricted / Safe area• Collecting Point

• Advance Medical Post

• Command Post

• Outer Perimeter• Staging area

• Media / Reserved area

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MCM Field Management PlanMCM Field Management Plan

Triage

Impact Zone

Evacuation

AMP

Command Post

Strictly Restricted

Restricted

“ACCESS”

Traffic

Traffic

Control

Working Area

VIP /Tri-Media

Staging Area

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COLLECTION POINT

AMP

Unsafe Area

1st Triage Done Here

Collection PointCollection Point

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Advance Medical Post AreasAdvance Medical Post Areas

2nd Triage Entrance Priest? Volunteers Evacuation

MD’s & Nurses Nurses & Volunteers

Non Acute

Acute

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Advance Medical Post

3T PrincipleTag

Treat

Transfer

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CONDITIONS FOR SUCCESS………

some fundamental PRE-REQUISITE for success :

• a broad health sector policy and strategy for emergency management as part of an inter-sectoral emergency management plan

• a clear designation and definition of :� overall authority and responsibilities� site authority and responsibilities

• programs of regular training for emergency management

• trained medical teams ready to operate in a special environment :� skilled and trained personnel� equipment and other resources

• Pre-established management mechanisms

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CONDITIONS TO BE EFFICIENT……………

the conditions of medical care efficiency :

1. to organize triage as quickly as possible1. to start with medical care as close as possible to

the site� stabilisation of patients� treatment of acute situations� without taking excessive risks

2. to integrate medical activities with rescue and relief operations

3. to provide at the sector level life-support measures as sons as possible

4. to avoid any discontinuity in the chain :� during first transportation to the AMP� during evacuation� between pre-hospital and hospital activities

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PLANNING PROCESS…….

the planning process should consider the following medical issues :1. Preparatory work & teaching and training2. Warning before impact (when applicable: mitigation)3. Alarm after impact, processing and alert4. Reconnaissance & triage activities & first-aid5. Medical organization of the pre-hospital phase6. Medical care adapted : strategy/ procedures7. First-aid and rescue: procedures/ roles &

responsibilities of different categories of staff8. IMS and role of the health sector9. Evacuations : coordination between hospitals/

transport capacity, etc.10.Hospital disaster plan 11.Rehabilitation of medical services and facilities12.Special procedures such as decontamination

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DEFINING SECTORS

the main objectives of the sectorisation of a site :

1. not to forget any part of the disaster site2. not forget any casualty3. not overlook any secondary hazard (chemical

leaks, gas..)4. to allocate efficiently the medical resources :

� dynamic process� meet actual needs� renew usable items, etc.

5. to facilitate the coordination and the command process

6. to ensure general security of the personnel7. to ensure good communication8. to avoid crowd gathering

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NON MEDICAL AND MEDICAL TRIAGE

From the French verb « trier » (Napoleon wars)� to sort� to select� to classify

� reasons for triage : � deep imbalance : immediate needs – available

resources� necessity for categorization of victims in order to

ensure the most efficient use of available resources :� to save as many as possible lives� to reduce human suffering as much as possible� to adapt the level of ambition

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TRIAGE CATEGORIES

Patient Status STARTMilitary /

International

Color

CodePriority

ImmediateCritical /

ImmediateImmediate Red 1

Delayed Minor Delayed Yellow 2

HoldUrgent /Delayed

Minimal Green 3

DeceasedDead / Dying

Expectant Black 4

Contaminated

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ImpactZone CP AMP Evacuation

On SiteTriage

MedicalTriage

TransportTriage

RED/GREENRED/GREEN

YELLOW/BLACKRED/GREEN

YELLOW/BLACK

3 Level Triage

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START TRIAGE

• Assessment using RPM• Casualties are color coded to quickly

identify a casualty’s priority for medical treatment. Black –Expectant/Dead-DyingRed - ImmediateYellow - DelayedGreen – Minimal/Minor

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UNIFIED SYSTEM WITHIN THE COUNTRY

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MEDICAL TRIAGE : goals

Determine priorities for evacuation

Dispatching of patients to hospitals

Establish priorities for surgical treatment

Ensure med care to casualties according to : - severity of injury- need for treatment- possibility of good quality survival – functional aspects- availability of med care

GOALS

Ongoing & Dynamicprocess: Re-evaluation

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Medical care DELIVERY on the scene

�secure vital functions:• airway – breathing – circulation

�diagnosis:• rapid & systematic examination• chest / abdomen / pelvis / head / spinal /limbs

�decision:• only measures that have significant effects on

survival / function or• can lead to a lower priority (downgrading priority)

�treatment:• register performed measures on the triage-card or

the patient record• setting priority:

• continuous process - re-evaluation • using tags

�transfer or evacuation:• how, where, medical surveillance, when……

�Airway�Breathing�Circulation

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S Lennquist 2001

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S Lennquist 2001

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S Lennquist 2001

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Middle aged man with severe crush injury left limb. HR 128. Breathing OK

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MEDICAL TRIAGE - a frequent template

Able to walk ? GREENyes

Is casualty conscious?

no

Does casualty present with

external arterial bleeding ?

RED

yes

no

Is shock present?

CESIRA PROTOCOL

REDyes

REDyes

Respiratory failure?yes

RED

Fractures / cranial trauma / injury to

backbone?YELLOW

yes Another pathology: poisoning / heat

stroke / hypothermia / thoracic pain,

burns..

YELLOW

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TRIAGE CATEGORIES

Patient Status STARTMilitary /

International

Color

CodePriority

ImmediateCritical /

ImmediateImmediate Red 1

DelayedUrgent /Delayed

Delayed Yellow 2

HoldMinor

Minimal Green 3

DeceasedDead / Dying

ExpectantBlack

4

Contaminated

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START TRIAGE

• Assessment using RPM• Casualties are color coded to quickly

identify a casualty’s priority for medical treatment. Black –Expectant/Dead-DyingRed Red -- ImmediateImmediateYellow Yellow -- DelayedDelayedGreen Green –– Minimal/MinorMinimal/Minor

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HAZMAT Considerations

Presence of Contamination

Initiate STARTPrimary Decon

Strip/Bag Evidence

Initiate Secondary Decon

SecondaryTriage

Move toTx & Transport

YES

Symptomatic Tx PRN

CONTAMINATED

1

3

4

5

6

2

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ADVANCED MEDICAL POST

The AMP is NOT a structure but a concept :

1. All casualties should go through when AMP is set up :• for registration / triage / medical care / discharge

or evacuation

2. Not all situations require a formal AMP to be set up but the “functions and activities” of the AMP still have to be carried out through other organizational arrangements

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ADVANCED MEDICAL POST

1. the AMP is NOT a structure but a concept :2. the location of the AMP :

• should be as close as possible to the site• should not be exposed to foreseeable

developing risks• poisoning fumes, collapse of buildings, etc.

• should be as much as possible accessible to transport :• access in and out• suitable roads….

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Advanced medical post – common template

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Medical Evacuation Centre

Command section

Psycho-social section

Logistic & supply section

triage & medical care section

Evacuation & regularization

section

MEC

hospitalsInformation & support activities

/center

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TRAINING

ACTIVATION OF PLANS

COMMAND

CONTROL

COORDINATION

INTER-SECTORAL

INTER-AGENCIES

ALL ARE NECESSARY

FOR MANAGING

EFFICIENTLY

THE CHAIN

TRAINING

EXERCISES

MEDICAL CARE

TRAINING

EXERCISES

TRAINING

EXERCISES

TRAINING

EXERCISES

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INFORMATION AND SUPPORT CENTRE (1)

• information management to relatives, to affected people

• sheltered from public and media where survivors and relatives can gather and meet; psychosocial support teams

• support and holding environment (psychosocial programs can be initiated in this Centre)

• forum place and meeting place (reduce convergence t o site or hospitals….)

• identification of immediate and urgent social and economical needs

• inquiry (casualty bureau for police, coroner…)

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INFORMATION AND SUPPORT CENTRE (2)

• facilitation of the management on the scene• linkage activities : local and distant (internatio nal

transport, information to away families, etc.)• presence of :

• health personnel / social workers / religious leaders/ police / volunteers…

• help line 24/24 for several days or weeks•

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GROUP WORK

• What is the reality context in your country for managing on site activities?

• How the health sector contributes to the overall management of these activities?

• What are the existing training programs?• What are the exercises conducted by the health

sector?

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Middle aged woman, traumatic; amputation lower limb. HR 116. Pale. Severe pain.

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Middle aged woman, soft tissue injury in the face. Fully awake. HR 84. Breathing OK.

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Young man with penetrating abdominal injury, severe pain. HR 140. Breathing forced.

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Old man with chest pain and a big haematoma on the right side of the chest. HR 88. Breathing forced. Coughing.

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Middle aged man with bilateral fractures if the low er limbs, open on the left side. HR 94. Peripheral circulatio n ok.

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Soft tissue injury right hand. Severe anxiety.HR 90. Breathing OK

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Head injury. Respond normally to pain but not to ta lk.HR 86. breathing OK.

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Middle aged woman. Open fracture left femur, severe pain. HR 116. Breathing OK.

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Young woman, no visible injuries. Very pale. Cold and clammy but awake. HR 124, weak. Breathing OK.

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Old man with severely contaminated soft tissue inju ry. HR 116. Breathing OK.

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Young woman with abdominal injury. HR 130. Breathing OK

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Young man with head injury. Soft tissue injuries face and arm. Responds adequately to pain but not to talk. HR 74. Breathing OK.

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Middle aged man with chest injury severely contamin ated

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Head trauma. Respond to pain and slowly to talkHR 72. Breathing OK.

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Open fracture of the hand. Severe pain.HR 96. Breathing OK

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78Thank You!