WONCA RURAL

WONCA RURAL 2014 Rural Skills Workshop Dr Jo Scott-Jones MRCGP FRNZCGP MMsc Dip Obs, Sports, Geriatric Medicine

Conflicts of Interest and Bio

Registration and travel has been paid by conference organisers, NZRGPN, and RNZCGP.

GP in Opotiki

Chairperson of the NZRGPN

Faculty member of the Rural Chapter RNZCGP

Senior lecturer (rural health) Auckland Uni

PRIME doctor

ProcessPre and post questionnaire Being a rural GP MCI introduction / review of conceptOur experiences Triage concepts Application of concepts in practical exercisesDiscussion of challenges Emergency medicine skill sharing

What things affect YOUR MCI response?Typical staffing of your health service?How do you handle the following?4 victims in a two car head-on17 victims in a team van43 victims on a school bus350 victims on a trainNeed Resources &Coordination

Mass Casualty Incident Definition When your resources are overwhelmed by events. Get to know someone you dont know already -Their name ? Where are they from ? What resources do they work with ?Talk about an example of the experience of being overwhelmed by events ?How do you cope ?

START one way to cope !

GOAL

TO SAVE THE LARGEST NUMBER OF SURVIVORS FROM A MULTIPLE CASUALTY INCIDENT

8AIMTo give a focus on the reason for this training.

To save the largest number of survivors from a multiple casualty incident

Teaching pointsThis is what this presentation and training is ultimately concerned with. The aim should be referenced throughout the presentation.

NoteThroughout the training you must constantly assess if concepts and systems used will lead to producing maximum survivors.

So what do you have to think about?

So what do you have to think about?

ASSESSMENT

So what do you have to think about?

SAFETY

ASSESSMENT

So what do you have to think about?

COMMUNICATIONS

SAFETY

ASSESSMENT

So what do you have to think about?

STAGING

COMMUNICATIONS

SAFETY

ASSESSMENT

So what do you have to think about?

TRIAGE

STAGING

COMMUNICATIONS

SAFETY

ASSESSMENT

So what do you have to think about?

COMMAND

TRIAGE

STAGING

COMMUNICATIONS

SAFETY

ASSESSMENT

So what do you have to think about?

TREATMENT

COMMAND

TRIAGE

STAGING

COMMUNICATIONS

SAFETY

ASSESSMENT

So what do you have to think about?

TREATMENT

COMMAND

TRIAGE

STAGING

COMMUNICATIONS

SAFETY

ASSESSMENT

So what do you have to think about?

TREATMENT

LOPERAMIDE

COMMAND

TRIAGE

STAGING

COMMUNICATIONS

SAFETY

ASSESSMENT

18

THE INITIAL PROBLEM ON SCENE

CasualtiesResources

19AIMTo understand the importance of correct resources.

Teaching pointsRescue services normally work in a resource rich environment. The multiple casualty scene often presents a scenario where there are more casualties than initial resourcesOn scenes where an initial assessment indicates heavier casualties than resources, clinical intervention is often not the first priority.

Question to delegatesWhat number of casualties would be required to out number one of your units ?Expected answerNormally one seriously injured person or two or three minor injuries.Teaching point from questionSmall incidents such as motor vehicle accidents can produce a resource poor scenario.

CasualtiesResources THE OBJECTIVE

20

CasualtiesResources THE OBJECTIVE

21

CasualtiesResources THE OBJECTIVE

22

CasualtiesResources THE OBJECTIVE

23

CasualtiesResources THE OBJECTIVE

24

CasualtiesResources THE OBJECTIVE

25

CasualtiesResources

THE OBJECTIVEAchieve balance

26

ARRIVAL OF REQUESTED RESOURCES

TIME IS IMPORTANT

27

THE GOLDEN HOURThe critical trauma patient has only 60minutes from the time of injury to reachdefinitive surgical care, or the odds ofa successful recovery diminish dramatically.

Pre-Hospital Trauma Life Support, Second Edition,Patient Assessment and Management, page 42. 1990.

TIME IS VERY IMPORTANT

28

Balancing Act

CasualtiesResources

Time Management Resources ArriveGolden Hour

= Maximum survivors

CasualtiesResources

+

30

Planning Ahead The 7 Ps Piss Poor Planning Produces Piss Poor Performance

SCENE MANAGEMENT

The Scene

TIMECommand Safety Assessment Communication

Triage TreatmentTransport

Definitive Care

H

H

HMANAGEMENTEMS OPERATIONS

32

Scene ManagementCommandWho is in Charge?Who is in charge of what?Who is going to do what? Who else needs to be here?

SafetyIs there a hazard or threat?Should I be here? Am I protected? What should I worry about?

Scene ManagementAssessmentWhat is going on? How big is this, how many people?What do I need?How does what I do affect others? What are they doing that can affect me? CommunicationsWho needs to know? What do they need to know? Does Command & Ops know? Do the other players know?

Scene ManagementTriageWho is doing it?Where are they doing it?What are they finding?TreatmentWhat skills do your local health providers have?How to organize?How much can we do?

Scene ManagementTransportWho is doing it?From where are they doing it?Where are the patients going? How many patients going where?

TRIAGEYou know you are a nurse if ..you triage the laundry when at home this pile needs immediate attention, this pile can wait, this pile, with a little stain stick will be OK until you get back to it ( Donna Wilk Cardillo RN )

37

AIMTo educate students that triage is carried out in difficult circumstances and will be one of the most complex tasks they will face.

Teaching pointsAlthough triage is a difficult job with the correct training and equipment we can make personnel effective in this skill.

TRIAGE CODING

Immediate 1 Urgent 2 Delayed 3 Dead 0

REDYellowGreenBlackColorPriority Treatment

38AIMTo explain how triage decisions are communicated and introduce the Smart Tag.

Teaching points A simple color coding system is used in triage to communicate a priority. The Smart Tag is designed to communicate this decision.

ActivityHand one Smart Tag to each delegate and demonstrate how it is folded. Run a competition to see who can fold a Smart Tag the fastest to red and yellow labels

DemonstrateLight stickWaterproof and tear proof material

MOBILE?DelayedBREATHING?DIFFICULTY BREATHING?RADIAL PULSE PRESENT?BREATHING?OBEYS COMMAND?DeadImmediateURGENTOpen AirwayYESYESYESYESYESYESNONONONONONO

In this initial phase ..Open airways using position Compress life threatening bleeding Move patients to clearing pointsUse other people / bystanders to provide interventions

THE FIRST STEP IN BALANCING RESOURCES WITH CASUALTIES

YESPRIMARY TRIAGE

41Whats the first step, the first thing to do? See whos dead?

AIM - To teach a flow chart on primary triage

Teaching pointsPeople who are walking have at that point in time; an airway adequate respiratory and circularity systems to maintain upright walking posture

In a multiple casualty scene these people should be tagged as priority three . Remember priority three patients may have a wide range of injuries that could be potentially be life threatening. It is important we constantly re-assess these people. You may be able to use uninjured survivors who have first aid training to help you with these patients

PRIMARY TRIAGEDetermining whether there is an airway and breathing

42continued

AIMTo teach the flow chart on primary triage

Teaching points The airway is assessed by performing a simple opening manoeuvre (chin lift and jaw thrust). Those people who cannot breath despite this manoeuvre are dead.

Those who can breathe are categorised as priority one.

If an airway has to be maintained then a bystander can be quickly instructed how to maintain a jaw thrust and call for help if there are signs of danger.

PRIMARY TRIAGEIf breathing is it good enough or will something need to be done soon ?DelayedBREATHING?DIFFICULTY BREATHING?BREATHING?DeadImmediateOpen AirwayYESYESYESNONONO

43How do you define difficulty breathing ? Resp rate > 30 or visible indrawing, flail chest, etc.

PRIMARY TRIAGEThey have an airway, and are breathing. Are they circulating blood sufficiently? MOBILE?DelayedBREATHING?DIFFICULTY BREATHING?RADIAL PULSE PRESENT?BREATHING?DeadImmediateOpen AirwayYESYESYESYESNONONONONO

44Put pressure on areas of life threatening bleeding, capillary refill of > 2 seconds can also be a sign of poor circulation

MOBILE?DelayedBREATHING?DIFFICULTY BREATHING?RADIAL PULSE PRESENT?BREATHING?OBEYS COMMANDS?DeadImmediateURGENTOpen AirwayYESYESYESYESYESYESNONONONONONO

45Can do - if they are alert and able to do as you ask, this is clearly a good sign. The aim of primary triage is to ensure you can treat the people who are most likley to survive, who need it most using the resources you have.

Secondary Triage Primary and Secondary survey in order of priority Note if triage category changes

Treatment Group patients of the same triage colour together around a central equipment pool Experienced personnel make decisions where possible others implement themPatients with the greatest chance of survival and the least drain on resources are treated first. If the treatment is not likely to work dont do it. Treatments that tie up resources ( e.g intubation and ventilation) should be delayed unless there is a very good reason and resources to support them.

Patient Scenario #1

This patient states he cannot move or feel his legs

His respirations are 24

He has a radial pulse of 100

He is awake are oriented

How would you triage this patient?

Patient Scenario #1

This patient states he cannot move or feel his legs

His respirations are 24

He has a radial pulse of 100

He is awake are oriented

URGENT - (YELLOW)

Patient Scenario #2

This patient has a blood soaked shirt on

His respirations are 36

His capillary refill is less than 2 seconds

He is awake are oriented

How would you triage this patient?

Patient Scenario #2

This patient has a blood soaked shirt on

His respirations are 36

His capillary refill is less than 2 seconds

He is awake are oriented

IMMEDIATE (RED)

Patient Scenario #3

This patient has some minor abrasions on his forehead

His respirations are 16

His capillary refill is less than 2 seconds

He is very slow in recalling his name and whereabouts

How would you triage this patient?

Patient Scenario #3

This patient has some minor abrasions on his forehead

His respirations are 16

His capillary refill is less than 2 seconds

He is very slow in recalling his name and whereabouts

IMMEDIATE (RED)

Patient Scenario #4

This patient appears to have no injuries

Her respirations are 20

Her capillary refill is less than 2 seconds

She is unconscious

How would you triage this patient?

Patient Scenario #4

This patient appears to have no injuries

Her respirations are 20

Her capillary refill is less than 2 seconds

She is unconscious

IMMEDIATE (RED)

Patient Scenario #5

This patient is lying quietly on the floor

He is not breathing

His capillary refill is more than 2 seconds

He is unconscious

How would you triage this patient?

Patient Scenario #5

This patient is lying quietly on the floor

He is not breathing

His capillary refill is more than 2 seconds

He is unconscious

REPOSITION THE AIRWAY!

Patient Scenario #5

He gurgles a couple of times as you attempt to openhis airway but does not resume breathing on his own

His capillary refill is still more than 2 seconds

He is still unconscious

How would you triage this patient?

Patient Scenario #5

He gurgles a couple of times as you attempt to openhis airway but does not resume breathing on his own

His capillary refill is still more than 2 seconds

He is still unconscious

DECEASED (BLACK)

EXERCISE Paper exercise

AnswersVICTIM TRIAGE 1Green 2Yellow3Red4Green5Red6Red7Black 8Yellow9Black 10 Green 11Green 12Red

Answers Victim TRIAGE 13Red14Green 15Yellow16Red 17 Green 18Red 19 Green 20 Green 21Green 22Black 23Yellow24Yellow25Green 26Green 27Red

Exercise Online exercisehttp://www.pennwellblogs.com/fireengineering/simulations/FESim11-BusMCI/Index.html

Challenges of Triage What about children ? What about the nearly dead?

Common Prehospital Analgesics

Who should receive analgesics?Everyone in painNo reason to with hold pain reliefDoes not mask other symptomsPain is not a vital signNo risk of addiction

How do you choose?Desirable characteristics for analgesic Quick acting (short onset and peak effect) Short duration Minimize side effects Hypotension, respiratory suppression, emesis, etc. Easy to administer Multiple administration routes available Reversible Inexpensive

How do I choose?What is available Take patient allergies into considerationTake patient condition into consideration Use the least hemodynamically active agent if patient is unstableThe analgesic ladder

Non Pharmacological approach Safe and can be effective Ice or heat Elevation Splinting/positioning Emotional support Distraction (guided imagery, biofeedback, breathing exercises)

Mild ModerateSevereNon pharmaceutical methods are often effective, reassurance, positioning, splinting. Combinations work better than single agents, choose the step in proportion to the level of pain.

Paracetamol Indications mild pain / adjunct to more severe pain Contraindications paracetamol overdoseDosage 1gm < 80 kg > 1.5gm Comments Higher than normal dose safe in short term, not for fever unless uncomfortable.

Ibuprofen Indications - mild pain / adjunct to more sever pain Contraindications 3rd trimester pregnancy Dosage - 400mg < 80kg > 600mg Comments Contraindications listed normally are to long term administration.

Tramadol Indications moderate pain / adjunct to severe pain Contraindications confusion / dementia (children 50 mg

Entonox Indications moderate / severe pain Contraindications unable to obey commands, suspected pneumothorax, bowel obstruction, diving in the past 24 hrs. Dosage - self administered Comments N2O expands gas filled spaces in the body, watch for worsening of symptoms and stop.

Methoxyflurane Indications moderate / severe pain Contraindications unable to obey commands, FHx malignant hyperthermia, renal impairment, already used in the past week. Dosage 1 dose (3ml) < 12 > 2 doses (6ml) Comments Not contraindicated for acute renal pain, or if on dialysis, single use inhalation device, caution in toxaemia / labour with foetal distress.

Morphine Indications - severe pain Contraindications respiratory depression, premature labourDosage 1-5 mg IV every 3-5 minutes for adults or 5-10 mg IM every 10 mins0.1 mg / kg IV children

Comments takes up to 20 minutes to have maximal effect in the elderly, dilute to 1 mg/ ml and titrate to effect, duration of effect IV 2-3 hrs , nausea and itch are side effects not allergies.

Fentanyl Indications severe pain esp if no IV access, haemodynamically unstable.Contraindications respiratory depression, prem labourDosage every 10 mins if needed 10-50mcg IV every 3-5 mins adults100mcg IN < 80kg > 200mcg IN 2mcg/kg IN children Comments dilute 100mcg in 10 ml contains 10 mcg/ml, IN use 1 ml syringe and MAD - onset 1-2 minutes, peak 15 minutes, duration 20- 60 minutes +

Fentanyl Generally minimal effect on blood pressure, heart rate and ventilatory drive Helps to blunt HR and BP associated with intubation Chest wall rigidity or muscle twitching can occur Should be reversible with Narcan Most side effects result from pushing the medication too quickly

Ketamine Indications - severe pain Contraindications unable to obey commands, MI, psychosis Dosage rpt once after 10 mins 10-50mg IV every 3-5 mins 1mg/kg IM, IN, Oral max 100mg Comment adjunct to opiate hallucinations usually indicate sub therapeutic dose rx with more ketamine ! Duration up to 2 hrs.

Midazolam Indications - muscle spasm, if other analgesics have not worked Contraindications - benzodiazepine allergy Dosage 1- 2 mg IV - wait 10 mins and a further 1 mg max of 5 mg 0.2 mg / kg IN Comment conscious sedation cause of retrograde amnesia not an analgesic. Combine with ketamine in infusion for sedation and analgesia.