The General Practitioner as First Responder in a Major Medical Emergency
George T. Somers, M.B., B.S., B. Med.Sci, F.A.A.E.T.S.
E. John Drinkwater, M.B., B.S., FRACGP
Nicolette Torcello, B.A.

Please note that this article was reprinted from Autralian Family Physician (1997), 26(12), 1406-1409 with the permission of the authors.


INTRODUCTION

In January 1994, a 'Mock Disaster' exercise took place at Menzies Creek (near Emerald) in the Dandenong Ranges, Victoria, Australia, and involved the collision of a petrol tanker with the Puffing Billy tourist train. The accident resulted in forty 'victims' sustaining injuries of varying severity, many with spinal, femur and pelvis fractures. The two nearest hospitals are 25 to 30 minutes away, and, apart from the Emerald Ambulance Station and local general practices, the area lacks medical facilities. Due to the magnitude of the 'disaster', problems extricating victims with spinal injuries from the rough terrain, and the problems of access and transporting victims to hospitals, many of the injured 'died' unnecessarily and many more had not been evacuated from the site two hours after the incident. This is not an unlikely scenario as the Puffing Billy is a popular tourist attraction and the busy, narrow, rough and winding roads of the Dandenong Ranges make driving particularly hazardous. At the formal debriefing, local authorities agreed that these conditions, and worse, could have applied in a real situation.

It was apparent here, and has been reported elsewhere (Evans & Evans, 1992; Hogan & Grantham, 1994; Skinner & Fisher, 1988), that if the injured had received immediate medical care, more lives could have been saved. Indeed, Hogan and Grantham (1994) reported in a study of 183 road trauma victims, that "6 lives were definitely saved and morbidity was reduced in many other instances" through local General Practitioner (GP) attendance at the accident scene. This led us to the hypothesis that the early involvement of a team of well-trained local General Practitioners and Nurses at a Disaster, could also result in improved outcomes.

THE NEED FOR 'IMMEDIATE CARE'

Deaths from trauma typically occur in one of three distinguishable time periods (Evans & Evans, 1992). The first peak occurs within seconds/minutes of the injury, where only prevention of the accident could have avoided deaths. The second peak occurs in the second to fourth hours post injury, (described as the 'golden hour') resulting in 35% of deaths from trauma in motorized countries with advanced trauma services. The third peak occurs several days/weeks after the initial injury where death results from sepsis or multiple organ failure. Not only are increased survival rates likely to result from early and appropriate medical, but the costly treatment offered in Intensive Care Units would be significantly reduced (Royal Australian College of Surgeons, 1992).

Preventable deaths occur due to a failure to make fast and appropriate clinical assessment and rapidly institute the appropriate resuscitative measures which should be within the capability of all medical graduates. The Golden Rule of disaster medicine is to "do the best for the most," and not to perform "heroics for the hopeless" (Medical Displan Victoria, 1995). This is at odds with the General Practitioner's usual modus operandi in "one-on-one" care (Campbell, Strasser & Kirkbright, 1996). Triage, (and this Golden Rule in particular), requires particular attention in the training of GPs for disasters, and in debriefing afterwards.

Although some would advocate a "scoop and run" policy when an incident is near a large medical facility, most would agree that, in the case of considerable time delay, adequate resuscitation is essential before and after transport, to increase the chances of the patient arriving at the hospital alive and in a reasonable condition for definitive surgical care (Evans & Evans, 1992). A General Practitioner medical team, therefore, needs to be able to institute appropriate resuscitative measures.

MEDICAL PERSONNEL AT THE DISASTER SITE

A source of medical personnel which until now seems overlooked in disaster planning throughout Australia (Australian Emergency Manual, 1995) is the General Practitioner workforce. It is ubiquitous and therefore local to the Disaster site with local knowledge of resources and obstacles. It is generally "on-call" 24 hours of the day, especially in the country, and can be rapidly mobilized. Our research has shown that rural General Practitioners themselves feel they should be involved in disaster planning (87%), and 64% think most GPs (urban and rural) will one day be obliged to attend a disaster.

Despite having several senior Australian GPs on the National Consultative Committee on Disaster Medicine, The Australian Emergency Manual discusses the role of local General Practitioners in two paragraphs. The first admits their ability to assist, and the second states that their contribution is maximized by appropriate planning and liaison. Far greater detail is needed, and this paper seeks to start this process.

Currently, the source of medical personnel for a major medical incident would be a large distant hospital (Medical Displan Victoria, 1995). It seems inappropriate to deplete the response capability of the local hospital by sending its doctors and nurses to the scene. In rural areas with nearby hospitals, however, this may provide the most rapid initial response. Hospital staff could be relieved to return to the local hospital as soon as more of the local General Practitioners/Nurses are mobilized.

Towns without hospitals are becoming increasingly prevalent, and General Practitioners/Nurses in these towns would more likely be first responders. The absence of a local hospital means that these GPs will need to have better emergency training and equipment availability, as patients are more likely to present directly to their surgeries. These practitioners have been identified as requiring special consideration in the provision of equipment and ongoing training, both for the day to day emergencies and disasters (Campbell, Strasser & Kirkbright, 1996). In 1997, Medical Displan Victoria now introduces GPs at the first responder and possibly, at field medical team levels. Whilst their role is not yet fully explained, there is, we believe, a framework in that document for the integration of GPs as first responders to disasters.

One of the most significant reasons GPs have not hitherto been called upon to give more than an ad hoc response to a disaster is that there has been no widespread regionalization of Australian General Practitioners prior to the introduction of Divisions of General Practice. Our research has shown that General Practitioners see their Divisions as the appropriate organizations to facilitate their integration into Displan.

It is appropriate that local Nurse Practitioner volunteers should be included in this local Field Medical Team (Huntington, 1996). During the implementation of our project, we have found that local nurses are at least as keen to be involved in Displan as the General Practitioners.

GP INVOLVEMENT

Overseas, GPs are increasingly involved in Emergency Medicine. The United Kingdom has seen a massive return of General Practitioners into the emergency medicine field of road accidents (Silverston, 1985). Canada seems to have a mixture of Specialist and General Practitioners involved in Emergency Medicine (Cohen, 1991). The United States of America has built its local Emergency Medicine Services around the paramedics, and have regional centers which supplement and support the local response to disasters (Pretto & Safar, 1991; Roth, 1991).

In Australian disasters, local General Practitioners/Nurses are currently called upon only sporadically to render medical assistance. This is in spite of a call to utilize local community resources by several agencies (Australian Emergency Manual, 1995). Their desirability at a disaster site is well recognized (Evans & Evans, 1992; Hogan & Grantham, 1994). Australian GPs have long had an interest in Emergency Medicine, and there have been attempts to focus this into an organized response as long as twenty-five years ago (Pacy, 1972).

THE RISKS OF AN ad hoc RESPONSE

It has been shown by Tolhurst et al. (1995), that 8.4% of emergency attendances of rural GPs involve "very urgent" or "life threatening" problems. GPs believe they will cope when called upon in a disaster, as they believe the skills required are merely an extension of their everyday activities (Klein & Weigelt, 1991). This is open to some dispute, and some areas of contention.

Our experience has identified two factors in a disaster which may compromise the General Practitioner which are not present in an emergency in the surgery. The first is the effect of the disaster on the community. As a member of the community, the GP will suffer the same overwhelming feelings of loss and hopelessness as everyone else and may also be a victim of the disaster. This may affect his/her ability to respond unless he/she understands the "bigger picture" and feels a part of it. This may be ameliorated if the GP is officially integrated into Displan and trained as a part of the "team."

While being seen to be involved in the response phase will set the scene for a more effective role in the recovery phase, this is the second factor which marks the General Practitioner as a victim of the disaster. Harm minimization and the recovery of General Practitioners requires recognition of their special needs. Inclusion into a GP team may help the effect on the GP of having to be seen as a stable, responsible, influential and helpful leader while, in reality, feeling as lost as the next victim. The formal team structure would enable appropriate preparation and help ensure the best possible response and the safest recovery.

The ability to function during the response phase may be affected by the degree to which the doctor has become a victim of the emergency. The ability to function effectively during the recovery phase may also be a product of the extent to which the doctor is a victim of his or her involvement in the response phase. This latter effect may not declare itself until much later.

PROPOSED CALL-OUT PROCEDURE

Medical Displan Victoria (1997) describes two avenues of involvement for General Practitioners in the Response Phase of a Disaster. The first is as Volunteers arriving on-site individually, and the second is as the Field Medical Team. Our proposal, modified since the published plan, is to utilize both of these (Somers, Torcello, & Auden, in press).

Individual attendance

Local rural GPs would attend the site upon notification by their own local networks (usually local ambulance, local police or patients) after first alerting the Divisional GP Key Contact Person (GPKCP), with whom they would remain in telephone (mobile) contact. The GPKCP, who has a close working relationship with the local Area Medical Coordinator (AMC), will notify the AMC of the activities of the Division members. After consultation with the GPs and the AMC, the GPKCP will mobilize more volunteer GPs, Nurses, and/or a GP Field Medical Team (FMT) as appropriate. These local volunteers will naturally be responsible to the AMC.

Field medical teams

Then, the Chief Medical Coordinator (CMC) would activate the GP Field Medical Team by ringing the Division's GPKPC, who would notify the GPs of the incident and conditions and coordinate deployment of the GP FMT. Additional reserves of equipment and personnel could be sourced from within the Division, or from other urban or rural Divisions as appropriate. Such a structure has been implemented in the Emerald local Displan (Huntington, 1996).

EXPERIENCE OF THE PLAN

The plan, as outlined above, has been activated once in a mock disaster, and once in a real disaster (the Bushfires of January, 1997). The mock disaster consisted of a telephone call-out of the GPs of the Sherbrooke and Pakenham Divisions of General Practice in response to a fictitious bus crash at 5 p.m. on a Saturday afternoon. Participants had had no pre-warning and were not expected to actually attend the site, but to state whether they would have done so in a real situation, and how long they expected it would take to arrive. Our Nursing Team had not been fully established at this time and was not involved. The result of the exercise was that ten General Practitioners could have been 'on-site' within an hour of call-out, the first within 5 minutes.

During the Bushfire Disaster in the Dandenongs on January 21, 1997, the Division was put on standby by the CMC. There was concern that a supportive residential care home may have been at risk. The GPKCP had the first two GPs on standby within four minutes and seven more on alert within an hour. The first Nurse Practitioner was present at the GP Headquarters (GPHQ) within 35 minutes, and another five within 90 minutes of activation.

Whilst the General Practitioners and Nurses involved were not required to save lives or attend the scene of a major incident they did all that the CMC asked of them, and more. This event highlighted the effectiveness and flexibility of the Plan, and the usefulness of local General Practitioner involvement in the management of Displan.

SUMMARY

In many rural areas, the General Practitioner is involved in major emergencies through involvement with the local hospital. Most Area Medical Coordinators in Victoria are, in fact, GPs. However, an organized response by teams of GPs per se has not been fully recognized.

The role of the General Practitioner in a disaster has been discussed, and a local General Practitioner based disaster response plan has been described. The plan that has been developed based on the needs of the region could easily be set up throughout the whole of rural Australia.

Based on our research of General Practitioner attitudes toward Disasters, we believe that they consider that involvement in a disaster is inevitable, and that the majority of GPs are not comfortable with their competence to respond. These GPs want their Divisions of General Practice to address the problems of Emergency Management training, liaison and planning.

This Project was not expensive to set up at a local level, and maintenance of the plan as described is relatively simple. The challenge is out for all Divisions to take an interest in this exciting and rewarding area of General Practice.

 

REFERENCES

 

Australian Emergency Manual - Disaster Medicine (1995). Emergency Management Australia. Commonwealth Department of Human Services and Health, National Consultative Committee on Disaster Medicine, National Disaster Relief Committee.

Campbell, D. Strasser, R. Kirkbright, S. (December, 1996). Survey of Victorian rural general practitioners in towns without hospitals. Monash University, Moe Campus.

Cohen, L. (1991). Federal disaster-planning exercise brings 30 emergency MDs together for week-long course. J. Can. Med. Association, 145, 871-872.

Cooke, M. W. (1992). Arrangement for on scene care at major incidents. BMJ, 305, 748.

Evans, R.C. Evans, R.J. (1992). Accident and emergency medicine, Postgrad. Med., 68, 714- 734.

Hogan, C. Grantham, H. (1994). The role of the GP at the roadside. M.J.Aust., 161, 175-176.

Huntington G. (1996). Local Emergency Plan-The Initial Response. Relative to the Emerald, Clematis Menzies Creek Areas. Standing Plan. Revised Copy.

Klein, J.S. Weigelt, J.A. (1991). Disaster management-Lessons learned. Surg. Clin. Of N. America, 71, 257-267.

Medical Displan Victoria (1995). Hospital Medical Team Sub Plan & Disaster Site Procedures Revised.

Pacy, H. (1972). Rescue and first aid for our highways. M.J. Aust., 1, 704-707.

Pretto, E.A. Safar, P. (1991). National medical response to mass disasters in the United States: Are we prepared? JAMA, 266, 1259-1262.

Roth, P.B. (1991). Status of a national disaster medical response. JAMA, 266, 1266.

Royal Australian College of Surgeons. Early Management of Severe Trauma (1992). Capitol Press Pty Ltd. Box Hill Victoria.

Silverston, P.P. (1985). Physicians at the roadside: Pre-hospital emergency care in the United Kingdom. Amer. J. of Emer. Med, 3, 561-564.

Skinner, D. Fisher, J. (1988). The multiply-injured patient and the GP. The Practitioner, 232, 870-873.

Somers, G.T. Torcello, N. Auden, K. (In Press). The Medical Disaster Plan-A proposal for the integration of General Practitioners into local Displan. Published by the Sherbrooke and Pakenham Division of General Practice. (distributed to all GP Divisions in Australia.)

Tolhurst, H., Dickinson, J., & Ireland, M.C. (1995). Severe emergencies in rural general practice, Aus. J. Rural Health, 3, 25-33.

Victoria State Medical Emergency Response Plan (March, 1997). Medical Displan Victoria.

©1998 by The American Academy of Experts in Traumatic Stress, Inc.