| 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. |
