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