Code Brown - Disaster Medicine in the ED

Disaster Medicine in the ED

1. CODE BROWN 2018 EMERGENCY DEPARTMENT

2. OUTLINE What is a Disaster? The Emergency Department’s response

3. WHAT IS A DISASTER?

4. DISASTER/MAJOR INCIDENT A disaster or major incident is when the number or type of casualties exceeds the normal working capacity of the Emergency Department / Hospital The aim of Code Brown is to deal with mass casualties from a sudden impact event (disaster) in a timely and effective manner

5. TYPES OF DISASTERS NATURAL MAN MADE -Unintended -Deliberate/terrorist BIOLOGICAL -Terrorist -Pandemic infection

6. AUSTRALIAN DISASTERS YEAR KILLED INJURED AFFECTED HOMELESS Black Saturday bushfires 2009 173 414 60, 000 7, 562 Queensland/ NSW floods 2010-2011 44 200, 000 38, 460 Lindt-Sydney hostage crisis 2014 3 4 18 Melbourne car attack 2017 6 36

7. INTERNATIONAL DISASTERS YEAR KILLED INJURED AFFECTED HOMELESS Twin tower attacks-NYC 2001 2, 977 6, 000+ Kuta -Bali bombings 2002 202 196 Haiti earthquake 2010 316, 000 200, 000 Boston marathon bombing 2013 5 280 MH17 Ukraine plane crash 2014 298 Paris attacks 2015 130 80-99 368 Westminster attack-London 2017 5 49

8. WHAT IS A CODE BROWN? A Code Brown refers to the hospitals response to an external emergency (disaster or major incident) that will result in the presentation of casualties that exceeds the emergency department or hospitals normal working capacity . DIAL ‘ 55 ’ CODE BROWN

9. WALKING WOUNDED STRETCHER CASES EXTERNAL INCIDENT! CASUALTY CLEARING POST SELF PRESENTERS CONTROLLED PRESENTERS

10. OUTLINE OF RESPONSE The 4 phases of a Code Brown are: -Notification -Standby / Prepare to receive casualties -Reception of casualties -Stand down

11. EXTERNAL INCIDENT FIRST RESPONDERS AMBULANCE CONTROL DOH DUTY OFFICER ED DUTY CONSULTANT/REGISTRAR HOSPITAL RESPONSE TEAM

12. What is the first thing that should be done as the SCO? READ THE DEPARTMENTAL SUB PLAN!

13. SCGH CODE BROWN RESPONSE The level of response depends upon: -the number of casualties -the type of injuries -the location & its proximity to other hospitals -the time of day & availability of staff & resources

14. EMERGENCY CONTROL GROUP The Emergency Control Group (ECG) consists of key personnel trained to deal with a major incident concerning SCGH Comprised of: -Medical Executive -Nursing Executive -Patient S upport Services Management -Facilities Management -Expert Advisors as required

15. HOSPITAL RESPONSE TEAM The Hospital Emergency Operations Centre Co-ordinator (HEOCC) determines whether a hospital response team (HRT) is required. Comprises of 2 Doctors & 4 Nurses.

16. COMMAND & CONTROL Decisions regarding the department are made by the ED DC & ED Nurse Supervisor Regular reports are given to the ECG by the ED DC & ED Nurse Supervisor Area Doctors report to DC

17. Preparing to Receive Casualties

18. The ED DC or Reg will: Review patients in the WR Review patients in the main department All patients within the department will be discharged, transferred to their ward or the Acute Assessment Area when set up by the ECG

19. STAFFING The ED DC & ED Nurse Supervisor will activate the call back of duty staff as required. Contact numbers of off duty staff are in the phone book

20. DEPARTMENT LAYOUT Dependent on numbers C27-R7 : Area 1 RED 1 dr & 1 nurse: 1 patient C8-C14 : Area 2 RED C15-C26 & Fast Track : Area 3 Yellow 1 dr & 1 nurse: 2-3 patients Obs ward : Area 4 Yellow Outpatients Department (Eye clinic) : Area 5 Green 1 dr & 1 nurse: 4-5 patients

21. AREA DOCTORS – area leader Resus Doctor Assessment Doctor Obs Ward Doctor Area 5 Doctor Help prioritize ongoing investigations & treatment Liaise with ED DC

22. TRIAGE One Doctor & Two Triage Nurses Patients triaged as Red , Yellow or Green Ensure disaster triage card is filled out Triage clerk enters details onto EDIS Two name bands

23. TRIAGE sieve vs sort

24. 54 year old male: Chemical Burns to arms and legs, Shrapnel to face, compound # to Rt forearm Ambulating . A: Nil Airway compromise. B: RR 20 Nil Respiratory Distress. C: CRT <2 sec. Perfused, nil bleeding D: Alert

25. 64 year old female: Blunt injury to head. Lacerations to face. Collapses upon arrival to triage A: Clear B: RR 22 C: CRT <2Sec. D: Groaning

26. 38 year old Female: Burns to arms and legs On stretcher carried by DFES A: clear B: RR 30 C: CRT 3secs D: Groaning

27. 54 year old male: - Chemical Burns to arms and legs, Shrapnel to face, compound # to Rt forearm - A : Nil Airway compromise. - B : RR 20 Nil Respiratory Distress. - C : HR 100, BP 110/70, perfused , nil bleeding - D : GCS 14 - E4, M6 V 4

28. 64 year old female: Blunt injury to head. Lacerations to face. Collapses upon arrival to triage A: Clear B: RR 22 C: CRT <2Sec . HR 60, BP 90/60 D: GCS 8 - E1, M5, V2

29. 38 year old Female: Burns to arms and legs On stretcher carried by DFES A: clear B: RR 30 C: CRT 3secs, BP 80/50, HR 125 D: Groaning – GCS 10 - E3, M5, V2

30. RECEPTION OF CASUALTIES

31. PATIENT FLOW Patients triaged Red or Yellow go directly to area where area leader allocates location & ensure EDIS reflects this. Patients triaged Green go to outpatients via Hospital Ave. Must be able to walk or go via wheelchair. Area leader then allocates location & ensure EDIS is updated. Charlies Chariot maybe utilised.

32. PATIENT FLOW CONT… Patients from A r e a s 1 - 4 should not return to Emergency if leaving for an investigation or for treatment. Activation of the Acute Admission Area & discharge area as needed. Patients in Area 5 may return following leaving.

33. WHAT PROBLEMS are we likely to ENCOUNTER? BOTTLENECK’S Theatre Radiology Bed Block (General Hospital Beds) High Dependency beds (ICU)

34. RELATIVES Social Work department takes care of relatives Visitors Centre may be activated located on first floor E Block

35. MEDIA & PATIENT ENQUIRES All media calls & patient enquires are to be redirected to communications (switchboard) on extension 91 who will then forward them to the Public Relations/Media Liaison Officer

36. STAND DOWN No more disaster casualties expected ‘ALL CLEAR’ declared by ECG Return to normal procedures Staff informal defusing session if required prior to leaving Ensure staff sign off Debriefing formally within 7 days Evaluation of response

37. Fremantle Ship Fire 11am call to DC – Code Brown Standy -by SJA requested HRT 3 doctors and 4 nurses deployed 1130am 2 x SJA arrived to transport HRTs

38. HRT returned to ED at 1300 40 casualties reviewed and treated at the scene 4 Crew members transferred to hospital – 1 to RPH, 3 to FH

39. Other issues to think about

40. Chemical weapons Chemical weapon attacks may be disguised with conventional attack Potential to cause more harm to care givers Know your toxidromes that suggest agents requiring antidotes NEJM April 2018 Toxidrome Recognition

41. Increased secretions, muscle effects, +/- miosis Nerve agents – sarin, organophospate Initial antidote – atropine, pralidoxime , spot decontamination at site, emergency care

42. Bradypnoea /apnoea, collapse, seizures +/- cyanosis Asphyxiant Agent – hydrogen cyanide, cyanogen chloride Antidotes – hydroxycobalamin , sodium thiosulfate, spot decontamination at the site and urgent care

43. Bradypnoea /apnoea, sedation, miosis Opioid agents – fentanyl, remifentanyl Antidote – naloxone, spot decontamination at the site and urgent care

44. ANY QUESTIONS?