14

Injury, 10, 14-21

Printedm GreatBrltam

M e d i c a l care at accidents and disasters R. Snook Consultant in A ccident and Emergency Medicine, Royal United Hospital, Bath MODERN technology is involved in the cause of much of our present day trauma. Accidents frequently involve young, healthy people of working age, with most to gain from treatment and most to lose from avoidable morbidity and mortality. For social, economic and humanitarian reasons it would, therefore, seem logical to apply technology to the intensive care of the accident victim. Intensive care is not a field of medicine confined to the special units of a large hospital; it is rather a concept of immediate intervention that can equally be applied at the scene of the accident as at the patient's bedside. To provide such a service requires efficient organization and communication, whether that service is a hospital cardiac arrest team, hospital accident flying squad, GP immediate care scheme or major accident team.

Communications There are two principal requirements of an emergency 'call-out' system: rapid activation of the system and immediate alerting of the individual. These two requirements are met by the long range VHF personal paging system with a pocket-sized 'bleeper'. Future developments in this field seem likely to involve refinements to increase the usefulness of this equipment, including provision of rechargeable batteries, warning of low battery state, addition of voice reception and extension of range. This last feature may be achieved by using a car-mounted radiotelephone to relay the call-out signal to the pocket receiver. Such a system has many attractions. The vehicle-mounted set is more sensitive in difficult reception areas, the user is likely to require his car for the emergency call and so will always be in radio and walking distance of the vehicle and the radio-telephone can be used for

immediate vocal communication. A development of this concept will undoubtedly include the further miniaturization of a pocket set with full receiver, transmitter and personal call facilities. Developments at the control roem end of radio communication equipment are already fairly advanced and modern electronic technology promises to extend this in the future. It is already possible to talk from one vehicle to another, to the hospital accident and emergency department and even to any extension on a hospital switchboard. The future is likely to see developments in the transmission of data, including ECG or even facsimile. Automatic identification of the vehicle calling and its position may also be more widely used. However, a word of caution rray be appropriate at this stage. Emergency work demands reliability. The more complex the system the greater the difficulty if it breaks down. Cost is also a not inconsiderable problem. One of the developments which can justify more expensive communications equipment is the centralization of the organization. Where team work is involved, personal relationships are important; large organizations may become impersonal. The health district is a basic working unit: beware the problems of expansion!

Organization Undoubtedly the organization of large groups can be managed successfully--often by subdivision into smaller groups. An essential feature of a successful immediate care scheme is its relationship with the fire, police and ambulance services. Practical experience has shown that if regular meetings of the various disciplines can be arranged, an efficient, friendly and satisfying relationship develops without any conscious effort.

Snook : Accidents and D=sasters

The types of meeting may vary from area to area and service to service. Education may be the common theme and may involve first aid exams for the police, rescue and casualty handling for the fire service and advanced training for the ambulanceman. This last mentioned aspect is of growing importance. One of the important effects of medical involvement in immediate care must be to advance the complete field of emergency patient care. This must include assisting the ambulance service to improve, by providing better vehicles, better equipment for use on the ambulances and more medical training for the crews. Medical involvement in this field has not been on a large scale to date. Only the very basic research has been completed on ambulance ride and much more could be achieved in respect of the layout and equipping of the emergency ambulance. Basic training of ambulancemen is good and of a uniform standard throughout the country. Advanced training is still limited to certain areas of the country and thus differs widely from service to service. This is in some ways parallel to the state of affairs in the medical profession. Many medical students still have little formal training in the emergency field. There is no postgraduate diploma m accident and emergency care and little in the way of training in the same field. The new generation of accident and emergency consultants should be able to organize teaching for medical students, junior staff and ambulancemen, improve the standard of patient care, attract research funds, analyse results of trials and statistical surveys and organize meetings. Accident and emergency medicine is often multidisciplinary from start to finish, involving the various emergency services before arrival at hospital and &fferent disciplines during resuscitation, treatment and even rehabilitation. Coordination is an essential part of teamwork and the accident and emergency consultant has much to offer in this role. The future should therefore see an extension of existing advanced training of ambulancemen, of GP vocational training in accident and emergency medicine and of the career grade for the hospital specialty. The future organization of hospital accident flying squads is more likely to involve the expansion of the number of hospitals offering such a service than alterations in the details of the existing services. One valid, new reason for the organization of hospital-based immediate care schemes is the growing number of accidents involving the

15

spillage of toxic chemicals on the road and in industry. Such an incident poses particular problems of organization because the scale of the mishap may fall anywhere between the isolated road crash and the large major accident. This situation poses problems both with regard to the general response and to organizing the specific measures necessary to deal with hazards to the public and rescue workers--providing protective clothing, use of spark-proof electrical equipment and many other details related to the safe management of the incident. Immediate care also embraces the provision of a hospital or GP team to attend major accidents where a casualty is trapped and may require supportive or surgical treatment on the spot. Such attendance necessarily involves the use of equipment, and it is valuable to identify areas where future developments are desirable: 1. A resuscitator that could combine intermittent positive pressure ventdation with the alternative of free flow by demand would be of value in rescue in noxious atmospheres. 2. Devices already exist for providing external cardiac compression mechanically and they could be of considerable value in the ambulance service. Imtial investigation suggests that manual cardiac massage is subject to failure rates of up to 14 per cent. Further research could examine this and perhaps justify the more widespread use of such equipment. 3. The use of traction splinting for fractures of the shaft of the femur before arrival at hospital is technically feasible with such equipment as the Tauranga and Hare splints. Education should be aimed at encouraging a more widespread use of these modified Thomas's splints. It is possible to identify areas of potential development--the provision of more and improved equipment and the training in its use-but is there any way of translating this theory into practice ? A possible solution involves the reorganization and development of existing facilities. All district general and teaching hospitals are required to have a plan for organization in the event of a major accident. Normally this will include provision of equipment for a team to go to the site of the accident. The plan exists on paper, the equipment exists in the cupboard. How may a wider use be made of this ? The first and simplest step is to break the equipment down into sets of 'individual' size, from the large hamper to the individual box, and preferably including at least one set in a 'backpack' form. This will allow the equipment to be

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18

Injury: the British Journal of Accident Surgery Vol. 10/No. 1

used either by one doctor for a small scale incident, or by the hospital team when attending a disaster. The second stage is to provide special protective clothing for the chemical incident: helmet, goggles, mask, PVC gloves, a suitably resistant suit and PVC boots. In addition, respiratory protection may be afforded by breathing apparatus provided by the fire service. This personal equipment may need to be supplemented by such items as spark-proof torches, a set of resuscitation and antidote drugs and PVC patient bags to counter airborne dust and similar hazards. The third stage is to design a small mobile unit capable of carrying the equipment to the small, medium or large scale incident. This is the most difficult step to justify in terms of cost. One way of achieving this is to combine the roles of flying squad, chemical incident unit and major accident vehicle with that of a mobile teaching unit. By this means the same vehicle is equipped for small scale, specialist, large scale or teaching use. If the medical requirements of rescue at a major accident are examined in detail they may be defined as follows: Transport of team to the incident. Supply of medical equipment on site. Provision of a treatment area for selected cases. Coordination of control and communication. Isolation and decontamination of selected cases. Base for personnel requirements. Translated into vehicle requirements, the picture is thus of a rapid intervention 'medical rescue unit' which will be able to get as near to the accident as possible, offer supervisory control, supply means of rapid sorting of patients, be equipped for occasional surgical or medical intervention and it should also keep the team supplied with equipment and refreshment. Such a mobile unit has recently been designed and includes a number of features for the future (Fig. 1) (see Appendix): I. Improved identification by means of blue beacons selected by visibility trials to have a large reflector and lighter blue colour. 2. Rapid transit through traffic by remote switching of traffic lights to give emergency priority using a vehicle-mounted actuator and wire loop receiver buried in the road. This has already proved its value in field trials, 3. Four-wheel drive vehicles could reach an

incident whatever the weather or terrain; this system is now developed to the stage of being obtainable as an optional extra on a standard ambulance. 4. Identification of function by new international coiour coding: green and white checks and a rotating beacon externally signifying control function and equipment colour coding on storage cupboards (red, medical; orange, advanced airway; yellow, basic airway; blue, intravenous; green, splinting; white, first aid). In addition to these features this new vehicle carries its own independent floodlight (Stemlite), electrical supply (mobile generator), heating system (petrol burner), provisions (freeze-dried foods), catering and toilet facilities. The communications system includes a fixed V H F radiotelephone on the ambulance emergency reserve channel with linked U H F personal pocket radiotelephones and pagers. This permits direct speech between the accident scene, the vehicle, ambulances, ambulance headquarters or the base hospital. In addition, terminal equipment for a field telephone is included. Individual items of new and accepted equipment include the Tauranga Thomas rescue splint for traction splinting, a Paraguard stretcher for evacuation of the casualty and a kit for identification of toxic substances. The vehicle is based on the Bedford C F 350 chassis and differs from the standard ambulance body in having a large side entrance that leaves the rear free for a canvas awning shelter in line with the vehicle for roadside or other confined spaces. Other differences include a single stretcher and extra interior and exterior lockers. The interior layout is planned for both operational and teaching use. Teaching equipment includes audiovisual cin6 and tape/slide display units and models for teaching techniques of infusion, intubation, cardiopulmonary resuscitation, monitoring and defibrillation. The audiovisual material includes self-instructional programmes for practical aspects of emergency care. The equipment and vehicle form an integral part of the hospital major accident plan. Neither the equipment nor the plan is of value without its function and capabilities being understood by the individual and therefore reconsideration of the presentation of the major accident plan must be undertaken.

Fzg. 2. (Opposite) Flow dmgram of a major accident plan presenting the main orgamzattonal features clearly in relation to the principal areas of activity. This document would be printed in green with the green and white chequered symbol.

Snook Accidents and Disasters

19

MAJOR ACCIDENT (ring priority)

AMBULANCE INFORMATION FORM

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F~g. 3. A newly researched and designed ambulance reformation form for dally use and incorporating a triage section for use m a major accident. This document would be printed in green with the green and white chequered symbol

The scheme can be presented in a one-page flow diagram (Fig. 2) illustrating the train of events from alert to arrival on site, treatment and sorting of casualties, evacuation to hospital, further sorting and defimtive treatment in hospital and organization of support services. All

casualties are labelled using a newly designed ambulance information form (Fig. 3) including the triage classification of immediate, delayed (can wait), palliative (must wait) and minor (and dead). The same form is used for day-to-day emergencies and disasters and is available for

20

Injury the British Journal of Accident Surgery Vol. 10/No. 1

The vehicle thus dovetails in with the plan for the future: maproved standards of early patient care, ability to deal with new hazards, flexible communications operating throughout the health district and a teaching system for medical, nursing and emergency services' use based on the accident and emergency department and the techniques it may help to evaluate in the future.

MAJOR ACCIDENT PLAN Bath Hearth Dlstt*c!

Team 1 Medical Officer 1

1. Report to Wa~tmg Area 'C' Out-Pat~ents Dept 2. Change into clothmg--mcludmg Orange tabard 3. Pick up haversack 4. Meet transport at OPD main door 5. On arrival at disaster go to Ambulance Control Vehicle (with Green and White chequered top) fo.r rest of equipment, l.e MO's box, and report to Site Medical Officer (wearing Green and White tabard) 6. Also collect emergency box if required---contains amputation set, tracheostomy set, laryngoscopes, w~re cutters, Brook airway, Heimhch chest valve (All team members should remember to ensure that they are protected against tetanus)

Fig. 4. A representatwe action card for the major acodent team medical officer. This document would be printed with the green and white chequered symbol at the head.

ambulance and medical use. Also incorporated in the plan is a diagram of the Accident and Emergency Department and action cards giving the functions of all key personnel (Fig. 4). One final detail includes the incorporation of past experiences into future planning by the use of a rapid patient numbering and documentation system on arrival at hospital, so as to avoid the otherwise inevitable bottleneck at the hospital door. To identify the plan, documents, key personnel and the medical rescue unit the green and whlte chequered symbol is used in print and on armbands as well as on the control vehicle itself and on the identity jacket of the site medical officer.

Acknowledgements The ideas of the past are thus incorporated into the plans for the future, and in so doing acknowledgement is due to the sources of published research listed below as well as to the assistance received by exchange of ideas with colleagues in the health and emergency services of Wiltshlre Area Health Authority and Bath Health District. I am also pleased to acknowledge the funding and assistance received from the Rehabilitation and Medical Research Trust, Bath, and from my wife and secretary, Mrs S. Snook.

Appendix Outhne spemflcat=on for major acmdent ambulance and educational umt and acknowledgements of assastance w=th des=gn

Vehicle chass=s" Bedford CF 350. Petrol engqne. Automatic gearbox. Ferguson four-wheel drive conversion: F F Developments Ltd Bodywork: Rootes Maldstone Ltd Electrical generator and floodhghts. Stemllte, Dale Electric Ltd. Radiotelephone V H F / U H F linked system. Pye Telecommumcat~ons Ltd Static heating system: Eberspacher (UK) Ltd Medical equipment. Laerdal disaster kit, Vlckers Medical Lid; anaesthetic eqmpment, Penlon Ltd; oxygen and Entonox, British Oxygen Co. Ltd. Audiovisual equipment: Singer Caramate system, 16 mm cm6 system, Rank Audio-Visual Ltd. Trairung mamklns for mouth to mouth, external cardiac massage, intubatlon, infusion, defibrillation and wound simulation; Vlckers Medical Ltd. Ambulance stretchers, splints and rescue eqmpmerit" F W Equipment Ltd; R. F. D Mdls Eqmpmerit Ltd. Provisions: J Samsbury Lid Full details and speoficatlon may be obtained from Dr R. Snook, Consultant m Accident and Emergency Medicine, Royal United Hospital, Bath.

Snook Accidents and Disasters

BIBLIOGRAPHY Baskett P J F , Lawler P G P , Hudson R. B. S. et al (1976) Resuscitation teaching room in a district general hospital, concept and practice. Br Med. J. 1,568 McMahon A. G (1974) The use of the Tauranga Thomas rescue sphnt. S. Aft" Med. J 48, 835. Rutherford W H (1975) Civil disturbances. In. Rtchardson J W (ed) Dzsa~tel Planning. Bristol, Wright

21

Savage P E. A. (1972) Disaster planning. The use of action cards Br M e d J. 3, 42. Snook R. (1972) Automatic traffic light control. Ftre (J Br Fire Serv ) 65, 3. Snook R. (1972) The use of flashing beacons. File Protectton Rev. 5, 214. Snook R (1972) Medical aspects of ambulance design. Br Med../. 3, 574. Snook R (1974) Medical Atd at Acctdents. London, Update.

Requevt~ for reprints should be addressed to Dr R Snook, Consultant in Accidentand Emergency Medicine, Royal Umted Hospital

Bath