Injury (1990) 21, 21-24
Printed in Great Britain
The work of the South Manchester Accident Rescue Team (SMART) A. D. Redmond Consultant
A & E Service, Manchester,
Introduction Almost 4 years ago when a small child was impaled on railings, the ambulance service in South Manchester failed to get a medical team to attend, although three neighbouring hospitals were contacted. Each of these hospitals claimed to have a ‘flying squad but the duty junior doctors who made up the ‘team’ could not be released at the time. This d hoc arrangement whereby inexperienced junior doctors are dispatched to the scene of an accident is unfortunately not uncommon and is a feature of many major accident plans. The first brief for the new accident and emergency consultant was to deliver on-site medical care to South Manchester, bearing in mind the following points: 1. The medical and nursing 2. 3. 4. 5. 6.
staff involved must be senior and experienced in work outside hospital. The staff on call for this work must have no other conflicting duties. Contact with on-call staff must be rapid and easy. In towns, the time spent in waiting for a team can be longer than the transit time to the hospital. Highly trained ambulancemen can now perform many of the skills that doctors were called out for in the past. Summonses to accidents are not common and may become less when more ambulancemen have advanced training. The provision of a site medical officer for a major incident is often haphazard, involving a doctor with no previous experience or appropriate training for this difficult task. The mobile medical team dispatched to a major incident is often untrained and gathered together purely for that incident from a pool of inexperienced junior doctors.
Against this background the South Manchester Rescue Team (SMART) was formed:
1. The team consists of senior doctors and nurses from the accident and emergency department and ICU with support from other relevant specialties (e.g. plastics) when necessary. 2. There are regular, frequent training sessions in care at the site in conjunction with colleagues from the police, fire and ambulance services. 0 1990 Butterworth & Co (Publishers) Ltd 0020-1383/90/010021-iJ4
The duty SMART doctor carries a mobile telephone, the number of which is known to the emergency services. For as long as this doctor has the telephone he remains the duty doctor. SMART responds to patients trapped by the accident but not to all accidents. The team is used for transfer of critically ill and injured patients from outlying hospitals into the specialist hospitals in South Manchester. This ensures a frequent exposure to working outside the hospital and provides all staff with regular experience in monitoring and treating patients in ambulances and occasionally helicopters. SMART has assumed responsibility for the provision of a site medical officer and mobile medical team to major incidents within the South Manchester area.
Experience in 1988 SMART was established in 1987 but evolved into its present form in 1988/9. It is registered with BASICS. The Accident and Emergency consultant is the overall director. A GP member coordinates on-site immediate care activities and an Intensive Care Consultant the interhospital transfers. On-site medical care
There were 10 calls to SMART from the ambulance in 1988, four of these are described in T&e 1.
There were 95 interhospital transfers. These have included ventilated patients with head injuries, with multiple injuries, bums, poisonings and septicaemia. The RAF have flown the team to more distant hospitals to assess and bring back burned patients. The policy has been to paralyse, intubate, ventilate and sedate all critically ill patients before transfer. Chest drains are inserted before transport and not necessarilywithradiologicalconfirmation,recognizingthepenalties of delayed treatment of even small pneumothoraces and the difficulties of making the diagnosis in transit (Jones, 1989). The team has transported many patients with femoral arterial lines in sittl and occasionally with indwelling pulomonary artery catheters. The Marquette ‘Tram’ portable monitor enables continuous monitoring of femoral and pulmonary artery pressures.
Injury: the British Journal of Accident Surgery (1990) Vol. 2WNo. 1
Table I 1. Male - 31 years Problem Trapped in upturned cab of car transporter. Crush injury to chest. Venous access difficult during pXrolongedextrication. Action Intravenous drip set up and analgesics and fluid replacement (> 3 I) given on scene. Full recovery. 2. Female-41
Problem Trapped by legs in car. Open, grossly displaced fractures of tibia with circulatory compromise in feet. Action Intravenous infusion. Blood despatched to hospital for crossmatch. Analgesics. Rapid extrication advised and fractures reduced on scene with restoration of pulses. Good recovery. 3. Male - 36 years Problem Trapped by falling earth while tunnelling 40ft underground. Prolonged extrication. Ambulance Officer had established intravenous infusion but was concerned about the circulatory effects of the man’s sudden release. Action Doctor and nurse taken down by Cave Rescue Workers. Coordinated release accompanied by copious fluid infusion. Urine ouput initially poor but renal failure did not develop. Good recovery. 4. Male - 28 years Problem Impaled on pedestrian barrier which penetrated the car windscreen and passed through the driver’s abdomen, seat and rear passenger seat. Action With the light from a helmet lamp the metal bar was seen to lie subcutaneously. The skin and subcutaneous tissue was dissected under local anaesthesia to release the patient. The wound was tidied up and closed later in theatre. Full recoven/.
There were no local major incidents during this period. The team was, however, been involved in events further afield (Redmond, 1989a,b). In December 1988 the Overseas Development Administration discussed with SMART a request from Moscow for specialists in the management of severely injured and crushed patients. The plastic surgeons and intensive care consultants at Withington Hospital have a wide experience of these conditions. The regular SMART members experienced in on-site medical care accompanied a consultant plastic surgeon, consultant general surgeon and intensive care consultant to the scene of the earthquake in Armenia. The lack of a national organization to coordinate the medical response to disasters meant that the UK response was slow and fragmented. The team used scheduled airlines while teams from other nations were flown directly to the scene by military aircraft. The eight SMART doctors arrived in Russia 5 days after the earthquake. The team travelled the last 80 miles in a battered coach to Leninakan. This major city had been devastated. We arrived at night and on Foreign Office instructions, were without supplies of food, water or tents. Fortunately we had purchased arctic clothing before departure so at least we could survive the temper-
ature of - 20°C. The city was without food, water, electricity or shelter. The generosity of the US national team enabled us to stay in the earthquake zone. Members accompanied team workers in the search of the rubble and attended patients in the casualty clearing station. Fortyeight hours later it was clear the rescue attempt was over and the team transferred to Yerevan. This, the capital city of Armenia, was untouched by the earthquake and injured patients had been transferred there. Members split into groups of two and worked in various hospital departments. It was clear that many cases of ‘crush syndrome’ were in fact acute tubular necrosis secondary to hypovolaemia. When crush syndrome did occur it was not treated according to modem protocols (Bursztein, 1986). Fluid replacement was grossly inadequate and amputation of damaged limbs carried out too late. One week later the team returned home. Relationships with Russian colleagues were excellent and reinforced when two SMART team members were invited by the Soviet Academy of Medical Sciences to address a conference in Moscow on Medicine and the Environment. Forty-eight hours after returning home the duty SMART doctor was informed by RAF Edinburgh that a plane had crashed north of Carlisle (F&u-e I). A team was airlifted from Manchester to Lockerbie and joined the other doctors in the search for survivors. Again the lack of a national UK response to disasters produced a fragmented effort. Individual rescuers behaved extraordinarily well but the inevitable confusion and chaos that surrounds the early stages would have been curtailed had incoming rescue teams been known to each other and if there had been an established framework in which they could work, both with each other and with other rescue workers. The present medical response to major incidents continues to depend solely on what is available locally. If a plane falls on the Ml, between three major hospitals and within sight of the airport and all its rescue facilities, the response will be satisfactory. When it falls onto remote Scottish countryside, with only one relatively small hospital within a reasonable distance and specialist centres much further away, there will inevitably be problems. The unfortunate fact that, when this occurred in Lockerbie, there were few casualties on the ground and no survivors from the air, may have served to divert attention from some sensitive but built-in difficulties with present national policy. Extra medical help was clearly needed as the search for survivors, particularly those who might be injured on the ground, had to continue throughout the night and over a large area. In the absence of any national response, doctors from independent voluntary immediate care schemes were called in, and medical rescue teams flown in by the RAF from Edinburgh and Manchester. This was done largely on an ad hoc basis with rescuers contacting anyone they knew. If there had been more injured on the ground or survivors from the plane the local response could not have been expected to cope. Yet the exclusive use of local facilities as laid down by the Home Office leaves areas of this nation totally dependent on their small local hospital, even when a plane lands on their town. Extra police were drafted into areas such as Lockerbie, but as we have no central stocks of the most basic equipment when the batteries on their torches gave up, so did they. Simple items such as maps of the area were not available. Civilian mountain rescue, and search and rescue dog teams were quickly on the scene at Lockerbie, but not apparently as a consequence of any central plan. A local member of their
Redmond: The South Manchester Accident Rescue Team
Figure 1. Debris from Pan Am flight 103 in Lockerbie. (Courtesy of The Independent.)
association appears to have mobilized a network of helpers using their own well-established cascade system of call-out. This system could be copied or modified for all the emergency services. The final danger in a total reliance on the local response is the erroneous assumption that those responsible locally will always survive the disaster and remain physically and mentally unharmed. Much unwarranted criticism was levelled at the Soviet authorities over their response to the earthquake in Armenia, yet those of us who were there and worked in the earthquake zone (as opposed to reporting from the unharmed capital, Yerevan) realized that the earthquake spared no one. In Leninakan alone, all four of its hospitals were destroyed. From the largest one only four medical staff survived. The fire stations were destroyed and many of the civil servants who would be expected to coordinate the rescue and relief operations also perished.
Summary Skills acquired in the hospital do not necessarily translate to the scene of an accident. However, training in certain hospital specialties, particularly accident and emergency medicine, will expose doctors to dealing with very ill patients in a less rigidly structured environment. The operating theatre is a disciplined and controlled environment. Skill in anaesthesia, monitoring and operating, if tested only in these circumstances may be found to be gravely inadequate when exposed to the fluctuant and hostile environment at the site. Doctors who wish to do this sort of work or are designated to do it, must undergo regular and frequent training, especially if they are not trained in accident and emergency departments. This has long been recognised by the British Association for Immediate Care. In combination with the Royal College of Surgeons of Edinburgh they have now established a diploma in Immediate Medical Care.
In urban areas the need for a doctor to attend at the scene of an accident is usually limited to entrapment. These occasions are likely to be infrequent and this can result in a lack of preparedness for such events. Interhospital transfer, primarily from peripheral hospitals to the specialist services of a teaching hospital, often involves critically ill and injured patients. The management of these cases by the mobile team provides regular, frequent exposure to working in a ‘hostile’ environment. Relationships with the rescue services are developed and staff become familiar with equipment and call-out procedures. The care of transported patients is improved. None of our patients have died in transit or within 6 h of arrival at base. Having established a team of doctors and nurses with considerable experience of work outside hospital, they should be used for major incidents. The site medical officer and mobile medical team should be drawn from this pool of experience and not plucked from the rota. The Royal College of Surgeons of England has pointed out the serious deficiencies in trauma management in the UK (Royal College of Surgeons of England, 1988). It will not necessarily improve to cope with a disaster. Concern over the artificial separation of disaster plans from day-to-day trauma plans has recently been expressed in the USA (Trunkey, 1988). There is a growing number of experienced mobile teams and systems throughout the UK. Some are hospital based, some GP based and some, like SMART are mixed. There should be a better intregration of these teams to facilitate mutual assistance at disasters.
General points The first response to a disaster will be from the local agencies. However, when the disaster is large enough, in a remote or poor area where local facilities are limited or the rescue attempt will last for more than a few hours, the local response will be overwhelmed and additional outside help
Injury: the British Journal of Accident Surgery (1990) Vol. tl/No.
will be required. The alerting and dispatching of this additional help to the scene and its intregration into the local plan requires planning. The aIerting, dispatching and coordination of additional outside help to the scene of a disaster should be through a recognized disaster coordination centre (DCC). Experience has shown that doctors are required in the early phase of a disaster for triage, appropriate resuscitation, treatment of trapped patients, rapid and accurate identification of human remains and the care of the rescuers themselves. The role of the military in the preparation and planning for such events is underused and should be incorporated in any plans forthwith. The doctors who are involved in this early phase must already function as part of a multidisciplinary team. If the rescue attempt is to be effective teams with their doctors must be dispatched within 24-48 h of the event. This is possible and was achieved by other nations in Armenia for example, but requires the availability of a coordination centre and a system. When the Foreign Office receives a request for assistance from another country there should be available to them a single phone number of a centre which will assemble an appropriate team within a matter of hours. The coordination centre will have gathered and stored on computer the location and availability of teams and individuals with relevant and proven capabilities. A small team with a limited amount of equipment should be dispatched first, ideally by military aircraft, directly to the site of the disaster. They would communicate to the centre the exact nature of any further assistance required. The development of a Disaster Coordination Centre (DCC) would ensure that only experienced help was offered and would filter the many other offers to prevent unsolicited volunteers invading the disaster area. Following S-7 days of rescue, the relief phase develops. Specialist medical help can be supplied for hospital work following liaison between the core team and the authorities. The DCC would be responsible for the identification and dispatch of these specialist teams. On return to the UK the DCC would ensure that all workers were debriefed and informed later of the progress in reconstruction and recovery. It is clear from recent disasters in the UK that our current exclusive dependence on the local response is unrealistic. Additional help from other agencies is required and used in
the event. The effectiveness of this additional help is hampered by the absence of a system whereby such help can be integrated into local plans. At present medical teams can be summoned by a variety of agencies without reference to each other or the site medical officer. Furthermore, individual doctors can, and do, turn up independently and work on scene. A DCC would ensure that additional outside help is drawn from a recognized pool of experienced teams. Local agencies would inform the centre automatically of every disaster and the nearest team(s) would be identified. This system coordinated through the DCC would ensure that the previous experience of others is brought to the benefit of each disaster. There must be certain minimal standards for inclusion in the computer records of the DCC, and the DCC must be the only channel through which medical teams, other than those written into the local plan, can reach the scene of a disaster.
References Bursztein S. (1986) Pathophysiology and management of crush injury, In: J. L. Vincent, ed. Update in Intensive Cure and Emerpncy Medicine. Springer-Verlag, 1, 384. Jones N. S. (1989) An audit of the management of 250 patients with chest trauma in a regional thoracic surgical centre. Arch. Emerg. Med. 6 (Z), 97. Redmond A. D. (1989) Being there. Lancet I, 660. Redmond A. D. (1989). The response of the South Manchester Accident Rescue Team to the earthquake in Armenia and aircrash at Lockerbie. BY.Med. 1. 299,611-612. Royal College of Surgeons of England (1988) Tke Management of Patients with Major Injuries. Trunkey D. D. (1988) Trauma care at mid-passage - a personal viewpoint. J. Tnwna 28 (7), 889.
Requesfs for reprints should be a&essed to: A. D. Redmond, Consultant in Charge, Accident and Emergency Department, Withington Hospital, Nell Lane, West Didsbury, Manchester M20 8LE, UK.