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Deficiencies should be corrected where possible—if not, the ATM must be informed; 1. Evacuation Triage. In such circumstances the Evacuation Officer maintains observation of the victims and informs ATM of any deterioration in their condition.

This short-term monitoring should only be required in exceptional cases, as the evacuation area is supposed to serve only as a check point for victims before their departure. One of the roles of the first responding team arriving on the scene will be to stop spontaneous evacuation organized by witnesses. This unmanaged transport in unsafe, uncontrolled conditions to any unprepared health care facility will endanger the lives of victims and disrupt the implementation of the Mass Casualty Management System—thus endangering the lives of those to follow.

Control of Victim Flow 2. From impact zone site to collecting point, from collecting point to AMP entrance, from AMP entrance to treatment area, from treatment area to evacuation area, from evacuation area to hospital receiving area, from hospital receiving area to appropriate care area, the victims will be on a kind of oneway "conveyor belt," taking them from a basic first aid care level to sophisticated care level see Figure In a mass casualty event, it will never be possible to have a transport resource for each victim.

So, each transport level will have to use its own limited resources in a rotating system, to bring all patients from one level to the next. The efficiency of each successive transfer between levels will be maximized by ensuring that the circulation follows in a "one-way", controlled rotation. This one-way progression from level to level by rotating transportation resources was labelled "Noria" in during the World War I battle of Chemin de Dames in Verdun, France.

The Transport Officer must be aware of the exact location of each ambulance.

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The driver must never leave the vehicle even to assist with the carrying of the patient. The vehicle must be parked on standby in a specified area designated by the Transport Officer in such a way that the vehicle is accessible and clear to move. However, nonacute victim transfer can be inserted in the general evacuation process when: - Primary health care facilities are available; - Non-medical transport resources are available e. At all times, priority for evacuation must be given to acute victims. Figure 13 is a checklist of the elements of field organization for mass casualty management.

John Smith, is trapped in a collapsed building. We will follow this victim through the system. The search and rescue team extricates Mr. Smith and reviewing injuries and status thoracic trauma, abdominal trauma, crushed legs; conscious; breathing slightly laborious; pulse classifies him as Acute Red ribbon. Victim is received in Red Treatment Area where following takes place: - Infusions IV lines x 2 - Oxygen - No obvious rib fracture, bilateral rhonchi lung contusion?

Red Team Leader requests priority evacuation to surgical facility in equipped ambulance escorted by EMT. Hospital identified 10 km from disaster site with operating theater and surgical team immediately available. Victim is assessed and secured in the ambulance by the Evacuation Officer and dispatched to the receiving hospital. This scenario emphasizes the need for rapid stabilization and appropriate dispatch of the victim according to the type of injury. Stabilization means not simply the establishment of infusion and immobilization but arresting deterioration or improving victim status.

Mass Casualties Disaster

In this scenario, the victim received stabilization care 20 minutes after the incident. This organization, utilizing pre-established and tested procedures, will allow: - Active mobilization and management of available resources human and material ; - Links with pre-hospital organization; - Management of in-patients and victim flow; - Management of care; - Management of secondary evacuations; - Informing and updating authorities and relatives of victims. Timely implementation of such an organization cannot be improvised and requires a well conducted preparatory phase including: - Draft of a specific Hospital Mass Casualty Management Plan HMCM , which forms part of the Hospital Disaster Response Plan as well as of the National Mass Casualty Management Plan; - Dissemination of this HMCM plan to concerned persons and sectors hospital staff, ministry of health, police, fire service, national disaster office ; - Regular testing and up-dating of the plan at hospital and multi-sectoral level.

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Alerting Process The alert message originating from the dispatch center must be communicated directly to the Accident and Emergency Department via hotline or radio. This message must be received personally only by the nurse in charge or physician on duty. At this time, the hospital telephone operator will begin to call persons on the established list. Mobilization 2. If the event is further than twenty minutes away, the hospital mobile disaster team will proceed to the site only at the request of the district health team.

Staff from other wards must assist staff clearing specific wards. Centripetal Mobilization of Hospital Staff Reinforcement of key departments, i. For greater efficiency, reinforcement must be carefully planned and staggered to ensure a quick turnover of staff in the most exposed areas e. This protects against staff burn-out during a mass casualty event and ensures prompt return to routine activities with adequate personnel. In accordance with the National Mass Casualty Management Plan, the hospital will coordinate with the following sectors: The national Mass Casualty Management Plan must make provision for the automatic dispatch of an adequate police squad to the hospital as soon as a disaster is declared.

This police squad will reinforce the security at the hospital with particular attention to securing the reception area and all the hospital entrances. If within 15 minutes of the disaster notification the police squad has not reported to the hospital, the telephone operator must notify the dispatch center, the Emergency Operations Center, or the central Police Station. The hospital administrator should contact the Red Cross office and the Ham Radio Association directly or through the Emergency Operations Center if these teams have not reported within 30 minutes of the disaster notification.

Chapter 5: Hospital Organization 3.


Hospital Command Post In each hospital, a room should be identified to serve as the Hospital Command Post during a mass casualty event. This room should be pre-equipped with radio and telephone or be pre-fitted with the appropriate connections to facilitate immediate operation of radio and telephone communications.

The room should be large enough to accommodate a maximum of ten persons and be easily identifiable. The following persons will constitute the core of the Hospital Command Post: - Hospital Administrator - Medical Superintendent - Matron - Secretary - Spokesperson liaison with families and media 4.

Clearance of Receiving Facility Beds should be made available in the hospital to accommodate victims of the mass casualty incident. The Hospital Command Post must initiate, immediately, pre-established procedures to clear in-patients who are able to be moved. Estimate of Hospital Care Capacity The reception capacity of a hospital is not only linked to the number of beds available, but to its capacity to deliver care.

In a mass casualty event that produces trauma victims, the "bottleneck" of the care delivery system will definitely be the surgical and intensive care capacity of the receiving hospital see Figure A multiple trauma victim will need, at minimum, two hours of surgical attention. The number of effective operating rooms which includes availability of the room and sur- 37 geon, anaesthetist and equipment simultaneously determines the surgical treatment capacity and thus the hospital care capacity.

If a hospital with three effective operating theaters receives twelve "red" victims needing prompt surgical attention during a mass casualty event, it will be able to treat, on an average, three patients every two hours. So, three of these twelve victims will have access to operating theaters six hours after their arrival at the hospital. This situation can severely endanger the life of these victims, if intensive care is not able to stabilize them.

Taking these limitations into consideration, it would then be more efficient to organize the rapid evacuation of these victims to health care facilities which would be able to provide appropriate care in a shorter time. Moreover, in such a situation, the Hospital Command Post must inform the Field Command Post that it cannot receive more "red" victims and that it is necessary to proceed to another health care facility. Location A reception area is where the hospital triage is conducted. However, if the prehospital management system fails and uncontrolled large numbers of victims arrive at the hospital, it will be necessary to hold patients after triage in a large room adjacent to the triage area, where victims will be stabilized and monitored before dispatch.

Such a situation can overwhelm the hospital's capacity.

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Personnel The hospital triage officer will assess each victim in order to either confirm the evacuation triage or to recategorize. With efficient pre-hospital management, hospital triage could also be carried out by an experienced nurse from the emergency department. If the pre-hospital management was not effective, an experienced emergency department physician or anesthesiologist should manage the hospital triage. In the hospital, there must be a constant flow of information between the hospital triage area and other key departments and the Hospital Command Post.

The ambulance will establish contact with the hospital triage area 5 minutes prior to arrival. Red Treatment Area A minimum of two hours of surgical attention is necessary to treat a multiple trauma patient. In a country or province with a limited number of operating theaters, it will be impossible to provide simultaneous surgical care to victims requiring such care. Hence, it is necessary to have available a specific area where these "red" victims will receive appropriate attention. This area will be called the "red treatment area", should be managed by an anesthesiologist, and is best located in the Accident and Emergency Department which is already equipped and accustomed to managing acute patients.

Yellow Treatment Area Victims tagged in the yellow category will be sent immediately after triage to a surgical ward which has been cleared during the activation phase for that purpose. This area will be managed by a hospital physician. The victim's status must be continuously monitored, reassessed, and stabilization maintained.

If the victim's status worsens, he or she must be transferred to the "red" area. Green Treatment Area Green coded patients should not be transferred to the main hospital, but referred to health centers or clinics. However, when the pre-hospital management system fails, many "green" victims will arrive at the hospital.

Therefore, provision must be made in hospital mass casualty management plans for a holding area for this category of victim. Hopeless Victim Area These patients, needing only supportive care, are most appropriately held in a medical ward, previously cleared during the activation phase. Deceased Black Category Victims Area Space large enough to accommodate a minimum of ten bodies in acceptable conditions should be identified in the Hospital Mass Casualty Management plan.

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This can be to another hospital in the same area, to another district or province, or might include overseas evacuation. The Hospital Command Post transmits requests for evacuation to the Medical Officer in the Emergency Operations Center who will make the necessary contacts and organize the transfer. John Smith arrived at the hospital triage area where he was assessed by the hospital triage officer who confirmed his status as a "red" category victim as determined by the evacuation officer of the Advance Medical Post.

This patient required immediate surgical care for internal abdominal bleeding and crush syndrome. The officer in charge of the hospital triage contacted the Hospital Command Post requesting immediate access to the operating theater.