| 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.
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Monash University, Moe Campus.
Cohen, L. (1991). Federal disaster-planning
exercise brings 30 emergency MDs together for
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Cooke, M. W. (1992). Arrangement
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©1998 by The American Academy
of Experts in Traumatic Stress, Inc. |
