(Courtesy of JP Favero)
Associate Professor Dr David Heslop kicked off the day with a talk on CBRN Issues explaining the characteristics of these type of threats – usually deliberate, sometimes accidental, often used to kill or incapacitate military and/or civilian targets. They an be engineered to defeat defences with strategic and political effects. We noted the 5 Pillars of CBRN-D: Warning and Reporting; Detection, Identification and Monitoring; Physical Protection; Medical countermeasures and supports; Hazard management.
There was explanation of Mission Oriented Protective Posture (MOPP), types and levels of Personal Protective Equipment. We touched on the effectiveness of decontamination and principles to employ both pre and post this type of terrible event. Our senior doctors, many of whom lead major Sydney emergency departments, appealed for advice on who to call in real time.
The Grenfell Fire Experience
Laurence Ioannou gave us a first hand run down of his Grenfell Tower Fire experience as Ambulance Scene Commander. You probably know the story… A 24 storey block of flats in North Kensington, West London, went up in flames early on the morning of 14 June 2017. It took 60 hours to put it out. There were sadly 72 deaths, about 80 people were treated on the scene, 70 transported. At the peak there were 71 ambulance vehicles in play and approximately 30 patients had intensive care post the event.
The value of Joint Emergency Services Interoperability Principles (JESIP) was emphasised – 5 important principles for joint working in major incidents – Co-Locate, Communicate, Coordinate, Jointly understand risk, Shared situation awareness. Laurence found it was vital to brief and share info between agencies every 45 mins or so. He also explained the value of Pre-Determined Attendance. London Ambulance has PDA for ‘Significant’ and ‘Major’ Incidents – early declaration and resource activation saves lives. Simple things make a huge difference – disposable carry sheets / frameless transport devices for patients and coloured tarpolines on the ground for casualty clearing stations, weather allowing.
There’s a great deal of trust in managers and peers during this type of response. Paper log books and a scribe are a must if you find yourself in charge, and don’t forget it takes a long time to complete formal handover, an important consideration in a protracted incident alongside fatigue. Oversight is difficult. Delegate another senior colleague to walk through the casualty ‘journey’, optimise and report back. Control can do a lot to offload scene commander(s), determine hospital destinations and streamline communications – it’s next to impossible to receive information on multiple channels and properly monitor the radio when you’re the on scene boss.
Later in the morning Oli Ellis and Scott McNamara had a chat about Tactical Medicine and the need to practice it in any incident that involves the risk of imminent physical harm to the responder(s).
Remember Rule No 1: Manage your own trauma and don’t willingly expose yourself to these environments without proper training
We know it’s about the correct intervention at the correct time, and that there’s a continuum of BLS to ALS dependent on threat. Unfortunately, when in the hot zone, a medically correct intervention at an incorrect time can lead to further injury. And it’s worth remembering a threat can shift, capturing you and your team in what may have been a previously clear or apparently benign environment. Increased Threat = Decreased Treatment
It was a shame Ben Roberston wasn’t there – he was probably out saving lives in the place where he lives, the danger zone. Meanwhile we noted its all about:
Hot – Danger – Threat suppression
Warm – Not Secure – Haemorrhage control, Rapid extrication
Cold – Safe – Assess and treat patient, Transport to Hospital
The boys made Tactical Emergency Casualty Care (TECC) look HOT, ready to rapidly treat or exclude the 3 big preventable causes of death Haemorrhage, Obstruction of the airway and Tension pneumothorax. They touched on RAMP Triage (Rapid Assessment of Motor and Pulse) and utility in predicting mortality from US military data.
Our afternoon workshops covered off HEMS Team PPE, mask application, Tyvec suits and a real tasking cased based discussion. There were examples of PPE carried by the Special Operations Team, SOT tactical apparel and equipment. Scott gave us a demonstration of wound packing, great fish hook, tourniquet application and labelling. Oli provided an excellent look at patient assessment – radial pulse and simple assessment of level of motor function RAMP style along with a ‘sweep’ in the hostile environment. Integrating “tactical breathing” into the primary survey is something we can all do. We spoke a little about the utility of posturing expectant and deceased patients in a mass casualty scenario and sharing that with other services or those accessing the scene later. Positioning, maintenance of situational awareness, scanning, tactical breathing and great commentary were all on show.
Oli demonstrating a primary survey in a tactical setting.
Scott “fish-hooking” a wound prior to packing.