Disaster Medicine in the ED

1. CODE BROWN
2018
EMERGENCY DEPARTMENT

2. OUTLINE
• What is a Disaster?
• The Emergency Department’s response

3. WHAT IS A DISASTER?

4. DISASTER/MAJOR INCIDENT
• A disaster or major incident is when the
number or type of casualties exceeds the
normal working capacity of the Emergency
Department / Hospital
• The aim of Code Brown is to deal with mass
casualties from a sudden impact event
(disaster) in a timely and effective manner

5. TYPES OF DISASTERS
• NATURAL
• MAN MADE
-Unintended
-Deliberate/terrorist
• BIOLOGICAL
-Terrorist
-Pandemic infection

6. AUSTRALIAN DISASTERS
YEAR KILLED INJURED AFFECTED HOMELESS
Black Saturday
bushfires
2009 173 414 60, 000 7, 562
Queensland/
NSW floods
2010-
2011
44 200, 000 38, 460
Lindt-Sydney
hostage crisis
2014 3 4 18
Melbourne car
attack
2017 6 36

7. INTERNATIONAL DISASTERS
YEAR KILLED INJURED AFFECTED HOMELESS
Twin tower
attacks-NYC
2001 2, 977 6, 000+
Kuta-Bali bombings 2002 202 196
Haiti earthquake 2010 316, 000 200, 000
Boston marathon
bombing
2013 5 280
MH17 Ukraine
plane crash
2014 298
Paris attacks 2015 130 80-99 368
Westminster
attack-London
2017 5 49

8. WHAT IS A CODE BROWN?
• A Code Brown refers to the hospitals response
to an external emergency (disaster or major
incident) that will result in the presentation of
casualties that exceeds the emergency
department or hospitals normal working
capacity.
• DIAL ‘55’ CODE BROWN

9. WALKING WOUNDED
STRETCHER CASES
EXTERNAL INCIDENT!
CASUALTY CLEARING POST
SELFPRESENTERS
CONTROLLEDPRESENTERS

10. OUTLINE OF RESPONSE
• The 4 phases of a Code Brown are:
-Notification
-Standby / Prepare to receive casualties
-Reception of casualties
-Stand down

11. EXTERNAL
INCIDENT
FIRST RESPONDERS
AMBULANCE CONTROL
DOH DUTY OFFICERED DUTY
CONSULTANT/REGISTRAR
HOSPITAL
RESPONSE
TEAM

13. What is the first thing that should be
done as the SCO?
READ THE DEPARTMENTAL
SUB PLAN!

14. SCGH CODE BROWN RESPONSE
• The level of response depends upon:
-the number of casualties
-the type of injuries
-the location & its proximity to other hospitals
-the time of day & availability of staff &
resources

15. EMERGENCY CONTROL GROUP
• The Emergency Control Group (ECG) consists of
key personnel trained to deal with a major
incident concerning SCGH
• Comprised of:
-Medical Executive
-Nursing Executive
-Patient Support Services Management
-Facilities Management
-Expert Advisors as required

16. HOSPITAL RESPONSE TEAM
• The Hospital Emergency Operations Centre
Co-ordinator (HEOCC) determines whether a
hospital response team (HRT) is required.
• Comprises of 2 Doctors & 4 Nurses.

18. COMMAND & CONTROL
• Decisions regarding the department are made
by the ED DC & ED Nurse Supervisor
• Regular reports are given to the ECG by the ED
DC & ED Nurse Supervisor
• Area Doctors report to DC

19. Preparing to Receive Casualties

20. The ED DC or Reg will:
• Review patients in the WR
• Review patients in the main department
• All patients within the department will be
discharged, transferred to their ward or the
Acute Assessment Area when set up by the
ECG

21. STAFFING
• The ED DC & ED Nurse Supervisor will activate
the call back of duty staff as required.
• Contact numbers of off duty staff are
in the phone book

22. DEPARTMENT LAYOUT
• Dependent on numbers
• C27-R7: Area 1 RED 1 dr & 1 nurse: 1 patient
• C8-C14: Area 2 RED
• C15-C26 & Fast Track:
Area 3 Yellow 1 dr & 1 nurse: 2-3 patients
• Obs ward: Area 4 Yellow
• Outpatients Department (Eye clinic):
Area 5 Green 1 dr & 1 nurse: 4-5 patients

23. AREA DOCTORS – area leader
• Resus Doctor
• Assessment Doctor
• Obs Ward Doctor
• Area 5 Doctor
• Help prioritize ongoing investigations &
treatment
• Liaise with ED DC

24. TRIAGE
• One Doctor & Two Triage Nurses
• Patients triaged as Red, Yellow or Green
• Ensure disaster triage card is filled out
• Triage clerk enters details onto EDIS
• Two name bands

25. TRIAGE sieve vs sort

26. • 54 year old male:
– Chemical Burns to arms and legs, Shrapnel to face,
compound # to Rt forearm
– Ambulating.
– A: Nil Airway compromise.
– B: RR 20 Nil Respiratory Distress.
– C: CRT <2 sec. Perfused, nil bleeding
– D: Alert

27. • 64 year old female:
– Blunt injury to head. Lacerations to face.
– Collapses upon arrival to triage
– A: Clear
– B: RR 22
– C: CRT <2Sec.
– D: Groaning

28. • 38 year old Female:
– Burns to arms and legs
– On stretcher carried by DFES
– A: clear
– B: RR 30
– C: CRT 3secs
– D: Groaning

30. 54 year old male:
- Chemical Burns to arms and legs,
Shrapnel to face, compound # to Rt
forearm
- A: Nil Airway compromise.
- B: RR 20 Nil Respiratory Distress.
- C: HR 100, BP 110/70, perfused, nil
bleeding
- D: GCS 14 - E4, M6 V 4

31. • 64 year old female:
– Blunt injury to head. Lacerations to face.
– Collapses upon arrival to triage
– A: Clear
– B: RR 22
– C: CRT <2Sec. HR 60, BP 90/60
– D: GCS 8 - E1, M5, V2

32. • 38 year old Female:
– Burns to arms and legs
– On stretcher carried by DFES
– A: clear
– B: RR 30
– C: CRT 3secs, BP 80/50, HR 125
– D: Groaning – GCS 10 - E3, M5, V2

33. RECEPTION OF CASUALTIES

34. PATIENT FLOW
• Patients triaged Red or Yellow go directly to
area where area leader allocates location &
ensure EDIS reflects this.
• Patients triaged Green go to outpatients via
Hospital Ave. Must be able to walk or go via
wheelchair. Area leader then allocates location
& ensure EDIS is updated. Charlies Chariot
maybe utilised.

35. PATIENT FLOW CONT…
• Patients from Areas 1-4 should not return to
Emergency if leaving for an investigation or for
treatment.
• Activation of the Acute Admission Area &
discharge area as needed.
• Patients in Area 5 may return following
leaving.

36. WHAT PROBLEMS are we likely to
ENCOUNTER?
BOTTLENECK’S
• Theatre
• Radiology
• Bed Block (General Hospital Beds)
• High Dependency beds (ICU)

37. RELATIVES
• Social Work department takes care of relatives
• Visitors Centre may be activated
– located on first floor E Block

38. MEDIA & PATIENT ENQUIRES
• All media calls & patient enquires are to be
redirected to communications (switchboard)
on extension 91 who will then forward them
to the Public Relations/Media Liaison Officer

39. STAND DOWN
• No more disaster casualties expected
• ‘ALL CLEAR’ declared by ECG
• Return to normal procedures
• Staff informal defusing session if required
prior to leaving
• Ensure staff sign off
• Debriefing formally within 7 days
• Evaluation of response

41. Fremantle Ship Fire
• 11am call to DC – Code Brown Standy-by
• SJA requested HRT
• 3 doctors and 4 nurses deployed
• 1130am 2 x SJA arrived to transport HRTs

43. • HRT returned to ED at 1300
• 40 casualties reviewed and treated at the
scene
• 4 Crew members transferred to hospital – 1 to
RPH, 3 to FH

44. Other issues to think about

46. Chemical weapons
• Chemical weapon attacks may be disguised
with conventional attack
• Potential to cause more harm to care givers
• Know your toxidromes that suggest agents
requiring antidotes
• NEJM April 2018 Toxidrome Recognition

47. • Increased secretions, muscle effects, +/-
miosis
• Nerve agents – sarin, organophospate
• Initial antidote – atropine, pralidoxime, spot
decontamination at site, emergency care

48. • Bradypnoea/apnoea, collapse, seizures +/-
cyanosis
– Asphyxiant Agent – hydrogen cyanide, cyanogen
chloride
– Antidotes – hydroxycobalamin, sodium
thiosulfate, spot decontamination at the site and
urgent care

49. • Bradypnoea/apnoea, sedation, miosis
– Opioid agents – fentanyl, remifentanyl
– Antidote – naloxone, spot decontamination at the
site and urgent care

50. ANY QUESTIONS?