How to Deal with the Disaster and Overcrowding in the

How to Deal with the
Disaster and Overcrowding
in the ED
Juan Manuel Gutiérrez
Chairman ED Clínica Colsanitas
Emergency Medicine
Colombia, Southamerica
gutierrez.juanmanuel@gmail.com
SouthAmérica
Colombia
• Colombia, at the
northern tip of South
America, is a country of
lush rainforest,
towering mountains
and coffee plantations.
Statistics
• In the past 30 years, Colombia has been
one of the most vulnerable countries to
natural disasters in America.
• A report submitted in September 2008 by
the National Planning Department (DNP)
reveals that on average 597 disasters occur
every year in Colombia, beating Peru (585),
Mexico (241) and Argentina (213).
DNP, Colombia 2008
Homes destroyed
Numbers
between
2006-2014
• How we have
been afected.
• Floods and
landslides have
grown because
of man.
Affected families
Affected routes
The December 12, 1979, in Tumaco
(Nariño), almost destroyed by an
earthquake of 7.9 magnitude on the Richter
scale, followed by waves of 5 to 6 meters of
cracks quartered streets and squirting water
it sprang from the floor thousand homes
destroyed.
•
The tragedy resulted in the deaths of more than 450 people along the Pacific
coast between Tumaco and Guapi (Cauca).
• 1983 - POPAYÁN
March 31, 1983, at 8:15
am, the city of Popayan
(Cauca), suffered an
earthquake of magnitude
5.5 on the Richter scale.
1985 – Armero
The Tragedy of Armero (Tolima) occurred on November 13, 1985, when approximately 11:30 pm, an
avalanche of Lagunilla river, caused by the eruption of Arenas crater of Nevado del Ruiz volcano, an event
that wiped out the town of Armero, leaving a balance of approximately about 25 000 dead
• 1987 Villatina
A landslide in Villatina, Medellin of
September 27, 1987, was similar to
the Popayan earthquake and the
eruption of Nevado del Ruiz
consequences.
• 1992 – Drought
The dry season known as Energy
Crisis occurred during the
administration of President César
Gaviria, between March 2/1992
and April 1/1993 caused by El Niño.
1999 ARMENIA
The earthquake in Armenia
(Quindio), the January 25/1999,
with an intensity of 6.4 degrees
on the Richter Scale, is a natural
disaster that affected 18 towns
and 28 villages
• The February 12, 2005,
continuous rains generated
overflow Gold River, in the
municipality of Girón, for
which the water swept nine
districts, plus suburban Giron
• The November 24, 2008,
another tragedy struck the
town of Paez Belalcazar
(Cauca), when a stream that
crosses the town and runs
between a barrel grew and
came stampeding over four
kilometers
Avalanche
takes
families
• Build near
the river
without
foreseeing
the danger
• Spring 2015
• Rural area
most affected
We also had terrorist attacks
Terrorist bomb at the social club,
El Nogal 2003
1998-2003
2014-2015
Emergency Plan Responce
Daily
News that day
We receive 28 disaster patients plus the
daily overcrowding, in less than 20 min,
but we learned how to response with
out collapse.
Car bomb
The support
brigade is a
fundamental tool
Emergency Deparment
•
•
•
•
•
Emergency plan with multiple victims.
How to activate the plan.
Everyone should know where to go.
Verify attendance and conformation of each team.
Redistribute work areas to have a safe expansion.
We have learned how to
respond even with
overcrowding
The city is committed to responce
• Emergency plan with multiple victims.
• A big response from everyone in the Emergency Net.
• It was hart to know how to work as part of a team.
Regulatory Center for Emergency; Fund for care and emergency prevention
• Mobile hospitals for disaster demand
The response can be improved and extended with one or more hospitals.
The time response can be adapted and arranged with the occupation of
each hospital.
Bogotá, Colombia
Hospital Net
Connected when the emergency is activated
and on overcrowding
We adapt the START TRIAGE to a flexible
Trauma Triage, with the same colors:
• We've noticed that the proportion of
color behavior, remains:
70% Green Triage in the first hour
20% Yellow Triage with prehospital care
10% Red Triage, several contamination
We redistribute the areas by
colors to contain demand…
We improve our Security
•
•
•
•
•
Less timeouts.
Less infection associated.
Less complication or adverse event.
Best chance to surgery.
Optimization of the installed capacity service.
8,000 p/month
96,457 p/year
With the same volume behavior, less delay in the opportunity of attention
We work to have a stay, less than 6 h
2014
-
2015
Emergency
Deparment
Know your service, means knowing
dynamically, how your team behaves
during the day and how it handles the
collapse.
It means to know what kind of
emergency you deal everyday, how long
it stays and how much did you observed
and resolved.
If you know your response times, you
can handle an event with multiple
victims.
What we have done
• In order to be a part of the Emergency
Net, we work with others.
• Keep communication with the HS.
• Made many drills.
• Constant training.
• Learn from mistakes and publish the
improvements.
• Adapting our facilities
TRAUMA
• Improve communication with
pre Hospital care, so your
goals will be the same.
Decontamination
• How to treat contaminated patient.
• Avoid secondary contamination.
• Providing a path for the biological incident and
for the chemical or radiological incident.
• Sensitize everyone in the ED, including people
who do cleaning.
Control yourself
• Care Structure and
Organitation.
• Haemodynamic resuscitation
targets.
• Fluid manegement.
• Transfusion and coagulopathy
and haemorrhage control.
Bleeding must be stop
Pain must be relieve
A Team responce to Soft tissue injuries,
make it easy to handle
Concussion and wounds
Chafing
Lacerations
Clean with soap and water
Occlude with dry and clean dressings
Control bleeding
Contusion. Usually do not affecting bones or joints, and does not
alter function, but causes great pain.
Relieve pain is you goal
Injuries: Control C, pain control, temperature control
Do what you have to do but do not overreact
Trauma by explosives
• Trauma by explosive devices, should be
considered different from that caused by
any other mechanism of trauma.
• We started with injuries by landmines.
• And then with massive explosions.
• Now we know 5 kinds of injuries associated
with explosions.
1.
2.
3.
4.
5.
Primary, associated with the shock wave that affects the lungs.
Secundary, when accelerated debris, impact the victim.
Tertiary, when the displacement of the body makes impact with solid
structures.
Quaternary, when poisoning or inhalations or crushed occur.
And the last will be when radiation or chemical is added to the pump
Same Team for Fractures, and to keep it
simple
• Closed, immobilize, do not try to reduce by
yourself. With this you reduces pain and
prevents
complication
• Open, Clean it, check the bleeding and occlude
before immobilize.
Hypothermia: Consider it always
slight
35°-33°
moderate 30°-33°
severe
<30°
tremors, confusion, clumsiness
disoriented, drowsy
unconsciousness, hypotensive, mydriatic
Team for Burns,
again keep it simple
Apply cold compresses
Control pain always
Do not break blisters
Clean and cover, pollution control
Optimize intravenous fluids
Shelter and heat must be provide, wind protection too.
Expansion zones must be secure.
Make small functional
groups no larger than 5
people
Control your environment and calm down
Situate patients by severity, in a safe place
Care Structure and Organisation
DECON ZONE
easy installation
Control of chemical,
radiological or
biological incident.
Avoid Contamination
Decontamination Zone
• Shower and take off all the
contaminated clothing
shower
From de hot zone
to the cold zone
Decontamination
area
Agu-2015
Your Action Zones
color according
complexity
optimize
spaces
Adapt your waiting room
Walking Wounded
Not Walking
unimpared breathing and circulation
(after clearing of airway)
Work teams, in their defined areas
Action cards
Color vest,
identifies the team
leader
Fluid management control
Damage control
Coagulopathy and
haemorrhage control
Not Walking
impared breathing and circulation
(after clearing of airway)
We keep part of the servicie with the
normal demand of attention
• We divide the areas,
Avoid
in order to treat
paralyzing the
patients who are not
service during
from the disaster.
the
emergency.
• This area is an
And relative
expansion of the
calm allows
service.
• Patients are prioritized isolate these
patients from
by severity and
disaster
resolves them by
complexity.
Victims plus Patients
• Even with
overcrowding we
have received over
30 multiples victims
and resolved them in
less than 120 min.
• We are capable of
maintain our
responce to the daily
demand of attention
and to the disaster
as well.
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0
1
2
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Time in the ED, after which all the victims are
defined and removed
6
What we have learned
• You can hold the responce even with
the daily overcrowding.
• You need to know how your service
works and how quickly you can
assamble the emergency plan.
• We made a lot of simulations.
• We learn from the disaster.
• We became a team.
Thanks
See you in México