Wednesday, November 24, 2010

ER: Disaster

I’ve discussed about the principle of disaster management based on the administration aspect previously, so now would be about the clinical or medical emergency response during disaster as much as how it’s related to our responsibility and ability in the border of proper ethics. I'll use picture below as the guidance to discuss this topic efficiently:)


The mnemonics of METHANE:)
M = major incident standby / declared
E = exact location
T = type of injury
H = hazard, present and potential
A = access
N = number of casualties
= emergency services, present and required

An important procedure under the above actions is the Triage.

Triage is the priority arrangements process to manage a large number of victims of which the principals include:

1. Degrees of life threatening conditions as consequences of injuries (ABCDE of Trauma Victims Management): For instance, patient with threatened airway and breathing are more prioritized than patients with circulation or neurological disturbances.

2. Severity of injuries: Eg. Single fracture may get low priority, but if its single fracture + massive bleeding- high priority.

3. Survival probability: Save the patient with higher chance of survival first.

4. Resources and equipments: Patients requiring unavailable equipments will get low priority till resources are feasible.

5. Time, distance, and circumstances: Treat injuries which take the shortest time of management first.

Let's try arranging these examples of cases from highest priority to the least.
  • Case 1: A little 2 year- old girl with heavy diarrhea.
  • Case 2: A 75 year- old man with dyspnea and history of COPD since 7 years ago.
  • Case 3: A woman with a bleeding wound on her elbow as she just got injured after falling down.


This means “delayed”. The management for toddler can be delayed first, but it is still indeed necessary as heavy diarrhea can cause dehydration which leads to shock if no management is taken.

“Immediate”! Obviously, he’s the patient with ABC problems with history of respiratory tract disease, plus another co morbid factor: he’s old.

“Minor”. Treatment is to be given, but after the RED’s and YELLOW’s are done. The bleeding needs to be stop and managed properly anyway to avoid infection.

So the TRIAGE goes as:

The old man --> The little girl --> The woman 

One very important thing to remember is that the person who's in charge in this Triage Card labeling should be one with the most competency, not necessarily be a physician.

Resuscitation, Stabilization, and Transportation are also the important procedural actions to be highlighted in pre- hospital medical response as they are the significant continuation processes after Triage.

On the other hand, emergency response for neurological disturbances are also important as mental health is one of the most common impact experienced by the victims of disaster, be it quite as simple as minor depression or as complicated as PTSD.

Psychological first aids
  • nActive listening
  • nEmpathy: Being sympathetic will only cause the victims to lament more on their plights)
  • nAccess the basic needs: Their need may differ from one to another, we can't assume one refugee can list down all the necessities on behalf of others')
  • nDon’t push to speak: This is indeed an emergency situation, but we must not rush.Allow them to take their time to calm down a little and express their emotions or thoughts.
  • nAvoid from secondary stressors
  • nNo medications: Avoid prescribing drugs unless there's an indeed true indication for such.
Authorities playing role in this chain include the community of the disaster itself, NGOs or any other organizations, health center of the specific area or even region, and any voluntary individuals or teams.


Hospitals have their own Disaster plan which generally has these important procedures:

Management Support
Medical Support
  • Command
  • Safety
  • Communication
  • Assessment
  • Triage
  • Treatment
  • Transport

Psychological (mental health) intervention:
  • Manage emergency psychiatric symptoms (major depression, agitation etc)
  • nEnsure the availability of psychopharmacy (Eg. haloperidol, benzodiazepines, )
  • nContinue the administration of psychopharmacy for chronic mentally ill people who have taken medication previously. Hence, a thoroughly anamnesis is required.

The plans by points are:
  • Coordinating Team
  • Medical team
  • Surveillance
  • Management back up
  • Logistic (resources)
Further posts I'll make later will explain about these deeper. Keep checking me here:)
    • "Medical Emergency Response", lecture by dr. Hendro Wartatmo, Sp. B- KBD
    • "Disaster Management in Mental Health", lecture by dr. bambang HAstha Yoga, Sp. KJ

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