The day opened with a sobering plenary about climate change.
During the morning concurrent, I attended the Disaster session. Practitioners from around the world shared experiences and lessons from disaster level events.
This session was really quite something.
The first talk was about the Manchester bomb, given by Fiona Lecky. Interestingly, there had been a tabletop simulation exercise of a suicide bombing undertaken in Manchester just six weeks prior to the bomb itself. As with so many of these events, it was people on scene – in this case, security and police – who acted as immediate responders provided the initial response in a phenomenon eloquently described by Christina Hernon at SMACC in 2016 as the disaster gap.
It was reassuring to hear that hospital processes to clear the ED on establishment of a major incident worked well, with the ED cleared within 30mins. Beyond the ED, twice daily MDTs were essential in balancing the ongoing surgical needs of victims with cancelled planned surgery – it is essential not to step down the response plan too soon as the surgical response continued for more than a month.
From my personal prehospital practice, I took away some reflections on the importance of clearly documenting tourniquet times and focusing on identification of patients; often the cruciform cards used for major incident triage category allocation were discarded on arrival to ED and this lack of identification reconciliation created issues, particularly for blood product administration. In addition, Fiona Lecky shared that some colleagues found that giving evidence at the subsequent enquiry was more stressful than the event itself.
In contrast to the Manchester setting, the local hospital was a very small centre with an ED staffed by 6 staff members per shift (1 consultant, 1 registrar and 4 members of nursing staff). The eruption occurred in the afternoon, with the typical initial rumours and misinformation, but the hospital wisely chose to begin preparations as if they were to receive a large number of critically injured patients. There was a long period of waiting, which Kathryn Duffy described as “the worst part” – a comment which resonate with me in the context of the NSW COVID-19 response.
Because the eruption occurred offshore, in contrast to the usual situation where the majority of initial presentations are the walking wounded, the first patients were often critically injured but all had to be extricated from the island (which has been a significant tourist attraction). The department, which usually intubates 1 patient per week on average, intubated 21 patients that day. A task-focused intubation team helped make this happen. The burns were significant – 60% BSA or more and mostly full thickness. Most of the patients met criteria for transfer to a major centre; 24 patients were transferred out. Kathryn Duffy described how in a centre where patients often struggled to access the care they needed, suddenly there was a rainbow of specialist retrieval teams arriving to take patients to ensure they received the best possible care. When we need to, she reflected, we can work together to make things happen. With this in mind, she left us with a challenge; to work together to address our daily mass casualty event of structural racism, poverty and the effects of colonialism.
Mariana Helou spoke from Beirut next, describing the effects of the Beirut explosion in 2020.
The numbers were incredible; >30 facilities involved, 5554 injured people registered. Many hospitals in the city were damaged with two completely destroyed and unable to function at all – necessitating the transfer out of their existing patients, to other facilities which were already trying to cope with the influx from the event. 6 nurses were killed, 68 doctors were injured. The Emergency Department at Mariana Helou’s institution was very small – only 10 bed – and received 357 injured patients. Most injuries were secondary blast injuries caused by glass – the majority to torso and upper extremities – and they used a lot of staples.
72 patients were admitted with 64 requiring surgery (71% to the limbs), 11 needing ICU and 5 deaths. Similar issues with patient identification occurred; Mariana Helou also flagged an issue with identifying staff members and their roles within the chaos. “Your disaster plan does not prepare you for the chaos,” she said.
The nature of the event meant transfer between hospitals and even communication between them was impossible so however small or unprepared the unit was, it was forced to try to manage a huge influx of patients. I was left reflecting on my assumption that whatever event occurs, the hospital system will exist in its current form to react. I need a rethink!
Paul Penn spoke next, on the transition of civility to civil unrest. It’s not hard to think of recent examples of civil unrest impacting healthcare, from riots to the invasion of Ukraine. Paul Penn’s advice was to ensure you have a simple common organisation plan to cover all emergencies with functional and hazard-specific annexes, reflecting something that Mariana Helou had brought up about the major incident plan proving inadequate preparation for her facility.
“No matter how much you thing you are communicating and coordinating,” he says, “it’s never enough.”
“Law enforcement can either make things better or worse,” he says, echoing a phenomenon we see in the Emergency Department with agitated patients every day of the week. “This is your facility; you are there to deliver healthcare but to remain apolitical.” He advises greeting law enforcement as they arrive, not just to maintain relationships but also to ensure they get to the right place.
Mick Molloy took on “the disaster sandwich” – workload, balance, burnout.
As well as sharing chocolate, Mick Molloy shared his biggest learning point from COVID19 – when it comes to your workplace, nobody is irreplaceable (along with the story of the sudden cardiac death of a young colleague – the department was rocked, but 48h later it had moved on. You get one life. You are more than your work.)
Finally, Adrian Kerner talked to Kaloafu Tavo about the Tongan eruption, which began in Dec 2021 and continued into January 2022. The main eruption reached climax on 15th January 2022 and was the most powerful volcanic eruption since Karakatoa in 1883.
Staff working at the time felt the change in air pressure with the explosion in their eardrums and Kaloafu Tavo described the initial staff response – “the place was flooded with a lot of people, it was all dark with the ashes rain, people were running in and lying on the floor and in chairs, there were men assembled in the corridors.” The resultant tsunami had washed out several cemeteries leaving corpses and skeletons scattered on the ground when flood waters receded. As in the Lebanese experience, health centres were affected too as many were destroyed and unusable. A temporary hospital was set up in someone’s house. The majority of the patients Kaloafu Tavo treated were acute stress disorders; many lost homes. Supply chain disruption occurred too; a ship bringing oxygen and emergency drug supplies sank.
The session closed with a reminder of the importance of self-care.
After lunch, I headed for the session on Prehospital and Retrieval Medicine. The first speaker was Gary Tall, who is one of the medical directors of NSW Ambulance, describing our experience of COVID-19 from a retrieval perspective.
We transferred 191 critically ill patients for ICU networking purposes (sharing capacity across the higher level care centres within the state) between 16th June and 12th October 2021; about 2/3 of those patients were COVID positive and almost all were ventilated. We moved around 4 patients per day from mid August, then 6-9 per day for three weeks in September, then back to “normal” (4+ per day) until mid-October.At peak, there were around 250 COVID positive patients in ICU bed in the state (with an expanded state ICU bed capacity of 612). The majority of patients were moved by road as most were within metropolitan Sydney, and we tried to preserve our rotary wing assets for “normal” business.
Early on, cleaning our vehicles was a challenge – the fear surrounding theoretical fomite-related spread meant we were fastidious about preventing onward transmission, but this vastly increased vehicle turnaround times. We created new procedures and workflows which were all hosted on the Sydney HEMS website. We are not aware of any retrieval healthcare workers with retrieval-work-related COVID, nor any deaths nor critical incidents during our COVID-19 work.
Sam Bendall, another colleague of mine, spoke next. It was fascinating to hear her reflections on the differences in approach to human factors between hospital and pre-hospital medicine, and what we can take from our aeromedical human factors experiences and expertise into the hospital environment. At the centre, in aeromedical humans are seen as the answer, whereas in hospital humans are seen as the problem.
COVID-19 was unusually uncharted territory as at the start of the pandemic there was a huge amount of uncertainty and no “right” answers. For a start, in prehospital and retrieval medicine there was a different mindset; usually we realise we have to fix the problem, we open up to other perspectives and create a series of plans to deal with eventualities – whereas there seemed to be no plan B in hospitals.
We also use a shared mental model; in health, information is seen as power and isn’t shared as readily. Situational awareness relies on being able to make good decisions and to have access to the right information at the right time. Asking the people who actually do the job is a really good step to take and often missing. This is seen in Erik Hollnagel’s Safety I vs Safety II concept of “work as imagined” versus “work as done”, that describes how the gap between what people think will happen and what actually happens is critical to mission success. Collective decision-making and teaming is central to prehospital and retrieval medicine, but in hospital staff are less involved and this leads to anxiety, disengagement and burnout. Critical event teams, formed from pre-identified and pre-trained individuals, were often missing but may be vital for our broken health systems going forward. And lastly, leadership dynamics are really important – to do extraordinary things at extraordinary times we need to cede control to those who need it to do the job and share collaborative leadership.
Michael Christian spoke about multidisciplinary prehospital care. The older EMS models are outdated now, with diverse care models seen across systems and indeed across the globe. His talk had a nice shout out to Tony Joy and the PRU, which you can find out more about in this podcast with Rich Carden.
He finished with a reminder of resuscitation legend Peter Safar’s rules for life.
Chris Denny of Auckland HEMS was the penultimate speaker, talking about collective leadership. The Auckland rescue helicopter service finds its origins in surf life saving, which is relevant as surf life saving has a history of service disruption (think jet skis and inflatable flotation devices). The service has evolved and currently achieves continuous operations with multiple aircraft types and dual clinician teams (with different configurations). The challenge, he suggests, is to move from ego based systems to ecosystems; from heroic leadership to more human-factor-focused solutions. He showed a great example of dynamic insubordination, where pairs working together divide responsibility and work with great trust to share oversight and leadership (an exercise I can see us trying in the hangar at Sydney HEMS…)
Lastly, Stefan Mazur from South Australia, spoke about the development of the DipPHRM curriculum, and transformative change. Our understanding of what prehospital and retrieval medicine is varies considerably, he says. So developing a curriculum and then assessment tools to define their competence was not as easy as it first might have appeared to be.
As with so many things, COVID threw a spanner in the works as exam dates were postponed and a face-to-face OSPE offered potential for disaster as prehospital and retrieval clinicians potentially gathered from various services, which were then crippled if COVID spread between them.
The final plenary of the day was on sustainability in healthcare. For my own sustainability, I snuck out to go to the Melbourne Museum to see dinosaur skeletons with my family – but I’ll be back tomorrow for a little bit more before I return to Sydney.