Rural mass trauma
BY DR SANDRA HIROWATARI, CHAIR, COUNCIL OF RURAL DOCTORS
In the wake of two devastating multiple trauma incidents in Canada, my mind went to a multiple victim trauma that occurred in one of the little rural towns I was working in.
Three multiple victim trauma incidents, one rural, one urban and one I personally attended in the Outback.
6 April 2018: Outback Canada, good daylight driving conditions, bus transporting an ice hockey team versus semi-trailer (B double). Dry, tar sealed, rural road, snow on fields, 16 dead, 13 injured. 30 km away are two small rural hospitals, staffed by GPs. The injured arrived there first. Five hours from time of the accident, the injured first make it to a trauma centre 250 km away, by multiple choppers, fixed wing and road. Five hours. A long time but as it turns out, most of the boys died on the scene, so the time made little difference.
23 April 2018: Yonge Street, one of the busiest, longest streets in Toronto. The carnage occurred after 1300h. 10 dead, 14 injured. Nearby, less than 10 km away, is the largest trauma centre in Canada. In less than an hour, they were able to gather three trauma surgeons, one orthopaedic surgeon, a neurosurgeon and multiple other doctors. Their ICU has 181 beds. They called Code Orange at 1347h. The first injured arrive shortly after 1400h. Forty-five minutes. Some went straight to the Operating Rooms. This hospital had run multiple simulations and table top sessions. The teamwork was impeccable.
23 March 2014: Remote WA unsealed road, Landcruiser versus ditch, no seat belts, 15 people whose ages ranged from three to 70. One dead, 13 injured. This town was a remote community with 1500 people, five doctors in the community, only one ED doctor rostered, four others available somewhere. The accident occurred about one hour away from our hospital, we had one ambulance. Many had to be left at the accident site. At the site, there was unforgiving heat, little water, confusion, pain. Three doctors came in to help. At the hospital, the most critically injured patient (who did not make it), was in the only resus bay. Management was complicated with a consulting doctor on telehealth and the doctor on the ground calling out orders. Later we found that another occupant in the vehicle suffered a splenic injury. For others, spinal cord injuries were feared.
What’s the same?
- Critical illness does not respect geography;
- FIRST principles regardless of location. ABCDE;
- Our inner terror, our outer calm;
- The noise; and
- The aftermath.
What is different?
- The tyranny of distance;
- The problem of smallness, fewer of us, less mobile coverage, less resource (like ONeg blood);
- We are not specialists, not surgeons, anaesthetists, FACEMs;
- We may know the injured, they are us;
- We are treating a person where a familiar attachment exists; and
- More trauma deaths with rural and especially remote traumas.
Rural doctor, what you can do to prepare? Rehearse. Simulate. When you go into your rural hospital, crack open the crash cart, touch the ETT, find and turn on the paddles, locate the chest tube set up, where is the RIC pack, IO gun? Do this alone then in a team. Take a trauma management course. We are lucky in Australia to have two choices: ETM Course and ESTM. In North America it is ATLS. If you have internet, we have online resources: lifeinthefastlane.com, resus.me, college resources. Thank you for being there, you are not alone.
Here is a good approach to help with both being prepared and later in the debrief:
Dr Tim Leeuwenburg, a rural generalist from Kangaroo Island, SA, says:
“Many people think that success in a resus is due predominantly to their clinical knowledge and skills. All that stuff we learn at medical school and in postgraduate training which pertains to the patient.
While this is certainly, true, experienced clinicians realise that understanding three other domains - self, team and environment are important.
I learned this from renowned ‘resuscitologist’ Dr Cliff Reid and team of SydneyHEMS
To break that down:
Self – It’s important to understand the impact of stress on yourself and how you manage the resus. Cognitive overload, bandwidth limitation and the sympathetic surge of stress can degrade performance.
Team – There is an old phrase: "What’s spoken is not heard, what’s heard is not understood, what’s understood is not actioned.” On ETM we teach the use of a ‘shared mental model’, of frequent summarising of key action points…and we emphasise the use of 'closed loop’ communication. If a 16-year-old can ‘close the loop’ at the Maccas’s drive through when ordering fast food, we should be able to do the same in a complex resus.
Environment – This is often under-appreciated. The importance of 360 degree access to the patient, of good lighting, of working in an ergonomically appropriate position, can all impact on the success of a resus.
Published: 14 May 2018