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Preparing for the unknown

Training and psychological preparedness is essential for prehospital and disaster clinicians, in order to effectively care for victims in austere environments.

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Preparing for the unknown

  1. 1. PREPARING FOR THE UNKNOWN DAVE TINGEY
  2. 2. In December 2004 a deadly tsunami formed off the coast of Indonesia. With the speed of a jet plane it crashed into the island of Sumatra. Two weeks later I was part of a South Australian medical team that responded to Banda Aceh to continue emergency surgical and medical care started by a team from NSW. (Next slide - equipment and team)
  3. 3. We left Adelaide with 10 tonnes of equipment using a combination of commercial and military aircraft. Due to multiple delays we arrived 3 days later. Exhausted, we collapsed into the damaged but functional hospital to rest overnight and come up with a plan of attack in the morning. (Next slide - TNI soldiers)
  4. 4. However that night we were woken by the Indonesian army who had brought in two soldiers with gunshot wounds. One had unsurvivable injuries, the other needed urgent surgery. With armed soldiers watching our every move, and with palpable tension between them and the local police, we set about saving his life. (Next slide: chest Xray)
  5. 5. That night set the scene for the next two weeks. Despite many more challenges we performed 130 surgical procedures, set up a high dependency unit, managed dozens of cases of tetanus, as well as the everyday medical and trauma patients that continued to present. (Next slide: Blank - “preparation")
  6. 6. So, how do we prepare for such an unexpected and overwhelming situation? My discussion will focus on overseas deployment, but may be just as useful for your role in a hospital, or on the side of the road. (Next slide: Sphere project)
  7. 7. Regardless of whether it's a local or international event, responders should understand the big picture. Internationally, there is an agreed charter which all countries must abide by. Host nations laws must also be obeyed. Those volunteering independently must ensure they support and not hinder formal arrangements. Expectations must also be realistic. Austere conditions and local standards must be taken into account, and any care provided must contribute to community recovery and be sustainable by local clinicians once we leave. (Next slide: broaden skills)
  8. 8. The Canadian astronaut Chris Hadfield described how members of the space mission train to be able to perform other roles, not just their own. Pre-hospital and retrieval providers also recognise the advantages of a cross-trained workforce, with doctors, paramedics and nurses trained to interchangeably perform critical tasks. Seek to broaden your skill set. Approach your colleagues from other health professions and learn from them. Sign up for disaster medical training, learn a second language or do an emergency obstetrics or ultrasound course. Be aware though, that while role flexibility is advantageous, disasters are not opportunities to go off piste and exceed your scope of practice. (Next slide: surgeons training locals)
  9. 9. In Aceh, I admired how our surgeons trained their local colleagues. They recognised the importance of leaving a legacy. Knowledge and skills passed on to local providers will be far more powerful and enduring than any treatment you provide. Equally, record and publish your activities so that others may benefit from your experience. (Next slide: Blank)
  10. 10. But what about situations you have never imagined? (Next slide: picture of Thai rescue)
  11. 11. You may have may have heard of Dr Richard Harris’ involvement in the rescue of 12 boys and their coach from a flooded cave in Thailand. Now Harry is a senior anaesthetist with years of experience in retrieval medicine. But I bet none of his formal medical training involved anaesthesia in dark caves or muddy water! It is the combination of medicine and Harry's other passions that contributed to the success of the Thai cave rescues. (Next slide: Harry in water)
  12. 12. His group has participated in some of the longest and deepest cave dives ever recorded, often in the remotest parts of the world and requiring long periods with little if any outside support. In addition to being adventurous, they are self-reliant and creative. Their dives are so extreme that equipment such as camera lights implode from the pressure, so Harry’s group have resorted to building their own equipment because there are no commercial products available. (Next slide: examples from Aceh)
  13. 13. In Aceh, a combination of teamwork, creativity, and old-school skills were put to good use. External fixators for fractured limbs were made from water pipe and dental putty, empty water bottles were used as ventolin spacers; and handyman tools were modified to perform medical procedures. These are not new skills, and those looking to work in this space can learn from experienced responders and the published literature. You don’t need to become an underwater anaesthetist, but time spent preparing will never go to waste. (Next slide: Blank)
  14. 14. So what about high acuity, low frequency cases that may only occur once in a career? (Next slide: SPRINT car at night)
  15. 15. On a retrieval shift one night my partner and I were sent to a victim with stab wounds. On the way we discussed options, including the possibility of a thoracotomy. When we arrived the patient had just arrested, the paramedics had intubated and were commencing CPR. The stab wound was just under the left ribs. We simply nodded to each other, explained to the paramedics what we were about to do, then proceeded to open the chest, scoop out the pericardial clots, close the hole in the right ventricle, and commence internal cardiac massage – all with barely a word spoken. (Next slide: Mental rehearsal)
  16. 16. The procedure was performed as if was a daily occurrence, even though neither of us had done one “in anger”. Both of us had practiced it many times in training and, importantly, we had both mentally rehearsed the procedure over and over. The importance of mental rehearsal and a shared mental model cannot be underestimated. (Next slide: “Expedition mentality”)
  17. 17. Mission ResourcesSelf Team Expedition mentality accepts that the success of the mission is more important than the needs of the individual. Team members must be willing to go beyond their personal comfort level in order to support mission requirements and team harmony. Start by developing a “can do” mentality in your daily life. Equally the team must support individual members in times of need, as the loss of a team member may compromise the performance of the team. (Next slide: Self / team monitoring)
  18. 18. Missions such as international deployments must be treated as a marathon not a sprint. In Aceh we rapidly became fatigued from the incredible heat and humidity, long working hours, and physical challenges. Team members need to look after themselves and each other, ensuring that enthusiasm is balanced against the need to last the distance. Tempers can fray due to physical and emotional stress. Tolerance, humility and sensitivity are highly desirable qualities for any expedition member. (Next slide: Self-sufficiency)
  19. 19. Teams and individuals must be self-sufficient. Food and other commodities may be in short supply, and we should not add to the burden of the communities we are there to help. Additionally, further threats such aftershocks or violence may require evacuation with little notice. Responders should therefore be equipped and ready to evacuate without notice. (Next slide: Teddy bear)
  20. 20. And finally, we need to look after our psychological health while away and when we get home. After I returned from Aceh, I would get angry about issues at work and home that seemed trivial compared to what I had just witnessed. Most organisations have support available and responders must be willing to make use of these resources. (Next slide: Take home messages)
  21. 21. Take Home Message: Expand your skills Educate others Prepare physically and mentally “Mission first” attitude Psychological preparation In summary, we can’t possibly prepare for every eventuality, but we can work on developing the skills and attributes that will support meaningful activities in a crisis. * Look for opportunities to expand your skillset and pass your knowledge on to others * Ensure you are as physically and mentally prepared as you can be * Adopt a “expedition” mentality. Be a problem solver, not a burden. * And be prepared for the psychological challenge you may face (Next slide: Summary)
  22. 22. If we enthusiastically develop these skills and attributes, we will ensure that we are prepared as possible for the unknown. Thank you.

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