Malaysian Trauma Life Support

(MTLS) Penang 2013

MAJOR INCIDENT
MANAGEMENT
EMERGENCY
MEDICAL
SERVICE
RESPONSE

ONLY A FOOL LEARNS FROM

EXPERIENCE.
I LEARN FROM THE EXPERIENCE OF
OTHERS.
Otto Von Bismarck 1815-1898

MAJOR INCIDENT MANAGEMENT

1. Definition & Types
2. Directive 20, N.S.C
3. Component of Management
4. Contingency Planning & Protective
5. Hospital Activation Phase
6. Incident Site Management
7. Recovery & Rehabilitation

MAJOR INCIDENT MANAGEMENT

Emergency Preparedness-prevention
planning, research and response in
connection with emergencies in peace and
war time.

DEFINITION
(Referring Directive 20, N.S.C)
A regional event that involves a large number of
casualties in a large geographical area that
overwhelms the available local resources & service.

DEFINITIONS
Mass Casualty Incidents (MCIs)
Disaster in which patient care resources
are overextended but not overwhelmed,
focus on most life threatening injuries
Mass Casualty Events (MCEs)
Disaster in which patient care resources
are overwhelmed and cannot be
immediately supplemented, focus on
identifying those patients with the greatest
possibility of survival.

DARK SIDE OF
MODERNITY
More complex, widespread &
with a larger scale of losses
due to:
Increased technology
Intensive urban
development
Greater area of habitation
Sophisticated

DISASTER
An interface
between an
extreme physical
event & vulnerable
human population
Susman et al

TYPE OF DISASTER OR MCI

1. NATURAL DISASTERS
Earthquakes, hurricane, volcano eruption
etc.
2. TECHNOLOGY & HUMAN RELATED
Collapsed building, war, air crash,
transport accidents.
3. HYBRID CIVIL EMERGENCIES
When both components are involved eg.
Flood with collapsed building.

ANATOMY OF A DISASTER
The physical happening which is determined
by the geographical area, physical
structures, infrastructure of the area,
number of lives and the exact nature of
destruction

PHYSIOLOGY OF A DISASTER
The social occasion and mechanism of the
process of disruption which will determine
the consequence and impact of the event.

Human and Technology Related

Incident
Structural Collapse
Mass
Transportation e.g.
Plane crash
Terrorism
War
Weapon of Mass
Destruction
Petrochemical
Industry

HYBRID
Ecological Balance
Disruption
Landslide
Flooding
Urban Oriented
Flash Flood
Storm and
Typhoons El Nino

Weapon of Mass Destruction

(WMD)
Definition
Very High Yield Conventional Explosive
Dispersal of an Agent
Chemical, Biological or Radiological
Unknown by Kind, Method, quality
Causes Casualties and or Damage to Property

Outcome
Mass Casualties
Psychological
Loss of Public Trust in Authorities
Economical

TYPES OF W.M.D.

Radiological
Biological
Chemical
Explosive and
Incendiary
Devices

W.M.D.
Similar to Hazardous Materials
events
Chemical, Biological, Radiological has
the potential for mass casualties
Chemical, Biological, Radiological
event is a crime scene
Widespread psychological impact
Emergency Medical Service and
hospitals and overwhelmed

W.M.D.
Psychogenic casualties predominate
Responding personnel are at risk for
personal injury
Criminal event - need for evidence
preservation
Number of victims and dead are
greater.

CHEMICAL TERRORISM
Copycat attacks in Japan using
cyanide, phosgene, and pepper spray
Possible sarin attack in Disneyland
1997 Sydney, Australia chlorine
bombs in shopping centers injure 14500 evacuated.

DIRECTIVE
20,
NATIONAL
SECURITY
COUNCIL
( N.S.C.)

DIRECTIVE 20 NATIONAL
SECURITY COUNCIL
DISASTER:
An event that occurs suddenly.
Complex in nature.
Loss of lives.
Destruction of property and/or environment.
Disruption of the community daily activities.
Divided into 3 main level of categories
depending on the management capability and
capacity

DIRECTIVE 20 NATIONAL
SECURITY COUNCIL (NSC)
LEVEL 1
Localized major incident
under control
not complex
small no. of casualties and property loss
minor disruption of daily community activities
manageable by the local authorities not
requiring multi sectoral involvement.
e.g. bus accident, train derailment, landslide.

Directive 20 NSC Level 1:

Bencana
Tahap 1

LEVEL 2
Widespread over a large area but under
control
Complicated and complex
Large no. of casualties and property loss.
Affecting daily community activities
Not manageable by the local authorities
requiring assistance from other states or
National Authorities
Support required, Regional or National
Support
e.g.: Highland Towers Collapse, Greg
Storm Sabah, Bright Sparklers.

National Security Council

Prime Ministers Dept.
Chairman : DPM/ Ministers
Member :
All Director General and Sec. Gen. of all
MAJOR Relevant Ministry
Consultant/Expert/Core Team
Secretariat: National Security Unit

LEVEL 3
Involves a very large area.
Loss of many lives.
Total Destruction of infrastructure and public
facility.
Complicated and complex.
High risk to rescue workers.
Complete disruption of daily community activities.
Major destruction of resources.
All local resources destroyed and assistance from
external resources required.
e.g. Earthquake, typhoons, volcanoes, war.

MAJOR INCIDENT MANAGEMENT

1. Depend on the severity of
conditions
2. Depend on the resources available
3. Geographical location
4. Political situation

APPROACH
PRINCIPLE OF DISASTER
MANAGEMENT
DO THE GREATEST GOOD FOR
THE GREATEST NUMBER

Phases of Disaster Management

1.Preparation
2.Mitigation
3.Response
4.Recovery

CONTINGENCY
PLANNING

CONTINGENCY PLANNING

Forward Planning Process

Process rather than documentation
Consensus building
Defining actions
Putting systems in place
Prevent damage control and limit
consequences

CONTINGENCY PLANNING
Risk analysis and assessment
Resource matrix preparation
Obligation of all
Director, HOD, Community Leader

Dynamic
Inter agency and multi sectored
ERP and alert system

Contingency Planning
COMMITTEE
General Committee
JKKD/ JKKN / MKN

Specific Committee
Radiation, Disease Outbreak, Petrochem, Flood

High Profile Membership

GOVT, CORPORATE, NGOS

Contingency Planners

Political will
Expert group
Strategist
Financier
Technical group
Researcher
Analyst
Policy makers

Contingency Plan
Researcher

Industrie
s

Corporate
JKKN
Policy Maker
Law &
Enforcement

Public
Govt
Agencies
Medical

Fire &
Rescue

Police

SURVEILLANCE AND DETECTION

Natural Disaster:
Seismological, Forecasting, Remote
Sensing & Warning System
Alert System e.g. Satellite Radar
System
G.I.S. & Remote Sensing ( N.R.S.A. )
Hazard Mapping
Tracking e.g. Cyclone Tracking

INCIDENT SITE
MANAGEMENT

INCIDENT SITE MANAGEMENT

1.
2.
3.
4.
5.
6.

Zoning and coding

Work matrix
Medical Base Station Layout
Role & responsibilities
Human resource management
Triage
- Primary
- Secondary
7. Forensic activities
8. Public Health
9. Psychological Management

ZONING CONCEPT AT THE

INCIDENT SITE:
Police Base Station

PRES
S

Medica
l Base

Family &
Relative

Incident
Area
High Risk
COMMAND CENTRE
Zone
(TACTICS
ZONE)
STRATEGY
ZONE

On Scene
Commander
POLICE ( OSC )

On Site Medical
Commander
( OMC )

Fire
Base
Station
Ambulance
HQ
Transportatio
n
Forward Field
Commander
BOMBA (FFC)

Incident Site Management

ZONING
1.RED ZONE
Inner Zone
High Risk Zone
Approx. - 50 to 100 m
For Rescue workers, marshal, fire unit
Rapid response team (Medical Team)

INSIDENT SITE MANAGEMENT

Take a genuine inventory of current
capabilities
Instruct personnel about disaster
plan using realistic scenarios
Plan must address triage,
decontamination, and treatment
Rectify deficiencies in training,
equipment, and supplies

INSIDENT SITE MANAGEMENT

Develop strategies to overcome resistance
to preparedness
Incorporate responsible people in the
planning process
Keep the plan cost effective
Plan for problems that are likely to occur
Communication and sharing of
information
Security, traffic control, hospital access
Staff identification, triage,
decontamination, information

INSIDENT SITE MANAGEMENT

Participate in joint planning
- Work together with emergency
medical
service, law enforcement, fire
- Integrate plan into communitywide
disaster plan
Develop mutual aid agreements
Develop policies and procedures

Incident Characteristics
Effect on First Responder
- Need for Protective Gear
- Constraints on Movement and
Communications
- Limitations on Duty Time
- Coordination Challenges
- Psychological

Universal Protection System

Behaviour and Culture of practice: Hand wash.
Handling patient.
Handling specimen.
Handling of contaminated item.
Barrier nursing.

Personnel Protection Suit

1. Suit
2. Glove
3. Boots
4. Oxygen
respirator
5. Suit cooling
system
6. Sealed container
7. Goggles
8. Work Discipline

Decontamination of the Victim

Decontamination Process

Decontamination process of Environment

Sealing of Contaminant

Decontamination of Personnel

PITFALLS
Requires increased awareness and
training of Emergency Medical
Service personnel
Detection equipment is not available
Emergency Medical Service
personnel must depend on clues to
identify a Biological Warfare attack
Report concerns to officials

Rescue, Evaluation & Treatment

Detection
Detection is difficult since Biological
Warfare have no immediate warning
properties
Stark contrast to chemical agents
Detection equipment not readily
available

Mobile Decontamination Cargo

Protection Suite

KEY POINTS
Public Education
Helps alleviate public fears
Mechanism to teach protective
measures
Must include media and public
officials (centralize)
Educate the public

Handling the Dead

Large numbers of dead expected in
an Chemical, Biological, Radiological
terrorist event
Consider special decontamination
procedures
Temporary morgue are required

Hospital Activation
Phase

HOSPITAL ACTIVATION PHASE

A Hospital Response NOT Emergency
Dept. Response
A Hospital Strategy
Handled by Hospital Authority
A Mandatory requirement by Ministry
of Health, Malaysia
ALL Hospital personnel must be
AWARE of the Response Plan.

HOSPITAL ACTIVATION PHASE

1. Activation Of the Alert System
2. Establishment of specific
zones/centers

HOSPITAL ACTIVATION PHASE

Must contain specific measures relating
to:
1. Assessment of the hospitals
capacity
2. Activation of the plan
3. Establishment of chain of command
4. Communication
5. Logistics aspects/treatment areas

HOSPITAL ACTIVATION PHASE

ALERT PHASE
INCIDENT
999
Police

NGOs
MRCS
St.John
Fire &
Rescue
Civil
Defense

False
Alarm

Confirmatio
n

Hospital
Operator
Emergency
Dept.
Registrar

Director
of
Hospital

Yellow
Alert

Stand
Down

CALLER

Police
Confirmation

Head of
Dept.
Emergency
Services

Declare Red
Alert

Establishment of Chain of
Command
1. Interhospital
Primary responding hospital
Secondary responding hospital

2. Intrahospital

Primary Responding Hospital

The main hospital leading the
management
Coordinating Role
Closest and most well equipped
hospital

Role Of Primary Responding

Hospital
Coordination with other agencies e.g.
Police, Fire
Dispatching Search and Rescue Team
Providing On Line supervision and
assistance to the incident site.
Coordination with other support hospitals
Coordination with Communication and
Dispatching Center

Secondary Responding Hospital

Supporting Hospital
Assist in the following
Receiving patient
Supplies
Personnel
Equipment
Activate on request of the Primary
responding Hospital

CHAIN OF COMMAND
Organizational
Aspect:

HAP
Coordinator
Hosp Director

Admin
Coordinator
Dep. Director
of Hosp
Dietici
an
Matro
n

Securit
y

Clinical
Coordinator
Senior Clinician
Supervis
or

Pharma
cist

SMA of
ED
HOD

Pharmac
ist

ED
Sister

Role of Hosp Coordinator

Declare Red
Alert

Activate
Supporting Hosp

Liase with
Relevant
Agencies

Public Info &

Press Release

HOSPITAL
COORDINA
TOR
HOSPITAL
DIRECTOR

Elect Administrative
Coordinator

Establish Control
Centre

Elect Clinical
Coordinator

Administrative Coordinator
Admin
Coordinator
Dep. Director
of Hosp
Dietici
an

Securit
y

MA
Supervisor

Pharma
cist

Matro
n
Traffic

Ward

Relativ
e Mx
Area

OT

Total
Securi
ty

Transp
ort

Contro
l
Centre

Logisti
cs

ESTABLISHMENT OF SPECIFIC
ZONES/CENTERS
1. Control Center/ Operation Room
Nerve center where all decisions and strategies are
discussed / issued.
Coordination of all activities
Act as main communication center & sources of all
information / press statements
Manpower For The Center
a. Members of Major Incident Mx Committee
b. Medical Director
c. Administrative Coordinator and his team of
supervisors
d. Other members identified by the medical director

2. Non Clinical Areas/Zones

a) Hospital Information Center
- center to provide information and queries
of relatives of victims
- provides counseling and assistance to relatives
when needed
- can also serve as the information center for the
press
- should be away from the clinical areas eg lobby
- manned by social worker, PRO and non-critical
staff
b) Relative Management area
- functions as waiting room for relatives
- best placed beside the information center
c) Bereavement room
- close to body holding area
- staff trained in grief management and counseling

3. Clinical Zones
- At the Emergency Department (ED)
- At designated treatment areas
a) Patient reception and triage area
b) Treatment area
c) Body holding area
d) Emergency department control center

a) Patient Reception & Triage Area:

Designated for triaging & sorting and of
patients
Usually located at the front entrance of the
dept.
Serves as a crowd controlling area
Direct relatives to appropriate zones
Managed by Doctors, Paramedics
Tight security area

Triage Zone In Hospital:

Strategically located
Manned by senor and experience
staff
Not a registration Zone
Smooth triaging prevent congestion
Channel patient to the appropriate
zone

b) Treatment areas

Department Divided Into Zones:

RED ZONE
Critical
Stabilized, resuscitated and managed
immediately
YELLOW ZONE Trolley area (semi critical)
Expand the existing area
Move patients up to the ward rapidly
Open up wards for the trolley patient
GREEN ZONE Walk - in area (non-critical)
Away from the Emergency Dept.
Do not congest the dept
Record and Document ALL Discharges

c) Body holding area

placed away from the clinical area

d) Emergency Department Control

Center
situated in the ED
keeps tract of patients movement
the link and support for the ED and incident
site
close communication with the hospital
operations center and relay and update
information to the center
manned by ED supervisor and matron

CONCLUSION

BE PREPARED!

Malaysian Trauma Life Support

(MTLS) Penang 2013

THANK YOU!