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EMERGENCY MEDICAL CARE AND EMERGENCY ROOM IN MSF SETTINGS EMERGENCY ROOMS No emergency medical care referent in MSF F before September 2010. We are now 1 year and 2 months old! Let’s see what we have done or not done yet. EMERGENCY ROOMS MSF emergency rooms in regular missions: • Drouillard hospital / HAITI --- 300/sem • Teme Hospital / NIGERIA --- 150/sem • Hangu Hospital / PAKISTAN --- 400/sem • Rutshuru Hospital / CONGO DR --- 275/sem • +/- Khameer & Althal Hospitals / YEMEN • Mullaitivu Hospital / SRI LANKA --- 50/sem • Awil Hospital / SOUTH SUDAN • Pawa Hospital / CAR EMERGENCY ROOMS MSF ER in emergency missions: • Ivory Coast • Libya • Syria • Egypt? • Yemen? EMERGENCY ROOMS Common strategy for • Organization • Protocols • Medical material and drugs • Human resources EMERGENCY ROOMS ORGANIZATION: Triage area TARGETS: – To attend in priority patients with life-threatening conditions or higher risk of complication. – To improve medical care. – To manage patients flow and decrease overcrowding. – To improve patient satisfaction and decrease overall length of stay. ESSENTIAL IN ANY EMERGENCY ROOM EMERGENCY ROOMS ORGANISATION: Triage area • Routine triage : – syndromic approach or vital signs approach (depends of skills, patients flow, material…) – Triage area at ER entrance • Massive influx: – Large area prepared at ER entrance (empty and closed in routine activity) – Mass casualty incident guide line ROUTINE: SYNDROMIC APPROACH RED PATIENTS PATIENT TO BE SEEN BY DOCTOR IMMEDIATELY: patients are critical and need immediate treatment Direct to resuscitation room. Inform doctor and other nurses. Registration is done after nitial i treatment. Any patient with shock or signs of early onset of shock (tachycardia, low blood pressure, poor capillary refill, cool peripheries) Polytrauma (traum a with multiple injuries) High energy trauma Any bleeding (trauma or non-trauma) with impending shock Severe burns: Large area, burns to face or perineum, electrical or chemical burn, smoke inhalation Fracture or dislocation with neurovascular compromise Altered level of consciousness / coma Ongoing seizures Respiratory rate <9 or >20 in adult and/or cyanosis Severe chest pain Hypothermia < 35°C Envenomation Suspicion of meningitis ADULT TRIAGE SCORE 3 2 1 Mobility ADULT TRIAGE / SYNDROMIC COMPLEMENT 0 1 2 3 Walking With help Stretcher immobile 9 - 14 15 - 20 21 - 29 > 29 RR 101-110 111-129 > 129 HR Mobility RR <9 HR < 41 41 - 50 51 - 100 71 - 80 81 - 100 101-199 > 199 SBP COLOR / CATEGORY SCORE TARGET TIME TO TREAT MECHANISM OF INJURY RED YELLOW GREEN 5 OR MORE 3-4 0-2 IMMEDIATE < 1 HOUR < 4 HOURS HIGH ENERGY TRANSFER BREATH SHORTNESS - ACUTE temp < 35 35 - 38,4 > 38,4 temp AVPU Confused Alert Reacts to Reacts to Unresponsi voice pain ve AVPU COUGHING BLOOD CHEST PAIN SEIZURE - CURRENT SEIZURE - POST ICTAL HAEMORRHAGE UNCONTROLLED Trauma FOCAL NEUROLOGY - ACUTE Trauma < 71 NO YES DISLOCATION OTHER JOINT ROUTINE: VITAL SIGNS APPROACH HAEMORRHAGE CONTROLED REDUCED LEVEL OF CONSCIOUSNESS THREATENED LIMB age > 12 years / taller > 150 cm PRESENTATION SBP FRACTURE - COMPOUND DISLOCATION FINGER OR TOE FRACTURE - CLOSED BURN - FACE / INHALATION BURN > 20% BURN - ELECTRICAL ALL OTHER PATIENTS BURN : OTHERS BURN - CIRCUMFERENTIAL BURN - CHEMICAL POISONNING / OVERDOSE PAIN HYPOGLYCAEMIA glu<3mmol/l or 0,6g/l PSYCHOSIS / AGRESSION DIABETIC - glu>11mmol/l or2g/l WITH KETNONURIA DIABETIC - glu>17mmol/l or3g/l NO KETNONURIA VOMITING - FRESH BLOOD VOMITING - PERSISTENT PREGNANCY & ABDOMINAL TRAUMA PREGNANCY & ABDOMINAL PAIN SEVERE PREGNANCY & TRAUMA PREGNANCY & PV BLOOD MODERATE RED COLO UR Mass casualties incident PATIENTS IMMEDIATE (ABS OLUTELY URG ENT) Patients who need IMMEDI ATE surgical or medical treatment; their condition is life-threat ening in the short term, but they have a reasonabl e chance of survival . Airway obstruction: neck or facial injuries, chest wound s, etc. Respiratory distress: tension pneumothorax, hemothorax , cardiac tamponna de, flail chest, etc. Active bleeding with hemorrhagi c shock: extremity wound s, abdo minal wounds, etc. Hypovole mic shock/dehydration: e.g., cholera epidemic. YELLOW This lis t is not ex haus tive DEL AY ED (RELATIVELY UR GENT ) Patients who need surgical or medic al treatment, but whose condition is not immediately life-threatening, and who are stable enough to wait. Chest or abdominal wounds or trauma without respiratory distress Wounds or tra uma without hemorrha gic shock; hemodynamically stable. Head trauma with good prognosi s (Glasgow Coma score >8) Open fractures or traumatic amputations, suspected pelvic o r femora l fracture. Large w ounds with no active bleeding. This lis t is not ex haus tive GREEN MINOR (NOT URGENT) Patients who need non-urge nt care, with no short- or medi um-term lifethreatening conditions. Conscious p atients. Patients who do not need hospitalisation, but just outpatient treatment. Superficial wounds Closed fractures This lis t is not ex haus tive BLACK DEAD OR DYING Patients who have died, or whose condition is life-threatening and who have very little chance of surviva l, with or without medical or surgical care. Sever e multiple trauma Severe head trauma (Glasgow Coma score <8), or penetrating head trauma Trau matic quadriplegia Burns over more than 50 % of the body (unless 1 This lis t is not ex haus tive st degree) EMERGENCY ROOMS ORGANISATION: Medical care area ER = severe patients management (trauma++) ER = ADAPTED RESOURCES NEEDED (++ considering good quality of surgery / anaesthesia) – Resuscitation zone / red zone : • Specific material: automatic BP, vacuum, electrical syringe driver… • Resuscitation material and drugs • Dedicated HR? – – – – Yellow zone: acute patients / no needs of resuscitation Green zone: non seriously sick patients Plaster and suture: dedicated room or trolley. Isolation room? Link +++ with OT, radiology, ICU, lab, wards : central position ORGANISATION: Observation room EMERGENCY ROOMS MEDICAL PROTOCOLS • Long process ! Very long! • Evidence based protocols • Problem: validation and implementation (training) TARGET: same severe patients management in all MSF settings. Problem: different levels in terms of material, skills, logistics… • Achieved: – Triage in routine – Triage in mass casualty incident – Intra-osseous catheter ADULT AND PAEDIATRICS • Almost achieved or in process: – Trauma – Shocks – Asthma – Convulsions… EMERGENCY ROOMS EQUIPMENTS • • MONITORS / AUTO BP: no unstable patient management without adapted tools ! SYRINGES DRIVERS: essential for dopamine, adrenaline • FAST echo EXCELLENT ALTERNATIVE / scanner = dream • INTRA OSSEOUS KT / ELECTRICAL DEVICE: central IV = dangerous and difficult / excellent alternative urgent IV access • ECG: pb for ECG diagnosis AND pb for treatment even if diagnosis is well done =====> ADAPTATION to new tools = TRAININGS EMERGENCY ROOMS DRUGS / MEDICATIONS: • Implementing new protocols (evidence based), we’ll have to implement new drugs • Worldwilde health changes (thanks to mondialisation). We have to face more and more western pathologies – Diabetes – Cardiac and vascular – Old and multi pathologies patients ====> ADAPTATION ++++ to new health problems and new treatments EMERGENCY ROOMS HUMAN RESOURCES: • TRAININGS : how to train our national staff to EM? – Most countries: no concept of emergency med speciality. – Most expat volunteers : different back-grounds in EM. • SOLUTIONS / ISSUES? – – – – – – ATLS Impact? FAST ECHO Value? Certification? BASIC ACLS? PALS, ASLO? “MSF made” trainings? Qualified Expat emergency doctor: senior doctor. EMERGENCY ROOMS REAL CHALLENGE TO HAVE EFFICIENT EMERGENCY ROOMS • TRAININGS • NEW MATERIAL • NEW ADAPTED PROTOCOLS AND DRUGS • EXPAT EMERGENCY DOCTORS / SENIORS • ….. Step by step we achieve interesting progresses ! EMERGENCY ROOMS TARGETS IN THE FUTURE : SEVERE TRAUMA WILL NEED • surgeon + anaesthetist/intensivist + ER physicians commitment • Patient pathways • Development of technologies as we began (Ultrasound, Intra osseous cath.) • Training in specific fields : ultrasound, trauma management (ATLS, BASIC) • Dedicated protocols (hemodynamic and fluids management, ...) EMERGENCY ROOMS HAITI / Hôpital Drouillard Implementation of FAST Echo in emergency Room Experienced and qualified EM doctor expat, for 6 months (+ 3 months)