Team Triathlon ASEM (vic) Emergency Department March 2009
There is no denying the dedication of Emergency Department staff. Alarms were set as early as 4am and it wasn't even a work day! On Sunday 22nd of March staff members from Emergency Departments across Victoria discarded the scrubs for some lycra and runners to participate in the Annual Australian Society of Emergency Medicine Team Triathlon.
Unlike the icy conditions from the previous year, conditions were perfect with a pleasant 17 degrees being displayed on the Nylex as teams made their way to the Cantani Gardens at St Kilda.
Despite the early start, spirits were high as teams gathered to discuss their tactics and more importantly ensure all team members were accounted for. As always some las minute team changes were required due to injury or illness. Emergency staff are well equipped to cope with sudden changes so teams were shuffled and the necessary equipment changed hands to ensure the event ran smoothly.
This year's major sponsors were The Australasian Society for Emergency Medicine (ASEM) and Bed Brokers. Their support of the event was greatly appreciated and their tent was a hub of activity as competitors were discarding the warmth of their tracksuits and scribbling numbers on each other's limbs.
The triathlon distances of 300 metre swim, 10km ride and 3km run were not too intimidating and encouraged competitors with varying levels of fitness. Some competitors were dusting off the cobwebs from their joggers while others were rubbing out the tightness in their calves from a run the day before.
Participation in this event has continued to grow from year to year with over 40 teams taking part for 2009. Epworth entered the event as favorites having been victorious in last year's event. They didn't disappoint and took the title again with an impressive time of 35 minutes and 26 seconds. A gallant second place was achieved by Casey and Monash Medical Centre were not far behind in third place.
Regardless of the results, an event such as this demonstrated the camaraderie of Emergency Department staff and provides a great opportunity for both fun and fitness. Tim Baker once again did a fantastic job in coordinating this event. We look forward to next year with anticipation! Can Epworth make it a hat-trick?
P.S) An extensive collection of ED Triathlon pictures is available for downloading from co-sponsor (Bed Brokers) website: www.bedbrokers.com.au
Taking the work out of Inter-hospital Transfers!
Bed Brokers aims to reduce the time you spend each day making arrangements for the admission and transfer of compensable patients to private hospitals.
By taking care of the necessary telephone calls and administrative arrangements, we you time to be with your patients, which is in everyone's best interest.
Fires in the vicinity of St Andrews taken from Doncaster Shopping Town, Melbourne on Black Saturday 2009
"Black Saturday Night" was taken by Chris Mulherin from Doncaster, Victoria on February 7th, 2009. Chris is selling limited-edition framed prints of this awe-inspiring photo to fund his doctoral studies. There are more details available at www.blacksaturdaynight.com or you can write to Chris@blacksaturdaynight.com
The juxtaposition of extreme climatic conditions (record temperatures, excessive dryness and wild winds) caused havoc over much of Victoria this summer.
Receiving little publicity in the week preceding the great fires, extreme temperatures in the mid 40s (centigrade) resulted in infrastructure failure and loss of life. Whilst Melbournians braced themselves for a "sizzler" of major proportions, the associated power outages, transport meltdown and infrastructure failures came out of left field. Staff working in Emergency Departments (EDs) across Melbourne on January 30th will vividly remember the cubicle chaos, as fleets of ambulances arrived with the thermally challenged (mainly elderly) requiring urgent treatments and/or admissions. It now appears that somewhere between 200 - 300 people died from thermal related causes over those 3 successive hot days in Victoria (with smaller but similar numbers in South Australia). We now know this from the major spike of deaths (above the 90 per day baseline death figures for Victoria) and from statements issued by the Department of Health, Coroner's Office and Newspapers articles written on the subject.
Public health advice given preceding this advancing heat emergency was to stay inside, drink plenty of fluids, stay cool (presumably beside ones air conditioner) and keep an eye out for elderly friends and neighbours. This advice might have been useful if power supplies did not fail, if some people actually had cool places to stay in or were competent/independant enough to seek cooler refuge and maintain adequate fluid intake during the heat wave.
As the scenario rolled out within the ED I was working in, I attempted to make contact with a counter disaster (CD) branch of our Health Department - advising of the large patient surge and suggesting the establishment of pre-hospital setting up of cooling first aid posts within designated municipal evacuation centres. Such centres are mandated for emergency accommodation in disasters and are located in every municipality and town under standard State Emergency Plan provisions.
My suggestion obviously fell on deaf ears and so after the heat wave, I set about researching how thermal emergencies are handled in other jurisdictions. I was surprised how little time it took me to find the Californian Heat Contingency Plan on the Internet. Readers of this Plan (who have an interest in CD medicine) will applaud it as the kind of Public Health Plan Victoria should have had in place to protect its most vulnerable citizens. Without going into details of the Plan, suffice to say it is elegant in its simplicity and comprehensiveness. Apart from defining by way of a temperature and humidity matrix, activation danger trigger marks, the Plan importantly defines task oriented specific responsibilities for government agencies to look after the well being of at risk and vulnerable citizens. Copies of this Plan have now been sent by ASEM to counter disaster agencies in Victoria as well as the State Coroner.
One week after the heat wave, Victoria was rocked again by high temperatures as well as extreme winds, reminiscent of conditions during the infamous Ash Wednesday bushfires of 1983 (which claimed 75 lives). CD authorities minced no words in conveying a sense of impending danger yet, when the fires first ignited, none could have imagined their speed of spread, their heat intensity or the devastation and deaths that would follow. On Black Saturday as we now call this fire, forests and towns on the outskirts of Melbourne (such as Kinglake and Marysville) were literally incinerated as the fast advancing walls of fire killed people in their homes or fleeing cars.
From the medical point of view, the Victorian bushfires did not produce the usual distribution of casualties that are typically associated with fires. History informs us that during :
the 1985 Bradford Stadium fire (UK), a wooden stadium caught alight during a well attended soccer match and collapsed upon supporters killed 56
and injured 256 persons;
the 2004 Republica Cromagnon nightclub fire (Argentina), a pyrotechnic flare ignited the ceiling of the discotheque during a pop concert killed 194 and injured 714 persons.
The casualty figures for our recent Victorian bushfires appear to be more heavily skewed towards serious injury or fatal outcomes. Thankfully there were of course survivors with an estimated 400 ED attendances statewide and 80 admissions to hospital (including the 20 or so admitted to the major burns unit at the Alfred Hospital). However these numbers remain relatively small compared to the numbers of deceased (210) persons. Explanations for this will in due course be determined by Coronial and/or Royal Commission deliberation. However the likely hypothesis is that the sheer intensity of the fire (estimated at around 1200*C) was not compatible with survival at close quarter.
No doubt many changes will be recommended to rural building codes, emergency service response procedures, fire mitigation strategies (in heavily treed areas) and to fire warning advisories, such as the now controversial "stay and defend OR leave early" Country Fire Authority policy,
CD policies and procedures have an important role in disaster management but require high level planning, compilation, integration into agency practices and testing - preferably prior to an actual disaster. Many of these areas will likely need greater attention and resourcing than previously afforded.
History tells us time and time again, that what isn't learnt from past events, inevitably is repeated again in the future.
Written by Rick Lowen
Vic Councilor ASEM
Former Deputy Chief Medical Commander - Medical Displan Vic
Postscript: Readers should watch out for a definitive medical review on the Victorian bushfires that is being prepared for publication in the MJA by A/Prof Peter Cameron (EP-Alfred Hospital).
ACEM Access Block Summit
Friday 12th of September 2008
The Honorable Nicola Roxon, Federal minister for Health, left the ACEM Access Block Solutions Summit immediately after her opening address. Representatives of ACEM, ASEM, CENA, politicians, consumers and others gathered in Melbourne to seek solutions to access block on Friday 12 September 2008 at the Hilton in East Melbourne. In her address, the minister agreed that “access block is the most serious problem facing EDs”. But when referring to high presentation numbers she said that “40% are triage 4 or 5…this is sometimes regarded as a proxy for primary care.” She pointed out that the federal government has allocated $300 million for super clinics. She also listed federal initiatives including $1 billion into public hospitals, $300 million to improve the transition between hospitals and aged care, loans at zero interest for aged care residential beds, and establishing the $10 billion hospital and health fund. The number of medical graduates will rise from 1820 this year to 2800 in 2012. Referring to the literature review published before the meeting she said, “I believe the paper argues that beds are the solution. They may be one; but I believe this is one of many issues.”. Subsequent speakers seemed to feel that this missed the point.
Lorri Spry; journalist, biography writer and one of Australia’s first female undertakers, presented a plenary at the ACEM Access Block Summit. She recounted her experience when she accompanied her father-in-law to an overcrowded ED after he had two falls. The waiting time was 5 hours but there were not a dozen people in the waiting room. At first she felt the staff seemed incompetent. But access block meant she witnessed the ED for the next 36 hours.“The pressure was like…an episode of MASH,” She said. Emergency Physician Daniel Fatovich said that evidence suggested that patients who were access blocked would prefer to wait in the ward corridor than the ED corridor. He spoke with feeling about the “Corridors of Suffering” in the ED versus the “Corridors of Tranquillity” in the wards. His photos of each graphically showed the difference. Chairman George Negus suggested that documents for politicians should have attached a photo of the ED corridor and a photo of the ward corridor, suffering versus tranquillity.
Spare bed capacity is essential for the effective management of emergency admissions and to have surge capacity. If average bed occupancy routinely rises to >90% access block crises are consistently present. Access block is both a quality and equity issue. Capacity is vital to optimising patient access and flow.
General strategies that have some effect in managing access block include pre-hospital, ED and inpatient care. Areas included: KPI’s; developing ED capacity; short stay units; nurse-initiated tests; increasing system capacity and inpatient beds; ongoing/sustained Federal/State funding; “full capacity protocols” where 1-2 patients are sent to their destination ward as the ED becomes overcrowded for ongoing care; matching staffing to predictable demand; improved chronic disease management in the community; medical outreach teams eg to nursing homes; inpatient teams to be accountable with LOS measured in hours, not days and measuring median review times of inpatients; improved discharge training and planning.
Overall health care reforms were also mooted. Funding and business models need to change. Conflicting State and Federal interests need to be resolved. Clear role delineation of every public hospital as cannot be all things to all people. Hospital networking to improve inter-hospital transfers. Bottom-up modelling means that clinician input is imperative. Finance staff to have joint accountability for quality outcomes. Improve IT skills eg barcode patients and their medical histories. Develop genuine partnerships between public and private hospitals.
Professor Drew Richardson, speaking at the access block summit, said that there is a strong association between overcrowding and mortality. The low risk patients have the greatest increase in mortality. Dr Richardson said, “The number that die as a result of access block is similar to the road toll.”. He emphasized that the workload of ED staff is measured by the number they are caring for, not the number waiting for treatment. He commented: “You cannot get new patients in unless you get old patients out. It is true of both ED and the wards.”. He listed proven effects of access block which include: ambulance delays in chest pain patients; increased missed MI's; delay to reperfusion; increased did-not-waits; delay to antibiotics in pneumonia; inferior pain management; and increased short term mortality.
Emergency physician and AMA representative Dr David Mountain said that the lack of hospital and system capacity is the cause of access block. He said it was a myth that access block was caused by inappropriate patients. He said, “GP patients don’t use up trolleys or take up much time”. Professor Peter Cameron agreed that beds per thousand had reduced. But he said that demand had also increased due to the ageing population and increasing expectations. Meanwhile Dr Tony Joseph, ACEM college councilor, listed beds per thousand population at 2.6 for Australia, exceeded by USA (2.8), UK (3.7) and Germany (6.6). He said that in USA many hospitals had decided to spread the boarders (access blocked patients) throughout the hospital corridors rather than keep them all in the ED corridor.
In a session on solutions at the Access Block Summit, Dr Sally McCarthy, ACEM vice president, said that an over census policy, where one or two patients go to each ward when the ED is full “lets people receive expert care in the right area.”. She also advocated measuring downstream KPIs. Dr McCarthy said, “It’s all about length of stay.”. Professor John Dwyer called for more funding, role delineation for every public hospital and an integrated primary and secondary community based service.
The next morning's Melbourne Age Newspaper carried an article headlining Dr Richardson's comments about additional deaths in Emergency Departments around Australia with numbers similar to the road toll.