Challenging triage: the Aden experience 5th Dec. 2015
Yasushi Tanabe MSF surgeon
Usually working environment is,,,5
star☆☆☆☆☆
• Great assistance for medical team;
Accommodation
4/1/16
Nice cook !!
ER doctors, nurses, IPD doctors • Good friends
Simple life ! 7:30 wake up 8:00 meeting 8:30 ICU round 9:00 start operations—
That’s all
Well organized equipment • Not perfect, but more than minimum
MASS CASUALTY !!
seriously injured cases
Difficult situations; Mass Casualty • Not enough time • Not enough tools for operation (hardware) • Not enough blood for transfusion
• Not enough man-power
Not enough tools
final diagnosis is on the OT table • Be flexible • Be tolerate • Be calm
eon
chamel
Not enough time • Severely injured trauma patient
can’t stand for long operation
Not enough blood • Stop bleeding soon !! • take patient on OT table soon !! • Finish operation soon !!
Not enough man-power • Many operations for surgeons; how to save energy?
Not enough tools • No time for sterilization • Finish thread and needle Where is my assistant? Oh!! Sleeping!!
An example 6 patients simultaneously in red zone 1 Trachea perforated, abdomen, chest, extremi ty, severely injured, drowsy, and shock 2 only chest, heavy bleeding, shock, drowsy 3 Leg ischemic, stable 4 Intestine exposed, stable 6 Abdominal bleeding, shock, unconscious 7 A Leg amputated, arterial bleeding, shock
1 Trachea perforated, abdomen, chest, extremity, severel y injured, drowsy, and shock 2 only chest, heavy bleeding, shock, drowsy 3 Leg ischemic, stable 4 Intestine exposed, stable 6 Abdominal bleeding, shock, uncouscious
7 A Leg amputated, arterial bleeding, shock
1 Trachea perforated, abdomen, chest, extremity, sev erely injured, drowsy, and shock 2 only chest, heavy bleeding, shock, drowsy 3 Leg ischemic, stable 4 Intestine exposed, stable
6 Abdominal bleeding, shock, unconscious
2 only chest, heavy bleeding, shock, drowsy 3 Leg ischemic, stable 4 Intestine exposed, stable
3 Leg ischemic, stable
4 Intestine exposed, stable
3 Leg, ischemic, stable
Lost 2 patients, 1 leg 1 Trachea perforated, abdomen, chest, extremit y, severely injured, drowsy, and shock 2 only chest, heavy bleeding, shock, drowsy 3 Leg ischemic, stable 4 Intestine exposed, stable 6 Abdominal bleeding, shock, unconscious 7 Leg amputated, arterial bleeding, shock
Decision making, difficult,,, on mass casualty situation • Maximum result for over all patients • Do not do too much for hopeless patients
• Time is Life
Time is LIFE •
isn’t Money
Shorten OT time for severely injured patients and Shorten OT time for the other patients
• Take patient into OT ASAP • Make sure how much time I need for procedures
Damage control surgery
• Time is life, finish the operation quick !!
• sometimes it is for the other patients’ life • Avoid deadly triad; low temperature, acidosis and co agulopathy • Control bleeding and avoid contamination • Don’t forget extremities, stop bleeding and wash wou nd and DBR
Predict the duration of the operation •Sterilization and draping •Laparotomy •Quick investigation and systematic Gauge packing •Closure of abdomen by 2 layer continuous stitches
5min 2min 5min 8min 20min
•investigation of whole abdomen •Repair a gastro-intestinal perforation •a resection and a anastomosis of intestine •a colostomy
15min 5min 15min 15min
Time for farther procedure • External-fixation for bone fracture
15min
• Splenectomy, nephrectomy, resection of intes tine 15min • Liver resection
>30min
• Pancreas- jejunum anastomosis
>30min
• Vascular repair
>30min
Communicate to Anesthetist From surgeon: • how injured • How much bleeding • Which procedure will do • how long is it take
Communicate from Anesthetist From anesthetist:
• how is the patient • how much time acceptable
Summary
important things,,, • Time management; ‘Time is life’ • Communications to all OT stuffs • Have technical options; time saving tech. • Flexibility, think about damage control surgery • Strong willing to face psychological stress How difficult,,,,,, It’s worth to challenge
Ideal Emergency Surgeons • Co-operative • Hard working • Nice skill • Quiet • patient
Waiting for you • Challenging , enjoy it !!