Challenging triage the aden experience

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 !!