Sydney 2000: guarding against disasters

In the incident described by Nocera, the prompt response by emergency services was the key to the survival of the injured. The first ambulance arrived five minutes after the explosion, followed by two more in the next six minutes. As part of the controlled response, a helicopter was put on stand-by nine minutes after the accident and took off five minutes later, carrying universal donor (O Rh-negative) blood, a paramedic and an emergency medicine doctor. The obvious cooperation between all personnel involved -- including police, fire, ambulance officers and helicopter staff -- enabled appropriate deployment of resources, prompt triage and transportation (making allowances for peak hour traffic and matching the capabilities of the hospitals in the area with the patients' conditions).

A disaster may be defined as "Any incident, involving large numbers of casualties, which overwhelms the capacity of available resources to cope with it."¹ A disaster is, obviously, unexpected, but we might expect Murphy's Law to operate.

The recent history of the Olympics includes the tragedies of Munich (1972) and Atlanta (1996). Disaster preparedness was part of our successful bid for the Games in 2000. The response plan was based on DISPLAN/MEDPLAN. MEDPLAN has now been superseded by HEALTHPLAN,² which defines the command structure and standard operating procedures to be followed in a disaster by the New South Wales health services (ambulance, medical, mental health and public health).

These disaster-response plans have been tested and refined through the challenges of bushfires, the Newcastle earthquake, bus crashes and mass gatherings such as visits by two Popes, Royalty and United States Presidents, at rock concerts,³ City to Surf runs and many other occasions.

The New South Wales State Emergency and Rescue Management Act 1989 has required increased disaster planning and preparedness at local government, district, area health and State levels. Training and certification of selected health professionals and practical texts⁴ are now readily available.

A glimpse of the complexity of the overall picture of disaster response is provided by the table of contents (10 pages) of the Commonwealth's Australian emergency manual: disaster medicine,⁵ which covers all aspects of disasters through to recovery. Both this manual and the New South Wales HealthPlan² have been revised for 1997.

Disaster planning brings forth apathy, denial, squabbles about resources, turf battles and many committees representing various disciplines creating camels,* as well as serious professionals trying to plan for "What if . . . ?". The Olympic Health and Medical Working Committee, with senior representatives from the Sydney Olympic Games Organising Committee, the NSW Department of Health and other agencies, is setting up the framework for events in 2000.

There are several established principles in disaster planning:

• In disasters, do the greatest good for the greatest number (a reversal of the usual clinical emphasis on quality of care for the individual). This explains why any disaster scene has to be declared safe by fire officers, why police are in charge overall, why systems are set up to evacuate "walking wounded" before attention is given to the mortally injured.
• Both military and civilian experience has confirmed that in a disaster a rigid chain of command is essential (doctors, with their individualistic training and professional independence, are poor at this), and that personnel should perform tasks similar to their normal duties (e.g., that surgeons should continue in surgery and not be called upon to organise transport).
• Overall service command must be led by a controller off site . Each service must have liaison officers from all other major agencies involved. The biggest problem is always communication: this must be organised by those agencies with the relevant expertise and equipment.
• Emergency physicians are the appropriate controllers of the medical response to a disaster: ". . . they are familiar with the system and personnel providing care before hospitalization; they are practiced in rapid assessment, basic treatment, and triage; and they have a good working rapport with other specialists needed during the response."⁶

As Waeckerle states in an article on disaster planning, it is too late to plan a response once a disaster occurs.⁶ Disaster response will always be a team collaborative effort which must be planned and practised. As everybody's time and resources are short, we have to use tabletop exercises, mass gatherings and even expensive exercises with moulaged victims to practise to get it right well before 2000.

Gordian W O Fulde
Director, Emergency Department
St Vincent's Hospital, Sydney
A Senior Commander, NSW Healthplan .

* "A camel is a horse designed by a committee and an elephant is a mouse built to military specifications" -- Caxton C Foster

1. Ambrose G. Disaster medical planning. In: Fulde GWO, editor. Emergency medicine: the principles of practice. 2nd ed. Sydney: Maclennan and Petty, 1992: 13-19.
2. NSW Healthplan . Functional area supporting plan to the NSW State Disaster Plan (NSW DISPLAN). Sydney: Department of Health, 1997.
3. Fulde GW, Forster SL, Preisz P. Open air rock concert: an organised disaster. Med J Aust 1992; 157: 820-822.
4. Hodgetts TJ, Mackway-Jones K, editors. Major incident medical management and support. The practical approach. London: BMJ Publishing, 1995.
5. Australian emergency manual: disaster medicine. Canberra: Commonwealth Department of Human Services and Health, 1995.
6. Waeckerle J. Disaster planning and response. N Engl J Med 1991; 324: 815-821.