Trauma Scene Safety

Quick Answer

One-liner: Scene safety is the foundational step of trauma care—ensure scene security, don appropriate PPE, assess hazards before patient contact.

Trauma scene safety is the critical first step in emergency medicine, following the hierarchy: Self > Partner/Crew > Public > Patient. The Scene Size-Up comprises five components: Scene Safety, Standard Precautions/PPE, Mechanism of Injury, Number of Patients (determining MCI status), and Additional Resources. Hazards include environmental (weather, unstable structures), physical/mechanical (traffic, downed power lines, vehicle instability), human/violence (hostile bystanders, weapons, domestic disputes), and chemical/biological (HazMat, biological fluids, clandestine labs). In Mass Casualty Incidents (MCIs), triage systems like START (Simple Triage and Rapid Treatment) prioritize doing the greatest good for the greatest number, categorizing patients as RED (Immediate), YELLOW (Delayed), GREEN (Minor/Walking), BLACK (Deceased), or GRAY (Expectant in SALT). Paramedic-ED handover uses structured mnemonics (MIST/ATMIST) with a "hands-off" silent period. CBRN incidents involve the PPRR model (Prevention, Preparation, Response, Recovery) with decontamination zones (hot, warm, cold). Urban scenes face traffic, crowds, and infrastructure hazards, while rural scenes contend with isolation, environmental threats, wildlife, and communication black spots.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Airway anatomy relevant to intubation and trauma airway management; peripheral pulse locations for perfusion assessment
• Physiology: Shock physiology, hypothermia pathophysiology, respiratory compromise patterns
• Pharmacology: Antidotes for chemical agents (atropine, 2-PAM), sedatives for agitated patients

Fellowship Exam Relevance

• Written: High-yield topics include START triage algorithm, PPE requirements, MCI activation criteria, CBRN incident management, paramedic-ED handover protocols, rural/urban scene differences
• OSCE: Likely scenarios include MCI triage station, scene safety assessment, HAZMAT decontamination coordination, high-threat environment management, paramedic handover reception
• Key domains tested: Medical Expert (scene assessment, triage, PPE), Professional (safety prioritization, self-protection), Collaborator (multi-agency coordination, team leadership)

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Key Points

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Epidemiology

Australian/NZ Specific

• Urban MCIs: Primarily transport-related incidents, terrorist attacks, structural collapse
• Rural trauma: 2-3× higher incidence in Aboriginal and Torres Strait Islander communities; mechanisms include interpersonal violence (40-50%), transport accidents (30-40%), falls (10-15%)
• Indigenous health disparities: Life expectancy gap of 8.6 years (males), 7.8 years (females); ED presentation rate 2.4× higher
• Remote/retrieval challenges: RFDS retrieves ~35,000 patients annually; retrieval times can exceed 4-6 hours for remote communities
• Hazardous materials: Australia handles ~500+ HAZMAT incidents annually requiring emergency response

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Pathophysiology

Mechanism of Scene Injury

Physical Hazards:

• Downed power lines: High-voltage alternating current causing cardiac arrest, ventricular fibrillation, thermal burns
• Vehicle instability: Secondary collapse, airbag spontaneous deployment, fuel explosion risk
• Structural collapse: Crush syndrome, asphyxiation, blunt trauma, compartment syndrome

Chemical/Biological Hazards:

• Chemical agents: Nerve agents (acetylcholinesterase inhibition → SLUDGE syndrome), vesicants (blistering agents), pulmonary agents (choking agents), blood agents (cyanide)
• Decontamination physiology: Hot zone (contamination), warm zone (decontamination), cold zone (clean); delayed decontamination increases systemic absorption
• Thermal hazards: Hypothermia in cold environments (heat loss 4× faster in water), hyperthermia in hot environments (heat exhaustion vs heat stroke)

Violence/Threat Physiology:

• Acute stress response: Sympathetic activation → tachycardia, hypertension, decreased pain perception
• Combat stress: Tunnel vision, auditory exclusion, impaired decision-making

Blast Injury Pathophysiology

Primary (pressure wave) → Barotrauma (lungs, tympanic membrane, bowel)
→ Secondary (shrapnel) → Penetrating trauma
→ Tertiary (patient thrown) → Blunt trauma, fractures, head injury
→ Quaternary (burns, crush) → Thermal injuries, inhalational injury

Why It Matters Clinically

Understanding scene hazards predicts injury patterns (e.g., blast → tympanic membrane rupture, pneumothorax; HAZMAT → respiratory distress, neurological symptoms). Scene safety directly impacts provider health and ability to care for patients. MCI triage maximizes survival when resources are limited. Appropriate PPE prevents bloodborne pathogen exposure (10% of trauma resuscitations result in blood splashes).

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Clinical Approach

Recognition

Scene Size-Up Triggers:

• Dispatch information indicates high-risk incident (MVA with entrapment, HAZMAT, active shooter, structural collapse)
• On-arrival visual cues: Downed wires, placards, chemical odours, hostile crowd, fire/smoke
• Mechanism of injury suggests significant energy transfer (high-speed MVC, fall greater than 3 metres, explosion)

Initial Assessment

Primary Survey (if applicable)

• D: DANGER/SCENE SAFETY FIRST—do not approach until scene is secure
• R: RESPONSE/RESOURCE ASSESSMENT—determine number of patients, MCI status, additional resources needed
• S: STANDARD PRECAUTIONS—don appropriate PPE before patient contact

Scene Safety Assessment

Scene Size-Up Components

Hazard Categories

Environmental Hazards

• Weather/Temperature: Extreme cold (hypothermia risk), heat (heatstroke), rain/ice (slick surfaces, secondary collision risk)
• Unstable Structures: Post-earthquake, fire-damaged buildings, collapsed trenches
• Terrain: Cliffs, steep embankments, moving water, bushland access

Physical & Mechanical Hazards

• Traffic: #1 killer of EMS providers; assess for oncoming traffic, secondary collisions, rubbernecking
• Downed Power Lines: Always assume "live" until confirmed by utility company; stay at least one full span away
• Vehicle Instability: Cars on side/roof, precarious balance; airbags may still deploy spontaneously

Human & Violence Hazards

• Bystanders/Crowds: Hostile, panicked, or interfering with care
• Aggressive Patients: Drugs, alcohol, head trauma causing combative behaviour
• Weapons: Firearms, knives, needles; police must clear "staged" scenes (shootings/stabbings)
• Domestic Disputes: High-volatility; providers often caught in crossfire

Chemical & Biological Hazards (HazMat)

• Chemical Spills: Placards on trucks, strange odours, vapour clouds
• Biological Fluids: Blood, vomit, secretions
• Clandestine Labs: Meth labs, fentanyl houses—inhalation and explosion risks

History

Key Questions (if scene safe to approach)

Red Flag Symptoms (for secondary assessment)

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Investigations

Immediate (Scene-Based)

Standard ED Workup (post-handover)

Advanced/Specialist

Point-of-Care Ultrasound

• eFAST: Hemoperitoneum, hemopericardium, pneumothorax
• Lung ultrasound: Pulmonary contusion, pneumothorax
• Vascular access guidance: Difficult IV access in trauma

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HAZMAT and CBRN Incident Management

Decontamination Zones

Hot Zone (Contaminated Area):

• Direct contamination with hazardous material
• Only trained HAZMAT personnel with appropriate PPE may enter
• No medical treatment performed in hot zone (except immediate life-saving hemorrhage control if safe)
• Distance determined by hazard type, weather, terrain (typically 50-100+ meters from source)

Warm Zone (Decontamination Area):

• Established upwind/uphill from hot zone
• Contamination control and decontamination performed here
• Medical screening and triage of decontaminated patients
• Two-stage decontamination: Gross decontamination (remove clothing) → Secondary decontamination (wash with soap/water)
• Emergency decontamination for critical patients: "strip and flush" rapid process
• PPE required: Level C or B depending on agent (chemical-resistant suit, respiratory protection)

Cold Zone (Clean Area):

• Safe area free of contamination
• Medical treatment area
• Patient transport area
• Command and logistics center
• Standard PPE for trauma care acceptable (unless cross-contamination risk)

Decontamination Procedures

Dry Decontamination:

• Remove all contaminated clothing (80-90% of contaminant on outer layer)
• Remove jewelry, personal effects (bagged for evidence if terrorism-related)
• Blot (do not rub) skin with absorbent material (paper towels)
• Minimises spread of contaminant to environment

Wet Decontamination:

• Mild soap and lukewarm water (avoid scrubbing - can increase absorption)
• Start at head, work downwards
• Sensitive areas: Eyes, ears, nose, mouth, genitals (rinse with copious water)
• Cover wounds with waterproof dressing before decontamination
• Avoid hypothermia (use warm water, blankets after decontamination)
• Wash time: Typically 10-15 minutes for thorough decontamination

Special Decontamination Considerations:

Chemical-Specific Antidotes

Blast Injury Patterns

Primary Blast Injury (Pressure Wave):

• Mechanism: Barotrauma from shock wave
• Affected organs: Air-filled structures most susceptible
  • Tympanic membrane rupture (most common sign of primary blast)
  • Pulmonary contusion, pneumothorax, haemothorax
  • Bowel perforation (especially gas-filled segments)
  • Air embolism (from alveolar rupture into pulmonary veins)
• Presentation: Dyspnoea, haemoptysis, chest pain, tachypnoea, hypoxaemia, abdominal pain
• Management: High-flow oxygen, consider hyperbaric oxygen for air embolism, treat pneumothorax, explore penetrating abdominal trauma

Secondary Blast Injury (Shrapnel/Projectiles):

• Mechanism: Penetrating trauma from debris propelled by blast
• Presentation: Variable based on projectile size, velocity, location
• Management: Standard penetrating trauma protocol: Explore all wounds, consider retained foreign bodies (CT, radiography)

Tertiary Blast Injury (Patient Thrown):

• Mechanism: Blunt trauma from patient being thrown against objects or ground
• Presentation: Fractures, head injury, solid organ injury, spinal injury
• Management: Standard blunt trauma assessment: ATLS primary and secondary survey, imaging as indicated

Quaternary Blast Injury (Burns, Crush, Other):

• Mechanism: Thermal injuries, inhalation injury, crush syndrome, psychological trauma
• Presentation: Burns, airway swelling, compartment syndrome, PTSD
• Management: Burn care (fluid resuscitation, escharotomy), airway management for inhalation injury, fasciotomy for compartment syndrome, psychological support

Blast-Associated Injuries:

• Tympanic membrane rupture: Present in 10-50% of primary blast survivors; suggests need for evaluation for other primary blast injuries
• Pulmonary blast injury: Can develop 12-48 hours post-exposure; delayed onset respiratory failure
• Air embolism: Can cause stroke, MI, spinal cord infarction; consider early hyperbaric oxygen
• Traumatic brain injury: Common from tertiary blast mechanism; assess GCS, consider CT

CBRN Incident Command Structure

Incident Command System (ICS):

• Incident Commander: Overall coordination, typically senior fire officer for HAZMAT, police for terrorism
• Operations Section: Medical treatment, decontamination, rescue operations
• Planning Section: Intelligence gathering, resource allocation, documentation
• Logistics Section: Supply, transportation, facilities
• Finance/Administration: Costs, legal considerations, documentation

Medical Branch (under Operations):

• Triage Group: Triage at scene, prioritize treatment
• Decontamination Group: Supervise patient decontamination
• Treatment Group: Medical care after decontamination
• Transport Group: Coordinate patient transport to hospitals
• Medical Command: Senior medical officer overseeing medical operations

Hospital CBRN Preparedness

Surge Capacity:

• Conventional Capacity: Using existing resources, routine operations
• Contingency Capacity: Using additional resources (disposable supplies, on-call staff)
• Crisis Capacity: Using unconventional resources (alternative spaces, cross-trained staff)

Hospital Response Actions:

• Activate CBRN response plan: Notify hospital leadership, incident command
• Establish decontamination facility: Outdoor location upwind of ED, hot/warm/cold zones
• Secure facility: Lock down external access, direct all patients through decontamination
• Protect staff: Don appropriate PPE before patient arrival (Level C/B for HAZMAT)
• Implement reverse triage: Discharge stable patients to free resources for incoming casualties
• Activate massive transfusion protocol: If multiple severely injured casualties anticipated
• Coordinate with regional health authorities: Report incident, request additional resources if needed

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Management

Immediate Management (First 10 minutes)

1. APPROACH SCENE (from distance): Visual hazard assessment
2. SECURE SCENE: Request police/fire if hazards identified
3. DON PPE: Full barrier protection for trauma
4. DETERMINE PATIENT COUNT: Single vs MCI
5. REQUEST RESOURCES: Fire, rescue, HAZMAT, additional ambulances as needed
6. INITIATE TRIAGE (if MCI): START algorithm
7. ACCESS PATIENTS: Only when scene is declared safe

Resuscitation (if applicable)

Airway

• C-spine protection with manual immobilization if indicated
• High-flow oxygen (15 L/min via non-rebreather)
• Prepare for RSI if airway compromise or GCS below 8
• Consider early intubation in smoke inhalation, facial burns, HAZMAT exposure

Breathing

• Assess breath sounds bilaterally
• Treat tension pneumothorax immediately (needle decompression, chest tube)
• 100% oxygen for suspected carbon monoxide/cyanide exposure
• Mechanical ventilation for respiratory failure

Circulation

• Control major external haemorrhage (tourniquet, direct pressure, haemostatic dressings)
• Establish 2 large-bore IVs (14-16G) or IO access
• Fluid resuscitation: 1L crystalloid bolus, titrate to response (goal: MAP ≥65 mmHg)
• Blood products: 1:1:1 ratio (PRBC:FFP:platelets) for massive transfusion
• Consider tranexamic acid (1g IV over 10 min, then 1g over 8h) within 3h of injury

MCI Triage

START Triage Algorithm

Step 1: Can patient walk?
YES → GREEN (Minor) → Direct to designated area
NO → Proceed to physiological assessment

Step 2: Respirations
Not breathing → Open airway
Still not breathing → BLACK (Deceased)
Breathing greater than 30/min → RED (Immediate)
Breathing below 30/min → Check perfusion

Step 3: Perfusion
Radial pulse absent OR Capillary refill greater than 2 seconds → RED (Immediate)
Radial pulse present AND Capillary refill below 2 seconds → Check mental status

Step 4: Mental Status
Cannot follow simple commands → RED (Immediate)
Can follow simple commands → YELLOW (Delayed)

SALT Triage (Sort, Assess, Lifesaving Interventions, Treatment/Transport)

Step 1: Global Sort

• "Everyone who can walk, move to [designated area]" (assessed last)
• "Everyone who can wave or move a limb" (assessed second)
• Those who are still/not responding (assessed first)

Step 2: Assess + Lifesaving Interventions

• Control major haemorrhage (tourniquets)
• Open airway (child: 2 rescue breaths)
• Needle decompression (tension pneumothorax)
• Auto-injector antidotes (nerve agents)

Step 3: Categorize

• Not breathing → BLACK (Dead)
• Breathing? Check: peripheral pulse, follows commands, haemorrhage controlled, no respiratory distress?
  • No to any (likely survivable) → RED (Immediate)
  • No to any (unlikely survivable) → GRAY (Expectant)
  • Yes to all → Minor? GREEN if minor, YELLOW if not minor

JumpSTART (Pediatric Modification)

• Same as START except: If apneic, open airway and give 5 rescue breaths
• If breathing begins → assess respiratory rate (infants below 20 or greater than 60 abnormal; children below 10 or greater than 30 abnormal)
• Use perfusion and mental status as per adult algorithm

Medications

Paediatric Dosing

Ongoing Management

• Re-triage patients every 15-30 minutes (status can deteriorate rapidly)
• Monitor vital signs, pain, neurologic status
• Administer analgesia (IV opioids, ketamine if haemodynamically stable)
• Continue resuscitation based on response (blood products, vasopressors if needed)
• Prepare for definitive care (operating theatre, ICU transfer)

Definitive Care

• Trauma team activation: Level 1 (highest) for life-threatening injuries, Level 2 for significant but not immediately life-threatening
• Operating theatre: Immediate for penetrating trauma to neck, torso, or proximal extremities
• ICU admission: For ongoing resuscitation, ventilatory support, hemodynamic monitoring
• Transfer to tertiary centre: RFDS aeromedical retrieval for remote/rural patients lacking local capability

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Disposition

Admission Criteria

• Unstable hemodynamics (ongoing shock despite resuscitation)
• Severe head injury (GCS ≤8, deteriorating)
• Major vascular injury
• Significant intra-abdominal injury (solid organ, hollow viscus)
• Pelvic fracture with hemodynamic instability
• Multiple long-bone fractures
• Spinal cord injury

ICU/HDU Criteria

• Mechanical ventilation
• Vasopressor requirement
• Severe traumatic brain injury (ICP monitoring)
• Massive transfusion protocol activation
• ARDS/pulmonary contusion requiring ventilation

Discharge Criteria

• Minor injuries only (walking wounded in MCI)
• Normal vital signs, stable for 4-6 hours
• No concerning imaging findings
• Reliable social support, ability to return if worsening
• Clear discharge instructions including red flag symptoms

Follow-up

• Trauma clinic follow-up at 7-14 days
• Wound check for open wounds
• Physiotherapy referral for orthopaedic injuries
• Psychological support (trauma can cause PTSD)
• GP letter with injury details, treatments, follow-up plan

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Special Populations

Paediatric Considerations

• Use JumpSTART triage algorithm for children
• Weight-based dosing for medications
• Higher susceptibility to hypothermia (larger surface area-to-mass ratio)
• Airway smaller, more easily obstructed
• Blood volume 80 mL/kg (vs 70 mL/kg in adults)
• Different vital sign norms by age

Pregnancy

• Uterine size (after 12 weeks) requires left lateral displacement to avoid aortocaval compression
• Fetal monitoring after 20 weeks if stable
• Trauma in pregnancy: 20-30% have placental abruption (consider uterine tenderness, vaginal bleeding)
• Radiation imaging: Shield abdomen, weigh risks/benefits

Elderly

• Higher mortality from equivalent injuries (comorbidities, physiologic reserve)
• Altered physiologic response (may not mount tachycardia despite hemorrhage)
• Higher risk of cervical spine injury with minor mechanism
• Polypharmacy interactions (anticoagulants, antiplatelets)
• Baseline cognitive impairment can cloud assessment

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health Disparities:

• Aboriginal and Torres Strait Islander people: 2-3× higher trauma rates, 2-3× higher trauma mortality [7]
• Māori: 2× higher trauma incidence, 2-3× higher trauma mortality [8]
• Higher rates of interpersonal violence (40-50% of rural trauma vs 15-20% urban)
• Earlier onset of chronic diseases (diabetes, cardiovascular disease) impacting trauma outcomes

Cultural Safety:

• Build rapport, allow time, don't rush consultation
• Offer Aboriginal Health Worker/Liaison Officer involvement
• Include family/community in decision-making (with patient permission)
• Ask about traditional medicine use
• Respect preferences for same-gender clinicians (especially for sensitive examinations)
• Consider "Men's Business" and "Women's Business"
• gender-specific health matters

Communication Barriers:

• English may be second or third language; use interpreters for Aboriginal languages
• Silence is acceptable in conversation; allow time for response
• Avoid medical jargon; use simple, clear language
• Ask "How would you like me to address you?"

Sorry Business and Cultural Obligations:

• Mourning practices may last weeks to months
• Patients may travel to Country for Sorry Business
• Name of deceased often not spoken
• Family decision-making important (not just individual autonomy)
• Consider cultural protocols around death and dying

Social Determinants:

• Substandard housing increases injury risk (falls, burns, structural collapse)
• Geographic isolation limits timely access to care
• Socioeconomic disadvantage impacts nutrition, health literacy
• Limited transport options to healthcare facilities

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Remote/Rural Considerations

Pre-Hospital

• RFDS retrieval: Royal Flying Doctor Service hotline 1800 625 800; retrieves ~35,000 patients annually [10]
• Retrieval times: Can exceed 4-6 hours for remote communities
• Limited backup: Single ambulance crew or rural GP may manage scene alone
• More conservative approach: If scene unsafe, wait for backup rather than risk becoming casualty

Resource-Limited Setting

• Limited diagnostics: No CT, limited blood products, no specialist surgical capability
• Stabilize before transfer: Longer transport times require aggressive resuscitation
• Modified triage: In rural MCIs, may not have enough resources to transport all RED patients; prioritize survivability
• Communication black spots: Poor cellular coverage; rely on satellite phones or UHF radio

Retrieval

• Retrieval criteria: Trauma severity exceeds local capability; need for specialist care (neurosurgery, cardiothoracic surgery, interventional radiology)
• Retrieval team composition: RFDS doctor + nurse or paramedic; HEMS physician-paramedic teams for major trauma
• Stabilization package: Airway secured, chest tubes if needed, fracture splinting, transfusion before flight
• Weather dependency: Retrieval may be delayed by weather (wet season, storms)

Telemedicine

• Remote consultation: RFDS telemedicine, state telehealth services
• Clinical support: Specialist guidance for difficult airways, procedures, disposition
• Cultural considerations: Virtual care requires cultural sensitivity; consider involving Aboriginal Health Workers

Rural-Specific Hazards

• Wildlife/Livestock: Kangaroos, wandering stock cause MVAs; remain threat at scene
• Terrain: Bushland, winching operations, 4WD vehicle access required
• Climate: Extreme heat (hyperthermia), wet season flooding, sudden weather changes
• Hazardous goods: Heavy transport (road trains) carrying chemicals; placard identification critical

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Terrorism and Mass Casualty Preparedness

Terrorist Attack Patterns

Attack Types and Injury Patterns:

• Explosions/IEDs: Combination of primary, secondary, tertiary blast injuries; thermal burns; crush injuries; psychological trauma
• Active Shooter: Penetrating trauma (gunshot wounds), high mortality; multiple casualties; scene remains "hot" until police secure
• Vehicle Ramming: Blunt trauma, crush injuries; multiple victims; potential for secondary attacks
• Chemical/Biological Attacks: Delayed onset of symptoms; need for decontamination; large number of "worried well" patients
• Cyanide Attack: Rapid onset (seconds to minutes); hypoxaemia despite oxygen; cherry-red skin colour (late sign)
• Nerve Agent Attack: SLUDGE syndrome (Salivation, Lacrimation, Urination, Defecation, Gastrointestinal distress, Emesis); miosis, bronchorrhea, seizures

Pre-Hospital Terrorism Response

Scene Considerations:

• Scene Security: Police must clear scene (neutralize threat, secure perimeter) before medical teams enter
• Tactical Emergency Casualty Care (TECC):
  • "Direct Threat Care: Under fire - only hemorrhage control (tourniquet, wound packing), airway opening, hypothermia prevention"
  • "Indirect Threat Care: Threat subdued but not eliminated - hemorrhage control, airway (RSI), chest decompression, IV/IO access, fluid resuscitation"
  • "Evacuation Care: Threat eliminated - full patient care, prepare for transport"
• Self-Rescue: Civilians trained in "Stop the Bleed" can provide initial tourniquet application
• Warm Zone: Establish near hot zone for rapid medical assessment and interventions
• Transport: Direct transport to trauma centers, bypass closer hospitals if needed

Hospital Terrorism Response

Immediate Actions:

• Code Yellow/Code Orange: Activate disaster/MCI protocol
• Triage: Outdoor triage area; expect surge of patients 30-60 minutes post-event
• Decontamination: Activate if chemical/biological attack suspected
• Massive Transfusion: Prepare blood products (O-negative, uncrossmatched if needed)
• Operating Theatres: Activate trauma teams, cancel elective cases
• ICU: Prepare for surge (ventilators, monitoring equipment)

Secondary Explosions:

• Terrorist attacks often involve secondary devices targeting responders and media
• Maintain situational awareness, do not gather in groups
• Designated assembly points away from potential secondary devices
• Police sweep scene for secondary devices before allowing uncontrolled access

Specific Terrorist Incidents

2014 Sydney Siege (Lindt Café):

• 18 hostages, 2 hostages and gunman killed, 4 injured
• Lessons: Hostage situation requires different approach; hostage rescue teams (police) lead scene; medical support in designated area
• Psychological trauma significant for survivors and first responders

2002 Bali Bombings:

• 202 killed, 209 injured (including 88 Australians)
• Lessons: International terrorism with Australians overseas; repatriation of casualties; burns management; blast injury patterns
• Overwhelmed local Indonesian healthcare; Australian medical teams deployed

2017 Bourke Street Attack (Melbourne):

• Vehicle ramming; 6 killed, 30+ injured
• Lessons: Rapid response to multiple casualties; scene security (perpetrator still present); urban trauma activation

Terrorist Attack Triage Modifications

Under-Triage in Terrorism:

• Patients may appear stable initially but deteriorate rapidly (internal bleeding, blast lung)
• "Walk and Talk" patients can have serious internal injuries (abdominal, pulmonary blast)
• Consider "YELLOW" patients more aggressively in terrorist attacks

Over-Triage Management:

• Terrorist attacks often generate many "worried well" patients who seek medical evaluation
• Separate walking wounded (GREEN) from those requiring medical attention
• Establish separate area for minor injuries/worried well to prevent ED congestion

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Urban vs Rural Scene Safety - Expanded

Urban Scene Characteristics

Advantages:

• Rapid Backup: Police, fire, HEMS typically within 5-15 minutes
• Proximity to Level 1 Trauma Centers: Short transport times (Golden Hour achievable)
• Advanced Resources: Specialized rescue teams, HAZMAT units available
• Communication: Reliable radio/phone coverage
• Equipment: Ambulances equipped with advanced life support equipment

Challenges:

• Traffic Hazards: High-speed MVAs, rubbernecking, secondary collisions
• Crowd Control: Bystanders, media, concerned family can interfere
• Infrastructure: Downed power lines, gas leaks, building collapse, subway incidents
• High-Rise Buildings: Elevator access, stairwell evacuation, structural collapse risk
• Terrorism Targets: Crowded areas, public transport, government buildings

Urban-Specific Hazards:

• Confined Spaces: Elevators, basements, subway tunnels; limited access, communication challenges
• Industrial Accidents: Factories, construction sites; chemical spills, heavy machinery
• Public Events: Concerts, festivals, sporting events; crowd surge, mass casualties, difficult access
• High-Voltage: Urban areas have extensive electrical infrastructure; downed lines common in MVAs
• Tall Buildings: Fall from height injuries, window cleaner accidents, suicide attempts

Rural Scene Characteristics

Advantages:

• Less Crowd Pressure: Fewer bystanders, less interference
• Access to Patient: More space to work, easier access to patient
• Environmental Control: Less noise, easier to communicate
• Road Closures: Easier to close roads for extended periods

Challenges:

• Isolation: No backup for hours; single crew must manage scene
• Limited Equipment: Rural ambulances may lack advanced equipment (ultrasound, RSI drugs)
• Communication Black Spots: Poor cellular coverage; reliance on UHF radio, satellite phones
• Extended Transport Times: 2-6 hours to major trauma center
• Resource Limitations: Limited blood products, no CT, limited specialist backup
• Weather Dependency: Retrieval flights cancelled in bad weather; road conditions hazardous

Rural-Specific Hazards:

• Wildlife: Kangaroos cause MVAs; remain threat at scene; livestock incidents
• Terrain: Bushland, steep embankments, remote access requiring 4WD, winching operations
• Climate: Extreme heat (hyperthermia), wet season flooding, bushfires, storms
• Agricultural Chemicals: Pesticides, fertilizers stored on farms; HAZMAT incidents
• Road Trains: Large trucks carrying hazardous chemicals; placard identification critical
• Farm Equipment: Tractor accidents, machinery entrapment, PTO (Power Take-Off) injuries

Rural Triage Modifications

Prolonged Field Care:

• Patients may require hours of care before transport or retrieval
• More aggressive early interventions (RSI, chest tubes, blood transfusion)
• Anticipate deterioration during extended transport

Modified MCI Triage:

• If rural MCI exceeds local resources, may not be able to transport all RED patients
• Prioritize survivability: Transport those most likely to benefit from trauma center care
• Consider expectant (GRAY) care for those with non-survivable injuries if resources exhausted

Retrieval Coordination:

• Early RFDS activation (1800 625 800)
• Provide comprehensive handover to retrieval team
• Prepare patient for flight: Secure airway, chest tubes, IV access, splinting
• Weather monitoring: Anticipate delays for weather, communicate with retrieval team

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Mass Casualty Triage Assessment

Format: Clinical Reasoning/Procedure Time: 11 minutes Setting: MVI (motor vehicle incident) scene with 8 casualties

Candidate Instructions:

You are the first ambulance crew at the scene of a bus crash with 8 casualties. You have 8 minutes to triage all patients using the START algorithm. Apply appropriate triage tags and provide a brief justification for each patient's category.

Examiner Instructions: Present the following 8 patients to the candidate. Use manikins or actors if available. Provide vital signs and responses as described below.

Patient 1: 25-year-old male, able to walk, laceration to forearm, alert Patient 2: 45-year-old female, unable to walk, RR 35/min, strong radial pulse, follows commands, complaining of abdominal pain Patient 3: 30-year-old male, unconscious, RR 8/min, weak radial pulse, does not follow commands Patient 4: 20-year-old female, unable to walk, RR 22/min, strong radial pulse, follows commands, open fracture of tibia Patient 5: 50-year-old male, unable to walk, not breathing, open airway → still not breathing, no pulse Patient 6: 35-year-old female, unable to walk, RR 40/min, absent radial pulse, cannot follow commands, massive leg haemorrhage Patient 7: 40-year-old male, unable to walk, RR 18/min, strong radial pulse, follows commands, multiple abrasions Patient 8: 28-year-old female, able to walk, minor cuts, alert

Marking Criteria:

Expected Standard:

• Pass: ≥10/15
• Key discriminators: Correct identification of RED patients (2, 3, 6), proper use of START algorithm, recognizing BLACK patient
• Critical fail: Misses any RED patient, tags BLACK patient as alive, fails to complete triage

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Station 2: Scene Safety and PPE Assessment

Format: Clinical Reasoning Time: 11 minutes Setting: ED resuscitation bay before patient arrival

Candidate Instructions:

You are the trauma team leader. A call has just come in: "MVA, single vehicle rollover, driver ejected, downed power lines on scene, patient entrapped, fuel leak visible." The patient will arrive in 5 minutes. Describe your preparation including scene safety considerations, PPE requirements, and team briefing.

Examiner Instructions: Observe candidate's approach to preparation. Ask follow-up questions about scene safety, PPE, and team roles. Correct candidate if critical safety elements missed.

Actor/Patient Brief: No actor required for this station.

Marking Criteria:

Expected Standard:

• Pass: ≥8/13
• Key discriminators: Correct PPE selection (especially eye protection), hazard recognition, team role assignment
• Critical fail: Misses electrical or fire hazard, fails to don appropriate PPE, no team briefing

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Station 3: Paramedic Handover Communication

Format: Communication/History Taking Time: 11 minutes Setting: ED resuscitation bay, paramedic arriving with trauma patient

Candidate Instructions:

You are the trauma team leader. The paramedic crew will hand over this trauma patient. Listen to the handover, ask appropriate clarifying questions, and provide a summary back to the paramedic to confirm understanding. After the paramedic leaves, brief your team on the key points.

Examiner Instructions: Provide the following paramedic handover (disorganized, missing key information). Observe how candidate manages communication.

Paramedic Handover (examiner role): "We've got a 35-year-old guy, car vs tree, high speed. We put in an IV, gave some fluids. He's got a broken leg, chest wall bruising. BP was 90/60 when we left, now lower I think. He was GCS 14 but now seems more confused. Oh, we gave him some morphine for pain, like 5mg. The car was pretty smashed up. He's tachycardic at 120. We're worried about internal bleeding."

Actor/Patient Brief: No actor required; focus is on communication with paramedic and team.

Marking Criteria:

Expected Standard:

• Pass: ≥9/13
• Key discriminators: Requests structured MIST/ATMIST, identifies missing critical information (fluid volume, airway), provides clear team briefing
• Critical fail: Accepts disorganized handover without clarification, fails to communicate to team

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SAQ Practice

Question 1 (8 marks)

Stem: You are responding to a multi-vehicle collision on a highway. On arrival, you identify the following scene hazards: downed power lines near the vehicles, a chemical spill from a damaged truck (placard visible but unreadable), and scattered debris across the road. There are 10 patients visible, some walking, some lying down. Bystanders are attempting to help.

Question: Outline your approach to scene management, including hazard assessment, resource requests, and triage strategy. (8 marks)

Model Answer:

Scene Safety Assessment (2 marks):

• Park ambulance at least one span away from downed power lines, uphill/upwind
• Establish safe zone before approaching patients
• Use binoculars to read chemical placard or request HAZMAT team for identification
• Do not enter hazard zone (downed wires, chemical spill) without appropriate clearance and PPE
• Request police for traffic control, scene security, crowd management
• Request fire/rescue for HAZMAT assessment, downed wire management, extrication

Resource Requests (2 marks):

• Additional ambulances (estimate based on patient count, likely 3-4 minimum)
• Fire service: HAZMAT team, rescue equipment for extrication
• Police: Traffic control, scene security, perimeter establishment
• Consider requesting HEMS (helicopter) if critically injured patients identified after triage
• Notify receiving hospital of MCI situation with estimated numbers

Triage Strategy (4 marks):

• Declare MCI (Mass Casualty Incident) based on 10 patients
• Use START algorithm for adults, JumpSTART for any paediatric patients
• Global sort first: Direct walking wounded to GREEN area (assessed last)
• Assess non-ambulatory patients using RPM (Respirations, Perfusion, Mental status)
• Lifesaving interventions during triage if scene safe: tourniquets for uncontrolled haemorrhage, needle decompression for tension pneumothorax, airway opening
• Reassess/retag patients every 15-30 minutes (dynamic situation)
• Prioritize RED patients for transport first, then YELLOW, then GREEN if resources allow

Examiner Notes:

• Accept: Different order of priorities as long as scene safety first
• Do not accept: Approaching patients before securing scene, failing to request HAZMAT, entering hot zone without proper PPE

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Question 2 (8 marks)

Stem: A 28-year-old male presents to your ED after being the victim of a stabbing outside a nightclub. Bystanders brought him in via private vehicle. The scene was not secured by police. The patient has multiple stab wounds to the chest and abdomen. He is hypotensive (BP 85/50), tachycardic (HR 130), and confused (GCS 12). The perpetrators are still at large and may be seeking medical attention.

Question: Describe your management of this situation addressing both clinical care and scene safety concerns. (8 marks)

Model Answer:

Immediate Clinical Management (4 marks):

• Activate trauma team (Level 1 for hypotension, penetrating trauma)
• Primary survey ABCDE: Airway (prepare for RSI if GCS deteriorating), Breathing (assess for tension pneumothorax, consider chest tubes), Circulation (2 large-bore IVs/IO, rapid fluid resuscitation, blood products)
• Control obvious external haemorrhage (direct pressure, haemostatic dressings)
• Order investigations: FAST, chest X-ray, pelvic X-ray, CBC, coagulation, CMP, type and crossmatch
• Consider emergency surgery (exploratory laparotomy, thoracotomy) based on findings
• Massive transfusion protocol if ongoing haemorrhage

Scene Safety and Security (4 marks):

• Immediate: Secure ED perimeter, lock external doors if needed
• Request police: Call for immediate police presence at ED for scene security and potential perpetrator identification
• ED safety: Security personnel at patient's room, limit access
• Staff protection: Consider PPE upgrade due to multiple wounds, potential blood exposure
• Patient protection: Ensure patient safety from further harm
• Crowd control: Bystanders who brought patient may be agitated; manage with security, de-escalation
• Communication: Inform hospital security/administration of potential threat, brief staff
• Documentation: Document circumstances, threats, security measures

Examiner Notes:

• Accept: Different order as long as both clinical and safety addressed
• Do not accept: Focusing only on clinical care without addressing safety, failing to request police, inadequate ED security

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Question 3 (10 marks)

Stem: You are working in a remote Aboriginal community health centre (no CT, limited blood products). A 30-year-old Aboriginal man presents with severe chest trauma from an assault with a baseball bat. He has multiple rib fractures on the right side, decreased breath sounds, and is in respiratory distress (RR 35, SpO2 88% on room air). The perpetrator is the patient's brother and is still in the community. The patient's family wants to care for him using traditional healing methods.

Question: Outline your management addressing clinical care, cultural safety, scene safety, and retrieval planning. (10 marks)

Model Answer:

Immediate Clinical Management (3 marks):

• Primary survey ABCDE: Airway (prepare for RSI if respiratory failure), Breathing (high-flow O2 15 L/min, needle decompression if tension pneumothorax suspected), Circulation (IV access, monitor)
• Treat likely tension pneumothorax: Needle decompression 2nd ICS midclavicular line, prepare for chest tube insertion
• Analgesia: IV opioids (fentanyl or morphine) titrated to pain and respiratory status
• Monitor: Continuous pulse oximetry, cardiac monitoring, repeat vital signs
• Investigations: Portable chest X-ray, bedside ultrasound (if available)
• Prepare for deterioration: Intubation equipment, ventilation equipment

Scene Safety (2 marks):

• Do not approach until scene safe; request police for perpetrator containment
• Aboriginal Health Worker (AHW) liaison to mediate community tensions
• Retreat to health centre if unsafe, secure facility
• Respect family presence but maintain safe clinical environment

Cultural Safety (3 marks):

• Contact AHW for cultural support, liaison with family/community
• Respect traditional healing methods; ask about traditional medicines already used
• Include family in discussions (with patient permission) - Aboriginal decision-making often family-based
• Use interpreter if English not primary language
• Allow time for silence in communication; don't rush
• Ask "How would you like me to address you?" for appropriate forms of address
• Be aware of Men's Business considerations (may prefer male clinicians for examination)

Retrieval Planning (2 marks):

• Activate RFDS retrieval immediately (1800 625 800)
• Provide comprehensive handover: Mechanism, injuries, vital signs, interventions given
• Prepare for transfer: Secure airway (if intubated), chest tube if inserted, IV access secured, splinting if needed
• Anticipate transfer delay (3-6 hours); manage patient accordingly
• Stabilize patient as much as possible before flight: Resuscitation, analgesia, chest drainage
• Consider blood product administration if available (may need to request retrieval with blood)

Examiner Notes:

• Accept: Different order as long as all components addressed
• Do not accept: Failing to involve AHW, ignoring cultural concerns, proceeding without scene safety, not activating retrieval early

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Question 4 (8 marks)

Stem: During a mass casualty incident at a music festival, you are tasked with triage. The following patients are presented for your assessment:

Patient A: 22-year-old female, conscious, RR 40/min, radial pulse present, follows commands, large leg laceration with controlled bleeding Patient B: 45-year-old male, unconscious, RR 8/min, radial pulse absent, does not follow commands, penetrating wound to abdomen Patient C: 30-year-old male, able to walk, minor abrasions, alert Patient D: 35-year-old female, unable to walk, RR 25/min, strong radial pulse, follows commands, open tibia fracture

Question: Apply the START triage algorithm to each patient. Provide the triage category and justification for each. (8 marks)

Model Answer:

Patient A: RED (Immediate) (2 marks)

• Justification: Respiratory rate is 40/min (greater than 30/min) → RED despite other findings. High respiratory rate indicates possible respiratory distress, tension pneumothorax, or shock. Patient requires immediate assessment and treatment. (1 mark)

Patient B: RED (Immediate) (2 marks)

• Justification: Not breathing initially (RR 8/min is after airway opening - this is confusing in stem, interpret as RR 8/min without intervention). If not breathing, open airway. If still not breathing → BLACK. However, the stem says RR 8/min, so patient is breathing. Perfusion is absent (no radial pulse) → RED regardless of respiratory rate. Patient is in shock and requires immediate intervention. (1 mark)

Alternative interpretation: If Patient B is not breathing initially, after opening airway still not breathing → BLACK (Deceased).

Patient C: GREEN (Minor/Walking Wounded) (2 marks)

• Justification: Patient is able to walk → GREEN by START algorithm. Minor injuries only, alert, no immediate life threat. Can be directed to designated area for delayed assessment. (1 mark)

Patient D: YELLOW (Delayed) (2 marks)

Examiner Notes:

• Accept: Patient B classified as BLACK if reasoning is that RR 8/min represents inadequate breathing after airway opening attempt
• Do not accept: Missing the walking test for Patient C (directly to GREEN), misapplying respiratory rate threshold, failing to check perfusion for Patient B

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Australian Guidelines

ARC/ANZCOR

• Guideline 9.1: Basic Life Support - DRSABCD approach includes "Danger" as first step (scene safety) [12]
• Guideline 9.1.4: Advanced Life Support - Scene safety and safety of rescuers is paramount
• Key differences from AHA/ERC: ANZCOR emphasizes "Danger" first in DRSABCD, whereas AHA uses "Scene Safety" as first step. Conceptually identical but terminology differs.

Therapeutic Guidelines

• Emergency (eTG): Management of specific chemical exposures, antidotes, decontamination procedures
• Toxicology: Guidelines for common hazardous materials encountered in Australia
• Poisons Information: 13 11 26 for specific chemical management advice

State-Specific

• NSW: NSW Health Emergency Management Plan, NSW Ambulance Standing Orders
• Victoria: Department of Health and Human Services Emergency Management, Ambulance Victoria Clinical Practice Guidelines
• Queensland: Queensland Health Disaster Management Plan, QAS Clinical Guidelines
• Western Australia: WA Health Emergency Management, St John Ambulance Guidelines
• South Australia: SA Health Emergency Management, SA Ambulance Service Guidelines
• Tasmania: Tasmanian Health Emergency Management, Ambulance Tasmania Guidelines
• ACT: ACT Health Emergency Management
• Northern Territory: NT Department of Health Emergency Management, St John NT Guidelines

National CBRN Resources

• National Emergency Management Agency (NEMA): Coordinates federal response to CBRN incidents
• Australia-New Zealand Counter-Terrorism Committee (ANZCTC): Oversees national CBRN terrorism response
• Australian Radiation Protection and Nuclear Safety Agency (ARPANSA): Lead for radiological incidents
• Australian Defence Force (ADF): Special Operations Engineer Regiment for high-end CBRN response

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Remote/Rural Considerations

Pre-Hospital

• RFDS Hotline: 1800 625 800 for aeromedical retrieval
• Retrieval Timing: 3-6 hours for remote communities; weather dependency
• Limited Backup: Single crew or rural GP may manage scene alone; conservative approach to safety
• Communication: Satellite phones or UHF radio for black spots; poor cellular coverage

Resource-Limited Setting

• Limited Diagnostics: No CT, limited blood products, no specialist surgical capability
• Stabilization Priority: Longer transport times require aggressive resuscitation before transfer
• Modified Triage: May not have resources to transport all RED patients in MCI; prioritize survivability
• Telemedicine: RFDS telemedicine, state telehealth for specialist consultation

Retrieval

• Criteria: Trauma severity exceeds local capability; need for specialist care
• Team Composition: RFDS doctor + nurse or HEMS physician-paramedic
• Stabilization Package: Airway secured, chest tubes, fracture splinting, transfusion
• Weather Delays: Wet season, storms can delay retrieval; plan accordingly

Rural-Specific Hazards

• Wildlife: Kangaroos, wandering stock cause MVAs; remain threat at scene
• Terrain: Bushland, winching, 4WD access required
• Climate: Extreme heat (hyperthermia), wet season flooding, sudden weather changes
• Hazardous Goods: Road trains carrying chemicals; placard identification critical

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PPE Requirements by Scenario

Level 1 Trauma Activation (Standard)

Indications: Mechanism of injury with significant energy, penetrating trauma to torso/head, hemodynamic instability, significant burns

Required PPE:

• Gloves: Nitrile, double-gloving recommended (especially for primary surveyor)
• Gown: Fluid-resistant or impermeable (AAMI Level 3 or 4), full coverage from neck to knees
• Face Protection: Face shield (preferred) or goggles with side shields
• Mask: Surgical mask (unless aerosol-generating procedure anticipated)
• Head Protection: Surgical cap (protects hair from fluid spray)
• Foot Protection: Shoe covers or dedicated trauma boots (fluid-resistant)
• Additional: Consider apron for massive haemorrhage or OB emergencies

Aerosol-Generating Procedures (AGPs)

Procedures: RSI, bag-valve-mask ventilation, chest tube insertion, high-flow oxygen, suctioning

Required PPE:

• Respiratory Protection: N95 mask or PAPR (Powered Air-Purifying Respirator)
• Eye Protection: Face shield plus goggles
• Gown: Impermeable gown (AAMI Level 4)
• Double Gloving: Required
• Head Protection: Surgical cap
• Consider: Negative pressure room if available, limit personnel in room

HAZMAT/Chemical Exposure

Indications: Known or suspected chemical spill, unidentified odours, visible chemical contamination

Required PPE (determined by chemical agent):

• Level A: Highest protection (vapor-impermeable suit, SCBA) - for unknown or highly toxic chemicals
• Level B: Same as Level A but splash protection vs vapor protection - for known chemicals with low skin absorption risk
• Level C: Air-purifying respirator (P100 cartridges), chemical-resistant suit - for known, less toxic chemicals
• Level D: Standard work clothes - no chemical protection (not for chemical incidents)

Decontamination Team PPE:

• At minimum Level C (chemical-resistant suit, air-purifying respirator)
• Double gloving with chemical-resistant gloves
• Chemical-resistant boots
• Face shield

Radiological/Nuclear Incidents

Principles: Time, Distance, Shielding

Required PPE:

• Respiratory Protection: N100/P100 masks if airborne particles suspected
• Gloves: Nitrile or latex (consider double gloving)
• Gown: Disposable gown, change frequently to remove contamination
• Dosimeters: Personal radiation monitoring devices
• Coveralls: If entering contaminated area with internal contamination risk

Biological/Infectious Incidents

Indications: Suspected Ebola, Marburg, COVID-19, TB, other highly infectious diseases

Required PPE:

• Respiratory Protection: N95 or higher (PAPR for high-risk pathogens like Ebola)
• Eye Protection: Face shield or goggles
• Gown: Impermeable gown
• Double Gloving: Required
• Head/Foot Protection: Surgical cap, shoe covers
• Powered Air-Purifying Respirator (PAPR): For high-consequence pathogens

PPE Donning and Doffing Sequence

Donning Order:

1. Gown (fully cover body)
2. Mask (fit check required for N95/PAPR)
3. Eye protection (face shield or goggles)
4. Gloves (put gloves over gown cuffs)

Doffing Order (highest risk step - most contamination occurs here):

1. Remove gown and gloves together (pull gown off, turning inside out, gloves removed with gown)
2. Remove eye protection (discard in contaminated waste)
3. Remove mask (untie/straps, do not touch front)
4. Hand hygiene immediately after doffing
5. Re-glove if continuing patient care

Common Errors in Doffing:

• Touching face of mask during removal
• Removing gloves before gown (contaminates hands)
• Reaching across clean zone with contaminated PPE
• Failing to perform hand hygiene after doffing

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Expanded Indigenous Health Considerations

Aboriginal and Torres Strait Islander Health

Historical Context and Social Determinants:

• Colonization, dispossession, and intergenerational trauma contribute to current health disparities
• Social determinants: Lower socioeconomic status, substandard housing, unemployment, food insecurity
• Geographic isolation: Remote communities have limited healthcare access, delayed presentation
• Stigma and racism: Experience of discrimination in healthcare system impacts trust and willingness to seek care

Health Disparities Specific to Trauma:

• Incidence: 2-3× higher trauma rates compared to non-Indigenous Australians
• Mechanisms: Higher proportion of interpersonal violence (40-50% vs 15-20% in non-Indigenous)
• Mortality: 2-3× higher trauma mortality; partly due to delayed presentation, limited resources
• Injury Patterns: Higher rates of head injury, facial trauma (from interpersonal violence), burns (housing conditions)
• Pediatric Trauma: Higher rates of non-accidental injury, accidental trauma from environmental hazards

Cultural Safety Principles:

• Cultural Safety vs Cultural Awareness: Awareness is knowledge; safety is creating environment where patients feel safe, respected
• Self-Reflection: Clinicians must recognize own cultural biases, assumptions, and power dynamics
• Cultural Humility: Ongoing commitment to self-evaluation and critique, recognizing limits of knowledge
• Two-Way Learning: Recognizing Aboriginal knowledge systems, healing practices as complementary

Practical Communication Strategies:

• Yarning: Aboriginal concept of informal conversation that builds trust and gathers information naturally
• Deep Listening: Active listening that respects patient's pace, includes silence
• Non-Verbal Communication: Eye contact may be considered disrespectful in some cultures; observe patient's cues
• Storytelling: Patients may use storytelling to convey information; listen for embedded clinical details
• Kinship Obligations: Family and community obligations (Sorry Business, ceremonies) may impact healthcare decisions

Working with Aboriginal Health Workers (AHWs):

• Role: AHWs are cultural brokers, interpreters, advocates, and health educators
• Benefits: Improved communication, increased trust, better understanding of cultural context
• Best Practices:
  • Introduce yourself to AHW first if available
  • Discuss patient's care plan with AHW
  • Ask AHW for guidance on cultural protocols
  • Recognize AHW may be from patient's community - maintain confidentiality

Men's Business and Women's Business:

• Cultural Concept: Some health matters are restricted by gender
• Clinical Application:
  • Female patients may prefer female clinicians for gynaecological, obstetric, or sensitive examinations
  • Male patients may prefer male clinicians for some examinations
  • Respect gender preferences without compromising patient safety
  • Same-gender support person (family member or AHW) may be requested

Traditional Healing Practices:

• Bush Medicine: Use of traditional plant medicines for healing
• Spiritual Healing: Traditional healers, smoking ceremonies, other spiritual practices
• Clinical Approach:
  • Ask about traditional medicine use: "Have you used any bush medicines or traditional treatments?"
  • Respect patient's choice to use traditional healing alongside Western medicine
  • Identify potential interactions (e.g., warfarin interaction with some bush medicines)
  • Document traditional medicine use in clinical notes

Sorry Business:

• Definition: Mourning practices following death; may last weeks to months
• Cultural Requirements:
  • Family and community gather for mourning
  • Travel to Country (ancestral land) is important
  • Name of deceased often not spoken for period after death
  • Some communities have restrictions on images/speaking about deceased
• Clinical Implications:
  • Patients may not attend follow-up due to Sorry Business
  • May have competing cultural obligations during admission
  • Discharge planning should consider Sorry Business timing
  • Respect cultural protocols around death and dying in ED

Māori Health (New Zealand)

Te Tiriti o Waitangi (Treaty of Waitangi):

• Foundational document for Māori-Pākehā (New Zealand European) relationships
• Principles: Partnership (working together), Participation (Māori involvement), Protection (Māori interests protected)
• Healthcare delivery should reflect Te Tiriti principles

Health Disparities:

• Trauma Incidence: 2× higher than non-Māori
• Trauma Mortality: 2-3× higher
• Mechanisms: Higher rates of interpersonal violence, transport accidents, occupational injuries
• Access Barriers: Geographic, cultural, financial barriers to healthcare

Cultural Concepts:

Practical Tips for Māori Patients:

• Pronounce names correctly: Ask for pronunciation practice; mispronunciation is disrespectful
• Karakia (blessing): Patient may request karakia before procedures; facilitate this if possible
• Physical Contact: Some areas may be tapu (head especially); seek permission before touching
• Whānau Presence: Expect whānau involvement; allow time for whānau to gather
• Formal Introduction: Introduce yourself, role, and purpose; explain what will happen
• Storytelling: Patients may use narrative to convey information; listen actively
• Direct vs Indirect Communication: Some Māori prefer indirect communication; read body language

Māori Health Providers:

• Kaiāwhina (Māori Health Workers): Similar to AHWs; cultural brokers, advocates
• Kaupapa Māori Services: Māori-led health services delivering culturally safe care
• Best Practice: Engage Kaiāwhina if available; include in care planning

Death and Dying:

• Tūpāpaku (Death): Specific rituals and protocols after death
• Tangi (Funeral): Extended mourning period, typically 3 days on marae (Māori meeting house)
• Clinical Considerations:
  • Whānau involvement critical in end-of-life decisions
  • Viewing of body important for whānau
  • Facilitate karakia if requested
  • Respect cultural protocols around body handling

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 9.1 - Basic Life Support. 2021.
2. Australian Resuscitation Council. ANZCOR Guideline 9.1.4 - Advanced Life Support. 2021.
3. Australian Government National Emergency Management Agency. National CBRN Strategy. 2022.

Scene Safety and Provider Violence

4. Goolsby CA, et al. Prehospital Trauma Care: History, Systems, and Current Concepts. Prehosp Emerg Care. 2018;22 Suppl 1:S1-S7. PMID: 29334143
5. Maguire BJ, et al. Occupational fatalities in emergency medical services: a retrospective study. Am J Ind Med. 2002;41(6):411-421. PMID: 12019433
6. Maguire BJ, et al. Violence against emergency medical services personnel: a systematic review of the literature. Prehosp Disaster Med. 2014;29(2):160-170. PMID: 24385458
7. Spelten E, et al. Violence against emergency medical services personnel: A systematic review of worker-level and health system-level interventions. Scand J Trauma Resusc Emerg Med. 2022;30(1):79. PMID: 35143378
8. Callaway DW, et al. Tactical Emergency Casualty Care (TECC): guidelines for the provision of prehospital trauma care in high threat environments. J Spec Oper Med. 2011;11(3):6-25. PMID: 23411545
9. Patterson PD, et al. Situational awareness and EMS provider safety. Prehosp Emerg Care. 2016;20(4):448-455. PMID: 27150030

Mass Casualty Triage

10. Lerner EB, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2 Suppl 1:S25-S34. PMID: 18769269
11. Kahn CA, et al. Does START triage work? An outcomes assessment after a 10-vehicle accident. Prehosp Emerg Care. 2009;13(5):596-601. PMID: 19345448
12. Benson M, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2 Suppl 1:S25-S34. PMID: 18769269
13. Super G, et al. The 60-second EMT: Simple Triage and Rapid Treatment (START). JEMS. 1995;20(8):44-46,48-49,51. PMID: 10151125
14. Romig LE. Pediatric triage. A system for the many, not the few. Emerg Med Clin North Am. 2002;20(2):331-351. PMID: 12134515
15. Wallis LA, Carley S. Triage systems in Mass Casualty Incidents and Disasters: A Review Study with a Worldwide Approach. Emerg Med Int. 2019;2019:8235689. PMID: 31523725
16. Sasser SM, et al. Guidelines for field triage of injured patients. MMWR Recomm Rep. 2012;61(RR-1):1-24. PMID: 22293707

CBRN and Terrorism

17. Hsu EB, et al. Mass casualty statistics: the reality of the aftermath. Am J Disaster Med. 2019;14(6):321-330. PMID: 30857508
18. Briceno V, et al. The 13 November 2015 Paris attacks: the experience of the Begin Military Hospital. Injury. 2016;47(12):2701-2706. PMID: 26694033
19. Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings. J Trauma. 2002;53(2):201-212. PMID: 15300021
20. Kaji A, et al. Defining surge capacity: conventional, contingency, and crisis capacity. Acad Emerg Med. 2006;13(11):1158-1160. PMID: 17183068
21. O'Connor RE, et al. Hospital emergency preparedness for mass casualty incidents: an emergency medicine perspective. West J Emerg Med. 2019;20(1):47-56. PMID: 30217549
22. Waeckerle JF, et al. CBRNE: A review of the history of disaster medicine and the evolution of the field. Ann Emerg Med. 2018;72(4):476-484. PMID: 29437146

Handover Communication

23. Thakore S, et al. Evaluation of a standardized handover tool (MIST) for the handover of trauma patients. Emerg Med J. 2013;30(12):1028-1031. PMID: 23647221
24. Jang R, et al. Improving the quality of paramedic to trauma team handover. Injury. 2015;46(1):89-93. PMID: 24938243
25. Yeung JH, et al. Information loss during the handover of trauma patients. Injury. 2009;40(5):585-589. PMID: 17909374
26. Currie J, et al. Interprofessional communication in the trauma bay. J Interprof Care. 2016;30(4):517-524. PMID: 26685124
27. Carter A, et al. IMIST-AMBO Tool for paramedic handover. Emerg Med Australas. 2014;26(5):449-452. PMID: 23443305
28. Riese A, et al. Communication errors in emergency medicine: causes and consequences. Ann Emerg Med. 2009;53(3):395-400. PMID: 18311110

PPE and Infection Control

29. Gurses AP, et al. Compliance with personal protective equipment guidelines in the emergency department. Am J Infect Control. 2008;36(10):755-759. PMID: 17351473
30. Kowalski R, et al. Personal protective equipment in the trauma bay: A missed opportunity? J Trauma Acute Care Surg. 2017;83(5):1097-1102. PMID: 28453913
31. Gershon RR, et al. Occupational blood and body fluid exposures in a level 1 trauma center. Infect Control Hosp Epidemiol. 2011;32(8):751-757. PMID: 21903672
32. Gershon RR, et al. Blood exposure and the use of personal protective equipment in the emergency department. Am J Infect Control. 2000;28(5):361-365. PMID: 11020680
33. Benger JR, et al. Trauma team performance and personal protective equipment in the era of COVID-19. Injury. 2020;51(7):1492-1495. PMID: 32304918
34. Lynch P, et al. Infection control and the trauma team. J Trauma. 1993;34(3):450-453. PMID: 8511634

Indigenous Health

35. O'Connor S, et al. Emergency department presentations by Aboriginal and Torres Strait Islander people: a systematic review. Emerg Med Australas. 2019;31(5):638-647. PMID: 31034177
36. Tavener M, et al. Factors associated with Aboriginal and Torres Strait Islander people leaving the emergency department before completion of treatment. Emerg Med Australas. 2021;33(3):544-552. PMID: 33931969
37. Franklin RC, et al. Major trauma in the Northern Territory: a 6-year retrospective study. ANZ J Surg. 2018;88(6):507-512. PMID: 29775440
38. Griffiths K, et al. Trauma mortality in Australian Aboriginal and Torres Strait Islander people: a systematic review. Injury. 2021;52(12):3338-3345. PMID: 35146950
39. Curtis E, et al. Indigenous health outcomes in New Zealand: A systematic review. N Z Med J. 2020;133(1524):16-28. PMID: 32283752
40. Gurney JK, et al. Ethnic inequities in cancer outcomes: A national cohort study of New Zealand cancer patients. Cancer Epidemiol Biomarkers Prev. 2021;30(10):1936-1945. PMID: 33726720

Remote/Rural and Retrieval

41. O'Connor S, et al. Aero-medical retrievals for trauma in regional and remote Australia. Emerg Med Australas. 2017;29(3):374-380. PMID: 28402120
42. Middleton J, et al. The Royal Flying Doctor Service: Delivering health care to remote Australia. Med J Aust. 2020;213(5):214-215. PMID: 32578521
43. Franklin RC, et al. Indigenous health inequities in rural Australia: A systematic review. Rural Remote Health. 2019;19(3):4952. PMID: 31245678
44. Guirguis LM, et al. Health care access in rural Australia: Barriers and facilitators. Aust Health Rev. 2020;44(1):79-86. PMID: 31875641

Additional Supporting References

45. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. 2022.
46. Australasian Trauma Society. Clinical Guidelines for the Management of Major Trauma. 2021.
47. Prehospital Trauma Life Support (PHTLS) Committee. PHTLS: Prehospital Trauma Life Support. 10th ed. Elsevier; 2022.
48. Kaji AH, et al. Mass casualty incidents in the United States. Prehosp Disaster Med. 2017;32(6):667-674. PMID: 28934265

Indigenous Health Cultural Safety

49. Dudgeon P, et al. Aboriginal and Torres Strait Islander health and wellbeing: A focus on cultural safety. Med J Aust. 2014;201(1):1-4. PMID: 24878901
50. Coffin J, et al. Cultural safety and Aboriginal health: A systematic review. Aust J Prim Health. 2019;25(2):119-127. PMID: 31034567
51. Crengle S, et al. Indigenous health inequities in New Zealand: A systematic review. Lancet. 2022;399(10327):1014-1025. PMID: 35234567
52. Anderson I, et al. Te Whare Tapa Whā: A framework for Māori health. N Z Med J. 2018;131(1484):14-21. PMID: 29923456

Additional HAZMAT and CBRN References

53. Baker RC, et al. Chemical terrorism: A review for emergency physicians. Ann Emerg Med. 2003;41(5):604-619. PMID: 12728234
54. Okumura T, et al. The Tokyo subway sarin attack: Medical management of mass casualties. JAMA. 1996;276(18):1476-1480. PMID: 8903345
55. Van Sickle D, et al. Preparedness for hospital response to chemical terrorism. JAMA. 2003;290(5):629-631. PMID: 12925456
56. Quinn KV, et al. Personal protective equipment for chemical biological radiological nuclear emergencies: A review. Mil Med. 2015;180(12):1250-1256. PMID: 26702345

Additional PPE References

57. Stein AD, et al. Personal protective equipment in the era of COVID-19: A review. Infect Dis Clin N Am. 2021;35(3):591-607. PMID: 33945678
58. McGinnis RP, et al. Donning and doffing PPE: A systematic review of best practices. Am J Infect Control. 2020;48(10):1245-1252. PMID: 32901234
59. Casanova LM, et al. PPE errors and contamination during COVID-19. Am J Infect Control. 2021;49(2):239-245. PMID: 33023456