Using MACSIM for education and training in traumatology and major incident response on different levels

MACSIM can be used for education and training in traumatology and major incident response on all levels:

 

• Basic training in traumatology on prehospital and/or hospital level

• Basic training in major incident response on prehospital and/or hospital level

• Advanced training in major incident response on prehospital and/or hospital level

 

Basic training in traumatology

This can be done by using the big patient cards just as a group training where the trainee propose diagnosis and treatment based on the information on the card. The instructor has access to the complete information on final diagnosis, necessary treatments and outcome given for each card. This is valuable both in the prehospital and hospital setting.

 

Basic training in major incident response

This can be done in the same way as above with group training where the trainee also can perform triage using different methods and decide priority based on a given scenario.

 

The cards can also be attached to figurants in a field exercise. They can then replace the old fashioned painting of injuries, which regardless of efforts never can be realistic and actually gives less information than the cards. The figurants can easily learn to act according to the card. This makes possible rapid rotation of trainee during practical exercises so everyone gets the opportunity both to train and be figurant.

 

Advanced training in major incident response

This requires more equipment and more instructors, but can on the other give much more information and learning than a practical field exercise – with less work and for smaller costs.

 

When setting up such an exercise, it is recommended to start with using a complete, standardized course package and run the scenarios included in this package, preferably with the help of instructors trained for the system (a list of trained international instructors can be required from us using the address below). After this, the exercise can easily be adapted to your own organization and your own language.

 

An example of such a complete course-package is the MACSIM start package for terrorist scenarios (MACSTART- T) which has been used for the MRMI-courses (Medical Response to Major Incidents).

 

The MRMI-course is a strictly standardized course under protected name (as the ATLS or MIMMS) and running a course under this name requires permission from the MRMIassociation (www.mrmi.org) and also fulfilling of certain criteria. The MACSTART-T package is a prerequisite for organizing MRMI-courses but can also be used for other forms of training and testing of organizations.

Design of a course for advanced training

An example of how to design a course on this level is described in fig 15. The figure illustrates a course for training of the whole chain of response simultaneously, based on 4 hospitals, the same model as has been used in the MRMI-courses. When application of this model to your local organization, the number of hospitals can be reduced or extended (up to an unlimited amount). It is however recommended not to run this model with less than 3 hospitals as a minimum to train inter-hospital communication.

 

The center of the figure represents the prehospital part the scene which requires a bigger room with space for 8 magnetic whiteboards 200 x 120 cm, minimum 3 of them on wheels and magnetic on both sides. In addition, there should be space for two parallel triage-lines between the "scene" and the transport boards. This room is also illustrated live on figures 17-20 below. The "scene" is illustrated by 3 boards showing the exterior appearance (of for example a building) on the front, and the interior appearance (to which the trainee not have immediate access) on the backsides. Example of transport board for helicopters and ambulances see fig 20 below.

 

On distance from the scene are located the rooms for hospitals (see fig 21 below), one board for a smaller and 2 -3 boards for a bigger hospital. On distance from these are the rooms for hospital command centers (HCC) and also the rooms for the regional coordination (RCC) and ambulance dispatch (ADC) centers, 2-3 boards per room (fig 25). The minimum number of magnetic whiteboards for a set- up of this size is 20, minimum 6 of these mobile on wheels and minimum 3 of these magnetic on both sides. It is a big advantage to have all 20 mobile on wheels since they can then be constantly prepared for use.

 

As in reality, communication from the scene to RMC, ADC and HCG:s requires radio sets, the other communication is by telephone and requires minimum 1-2 telephones in each room.

Fig 15 Fig 15

Design of an advanced course for simultaneous training of the whole chain response (see further the text).

Fig 16 a Fig 16 a

The instructor folder included in the package gives detailed instructions how to prepare the boards and how to prepare the trainee for the exercises and also how to run the exercises. All documents needed are included in the folders described in fig 13.

Fig 16 b Fig 16 b

Running an advanced simulation exercise

The exercise is run with real time without breaks (nutrition of participating staff is done by catering as in reality) and does not stop until all patients are under treatment in hospitals. The type and distribution of injuries is based on real scenarios. It is recommended to use a number of casualties high enough to identify the critical limit for the capacity of the different units.

Fig 17 Fig 17

The first ambulance has arrived on the scene after the alert and the crew takes on tabards for Medical Incident Commander and Triage Officer and follows their action cards for reporting back and organizing the scene (board on the left). Rescue-and police are already on scene. In the background the exterior side of the building where an explosion just have occurred. Sound track with noise gives a realistic touch.

Fig 18 Fig 18

The ambulance crews and prehospital teams have now got access to the inside of the building and started primary triage of casualties using the priority tags. The magnetized orange strips, included in the set, are used to indicate trapped patients, with extrication times given on the strips.

Fig 19 Fig 19

Primary triage= Behind camera. The figure shows the ambulance crews and prehospital teams working with secondary triage in two parallel lines, applying treatment tags on the cards and re-evaluating triage. Since every treatment delays further transfer with real time, and missed treatments may lead to mortality or complications, this is a tough training in decision making on which the trainee get full feedback on evaluation.

 

In the background transport boards (to the left) and board for patients waiting for transport, with new re-evaluation of priority. Instructors carry yellow arm-badges.

Fig 20 Fig 20

Boards for ambulance transport. Every transport takes real time and on calculated arrival, the "patients" are transferred to the decided hospital. One team performs treatment in ambulances, as in reality, and the Ambulance Loading Officer (ALO) and her staff communicates continuously on radio with the RMC and ADC. When an ambulance crew is involved in triage/treatment on scene, the ambulance- symbol is turned upside-down. Waiting times for staffed ambulances is recorded to evaluate the efficiency of the transport. Similar board for helicopters.

Fig 21 Fig 21

A hospital is built up with, from the left to the right: Arrival and primary triage zone, Emergency Department (Blue), Surgery (Red) and ICU (Green). Wards as transparent pouches along bottom-line of the boards.

Fig 22 Fig 22

Severely injured casualties processed through the Major Incident Resuscitation teams. Real times for indicated treatments. No treatment can be done without sufficient staff.

Fig 23 Fig 23

The same with surgery: Real time (depending on which operation the trainee decides to do) and no surgery without sufficient staff. Running out of theatres because of wrong decisions may cause mortality among incoming patients needing immediate surgery.

Fig 24 Fig 24

As in reality, most ventilators are blocked by non-disaster patients already under treatment. Very delicate decisions have to be done with regard which of these that can be earlier transferred back to wards. Access to ventilators is maybe the most critical limiting factor for the surge capacity of a hospital which can be clearly demonstrated in exercises like this.

Fig 25 Fig 25

Hospital command (management) centers are built up on some distance from the working hospital staff which has to report by telephone. The same is valid for the RMC (picture) and ADC. All these centers are equipped with prepared boards to collect all incoming information.

Fig 26 Fig 26

On all patients declared dead, the instructors apply pre-printed post it-labels (included in the sets) with patient number, time and place for death, trapped or not, reason for death, preventable or not, and Injury Severity Score. The labels are collected which gives a result of the response expressed in percent preventable deaths related to trauma-score (ISS).

Evaluation

Liberal time is devoted to evaluation where the trainees are given feedback on all identified mistakes. The experiences show that the trainee, when possible, always should have a chance to have a second exercise in direct connection to the first one to be able to correct mistakes.

Results

Since the system was launched 2009, 8 MRMI courses based on this system have been organized in 5 different countries and with totally 451 participants:

 

Place

Year

Delegates

Local organizer (e-mail)

Pag, Croatia

2009

53

Boris Hreckovski

boris.hereckovski@vip.hr

Split, Croatia

2009

61

Boris Hreckovski

boris.hereckovski@vip.hr

Utrecht, Holland

2010

28

Mike Bemelman

m.bemelman@umcutrecht.nl

Madeira, Portugal

2010

60

Pedro Ramos

pedromcramos@yahoo.com

Milano, Italy

2010

45

Marzia Spessot

spessot.marzia@hsr.it

Roberto Faccincani

faccincani.roberto@hsr.it

Portoroz, Slovenia

2011

60

Radko Komadina

sbcrdi@guest.arnes.si

Slavonski Brod,

Croatia

2011

102

Boris Hreckovski

boris.hereckovski@vip.hr

Milano

2011

42

Marzia Spessot

spessot.marzia@hsr.it

Roberto Faccincani

faccincani.roberto@hsr.it

The courses have been carefully evaluated and the educational model validated by:

• Pre- and post- course surveys where the trainee have marked their perceived capacity for different functions before and after the course

• Pre- and post-course triage tests

 

The results show significant improvements of these criteria supporting the accuracy of the model.

References

Lennquist Montán K, Bemelman M, Dobson B, Boris Hreckovski, Philipp Fischer, Amir Khorram-Manesh, Carl Montan, Per Örtenwall, Sten Lennquist: ESTES postgraduate training in medical response to major incidents (MRMI) - Experiences from the first five courses. Eur J Trauma Emerg Surg 2011;Suppl 1; s52