Introduction to major incident:
The world is moving at a fast pace and the introduction of various methods and techniques to enhance an individual’s wellbeing has always been an important aspect of medical advancement (REF). This assignment discusses the “Big Bang” incident which causes catastrophe and results in creating a crisis-like situation. The incident that took place on M5 Motorway jolted viewers and rescue teams to cope with a situation that not only created footage but also affected the environmental traffic safety control. This incident had an adverse impact on the surrounding area which claimed over seven lives and more than 50 people injured. The fire that broke out due to this incident created havoc and resulted in an alarming situation. The individuals were stuck within their cars and it was very difficult for rescue fire-fighters to handle the crisis. The adverse weather conditions also played a vital role in affecting the environment thus creating more issues for the rescue effort that lead to number of casualties and severe injuries too many. This indicated the pathway of the events followed by series of incidents that can be caused due to any such event and what impacts it holds in making a traumatic situation for the severely injured patient (SIP) (Royal College of Radiologists (RCR), 2015). The duty of a trained and skilled triage clinician is to handle patients arriving in the emergency department as it helps in assessing the situation timely and providing the individuals with desired treatment to cope with this issue. Various injuries are identified such as fractures, bleeding, vessel rupture etc. which provides a base to understand and appraise the role of a radiologist and his department in providing accurate assessment about the condition of the patient, which cannot be analysed without reviewing the role of radiology department as they contribute in providing the level of treatment needed. The team work and its implementation within the hospital environment not only helps in diagnosing any information through friends and their experience followed by the sharing of information. Therefore, multi-disciplinary trauma teams ensure that the team members are effectively playing their part in patient’s well-being and success. The emphasis on the implementation of Standard Operating Procedure (SOP) and code of conduct is required to be evaluated. The importance of pathophysiology of various parts of the body including spine, head etc. are paramount (RCR, 2015).
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According to Yehuda, (2002), Major Trauma is considered as a situation where the individual may acquire injuries that take a longer time to recover and there is increased possibility of permanent disability. This situation may occur due to any major accident, including severe sports injury, which may be fatal. This trauma which is critical is a major cause of death for people aged 45 or more and results in long term injuries which are critical for the survival of such individuals (Yehuda, 2002).
According to the Department of Health Emergency Preparedness Division (EPD) (2013), there are commonly used classifications of types of incidents, such as business continuity, breakdown of utilities, fire, significant equipment failure, infection, violent crime, a hospital needs to be prepared for. “Rising Tide” may lead to an infectious disease epidemic, a capacity/staffing disaster or manufacturing malfunction. “Cloud on the horizon” is a serious threat such as significant chemical or nuclear release developing elsewhere and needing preparatory action. “Headline News” is defined as public or media alarm about an impending situation, potentially causing loss of confidence in management’s response to the situation. When an incident involves explosives, chemical, biological, radiological, nuclear and explosives (CBRNE), such terrorism is the actual dispersal of CBRNE material with deliberate intentions to cause crime, malicious or murderous intent. “Hazardous material” (HAZMAT) is an accidental incident involving hazardous material, (NHS England, 2018). “Cyber-attack” on systems may cause interruption and reputational and financial damages, attacks may be to organisational structure and facilitation or data confidentiality (EPRR, 2013).
Trauma centres are a major source of assistance provided to a SIP. These centres provide emergency medical services throughout the day. The level of injury is assessed and first aid is provided and patients suffering from major injury are referred to specialist medical units. The medical trauma centres having higher expertise are considered to be at par with state of the art hospitals where their aim is to treat patients with major injuries. The role of triage clinicians is important as they play a vital role in making sure that the patient gets the most appropriate treatment pathway (RCR, 2015).
Pathophysiology of injuries in road traffic collisions (RTC)
According to Kinoshita and Kosaku, (2016), the casualties can get blunt force trauma from impact with steering wheels and against seatbelts, as well as from shear forces from acceleration and deceleration which can cause injury to the abdominal, thoracic, and pelvic organs which may affect respiratory and cardiovascular function. Pain, dyspnoea, and hypoxia can occur from ‘flail chest’, pneumothorax, haemothorax, pulmonary contusion, and diaphragm rupture. Haemorrhage and hypovolaemia can be caused by blunt traumatic aortic injury, organ, renal, and pelvic injuries which can lead to a cause of preventable death in major trauma so require urgent treatment. Pelvic injuries are potentially life threatening because they are associated with internal bleeding of major blood vessels and caused by extreme forces to the pelvis. Tachycardia, hypotension, and confusion from cerebral hypoxia can be caused by inadequate tissue perfusion. Serious traumatic brain injuries (TBI) can be a cause of death and major illness and can be focal or diffuse. The focal injuries can be in direct (coup) impact or contrecoup (contralateral) which include extradural haematoma, with skull fracture usually present. It also includes subarachnoid haemorrhage, cortical contusions, and intracerebral haematomas from blood vessel rupture. Diffuse axonal injuries (DAI) are best detected through MR imaging and can be caused by rapid acceleration/ deceleration which can be characterised by multiple small lesions at grey – white matter junctions (Knipe and Gaillard, 2018). TBI is best diagnosed by using the quicker modality of CT head scans as any acute haemorrhage is clearly detected by adjusting window levels or the scan such as bones, soft tissues and blood levels.
CT is recommended for SIPs with multiple injuries for a quicker diagnosis despite the higher levels of ionising radiation, and as such, these requests always need to be justified a radiologist (RCR, 2015). Whole body CT (WBCT) is used in assessing the extend of multiple injuries, particularly when the SIP is unable to confirm this, but is clinically evident they require an emergency surgery (RCR, 2015). MR plays a role in secondary imaging specially for diagnosing the extend of spinal injuries. Cervical spine injuries are caused by severe extension and flexion, or axial forced to the head which can disrupt C1 and C2. Lumbar spine injuries include disc herniation or cord compression which can lead to paralysis if not treated. Thoracic spine can have wedge fractures due to extreme flexion shown on X-ray as having an “empty box” appearance (NICE, 2016).
The role of triage prior to the patient attending the A&E department
According to Sandoval and Diane, (2016), the emergency department is one of the most critical department that requires the full attention of the staff working within the hospital and aims at saving the lives through effective decision making and intervention from experienced personnel. Triage is a process to understand what measures are required to be taken in order to increase safety and well-being of the patient. It is a system that is used mainly in emergency departments where the emphasis is to give first aid and save lives. Triage is not a diagnostic tool but a systematically structured and methodical way of assessing the severity of patients’ conditions to determine their clinical priorities using their presenting symptoms and vital signs such as oxygen saturation or blood pressure, and it aims to optimize the provision of emergency care efficiently to produce the best outcome for every patient by identifying and ranking patients in the need of rapid intervention and/or removal (Leite et al., 2015).
The factors that are considered are severity of illness, level of urgency and impact of life saving Intervention to reduce mortality, as well as level of care needed bearing in mind limited resources. These factors can be measured objectively using mortality rate, number of admissions to critical care unit and wards as well as patients referred to low urgency care services (England.nhs.uk, 2019). There are two different types of triage: sieve and sort. Sieve is the primary method to prioritize patients with 4 levels of categorisation and is carried out at the scene of the incident which is usually done by two practitioners, involving little or no medical intervention (Leite et al, 2015). As mentioned by Pereira et al., (2018), at this stage the emergency staff will use NASMED triage sieve and SMART triage pack to label and colour code patients. However, the SMART triage system for paediatrics should be used as the respiratory and cardiac rates of children are different to adults and this tool will prevent over- ranking. Additionally, P1 and P2 are patients with very severe injuries so they should be moved to casualty clearing stations (CCS) as they need immediate and urgent medical intervention with maximum waiting time MWT of 10 minutes of treatments. P3 are lower-priority patients with minor or moderate injuries and depending on their injuries they are either moved to CCS or place of safety for more evaluations. Unharmed patients are transferred to survivor reception centre where the police identify them. Finally, P4 characterises dead patients and they are kept and labelled for ID by a family member and for investigations (appendix 1). Labels are colour-coded: red, yellow, and green for P1, P2 and P3 respectively, and black for P4 (NICE, 2016).
Role of Radiographer within Major trauma incident:
According to Brealey et al., (2005), radiographers play a vital role in ensuring that the SIP can be diagnosed with X-rays and other imaging such as Computed Tomography (CT) Scan, Magnetic Resonance Imaging (MRI) or Focussed Assessment with Sonography in Trauma (FAST) Ultrasound for timely diagnosis of the severity of the injuries. When the hospital is notified about a major incident, the switchboard will contact a number of key individuals who have the authority to activate the major incident plan, with the advice of senior doctors and the emergency services. When the plan is activated, the switchboard will contact the relevant departments and notify them of the major incident to be on standby. In the radiology department the role of the radiographer is immense as they perform a number of tasks when involved in an emergency situation. He or She can be involved in providing medicine, providing first aid, taking diagnostic radiology-related imaging, providing desired findings and information about the patient and their injuries. They are expected to act fast and consistent as emergency situations cannot afford any mis-diagnosis. They are required to act quickly according to the situation and may be asked for their opinion for further treatment and consultation. A major part of the treatment within the emergency department is reliant on the Radiographer as they are the ones who clearly help in producing diagnostic imaging (Forsyth et al., (2007). They are equipped with skills to tackle diverse situations where they produce diagnostic images in a busy and pressurised environment, including within an operating theatre.
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According to RCR (2015), the responsibility of the Radiographer is always to consistently produce diagnostic images and must respond by assessing the situation independently and must lead from the front aiming at delivering the best care during the patient pathway. They are required to act calm and must not lose their concentration as one bad decision can cause harm to the SIP. They must ensure that all the radiology equipment has passed quality control testing and is in good working condition so that every medical situation must be dealt with priority with aim to save a valuable life (Hardy et al., (2006).
The Role of Radiology Department major trauma:
According to Wintermar et al., (2002), the diagnostic tests need to be quick and precise and radiographers undertaking this work not just have profoundly expert skills in imaging modalities yet are knowledgeable about the consideration and systems required for filtering intensely sick patients who require earnest evaluation during a critical period of the care pathway. Radiographers’ commitment to detailing within the emergency services is as of now broad and considers quick or entire day reporting. This commitment can conceivably be broadened fundamentally as more radiographers experience expert preparing in reporting skills. CT in major trauma plays a fundamental job in the quick finding of real injury cases, and an entire body CT protocol has risen as the best quality level in the UK for major trauma, in this manner sparing lives after a major incident occurrence. CT is the examination of decision for imaging head injury because of its capability to show bony injuries and bleeding. It is widely accessible and takes into consideration simplicity of checking the patient during examining. Postgraduate courses in understanding of head CT pictures have existed for certain years, and this is reflected as best practice for radiographers in many imaging department (Kawashima et al., 2001).
According to Wisner, (2016), a patient experiencing a blunt chest trauma, CT can quickly exhibit aortic injury, bone fractures and diaphragmatic tears, it is additionally magnificent for portraying spinal fractures and abdominal trauma, for example, burst spleen. In major trauma MRI isn’t utilized as much in the underlying evaluation since it isn’t as broadly accessible, has longer scan times and is more costly than different modalities, (NICE, 2016). Different obstructions to its utilization incorporate the need to screen patients (to prohibit any MRI mismatched devices, for example, pacemakers), and the need to guarantee similarity of observing and anaesthetic equipment with the high magnetic field strengths. Nevertheless, MRI has a significant job in head trauma, following beginning imaging for further arrangement of injury and for forward patient administration. For abdomen trauma, MRI is helpful after starting evaluation from CT for cutting-edge cross sectional imaging with expanded affectability in showing abdominal fluids gatherings, for example, haematomas. MRI does not include the patient receiving a radiation dose and in this way where repeated imaging is required after trauma (Shyu et al., (2017).
As mentioned by Erwood et al., (2016), following spinal Trauma, MRI is valuable to assess soft tissue structures encompassing the spine to distinguish, for instance, ligaments damage and to evaluate the spinal cord. The trauma radiograph reporting is installed in the expert field of diagnostic radiography in the UK and is proceeding to grow and progress. The specifying of trauma radiographs is embedded in the professional field of diagnostic radiography in the UK and is continuing to progress. Clearly radiographers’ responsibility and commitment to trauma reporting can be widened on a very basic level. This acknowledge progressively noticeable noteworthiness with the change to 24-hour imaging managements and the extended attraction for the ‘hot’ report, issued by the fully approved, trained and authorised practitioner, as per the requirements of good clinical practice and governance.
According to Armstrong et al., (2018), the value of ultrasound in evaluation of the trauma patient has been acknowledged for more than two decades, and many consider FAST standard of care. Incorporation of FAST into clinical practice ought to be basic given that it is quick, moderately painless, and maintains a strategic distance from the potential harm from ionizing radiation (Berger et al 2016). Follow-up assessment utilising other imaging modalities, for example CT and/or serial abdominal tests can be utilised to decide a provider’s accuracy and moderate the potential effect of a false-positive or false-negative FAST.
- Armstrong, L. B., Mooney, D. P., Paltiel, H., Barnewolt, C., Dionigi, B., Arbuthnot, M., & Zalieckas, J. M. (2018). Contrast enhanced ultrasound for the evaluation of blunt pediatric abdominal trauma. Journal of pediatric surgery, 53(3), 548-552.
- Berger, F., Korner, M., Bernstein, M,. Sodickson, A., Beenen, L., Mclaughlin, P., Kool, D. & Bilow, R. (2016). Emergency imaging after a mass casualty incident: role of the radiology department during training for and activation of a disaster management plan. The British journal of radiology. DOI:10.1259/bjr.20150984
- Brealey, S., Scally, A., Hahn, S., Thomas, N., Godfrey, C., & Coomarasamy, A. (2005). Accuracy of radiographer plain radiograph reporting in clinical practice: a meta-analysis. Clinical radiology, 60(2), 232-241.
- Forsyth, L. J., & Robertson, E. M. (2007). Radiologist perceptions of radiographer role development in Scotland. Radiography, 13(1), 51-55.
- Kinoshita, K. (2016). Traumatic brain injury: pathophysiology for neurocritical care. Journal of intensive care, 4(1), 29.
- Knipe, H., & Gaillard, F. (2018). Diffuse axonal injury. Radiopaedia. Last accessed 1 August, 2019 from https://radiopaedia.org/articles/diffuse-axonal-injury?lang=gb
- Leite, L., Baptista, R., Leitão, J., Cochicho, J., Breda, F., Elvas, L., … & Costa, J. N. (2015). Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score. BMC cardiovascular disorders, 15(1), 48.
- National Institute for health and care Excellence (2016). Major Trauma assessment and initial management. Last accessed 1 August 2019. https://www.nice.org.uk/guidance/ng39/chapter/recommendations
- NICE: a Resource impact report: Trauma guidelines (NG37—41)assessment and initial management. NICE guideline [NG41] 2016. Available from https://www.nice.org.uk/guidance/ng41.
- NICE guideline. (2016). Major trauma: service delivery | Guidance and guidelines | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng40. Last accessed: 01/08/2019
- NICE. Head injury: assessment and early management: NICE guideline [CG176] (updated 2017). 2014. Available from https://www.nice.org.uk/guidance/cg176 . Last accessed: 01/08/2019.
- NICE. Spinal injury: assessment and initial management. NICE guideline [NG41] 2016. Available from https://www.nice.org.uk/guidance/ng41 . Last accessed: 01/08/2019
- Pereira, J., Greene, K., Sullivan, L., Zinkie, S. M., Rutkowski, N., Lawlor, P., & Grassau, P. (2018). A Technology-Enabled Solution to Manage Referrals to Hospice and Palliative Care Beds: The Ottawa SMART System as a Case Study. Healthcare quarterly (Toronto, Ont.), 20(4), 63-67.
- Richards, J. and McGahan, J. (2017). Focused Assessment with Sonography in Trauma (FAST) in 2017: What Radiologists Can Learn. Radiology, 283(1), pp.30-48.
- Royal college of Radiologists. (2015) Standards of practice and guidance for trauma radiology in severely injured patients (2nd ed.) . Last accessed from 1 August. https://www.rcr.ac.uk/publication/standards-practice-and-guidance-trauma-radiology-severely-injured-patients-second
- Sandoval, D. (2016). Implementing Change to Decrease the Emergency Department Visits for Pediatric Clients Referred to Mental Health Services.
- Shyu, J. Y., Askari, R., & Khurana, B. (2017). R-SCAN: whole-body blunt trauma CT imaging. Journal of the American College of Radiology, 14(4), 531-533.
- Wintermark, M., Poletti, P. A., Becker, C. D., & Schnyder, P. (2002). Traumatic injuries: organization and ergonomics of imaging in the emergency environment. European radiology, 12(5), 959-968.
- Wisner, D. (2016). Blunt thoracic aortic injury. In Trauma, Critical Care and Surgical Emergencies (pp. 100-109). CRC Press.
- Yehuda, R. (2002). Post-traumatic stress disorder. New England journal of medicine, 346(2), 108-114.
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