Frontline care in the face of fire

As a rural GP, I honestly hadn’t given much thought to disaster planning. In the rural town where I grew up, I subconsciously believed geographical isolation offered some kind of buffer. I knew our clinic had talked about disaster planning during the accreditation process, but I remember discussing a mass casualty at the airport as an example, rather than a bushfire.

Throughout the festive season, the far south coast was surrounded by bushfires. We had been consulting as normal, while watching the increasing smoke outside and becoming aware of the encroaching fires. We were lucky we had 48-72 hours to prepare – a window of time when the most critical planning decisions were made.

I intended to offer my services at the rural emergency department, thinking they would be overwhelmed with burns and respiratory distress. But most people chose to present to evacuation centres where the most common presentations were anxiety, respiratory distress, and corneal foreign bodies.

I attended the ED on Friday night to find it empty and overstaffed, so I left with some hospital supplies to lend a hand in the evacuation centres that were opening closer to home. By 8pm, two private general practices were setting up a makeshift medical room in the town’s main evacuation centre located at the Bowling Club. The numbers quickly swelled to 800 after mass evacuation orders were given. 

GPs are well positioned to mobilise people. On Saturday, we created a WhatsApp group for local medical professional volunteers. Over the next 24 hours, the Bowling Club reached maximum capacity, spilling over to the RSL Club and the Golf Club before reaching numbers of 1,400+ local residents.

We centralised our limited resources at one venue, the Bowling Club, which proved to be an excellent decision. We arranged a basic triage through a nurse stationed at peripheral evacuation sites and organised the ‘Club Courtesy Bus’ to drop unwell patients from the peripheral centres to the Bowling Club.

Due to the extreme nature of the fire, with roads and airways cut off, we had to manage countless patients over three days. Other local sites used a model of St Johns Ambulance acting as triage or patients being directed to a local GP clinic, but these weren’t available to us. Fortunately, NSW Ambulance was able to offer a partial service, with our local district hospital 35km away.

My reflections from this experience

What we did well

• Used a range of health professionals and drew on their specialist knowledge
• Wore a badge to identify ourselves 
• Nominated a clear leader of the group and played to the individual strengths of the medical professionals available
• Gathered stock from wherever we could – including our homes, private pharmacies, private general practices and the local district hospital – and photographed all stock with the contributor so it could be returned after the event
• Set out clinical space appropriately, including clear a space to perform CPR when necessary
• Set up a screen to offer some privacy when dealing with very personal problems in the public space
• Encouraged people with known medical morbidities to sleep or stay near the medical area for easier monitoring
• Used a mobile communication aid (e.g. WhatsApp) to manage short, rostered shifts to facilitate adequate breaks and reduce fatigue
• Ensured appropriate storage and documentation of S4 medications

What we found challenging

• The lack of a practical local disaster plan
• Establishing a chain of command during chaos and rapidly changing conditions 
• Documentation and storage of notes – working out how to meet clinical obligations in strange and unfamiliar territory 
• Anxiety about whether we were indemnified for volunteering in a crisis
  - MDOs are usually prepared for these questions, so make contact if you’re concerned
• Transitioning back to general practice
  -  As Monday arrived, we put up signs at the evacuation centre directing to the two general practice clinics for better triage, documentation and treatment
• Distress among colleagues
  - A natural disaster is a time to be tolerant and supportive of one another. Encourage debriefing and monitor your colleagues after the event
• Managing difficult patients
  - People will be extremely distressed so you must prioritise your personal safety. Keep a register of difficult patients for handover to the next shift. Ask for police presence, as this can help keep everyone calm

“If there’s one thing I learnt during this experience, it’s to offer what you can. You might surprise yourself and be amazed at just how much a team of likeminded professionals can achieve when they work together.”