Triage

Saturday 2 July 1988.

About 17H20.

I was at work as a Charge Nurse in the Department of Emergency and Ambulatory Paediatrics aka 'Children's Casualty' , (Area 161) in the Johannesburg Hospital .

We were having a very pleasant afternoon...reasonably quiet,a few interesting cases to keep us on our toes but mostly we were relaxed and chatting.

At about 1700 I walked 'next door' to the adult Trauma Unit Area 163 to see if they needed any help.

The emergency area at JH is a single block with all the Units facing onto the ambulance parking area which is adjacent to the emergency helipad. The Children's Casualty area is on the South side of the block;then the Trauma Unit;then the Medical Emergency Unit (Area 165);finally the Labour Ward (Area 166) on the North side of the block.

It was the middle of winter...and as I walked past the admitting desks (Area 162) I glanced outside and the sky was already dark.I was relieved to see only a few ambulances in the parking area.

The RN in charge of 163 that evening was a cheerful and very competent young woman called Gill...who worked part time in the Unit;and who had a horse.

No conversation was complete without talking about the horse!

I asked her if she needed any help and she asked if I could stitch a face as the plastic surgeons were being difficult.

At about 17H45 we were standing chatting behind the nurses station when the doors burst open and an ambulance crew from the SA Noodhulpliga (a local Afrikaans community version of the Red Cross) came running into the Unit with a man whose legs had been blown off....in a bomb blast at the Ellis Park rugby stadium.

The ANC had detonated a bomb just as the crowds were leaving after a match.

Although we had radio comms with all the local surrounding government ambulance services we didn't have a link to private ambulance services...

And so the first we knew of the bomb blast was the crew pushing through the doors at 163.

It was the fourth bomb in two days in the Johannesburg/Pretoria urban complex;and there had already been about 25 bomb or limpet mine explosions that year which had killed about ten 'black' and four 'white' civilians.

What we did have however was a very well written and frequently implemented disaster plan...actually called "Operation Disaster"...which was initiated (as I recall) by the most senior (full time) person on duty and run by that person and the Head of Department.

I looked at Gill...she looked at me...we decided I would call the emergency since I had long worked in 163 and knew the protocols and that she would go into the Resus Room with the patient since she was the Nurse in Charge.

The doctors then on duty were all SHO's and Registrars doing their training.

I called the Hospital Superintendent and then the HoD, Dr Ken Boffard.

I then called the Duty matrons for Emergency;ICU;operating theater; and for the rest of the hospital.

They in turn had a cascade system calling in their own staff and executing their part of the plan.

Of course,in addition to the formal cascade system,there was a huge informal cascade,where nurses and doctors contacted their colleagues and staff and asked them to come into the hospital.

Fortunately the Emergency Units are in a block on their own and the main staff and public parking is some distance away so there were no problems about getting to work.

My staff in 161 in the meantime were rapidly discharging our patients further into the hospital.

I also called the On-call Pharmacy person...a well known bitter-and-twisted woman who had for many years made the life of Junior Doctors an absolute misery...she rudely asked me on what authority I had dared to disturb her on a Saturday evening.

She was advised to stick her head out of the window and listen to the sirens….that was my authority.

The Labour Ward staff got a little sniffy that we expected them to see non-pregnant-people but we were only sending the walking wounded to them for dressings...and even a midwife can change a dressing.

By 18H00,since so many of the staff lived close to the hospital pretty much anyone who needed to be there, was there by the time the Johannesburg Ambulance service started to bring patients in for triage.

By 18H30 we were very well staffed...staff finding friends and colleagues and quietly and quickly sorting out their roles and equipment.

Although the stadium is only about 5 minutes away in an emergency vehicle from the hospital it had obviously taken the first crews some time to perform a preliminary triage and provide initial care and first aid…also…there were a few car fires that had needed to be extinguished.

By the time the first tranche of patients started to arrive Ken and I were standing outside the doors on the helipad with the "miraculous triage machine"....a battered but sturdy and utilitarian grey metal filing cabinet on wheels,with 4 drawers stuffed with pre-made hospital folders...one for each category of patient...

...Black for those who were dead or who would require too much intervention to be resuscitated...

,,,Red for those requiring immediate resuscitation...

...Green for those needing urgent care...

...Yellow for those requiring a dressing or a broken bone to be set...the walking wounded.This last category also included those who were psychologically shocked.

Most of the ambulances were accompanied by a traffic police car or motorbike...the cadence of their sirens like some Tarantella written by Lucifer...

...and several of them were driven by firemen used to driving big fire appliances,as the paramedics wanted to stay at the scene and continue to provide care to the wounded...

...the ambulances would bounce down the ramp,the red light from their visi-bars bouncing lazily,crazily off of the cold grey concrete...

...they would slow slightly to take the first corner around the helipad, and then start to slow further at the second corner and then shudder to a stop whereupon the doors would be flung open by the staff and the cops.

Ken would look into the back of the ambulance,briefly examine the patient and then call out a colour to me...the patient would then be wheeled into the appropriate area with his paperwork on his chest.

As each patient went through the door they would have different pre-filled resus boxes put on them or on the trolley....IV/fluid sets or airway management sets or dressing sets.

Very quickly we were joined by some senior staff who could take patients directly from us to the Resus Room or directly to theater if necessary;and we were also joined by officers from Johannesburg Ambulance and the Police.

By 19H00 we felt we were on top of the situation and by 19H30 were well into the second and third part of the plan.

By 20H00 relative calm had returned to the Unit...triage had finished as such and my role was then to walk around acting as a facilitator.

Tish Minne, -the Trauma Queen-,was running the Unit and people were starting to scribble notes and tidy up and make plans for follow up treatment.

I remember phoning home to say 'goodnight' to my kids.

At about 20H30 I phoned Charles Tobias who was a member of the Jewish "Helping Hand",a voluntary/charity organisation who did hospitals visits...I asked him to come in and pass out some chocolate.

I remember that he used to drive a green Mercedes and that night his was the only private car allowed to enter the ambulance zone...he always gave the security guards a box of chocolates when he came in on a Sunday to do his rounds...that night was no exception!

Very soon he found me in the middle of a group of patients, and we walked around the various Units giving everyone we saw a bar of chocolate with Charles also solicitously holding their hands and patting them on the arm.

At about 22H00 we were all done and I remember standing outside in the cold drinking some crap coffee,watching Lawrence Katz from Jo'burg Ambulance field questions from the worlds assorted media.

And then the Night Staff had to tidy up and re-stock and deal with the usual Saturday night "Ma slaan vir Pa" ...(drunk mum hits drunk dad).

And three weeks later we did it all again when a bomb went off at a Wimpy fast food outlet...we were not the initial receiving hospital that day but I flew to fetch two children who were critical.

Man...its no wonder I'm so fat the amount of chocolate I've eaten.