Medical Emergency Management: A medical emergency is a situation in which, due to an acute illness or injury, there is an immediate risk to a person's life or long-term health. To manage medical emergencies, each location should develop a site-specific medical emergency response plan (MERP), taking into account the potential for individual and multiple casualties, describing the response to various medical emergency scenarios based on the health risk and impact assessments, and utilizing available resources. The MERP should consider specific needs of the work activities and the general situation of the country in which these activities are carried out, as well as any collaboration with local authorities. Resources Required for the Implementation of the MERP: Resources required for the successful implementation of a MERP are discussed below, and include: (a) effective means of communications; (b) first responders and trained competent healthcare professionals, e.g. doctors, nurses, paramedics, emergency medical technicians; (c) adequate means of transportation (ground, water, air); and (d) adequate medical structures (primary, secondary and tertiary health-care units). Effective Means of Communication: Commonality of language is critical to effective emergency response. The ability to transmit and exchange information clearly and efficiently between the field, designated medical facilities and support structures is essential to minimize adverse impact and assure a successful outcome. See: Communication on page 14 for further details. First Responders and Trained Competent Health-Care Professionals: (A) Basic (Level 1) and Advanced (Level 2) First Aid: First aid is the immediate application of first line treatment following an injury or sudden illness, using facilities and materials available at the time, to sustain life, prevent deterioration in an existing condition and promote recovery. The content and duration of training courses and the titles given to trained first-aiders vary widely from country to country and even between training institutes within the same country. Assessment of a first-aider's qualifications will require scrutiny of their training, experience and references. Firstaiders should carry a valid recognized certificate of first-aid training which should at least meet national requirements. There are two levels of first-aiders: basic first-aiders (Level 1 health-care providers) and advanced first aiders (Level 2 health-care providers). Emergency medical technicians (EMTs) used in some countries may come under Level 2. The number of first-aiders and their level of competence will depend on both the size of the workforce exposed and the degree of risk. Thus, a two-man team operating in a remote or dangerous locality may require one member to have basic first-aid capability and the other to have more advanced skills, while a team of 25 operating close to high-quality medical facilities with good means of communication and evacuation may require only one basic first-aider. In addition, certain countries may have national guidelines stipulating the numbers of first-aiders required for given numbers of workers. (B) Level 3 health-care professionals: These are individuals with specialized training in emergency care; they are accredited by various professional organizations around the world, and are usually employed in field operations to manage medical emergencies with remote support from a Level 4 health professional. (C) Level 4 health-care professionals: The designated primary health-care unit (HCU) should be staffed by registered and licenced health professionals. These could be doctors, nurses, physician assistants or other trained personnel with experience in emergency and primary care. They would be expected to provide advanced emergency medical care to resuscitate a patient, and to participate in the MERP in case the patient is to be transferred to the secondary or tertiary HCU. (D) Level 5 health-care professionals: The designated secondary HCU (usually a hospital) and tertiary HCU (usually a critical care centre) would ideally be staffed by medical specialists - medical personnel who have undertaken postgraduate medical training and obtained further medical qualifications, and whose competence has been certified by a diploma granted by an appropriate specialist medical college. They would be expected to assess, diagnose and treat specialized and complex medical conditions. The folloing table provides guidance on response times for provision of basic life support and immediate first aid: (a) Response Time: < 4 minutes; Responder: Level 1 health-care provider; Site of Health Care: Site of the incident. (b) Response Time: < 20 minutes; Responder: Level 2 health-care provider or Level 3 health-care professional; Site of Health Care: Site of the incident (Level 2) or field first-aid station (Level 3). (c) Response Time: < 1 hour; Responder: Level 4 health-care professional; Site of Health Care: Designated primary health-care unit. (d) Response Time: < 6 hours; Responder: Level 5 health-care professional; Site of Health Care: Secondary and tertiary health-care unit. The response time for provision of basic life support and immediate aid should be less than 4 minutes, and for advanced life support (Levels 2 and 3) less than 20 minutes. Access to more advanced level health-care units should be based on the results of the site-specific health risk assessment. Prescriptive timings should be as short as reasonably practicable. See: Table 1 for guidance. Adequate Means of Transportation: Evacuation procedures will need to take into account the available resources, the urgency of the transfer and the medical condition of the casualty. Transportation could be by ground, by water or by air. The casualty escort could be a doctor, nurse or paramedic and in some cases a certified first-aider, dependent upon the severity of the condition. All should be trained and familiar with the equipment that they are expected to use. In certain circumstances, the use of a specialist medical evacuation organization may be desirable. In this case, a contract with the assistance company or specialist transport company must be part of the emergency plan. All components of the medical evacuation process (personnel, vehicles, equipment, training, communications, etc.) should be audited at regular intervals by the company. See the Annexes for further details. Adequate Medical Structures: The medical emergency chain includes primary, secondary and tertiary HCUs: (1) The primary HCU is the local unit covering the entire workforce involved in the operations. It could be the worksite clinic or a designated third-party clinic nearby. Its key functions are: (a) the provision of emergency response and medical care to resuscitate a casualty and (b) participation in the MERP in case the patient is to be transferred to the secondary or tertiary HCU. (2) The secondary HCU is usually a hospital, and is used when the capabilities of the primary HCU are exceeded. Its key functions are: (a) the management of inpatient medical and surgical cases requiring investigation and/or treatment; (b) the emergency resuscitation and stabilization of casualties, in preparation for their referral to a tertiary HCU if necessary; and (c) participation in the MERP in case the casualty is to be transferred to the tertiary HCU. (3) The tertiary HCU shall be able to handle critical conditions that exceed the capabilities of the secondary HCU. Such conditions include, but are not limited to: major trauma; neurosurgery; severe burns; cardiac surgery; high-risk pregnancy; complex tropical diseases; organ failure and transplant; oncology; and major psychoses. This advanced tertiary HCU may not be available in some countries, in which case it is desirable to identify such a facility in another country or in the country of origin of the casualty. Medical Emergency Response Plan (MERP): The medical emergency response plan should: (a) be risk and scenario based (e.g. pandemic, food-borne illness outbreak, infectious diseases such as varicella and influenza-like illnesses), and should include mass casualty planning; (b) identify the designated health/medical provider(s) involved in the plan, together with their capabilities and limitations (these providers could be under the direct control of the company or a third party; if the latter, a formal agreement on the level of medical support should be made); (c) determine the likely evacuation route(s) and means of transport from the incident location to the place(s) of medical care - particular attention is required regarding transportation limitations (e.g. distances, mode of transport, weather limitations, etc.) and consideration should be given to requirements for local authority/government authorization prior to evacuation out of the country; (d) include contact details for key personnel; and (e) include contact information for all individuals who are covered by the MERP - such persons should be advised that they must have a valid passport and appropriate visa in case evacuation out of the country is required. Effectiveness of a MERP: To be effective, the MERP should be: (a) developed systematically before the start of any activity; (b) communicated effectively and well understood; (c) designed so that important actions are taken in parallel (different actions should be taken at the same time) and not in series (actions should not be taken one after the other); (d) integrated into the company's more general emergency response plans; (e) under the responsibility of line management; (f) organized in collaboration with both company and client health-care professionals where subcontractors are involved; and (g) tested and reviewed regularly through structured drills. Drills, Review and Revision: (a) Drills: Once the MERP has been developed it should be practised regularly and should include testing of all logistical support required, e.g. communications, transport. The results of drills should be reviewed and the plan revised if necessary. The extent of resource deployment during drills should be predetermined by management and company-designated health-care professionals. This should include scenario planning, as well as simulated events addressing triage for multiple cases, followed by a thorough debriefing. (b) Review following medical emergency: A debriefing should be conducted after each use of the MERP so that the company can make improvements if necessary. (c) Regular revision: The MERP should be audited and revised if necessary, at least annually and following any significant change in circumstances, e.g. type of operation, location or health-care resources. (d) Contractors: Where suitable, contractor companies should develop their own MERP, compatible with that of the client company. Alternatively, the company may include contractors in its own MERP but this must be formally established prior to the start of operations.