An Australian mass casualty incident system for the future based on mistakes of the past: The Homebush Triage Standard

Introduction injuries into slight, serious and fatal and The combined effects of an aging popu- by Dr Antony Nocera, FACEM & Dr Alan described a system of treatment priority lation, the trend towards day and mini- directed towards the control of life Garner, FACEM, NRMA CareFlight mally invasive , plus the increasing threatening hemorrhage, ‘To a serious cost pressures upon hospitals have Westmead New South Wales bleeding everything must of necessity at significant implications upon the avai- once give way, and the vessel be secured’ lability of health resources during a mass Dr Wilson advocated the treatment of casualty incident (MCI) There are no those with fatal injuries be restricted to ‘a the end of battle The wounded were then universal definitions of what constitutes stimulus, an opiate, a proper easy position’ evacuated and treated according to rank either a disaster or a MCI within Australia (Wilson 1846) including the removal of dead nobles A ‘disaster’ is said to have occurred when In the Second World War the procedure taking priority over wounded common normal community and organisational of patient triage was regarded as the biggest soldiers (Hamby 1967) arrangements are overwhelmed by an single factor contributing to survival Dominique Jean Larrey, Surgeon Gene- event and extraordinary responses need following abdominal wounds in the US ral to ’s Army of the Rhine, to be instituted (Emergency Management Army (Welch 1947) In the Korean War the introduced a major revolution in combat Australia 1995) application of a four tiered triage system, casualty care When available medical resources are (immediate, delayed, minimal and expec- Larrey’s philosophy was to rescue overwhelmed by casualties, transport and tant) lead to a striking improvement in casualties during battle, with a dedicated treatment priorities need to be assigned casualty survival (Hughes 1976) The corps using purpose built wagons, the to individuals to ensure limited medical combination of triage, advanced resus- ambulance volantes, and rapidly trans- resources are used efficiently The term citation and rapid helicopter evacuation port them to a central collection point triage was transposed from French into of casualties in the Vietnam War contri- Here the most seriously wounded would the English language during the First buted to reducing mortality rates down to be operated on, without regard to rank World War to describe the process of 1%, compared to the 4 7% observed during or distinction, by either the Surgeon-in- sorting casualties for treatment priority World War Two (Kennedy et al 1996) Chief or a competent surgeon under his by the American Army Medical Corps direction (Richardson 1974) In 1792 Goals of MCI triage (Rutherford 1989) Casualty triage is the Larrey personally lead his ambulance The primary objective of military triage most important medical function during volantes to treat wounded French soldiers was to identify those wounded soldiers a mass casualty incident (MCI) and in the field and transport them from the who could be treated rapidly and retur- accurate triage a major determinant of front line during the battle against the ned to the battlefield (Kennedy et al 1996) an individual’s survival (Rutherford 1989; Austrian Army near Königsberg (Leroy- In civilian practice, the triage process Waeckerle 1991; Fryberg et al 1988) Dupré 1862) attempts to achieve the greatest good for This study reviews the evolution of In 1807 at the against the the greatest number of patients (Emer- triage, and factors that can potentially Russian Army, Baron Larrey, now gency Management Australia 1995; Ruth- interfere with the triage process and Surgeon-in-Chief to Napoleon’s Grand erford 1989; Waeckerle 1991; Fryberg et al compromise the medical response to an Army, gave treatment based on medical 1988; Burkle 1984) Traditional individual MCI These are then used to synthesize a need but with priority to the wounded of doctor-patient relationships are over- triage system to provide a common Napoleon’s Imperial Guard over other ridden by a collective medical respon- platform so that patient priorities at the wounded French soldiers (Dible 1970) In sibility to the group of casualties (Wae- incident site can be interfaced with those spite of Larrey’s pioneering example, ckerle 1991; Burkle 1984; Llewellyn 1992) arising within receiving hospitals during the American Civil War in 1862, In general there is no role for cardio- Historical perspectives MCI triage three thousand wounded Union soldiers pulmonary resuscitation during an MCI The advent of gunpowder and the were left virtually unattended and un- (Emergency Management Australia 1995) development of the rifle forced infantry treated for three days after the second except in cases of lightening strikes into linear battle formations As battle- battle of Bull Run (Adams 1952) involving multiple individuals Here fields became larger it became increa- In 1846 British Naval surgeon Dr John medical efforts should be directed at those singly more difficult to locate wounded Wilson described the principles of MCI victims in cardio-respiratory arrest, since soldiers who were left where they fell until triage Dr Wilson classified combat the majority of other victims will make a

Winter 2000 41 good recovery (Myers et al 1977) Normal triage priorities may be reversed for Injury High evacuation and Low evacuation and casualties involved in highly toxic hazar- treatment priority treatment priority dous material exposures where decon- Penetrating abdominal Individuals who can access Survival after 12 hours tamination and treatment priority should wounds definitive surgical treatment without operative care be directed at the uninjured and even within 6 hours of injury asymptomatic patients (Kirk et al 1994) The success of the triage process as a Major vascular injury Individuals who can achieve If vessel reconstruction cannot in an extremity vessel reconstruction within be achieved within 10 hours means of minimising preventable deaths 10 hours of injury direct ligation of the vessel will during an MCI depends upon being able result in limb loss in 50% of cases# to rapidly identify those casualties at the extremes of care Medical resources are Penetrating head injuries Unstable patients with Individuals who are stable, conscious diverted from those who will either die, evolving neurological signs with either no deficit or moderate paresis or hemianopia can survive for or recover irrespective of the medical care 36 hours without neurosurgical care they receive, and concentrated on those with appropriate fluids, wound care critically ill casualties with a reasonable and antibiotics probability of survival (Emergency Management Australia 1995, Waeckerle Table 1: triage considerations for single practitioners in isolated locations 1991, Kennedy et al 1996, Burkle 1984) Problems with MCI Triage warning before an emergency medical systems (Burkle 1984; Coupland et al 1992; During an MCI, triage is approximately system (EMS) response has been initiated Caro et al 1973; Hodgetts et al 1995; Lumley 70% accurate (Burkle 1984) with a (Caro et al 1973) In addition, large et al 1996; Mac Mahon 1985; Miller 1971; tendency to under estimate injury severity numbers of casualties may be transported Baskett et al 1988) along with differing This underscores the need for triage to directly to the hospital from the incident triage tag designs to document casualty be viewed as a process of repeated scene by EMS (Anderson et al 1977) or triage status (Coupland et al1992; Finch casualty reassessments until the patient they may simply overwhelm established et al 1982; Hodgetts et al 1995; Lumley et al receives definitive care The difficulties EMS field triage & treatment posts, and 1996; MacHahon 1985; Baskett et al 1988) in making rapid value judgements based then move en masse to the nearest have been developed The crash of a upon relative percentage survival proba- hospital (Maningas et al 1997) Boeing 737-400 in 1989 at Kegworth in bilities (Kennedy et al 1996; Hughes 1976; The hospital triage process has to be the United Kingdom occurred on the Wardrope et al 1991) adds to the emotional fluid as well as continuous and capable of boundary of three different counties stress upon the individual attempting to dealing with incidents where the major whose respective ambulance services perform casualty screening assessments casualties are medical rather than surgical used different systems of MCI triage This in a hostile environment during an MCI (Myers et al 1977; Wardrope et al 1991; incident highlights the avoidable con- (Spengler 1995) Buerk et al 1982) During an MCI hospitals fusion that can arise when responding Triage accuracy is also adversely have to integrate casualty triage with the personnel attempt to use different triage affected by other factors including, the triage of normal daily emergency presen- systems and triage tags during an incident physiological ability of the young to tations (De Lorenzo et al 1996) In (Barton et al 1991; Malone 1990) compensate for hypovolaemia, altered addition, there may be an increase in Experience has shown that the key perceptions of pain in high stress situa- normal daily emergency presentations operational principle for an efficient tions (Beecher 1946) and neuropsychia- from ischaemic heart disease or exacer- disaster response is to ensure staff work tric reactions amongst surviving casual- bation’s of airways disease in response to as near as practical to their normal daily ties (Burkle 1996) the occurrence of an incident ( Duclos et routines (Pepe et al 1991; Rutherford 1973; al 1990; Leor et al 1996) Vayer et al 1986) Planning must be based MCI Triage considerations for Special triage situations can arise when upon what people are likely to do in the single practitioners in isolated hospital resources are either damaged stress of an MCI and procedures should locations (Schultz et al 1996) or have to be aban- be kept simple and practical (Burkle 1984; The limited resources and long trans- doned (De Lorenzo et al 1996, Smith et al Mitchell 1986) Accordingly, a triage system portation times dramatically reduce the 1996) during an incident Staffing shortages must have simple structure and be based threshold of what constitutes an MCI in can suddenly arise as health care workers on normal daily operating procedures isolated locations and creates unique spontaneously evacuate their families in that can also be applied during an MCI ethical and practical difficulties in anticipation of a hazard (Smith et al 1981) The Homebush triage taxonomy managing incidents Collective experience or cannot reach hospitals due to disrup- There are clear benefits from the stan- from the Korean and Vietnam wars tion of transport links Hospital triage dardisation of disaster responses within provides some triage guidance in delayed decisions may also have to take into Australia (Senate Standing Committee on management of penetrating trauma account those outpatients normally Industry, Science, Technology, Transport, (Moyasenko 1984; Coupland et al 1992) dependent on domicillary medical ser- Communications and Infrastructure vices who may have to be admitted should MCI triage considerations for 1994) A national MCI triage system will an incident temporarily prevent these hospitals mean, in the event of an MCI, both services from being delivered Hospitals must have triage systems to cope with potential incidents in close Operational difficulties with Note proximity to their facility where a large MCI triage 1 Standards Australia AS-2700 1996 Colour Standard number of casualties can present without Over the years a variety of different triage for General Purposes

42 Australian Journal of Emergency Management hospitals and ambulance services are already using familiar common termi- Classification Priority Priority code Colour Colour number1 nology which will allow effective and efficient communications under stressful Immediate Top A (Alpha) Red R 22 (Homebush Red) circumstances A triage system must rapidly screen Urgent High B (Bravo) Yellow Y 26 both children as well as adults (Kennedy (Homebush Gold) et al 1996; Klein et al 1991), be cost NOT Urgent Low C (Charlie) Green G 27 effective, and operable in adverse condi- (Homebush Green) tions if they are going to be relevant to Dying Terminal Care only D (Delta) White N 14 single practitioners in isolated areas The dead and human body parts should be Dead Not Applicable E (Echo) Black N 61 clearly and individually labeled as soon as possible to avoid time being wasted Table 2: The Homebush triage taxonomy reconfirming death (Rutherford 1989; Burkle 1984) and to prevent the dead being transported to an active treatment system reduces the problems that military directions for those patients assessed as area (Faxon 1948) personnel would also face trying to being beyond help either at the incident A simple triage taxonomy with four interface with different civilian medical site (Fryberg 1988), the casualty collection active treatment levels has been previously services especially with a large number point or emergency department (Ruther- used in MCI situations (Hughes 1976; of medical evacuations across State ford 1989; Williams et al 1974; Sharpe 1985; Ammons et al 1988; Gans et al 1996; borders, where different systems of MCI Artuson 1981; Das 1983; Seletz 1990) or Williams et al 1974) Increasing the number triage are used on the operating table (Burkle et al 1994) of categories has not improved the system The use of phonetic triage priority The introduction of this classification (Gans et al 1996) The Homebush triage codes instead of numerical codes takes into daily emergency department opera- taxonomy (table 2) uses these triage into account the problems with radio tions identifies those patients with priorities as a common core for both voice transmission Numbers are reserved advance medical treatment directives and prehospital and hospital emergency to either stratify patient priorities within directs appropriate care to patients with department operations Simple mechani- a particular triage category, or to quantify terminal chronic illnesses sms can expand the four core active the number of casualties within a parti- treatment groups if required for emer- cular triage category Homebush Triage methodology gency department quality assurance In an overwhelming situation there will The Simple Triage and Rapid Treatment purposes be patients for whom the difficult deci- (START) and Secondary Assessment of Using standard colors1 means there will sion not to treat must be made (Parke et Victim Endpoint (SAVE) (Benson et al be consistent production standards for al 1992) However the decision on what 1996) attempt to apply the principles of triage materials Providing a common constitutes a non-survivable injury is a evidence based medicine to disaster triage language for all healthcare respon- balance between the magnitude of the triage START triage has been used ders eliminates potential communication incident, an individual casualty’s relative successfully at several MCIs within the problems associated with using different probability of survival, and the capacity United States These include the 1995 terminology This will facilitate the of available medical resources at different Oklahoma City Bombing, the 1992 Bom- integration of military medical services points in the casualty evacuation chain bing of the New York World Trade Center, in the event they were deployed to assist (Waeckerle 1991; Llewellyn 1992) Hurricane Andrew, and the 1989 North- the civilian response of a large-scale MCI A specific triage category for dying ridge earthquake (Personal communi- within a State A single common triage patients provides clear management cation Dr Carl Schultz)

The START triage scheme

Walking YES Not urgent Triage Priority Charlie (Homebush Green)

NO Breathing with airway maneuvers NO DEAD# Triage Echo (Black)

YES Obeys command NO Immediate# Triage Priority Alpha (Homebush Red)

YES Radial Pulse present NO Immediate# Triage Priority Alpha (Homebush Red)

YES Respiratory rate > 30 Yes Immediate Triage Priority Alpha (Homebush Red)

NO Urgent# Triage Priority Bravo (Homebush Yellow)

Table 3: The Simple Triage And Rapid Treatment (START) Triage scheme (modified)# Combining START with the Homebush triage taxonomy allows a simple triage decision tree to be developed# Reprinted with the permission of Prehospital and Disaster Medicine

Winter 2000 43 The simplicity of START (table 3) allows it to be performed rapidly as a quick screening tool and can be easily remem- SAVE Guidelines bered as: • Mangled Extremity Severity Score (MESS) (Johansen et al 1990) to assess crush injury to extremities • anyone who does not breathe with simple airway maneuvers is dead • Glasgow Coma Score less than eight in adults with significant head injury# • anyone who can walk is assigned a not • Abdominal trauma with refractory hypotension urgent triage priority • Chest trauma with abnormal vital signs • anyone who cannot walk but can obey • Spinal trauma commands, with both a radial pulse • Burns with < 50% probability of survival or adults over 60 years of age with an inhalational injury# being present and a respiratory rate less • Adults with pre-existing diseases than 30 breaths per minute, is assigned an urgent triage priority • Non traumatic emergencies • anyone else has an immediate triage • Special triage categories such as healthcare workers with minor injuries who with simple treatment priority may be able to assist in the medical response SAVE guidelines look at a number of parameters (table 4) which are designed to answer two key triage questions at a Table 4: Secondary Assessment of Victim Endpoint (SAVE) Guidelines major incident site (Benson et al 1996): • What is the victim’s prognosis if Triage is generally carried out once the Conclusion minimal treatment is provided? casualties have been taken to a casualty Australia has the opportunity to build • What is the victim’s prognosis with the collection point (Burkle 1984; Vayer et al upon past experience and develop a treatment resources available at the 1986; Orr et al 1983) Triage flags provide nationally integrated system of casualty area medical center? the first ambulance on scene at an MCI triage Appropriate preplanning can There has never been a situation to date with the capability to lay the foundation mitigate some of the problems that that has required the implementation of for the site medical response irrespective complicate the triage process, but those both START and SAVE triage criteria of the number of casualties Geographic involved in the medical response to an triage may reflect the normal disposition MCI must have a common language and Paediatric triage of trauma patients at an incident (Vukmir understanding of triage issues to remove The basic principles of triage remain the et al 1991) that can assist single practi- existing fundamental barriers to good same for children as they are for adults tioners with limited site resources to communications (Holbrook 1991) The START metho- triage casualties efficiently dology will tend to overtriage children The casualty profile following an MCI References This is acceptable given the higher typically has 6 to 25% of patients requiring Adams G W 1952, ‘Doctors in blue’, The probability of children surviving head medical or surgical treatment within 12 medical history of the Union Army in the injury (Luerssen et al 1988) and multiorgan hours to prevent loss of life or severe Civil War, Henry Schuman, New York system failure compared with adults morbidity (Anderson 1995; Sklar 1987) Ammons M A , Moore E E , Pons P T, & (Wilkinson et al 1986), along with the fact The bulk of the casualty load consists of Moore F A et al 1988, ‘The role of a regional that most blunt abdominal trauma is patients with non-urgent injuries who trauma system in the management of a managed conservatively in children have little to gain from immediate medical mass disaster: an analysis of the Keystone, compared with adults (Powell et al 1987) care Using expensive triage tags to Colorado, chairlift accident’, J Trauma, 28, The initial Glasgow Coma Score following identify them or label dead bodies is an pp 1468–1471 head injury in children does not reliably inappropriate use of resources especially Anderson G V & Feliciano D V 1977, predict outcome unless there is associated in a large scale MCI (Rutherford 1989; ‘The Centennial Olympic Park bombing: hypoxia and hypotension present (Lieh- Waeckerle 1991; Angus et al 1993) In 1974 Grady’s Response’, J Med Assoc Ga, 86, Lai et al 1992) a Turkish DC10 crashed into a forest at pp 42–46 Triage documentation Ermenoville, France killing 345 persons Anderson P B 1995, ‘A comparative Triaging patients into geographic areas Nearly 20,000 fragments of human tissue analysis of the emergency medical ser- has been raised as an alternative to the were produced from the impact with the vices and rescue responses to eight use of triage tags (Rutherford 1989; Vayer remains of 188 victims subsequently airliner crashses in the United States, et al 1986; Vukmir et al 1991; Kerns et al positively identified (Personal communi- 1987–1991, Prehospital & Disaster Medi- 1990) Geographic triage provides a major cation Mr Peter J Stuart) cine, 10, pp 142–153 time saving in triage documentation Triage procedures should avoid unnece- Angus D C & Kvetan V 1993, ‘Organi- especially when there is a large influx of ssarily complicating the subsequent zation and management of critical care patients (Waeckerle 1991; Kennedy et al investigation of the incident Labelling systems in unconventional situations’, Crit 1996; Vayer et al 1986; Angus et al 1993) In human remains with numbered chemi- Care Clin, 9, pp 521–542 a series of six major air accidents within cally resistant tags helps to document the Arturson G 1981, ‘The Los Alfaques the USA the largest incident, involving 297 location of human body parts and their disaster: a boiling-liquid, expanding- people with 59 critically injured and 124 relationship to objects such as motor vapour explosion’, Burns, 7, pp 233–251 less severely injured, had the shortest vehicles at the scene This facilitates their Barton D, Bodiwala G G 1991, ‘Assess- prehospital time using geographic triage systematic removal from the site for ment of a triage labels system during a instead of triage tags, combined with subsequent forensic examination and can major incident exercise’, Prehospital and efficient ground and rotary wing trans- play an important role in victim identi- Disaster medicine, 6, pp 473–476 port systems (Anderson 1995) fication Baskett P & Wells R (eds ) 1988,

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Winter 2000 45 Sharpe, D T , Roberts A H , Barclay T L , perspective’, Am J Emerg Med, 9, pp 64–71 Acknowledgement Dickson W A , Settle J A D , Crockett D J Waeckerle J F 1991, ‘Disaster planning & The authors would like to acknowledge the assistance & Mossad M G 1985, ‘Treatment of burns response’, N Eng J Med, 324, pp 815–821 of Ms Anne Newton in the formulation of the manuscript# casualties after fire at Bradford City Wardrope J , Ryan F , Clark G , Venables G , football ground, BMJ, 291, pp 945–948 Crosby A C & Redgrave P 1991, ‘The Hills- Declaration Sklar D P 1987, ‘Casualty patterns in borough tragedy’, BMJ, 303, pp 1381–1385 This paper has been prepared without any funding from any organization or institution# The original disasters, Journal World Association Welch C E 1947, ‘War wounds of the manuscript was exclusively submitted to the Emergency and Disaster Medicine, 3, pp abdomen’, N Eng J Med, 1, pp 156–162 Australian and New Zealand Journal of Surgery as 49–51 Williams R W , Burns G P, Andersen M an original work by the authors who retain the Smith J S & Fisher J H 1981, ‘Three Mile N , Reading G P & Border J R et al 1974, copyright over the manuscript# Island The silent disaster’, JAMAm, 245, ‘Mass casualties in a maximum security Author’s contact details pp 1656–1659 institution’, Ann Surg, 179, pp 592–597 Dr Antony Nocera, FACEM & Dr Alan Garner, FACEM Spengler C 1995, ‘The Oklahoma City Wilson J (D ) 1846, Outlines of Naval NRMA Careflight PO Box 159 bombing: a personal account’ J Child surgery, Maclachlan, Stewart and Co, Westmead NSW 2145 Neurol, 10, pp 392–398 Edinburugh Vayer J S , Ten Eyck R P & Cowan M L Wilkinson J D , Pollack M M , Ruttiman Dr Antony Nocera Unit 16, 68 Bradley’s Head Road 1986, ‘New concepts in triage’, Ann Emerg U E , Glass N L & Yeh T S 1986, ‘Outcome of Mosman NSW 2088 Med, 15, pp 27–930 pediatric patients with multiple organ sys- tonynoce@ozemail#com#au Vukmir R B & Paris P M 1991, ‘The tem failure’, Crit Care Clin, 14, pp 271–274 Tel# (Mobile): 0414-959599 Three Rivers Regatta accident: an EMS

EMA Safer Communities Awards

From flood recovery processes to innovations in firefighting, the entries in this year’s Emergency Management Australia (EMA) Safer Communities Awards have shown excellence in many areas of emergency management!

More than 75 entries were received from across Australia They were submitted by State Government,

Awards Local Government, private sector and volunteer organisations, and covered both pre and post- disaster emergency management The innovation and leadership exhibited in the entries demonstrated real achievement in helping communities prepare for, as well as recover from, disasters such as flooding, cyclones or bushfires

Safer Communities Following the selection of 26 winners at a State and Territory level, the judging panel chose the following eight National winners, with five commendations made to other entries The winners were presented with their Awards at a ceremony hosted by the Minister for Defence, Mr John Moore MP, at Parliament House, Canberra, on 28 June 2000

Department of Human Services, Wollongong City Council (NSW) Gippsland (VIC) Post-disaster category Post-disaster category Local Government Stream Federal/State Government Stream For the work of their geo-technical team which For its pro-active response in resourcing, had the task of assessing landslide risks following implementing and monitoring the immediate flash flooding in the area The team’s knowledge welfare and recovery activities following the and expertise saved valuable resources by

EMA severe flooding of the East Gippsland Shire in evacuating only those who absolutely had to be 1998 evacuated

46 Australian Journal of Emergency Management Australian Red Cross (NSW) Post-disaster category Volunteer Organisation Stream For the work of the NSW State Enquiry Centre which acts as the Melbourne Water (VIC) humanitarian interface between people affected by a disaster. Pre-disaster category The centre also helps friends and families of those affected by a FederallState Government Stream disaster. For work in improving community knowledge about urban flood risks, as well as promoting appropriate Richard Bryant Post-traumatic Stress Disorder building development, following significant drainage work in the greater Melbourne area. Unit, University of New South Wales (NSW) Post-disaster category Private Sector Organisation Stream Albany Coastal Safety Committee (WA) For his unit's work in developing the Acute Stress Disorder Scale Pre-disaster category (ASDS), the world's first scientifically derived instrument to FederallState Government Stream identify individuals at risk of developing post-traumatic stress For its Fish Safe, Be Coast Safe public education program, disorder. designed to raise awareness about safety along the south coast of Western Australia. NSW Fire Brigades (NSW) Pre-disaster category NSW Fire Brigades and ACT Fire Brigade FederalIState Government Stream (NW For its Static Water Supply Program, which identifies static water Pre-disaster category resources such as backyard swimming pools in high-risk FederallState Government Stream bushfire areas. Identification plates are placed outside the For the production of a CD-ROM which aims to train resident's property so that the water resource can be easily found rescuers and volunteers in the principles of Urban Search during a fire. and Rescue.

Shire of Augusta, Margaret River (WA) Gold Coast City Council (QLD) Pre-disaster category Pre-disaster category Local Government Stream Local Government Stream For the development of a new memorandum of understanding For its Nerang River flood mitigation project which aims which now means that emergency management procedures for to reduce the magnitude of river flooding, raise Margaret River, Augusta, and surrounding towns are addressed community awareness, as well as address land use controls. at a local level.

New Norfolk Fire Brigade (TAS) Success Management International Pre-disaster Category Learning Enterprises (NT) Volunteer Organisation Stream (joint winner) Pre-disaster category For its Home Fire Safety Audit program which involves inspecting Private Sector Organisation Stream the homes of sick, aged or frail people in New Norfolk to ensure For its four major hazard mitigation projects: the Public they are fitted with appropriate safety measures in the event of Cyclone Shelter Study: Greater Darwin region (1998); the a fire. Public Cyclone Shelter Study: Coastal Communities of the Northern Territory (1999); the Katherine District Flood Disaster Study (1998) and the Lifelines Northern Territory Australian Red Cross (NSW) Study (1999). Pre-disaster category Volunteer Organisation Stream (joint winner) For the development of its Team Leader handbook which, by containing step-by-step forms, policies, practical The National judging panel commented that the task of picking exercises and background information, aims to better equip the winners from the exceptional standard of entries was and support Team Leaders for the task of leading a Personal particularly difficult. Support Team.

For more information on the EMA Safer Communities Awards visit the EMA website at www.ema.gov.au winter 2000 47 4