Major incident management – in brief…

Recent years have seen some real thought put into major incident management in the UK, particularly after such high profile incidents such as the rail crashes at Paddington, Potters bar, and Selby, and large scale terrorist activity like the Glasgow and London bombings.  The July 7 2005 bombing incident highlighted many areas which still needed urgent attention including command and control, and communication.

What do I do if I’m first on scene?

In the words of Douglas Adams, “Don’t Panic”.  The first person on scene from Police, Fire or Ambulance is likely to be overwhelmed initially by the sheer scale of what is laid out before him/her.  It is in those first few minutes at a major incident that can make or break the following hours, so common sense needs to prevail.

It is very tempting for an ambulance crew/responder to get distracted by the first patient he/she encounters, but this cannot be allowed to happen, there may be sicker patients that need more urgent help; in fact it is likely that mobile patients who have self-extricated from the ‘hot’ zone will be some of the lowest priority for clinical attention.

If you are first on scene, a rapid assessment of the situation and accurate reporting back to your control centre will make a huge difference.

When assessing the scene, the first pieces of critical information can be collected and reported back using the following communication tool – METHANE:

  • M – My Call sign + “Major incident declared/standby”
  • E – Exact location
  • T – Type of incident
  • H – Hazards present or suspected
  • A – Access/Egress from scene
  • N – Number of casualties known and/or suspected
  • E – Emergency services present and required

“Major incident declared/standby”

Don’t be afraid to say the actual words “Major incident”.  It will always be possible to stand down additional tasked resources if they are not needed, and it will take longer to activate them if they are needed and the words were not used.  One of the lessons learned from July 7 was that the words “Major incident” were not uttered for a long time, and the command and control structure took longer to put into place subsequently.

A major incident for one service may not be a major incident for another.  A burning cargo plane in a field may not cause excessive demand on the ambulance service, but will require numerous resources from fire.  Just because one service declares a major incident, it does not mandate that the others follow.

“Exact location”

Clearly very helpful to provide accurate location data.  In a split site major incident, it is vitally important that communication is clear which site is being discussed.

“Type of incident”

A brief outline of the incident, e.g. “train derailment”, or “chemical factory fire”, or “potential CBRN explosion”.  The point of this is to allow targeted deployment of resources, including fire, HART, coastguard, mountain rescue, etc.  Little clues can make a big difference to the picture forming back at control e.g. a cargo plane vs freight train is likely to result in far fewer casualties than a passenger plane vs commuter train.

“Hazards known / suspected”

Follows neatly on from type of incident.  Hazards can be anything that might endanger rescuers, casualties, or property, e.g. smoke, fire, chemical, electrical wires, live track, fast flowing water.

“Access & egress”

Although this may seem superfluous in the first few minutes, the importance of considering where the deluge of vehicles will come from, park and the direction they will leave cannot be understated.  The delay in declaring a major incident in London quickly resulted in a traffic jam that wasted vital time sorting out:

Congestion on scene – Guardian “http://www.theguardian.com/education/2010/feb/23/emergency-services-incident-command-msc

 “Number of casualties – known or suspected”

A best guess at the time given the type of incident, the location, the time of day, the day of the week.  Definitive numbers will be required, but later on.  Further METHANE reports can give better estimates, and the importance will be the rapid communication of information so there is no need to spend time collecting numbers before passing your report.

“Emergency services present and required”

It used to be taught that the first person on scene would be able to make an educated guess as to how many fire engines, ambulances, police officers, and other services would be needed to deal with the incident; luckily, this has been shown some common sense, and you should only talk about what you know.  The format of the METHANE report is becoming standardised across services, so it can be shared from one control room to another; let them decide what response to send.

The METHANE report is now the standard teaching in the JESIP (Joint Emergency Service Interoperability Program).

So I’ve passed my METHANE report, what now?

Look for your major incident action cards.  Depending on your service and region there will be a comprehensive list of actions that the first few people on scene should do.  They will be along the lines of the following: e.g. Ambulance service

1st person – Command and control

You become the bronze commander.  Stay put, don’t leave your vehicle, be the only vehicle which still has its flashing lights on.  Coordinate the response with the next attendants.  If possible, meet together with the other emergency service commanders regularly at agreed intervals until this role is taken on by a trained silver officer.

2nd person – Scene assessment followed by loggist/comms

You will be sent by the bronze commander to gather the information for the METHANE report, and on your return start a log and be the link to control via ARP radio.

3rd person – Parking officer

As discussed above, the logistics of parking will become a vitally important consideration, including keeping access and egress routes open, and a system for parking ambulances in a sensible location near to the casualty clearing station – see below.

4th person – Safety officer

Ensuring that personnel on scene do not endanger themselves by a lack of appropriate PPE, or direction, or crowd control.

What about the casualties?

A traditionally taught mnemonic for major incident management is CSCATTT.  It emphasises the importance of keeping an organised structure at a mass casualty incident or major incident and getting that structure in place in order to do the best for the most.

  • C – Command and Control
  • S – Safety
  • C – Communication
  • A – Assessment
  • T – Triage
  • T – Treatment
  • T – Transportation

Triage

When faced with more casualities than there are ambulance personnel it will be important to rapidly assess all of them to see who needs attention first to save their lives.  There will also need to be a method of communicating the result of this triage process to the rescuers following behind.  It is suggested that non-clinicians make the best triagers, as they will be able to follow a simple protocol without making secondary deductions, and they will be far less likely to be tempted to provide clinical care along the way; this would slow the triage process down and potentially cost the lives of the unassessed.

Triage Sieve (cmej.org.za)

A protocolled system of triage like the one above will quickly differentiate between  the uninjured, and those with mild, moderate and severe injuries.  It is a far from perfect system, it’s easy to imagine a casualty with a sprained ankle (not walking) having a panic attack (resp rate >30) who will become a P1.  This system cannot be too complicated though, and must assess casualties quickly.

Once triaged, the casualty should be labelled in a way that oncoming rescuers can see and easily understand.  There are several systems available, most of which involve colours and numbers – Red=P1, Yellow=P2, Green=P3 for example.  Cards, tags, wristbands, and permanent markers have all been used.  In addition, one system uses coloured glowsticks to enable rescuers to find priority casualties in poor light conditions; although a red glowstick can sometimes be used in a CBRN incident to mean “Danger, stay away”.

What to do with the casualties once triaged

Hopefully, the majority of casualties in your major incident will have minor injuries, or be entirely uninjured.  The uninjured should be escorted to a “Survivor Reception Area” clear from danger (outside of the “Bronze” or “Hot” zone)

A bit about Zones

The incident will need to be cordoned to get control – to keep personnel away from danger, to keep the media and public away from sensitive sites, etc.

Bronze zone

The Bronze or Hot zone (depending on type of incident) is the immediate scene of the incident, and contains the majority of hazards.  Personnel working in these zones should be accounted for at all times, checked in and out.  Cordons into the Bronze zone is often controlled by the Fire service.  Bronze commanders coordinate teams within this area.  There may be more than one Bronze zone at an incident, if scale or multiple sites make this more practical.

Silver zone

The safe zone around the incident where casualties are processed and treated, and the location where the multi-agency coordination team – the Silver commanders, will direct their Bronze teams and lease with wider services.  This is usually cordoned off from the outside world by the Police.

Gold

Not technically a zone.  Gold is a term referring to strategic support, and is usually distant from the scene, including support from emergency services control centres, local authority, government, etc and deals with releasing funds to help manage the incident, and coordinating resources on a larger scale.  Gold is also charged with maintaining vital services to the public not directly involved e.g. normal ambulance service provision, keeping the buses running.

The P3s

The ‘Priority 3s’ or the ‘Walking wounded’ are unlikely to deteriorate quickly, so should be gathered together in a single location capable of housing them (under shelter, preferably indoors, potentially with catering if prolonged stays are expected).  They can then be evacuated from scene for further assessment in large capacity passenger vehicles e.g. buses/coaches to hospitals.  Careful consideration to hospital capacity should be made, as the closest and largest hospitals will quickly become overloaded.  It may be worth bypassing these with the P3s and going to more distant units.

The casualty clearing station

Within the silver zone, ideally close to ambulance parking there should be personnel and equipment set up in a ‘Casualty Clearing Station’ (CCS).  This could be placed in a nearby building, shop, warehouse, or in service provided tents, etc.

The purpose of the CCS is to quickly provide treatment on scene in order to stabilise the P1 and P2 casualties sufficiently to get them to hospital.  This treatment may involve cannulation, fluid therapy, analgesia, limb/pelvic splintage (if not already done by rescuers), and more intensive therapies for example intubation, ventilation, sedation, and surgical procedures.

Once stabilised, these casualties should be transferred to hospital via ambulance.  It is important that a record is kept of all patients brought to and leaving the CCS, along with their triage category and destination, so that the silver commanders (ambulance and medical) can assess remaining capacity at the different nearby hospitals.

How do I know who to treat first in the CCS?

Once delivered to the CCS, casualties should have a more in depth assessment, which will further sort urgencies, and will be more specific excluding those with less severe injuries (remember the ankle sprain?).  This is known as the “Triage Sort”.  An example is below:

Triage Sort (cmej.org.za)

The P1 patients might need to stay in the CCS for longer than some P2s in order to be stabilised, so it may also be useful to get some P2s treated and dispatched to hospital in the midst of a P1 crisis!

Phew!

So what was ‘silver’ doing all this time?

The role of Silver is to tie it all together.  Lessons learned from past major incidents have told us that we do not talk to each other enough, messages get lost or misinterpreted.  At the multi-agency silver command centre or JSEC (Joint Services Emergency Control), silver commanders from Ambulance, Medical, Fire, and Police will come together along with other voluntary agencies and local authority representatives to discuss the plan of action.  This will be done regularly, with agreed times for meetings, initially every 15 to 20 minutes would be a good start.  Information will pass back from the bronze commanders to the silvers, and they will discuss on a tactical level what resources should go where, which casualties should go to which hospitals.  The silvers will also liase with the outside world, both to gold, to surrounding hospitals, and to the media.  Ideally, regular media briefings should take place, with the silver commanders together so questions can be answered coherently by the right people.

I want to know more..

I’m not surprised! Being ready for a major incident is something we should all become, mentally rehearsing various scenarios in our downtime is a great way to generate mental toughness and be ready to act when the time comes.

Next steps

  • Read your own organisation’s major incident plan/policy.
  • Find your MI action cards and read them
  • Familiarise yourself with your organisation’s triage cards/system
  • Discuss MI scenarios with others; how would they arrange things?
  • Go on a course – MIMMS (Major Incident Medical Management and Support) is excellent.  I went on one arranged by Disaster Management Training which I would recommend (No conflicts of interest!).
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