Chapter 56. The major incident
An overview
Classification
• A simple major incident is one in which the infrastructure of the community in which it occurs remains intact, e.g. a train or air crash
• A compound major incident destroys or damages the infrastructure of the surrounding community
• A compensated major incident is one in which there are sufficient local resources to deal with the consequences
• An uncompensated major incident is one where the medical and other responding emergency services are destroyed or totally inadequate.
CSCATTT
CSCATT describes the priorities involved in managing a major incident.
Responsibilities of the first crew on scene
Attendant
• The attendant assumes the role of Ambulance commander until relieved by a senior ambulance officer
• He/she should undertake a rapid reconnaissance of the scene and feed back a situation report to the driver, who can then pass this to control using the METHANE mnemonic (see below)
• Suitable sites for ambulance parking point, control point and the casualty clearing station should be identified
• The Fire commander and Police commander should be identified and contacted at an early opportunity
• As ambulance commander, he/she must not become involved with the treatment of casualties.
Driver
• The driver is to stay with the vehicle at all times. He will form the communication link between the scene and ambulance control
• Park the vehicle as close to the scene as safety allows and leave the beacon switched on. The driver should then provide control with a brief report, stating the location and type of incident
• The driver must remain in contact with the attendant at all times and should not leave the vehicle until directed to do so by a senior ambulance officer.
Major incident standby/major incident declared
Exact location
Type of incident
Hazards
Access
Number of casualties
Emergency services present and required
Emergency services
• Overall control of the scene is the responsibility of the police who will control the outer cordon
• There will be a police manned incident control point through which all staff should enter and leave; all movements will be logged
• If hazards are present, the Fire service will have responsibility inside the inner cordon (the hot zone) until the danger is controlled
• Personnel entering and leaving the inner cordon must also be recorded for safety purposes
• The bronze ( operational) area lies within the inner cordon and is the area where the rescue operation is in place. There will be bronze commanders ( forward commanders) from each emergency service
• Silver ( tactical) command consists of the area within the outer cordon. The commanders from each service will be within this area, although they may move in and out of the bronze zones
• Gold ( strategic) command is removed from the scene – usually in the police HQ or local authority buildings – and is the location where the chief officers from each emergency service meet.
Silver (tactical) command
Silver command is usually handed over to more senior officers as they arrive. Commanders must not become involved in the rescue or treatment of casualties. There must be frequent documented meetings between the silver commanders from each service. The first priority is to share intelligence and establish what has happened:
• What are the main priorities for the next hour?
• What difficulties need to be resolved?
• Are other resources required?
• Which are the casualty receiving hospitals?
• Where is the survivor reception centre and who is resourcing it?
• Do any of the services present have particular problems or difficulties that another may be able to help with?
The health service response is controlled by the Ambulance commander (AC) at silver level.
There are several areas that should be allocated by the Ambulance commander:
• Ambulance Control Point – this is marked with a steady green roof-light. All health service staff are to report here on arrival
• Forward Control Point – this is where the forward incident officers meet to direct the rescue operation. The forward commanders report to their respective silver commanders
• Casualty Clearing Station – an appropriate site for secondary triage and treatment of patients, ideally sheltered, safe and accessible
• Liaise with other commanders
• Delegate tasks to other ambulance personnel
• Ensure adequate communications for all health service staff
• Determine (with the Medical commander) the receiving hospitals
• Determine (with the Medical commander) where mobile medical teams are drawn from
• Establish triage and treatment
• Determine appropriate transport routes
• Organise replenishment of equipment
• Liaise with police regarding the media.
• Ambulance Parking Point – where ambulances wait until called forward to the rear of the casualty clearing station (CCS)
• Ambulance Loading Point – where patients are loaded, preferably at the rear of the CCS.
There are several key roles that must be delegated by the Ambulance commander:
• Communications officer
• Forward ambulance commander
• Casualty clearing station officer
• Ambulance parking officer
• Ambulance loading officer
• Primary triage officer
• Ambulance safety officer
• Equipment officer.
The Medical commander
• The AC may be joined by an appropriately trained doctor who will act as Medical commander; this may be a doctor from the Ambulance service itself, a practitioner from the local immediate care scheme or a consultant from an Emergency Department and should be known to the Ambulance service
• In the future, this role may be provided by Department of Health MERITs (Medical Emergency Response and Intervention Teams)
• The primary role of the Medical commander is to work in close conjunction with the Ambulance commander and to this end, they should usually be found in close proximity to each other
• The Medical commander should establish and maintain direct contact with the receiving hospitals and decide if specialist medical teams should be called
• Communication with hospitals should go through the Medical commander
• To aid communication between hospitals and the scene, the Ambulance service should despatch a liaison team to each receiving hospital
• One officer should ensure smooth turnaround and re-equipping of ambulances and document the number of casualties. The other should join the hospital coordination team to advise and update the hospital staff on progress at the scene.
Triage
Primary triage occurs in the bronze area and aims to rapidly identify those in need of immediate life-saving treatments. The triage sieve is used for primary triage. Secondary triage occurs at the entrance to the CCS, where a more detailed system involving the triage revised trauma score (TRTS) is used.
The triage categories are:
• Delayed (green)
• Urgent (yellow)
• Immediate (red)
• Dead (white).
In extreme circumstances, an expectant category ( blue) may be used on patients who have a very high likelihood of dying anyway, in order to conserve resources for patients who can be saved. The expectant category will only be implemented on the joint agreement of the Ambulance and Medical commanders.
Once triaged, casualties must be marked, preferably with triage labels. Triage is a dynamic process and should be repeated at different stages and triage categories amended as required.
Ambulances
• Ambulances are parked at the ambulance parking point under the direction of the Parking officer
• Always leave the keys in the ignition so that vehicles can be moved
• Ambulance traffic should be directed in a circuit to prevent traffic jams. Ambulances are usually the only vehicles which will need to come and go from the scene
• All patients must be adequately packaged for transport, including securing of all lines and tubes, supply of sufficient oxygen and drugs for the journey and provision of relevant paperwork
• Casualties requiring specialist centre treatment (e.g. burns or neurosurgery) should be transported directly to a centre providing that speciality, to avoid delays later in secondary transportation
• Vehicles other than land ambulances may be used for transport: helicopters have advantages of speed, but can only transport one patient
• Patients with minor injuries may be sent to hospital by recruited buses or vans.
The dead
In England and Wales, the dead are the responsibility of the Coroner and in Scotland of the Procurator Fiscal. The police act as the Coroner’s agents and will control all further management of the deceased. Those casualties triaged as dead should be labelled as such and covered with a blanket where they are found unless they are blocking access to the living. An attached label should indicate the date and time, location found and the name of the doctor and police officer. Subsequently, when the pressure of the incident is reduced, a doctor accompanied by a nominated police officer should formally confirm death. Photographs of the body in situ should be taken, before it is removed to a body-holding point or temporary mortuary.
Terrorist incidents
• Bomb explosions result in devastation over a wide area
• Secondary devices are a common hazard and all attending emergency service personnel need to remember the basic rule – protect yourself
• The location of the rendezvous point for attending vehicles should be chosen with great care. A search of this area to confirm safety is of paramount importance
• Use of radios and mobile phones may be restricted, as these devices can trigger secondary devices
• A minimal number of personnel should be deployed in the explosion site, at least until safety has been established
• Considerable importance is attached to the preservation of forensic evidence after a bomb explosion
• The dressings, clothing and other belongings of the casualties may need to be preserved. Pieces of shrapnel must also be preserved and the scene disturbed as little as possible.
Civil disorder
The key to a successful operation in a civil disorder situation is neutrality. The paramedic must not take sides with the police or with demonstrators, with left-wing or right-wing political protestors or with racial groups
Three distinct patterns of civil disorder can occur:
1. Prearranged demonstrations along a prescribed route with preplanning and preparation by the emergency services
2. Static confrontation, usually with an area of conflict which is clearly defined
3. Uncontrolled rioting with no set pattern or direction, sometimes with changing focus of casualties.
Rival groups should be taken to separate hospitals. If the police form a third group then they too should ideally have a dedicated emergency department. Full riot protective clothing and in some situations flak jackets may be required by crews and ambulances should have a crew of three whenever possible.
Treatment facilities at a static point may avoid the need for a large number of people with minor injuries being moved to hospital. Police should recover their own personnel, evacuating them to paramedic forward aid points. An ambulance liaison officer in the police control room is vital in informing paramedic teams of police tactics to ensure their safety when working among demonstrators or rioters.
Underground incidents
Major incidents underground may present special problems since communications can be particularly difficult.
For caves and coal mines specialist rescue teams are usually available.
In the underground railway system, ambulance paramedics will be required to work in conditions of very high temperatures. In the London Underground railway system, temperatures regularly rise to 40°C.
Evacuation of trains with over 1000 passengers is often necessary. On occasion, the scene may have to be approached from two different stations either side of the incident.
Chemical and radiation incidents
The Fire service will of necessity take a lead role in ascertaining safety.
Only fire officers and HART (Hazardous Area Response Team) trained paramedics should enter the ‘hot zone’.
The National Arrangements for Incidents Involving Radiation (NAIR) scheme will direct the planning for incidents involving nuclear power stations, medical or military sources of radiation.
Debriefing
When paramedical staff have finished their duties at the scene of a major incident, it is most important that a senior officer takes the trouble to thank them personally and check that they are safe to travel home. This hot debrief can either occur at the scene or back at a suitable station. It should not last for very long and should be directed towards welfare issues.
Within a few days, it is necessary to arrange a more formal debrief for those involved. This should be directed towards fact finding. A final, full written report can then be prepared for all interested parties. The inevitable public enquiry will follow, so documentation and recording of all times and decisions are essential.
For further information, see Ch. 58 in Emergency Care: A Textbook for Paramedics.
