Major Incident Management

Major Incident Management is a very common topic these days for FCEM OSCE as well as SAQ papers. I have written here the strip down version and the basics which will be sufficient for the exam.

Classification of major incident:

• 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

The mnemonic describes a system widely accepted in the UK, and now in many other countries, which is designed to ensure the successful medical management of a major incident with live casualties. It is a hierarchy of actions that help the otherwise potentially chaotic actions of multiple staff to come together into a system.

The sequence can be remembered using the acronym "Command Spells Calm And Time To Treat". The overriding aim of this approach is to achieve the common aims of all emergency services at a major incident.

C – COMMAND

S – SAFETY

C – COMMUNICATION

A – ASSESSMENT

T – TRIAGE

T – TREATMENT

T – TRANSPORT

Responsibilities of the first crew on scene:

An ambulance is likely to be at the scene at an early stage. If it is a major incident, the crew should not get involved in treating individuals but they need to assess the situation and report back to control. There will be an Ambulance Incident Officer (AIO) who is the senior crew member who is in charge until a more senior officer arrives. His tasks include:

• Assessing the scene.


• Declaring a major incident and giving a situation report (SITREP or METHANE).


• Deciding where to locate the Control Point, Casualty Clearing Station (CCS), and Ambulance Parking Point, as well as planning ambulance entry and exit routes.


• The AIO is in charge of communication with all health service personnel on the scene.


• The AIO discusses with the chain of command the need for additional support, such as a Medical Incident Officer (MIO) on scene, the Medical Emergency Response Incident Team (MERIT) and additional equipment.

Reporting a major incident

This must go through the appropriate channels so that all necessary personnel and services are informed. Full and relevant information must be gathered. There are two mnemonics to help with this. They are METHANE and CHALETS and the contents are similar:

M ajor incident declared
E xact location
T ype of incident, eg explosion and fire in a tall building, release of gas in the underground system
H azards - present and potential
A ccess - routes that are safe to use
N umber, type, severity of casualties
E mergency services now present and those required.

C asualties - number, type, severity
H azards present
A ccess routes that are safe to use
L ocation
E mergency services present and required
T ype of incident, as above
S afety.

By now there may be several ambulances on the scene but the control vehicle is recognised as the one that still displays its flashing lights.

The medical emergency response incident team (MERIT)

This team (formerly known as the Mobile Medical Team) usually consists of a doctor and a nurse or two of each. They should stay together unless ordered to do otherwise. Ideally, they should not come from the hospital that will be receiving casualties as they need all their staff but, in a remote area, this may not be practical. They should arrive equipped with kit bags. These contain limited airway, breathing and circulation equipment. 

When the MERIT arrives at the scene they should report to the MIO whose position will be apparent from a flashing green beacon. If none is present, they should report to the AIO at the ambulance with the flashing blue light. The team will probably be sent to the CCS but may be required to assist with the triage and treatment of entrapped casualties. It is not the role of the doctor or nurse to get involved in search and rescue, counselling victims or commanding ambulance personnel.

Organisation at the scene and away

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. It is a dangerous area and medical activity within it is limited to:

• Primary triage.


• Evacuation of casualties.


• Treatment of trapped casualties.

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.

A doctor may also be required to certify death. Casualties are evacuated to the CCS that will be close to the scene yet at a safe distance and linked to the ambulance loading point. The CCS is for secondary triage, initial stabilisation and preparation for transportation to hospital.

Triage

Triage is a system for sorting casualties into priority for treatment by subsequent teams. It enables limited resources to be deployed efficiently. Treating a less critically ill patient could deny life-saving interventions to others who may die as a result. A form of rapid assessment is required and the triage sieve is usually employed. An experienced operator can perform this in about 20 seconds, so that it is possible to triage many people in a short time. Priorities are numbered 1 to 3 in descending order of need and are colour-coded as follows:

• P1: immediate priority. It is those who will die without immediate lifesaving intervention. Colour code red.


• P2: intermediate priority. They will also need significant interventions but can wait a few hours. Colour code yellow.


• P3: delayed priority. They will need medical treatment, but this can safely be delayed. Colour code green.


• Dead is a fourth classification and is important to prevent the expenditure of limited resources on those who are beyond help. Colour code black.

Walking wounded are automatically classified as P3. This is related to the motor score on the Glasgow Coma Scale and predicts favourable outcome. Time can be saved in the bronze zone by asking all who can proceed to the CCS unaided to do so, and automatically classifying them all as P3. This is a useful technique if the area is hazardous and it is necessary to clear it and move on the injured as soon as possible.

Casualties need to be labelled and the cruciate triage card is useful. It has 4 arms, coloured red, yellow, green and black and the appropriate arm can be displayed. It also facilitates change of category if required. If nothing else is available, write on the person"s forehead. Dead bodies should be left where they are, partly to avoid unproductive use of resources and partly because this may be a scene of crime.

It is quite common for up to 50% of patients to be triaged into too high a category, competing for limited resources. It is common for children to be placed in too high a category and old people in too low a category.

How to deal with the number of casualties

On site

By the time that the CCS is set up there may be adequate resources. As a general rule, advanced life support should not be performed in the bronze zone, as it is very labour intensive and the chance of success is limited. More lives will be saved by attention to others. At the CCS there may be enough staff to enable this to be performed without neglecting others who would benefit from immediate attention.

ED - the casualties

The first patients to arrive at the hospital A&E department are usually the least severely injured. This is because they are the most mobile and the more severely injured may require stabilisation before moving. Hence, the arrival of a large number of people who are not severely injured may be the trigger for the declaration of an emergency. Valuable resources such as ambulances should not be used to transport those who can use other means including cars, taxis or getting on a bus. Those who arrive in A&E have probably been triaged twice already but they will still require a further triage. A different system is required in hospital from in "the field". There is no uniform system but a common classification is resuscitation, major and minor.

Managing the casualty numbers in hospital

The hospital major incident plan can be activated either on the request of the Ambulance Service, or autonomously by the hospital. When a disaster is declared it is necessary to try to gauge the scale of the problem and to make a rough estimate of the number and nature of injuries. 

• It is common practice for one hospital to be the reception centre for injuries whilst another sends out staff to the scene.


• The receiving hospital needs all its staff on site.


• A centre of operations is set up there with clinical and managerial input.


• The clinical director should be a senior doctor with authority, who is not directly involved in the care of the injured, as he cannot do both jobs simultaneously. Hence, he or she will almost certainly not be the ED consultant or probably any surgeon.


• The command and control centre will probably not be in ED, as it will be extremely busy there.

ED - the non-casualties

There will be the usual flow of patients from unrelated events in A&E. Someone has to deal with them or send them elsewhere. This may be to another hospital or asking GPs to cope.

• If the system is stretched, patients from unrelated sources need to be put through the same triage procedures as those from the major incident.


• It is inappropriate to send away someone with a serious medical need just because he or she is not a victim of the major incident.


• It is still useful to note who was from the incident to help with inquires and also reflection on the adequacy of the operation afterwards.

Other hospital departments

All staff (and not just those skilled in the management of trauma) should report for duty when a hospital declares a major incident.

• Other patients will still need care when perhaps their usual carers have been called away.


• Someone may need to take the decision to discharge patients to free beds for new arrivals.


• Routine admissions must be halted.


• The extent to which this will need to be done depends on the anticipated number of admissions.


• There should be a designated area where staff can report to in order to be assigned to their duties.


• Standards of care must be maintained.

 

Major Incident Management