First off, the first “Grand Rounds” are at Blogborygmi – quite a few top-rate medical articles there, go and have a look.
As I promised yesterday, I'll explain what the LAS Major Incident policy and procedure is, and why you won't get me running towards two collapsed people.
First off, lets define a “Major Incident” is, from the little book I was given, “Any occurrence which presents a serious threat to the health of the community, disruption to the service, or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by the health service”, basically this means anything that has, or will cause, a large number of casualties. Anyone in the emergency services can declare a Major Incident, and to be honest its the one thing that makes me a little nervous, because you never know what you are going to see on scene until you get there.
The Potters Bar train crash was phoned into the Ambulance Service as a “Chest Pain”…
If I'm first on scene at a Major incident, then if I am the attendant I need to run around the scene to do a quick bit of reconnaissance, I'm not there to treat anyone. I then get back in the ambulance and radio in a “CHALET” report. This is…
C – Casualties (number and severity).
H – Hazards on the scene.
A – Access, meeting points, vehicle parking area.
L – Location, the map reference and best directions to get to the parking area.
E – Emergency services required.
T – Type of incident.
I'm then to work out the ambulance parking points, loading area and casualty clearing areas. Well, I say “I”, but I'm hoping that an officer turns up to do all that. When a fair ride collapsed in Alexandra palace and a Major Incident was declared officers outnumbered road-crews.
There is a big part in the LESLP (London Emergency Services Liaison Panel) booklet about how to set up a well run Major incident scene. Its a good site, run by the people who tell us what to do in a Major Incident, and you can even download the manual that we use. (Large .PDF)
Part of the LAS responsibility is for the first people on scene to do a Triage Sieve, this is essentially deciding who is most 'deserving' of our immediate treatment. This is only done when there are more casualties than there are rescuers. We do this so that we don't 'waste our time' dealing with someone who will probably die, to the detriment of being able to save other people.
We use a flowchart to decide which category patients fit into.
You start at the top left of the card and work your way through it for each patient. For example, if someone isn't breathing, and by opening their airway (tilting their head back) their breathing doesn't start then they are a 'Dead'. In a normal situation we would try to resuscitate a patient in this condition, but with a large number of casualties 'Dead stays Dead'.
We have on our ambulances a number of tags that you tie to the patient as you walk along making these snap decisions, it's something I hope I never have to do – walk amongst the wounded, ignoring their calls for help just tying tags on people…
'Immediates' get seen to as quickly as possible, as there is a chance we may save their lives, they are also normally the ones who get first transport to hospital. Then come the 'Urgent' patients, while the 'Delayed' can wait until last, and/or can make their own way to hospital.
It is important that we don't overload the local hospitals, so the two nearest hospitals are normally nominated as the 'receiving' hospitals with other nearby hospitals marked as 'overflow'. The 'receiving' hospital(s) tries to clear it's A&E department as quickly as possible and closes to normal 'walking wounded' patients.
The planners have thought long and hard about every major incident they can imagine, we have hundreds of contingency plans, training is ongoing, and every hospital in London has a decontamination unit. When I was working in hospital, I got training on how to use the NBC suits – and I'll tell you this, they are not the cheap and nasty ones…
If/when/should terrorists do something spectacularly nasty, I would like to think that we are as well prepared as we can be, but every incident is different in a million ways.
Why won't you catch me running towards two collapsed people? We use STEP 1,2,3 which means if there is one person on scene collapsed we proceed as normal, if it is two people then we proceed with care, if there are three people collapsed, then we hold back and get the chemical team in to have a look.