Maj. Inc.

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.

Adult Triage Sieve

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.

7 thoughts on “Maj. Inc.”

  1. France have the ORSEC plans (stands for ORGanisation des SECours – organisation of emergency services). They have subdivisions and cover things ranging from an oil spill to a nuclear accident via floods and cyclones in the overseas departments. Their triage system uses the following categories: EU- immediate treatment needed; U1 – treatement within 6 hours needed; U2 – treatment needed withing 18 hours; U3 – walking wounded; UD – dead + don't bother to resussitate. The plan aims to coordinate the 5 services which may be needed in an emergency (for example Police + Gendarmerie are responsible for the protections of people + goods and are also tasked with victim identification). A major Orsec operation was after the AZF accident in Sept 01. They are graded depending on the area they cover (department, 1 of 4 zones or national – so far the National plan has never been used – touch wood).

  2. The Potters Bar train crash was phoned into the Ambulance Service as a “Chest Pain”… (!) I'm intrigued; is there more of a story to this? It seems quite odd…


  3. Reminds me: while a student in the 1970s in Bishops Stortford, I played the part of a casualty in a mock aircrash at Stansted airport. The emergency services did not know that it was only an exercise until they got to the scene, and then everyone relaxed. I wore a tag that said I had a broken back, and I lay in the wet November leaf mould for about 20 minutes. After that, I was put in an ambulance, and off we went to Harlow – the siren going neenaw, and the ambulancemen cursing because my “broken back” was travelling with a “fractured skull” in the other bunk. Apparently, one should have had a fast (if bumpy) ride to hospital, and the other (the broken back, I guess) should have had a smooth ride. I was acting the part as if an Oscar depended upon it and spoke only when, at the hospital, the medical staff were writing down a description of me-as-casualty: the doctor made as if to lift my eyelids manually, to see what colour my eyes are, and I very quickly said, “brown”.Made a change from going to the laundrette, or whatever, but not terribly confidence-inspiring. I hope that the authorities learned a lot from that exercise.

    Rachel in SE7

  4. The way I heard it, one of the injured came out the station in front of some kids and complained of having pain after the accident. The kids phoned 999 and the first question that our dispatchers ask is “does the person have any chest pain?” to which the kids answered yes…Unlike other major incidents I was working the night shift, so I could sit indoors watching it on telly, and occasionally seeing the faces of the docs/nurses I worked with.

  5. Interesting.In my part of the US we call these “Mass Casualty Incidents” (MCIs). The triage is a tad different, but basically the first responders on the scene label people as you do – dead, walking wounded, second to go, first to go. In my EMT – Basic class one of the questions was who should be the triage officer. The expected answer as a first-responder or EMT-B who is a cold-hearted bastard (or bitch). The logic being that those with a warm heart and/or more advanced providers would think of ways to treat the “dead” patient when the right move is to keep walking.

    Tough job at that point.

    May none of us have to deal with this situtation in anything other than our nightmares.

    DJ “The Professor's Vent”

  6. I did some courses at the Emergency Planning College when I worked in Local Government, whcih convinced me that I never want to get involved in the real thing.Ian

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