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Major Incident Management

Posted Apr 22 2012 7:10pm

After some practical sessions practicing for our Objective Structured Practical Examinations (OSPEs) that were approaching at an alarming rate of knots, we rounded off the day with a session on Major Incident Management.

‘We were slated in the 7/7 report – why do you think that is?’ The thing with teachers is they often repeat themselves. I remembered the answer from an anecdotal bit of evidence he told us a few months ago. I said it was because the first on scene wasn’t actually treating, they were just counting casualties and retreating to feed that to control. ‘You’re absolutely right’ Klippity said. The problem lies in the idea of a ‘windscreen assessment’, where in the event of a major incident, what used to happen was the first on scene went in, counted all injuries, went out and reported the findings to control. Apparently, seriously injured patients with traumatic amputations didn’t appreciate being ignored as someone strolled around with a clip board, ignoring their pleas for help. The system’s now changed, so the first on scene will not only assess and report back, but will also apply tourniquets and recruit any non seriously injured to help apply bandages and pressure to wounds.

In major incident management, we’re moving to a role, not rank method. This means that if an officer appears, they won’t automatically assume command of the situation from, say, a Tam Leader, provided they’re doing a good job. The emergency services: fire, police, and ambulance, will meet every 15 minutes to have a quick brief on any changes in the situation. Good communication underpins all aspects of an efficient way of dealing with a major incident. There are a number of criteria an incident must meet in order to be called a major incident. For the NHS, these are:
Number or type of casualties overwhelmThreat to overwhelm normal servicesSerious threat to the health of the communitySpecial arrangements are needed to deal with themInternal disruption to the health service
If it doesn’t meet any of these criteria, the incident is considered serious, but not major. Serious incidents include trains stuck in tunnels, suspect packages, civil disorder, hospital fires and so on. These incidents have the potential to limit service provision to the rest of the population and involve several emergency services on scene. They can always tip into the major category if, for instance, the suspect package goes off and happens to be full of nerve agent. The way of reporting the incident is very similar either way. The mnemonic we use is ‘METHANE’ for major incidents and ‘ETHANE’ for serious. This stands for 
Major IncidentExact LocationType of IncidentHazardsAccessNumber of casualtiesEmergency services required.
In the London 7/7 bombings, the first paramedic on scene told control very simply to send everything. Klippity flashed pictures on the projector and asked us to judge whether we thought it was serious or major, not forgetting that it could move from one to another. ‘Kermit, describe this scene to me’. It showed a massive fireball on a landing strip, the nose and wings sticking out of the sides. ‘Oh shit’ was his reply, and it was a pretty apt response. In fact, before we engage our brains, that’ll be the first response we give, followed swiftly by ‘send everything’. We’re only human after all. 

The function of triage is to maintain the largest numbers of survivors. In a major incident, there are two triage processes. Triage sieve and triage sort. The patients will all be sieved initially, which involves the practitioner walking around and prioritising the victims 1 to 5. This determines in what order they’re taken out of the hot zone to a casualty clearing station in the warm zone. Here they’re triaged again and sorted into the treatment order. Here they can either move up or down in priority. The tags they get issued are:
1-Immediate (red)2-Urgent (amber)3-Delayed (walking) (green)4-Expectant (about to die) (blue)5-Dead (white or black)
Consider the psychological implications of putting this on a patient. Are you enhancing their patient experience?

Basically, anything other then a 3 ain’t good. ‘Do you think people switch numbers?’ Asked Klippity. ‘My legs hanging off, why am I a 2 and he’s a 1?’ ‘No, you’re talking, sit down and shut up. Or hobble off’. The reason behind the remark was because the patients are all issued tags which are placed on their person, either on their wrist or ankle. ‘You need to think about the psychological impact of someone who’s dead’. The class laughed and Klippity, with mock indignation, corrected himself. ‘Not them, the person next to them’. ‘Yeah like what watch do they have, where’s their wallet’ came someone’s remark.

We practiced the triage process from the comfort of our desk. The patients vital stats were given to us, together with a picture, and we held up the card we thought best matched their condition. We went through both the initial sieve and the sort, following the algorithms in the major incident kit bags we get issued.
It’s a cold and calculating process, a far cry from all the patient experience and autonomy we’d been learning for less extraordinary situations. ‘But all we’re doing is following the triage flowchart. Yes or no. Priority 1 of priority 2. If you’re excited, things will go wrong. And when you start to look at it, you understand why we got criticised for 7/7’. As a practitioner, major incident triage would be one of the hardest things we would do in our career. And living in a major city, Klippity emphasised that we would, in our life-time, attend a major incident, terrorist or otherwise.

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