We will briefly discuss major incidents as helicopters have a role and it is also another area of pre-hospital care where you may be involved
This is why the RAF are interested in major incident management . This is a video clip of accidents that have involved aircraft taking part in major international exercises. Because of the risk, it is worth us knowing the outlines of major incident management.
This is the content of the presentation. This was a Russian aircraft going into the crowd a few years ago but we have had similar incidents in Ramstein in Germany and also Farnborough many years ago.
This is everyone’s aim at a major incident. You must not focus on one patient – it is essential to maintain an overview.
So it is not just the number of casualties: a single hospital may cope with 50 minor injuries but 50 polytrauma casualties would paralyse a network of general hospitals. Equally, a small number of casualties with specialist injuries such as burns or spinal would swamp a region. An incident in a remote location could also require an extraordinary response even for few casualties. A major incident for the Health Service is not necessarily one for the other services. For example, an industrial fire with the potential to contaminate will tie up the fire service but their may be no casualties. Alternatively, a passenger crash with all fatalities will be a major incident for the police, identification cell and casualty retrieval teams for example the PANAM Boeing 747 crash at Lockerbie.
These are images of recent major incidents in Iraq`and Chechnya. However, think if there is similar potential where you work.
In simple incidents the infrastructure such as road and rail communications are intact. In addition, the hospitals are intact and all staff are uninjured. In a compound incident the road and rail links may be broken, electricity supply is interrupted, gas mains are leaking, water is unavailable and the hospitals may have been affected and the staff killed or injured. This is the scenario in an earthquake, floods or volcanic eruption. Obviously far more difficult to impose order on such chaos. Incidents may be due to natural causes such as those mentioned –also consider mud slides.
Or man-made incidents : These often involve transport eg Train crashes in India and the UK Aircraft crashes Major motorway accidents Can also be Chemical incidents – Bhopal in India. Nuclear incidents – Chernobyl Terrorist – Moscow Compensated There is the potential to move enough resources in to the incident to cope with the casualties Uncompensated There is not the potential to move in enough resources; either because there are not enough resources in the region or they cannot be moved to the site of the incident
The emergency service personnel respond to incidents which have multiple casualties on a regular basis. If procedures and equipment that you implement and use on a regular basis can be coordinated at a larger, more complex incident then you will be able to function more effectively, both as an individual and as a team. This ultimately increases the number of survivors from the incident. For the above incident to function correctly and produce the maximum survivors requires ; Effective command, both single and multi agency. Rescue personnel to work safely. Accurate scene assessments, communicated effectively. Correct patient priorities. Subsequent treatment. Correct transport to definitive care. This is the structure that is required at the site of a major incident.
This is the pnemonic to report a major incident. It gives all the essential initial information that a control room will require. This could quite easily have to be given by medical personnel arriving on board a helicopter if they are early on scenne because other methods of transport have been impossible in a natural major incident. The image is of a UK Chinook crash in the S of Scotland that I attended – I was not, however, first on scene.
The previous slides have indicated what an incident is and the problems we are faced with to produce the maximum survivors . This slide gives a structure as to how we can achieve this. Key points :- A structured approach is needed. Treatment is not the first on the list.
Command and control are essential to direct helpers appropriately and maximise the number of survivors. If you are first on scene then you cannot concentrate on one casualty or you may let 6 others die. If someone else is in charge as the Medical Incident Officer then you will be given a specific task to perform
This is the UK pattern of command and control with 3 levels of seniority within each emergency service. The Gold, Silver and Bronze levels are commonly used elsewhere and major incident exercises help to increase familiarity.
Communications are almost always poor but are essential to effective management. Consider all available options: different radio frequencies, mobile telephones, people to carry messages …
The next series of slides show how the control of a major incident is built up and order comes out of chaos
This is the layout of a typical casualty clearing station that may need to be set up at the scene of the incident to hold and stabilise patients if they cannot be transported away quickly. We will discuss triage shortly. ALP is the Ambulance Loading Point. Triage is a dynamic process as casualties both improve and deteriorate during evacuation and their triage category needs to change with them.
Triage involves the sorting of patients so that appropriate patients are treated first thus maximising the number of survivors. In a major incident, it may not be possible to treat everyone and the efforts must go on those who have the maximum chance of survival.
These are the triage gradings used in the UK: T1 need immediate treatment to survive and must be moved quickly T2 need urgent treatment T3 are non-urgent T4 are a difficult group as they may require so much care that they will disadvantage the remainder of the casualties ie if you treat one T4 then 3 of the T3s will die. This is a moral and ethical judgement and must be made by a senior clinician
The Triage Sieve is one simple way of triaging patients based on their physiological measures – it is quick, simple, reproducible and dynamic. It is used by the British Army and a number of our Ambulance Services.
There are supporting cards for the Triage Sieve and they also allow you to monitor how many patients you have seen and what triage category they are in. This information can then be passed to the Medical Incident Officer and transmitted to Gold Control who are responsible for providing strategic resources.
The Cruciform is another type of Triage Card
There are numerous forms of Triage Cards but not all of them are dynamic or user-friendly.
After casualties have been Triage Sieved then they need to be further assessed in a Triage Sort. This may occur in the Casualty Clearing Station
The Triage Sort looks at Glasgow Coma Scale, BP and Respiratory Rate and has been well validated against survival chance.
The Triage Gradings are based on the Triage Revised Trauma Score
Mortality can be compared with the score on the Triage Sort as shown. Hence, a score of 10 means that the casualty has a 88% chance of survival
MAJOR INCIDENTS <ul><li>Wg Cdr David Bruce MBE MSc MBBS FIMC RCS(Ed) MRCGP AFOM DAvMed MRAeS AKC </li></ul>Ecuador Jun 04
MAJOR INCIDENTS <ul><li>Definition of Major Incidents </li></ul><ul><li>Relevance </li></ul><ul><li>Management </li></ul><ul><li>Triage </li></ul>Ecuador Jun 04
MAJOR INCIDENTS Your aim at any major incident should be to produce the largest number of survivors
MAJOR INCIDENTS <ul><li>Any incident where the number, severity or type of live casualties, or its location, requires extraordinary resources </li></ul>
Major Incidents <ul><li>Simple </li></ul><ul><li>Compound </li></ul><ul><li>Natural </li></ul><ul><li>or …….. </li></ul>
<ul><li>Man-made </li></ul><ul><li>Compensated </li></ul><ul><li>Uncompensated </li></ul><ul><li>Most are man-made, simple and compensated in Europe </li></ul>
Routine Incidents <ul><li>Scenes similar to this are routine events in emergency service work. </li></ul><ul><li>Effective scene management allows for; </li></ul><ul><li>inter-service command </li></ul><ul><li>safe working practices </li></ul><ul><li>comprehensive scene assessments </li></ul><ul><li>effective communications </li></ul><ul><li>triage </li></ul><ul><li>appropriate treatment </li></ul><ul><li>transportation to definitive care. </li></ul>
TRIAGE SORT M - Major Incident declared E - Exact location T - Type of incident H - Hazards present and potential A - Access to scene N - Number and type of Casualties E - Emergency services on scene Major Incident
Command and Control <ul><li>Gold – strategic control, often remote </li></ul><ul><li>Silver – tactical, on scene comms / incident control room </li></ul><ul><li>Bronze – operational, functional commanders on scene and may be multiple </li></ul>
Casualty Clearing Station ALP Triage Point Body Holding Area Equipment Store T3 T2 T1 T4
Triage <ul><li>Trier ‘to sort’ </li></ul><ul><li>Used when casualties outnumber skilled rescuers </li></ul><ul><li>Recognises that you will not be able to save everyone </li></ul><ul><li>Repeated learning in conflict </li></ul>
Gradings Expectant T4 Delayed T3 P3 Urgent T2 P2 Immediate T1 P1 Plain Colour Civilian RAF/ NATO Army
Triage Sieve T3 Delayed T2 Urgent T1 Immediate Dead Walking wounded? Breathing? Open airway Breathing rate <10 or > 30? Pulse rate > 120 Breathing? No No Yes No No No Yes Yes Yes Yes