Introduction Traditionally disasters are divided into “natural” and “man made”. However the pressures on the poor to live in earthquake and flood prone areas and the power of the rich to protect themselves suggests to many that all disasters are ultimately man made. In 1988 an earthquake in Armenia killed more than 25000 people. One year later an earthquake of similar magnitude struck California USA and killed 300 and this number only because building regulations had been illegally ignored. The vulnerability of the affected population can contribute as much to the disaster as the triggering event and poverty constitutes the greatest vulnerability. This also compounds the other vulnerabilities associated with poverty - environmental degradation, poor land use and rapid population growth. The death rate from disaster is six times higher in richer than in poorer countries and not surprisingly therefore more than 90% of victims of “natural” disaster in the latter part of this century lived in Asia and Africa. A disaster may be referred to as “simple” where the infrastructure remains intact and “complex” where resources have been compromised. In some countries of course resources are always
compromised and any disaster is complex. Events may also be described as “compound” which is another term for “complex”. Of more obvious meaning and therefore of more use is the use of the terms “compensated” and “uncompensated”. These descriptions may describe the whole of the event or more commonly a phase within the event. It is important to recognize that whilst many disasters are characterized by an initial overloading of the local services some events may be compensated for in the short term but a system decompensate later, and often when wider attention for the incident has moved on. Key points •
It may be that all disasters are ultimately man made
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A disaster may be referred to as “simple” where the infrastructure remains intact and “complex” where resources have been compromised
The overwhelming of local resources will trigger the need for triage. Three or four multiply injured patients presenting to a small rural emergency department may overwhelm available resources, at least for a while. A
single critically ill or injured patient will overwhelm an under prepared department. A very large number of patients with relatively minor conditions will overwhelm the best prepared. Whether an incident tips over into a disaster rests in the balance between the size of the event measured in the number and/or complexity of casualties and the ability of the doctor/institution/region/nation to respond adequately. The latter will be determined by their training, preparedness and pre-existing and residual resources. It is the failure to respond adequately and to be overwhelmed that characterizes a disaster. Major incidents This term is generally used for those events that could potentially threaten an institution but are compensated for without collapsing into a disaster. A number of definitions are in use. A major incident is any emergency that requires the implementation of special arrangements by one or more of the emergency services health service or local authority. It may also be defined as an incident where the number, severity or type of live casualties or its location, requires extraordinary resources. However even events involving large
numbers of dead and especially when there are no survivors at all can still represent a very special and often very difficult major incident and in the public's mind may be the very worst kind. It may also be defined as any occurrence that presents a serious threat to the health of the community, disruption to the service or causes such numbers or types of causalities as to require special arrangements to be implemented by hospitals, ambulance services or health authorities. Common to all definitions is the concept of a very unusual event that requires an extraordinary response. Not all major incidents involve trauma. Chemical and nuclear accidents create major incidents of often huge proportions but do not usually require the input of a surgeon. Some involve the services of specialist surgeons for example when there are a large number of burns. Key points •
Major incident - this term is generally used for those events that could potentially threaten an institution but are compensated for without collapsing into a disaster.
Prepare practice and have a plan The response to a single critically injured patient probably
represents an institution’s best response to a stressful event. Major incidents can be seen as progressively larger versions of this scenario. As performance is unlikely to get better in a major incident, an institution has a daily reminder of its best response to a major incident in its response to a major trauma. The range of injuries and problems that occur simultaneously in a severely injured patient require the coordinated response of a multi disciplinary team who have been trained and appropriately equipped. So it is for a major incident, albeit in a more complex setting. As the number of casualties grows, so must the response, expanding to involve the whole of the hospital and at times neighbouring institutions. In the largest of catastrophes national and even international assistance may be required. The principles throughout remain the same however with senior staff supervizing the work of others, agencies continuously communicating with each other and casualties being repeatedly triaged as the evolving incident changes their priority for treatment within the overall scheme of things. To have any chance of getting a major incident right you must first get a major trauma right. In planning for major incidents many authors and institutions plan
their response on the number of “minor” and "major" casualties they could cope with. However a word of caution. Until a patient has been assessed and examined the severity of their injury may not be fully appreciated and a large number of patients of any severity all arriving at once will place considerable strain on even the best of emergency departments. In fact a hospital’s capacity for treating severe casualties will be limited by the number of ICU beds available at that time or that can be vacated or staffed within a very short time. Planning must prepare doctors and institutions to co-operate and not compete. A realistic appreciation of the capacity to cope will allow early and safe onward transfer of casualties and as wide a distribution as possible. Critically, if inappropriate over triage of patients to one institution has occurred, staff at that institution must recognize the need to transfer on whenever possible. A trauma system that usually directs severely injured patients past smaller hospitals towards a specialist trauma centre must not be misused to direct all patients to the centre in a major incident. All the hospitals within the system must share the burden of the response but with the trauma
centre taking special responsibility for those with the most complex injuries. Key points •
The response to a single critically injured patient probably represents an institution’s best response to a stressful event
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Until a patient has been assessed and examined the severity of their injury may not be fully appreciated and a large number of patients of any severity all arriving at once will place considerable strain on even the best of emergency departments.
Plans Plans must be discussed and agreed within the emergency department then outwards from there. Each department in the hospital must sign up to them with staff understanding their responsibility to be familiar with and up to date with plans for a major incident. Procedures should be discussed and agreed with all relevant external agencies with the ambulance service playing an integral part at every stage . Plans must be based on the familiar. Plans that involve staff
moving their activities to another location, however nearby, will inevitably create unnecessary tensions and confusion or be ignored – adding further to the confusion. Staff should work in areas and roles with which they are most familiar. When distressed we all gain comfort from the familiar and a major incident is not the time to learn new skills. A comprehensive major incident plan should be available to all departments and staff required to read it before taking up their appointment and at least yearly thereafter. The plan should identify roles not individual personalities who may be unavailable on the day of the incident. Who might fill these roles can of course be indicated but the most important function of the plan is to identify the key roles that must be filled by those available. As people more appropriate to a specific role become available they can takeover and the plan must illustrate and emphasise the need for flexibility. Each member of staff should be given action card for their role in a major incident and a full file of action cards be available in the A&E department at all times. Training for major incidents can
take several forms but should involve all staff at least at some stage. The simplest and most repeated exercise should be a communications exercise whereby staff are called unannounced to establish the likely strength of the immediate response on any given occasion. If carried out about once a year it will remind staff to stay in touch with the hospital when on call. Key members of staff can engage in a table top exercise with members of the emergency services and other potentially receiving hospitals. This helps establish how patients might be distributed across a region. Individual departments can run through their procedures and “walk through” patients to familiarize themselves with the dynamics of patient through put and where they will be working come the event.. Every five years or so an institution should look to holding a full scale practice. If carried out not too frequently but involving all staff it can quickly highlight the strengths and weaknesses of current arrangements and remove some of the mystery that often surrounds these events.
Those who may potentially be involved in on site care should look to exercising regularly with the emergency services to ensure they have some experience of the realities of working out of doors and in difficult circumstances. In the UK there is a major incident medical management and support course (MIMMS) which all doctors who might be involved in a major incident at a senior level should attend. Debriefing It is important that such extraordinary events are concluded with an occasion for all those involved to have an opportunity to relate their contribution and learn from the contributions of others. In this way the collective knowledge of the institution grows and individuals are made to feel a part of the overall effort. All staff should be thanked by those in charge. It is also an opportunity to identify those who may have been psychologically traumatized by the event. Counselling Psychological support should be offered confidentially to all those involved but in practice psychological sequelae will be minimized if staff are adequately trained and equipped, put to work in areas appropriate to their skills and tasked to a level appropriate to their training and qualifications.
The alert procedure This is usually activated by the ambulance service but may be instigated by the police. At times the unheralded flood of patients into the emergency department causes the hospital itself to declare a major incident. It is important that an incident is formally declared as failure to so do even in the face of the obvious will lead to confusion and unnecessary delay in mobilizing further resources. It is better to declare an incident and stand down than to begin mobilizing resources too late. In the UK the standard format is as follows – Major incident standby. Major incident declared - activate plan. Major incident cancelled – stand down. Major incident – casualty evacuation complete.
Pre hospital Hospitals must be prepared to provide support to the emergency services at the scene of an incident. Those likely to be required must be adequately trained and equipped for the event. The delivery of safe and appropriate medical care in the pre hospital setting is increasingly recognized as a speciality in its
own right. Training courses are available in the UK with specialist examinations in immediate medical care held by the Royal College of Surgeons of Edinburgh (DipIMC RCSEd) and a diploma in the medical care of catastrophes from the Society of Apothecaries of London (DMCC). An essential component of safe and effective pre hospital medical care is a recognition of the place of doctors in the overall scheme of things. In large-scale disasters, safety, shelter food and water will take priority over medicine. In lesser events safety and rescue will still take priority. Doctors must truly appreciate that they are part of a team and a team of which they are unlikely to be the overall leader. There are recognized tiers of command during a major incident. Bronze is operational and describes the medical teams involved with the on site care of casualties or the hands on care of patients in the hospital. Silver is tactical and refers to the on site incident officers who control activity at the scene and the triage officers at the hospital. Gold is strategic and describes medical directors of the ambulance service and hospitals.
The emergency services will establish inner and outer cordons at the scene. The outer will exclude all but official personnel and the inner circumscribe the rescue area itself Medical Incident Officer (MIO) The most senior doctor at the scene will be designated the Medical Incident Officer. Their task is to carry out triage of the casualties in association with the most senior ambulance officer – the Ambulance Incident Officer. At the scene the police and sometimes the army will be in overall charge. On arrival the MIO will locate the command and control centre and report to the police officer in charge. The MIO needs to wear highly visible and fire resistant clothing including a helmet. He/she will be clearly labelled as a doctor and at all times carry and show on demand a recognized official ID. In the UK, the Ambulance service are in charge of the on scene medical response. The MIO must quickly report to and stick with the Ambulance incident officer and as a team they will supervise and direct the despatch of casualties. They will decide in which order they will leave the incident and to which hospital they will be taken. This latter function is as important as the former. It is imperative that a balance is struck between
despatching the patient to the most appropriate hospital for their needs and not dangerously overloading one or more institutions. These decisions are made jointly between the ambulance and medical incident officers. It is the duty of the ambulance service in the UK to provide communications facilities for the medical team but an appropriately equipped and trained team will already have their own. The ambulance service will establish a casualty clearing station where the medical team will be based and carry out triage. The Fire service is in charge of the rescue. In addition it is their responsibility to establish decontamination facilities. Medical staff must only enter buildings etc after receiving clear and recent permission from the fire service to so do. Equally the fire service will decide who is contaminated and when they are decontaminated. In addition to performing triage the MIO will supervise the mobile medical team(s) and communicate regularly with all the receiving hospitals.
Fig. 3.2 Equipment Protective clothing inc. hard hat, gloves and eye protection (a, b, c)
Tabards (d)
Notepaper and/or pocket Dictaphone (e) Radio (f) Triage labels (g) Medical bag (h)
The mobile medical team Ideally this will be drawn from supporting and not receiving hospitals. The members of these teams should be identified beforehand to allow for appropriate training. They should be familiar with the equipment they will be carrying and wear full safety clothing including a helmet. Key points •
Ideally this will be drawn from supporting and not receiving hospitals
The hospital response In overall medical control of the incident will be a senior doctor, not themselves involved in treatment or triage. This will usually be the medical director of the institution or their deputy. Someone must assume this role until a designated person arrives. Alongside the chief executive of the institution and the director of nursing they will take their place in the designated control room. They will liase closely with the police and triage officers. A member of the administrative staff must be tasked very early on to deal with the media who should be kept informed by regular and punctual briefing sessions and well away form the treatment areas. The immediate response to a major incident will involve those staff
already in the building and rostered to be on call. The calling in of additional staff should be controlled and the plan should clearly indicate where they rendezvous. To avoid crowding out the emergency department this should be a designated place near to but separate from where the casualties arrive. Arriving staff should be registered and provided with a tabard that identifies their grade and speciality and given special documentation packs. These should contain a unique set of pre numbered notes and pathology request forms. This will allow for a rapid register of the patients even without names. Included in the pack is a property bag again pre numbered. When preparing staff for a major incident it should be emphasised that staff all ready on duty or on call are likely to cope initially and that additional help will be required some hours later and certainly by the next day. The excitement of wishing to be involved at the start should be tempered by a sense of responsibility to supporting the longer term needs of the victims. The hospital switchboard is the most important area in a major incident and staff must protect it. If an incident has occurred and you are off the premises don’t ring in to the switch board. Ideally wait by the number you have already given to the switchboard for such an emergency. Staff already in the building should by pass the switchboard whenever possible by using direct dial facilities or commandeering pay phones – which can be converted to direct dial in an emergency by prior arrangement with the phone company. Individual departments can assist by arranging their own cascade system for call out. An initial call from the department initiates a further cascade of calls from the recipient and so in. The use of pagers can further relieve the burden on the telephone switchboard. Internal communication can be greatly facilitated by the use of “runners” and is a good use of non qualified volunteers. Mobile phones are potentially of great use but the local cell can quickly become blocked with the weight of traffic. The media in particular dominate their use and will ring their news desk then keep the line open for as long as possible to protect their own access to the cell. This problem can be overcome by initiating “access overload”. Recognized agencies can gain prior approval from the government and confidential access code words to limit access to the local cell(s) to certain approved mobile numbers.
All routine work must stop as soon as an incident is declared. Urgent consideration should be given to the transfer of patients to other institutions to make room for the reception of casualties. With modern transport facilities one's imagination must stretch to considering securing the assistance of institutions far away from ones own. At all costs one must resist the temptation to see the event as special only to you and one in which you’ll cope at all costs. In developed countries there is often little need to compromise the care of patients in this way, even in the face of a major incident, if one involves all the resources in an area and sometimes in a country. Furthermore whilst the initial reception of casualties may last a few hours their ongoing surgical management may consume the human and physical resources of a hospital for months. Co-incidental emergencies unrelated to the major incident may still present to the hospital usually unannounced. These have to be absorbed into the triage process regulating the wider incident and take their place in the overall priorities identified by the triage officers. Key points •
All routine work must stop as soon as an incident is declared
Chief triage officer This will usually be the consultant/specialist in charge of the Emergency department or the most senior doctor in the department until he/she arrives. A guiding principle throughout disaster management is to avoid precious commodities such as senior experienced personal being captured by and therefore lost to a single patient. Rather such people should stand back a little and prioritize the casualties and supervise and direct the work of the less experienced. The chief triage officer places themselves at the door of the emergency department and all casualties will pass before them. By applying a quick triage sieve casualties will be divided into categories 1,2,and 3. Category 3 will be directed away from the main treatment areas to a designated minor area. Category 1 will go into the resuscitation bay and category 2 into the major treatment areas. The senior doctor in each of these areas will perform further triage to identify further priorities within patient groups or within treatment needs for an individual patient. Staff will be organized into teams assigned to individual patients and
given clear instructions by a designated team leader. All staff should wear large clear tabards that identify their grade and speciality. In the confusion of a major incident it is important that senior doctors know at first glance the resources available to them and do not over task the less experienced. It also acts as an extra protection against the unwelcome intrusion of the media. Surgical triage officer Once patients that might require surgery have been identified by the emergency department staff they will be referred to the surgical triage officer. Again this should be a designated senior member of staff. Rather than operate themselves the surgical triage officer will identify the type and limitations of surgery to be carried out and the order in which patients are to be treated. Triage •
To do the most for the most
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A job for the most senior person available
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Is to be done quickly but repeated continuously
It will be done first where the casualty is found, repeated on scene at the casualty clearing station, repeated when the casualties are despatched, carried out on arrival at the receiving hospital, repeated prior to surgery or other treatment and continuously updated until the patient is removed, discharged or dies. From the French verb trier meaning to sort, the word is used to describe the process whereby casualties are sorted into priorities. This process is an extension of the triage process whereby a severely injured patient is surveyed to identify those conditions that require treatment before others. An individual’s injuries are triaged and priority given first to Airway problems then Breathing problems and Circulation. Some injuries may be so minor that treatment can be delayed or so severe that no treatment can be offered. Just as in a multiply injured patient you can’t treat every injury first so triage is performed when the number of those requiring treatment exceeds the number of those available to treat.
Any discussion of triage is not complete without mention of Baron Dominique Jean Larrey, Surgeon Marshall of Napoleon’s Imperial Guard. It is he who is credited with recognizing the importance of prioritizing patients for surgery, sorting through the chaotic jumble of patients left in the aftermath of battle to rescue first those most likely to benefit from early treatment and it has to be said be most likely to be fit to return to the battle. His belief in the power of early surgery led him to break with battlefield tradition and rescue patients directly from the field of battle rather than wait till darkness brought a break in hostilities and cover for the rescue. The theatre of war still provides us with the basic models, and unfortunately repeated practical demonstrations, for developing and improving triage systems. Perhaps the greatest lesson from these experiences has been that priorities for the individual patient change as the condition and number of other casualties changes. Triage is dynamic and continuous. Triage involves rapid, repeated and authoritative decision making. It is therefore a job for the most experienced. When resources of skill are limited the greatest good for the greatest number may best be achieved by tasking your most experienced worker to identify those most in need of treatment and identify to the less skilled those procedures (and no more) they should perform. Unfortunately there are two triage “systems” in widespread use in the UK although they are really different names for more or less the same thing. The “P” system refers to priorities. P1 is immediate priority; P2 urgent priority and P3 delayed priority. The “T” system refers to treatment and describes T1 – immediate treatment, T2 urgent treatment and T3 delayed treatment. The T system also includes a T4 category – expectant. These patients would receive immediate treatment in normal circumstance but the severity of their condition is such that the likelihood of survival is so small that the greatest good for the greatest number dictates that resources are nor “wasted” on their care and they are out to one side in favour of those who will clearly benefit from immediate care. Such decisions require great experience and maturity. Whoever makes such decisions will have to live with its consequences – unlike the patient. These decisions must be constantly revisited. The first triage scan might very well reveal few patients in need of immediate life saving care and a T4 patient move up the scale to T1. It takes maturity to accept the consequences of what appears to have been a now avoidable delay and greater maturity to act appropriately
when a more “deserving” case appears. In fact the need for T4 decisions in civilian practice is rare but not uncommon in war, particularly with regard to gunshot wounds to the head. However large scale disasters in remote and poor areas of the world will pose similar triage challenges to members of rescue teams.
Triage Categories
1-
Life
threatening, immediate care required. 2
urgent
care within 6 hours
3-
delayed
4-
dead
5-