Major Disaster Plans

Disasters happen and when major disasters strike they put considerable strain on the system. This is partly because of the probable scale of the number of injuries but also because a major event is likely to disrupt the infrastructure that should help to deliver relief.

The nature of the problem may be a massive accident, a natural disaster or even an act of terrorism. The last is most likely in a major conurbation, especially London, and it may involve not just explosions but chemical, biological or even nuclear attack. The matter may be compounded by panic by those caught up in the disaster.

Every local government authority and every local health authority should have plans in place for dealing with such eventualities. They will involve hospitals, ambulance, police and fire services, traffic control, provision of accommodation, counselling services and strategic command. An integrated response from all participants is essential.

Although major cities are most at risk, especially from terrorism, it would be wrong for rural areas to neglect their duty. They are just as likely to have major accidents such as a train or aeroplane crash and terrorists may try to strike at a dam or a nuclear power station to induce a leak of radioactive material although it would probably take a direct strike from an airliner to be able to puncture the reactor of a nuclear power station. Disaster planning should take into account the locality and what may be vulnerable there. This might be an airport, a large chemical works, a nuclear power station or even vulnerability to natural disasters.

The Health Protection Agency has been responsible for much planning, looking at many scenarios. They also run a great many training programmes. Burns, blasts, chemical, infectious and nuclear incidents are all planned for and the plans rehearsed.

Since the 1990s there have been multidisciplinary plans in place to deal with emergencies. These need to be updated and to be tested with periodic exercises to ascertain that all runs well and to discover any problems that require solutions before the real event. It also helps the team to gain familiarity with the equipment and with each other. Just as no football team would take the field for an important match without having trained together, no disaster team should be without both individual and team training.

This must go through the appropriate channels so that all necessary personnel and services are informed. Full and relevant information must be gathered. There are 2 mnemonics to help with this. They are METHANE and CHALET and the contents are similar.

An ambulance is likely to be at the scene at an early stage. If it is a major incident, the crew should not get involved in treating individuals but they need to assess the situation and report back to control. The senior crew member will be the Ambulance Incident Officer and he is in charge until a more senior officer arrives. Survivors are better served by an informed and coordinated response than by instant treatment of a few on arrival. His tasks include:

• Assessing the scene
• Declaring a major incident and giving a situation report (SITREP)
• Deciding where to locate the Control Point, Casualty Clearing Station, Ambulance Parking Point as well as planning ambulance entry and exit routes
• He is in charge of communication with all health service personnel on the scene
• He discusses with his chain of command the need for additional support such as a Medical Incident Officer (MIO) on scene, Mobile Medical teams (MMTs) and additional equipment.

By now there may be several ambulances on the scene but the control vehicle is recognised as the one that still displays its flashing lights. The Ambulance Incident Officer (AOI) is responsible for and in command of all health service personnel on the site unless a Medical Incident Officer (MIO) is present. The police and fire service will cordon off the area. No one should enter this area without permission from the appropriate officer.

The hospital major incident plan can be activated either on the request of the Ambulance Service, or autonomously by the hospital.

When a disaster is declared it is necessary to try to gauge the scale of the problem and to make a rough estimate of the number and nature of injuries. If an airliner plunges from the skies there will probably be no casualties, only fatalities. It is common practice for one hospital to be the reception centre for injuries whilst another sends out staff to the scene. The receiving hospital needs all its staff on site. A centre of operations is set up there with clinical and managerial input. The clinical director should be a senior doctor with authority who is not directly involved in the care of the injured as he cannot do both jobs simultaneously. Hence he will almost certainly not be the A&E consultant or probably any surgeon. The command and control centre will probably not be in A&E as it will be extremely busy there. Routine admissions must be halted and all patients who can possibly be discharged should be. The extent to which this will need to be done is dependent upon the anticipated number of admissions.

The A&E department will become extremely busy. If very large numbers of casualties are expected it would be helpful if GP surgeries could help with those who do not require the facilities of a hospital. This will also require cancelling a certain amount of routine work to clear time and space.

The scene of a major incident is a dangerous place. There may be structural instability, fire, smoke or nuclear, chemical or biological hazards. Terrorists sometimes plant secondary devices to kill or injure rescue workers. A rescue worker who becomes one of the injured is not aiding the problem but contributing to it. Priority for safety is in the order of self, site, patient. GPs will probably not be involved with work at the scene unless they have specific training. Members of BASICS are an obvious example but they should be known to the organizers and part of the team.

On site, personal protective equipment (PPE) must be available and worn. This includes helmet, jacket, overalls, protective gloves, boots and ear and eye protection. There should also be personal identification. The Ambulance Safety Officer will refuse entry to the site to anyone who is not properly equipped.

As with a soldier preparing for action, equipment should be ready, together and familiar. Equipment should be ready in kit bags. MMT kits contain limited airway, breathing and circulation equipment. They do not contain antidotes for chemical weapons, or non-emergency drugs such as tetanus vaccine. All team members must be familiar with the equipment and how to use it. Additional equipment should be added only for a specific reason.

An MMT usually consists of a doctor and a nurse or two of each. They should stay together unless ordered to do otherwise. Ideally they should not come from the hospital that will be receiving casualties as they need all their staff but in a remote area this may not be practical.

When the MMT arrives at the scene they should report to the Medical Incident Officer (MIO) whose position will be apparent from a flashing green beacon. If none is present they should report to the Ambulance Incident Officer (AIO) at the ambulance with the flashing blue light. The team will probably be sent to the Casualty Clearing Station but may be required to assist with the triage and treatment of entrapped casualties. It is not the role of the doctor or nurse to get involved in search and rescue, counselling victims or commanding ambulance personnel.

The whole area around a major incident will be cordoned off by the police, and access controlled. The area within the cordon is the silver area. All medical activity within the silver area is directed by the Medical and Ambulance Incident Officers, working together. Doctors are under the command of the MIO and ambulance personnel are under the command of the AIO.

An inner area around the incident is termed the bronze area. Medical personnel will only enter the bronze area if instructed to do so by the MIO, and if permitted to do so by the service responsible for safety at the scene. This is usually the fire service. It is a dangerous area and medical activity within it is limited to:

• Primary triage
• Evacuation of casualties
• Treatment of trapped casualties

A doctor may also be required to certify death. Casualties are evacuated to the Casualty Clearing Station that will be close to the scene yet at a safe distance and linked to the ambulance loading point. The Casualty Clearing Station is for secondary triage, initial stabilisation, and preparation for transportation to hospital.

Triage is a system for sorting casualties into priority for treatment by subsequent teams. It enables limited resources to be deployed efficiently. Treating a less critically ill patient could deny life-saving interventions to others who may die as a result. A form of rapid assessment is required and the triage sieve is usually employed. An experienced operator can perform this in about 20 seconds, so that it is possible to triage many people in a short time. Priorities are numbered 1 to 3 in descending order of need and are colour coded as follows:

The first patients to arrive at the hospital A&E department are usually the least severely injured. This is because they are the most mobile and the more severely injured may require stabilisation before moving. Hence the arrival of a large number of people who are not severely injured may be the trigger for the declaration of an emergency. Valuable resources such as ambulances should not be used to transport those who can use other means including cars, taxis or getting on a bus.

By the time that the Casualty Clearing Station (CCS) is set up there may be adequate resources. As a general rule, advanced life support should not be performed in the bronze zone as it is very labour intensive and the chance of success is limited. More lives will be saved by attention to others. At the CCS there may be enough staff to enable this to be performed without neglecting others who would benefit from immediate attention.

All staff, and not just those skilled in the management of trauma, should report for duty when a hospital declares a major incident. It is not only in the entertainment business that the show must go on. Other patients will still need care when perhaps their usual carers have been called away. Someone may need to take the decision to discharge patients to free beds for new arrivals. There should be a designated area for staff to report to be assigned to their duties. Standards of care must be maintained.

There will be the usual flow of patients from unrelated events in A&E. Someone has to deal with them or send them elsewhere. This may be to another hospital or asking GPs to cope. If the system is stretched, patients from unrelated sources need to be put through the same triage procedures as those from the major incident. It is inappropriate to send away someone with a serious medical need just because he is not a victim of the major incident. It is still useful to note who was from the incident to help with inquires and also reflection on the adequacy of the operation afterwards.

Those who arrive in A&E have probably been triaged twice already but they will still require a further triage. A different system is required in hospital from in "the field". There is no uniform system but a common classification is resuscitation, major and minor.

Major incident management is not something that just happens in response to an event. Planning pays dividends and this includes training and rehearsals. If you wish to be part of the team let this be known to the appropriate authorities. You will need training, orientation and integration into the team. Just turning up on the occasion is like the thespian or musician who misses rehearsals but expects to be included on the night. Major incidents can occur at any time. It may be the middle of the night or the beginning of a Monday morning surgery but it does not often happen.

Even if you do not wish to be part of the emergency response team a surgery may still be able to offer help by volunteering to take some of the less serious cases away from the hospital. It may not be dramatic but every little helps.