Simple and compound incidents In a simple incident, the location \200\231s infrastructure r emains intact and effec- tive: communications are possible and the sick can be treated. Whe n an incident is compound, roads, electricity supply, railways, health services, and commun ications are disrupted. Compensated and uncompensated A compensated incident is one which can be dealed with by mob ilizing extra resources (for example, a major fire in a hotel or cinema). An uncompensated incident cannot be managed even when all available resources have been mobilized. Typical e xamples include natural disasters such as earthquakes and hurricanes. Disasters and catastrophes The terms \200\230disaster \200\231 and \200\230catastrophe \200\231 are usually used to refer to uncompensated major incidents (generally natural disa sters). MAJOR INCIDENT MANAGEMENT1 577 Table 10.1 Major incidents Date Place Incident Dead Injured Natural incidents 1931 China, Huang He River Flood 3.7 million Not known 1970 Peru, Yungay Landslide 17,500 Not known 1995 Japan, Kobe Earthquake 5502 Not known 2004 Pacific rim Tsunami >250,000 Not known 2005 Pakistan Earthquake 200,000 Not known Manmade incidents 1977 Tenerife Air crash 583 Not known 1985 UK, Bradford Stadium fire 55 200 1985 Belgium, Brussels Crowd crush 41 437 1987 Belgium, Zeebrugge Ferry capsize 137 402 1988 UK, Lockerbie Air crash 270 \200\223 1989 UK, Sheffield Crowd crush 96 200 1995 Japan, Tokyo Gas attack 12 5000 1998 Omagh Car bomb 29 200 2005 London Bombs 52 700 CHAPTER 10 Major incident management and triage 578 The phases of a major incident A major incident has three phases: - Preparation - Response - Recovery. Preparation The three components of preparation are: - Planning - Equipment - Training. Major incident planning Any site where there is a risk of a major incident (for example, ch emical plant, major sporting venue, or travel interchange) must have a major incident plan which is regularly updated and regularly practiced. Any agency which will have to respond to a major incident must have a service plan (once ag ain, regularly updated and practiced) which can be adapted for an individual incident wheth er it occurs at a high risk site (such as a chemical plant fire) or is random and unpredict able (for example, an intercity train crash). All hospitals must have a major incident plan and any health care pro- fessional who will b e called upon to respond must know his own role and how that role integrates into the overa ll response. All major incident plans must be multi-agency, reflecting the skills and responsibilities o f all those bodies which will be involved if an incident does happen. In order to facilitat e this, many agencies (and all official bodies) now use MIMMS \200\224Major Incident Medica l Management and Support as their template for a major incident response. Equipment Adequate equipment must be available and easily accessible. This will include per sonal protective equipment, medical equipment, communica- tions, and specialist equipment s uch as triage cards and major incident commanders \200\231 bags. MIMMS \200\224Major Incident Medical Management and Support The co-ordinated response to a medical incident is taught on the MIMMS course. This is a three-day course for health care professionals which covers the organization of the response to a major incident, communica- tions, equipment, and triage. Members of the other emergency services and the armed forces also attend. The course concludes with formal major incident exercises at chosen locations such as sports grounds or industrial sites. The MIMMS course is now accepted international ly. A one-day course is also available for those who may have to respond to an incident but who will not be called upon to assume a command role. (For details, see useful contact details p.600.) THE PHASES OF A MAJOR INCIDENT1 579 Successful completion of a MIMMS course should be considered essential for anyone who is li kely to have to respond to a major incident. Posses- sion of \200\230Major incident manage ment system \200\231 (Hodgetts and Porter, BMJ Books, 2nd edn., 2002) is recommended. Major incident management System is distributed to all MIMMS course candidates. Major incident response The response to a major incident is considered under the following headings: - Command - Safety - Communications - Assessment - Triage - Treatment - Transport ation Command Command is a vertical process; control a horizontal one: C CONTROL M M A N D Each emergency service will have a commander at the scene Control is enforced by means of c ordons (see p.584). Safety Safety of responders and victims alike is a key component of the major incident resp onse. The \200\2301 \200\2232 \200\2233 of safety \200\231 is: 1. SELF 2. SCENE 3. SURVIVO RS Command - Safety - Communications - Assessment - Triage - Treatment - Transportation Control Spells Calm And Time To Treat CHAPTER 10 Major incident management and triage 580 Communications Effective communications must be established between incident com- manders. Regular face-to-face communication is essential. Other methods include: - Radios - Runners - Whistles - Hand signals - Telephones (land lines) - Mobile phones. Health service communi cations are an ambulance service responsibility. Communications will be established from th e site to ambulance control. Radios Ambulance radio systems are usually VHF, allowing communication at the scene and wit h ambulance control. A radio net will be established with control and call signs. Single fr equency simplex allows all users to hear all messages (it is \200\230open \200\231) and of fers a broader \200\230picture \200\231 of the incident as it progresses. Two frequency si mplex means that call signs can only speak to and hear control. Control can hear all statio ns and can let stations hear each other ( \200\230talk through \200\231). Two frequency sim plex is the usual ambulance service system. A protected national frequency for doctors at major incidents is currently being trialed. Runners Runners are an effective method of communication, but ideally should carry written rather than verbal messages. They should be instructed to return in order to confirm that a message has been conveyed irrespec- tive of whether there is a reply. Whistles Repeated whistle blasts by the fire service indicate an immediate need to evacuate an area. Hand signals The military use a range of hand signals. These should not be used by civilian s unless they are thoroughly familiar with their use and meaning. Telephones (land lines) In prolonged incidents, it is possible to set up land lines at the scene of an incident. These can be provided by commercial companies or by the military. Mobile phones Mobile phones are an effective means of communication, but have two major pro blems. There is no central co-ordination of calls, so that confusion and duplication and ov erload of the system can occur with the result that no calls can be made. The latter is a p articular problem once the media have been notified. THE PHASES OF A MAJOR INCIDENT1 581 In order to prevent system overload and allow continued access to essential users, the ACCO LC (Access Overload Control) system can be activated. Once ACCOLC has been activated, only mobile phones which have been modified will remain in use. Requests for phones to be ACCOLC modified have to be approved at Cabinet Office level. Assessment Assessment of the number, severity, and types of injury is a key compo- nent of the major incident response. Triage Triage is the prioritizing of patients for treatment or transportation according to their severity of injury (p.602). Treatment Some treatment will be undertaken at the incident scene, although most will take place after evacuation to hospital. In order to achieve the maximum benefit for the victims , this must be co-ordinated so that each patient is delivered to the appropriate facility h aving received any necessary treatment before departure. In general, treatment at the scene should be restricted to that necessary to allow the patient to be trans- ported safely and comfortably to hospital and to ensure that evacuation is possible. Transportation The aim is to transportation the \200\230right patient to the right place a t the right time \200\231 and by the \200\230right method \200\231. The transportation sch eme within the incident scene is shown in Fig. 10.1. Relatives Reception Area Media Liaison Point Rest Center Outer cordon Ambulance Parking Point Survivor Reception Center Incident Control Units Ambulace Loading Point MIO-AIO Equipment Dump Casualty Clearing Station Body Holding Area FIO PIO Other Agencies Secondary Triage Fig. 10.1 The ambulance circuit. CHAPTER 10 Major incident management and triage 582 Decisions regarding patient destinations will be taken under the supervi- sion of the medic al commanders. Less injured patients may be transported in patient transportation vehicles or in minibusses or taxis. Patients sharing the same vehicle should obviously be going to t he same destination. Patients should not be sent to hospitals specializing in a single syst em if injuries elsewhere have not been excluded. However, patients with a neurosurgi- cal i njury should be sent to the local hospital with neurosurgical facilities. Major incident recovery Even after the scene of the incident is free of patients, the incid ent response is likely to continue for some considerable time. Hospitals will have a backlo g of surgery to perform, rosters will take time to return to normal, and roads and railways will have to be returned to full function. Following each incident, all the organizations involved must, separately and together, revi ew their actions. This will highlight areas for improve- ment and will also identify areas of particular achievement. An immediate operational debrief is usually held to identify key lessons, followed at a later date by a more formal debrief. Some responders may develop features of an acute stress response, including poor sleep, anx iety, flashbacks, nightmares, poor performance, and inability to concentrate. It is essenti al that these people are identified and receive the help they need. THE PHASES OF A MAJOR INCIDENT1 583 Declaring a major incident A major incident is usually declared by the first representative of the emer- gency services to reach the scene. The phrase used has been standardized: \200\230Major incident declared \200\231 Under some circumstances (for example, an airplane having difficulty landing), the following may be used: \200\230Major incident standby \200\231 to warn of a possible imminent incident. If a warning turns out to be false, or a major incident response is not required, the order is: \200\230Major incident canceled \200\231 Methane The acronym METHANE is used to pass information from the scene to control, but can also be used when passing information between indi- viduals (see box). M Major incident standby or declared E Exact location (grid reference if available) T Type of incident (chemical, terrorist, rail, etc) H Hazards present and potential A Access N Num ber and severity/type of casualties E Emergency services present and required Some emergency services use the mnemonic CHALET: C H Hazards present and potential A L E T Casualties \200\224number, severity, and type Access Location Emergency services present and required Type of incident CHAPTER 10 Major incident management and triage 584 The scene of a major incident Cordons and commands The inner cordon and bronze area The inn er cordon surrounds the actual site of the incident. It contains the wreckage and the hazar dous area. The area inside the inner cordon is the bronze area. The inner cordon is not alw ays physically marked with tape, but where there is any hazard, access to the bronze area w ill be strictly regulated with personnel being checked in and out. If the incident has more than one location (for example, wreckage at either end of a railroad tunnel), there may be more than one bronze area and more than one inner cordon. In this case, there will also be a command structure for each bronze area (see below). At terrorist or firearms incidents, the inner cordon is controlled by the police. When ther e is a fire or chemical hazard, the inner cordon is con- trolled by the fire service. The outer cordon and silver area The outer cordon surrounds the entire incident site, and t hus includes the survivor reception center, casualty clearing station, command post, body h olding area, and all the other designated locations which together make up a co-ordinated m ajor incident response. The area between the inner and outer cordons is the silver area. Th ere is normally only one silver area (multiple silver areas may be established during the \200\230sectoriza- tion \200\231 of a natural disaster effecting a very large area). Gold command The gold command is situated away from the scene of the incident at a pre-desi gnated location such as the regional police headquarters. Command structures and responsibilities Bronze area The bronze area is under the authority of the forward commanders, one for each service. A schematic diagram of the bronze command structure is shown in Fig. 10.3. Silver area The silver commanders are responsible for the area within the outer cordon. The bronze commanders report to the silver commanders. The command vehicles for the emergency services co-locate to form silver command \200\224the Joint Emergency Services Control (JES C). A schematic dia- gram of silver command is shown in Fig. 10.4. Good communication between the silver (or incident) commanders is the key to an effective r esponse. Silver commanders are not tied to the command location but may move around the inc ident scene gathering information and consulting with other responders. However, they must arrange to meet on a regular basis. THE SCENE OF A MAJOR INCIDENT1 585 Gold Silver Bronze Inner cordon Outer cordon Fig. 10.2 Areas and cordons. FMIO FFIO FPIO FAID Primary Triage INCIDENT Fig. 10.3 Command in the bronze area (schematic). Incident Control Units MIO-AIO FIO PIO Other Agencies Fig. 10.4 Silver command: the Joint Emergency Services Control \200\224JESC (schematic). CHAPTER 10 Major incident management and triage 586 Gold command Gold command is responsible for multi-agency liaison off site. Requests for as sistance from neighboring services are channeled through gold command which is also respons ible for liaison with central government, national agencies (for example, the Radiation Pro tection Board, Environ- ment Agency, security services), and bodies with multi-area remits such as rail service providers. The health services response at the scene The ambulance commander (silver) based at the JES C is responsible for the health services response with the silver medical commander. The am bulance commander is responsible for all ambulance service personnel (including the volunta ry aid societies); the medical commander for all doctors and nurses. The ambulance command vehicle is identified by a steady green light. The forward (bronze) commanders report to th e silver commanders. The forward control point is within the inner cordon. Primary triage i s carried out in the bronze area by the primary triage officer under the authority of the f orward medical commander. A structured response Casualty clearing station (CCS) The casualty clearing station is esta blished by the ambulance service for the assessment and treatment of survivors at the scene of the incident. A schematic diagram is shown in Fig. 10.5. Key assets at the casualty cle aring station include: - Safety - Shelter - Light - Heating - Cooking facilities - Toilets and washing facilities - Communications. Wherever possible, therefore, the CCS should be lo cated in a pre- existing building, although in some circumstances, improvization and the us e of temporary shelters may be necessary. Ambulance parking point The ambulance parking point is a designated area in which ambulance s can wait before being called forward for loading. The ambulance parking point is under th e control of the ambulance parking officer. Ambulance loading point Ambulances are called forwards (from the ambulance parking point) t o the ambulance parking point adjacent to the CCS for loading under the direction of the am bulance loading officer. THE SCENE OF A MAJOR INCIDENT1 587 EVAC P3 A E R A G N D L O H Y D O B P1 P2 I C E P X E TRIAGE P3 INCIDENT CASUALTIES P = priarity EXPEC = expectant Fig. 10.5 Casualty clearing station (CCS) layout. Reprinted with permission from Hodgetts a nd Porter (2002). Major incident management system, 2nd edn. BMJ Books. How to recognize incident commanders Police commander Fire commander Ambulance commander Medical commander Blue and white checker tabard Red and white checker tabard Green and white checker tabard T ext (medical commander) only CHAPTER 10 Major incident management and triage 588 Roles and responsibilities \200\224medical Medical commander The medical commander (silver) liaises with the other silver commanders and delegates tasks to the available medical and nursing personnel. He is responsible for channeling information to and from local hospitals and for carrying out a full medical assessment of the scene. The medical commander is also tasked with overseeing treatment and secondary triage and determining manpower and equipme nt requirements. Forward medical commander The forward medical commander is responsible for supervising doct ors within the bronze area and directing requests for medical equipment and personnel to th e medical commander. He is also responsible for ensuring that the medical commander is kept fully informed of developments within the bronze area. Casualty clearing officer The casualty clearing officer is responsible for the CCS. The sec ondary triage officer and the medical teams report to him. Secondary triage officer The secondary triage officer carries out triage of patients on arr ival at the CCS. He may also assist with treatment of patients within the CCS. Mobile medical teams Mobile medical teams sent out from local hospitals may either be used as a team in the bronze area or CCS, or broken up and distributed as appropriate, taking in to account the skills of individual team members. A mobile medical team usually contains tw o nurses and two doctors. Whenever possible, clinicians with no pre-hospital experience or training should NOT be allocated to work in the bronze area. The concept of the mobile medi cal team is being phased out. Mobile surgical teams Life-saving surgical procedures such as amputations are only rarely r equired due to advances in extrication techniques and pain control. When such a procedure i s necessary, a team should be requested from the local hospital to perform it. They should then return to the hospital. The usual composition of a mobile surgical team is a surgeon, an anesthetist, a scrub nurse, and an operating department assistant (ODA) or anesthetic nu rse. THE SCENE OF A MAJOR INCIDENT1 589 t n e d c n r e c i f f e c i l o P i o i n o d r o c t n e d c n r e c i f f s n o i t a c n u m m o C e r i F i r e t u O o r e c i f f i i o t n e d c n l a c d e M r e c i f f i i o i e c n a l u b m A t n e d c n r e c i f f n o d r o c i o i r e n n I t n o p e c n a l u b m A i y r a d n o c e S g n d a o r e c i f f e g a i r t i e c n a l u b m A o l g n d a o r e c i f f i o l y t l a u s a C g n i r a e l c n o i t a t s e c n a l u b m A g n k r a p r e c i f f e c n a l u b m a d r a w r o F t n e d c n y r a m i r e c i f f r e c i f f y t l a u s a C e g a i r t g n i r a e l c r e c i f f o i i r P o o o i t n e m p u q E p m u d i t n e m p u q E r e c i f f e c n a l u b m A g n k r a p r e c i f f i i o o Fig. 10.6 Health services response at the scene of a major incident (schematic). Reprinted with permission from Greaves I et al. (2005). Emergency care \200\224a textbook for paramed ics, 2nd edn. W.B. Saunders Co. Ltd. CHAPTER 10 Major incident management and triage 590 Emergency services responsibilities Health services Police and fire Police Local authority/social services Health/police Police Local authorities Care of the injured Care of uninjured survivors Dealing with the dead Evacuation and shelter Social and psychological support Social services/voluntary aid societies/health Health service communications Ambulance service Explosive ordnance disposal Fire and chemic al hazards Armed forces Fire (advice from community health and poisons units) Local authorities/armed forces Field engineering Roles and responsibilities \200\224ambulance service Ambulance commander The ambulance comm ander (silver) liaises with the other commanders and is responsible for task allocation wit hin the ambulance service. He delegates responsibility for safety and communication to the relevant officers. He is responsible for the health services scene assessment and for hospi tal and transportation selection. The ambulance commander works closely with the medical co mmander and his assistants. Forward ambulance commander The forward ambulance commander is responsible for ambulance se rvice personnel in the bronze area. He must ensure effective triage and removal of patients . The forward ambulance commander determines the location of the ambulance parking point wi th the advice of the police. Casualty clearing officer The casualty clearing officer is responsible for the CCS. The sec ondary triage officer and the medical teams report to him. He must ensure adequate patient documentation and liaise with the doctor in charge of the CCS and the ambulance service reg arding patient transfer from the scene. Ambulance parking officer Controls the ambulance parking point. Ambulance loading officer Controls the ambulance loading point and supervises the loading o f ambulances at the CCS. Ambulance safety officer The ambulance safety officer is responsible for the safety of all health services personnel within the outer cordon. He must ensure that all personnel are ap propriately dressed and advise on the treatment of THE SCENE OF A MAJOR INCIDENT1 591 injured staff. He must also ensure that tired staff are allowed to rest. Liaison with the o ther emergency services is a key role. Communications officer The communications officer co-ordinates all on-site communications b etween medical and ambulance service staff. He is responsible for the logging of all commun ications and for ensuring clear and effective com- munications on-site and with off-site ag encies. Equipment officer The equipment officer overseas health services equipment requirements at the scene. All requests for equipment must be channeled through the equipment officer if co nfusion is to be avoided. CHAPTER 10 Major incident management and triage 592 Roles of the other emergency services at a major incident Fire The roles of the fire servic e at a major incident are to: - Establish fire service command and control - Fight fires - Save lives - Prevent escalation of the incident - Eliminate hazards - Rescue trapped casual ties - Provide specialist equipment and shelter. The fire service are responsible for advis ing on health and safety for all those in the bronze area. Police The police will usually take an overall controlling role in land-based major inciden ts. The roles of the police service at a major incident are to: - Establish police command and control - Save lives - Prevent escalation of the incident - Supervise evacuation where necessary - Control traffic - Maintain appropriate records - Handle and identify the dead - Maintain order and protect property - Carry out any necessary criminal investigation - Lia ise with the media. Other agencies The local authority The roles of the local authority at a major incident inc lude: - Co-ordination of the response by agencies other than the emergency services (for example, the Environment Agency) Provision of heavy machinery - Provision of manual labor - Provision of specialist technica l advice and assistance - Provision of environmental health advice and services - Allowing access to buildings used for shelter of casualties, survivors, and evacuees, temporary mortuaries, and other functions, as required Staffing survivor reception centers and other functions (council employees and members of the voluntary services). In addition, the local authority is charged with co-ordinating disaster planning and traini ng in its area. Each authority has an Emergency Plan- ning Officer (EPO) who works closely with the emergency services and other bodies such as the Environment Agency. The EPO is the point of contact in the event of an incident. A representative is usually sent to silver c ontrol for the duration of the incident. Once the incident is \200\230over \200\231, the local authority will play a major role in reconstruction and the return of \200\230society \200\231 to normal function. THE SCENE OF A MAJOR INCIDENT1 593 The armed forces The armed forces provide assistance at major incidents under the Military Aid to the Civil Powers (MAC) scheme. The military are usually called in by the local autho rity. Once assistance has been agreed, the military will appoint a liaison officer who will work closely with the authority. The armed forces at a major incident can provide: Medical, nursing, and technical expertise - Field medical facilities, tents, and hardstandi ng - Ambulances, passenger transportation, and other specialist vehicles including helicopters - Generating equipment - Communications - Drinking water - Field engi neering - Disciplined personnel. Her Majesty \200\231s Coastguard Her Majesty \200\231s Coastguard (part of the Maritime and Coastguard Agency) is charged with co-ordinating the rescue of casualties from off-shore i ncidents. Specific responsibilities include: - Identifying the location of the incident - A lerting nearby vessels - Establishing communications with the involved vessels and others - Requesting helicopter support - Co-ordinating and requesting naval and lifeboat (RNLI) ass istance. The voluntary aid societies Providers of voluntary aid at major incidents include St John \200\231s Ambu- lance, the British Red Cross, the Women \200\231s Royal Voluntary Service, and St Andrew \200\231s Ambulance (in Scotland). There are also many smaller spe- cialist b odies, such as BASICS, and appropriately trained individuals. The Samaritans and other orga nizations provide help to those recovering from the effects of a major incident. The voluntary services can provide: Volunteer medical personnel and skilled assistance - Trained personnel to run rest and reco very centers and assist with documentation Clothing and bedding - Refreshments to emergency services personnel - Food, clothing, and s helter to victims of major incidents. The Faith Communities The major religious faiths (Christians, Jews, Hindus, Muslims, Sikhs, Buddhists, the Church of Jesus Christ of the Latter Day Saints, and the Chinese Community) have issued detailed guidance regarding specific religious aspects of major incidents (Gui delines for faith communities when dealing with disasters available from the Church of Engl and Board for Social Responsibility, Church House, Great Smith St, London SW1P 3NZ). CHAPTER 10 Major incident management and triage 594 Other specific responsibilities Dealing with the dead Although under certain circumstances, it is permitted for paramedics to pronounce death, at a major incident, this role is under taken by a doctor in the presence of a police officer. However, before this, when triage is being carried out, the triage officer will label a patient dead based on the triage algori thm. Pronouncement of death follows. Certification of cause of death will only occur follow ing a coroner \200\231s inquest. The coroner will issue a death certificate. Victims who are triaged dead must be clearly labeled as such in order to prevent time wasta ge in further repeated assessment. Dead bodies should only be moved for two reasons: - To g ain access to living casualties - To prevent them being destroyed (for example, by fire, ch emicals, or crushing). Bodies that are moved for these reasons and the bodies of those who have died at the CCS sh ould be taken to a body holding area which should be close to the CCS but away from public gaze. Following a major incident, a temporary mortuary will be used to accommodate bodies. In mos t cases, this will have been identified in advance and included in area major incident plan s. This page intentionally left blank CHAPTER 10 Major incident management and triage 596 Radio voice procedure All pre-hospital care practitioners must be familiar with correct rad io usage. Nowhere is this more important than during a major incident. The key features of a radio message are: - Clarity - Accuracy - Brevity. Each message must be clear, unambiguou s, and free of unnecessary information. In order to assist with this, speech should be stea dy, slightly slower than normal, loud enough to be clear without shouting, and at a slightl y higher pitch than normal for men (women \200\231s voices tend to be clearer over the radi o). Certain terms may be used to save time (see box) but unauthorized slang should be avoid ed. Unusual or difficult words, especially names and addresses, should be spelled using the NATO phonetic alphabet (see box). Numbers should be pronounced as indicated in the box. Making a call - Begin a call by stating the call sign of the number being called - Then giv e your call sign - Give the message - Finish with \200\230over \200\231. Using \200\230over \200\231 indicates that the recipient of your call can now reply. Approved radio communications shorthand terms Go ahead I am ready to receive your message Send I am ready to receive your message Roger I understand OK I understand Say again Repeat * Acknowledge Confirm that you have received my message Send I am ready to receive your message Over Please talk Spell Precedes difficult words such as addresses or names (also as \200\230please spell \200\231 when this is requested) Numbers Precedes lists of numbers such as telephone numbers Out The conversation is finished Wait I am unable to speak to you for five seconds (may be repeated once, then wait out) Wait out I am unable to reply, I will contact you later Standby Be alert, further information to follow Say again all after/say again all before \200 \200 . RADIO VOICE PROCEDURE1 597 The NATO phonetic alphabet A Alpha N November B Bravo O Oscar C Charlie P Papa D Delta Q Quebec E Echo R Romeo F Foxtrot S Sierra G Golf T Tango H Hotel U Uniform I India V Victor J Juliet W Whisky K Kilo X X-ray L Lima Y Yankee M Mike Z Zulu Numbers for radio messages 1 Wun 6 Six 2 Too 7 Seven 3 Thuree 8 Ate 4 Fower 9 Niner 5 Fiyiv 0 Zero Replying to a call - Begin by giving your call sign. Ending a call - Once a message or exchange is complete, the final speaker says \200\230out \200\231. - When speaking to more than one recipient, the phrase \200\230[call sign] out to you \200\231 can be used to particular recipients, whilst further communication continue s with the others. Corrections - As soon as you recognize an error, say \200\230wrong \200\231 and give the c orrect information. Repeating - If a message was unclear and you wish to hear it again, the expression \200 \230say again \200\231 is used. In order to avoid repeating the complete message, the expre ssions \200\230say again all after \200 \200\231, \200\230say again all before \200 \200\231, and \200\230say again all between x and y \200 \200\231 are used, giving the ne cessary words from the original message to indicate which sections are to be repeated. CHAPTER 10 Major incident management and triage 598 Performing a radio check - Radio checks can be initiated by control or any call sign - Begi n with the stations being called, then your station, then radio check ( \200\230all stations zulu from control, radio check over \200\231) Reply with your call sign and OK if reception is clear ( \200\230Zulu 1, OK, over \200\231) The initiator ends the radio check with his call sign OK and out ( \200\230Control, OK, out \200\231 ) Other terms are used for unclear transmission: Difficult \200\224can be understood but not clear (interference) Broken \200\224message onl y heard intermittently Unworkable \200\224occasional words only or continuous interference Nothing heard. This page intentionally left blank CHAPTER 10 Major incident management and triage 600 Sources of further information Arrangements for responding to nuclear emergencies. Health a nd Safety Executive. Available from the Stationery Office Dealing with disaster, Rev 3rd edn. Brodie Publishing. Available from the Stationery Office (Contains an extensive list of useful website addresses covering all aspects of major inci dent response.) Emergency planning in the NHS \200\224health service arrangements for dealing with major in cidents. Available from Department of Health Emergency Planning Coordination Unit, Room 603 , Richmond House, 79 Whitehall, London SW1A 2NS Guidelines for faith communities when dealing with disasters. Available from the Church of England Board for Social Responsibility, Church House, Great Smith St, London SW1P 3NZ Major Incident Medical Management and Support (MIMMS), 2nd edn. Advanced Life Support Group , BMA Publications. Military aid to the civil community 3rd edn (1989). Available from the Stationery Office This page intentionally left blank CHAPTER 10 Major incident management and triage 602 Triage Introduction Triage is the sorting of patients, by priority, for treatment or transp ortation. It is a dynamic process. Primary triage is carried out in the bronze area, second ary triage at the casualty clearing station. Triage may be repeated before evacuation of pa tients from the site (triage for transportation). Triage is the sorting of patients, by priority, for treatment or transportation Triage priorities Common triage priorities P T Description Color 1 1 Immediate Red 2 2 Urgent Yellow 3 3 Delayed Green 1 Hold 4 Expectant Blue Dead Dead Dead White or black In the UK, the T system is conventionally used at a major incident. Immediate priority These casualties require immediate life-saving intervention. Urgent priority These casualties require significant intervention within 2 \200\2234 hours. Delayed priority These casualties require intervention, but not within 4 hours. Expectant priority Treating these casualties at an early stage in the incident would divert resources from potentially salvageable casualties, with no significant chance of a success ful outcome. The expectant category can be marked by: Use of a blue card (not usually available) - Amending a P3 card with the word expectant - T urning down the corners of a P3 green card diagonally to expose a red card underneath. This page intentionally left blank CHAPTER 10 Major incident management and triage 604 Triage sieve The triage sieve is a simple reproducible triage method for use as a primary t riage tool (see Fig. 10.7). No DELAYED Treatment 3 DEAD Uninjured Walking Yes Survivor reception center No No Breathing ? Breathing ? Open the airway No Yes Yes Respiratory rate ? Less than 10 or more than 30 Yes IMMEDIATE Treatment 1 No Pulse rate ? Less than 40 or more than 120 Yes URGENT Treatment 2 No Fig. 10.7 The triage sieve. Reprinted with permission from Greaves I et al. (2005) Emergenc y care: a textbook for paramedics, 2nd edn. W.B. Saunders Co. Ltd. This page intentionally left blank CHAPTER 10 Major incident management and triage 606 The triage sort The triage sort is a more complex system designed for use at the casualty c learing station. However, if there are insufficient staff to deal with patients arriving at the CCS, the sieve can be repeated until it becomes possible to carry out the sort. The tr iage sort uses the triage revised trauma score. A coded score is derived for each of the three variables (respiratory rate, systolic BP, an d Glasgow Coma Score Scale). The three coded values are then added together, and the final triage priority is derived as shown in the box. THE TRIAGE SORT1 607 The triage sort PHYSIOLOGICAL VARIABLE Respiratory rate VALUE 10 \200\22329 >29 SCORE 4 3 6 \200\2239 1 \200\2235 0 2 1 0 Systolic blood pressure >90 76 \200\22389 50 \200\22375 1 \200\22349 0 4 3 2 1 0 Glasgow Coma Scale Score 13 \200\22315 9 \200\22312 6 \200\2238 4 \200\2235 3 4 3 2 1 0 Total score for coding (see box below) X Coded score 1 \200\22310 11 12 0 Priority T1 T2 T3 Dead CHAPTER 10 Major incident management and triage 608 Triage in children The normal physiological values given in the triage sieve on p.609 do no t apply in children and must, therefore, be adapted. Specific triage sieve protocols can be used, based on the child \200\231s length (top of head to feet) or weight: Weight = (2 x age in years) + 8 Alternatively, a pediatric triage tape can be used. This is placed along- side the child an d the appropriate triage sieve protocol read off the tape according to the child \200\231s length. TRIAGE IN CHILDREN1 609 Alert and moving all limbs DELAYED PRIORITY 3 Yes DEAD No No No Open airway Breathing Breathing Yes Yes <20 OR >50 IMMEDIATE PRIORITY 1 Respiratory rate 20 \200\22350 No Capillary refill <2 seconds (use forehead) Pulse rate <90 OR >180 90 \200\223180 Yes URGENT Priority 2 SEND UNINJURED SURVIVORS TO SURVIVOR RECEPTION center Fig. 10.8 Triage sieve 1: child 50 \200\22380cm or 3 \200\22310kg. Reprinted with permissio n from Hodgetts and Porter (2002). Major incident management system, 2nd edn. BMJ Books. CHAPTER 10 Major incident management and triage 610 Alert and moving all limbs DELAYED PRIORITY 3 Yes DEAD No No No Open airway Breathing Breathing Yes Yes <15 OR >40 IMMEDIATE PRIORITY 1 Respiratory rate 15 \200\22340 No Capillary refill <2 seconds (use forehead) Pulse rate <80 OR >160 90 \200\223160 Yes URGENT Priority 2 SEND UNINJURED SURVIVORS TO SURVIVOR RECEPTION center Fig. 10.9 Triage sieve 2: child 80 \200\223100cm or 11 \200\22318kg. Reprinted with permiss ion from Hodgetts and Porter (2002). Major incident management system, 2nd edn. BMJ Books. TRIAGE IN CHILDREN1 611 Alert and moving all limbs DELAYED PRIORITY 3 Yes DEAD No No No Open airway Breathing Breathing Yes Yes <10 OR >30 IMMEDIATE PRIORITY 1 Respiratory rate 10 \200\22330 No Capillary refill <2 seconds (use forehead) Pulse rate <70 OR >140 70 \200\223140 Yes URGENT Priority 2 SEND UNINJURED SURVIVORS TO SURVIVOR RECEPTION center Fig. 10.10 Triage sieve 3: child 100 \200\223140cm or 19 \200\22332 kg. Reprinted with perm ission from Hodgetts and Porter (2002). Major incident management system, 2nd edn. BMJ Book s. CHAPTER 10 Major incident management and triage 612 Triage labeling Because a patient \200\231s condition may improve (for example, with treat- ment) or deteriorate, any effective triage labeling system must allow re-categorization. I t is also helpful if clinical notes can be made on the triage card since this will prevent duplication and potential loss of records.