Major incidents

Abstract

A major incident is one that causes casualties on a scale beyond the usual capabilities of the emergency and healthcare services usual ability to manage. Major incident planning and rehearsal is vital to ensuring an appropriate response. Delivery of a major incident response requires command and co-ordination within and between emergency services, hospitals and specialist charitable organizations. Casualty management will require the set up of major incident infrastructure on scene to effectively extricate, triage, treat and transport casualties to appropriate facilities. There is a role for specialist doctors within the pre-hospital phase of managing a major incident, either within the ambulance command structure or operationally. Debrief and reviewing previous major incidents may identify individual, local and systemic factors that could be altered to improve the response to a future incident.

Learning objectives

After reading this article, you should be able to:

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describe the obligations on emergency services to prepare for and respond to major incidents
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describe the response to a major incident
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recognize the opportunity to learn from previous incidents

A major incident is one that causes casualties on a scale beyond the emergency and healthcare services’ usual ability to manage, and requires special arrangements to be implemented. Most major incidents will be as a result of sudden events, for example, explosion, fire, or flood, but there may also be gradual onset incidents, such as an outbreak of infectious disease. The special arrangements required to deal with an incident necessitates major incident planning and rehearsal to ensure that these arrangements are practical and achievable. This is relevant to both NHS hospitals and the emergency services. In comparison a mass casualty event is one involving hundreds or thousands of casualties and in which usual major incident responses are inadequate to manage the incident.

Responsibilities of NHS organizations

Major incident response is governed by the Civil Contingencies Act (2004). The emergency services and NHS Trusts are identified as category one responders which gives them statutory duties under the Act. This includes having and being able to implement an emergency plan, managing business continuity alongside a major incident and sharing information and co-operating with other services in the event of an emergency. The emergency services have specific roles at the scene of a major incident. The main roles of the ambulance service are to manage the health and safety of NHS responders at the incident scene and to provide effective triage, treatment and transport for casualties. The fire service are primarily responsible for rescuing casualties and protecting property. The police co-ordinate the emergency phase and are responsible for preservation of the scene and investigation. The police also co-ordinate the media response.

Treatment in unsafe areas

Ambulance personnel are, in general, not equipped to operate in unsafe areas. A balance must be struck between ensuring rescuer safety and providing timely emergency care to casualties. The term ‘therapeutic vacuum’ is used to describe the time between injury and the delivery of effective intervention. This vacuum arises because patients require very rapid intervention and a normal ambulance response is unable to access them due to either risk from environmental factors, for example, fire, or threats such as continued hostile activity. This ‘vacuum’ should be addressed in three ways: recognizing the role of bystanders, training other emergency service responders who are equipped to operate in those areas to deliver emergency medical care and enhancing the ability of health service teams to operate in these areas.

There is a great deal of ongoing work to empower bystanders to become ‘zero responders’, i.e. provide immediate aid prior to the arrival of the emergency services. In the UK, the citizenAID organization provide free information to the public on the appropriate response to deliberate attacks. In the United States, the Stop the Bleed education programme focuses on haemorrhage control.

The police have a national programme of emergency care training, initially integrated into the training of firearms officers, recognizing that police officers will normally be present before ambulance staff at incidents involving penetrating trauma. Skills taught include airway management, management of chest injuries and haemorrhage control.

Specialist resources

The ambulance service developed Hazardous Area Response Teams (HART) to deal with this therapeutic vacuum. HART have a variety of specialist training and personal protective equipment which allows them to access casualties in high risk areas. Examples include competence in swift water rescue, enabling work on waterways, or ballistic protection to access casualties in an area of a firearms incident where there is a risk of further threat.

In England, air ambulance organizations, as charities, are not normally designated category one responders. They will normally have an agreement with their local ambulance service about resources they can deploy and how those resources might be used. Previously, hospital-based teams may have been provided to incidents but this practice has largely disappeared. This is a result of the increased skill set of paramedics and the wider availability of pre-hospital enhanced care specialists, including critical care paramedics and specialist doctors. It was recognized that deploying small teams from hospital into an unfamiliar and dangerous environment alongside clinicians with whom they are not familiar was of limited value. For exceptionally large or protracted incidents, ambulance services may call upon their major emergency response incident teams (MERIT). Yorkshire’s MERIT team is an example that could deploy hospital personnel into an advanced casualty clearing station where they would work under the direction of an experienced pre-hospital clinician.

There may also be other charity organizations who may have relevant skills to offer depending on the incident involved, for example, Mountain Rescue, British Red Cross or St. John Ambulance.

Rescuer safety

Specific safety concerns relate to the type of incident and examples include ongoing threat at a terrorist incident or danger from chemicals at an industrial incident. The responsibility of the ambulance service for the health and safety of its staff must be balanced against the casualties’ right to life. The usual approach to hazard control of removing or reducing hazards may not be possible within a reasonable time frame. Therefore training, safe systems of work and the provision and utilization of appropriate personal protective equipment is vitally important to ensure that rescuers do not become casualties ( Figure 1 ). An example of a system used to protect pre-hospital responders is the STEP-1-2-3-Plus system which may warn of a chemical or biological threat: a single unresponsive casualty without cause should be approached as normal; two casualties require cautious approach; three or more require caution and further action suggested by a flowchart. Major incidents are often protracted due to multiple casualties or the type of incident. The scene may present new safety challenges as an incident evolves.