Although frequently occurring on dramatic television shows, major incidents are thankfully pretty uncommon in Australian paramedicine. However the down side of that is we are often ill-equipped to handle them when they do arise. This article will give a brief overview of approaching a major incident, the different roles of paramedics as well as some practice tips to make your life easier.

But first – what exactly is a ‘major incident’?

There are several definitions of major incidents, but I like to keep it basic. Generally speaking it’s where patients/casualties outnumber resources. Often you’ll see this described as “more patients than paramedics”. This will result in any incident with 3 or more patients being described as a mass casualty or major incident.

However we know there are other major incidents that this definition doesn’t take into account. Therefore here is a non-exhaustive list of them;

• Scenes where access to the patient is difficult. Eg. Paraglider on cliff face, vehicle crashed into shopping centre
• Where specialist skills or equipment are required. Eg. Hazardous materials (HAZMAT), building collapse with unknown occupants (urban search and rescue – USAR)
• Incidents where the general population may be impacted. Usually these are widespread incidents. Eg. Large bushfires producing smoke, thunderstorm asthma
• Situations where there are unique hazards or dangers. Eg. Active shooter
• Of course, situations where there are large numbers of patients. Eg. Multi vehicle MVA, plane crash.

Who are the key players at a major incident?

• The Incident Controller – this person has overall authority of the scene. This role is dictated by local emergency response plans (in Victoria this is the State Health Emergency Response Plan or SHERP). Examples include the senior fire officer for large fires, senior police officer for major collisions. Paramedics never fulfill this role in Victoria
• The Incident Management Team (IMT) – this is a group of people who work with the Incident Controller. Each member has a specific role/responsibility such as Logistics or Communications. IMTs are established for large/prolonged incidents, such as major bushfires
• 000 call taking – this is usually the first notification that a major incident is occurring
• Emergency Communications – dispatchers, managers and clinicians who coordinate resources, dispatch them to scene and provide clinical support. They can also provide the status of receiving hospitals
• The Health Commander – this is the person on scene in charge of managing all health resources. Whilst this is normally a paramedic, at larger, more prolonged scenes this may be a person from Department of Health. In that case an Ambulance Commander will be appointed to oversee paramedics. This role is usually fulfilled by an in-field manager
• The first paramedic crew to arrive has arguably the most vital role. They are no longer a clinical resource, but instead must become a management resource. This applies regardless of the crew’s skill set (including intensive care paramedics).
  • Triage Officer – by the book this will be the most senior paramedic in the initial crew, but in reality it’s often the ‘treating’ paramedic (Attendant 1). As the name suggests, the triage officer is responsible for assessing the number of patients, assigning a triage category and providing basic, life saving interventions.
  • Transport Officer – usually Attendant 2, however this role benefits from an experienced paramedic. So I don’t recommend graduates fulfill this role if at all possible. The transport officer is responsible for logistics, keeping the Casualty Movement Log updated and usually oversees the Casualty Clearing Post in the early stages of the major incident.

I’m first on scene to a major incident – HELP!

Being first on scene to a major incident can be daunting and stressful, but if you follow the basic principles it will lead to a good outcome. Lets break it down

Prior to Arrival

• Listen to the dispatch carefully – often the dispatcher will alert you this could be a major incident. Information indicative of a major incident includes reports of multiple patients, several calls for the same event or scene location is known to be difficult to access
• Respond quickly to your vehicle
• Read the page/data terminal carefully to look for flags of a major incident
• Discuss with your partner the potential for a major incident. Allocate roles. Generally I will say “if we get there and there are three patients or the scene is a mess, we’re going to adopt TO/TO (triage officer/transport officer) roles”
• On arrival at the scene, carefully consider the positioning of your vehicle. It needs to be parked out of the way and support the safety of patients and responders. Remember that in a major incident the TO/TO crew does not transport a patient, so it’s usually better to park a little way away from the scene.

At Scene – First 5 Minutes

• Don TO/TO vests appropriate to your role
• Windscreen SITREP [given to Dispatcher]
  • Confirm location
  • Give estimated number of patients
  • Request additional resources if necessary (typically police/fire at this stage)
  • Basically a windscreen SITREP boils down to “is the job legit or is it sh*t?”
• Consider PPE required (eye protection, helmet, work gloves?)
• Gather role appropriate equipment – note this is significantly different to the equipment you will grab for a normal case
  • Triage Officer: Triage Pack, Trauma Bag (dressings and tourniquets)
  • Transport Officer: Casualty Movement Log (normally found in a large folder)
• Make contact with other agencies on scene (police/fire) and identify yourself. Ask about known or potential hazards at the scene.
• Quickly survey the scene and gather relevant information for your first METHANE SITREP. This requires:
  • Performing a quick head count of casualties. If you can figure out their triage category just by looking at them – that’s great! But not necessary
  • Liaise with other services and assess the scene for dangers/hazards
  • Consider the access and egress to scene, remembering that the way you came in isn’t necessarily the best option
  • Eyeball the mechanism – what types of vehicles were involved, is there an active shooter, was it a chemical leak?
• The first five minutes will typically end with a METHANE SITREP being delivered to the communications centre

Next step – Divide and Conquer

Next the real work begins. Once the initial METHANE SITREP has been delivered, backup is on the way. It’s time to control the scene and sort out the patients.

NOTE: although this section is typically divide and conquer, junior crews may choose to stick together. Whilst this slows things down, it allows the paramedics to support each other.

Triage Officer

• Commence triage of patients
  • Direct any bystanders not involved to clear the scene – “if you’re not injured or involved, please leave”. Note that medically trained or willing bystanders may be helpful at the Casualty Clearing Post
  • An easy way to identify all the Priority 3 (Walking Wounded) patients is to call out “anyone who needs medical attention – come over here!” Anyone who starts moving towards you is a Pri 3 and should be handed over to the Transport Officer
  • Start the triaging of injured, non-walking patients. Work through the scene systematically to ensure you don’t miss anyone
• Use Triage Sieve
  • Triage Sieve is a rapid, easy to use and reproducible tool which is used for the initial triage of patients
  • Note that Triage Sieve does not assess the injuries or mechanism, instead it’s a blunt tool to assess life threat
  • Apply a triage tag to each patient (even Pri 3s). No need to write any details at this stage. If you run out of tags or lose them, use a permanent marker to write the triage category of the patient’s forehead or hand
  • Deceased patients should be tagged and left in place for the coroner. Only move them if necessary to access living patients
  • Note that each service likely uses slightly different triage tags and criteria – always use your local policy

• Triage children by utilising the Triage Tape system. This ‘tape’ is laid alongside the child, and utilises their height to estimate their age, and therefore normal vital signs. Generally speaking if there are only one or two children involved at a major incident, we will allocate them a Pri 1 category to ensure they receive early care. However in incidents involving a large number of children (school bus crash, kindergarten collapse etc) using the tape is most appropriate.

• Provide only life-saving interventions
  • Open the airway of apnoeic patients and assess for breathing
  • Roll unconscious patients into the recovery position
  • Apply tourniquet/wound packing to major haemorrhages
  • Do not delay by providing analgesia or other non-life saving interventions (these will be done at the Casualty Clearing Post)
• Provide direction to incoming crews
  • The Triage Officer is in charge of ambulance resources at a scene, until the arrival of a Health Commander
  • All newly arrived resources should receive a brief (30 second) scene orientation, particularly regarding any potential hazards
  • Incoming resources should be directed to the Triage Officer, who will then allocate them a task
    • Assist with triaging (typical if there is a large number of patients)
    • Move patients from scene to the Casualty Clearing Post (typical if there are large numbers of patients and few supporting agencies)
    • Load a patient and transport to hospital in order of triage priority (typical of most scenes)
    • Assist at the Casualty Clearing Post (typical where there are a large number of low acuity patients)
  • It’s important to note that the Triage Officer has absolute authority to direct crews – whilst we need to be open to feedback and good ideas, Triage Officers need to be direct and assertive in their directions. Avoiding scene convergence/congestion is essential to maintaining the flow of patients towards definitive care
• Once all patients have been triaged and moved to the CCP, relocate there and assist with treatment. If the scene is large or prolonged, consider re-triaging of patients at the CCP using Triage Sort. Using the sort method takes longer than sieve, but takes into account other factors such as GCS and blood pressure, therefore giving us a better indication of who is critically unwell. It is also useful for downgrading people who are physiologically well but have a high heart rate.

• The Triage Officer will continue to provide regular ETHANE SITREPs, usually at least every 15 minutes

Transport Officer

• Works at the direction of the Triage Officer. Usually will be allocated a role prior to arrival at scene as previously discussed. Tasks include
  • Choosing a site for the Casualty Clearing Post and commencing operations. There’s no such thing as an ideal CCP, but it should aim to have the following characteristics;
    • Well lit
    • Sheltered from rain/wind and excess sun
    • Provide good access and egress for ambulance resources
    • Have sufficient space to accommodate all the patients. Even better if there is enough space to separate them out into their different triage categories
    • Safe distance from the scene. This will vary depending on the incident. In suspected chemical/biological/radiological incidents;
      • 200m upwind
      • 200m uphill
      • Not likely to need to move – this is particularly important during dynamic emergencies such as bushfires

• Establish Ambulance Loading Point and Ambulance Holding Point (if required)
  • The Ambulance Loading Point should be immediately adjacent to the CCP and is where crews will park, collect their patient, load into the vehicle and depart. Its vital to keep this area clear for incoming crews
  • The Ambulance Holding Point is essentially a staging area some distance back from the scene, where arriving resources will prop until called forward. Holding Points are only required for scenes where access and egress is an issue, or where there are a large number of patients.
• Oversee the operation of the CCP
  • Providing basic treatment to casualties
  • Giving direction to first aiders and other personnel helping at the CCP
  • Coordinate access and egress of vehicles to the CCP
• Once triaging is complete and additional resources are arriving, the Transport Officer has a critical role in maintaining the Casualty Movement Log. Each service will have a different layout, but in general the information required includes
  • Patient Details – normally we will use the patient number off the triage tag, gender and estimated age
  • Triage Category – 1/2/3
  • Basic description of injuries
  • Transporting crew
  • Destination hospital
  • Departure time

• The Transport Officer should also assess hospital availability in order to help with transport decisions. This can be done by contacting the Duty Manager / Hospital Information Coordinator via radio and asking about hospital capability. Of particular interest will be how many critical patients each hospital can receive.
• Generally speaking the Triage Officer will dictate which patient goes next and the Transport Officer will dictate which hospital they go to. Where possible Transport Officers should avoid dispatching multiple patients to the same hospital simultaneously, instead opting to rotate through available hospitals to space out arrivals.

I’m not first on scene – *phew*. What do I need to know when arriving at a major incident?

Many people breathe a sigh of relief when they are not the first car to arrive at a major incident. However these subsequent crews have an essential role in the smooth running of a major incident.

• Listen out for SITREPs whilst en route and read the available information. Take particular note of details such as the Ambulance Holding Point (if established), Casualty Clearing Post, Ambulance Loading Point and any access/egress instructions
• On arrival be alert to hazards
• Establish that major incident management (Triage and Transport Officer) has commenced. If not, locate the initial crew and have them implement these roles. If they are unwilling or unable to undertake these roles, you have a responsibility to take over and implement them
• Seek out the Triage Officer and ask for direction. As stated above, they may request your assistance to triage, run the CCP or provide other management
• If you are allocated a patient, rapidly load them into your vehicle and alert the Transport Officer that you are departing scene. Do not delay loading and going for any assessment or management unless it is life saving.
• Perform all assessment and management en route to hospital
• Provide pre-hospital notification where appropriate, particularly if there are multiple patients being taken to that hospital
• Once at hospital consider completing an abridged patient care record if you are required back at the scene

Tips and tricks for young players

• When en route to a potential or known major incident, pull out a paper map and assess the local area. It provides a good level of detail and typically includes nearby features. Another option is to use Google Maps with the satellite image overlay
• Always check you have appropriate high-vis vests, triage tags and the casualty movement log at the start of every shift
• Carrying a sharpie in your pocket helps with tagging patients and filling out triage tags
• Petrol stations, large car parks and free-standing fast-food restaurants make for excellent Casualty Clearing Posts
• You cannot communicate too much during major incidents. A good METHANE SITREP is the difference between a smooth major incident and a dog’s breakfast
• If you are separated from your partner at a large scene, use the radio and add ‘Triage Officer’ or ‘Transport Officer’ to your call signs. Eg. “Car 123 Triage Officer to Car 123 Transport Officer, come to the CCP”
  

Bottom Line

Major Incidents are scary. They are paramedic nightmare juice. BUT by thinking about them and remembering the basic principles, your actions can save lives. Remember that the first crew on scene is a management resource and should not undertake any patient care unless it is life saving. You help the most people by getting additional resources rolling and by triaging appropriately. Backup crews should move expeditiously and consciously avoid delaying on scene. Early notification to hospitals is essential to prepare for the influx of patients.