Abstract Major Incident Medical Management and Support (MIMMS) DEFINITION: a major incident is any incident where the location, number, severity or type of live casualties requires extra-ordinary resources "To fail to plan is to plan to fail" INCIDENT MANAGEMENT "CSCATTT" * Command * Safety * Communication * Assessment * Triage * Treatment * Transport * Command - Aim: "to turn chaos into mild confusion" - Command is vertical, Control is horizontal - Take command of all medical assets - Remain near tactical command element - Start a log! - Suspected danger (i.e. IED): the four C's > C Confirm (visually from a distance) > C Clear (move away, evacuate personnel) > C Cordon (create a cordon to keep people at a safe distance) > C Control (create an Incident Control Point (ICP) to control the cordon and monitor arrival and departure of personnel) - Levels of command > Bronze= Operational: point of wounding, within Inner Cordon, multiple bronze areas possible > Silver = Tactical: overall major incident area, overall rescue effort, within Outer Cordon (physical cordon) for crowd control, FP and perimeter security > Gold = Strategic: highest level of command, not in the immediate area, might be provincial or national level October 2007 1/8 LCol. Ralph Vermeltfoort, Flight Surgeon RNLAF
* Safety - Take responsibility for the safety of all medical personnel at the scene - Tactical safety will remain responsibility for the tactical commander - Assess safety: > Am I safe? > Is the scene safe? > Are the survivors safe? - Different environments > Permissive: no danger whatsoever > Semi-permissive: anywhere in between > Non-permissive: you are taking effective enemy fire * Communication - Put together a "METHANE" report (initial and update reports from the scene of a major incident involving multiple casualties) > M My call-sign + MAJOR INCIDENT STANDBY / DECLARED > E Exact location (grid reference or GPS location) > T Type of incident > H Hazards, present or potential > A Access to scene and egress route + Helicopter Landing Site (HLS) > N Number and severity of casualties > E Emergency services, present and required - Put together a 9-line message, needed to request casevac (pick-up location, radio frequency, number of patients etc.) - Put together a "MIST" message (given at handover between each successive level of care) > M Mechanism of injury > I Injuries or illness found or suspected > S Signs (RR, SpO2, PR, BP, GCS) > T Treatment given - Cross of communications: communication between the Medical Commander, EOD, MP, Tactical Commander, Fire Services and EOD. - Causes of poor communication: Lack of information, confirmation or coordination - Radio Communication > do not talk for more than 30 seconds at the time. Somebody else might have more important information > terminology: over, out, OK or Roger, acknowledge, say again, wrong, correction > don't use please and thank you > when you spell, say: "I spell" > When you give a number, for instance 500, say: "Figures five zero zero" October 2007 2/8 LCol. Ralph Vermeltfoort, Flight Surgeon RNLAF
* Assessment - Establish areas for ambulance parking and for Casualty Clearing Station (CCS) ("gewondennnest") - Establish ambulance circuit - Assess developing hazards - Assess need for additional personnel and equipment resources - Assess need to rest or relieve medical personnel at the scene * Triage - Aim: "doing the most for the most", the right patient in the right place at the right time - Ensure triage is carried out properly - Determine the use of T4 (expectant) (at the discretion of the Medical Commander) - Primary triage at point of wounding using Triage SIEVE ("zeven") - Secondary triage at Treatment Facility (CSS) using Triage SORT ("sorteren") > use triage SIEVE to initially prioritise adults > use Paediatric Triage Tape to initially prioritise children > use Triage SORT if you have enough time and personnel - Keep a tally of number of casualties of each priority within your assigned sector - Triage categories: > T1 Immediate: intervention needed < 1 hr surgery needed < 2 hrs > T2 Urgent: intervention or surgery needed 2-4 hrs > T3 Delayed: safely delayed up to 4 hrs > T4 Expectant: cannot survive, injury is so severe that the treatment would compromise survival of others October 2007 3/8 LCol. Ralph Vermeltfoort, Flight Surgeon RNLAF
* Treatment - Establish a Casualty Clearing Station (CSS) = Casualty Collection Point - Provide medical personnel to treat patients at the point of first contact (bronze area) - Otherwise concentrate medical personnel at CCS - Aim to achieve best practice standards but accept compromise when resources are overwhelmed - Levels of care > Care Under Fire (only airway, prone position and torniquet) > Tactical Filed Care > Field Resuscitation > Advanced Resuscitation - Trauma algorithm: CABCDE > C catastrophic haemorrhage: apply torniquet > A airway > B breathing > C circulation > D disability > E exposure * Transport - Select appropriate transport for individual patients - Liaise with loading officer and tactical commander - MERT = Medical Emergency Response Team (helicopter borne team) - Patient flow: > from incident site (triage SIEVE) > to CCS (triage SORT) > to ambulance loading point > to receiving hospital - Scene vehicle flow > route in > ambulance loading point > ambulance circuit - Casualties requiring specialist treatment should be directly referred to the appropriate facility if possible - Vehicle selection: capacity, availability, suitability October 2007 4/8 LCol. Ralph Vermeltfoort, Flight Surgeon RNLAF
FIRST MEDICAL TEAM AT SCENE * Start a log and record time of arrival * Wear protective clothing (helmet, high visibility coat or tabard (civil), body armour (SOP)) * Make METHANE assessment, encode as necessary and send * Consider parking place for ambulances * Consider location for Casualty Clearing Station (discuss with Silver Commander) * Request Silver Commander to locate and mark a suitable Helicopter Landing Site (HLS) for the Support Helicopter (SH) * Continue to assess and communicate with higher formation as details become available * Continue duties of Medical Commander until relieved ANNEX A: Scene layout ANNEX B: Triage SIEVE ANNEX C: Triage SORT October 2007 5/8 LCol. Ralph Vermeltfoort, Flight Surgeon RNLAF
ANNEX A: SCENE LAYOUT October 2007 6/8 LCol. Ralph Vermeltfoort, Flight Surgeon RNLAF
ANNEX B: TRIAGE SIEVE October 2007 7/8 LCol. Ralph Vermeltfoort, Flight Surgeon RNLAF
ANNEX C: TRIAGE SORT October 2007 8/8 LCol. Ralph Vermeltfoort, Flight Surgeon RNLAF