Background
Best practice advice on major incident management
Preparation
Major incident plans
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HEMS units require a suitable, proportionate and up to date Major Incident plan that includes medical, aviation, and technical aspects. Further, support services e.g. communication, fuel and resupply should also be integrated into the service plan
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Local Major Incident plans should include clear pre-defined roles, responsibilities and command of HEMS medical personnel and helicopter utilisation
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HEMS Major Incident plans must be integrated with the Major Incident plans of other local medical and non-medical emergency services including fire, police and military
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Information on capability, capacity, landing site and contact details should be available to HEMS teams and their control centres for regional and supra-regional hospitals to facilitate patient distribution and optimise surge capacity
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Depending upon regional threat, HEMS teams may require formal planning cooperation with tactical law enforcement units to ensure team safety, helicopter base security and efficient clinical care in non permissive environments
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Consider maintaining units in reserve or delaying HEMS deployment until incidents are declared to avoid HEMS resources from becoming fully committed to potential or minor incidents at the expense of casualties at decompensated sites. Reserve assets also maintain the ability to respond to multiple incident sites and ensure that conventional activity can be fully resumed at the conclusion of the incident [6]
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Ensure robust communication methods between HEMS teams and other emergency services exist to allow interoperability and a cohesive response
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Establish efficient communication cascades within HEMS systems to ensure teams can be mobilised and coordinated in the event of a major incident
Training
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HEMS medical personnel must complete a recognised Major Incident management training course that allows operational integration with local emergency services
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HEMS operational staff must ensure that they are familiar with the HEMS and local Major Incident plans
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Major Incident exercises should be conducted on a regular basis together with other rescue services, in accordance with local statutory requirements, to confirm operational familiarity with plans and identify deficits [7]
Equipment
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Anticipate the provision of equipment and drug requirements of mass casualty incidents sufficient to deploy multiple equipped HEMS teams in exceptional circumstances [4]
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Provide Personal Protective Equipment (PPE) to allow safe working in a Major Incident environment with conventional scene hazards
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Risk evaluate for the likelihood of Chemical, Biological, Radiation, Nuclear or Explosive (CBRNE), ballistic or specific local scene hazards (temperature, immersion, etc) and consider stocking sufficient risk specific PPE, logistics and detection equipment to allow the safe deployment of multiple teams
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Consider the routine carriage of back-up communications equipment due to the multifactorial potential for conventional communication network failure
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Prepare items such as triage labels, action cards, event logs, etc. in accordance with local protocols to facilitate the organisation and documentation of Major Incidents
Support services
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Support structures like maintenance, supplies, transfusion services, human resources, public relations and communications departments are all integrated parts of operational HEMS units and should be embedded in major incident plans to maintain resilience in prolonged operations.
EHAC MWG statement
Response
Helicopter deployment at major incidents
Helicopter utilisation during major incidents may include
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Primary and secondary patient transfer
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Transfer of emergency service staff to and between major incident sites
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Deployment and resupply of medical equipment
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Aerial assessment of Major Incident scenes
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Access to remote sites
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Search and rescue
Helicopter control and safety
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Where multiple emergency services deploy helicopters into an uncontrolled airspace there must be predetermined procedures to coordinate activity and ensure aviation safety
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Organisations operating HEMS must have Standard Operating Procedures (SOPs) for incidents involving multiple HEMS units in uncontrolled airspace that ensure clear command, control, communication and safety
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The safety of HEMS crews should be prioritised when landing in unsurveyed landing sites
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Consider the risk from the cause and consequence of the Major Incident, such as ongoing fire, explosion, toxic chemicals, flooding, weather, building collapse, terrorist activity and secondary attacks directed at emergency responders [13]
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Authority for helicopter deployment should be coordinated by systems familiar with the logistical and clinical capability of the HEMS asset to ensure safe and efficient utilisation
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Contingency plans for regional and supra-regional major incident control centres should be established to mitigate the risk of local command centre communication overload or failure
HEMS/PHCC teams at major incidents
Command and control
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HEMS team may be required to assume medical command of major incident management due to geography, speed of response, medical seniority or predefined Major Incident role
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HEMS teams should contribute to the situational awareness of scene command with intelligence collected from the air and recognise that visual information from flight to and from the scene can be valuable for critical decision making in the scene command
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Deliver regular site report updates to the regional system control centre to allow effective utilisation of available assets
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When possible, HEMS personnel should operate in their usual teams and aviation platforms to minimise risk due to inter service variations in operational procedures
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HEMS teams often have extensive regional knowledge of the health care system and can utilise this knowledge in scene command decision making
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Facilitate scene coordination by wearing labels that clearly state designated Major Incident role and responsibility e.g. Casualty Clearing Station officer, Medical Major Incident Commander etc.
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In accordance with local Major Incident training protocols, responsibility for scene command, safety, communication and safety may take precedence over the personal delivery of medical care to individual casualties
Triage
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HEMS teams must be able to organise and implement dynamic triage at each stage of the Major Incident response according to national or local triage systems
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HEMS teams must be able to systematically prioritise casualties for treatment and transport. This is a vital element in the efficient management of Major Incidents
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HEMS teams must follow the same triage system as local resources if a national triage system is not in place or when operating in cross border incidents
Treatment
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Rapid application of simple interventions, such as tourniquet control of massive haemorrhage and recovery position for airway obstruction, may be superior to definitive clinical management of individual patients when managing large numbers of patients with limited resources or in a non permissive environment [8]
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The appropriate level of patient care may change during phases of a Major Incident and as a patient is moved away from direct danger into an increasingly permissive and safe environment
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Implementation of advanced medical procedures, such as intubation, requires situational judgement to ensure that it does not further endanger the individual patient and impair the care delivered to other unattended victims
Transport
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Decision making on helicopter transfer of patients will be influenced by many event specific factors and may be inappropriate if the helicopter is better deployed to convey staff and equipment. This may change during different phases of the response
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Helicopter evacuation may allow primary transfer to distant specialist care (e.g. burns, extracorporeal membrane oxygenation (ECMO)) or inter-hospital transfers to appropriately distribute patients for definitive care
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HEMS teams may be required to use a knowledge of regional resources and specialist centres to distribute patients according to need and capacity
EHAC MWG statement
Recovery
Post incident
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HEMS teams should plan to rapidly regain operational activity to meet conventional need and to respond to further related incidents
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HEMS teams that have been involved in major incident scene management should be relieved when the mission is over to allow for rest, debriefing and psychological support
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Team debriefing and psychological support should be available to HEMS members
Reporting
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Contemporaneous records of Major Incident events and decision making must be preserved to inform later investigation and analysis and in accordance with local regulations or laws
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Teams should be encouraged to write statements of Major Incident events soon after the incident to promote accurate recording and recollection of events
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A standardised Major Incident reporting template should be completed (http://majorincidentreporting.net)