34 Injury (1990) 21, 34-36 Printed in Great Britain

Major disasters: an ambulance service view

Frederick Thomley Region&Chief Ambulance O@er, Oxfordshire

Introduction

I should like to begin this paper with two quotations, both of which, in their own way, point our thoughts towards the issues which encapsulate our understanding of major disas- ters. The first quotation is from a recent book entitled Trauma’ edited by Stephen Westaby (1989). It is as follows:

Few events are more distressing than unexpected loss of life or

permanent disability caused by physical violence or accidental injury. Particularly tragic is the injured but potentially salvageable patient who dies needlessly through delay in retrieval, inadequate assessment or ineffective treatment.

The above statement prefaced the first chapter of the book and I think is important and should have an influential bearing when we think about planning for major disasters, even though it was not originally written with that in mind.

The second quotation is not taken from any medical book of learning, but from the lyrics of a popular ballard sung by a 1950/60s group called the Batchelors. Maybe there are only a few here today, besides me, who will remember this Northern singing group, but the phrase from the lyrics of their popular record has relevance when we think about major disasters. It is:

The more we learn the less we know.

Every major disaster is different and each one presents us with new challenges. There seems to be always something new to learn. There is always something we forget. There are always those who, after the event, are ever ready to criticize our human failings. My purpose in being here today is to share with you some thoughts from the Ambulance Service, consequent on our experiences of being involved in numerous major disasters.

The Ambulance Service

NHS planning for major disasters has been structured to involve the Health Authority through its medical services and the Local Authority. The three emergency services - Police, Fire and Ambulance - work very well together and have major disaster plans which are designed to comple- ment each other and provide for the closest co-oper+ion in the event of an incident.

In a major disaster the ambulance service has the prime responsibility for saving life, treating, caring for and transporting the injured to hospital. The ambulance service is also responsible for the initial alerting of hospitals and the mobilization of all NHS resources required for a major

0 1990 Butterworth & Co (Publishers) Ltd 0020-1383/90/010034-03

disaster. It is also responsible for the provision of all medical communications on site as well as other functions including the establishment of a triage area and ambulance loading points.

Its plans are designed to complement those of the accident receiving district general hospitals. The voluntary organizations, i.e. the St John Ambulance Brigade and the British Red Cross, are also often mobilized by the ambulance service and have agreed in most areas to place themselves under the control of the ambulance service in the event of a major disaster.

The service’s plans are structured to provide mutual aid from other surrounding ambulance services. Its plans are regularly practised in part or in total alongside the other emergency services and the military, but such exercises do not always involve the hospital in a practical sense. Efforts are made, however, to correct shortfalls which are identified. As the demands for more and faster travel grow on our roads, rail and air networks become under more pressure, so the risks increase. If you add to the foregoing terrorist activity, the movement of dangerous chemicals and other materials, the chances of a major disaster occurring any- where in the UK should not be underestimated.

In the past 2 years, the UK has witnesssed eight such major disasters resulting in many deaths and large numbers of people sustaining serious injury. The outcome of such tragedies is that many of the families of the dead and those who survived will possibly remain scarred both physically and psychologically for the rest of their lives. Indeed, many, if not all, of those involved in the rescue and treatment of the injured will never forget their experiences.

The ambulance service’s role in the response to major disasters, both as an emergency service and also as the front-line force of the NHS, should not be underestimated. It is critical to the success of the NHS response. Nevertheless, despite our considerable experience gained attending all manner and types of incidents, our views are often not sought, either from within the NHS or indeed outside.

Recently, the Regional Ambulance Officers Group organized a seminar at the Postgraduate Medical Centre in Nottingham to discuss three of the most recent major disasters, i.e. Clapham, Lockerbie and Kegworth. Senior Ambulance Officers with first-hand experience of those incidents provided much worthwhile knowledge to their ambulance service colleagues from all over the UK. The full report on this seminar is to be published soon and will be circulated to all Regional Health Authorities and also to Districts.

I should like today to highlight some issues that were raised at the seminar.

Tbomley: Major disasters: an ambulance service view 35

Some relevant planning issues

1. Health Service arrangements for dealing with major

incidents - H.C.(77)1. (4

@I

(4

(b)

This Circular is now over 12 years old and is in need of revision. Much of the terminology is dated and there is also a need to draw on the many experiences that have been gained since this document was first published. The Regional Ambulance Officers Groups has provided a substantial redraft to the Department of Health on those aspects of the circular which affect the ambulance service as well as modernizing some elements of the main body of the circular. There remain, however, those aspects of the circular dealing with the medical and nursing input at major disasters which may well benefit from a new look. Further thought needs to be given to the provision of Site Medical Teams, particularly if more than one receiving hospital is to be involved in accepting serious- ly injured casualties from a major disaster. This is still a ‘grey area’ in many places and can cause difficulty when a hospital is likely to be hard pressed receiving casualties. Another cause for concern is the effectiveness of many of our hospitals in coping with seriously injured casual- ties who are also contaminated, either as a consequence of radioactivity or a serious chemical spillage. Are there well-laid plans to have separate areas in our hospitals to deal with such casualties? What about decontamination of patients? What about protection and decontamination of hospital staff who receive such casualties? As far as radioactive accidents are concerned, a new Circular H.C. (89) 8 and Annexe has just been issued. How many accident and emergency staff are aware of this and what are we doing about educating such staff?

On-site issues There is certainly a need to recognize the ambulance service as the medical focal point at the major disaster site. Given its responsibility to set up an incident control point and triage area, it seems logical that all professional medical, nursing and voluntary first aid organizations should report to this point. It is at this point that the Senior Ambulance Incident Officer and Incident Medical Officer should be found. Experiences have shown that this does not always happen and it should. Failure to acknowledge this area as the medical focal point can cause confusion and loss of coordination. More thought needs to be given to the wearing of protective clothing, not just by ambulance staff, but also by medical and nursing staff working at the site. Major disaster sites can be, and often are, quite dangerous. There can be risks from jagged metal or chemicals; it may be dark and/or the weather inclement. Whatever the reason, there is a need for a disciplined approach to this issue. All protective clothing worn on site should be highly visible and clearly marked. This helps to identify staff quickly and assists the Incident Medical Officer and Senior Ambulance Incident Officer to deploy staff quickly in accordance with their skills, e.g. doctor, paramedic, nurse, etc.

The time has come for more consideration to be given to protection for the patient who is awaiting evacuation to hospital. This could be vital in out of the way places when it is wet and cold. What about the use of inflatable shelters in such conditions? Such shelters could also be used as temporary mortuaries if no suitable buildings are available.

In order to identify evacuation priority, casualty label- ling needs to be standardized. A Regional Ambulance Officers Working Party has done much work on this subject and has commended a National Standard Casualty Label to be used on primary triage. This is

known as the ‘Thames Label’ which works on a colour code and is recommended to replace the 132 different types of labels being used by the NHS. The Royal College of Surgeons of England in their recent report have laid stress on the need to train ambulance staff in paramedical or advanced life support techniques, coupled with improved skills in early injury recognition. Almost all services in the UK have now embarked upon such training in line with the NHSTAs training package. Indeed, some services have many years’ experience in such skills. The pace, however, needs to be quickened and to this end the full support of the medical profession is needed. As more ambulance staff are trained and they get more experience, particu- larly in the art of trauma scoring, this must surely improve triage and relieve the pressure on hospitals in their provision of medical teams. This is clearly a thought for the future. More work needs to be undertaken to improve media relationships and contacts. All our recent major disasters have shown that this aspect is very real. A priest writing in the Church Times (Arnold, 1989) refers to a TV crew being assaulted outside a Sheffield hospital entrance just after the Hillsborough disaster. He remarks that he had sympathy with the angry football fans, but also with the media. After all, they were only doing their job and it was the media who were instrumental in notifying a great many helpers who were able to assist, particularly with bereaved relatives. Any disaster plan must have a realistic section on dealing with the media. Someone with knowledge and experience must be quickly as- signed to this task. They can be a force for good if properly handled. The ambulance service and other NHS disciplines must improve their methods of giving staff more education and, above all, continuing help with relieving stress. Following the many major disasters which have occur- red over the last decade, and indeed in the light of many of the day-to-day pressures faced by NHS staff, it is now clear that we need to place much more emphasis on caring for the carers.

General comment

Over the next 3 years the NHS is going to be subject to further major changes in the way it operates. Hospitals are going to be encouraged to look at self-governing status and the long-term effects of the many changes envisaged do not provide the ambulance service with a clear picture of the future.

Protecting the public against the hazards, which includes being properly prepared for major disasters, requires much investment in planning, manpower resources, training, equipment and all the associated needs. The heavy emphasis which is now placed on competitiveness in the market place and the pressures this will bring within the NHS could bring with it a more fragmented approach to patient care and a loss of cohesion and mutual aid -the very ingredients which are most important when we are considering planning arrangements for dealing with major disasters.

36 Injury: the British Journal of Accident Surgery (1990) Vol. 2UNo. 1

Conclusion

This paper has sought to share an Ambulance Service view with the wider forum of the medical profession within the NHS, in the hope that we will all take out of the experiences gained those things which will be helpful for the future and, at the same time, shake us all out of any complacency that may still exist. It is a sobering thought that, within days of the Ambulance Service Seminar held at Nottingham, yet another major disaster occurred at Hillsborough, Sheffield, with a loss of 95 lives and over 171 injured.

We never know when, or where, a major disaster will occur next. Our level of preparedness will always depend on how much we learn from the tragedies of others. In the UK we are, in my view, still complacent about major disaster planning. It is always going to happen somewhere else. There is a need for more investment in equipment and also the training of staff. How often do we really practically test our plans? Do we put it off because of cost or, perhaps, some perceived higher priority?

Perhaps the real major change which needs to occur is in our thinking. A greater awareness needs to emerge. Perhaps we should stop thinking about What if’ and gear our thoughts and actions towards ‘it will happen’. In this way we may become more efficient and avoid hindsight recri- mination.

Only then, will we truly understand the meaning of the phrase - ‘The more we learn the less we know’.

References

Westaby S. (ed) (1989) Trauma, Heineman Medical, Oxford, UK Arnold R. (1989) Church Times

Requesfs for reprinfs shouti be dressed to: F. Thomley FASI LHSM

MRSH, Chief Ambulance Officer, Ambulance Service H.Q., Churchill Hospital, Oxford, UK.