Surge Capacity - the Surge Capacity - the Experience in London on 7Experience in London on 7thth

July 2005July 2005 Dr Penny BevanDr Penny Bevan

Head of Emergency PreparednessHead of Emergency PreparednessDepartment of Health, UKDepartment of Health, UK

ContextContext

LondonLondonPopulation 7.2 millionPopulation 7.2 millionApprox 2-3 million commuters per dayApprox 2-3 million commuters per dayMajority of people travel by public transportMajority of people travel by public transportLondon underground system over 100yrs old in London underground system over 100yrs old in placesplaces08.30 -> 09.00 hrs peak of the morning rush 08.30 -> 09.00 hrs peak of the morning rush hourhourSchool term timeSchool term time

Emergency planning in LondonEmergency planning in London

30 yr history of Irish Republican Terrorism30 yr history of Irish Republican TerrorismFire, Police & Ambulance coterminousFire, Police & Ambulance coterminousLESLEP GuidanceLESLEP GuidanceLondon Resilience Team in place 2 yrs London Resilience Team in place 2 yrs before any other resilience teambefore any other resilience team

Exercise, exercise, exerciseExercise, exercise, exercise[Atlantic Blue, Top Off 3, Triple Play[Atlantic Blue, Top Off 3, Triple Play]]

Health Services in LondonHealth Services in London

CurrentlyCurrently5 Strategic Health Authorities5 Strategic Health Authorities31 Primary Care Trusts31 Primary Care TrustsOne ambulance serviceOne ambulance service33 hospitals with Emergency rooms33 hospitals with Emergency rooms16,500 hospital beds [this includes mental 16,500 hospital beds [this includes mental health, care of the elderly and long stay]health, care of the elderly and long stay]

Health Services in LondonHealth Services in London

By the end of 2006By the end of 2006One Strategic Health AuthorityOne Strategic Health Authority31 Primary Care trusts31 Primary Care trustsOne Ambulance serviceOne Ambulance service33 hospitals with Emergency Rooms33 hospitals with Emergency Rooms

Health Emergency Planning in Health Emergency Planning in LondonLondon

All health organisations have emergency All health organisations have emergency plansplans5 SHA areas have all planned and 5 SHA areas have all planned and exercised in their patch and cross Londonexercised in their patch and cross LondonLondon participated in Triple PlayLondon participated in Triple PlayHealth sits on the London Resilience Health sits on the London Resilience ForumForumHealth involved in all multi-agency Health involved in all multi-agency planning and exercisesplanning and exercises

77thth July 2006 July 2006

Shortly before 09.00 hrs on 7Shortly before 09.00 hrs on 7thth July an July an incident at Aldgate Underground Station incident at Aldgate Underground Station Initially thought to be a Power surgeInitially thought to be a Power surge

London Underground SystemLondon Underground System

Incidents on 7Incidents on 7thth July July

Shortly after 09.00 hrsShortly after 09.00 hrsthree incidents reported on the “tube” three incidents reported on the “tube” these were rapidly confirmed as IEDsthese were rapidly confirmed as IEDs9.50 hrs bomb on bus in Tavistock Square9.50 hrs bomb on bus in Tavistock Square

Initial assessmentInitial assessment

At one hour At one hour – ??8 bombs ??8 bombs – ??1000 casualties??1000 casualties

By one and a half hours clearer idea on By one and a half hours clearer idea on number of incidents and number of dead number of incidents and number of dead and casualtiesand casualties

IEDS on UndergroundIEDS on Underground

Initial Health ResponseInitial Health Response

London Ambulance Service control alerted when London Ambulance Service control alerted when first incident reportedfirst incident reportedAmbulances deployed to all scenes [>4]Ambulances deployed to all scenes [>4]Helicopter Emergency Medical Service Audit Helicopter Emergency Medical Service Audit Day meant all staff at Centre – rapidly deployed Day meant all staff at Centre – rapidly deployed to the scenesto the scenesBus in Tavistock Square immediately outside the Bus in Tavistock Square immediately outside the British Medical AssociationBritish Medical Association7 Hospitals “on take”7 Hospitals “on take”Further hospitals “on stand-by”Further hospitals “on stand-by”

Difficulties with Underground sitesDifficulties with Underground sites

PowerPowerLightingLightingHeatHeatDustDustRestricted access to patientsRestricted access to patientsCrime scene (deceased are evidence)Crime scene (deceased are evidence)Secondary devices ?CBRNSecondary devices ?CBRNDistance from surfaceDistance from surfaceCommunicationsCommunicationsOther stationary trains on the systemOther stationary trains on the system

CasualtiesCasualties

52 plus 4 deaths52 plus 4 deaths700 “casualties”700 “casualties”350 transported to hospital by ambulance350 transported to hospital by ambulance103 patients admitted to hospital for at 103 patients admitted to hospital for at least one nightleast one nightNo inpatients aged over 60 yrsNo inpatients aged over 60 yrsNo inpatients were childrenNo inpatients were children12 with lower limb amputations12 with lower limb amputations

Blast injuriesBlast injuries

many self evacuated and later realised many self evacuated and later realised they were deafthey were deafmanagement of blast lung was not really management of blast lung was not really an issuean issue““tattooing” of victims with body parts and tattooing” of victims with body parts and bloodbloodconcerns re HIV and Hepatitis B & Cconcerns re HIV and Hepatitis B & Cwhat was released from the tunnels by the what was released from the tunnels by the blast?blast?

Mutual AidMutual Aid

Initial uncertainty about numbersInitial uncertainty about numbersAmbulance service requested mutual aid Ambulance service requested mutual aid from outside London – Co-ordinated by from outside London – Co-ordinated by ASAASAOffers of beds/ITU/Burns beds received by Offers of beds/ITU/Burns beds received by DH from all around the countryDH from all around the countryAmbulance support from voluntary aid Ambulance support from voluntary aid societies (Red Cross / St John’s societies (Red Cross / St John’s Ambulance)Ambulance)

Hospital ResponseHospital Response

Seriously injured casualties were distributed Seriously injured casualties were distributed around the nearest hospitalsaround the nearest hospitalsAll were teaching hospitalsAll were teaching hospitalsA significant number needed immediate A significant number needed immediate lifesaving support/surgerylifesaving support/surgeryStaff were called in or told to wait until next shiftStaff were called in or told to wait until next shiftAdditional supplies requested from NHS Additional supplies requested from NHS Logistics [5hr delivery time when traffic not Logistics [5hr delivery time when traffic not gridlocked]gridlocked]

e.g.e.g.

3 patients transported to one hospital3 patients transported to one hospitalAll had lower limb amputationsAll had lower limb amputationsThese 3 patients used 87 units of O neg These 3 patients used 87 units of O neg blood before bleeding was controlledblood before bleeding was controlledAll survived without ARDS/DIC or renal All survived without ARDS/DIC or renal failurefailure

Only three patients died after reaching Only three patients died after reaching hospitalhospital

Effect on hospitalsEffect on hospitals

Routine work suspendedRoutine work suspendedLong stays in ITU for some patientsLong stays in ITU for some patients

Claims of significant effect on some Claims of significant effect on some hospital year end financial position.hospital year end financial position.

Communication and MediaCommunication and Media

Massive, almost immediate, international Massive, almost immediate, international media coverage media coverage No scenes to film at resulted in enormous No scenes to film at resulted in enormous pressure on hospital switchboardspressure on hospital switchboardsInterviews are important both leaders and Interviews are important both leaders and front line stafffront line staffJoint Agency Working criticalJoint Agency Working critical

What worked well with the MediaWhat worked well with the Media

Crisis training and planning put into Crisis training and planning put into practicepracticeEffective joint agency communicationEffective joint agency communicationAbility to influence normal emergency Ability to influence normal emergency demanddemand““crisis” was played downcrisis” was played down

Lessons learnt from the mediaLessons learnt from the media

Access to timely and accurate informationAccess to timely and accurate informationMore focussed coordination of VIP visitsMore focussed coordination of VIP visitsVisual record of emergency responseVisual record of emergency responseBeing prepared for long-term press Being prepared for long-term press investigationsinvestigationsReal difficulty with media trying to get into Real difficulty with media trying to get into hospitalshospitals

Things that went wellThings that went well

HEMS Clinical Governance DayHEMS Clinical Governance Day– 18 pre-hospital doctors available18 pre-hospital doctors available– Provided good medical support on each siteProvided good medical support on each site

LAS Senior Managers ConferenceLAS Senior Managers Conference– 100 managers in one place100 managers in one place

Bus explosion outside the BMABus explosion outside the BMA– experienced doctors on siteexperienced doctors on site

Health Gold at LAS HQ for meetingHealth Gold at LAS HQ for meetingTwo neighbouring Directors of Ops attended HQTwo neighbouring Directors of Ops attended HQ

Lessons LearnedLessons Learned

Communications – mobile and fixed line Communications – mobile and fixed line telephony failed telephony failed All minor injuries taken to one hospital All minor injuries taken to one hospital [due to above][due to above]Minor injuries went to hospital with large Minor injuries went to hospital with large number of major casualties [due to above]number of major casualties [due to above]Transport for staff to get to and from workTransport for staff to get to and from workIdentify research issuesIdentify research issues

Lessons LearnedLessons Learned

Blood – the needs were great and there Blood – the needs were great and there were some difficulties communicating with were some difficulties communicating with the blood banks – have a dedicated linethe blood banks – have a dedicated lineSkin – plan to use banked skin Skin – plan to use banked skin appropriately or identify additional sourcesappropriately or identify additional sourcesSurge in switchboard capacity Surge in switchboard capacity When telephony failed most staff had When telephony failed most staff had stopped carrying their pagersstopped carrying their pagers

StaffStaff

Staff are people as well as professionalsStaff are people as well as professionalsHCWs were killed and bereavedHCWs were killed and bereavedManage staff so all do not come in a first Manage staff so all do not come in a first response – you need staff for further shiftsresponse – you need staff for further shiftsTransport and access Transport and access Support for those distressed by the eventsSupport for those distressed by the eventsparticularly those affected and staff at particularly those affected and staff at scene.scene.

AftermathAftermath

2121stst July – 4 failed bombs July – 4 failed bombs – BMA Memorial ServiceBMA Memorial Service

Heightened awareness and alerting meant many Heightened awareness and alerting meant many false alarm callsfalse alarm callsAmbulance in support of Police response to Ambulance in support of Police response to these callsthese callsMental Health consequencesMental Health consequencesResearch - contaminants and blast injuriesResearch - contaminants and blast injuriesSharing the lessons learnedSharing the lessons learned

2121stst July 2006 July 2006

any questions?any questions?

Department of Health Department of Health Emergency Preparedness Emergency Preparedness

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