Ross G Milligan, Superintendent Medical Illustrator, Monklands Hospital,

Monkscourt Avenue, Airdrie ML6 OJS, UK Tel: + 44(0) 1236 746121;Fax: + 44(0) 1236 746100; Email: rgm@mdgh-medill.demon.co.uk

The role of medical illustration in responseto major incidents

ROSS G. MILLIGAN

There is very little published information on the rolesand responsibilities of the Medical Illustration Depart-ment (MID) during Health Service major incidents. Thepurpose of this paper is to highlight the need for pre-planned protocols for medical illustration staff thatwould be used in such incidents. Various types of majorincidents are described and the potential contributionsof MID staff are detailed.

Introduction

The terms `major incident’ and `major disaster ’ tend to be

used imprecisely and interchangeably in the Health Service,

despite efforts to standardise definition. What might be

classified as a major incident by the police or fire service is

not necessarily categorised as such by the National Health

Service (NHS). In a previous paper, the author quoted the

British Association of Immediate Care Specialists

(BASICS), who defined a major incident in Health Service

terms as one that `cannot be stated simply in terms of the

total number of live or dead casualties. It must reflect the

ability of the service to cope with (the) number of live

casualties, using the resources available in normal daily

working practice’ .1 Alternatively, a major incident is one in

which the demand exceeds the resources that are imme-

diately available to respond effectively and requires special

provision to be made.

Classificiation of major incidents

The term `major incident’ is most often associated with

events involving trauma, such as plane or train crashes, road

traffic accidents, accidents at sea and other events, which

can be described as acute incidents. This type of event is

sudden and often traumatic in nature, but will have normally

run its course within hours. Designated receiving hospitals

will have Major Incident Plans that detail the necessary

actions required by the various hospital departments to deal

with this type of incident.2 These plans are normally tested

by undertaking regular disaster exercises, ranging from

table-top to full-scale simulations that involve other bran-

ches of the emergency services.

Not all major incidents involve trauma. Major medical

incidents can, and do, occur. A major medical incident may

be described as a `sub-acute’ event evolving over several

days. In this circumstance, the normal service of the

receiving hospital is disrupted, and the incident meets

BASICS criteria. Moreover, there is a steady build up of

admissions over a period of days, weeks or months, in

contrast to the sudden influx that would be caused by a

traum atic incident. Preparing for medical-based events is

more difficult because variations of cause and treatment of

the resultant clinical conditions may be much more diverse

than when dealing with trauma. There may, of course, be an

acute medical incident following, for example, an acute

outbreak of food poisoning arising in a single location. The

phases of a major incident may be defined as acute, sub-

acute and chronic.

The most difficult major incidents for the Health

Service to deal with comprise all three phases such as the

incident that occurred at Chernobyl, in Belarus, in April

1986. An explosion at a nuclear reactor caused two deaths

due to the initial blast (acute phase) and a further 29 as

a result of thermal or radiation burns, and the effect of

gamma radiation (sub-acute phase).3 The ensuing fallout

caused radiation-associated cancers, globally estimated to

be in tens of thousands (chronic phase).4 The implications

for the Health Service of such an incident are tremendous.

As the United Kingdom has a number of commercial and

military nuclear sites, many designated receiving hospitals

have major incident plans for dealing with radioactivity.5

Toxic and chemical contamination require similar advance

planning. Physical incidents, such as earthquakes, floods

and explosions, may result in outbreaks of infectious

diseases, due to the collapse of local infrastructure, such

as water and sewerage services.6 Such events have a

shorter `acute’ phase±the original disaster±and more

extended consequences.

Preparing for major incidents

The staff of Medical Illustration Departments (MIDs)

should be involved in major incidents only if they have

established a day-to-day working liaison with the staff of

the Accident and Emergency Department (A&E) and have

sufficient experience to be allowed to act on their independ-

ent professional judgement. Their role and responsibilities

should be clearly defined and accepted by both clinicians

0140-511X/99/010021-06 � 1999 Institute of Medical Illustrators

Journal of Audiovisual Media in Medicine, Vol. 22, No. 1, pp. 21 ±26

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and NHS senior managers. One of the first decisions that

MID managers have to take when constructing a protocol, is

to identify and define the purpose for which any photo-

graphs or other recordings may be used. The most obvious

is the recording of clinical conditions, but other applications

include:

· injury and/or treatment;

· clinical management planning;

· incident debriefing;

· audit of hospital response;

· clinical teaching;

· training of staff.

Major incidents can present clinical conditions that are seen

comparatively rarely in hospital and records of traumatic

injuries can be an invaluable part of the patient’ s records.

The primary objective in A&E is to resuscitate and stabilise

the patient. In practice, this means further treatment will

often be required, especially if the hospital is functioning

under major incident conditions.

Medical staff undertaking any additional treatment may

not necessarily have been involved in the initial response.

Having a pictorial record of the presenting injuries and

immediate treatment has been identified by senior A&E

medical staff at Monklands Hospital as an asset in treatment

planning, and in transferring information where specialised

medical care or tertiary transfer is indicated. The recorded

images will form an integral part of the patient’ s hospital

records.

In the author’ s experience of the working conditions

during a major incident, medical staff may not be in a

position to say what images they want captured and when.

Medical illustration staff should therefore be trained to work

independently within agreed parameters. This can be

achieved only if staff are familiar with the objectives of the

hospital’ s Major Incident Plan. To this end, staff must be

well versed with the working practices of A&E and other

high dependency units (HDUs) within the hospital. Medical

illustration staff should establish close links with these

HDUs, the staff of which should be aware of the role and

duties of the medical photographer. Equally importantly,

medical illustration staff can familiarise themselves with

each unit, and obtain recordings without unintentionally

interfering with treatment. Medical photographers should be

encouraged to record images that their experience and

training tells them may have a use later (Figure 1 ). It is

better to take a few unwanted images at the time, rather than

miss what later is identified as an important event or

incident, while respecting the rights of the patient to

confidentiality.

The protocol for the MID should meet the overall

objectives of the hospital. MIDs should keep a copy of their

response protocol readily available and all staff should be

familiar with its content. It is important that other members

of the health care teams are made aware that medical

photographers will be working in areas of the hospital

involved in a major incident, with clearly defined and

approved objectives. To avoid confusion with media

photographers, medical illustration staff should be clearly

identified.

New members of the staff of a MID should be subject to

induction training. The department must establish, and

practise, a telephone call-out cascade for out-of-hours

incidents. This involves all members of the MID having the

home telephone number of other MID team members listed

in priority order. W hen the first on-call is contacted by the

hospital, they will telephone the next member of staff on the

list prior to leaving for the hospital. If there is no reply from

the second on the list, contact is then attempted with the

next person on the list to ensure the cascade continues. A

high priority for the first member of the MID team should

22 Milligan

Figure 1 Application of Thomas splint in resuscitation room trauma bay

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be established on the hospital’ s cascade list if the medical

photographer is required to accompany the on-site medical

team. Having a departmental cascade system does not

necessitate a formal `on-call’ system. As with other

departments in Monklands Hospital, staff will report for

duty, if requested, for major incident duties. Overtime costs

will be recuperated by the hospital from the local Health

Board as additional funds are released in the event of a

major incident.

Prompt cards, detailing duties, should be devised by

medical illustration managers and issued to staff in the event

of a major incident (Table 1). Appropriate protective

clothing must be worn and training given for activity in

what may be a hostile environment, outside the hospital

premises. At Monklands Hospital, a medical photographer

often joins Flying Squad call outs of a non-major incident

emergency ±usually road traffic or industrial accidents that

require an on-site medical team. Such deployment with the

Flying Squad gives valuable experience. At Monklands, a

dedicated Flying Squad ambulance whose response is

integrated with the Scottish Ambulance Service transports

the team. Medical illustration managers should ensure that

if their staff are required to participate in the site medical

team, those staff are covered by additional accident

insurance. Hospitals that have a Flying Squad will normally

provide this additional cover for their medical and nursing

staff, but it should be ascertained that this insurance covers

medical illustration staff.

MIDs should ensure that their roles and responsibilities

are reflected in any major incident exercise carried out in

their hospital. Involvement in joint exercises with other

branches of the emergency services is to be encouraged as

this will help clarify the demarcation of duties between

photographers from the police and the audio-visual units of

the ambulance and fire services. Joint exercise video

recordings by the Monklands MID have been incorporated

with recordings taken by the ambulance and fire services to

produce an exercise video which was used at joint planning

meetings.

On-site

The role of the clinical photographer at the site of the

incident provides details of the surroundings in which the

patient was found, the circumstances in which the injury

occurred, and immediate treatment (Figure 2 ). If the patient

has been involved in a road traffic accident, images of the

interior of a vehicle may be recorded to assist A&E staff

subsequently in assessing penetrating or blunt injury from

the dashboard or steering wheel. Images are recorded on

video, still photographs and Polaroid prints. These Polaroid

pictures are returned to the department with the victim for

immediate assessment by medical staff in A&E (Figure 3 ).

Crash severity can be calculated by accident investigators

using the Vehicle Deformation Index (VDI) of the Collision

Deformation Classification,7 which is an alphanumeric

system designed to define the extent of crush into a vehicle.

The deceleration force at impact ( D v ) can be calculated

from the VDI and weight of the vehicles involved, and an

Injury Severity Code8 can be assigned. However, this

information is not available to medical staff receiving

casualties immediately after an incident. The on-site

medical photographer ’ s Polaroid prints of the vehicle

interior provide a useful source of information prior to any

accident investigation. This protocol would be carried out in

the same way in cases of major incidents requiring an on-

site medical team.

There have been major incidents where the clinical

photographer would have a very limited role on-site. One

example occurred in December 1988 when Pan Am flight

103 exploded over the town of Lockerbie in the Scottish

borders. Two hundred and fifty-nine passengers and crew

were killed. A further 11 residents of the town lost their lives.

The explosion at an altitude of 31,000 feet and resulting

Medical illustration and major incidents 23

Table 1 Prompt card–Medical Photographer 1: firstarrival in DMI

Deliver Polaroid 600 film ( 3 4) and camera to TriageReport to Incident Controller at A&E for instructions

Remember ID badgeIf on-site, collect protective clothing from A&E major

incident store

On-site with medical teamPhotograph patients in-situ. Wounds if possible (record

on patient Record Tag). If road traffic accident,document scene + interior on Polaroid–return printsto A&E with patient

Photograph immediate treatmentVideo team undertaking duties and circumstances of

incidentReturn to A&E with team and check theatre status

No medical team requiredBase in RESUS roomPhotograph patients’ wounds on arrivalPhotograph treatmentPhotograph patients’ wounds after stabilisation–prior

to theatreVideo staff clearing incidentIf conditions permit, video other areas involved in

incidentID photographs if patient is comatose, in extremis, dies

in department with no ID found

Equipment checklist for major incident rucksackSVHS camcorder3 3 EC45 SVHSc tapes3 3 video batteriesPolaroid camera3 3 Type 600 film35 mm F3 bodyspare 35 mm body28 mm Nikkor55 mm Nikkor105 mm NikkorMetz 45Ringflash–fresh batteriesWeston light meterMajor incident film stock

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break-up of the aircraft killed the victims on board. The

wings of the aircraft, which contain the fuel tanks, caused a

crater 100 yards wide by 30 feet deep on impact and

registered 1.3 on the Richter scale at a geological station 15

miles away.9 Flying Squad teams were sent from Edinburgh

Royal Infirmary and the South Manchester Accident Rescue

Team.10 No living casualties were found from the aircraft and

it is difficult to identify a role for clinical photography that

would not be subsequently met by police Scene of Crime

Officers (SOCO) collecting forensic data.

The fatal shooting of 16 infants and their teacher, and the

wounding of others, at Dunblane Primary School in March

1996 resulted in two Flying Squads being dispatched to the

incident.11 Unfortunately, the hospitals involved do not have

their own medical illustration service, therefore there was

no medical photographer with either team. It is possible that

identification photography might have helped to reduce

delays in confirming the survival of those who were

uninjured but initially inaccessible, thereby reassuring

relatives. These delays were a major cause of press criticism

at the time.

It is important that the difference between the roles of the

clinical and the police photographer is established locally to

try to avoid duplication of effort. In the author ’ s experience

24 Milligan

Figure 2 IV cannulation inserted on-site to maintain fluid volume

Figure 3 Interior of motor vehicle after removal of casualty by fire service

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this is difficult to achieve in practice. In Scotland, the

Procurators Fiscal Office, which has a similar function to

the English Crown Prosecution Service, will often wish to

deal with photographs taken by police photographers, while

medical staff often prefer to give evidence with reference to

clinical illustrations.

Identification photography

The author proposes that identification photography plays

only a limited role in the remit of the medical photographer.

In Monklands Hospital A&E, clerical staff allocate

attenders with a unique ̀ major incident number’ and casualty

records to speed up the registration process. Matching

numbered identity labels for investigations are pre-printed,

and these are used when sending samples to the laboratory or

requests to the Department of Diagnostic Imaging. During

major incidents, this unique number, rather than a name,

identifies casualties and therefore identification photographs

are not regarded as necessary. However, the potential value of

Polaroid photographs taken at the Triage point and attached

to the patient record should be considered. These Polaroids

could be taken by the Triage Nurse or A&E reception staff.

This would have particular value where the attenders have no

identifying docum entation, are not English speakers, such as

foreign nationals, or are unaccompanied children, and might

reduce delays in establishing formal identification. This has

the benefit of identifying uninjured survivors or those with

only minor injuries, thereby providing reassurance for

relatives. In an Institute of Medical Illustrators Diploma

Major Project, Rowles indicated that recording casualties,

including walking wounded, was a major part of the medical

photographer ’ s role in her and other hospitals. At the author’ s

hospital the MID supplies the Polaroid camera and film but

does not routinely undertake photography for identification

purposes.

At Monklands Hospital, it has been agreed that medical

photographers will undertake photography for identification

purposes only if the patient: (1) is com atose, (2) is in

extremis, or (3) died in the Department; and has no

identifying documentation. Clearly any Polaroid pictures

taken in these circumstances must carry the unique major

incident number and be permanently affixed to the casualty

record. This would have additional benefit if the patient

became separated from their records at any stage in their

treatment. Polaroid 600 film has an area below the image

that can be written on. As an additional safety feature, the

unique number can be written on the print using an indelible

ink marker.

Video monitoring in A&E at Monklands Hospital is part

of the remit of the MID, in as much as the specification and

positioning of equipment was undertaken under the depart-

ment’ s supervision. Video recordings from these cameras

may have a value in monitoring the departmental and

hospital response to the major incident, and in debriefing

and subsequent training purposes. Images could be relayed

to the hospital controller, providing an overview of the

response, particularly in A&E.

The equipment used

The equipment used in a major incident will depend on the

location in which the photographer is operating. At

Monklands Hospital a video camcorder is used to record the

on-site scene for de-briefing A&E staff at the end of the

incident. A domestic SVHS camcorder is used because of

the smaller size and weight compared with the industrial

units normally operated by the MID in routine programme

production. The video camera must be able to function in

low-light conditions, as accessory lighting is not taken on-

site. The fire service will install lighting at the scene if

required. Additional video camera batteries are kept on

`trickle charge’ within the department for use during these

incidents. Conventional 35 mm photographs are taken of

injuries and the patient treatment tag is marked to show that

clinical photography has been undertaken. As previously

described, a recent addition to the equipment list is a

Polaroid camera to assist A&E staff in assessing penetrating

or blunt injuries from the dashboard or steering wheel.

In major incident conditions, if a second photographer is

available or an on-site medical and nursing team is not

required, then duties include covering A&E. Particular

attention is paid to the resuscitation room where the trauma,

medical and paediatric bays are situated. The primary

objective here is to record patients’ injuries and treatment

given to patients as this has been found by other hospitals to

be of benefit.1 2 Any casualties that have been photographed

on-site are followed up. Other duties include taking location

shots of A&E to demonstrate how the department coped with

the clearing of casualties. The A&E medical photographer

will also be available to the hospital incident team to record

any other areas of the hospital that are having problems. This

would be used during de-briefing sessions between the

incident controllers and senior hospital management.

The operating theatres will be covered by the returning

on-site photographer or, if possible, by an additional

medical photographer. Priority will be given to patients

photographed on-site and in A&E, following up their

treatment. If for any reason only one medical photographer

is available, then they would base themself in A&E if this

has been agreed in advance with the consultant medical

staff. It should be noted that in the event of a large incident,

medical illustration staff could be seconded from other

hospitals, provided that this has previously been agreed with

other local departments.

At Monklands, the Senior Medical Illustration Assistant

has been allocated the role of `runner ’ and will commu-

nicate between the medical photographers and the main

department, delivering film and other required materials, in

addition to collecting and cataloguing exposed film.

Consideration should be given by hospital management

to the risks faced by medical photographers in the course of

their activities during major incidents. They may be at risk

in hazardous situations, particularly on-site, and their

activities may be misconstrued by the public as those of the

news media. Appropriate prominent identification should be

provided which is consistent with other members of the on-

site team.

Medical illustration and major incidents 25

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Patient consent

Clinical photography is normally undertaken only with the

patient’ s informed consent. In a major incident, this may not

be possible. Still photographs will form an integral part of

the patient’ s hospital record and will be subject to the

appropriate legislation and confidentiality must be main-

tained at all times. The patient will have right of access to

the contents of their medical record in appropriate circum-

stances at som e future date. It may not, however, be

disclosed to other agenices or for other purposes without the

patient’ s consent.

Ownership of video recordings taken to monitor the

hospital’ s response will lie with the hospital authority. Great

sensitivity will however, be required in handling this

information and editing will not be appropriate without the

full consent of all the participating parties. It should be

remembered that such docum entation may be required in

the event of a Fatal Accident Injury or Inquest as evidence

and appropriate safeguards should be put in place.

In medical incidents there may be no obvious external

clinical manifestations, therefore photographing a patient

may not be the primary object for the medical photographer.

However, if the treatment received is uncommon, or not

carried out frequently in the hospital, steps should be taken

to record it. Medical illustration staff will have to determine

their role and objectives in accordance with the nature of the

incident and the requirements of the clinician. It was

certainly the Monklands Hospital MID’ s experience, after

an E. coli O157 outbreak,1 that they subsequently provided

illustrated material and poster presentations that were

delivered to medical conferences world-wide, as well as

locally.

Post-incident

All staff dealing with major incidents are subjected to stress,

and their responses vary. Counselling may be necessary and

should be as readily available to medical illustration staff as

to any other participants. Post-traumatic stress symptoms

should be anticipated and recognised by management.13

However, Dolan11 reported reluctance by staff following

major incidents to take up counselling offers because they

believed that the information would be recorded on their

personnel file, and might subsequently be regarded as

disadvantageous. Occupational Health Services have a role,

as do Family Practitioners, in responding to the needs of

staff following exposure to traumatic events.

Conclusion

Although major incidents are rare, MIDs do need to be aware

that they may be required to participate and should be

prepared for all eventualities. Protocols should be developed

to ensure that the staff are familiar with their expected roles

within the overall hospital plan. The departmental system for

call out should be tested periodically, and new members of

staff should be introduced to their role at induction. The value

of their contributions should be recognised, and they should

be eligible for all the benefits and protection afforded to

participants in such events.

Acknowledgement

The author would like to thank Dr Marie Brookes,

Consultant in Accident and Emergency Medicine at Monk-

lands Hospital, for her guidance, and for reviewing this

paper.

References

1. Milligan RG, Todd WTA. The role of a medical illustration

department during the Lanarkshire E. coli O157 outbreak. J.Audiovis Media Med 1998; 21(4): 133±9.

2. NHS Management Executive. Emergency Planning in theNHS: Health Service Arrangements for Dealing with a MajorIncident, London: NHS Management Executive, 1990.

3. Bonte FJ. Chernobyl retrospective. Semin Nucl Med 1988; 18:

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83±7.5. Anon. Emergency Planning in the NHS: Health Service

Arrangement for Dealing with Accidents Involving Radioac-tivity. NHS Management Executive, 1989.

6. Howard MJ, Brillman JC, Burke FM Jr. Infectious disease

emergencies in disasters. Emerg Med Clin North Am 1996;14(2): 413±28.

7. Society of Automotive Engineers. Collision DeformationClassification Handbook Volume 4. Warrendale, PA: SAE,

1985.8. American Association for Automotive Medicine. The Abbrevi-

ated Injury Scale. Arlington Heights, IL: AAAM, 1985.9. Moodey GH, Busuttil A. Identification in the Lockerbie Air

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20±1.12. Duguid K. Editorial. J Audiovis Media Med 1988; 4:

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Unpublished observations

Rowles J. Developing a policy for photography in an Accident and

Emergency Department during a Major Incident. Cardiff:Institute of Medical Illustrations Diploma Major Project,

1997.

26 Milligan

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