Major Incident Planning and Support (MIP+S) Level 4
Course Content
- Course Introduction
- Personal Roles
- Ambulance Control
- Arriving on the Scene
- Triage Basics
- What is Triage
- The goal of triage
- Discriminators
- How do we triage correctly
- Initial impression
- ABCDE and triage
- Active listening
- Analgesia in triage
- Assessing pain
- Documentation and triage
- Establishing patient presentations
- Establishing patient history
- Existing medications
- NEWS2 and triage
- Triage categories
- Professional considerations
- Ten Second Triage
- Triage and MIPS
- Problems, Survivors and Casualties
- Radio Communications
- Types of radio
- Using radios
- Right and wrong way to use a radio
- Radio protocols and sending a message
- Phonetic alphabet and numbers
- Prowords in radio communications
- Call signs
- Radio Checks
- Radio check example
- Losing communications
- Broadcasting and talk groups
- Hytera PDC 550 – 4G/VHF/UHF combined
- Workplace radios
- Radio Licences
- Dual Sim Radio
- Increasing battery life
- Carrying and transporting radios
- Basic considerations when using radios
- Transmitting Techniques
- 3G and 4G radios
- METHANE Reports
- MIPS Lessons
- Course Content and introduction
- Preparation
- Command and Control
- The Developing Incident
- Treatment
- Health and Emergency Services
- Management of the Dead
- Safety
- Assessment
- Triage
- Communications
- METHANE
- Transport - part one
- Transport - part two
- CBRN Specialist Responses - part one
- CBRN Specialist Responses - part two
- Post Event Procedures
- Types of EMS
- Terminology
- Incident at a Quarry
- MIPS Location Introduction at the quarry
- Access and Egress
- Accessing Casualties
- Dealing with the media
- Dealing with the public
- Do all major incidents involve multiple casualties
- Getting further advice
- IIMARCH briefing
- Locally available assets
- Remaining calm
- Site planning
- Tabards
- Updating METHANE
- What is defined as a major incident
- Working with other services and organisations
- Effective communications
- The role of the HSE
- The importance of planning
- Aide memoirs
- Leaving the scene
- Tabletop Exercises - Quarry
- MIPS site planning table top exercise
- Table top exercise - Arrival Part 1
- Table top exercise - Arrival Part 2
- Table top exercise - Arrival Part 3
- Table top exercise - Triage and transportation
- Table top exercise - Liaising with other services - Part 1
- Table top exercise - Liaising with other services - Part 2
- Petrochemical Plant
- Tabletop Exercises - Petrochemical Plant
- Course Summary
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Course Content and introduction
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Hello and welcome to major incident practice and support. Uh my name is Justin Bert Jones. Uh and I started uh my career as a combat medical technician in the British Army. I was later commissioned as a medical support officer and around 2009 I moved from the military to the UK ambulance service where I've been an emergency planner and a resilience and special operations trainer. I've also been uh worked at the tactical and the strategic level within the ambulance service. Uh so have a fair number of experiences in running incidents um such as Alton Towers and the uh Bosley Mill explosion. I will be abley supported throughout this course by a couple of other instructors who will introduce themselves um at that time. What I would say about this course, this should not just be uh about us telling you how it's done. Uh all of you will have experiences and we expect you through the workshops to bring those experiences to the table. uh and they're all valid because different organizations and different agencies uh particularly from different countries work in different ways. So you should see them as an opportunity to cross-pollinate and share information. The aim of this course is to provide the knowledge, skills and required to effectively manage the scene of a major incident. uh also to familiarize the candidates with the organizational structure that is put in place to run a major incident in order to allow uh a rapid and effective integration with other statutory emergency services. What is a major incident? Outline what you need to do to prepare for a major incident. And for us that's very important uh because I would personally say about 90% of effectively dealing with a major incident is in the preparation. what will your priorities be when you first arrive on scene? What needs to be dealt with first? And we'll also outline the knowledge and skills required um to effectively manage the whole major incident in line with other agencies that will be responding as well. So the teaching materials for this course will be uh the manual that you'll find online. There'll be um these lectures. There will be some skill stations and workshops uh predominantly around uh triage and radio work. There will be some uh syndicate online tabletop exercises and there will be practical exercises without casualties and an assessment phase where you will attend and um be assessed as a commander. But we'll talk more about those later on. Uh we will be looking at uh several scenarios um most of which have been based on actual incences we've gone to uh and therefore get good valuable lessons out of uh those instances. Um the practical exercise without casualties will be hopefully done in an outside area um where you'll be able to walk the ground. Yeah. and put the principles that you're learning on this course into practice. Uh the assessment phase will be done by objective wrong objective structured practical assessment which is both a written and a practical test and those tests will revolve around radio work citing a casualty clearing station. your ability to brief other staff for duty in order to get your intent on how you're going to deal with this incident across. And uh because it's critical to the uh functioning of a major instance, we will ask you to do triage civ and triage sort as well. So where's the references for this come from? Um well, there are several references. There is the national ambulance resilience units major incident uh action cards. There's also the commander control guidance produces produced by NARU as well. Uh some of them are come from the military from the clinical guidelines of operations and there are plenty of other publications from which we have taken the material. So I suppose the first question here is what is a major incident? Uh it's defined as an incident where the number severity or a type of live casualties or by its location requires the implementation of special procedures. But let's break that down a bit. So when we talk about number, how many does that mean? And I think that you'll find that that actually is not a specific number, i.e. it's not 10 or more. uh but it's more to do with other factors. So for instance, if this morning we were go to a large city center in the United Kingdom, drop down about 15 casualties, it is unlikely that that would produce uh the definition of a major incident because there'll be lot of frontline vehicles to respond to that incident. There'll be lots of receiving units in the terms of hospitals to take the patients to. So, it should be absorbed by the local health economy without too much of a ripple. If, however, with my god-like hand, I picked up these 15 casualties, I moved them across the region and dropped them down in a small market town at 10:00 on a Saturday morning with only five ambulances in the county, then actually that may be a very different situation and may well be a major incident. So number is more about the resources that are immediately available to have an effect than the actual number itself. The next word in that was severity. And in general terms in prehosp environment um severity is measured by the priority of the patient and how sick they are the triage allocation that we send them to. And in general it's thought that um the distribution I the breakdown of those triage categories into P1 P2 P3 is around about 25% P1 25% P2 50% P3 could also be up to a third a third and a third however in some instances certain instance will require or will produce a far larger larger number of P1 casualties. In certain instances like uh marauding terrorist attacks like uh Manchester uh as a recent example, you could have the up to 80% of the patient load being priority one. And you might think yourself, well, so what what difference that make? But the difference is the impact on the health economy because 80% versus 25% is far more frontline vehicles. It's far more paramedic and ALS skill sets. It's uh more theaters, more ITU, uh more people in the emergency department. So actually it has a knock-on effect. Yeah. On the entire health economy. Um, and if you only planned and set up for expecting 25% uh, and you get 80% and your plans aren't flexible, then you can run into trouble. We also said type and type is defined as the type of injuries that people may get and it becomes a problem when all the casualties are the same type of injury. So as an example, burns now burns capability in this country and in fact most countries uh around the world is exceptionally finite. In this country there are around about 238 odd burns beds but immediately available for use on a daily basis is somewhere between 25 and 30 on a good day. So if you have a large number of casualties and they're all burns, you're going to exceed the local, regional, and national capacity for dealing with the niche specialtity, in this case, burns, very, very quickly. And when that occurs, you may end up um thinking about international casualty regulation. In other words, sending your patients outside of the country to be dealt with. This is often part of a secondary transfer process rather than a primary transfer process, but still needs to be considered. And people often go, well, are you sure about that? Does that sound like the real thing? So, if we look at two different incidents, uh, one would be the Ramstein air crash. Uh, a large number of burns casualties. And when that occurred, it took almost every burned bed in Europe to absorb the casualties from that particular incident. And Rhinestam was quite a long time ago, but in more recent years, um probably about 3 or four years ago now, uh there was a fire club fire in a nightclub in Romania. Uh the following day arriving at Birmingham by specialist transfer aircraft were 10 Burns patients to go into the Queen Elizabeth Hospital as part of an international casualty regulation process. So actually international casualty regulation does occur and again should be part of your preparation and your planning. One of the other key words in that statement was live. In general terms, they've got to be alive to be a problem for us. Yeah, come quick, there's 500 dead doesn't do it for me. I do resuscitation, not resurrection. Yeah. Um, but you need to bear that in mind because it's quite interesting that other agencies and organizations that you work with think that you as medical people deal with the dead and that is actually in general terms not the case. We've already talked about location. That's the difference between being in a wellresourced urban area to a more sparssely resourced uh rural area. And then we have to ask ourselves what does the word special procedures mean? Well, that means any process that is not adopted by your dayto-day business of how you function. And it could be that those special procedures are incremental. So it might be as an example that you have an incident but it's not defined as major but you will use part of the special instance or part of the major incident plan to deal with it without actually calling it a major instance. So the principles apply to dayto-day business. Yeah. When we are hit with a large number of casualties. Yeah. As well as when we have major incidents and they can be implied uh equally throughout. is also defined as an incident presents a serious threat to the health of a community. Now I think particularly at this particular point in time everybody's first thoughts of that will be pandemic and corona virus. um certainly presents a serious threat to the health of the community and we have all seen the impact of that um recently. Not what we were expecting because actually what the pandemic situation we were expecting was more likely to be normal influenza but turned out to be corona virus. The last part of the definition is an incident that disrupts the health service. We should remember as responding professionals that we can equally be caught up in the incident ourselves and our ability to respond can be compromised. Yeah. Just because we wear the blue lights on our head and our underpants on the outside of our uniform doesn't mean to say we're immune. Yeah. And we have prime examples of this. If you remember 911 uh the fire service with all the ambulances buried at the bottom of the tower when the tower came down thereby compromising the response. We saw in Mumbai uh marauding terrorists plant IEDs improvised explosive devices. Yeah. Uh within the hospital to compromise uh the response of emergency services. So how often does this happen? Well, people don't keep records as well as they used to on this sort of stuff. Um, and the last analysis we had is that we would have about 3 to four incidents a year within the uh United Kingdom ranging from 0 to 11. My experience has been that actually we now have more than that. It happens on a far more regular basis for a couple of reasons. We're all experienced at the moment and any country in the world cut backs in our funding as organizations. The cut back in those fundings mean less resources available, less resources available. The more often is that we're likely had to have to call a major incident to effectively deal with it. In the military environment from those that come from there actually the incidence for major incident is probably a lot higher because you have a finite amount of medical resources um to be available um to you. There is no mutual aid in a m in a military environment normally that a um European country would normally be able to call on. We must also remember that uh major incidents involve children and your plans should include the provision for children. We've seen both in Bellson in 2004 and Yatoya in 2011 that in some cases children have been the prime target. In fact, all so much more recently um Manchester the um Ariana Grande consonant again the population at risk was predominantly children and yet quite often people forget in their medical planning that children are not just small adults um and in fact they need to be dealt with slightly differently. The triage system is different. the equipment required to deal with them on an ALS level is different etc. So your plans need to include children as part of the process. Again children pediatrics is a niche specialtity. So the amount of uh specialist medical care available to them is sometimes finite. Yeah. So, you will have to take that into account when doing your planning and work out how you're going to maximize um your pediatric capability should you have a major incident. Don't also forget that major incidents can be medical. People tend to think of them as being trauma big bang type operations, but quite often um they can be simple as weather. uh too cold, too hot, too hot for too long. Um in some cases they could be uh man-made in the terms of um release of gas or other chemical products that affects your population at risk. Yeah. So uh medical um is a major part and so all your plans need to be flexible to cover both trauma and medical. We can classify major incidents in about six different ways. The first of these are natural and man-made. Natural is rather obvious. Um, earthquakes, hurricanes, floods, volcanoes, tsunamis. What you need to remember about natural instances is that they have a propensity to produce a far greater casualty load than anything man can do. Man-made incidents tend to fall in the tens, 20s or hundreds. Whereas if you take something like uh tsunami Boxing Day 2005 affecting multiple casualties. Yeah. Something in the sorry multiple countries. Yeah. 55. Yeah. Or 5 a half million casualties. That's a lot in anyone's book. And we're starting to move out of the realms of major incidents and into the realms of disaster medicine. Um and of course that will also have compromised your medical infrastructure at the same time. Man-made incidents are rather obvious. Transport be it road be it rail be it air we're used to seeing with on a daily basis. And to be fair uh in most countries the processes brought in on motorway systems um reduce the number of casualties that we get um by the safety features that are built in. We still get them. We don't tend to get them in large numbers. Industry releases chemical or something on a reasonably regular basis. Yeah. Uh tends to cause us to have to react whether it's acid release or uh plume or something like that. Um wherever people gather in large numbers, we quite often put um plans in place in advance in expectation. Yeah. that we will have a large number of casualties be they medical or trauma and uh pop contents are really good example of this. It's a pre-planned event usually in an isolated rural location and therefore uh medical um facilities and put in place in order to effectively manage that. Marathons would be another good example uh where you know you're going to get casualties and therefore medical sport is put in place in order to support that. Terrorism is ever changing and produces casualties uh for us in quite interesting and new ways. So again because of that your plans need to be flexible in their approach. Military operations produce by their very nature yeah casualties for both yourself yeah um the civilian population at risk uh and the enemy. And the problem with being a medic is it doesn't matter where they come from, you're going to have to deal with them. Yeah. So, uh needs to be good plans in place for that. We can also classify uh major incidents as both simple and compound. Simple means it's a major incident. Hey ho, let's carry on. Compound means that the infrastructure I require to deal with it has been compromised and therefore I can't respond. Now whether that is as we talked about earlier the ambulance is destroyed by the towers falling down whether it's flooding and the uh transport infrastructure has been compromised so you can't get there or for what any other reasons um industrial action can be compound. Yeah. If you lose you know 2/3 of your staff because they're on strike actually suddenly you've got a problem. Yeah. uh if you then have a major incident, be aware, yeah, that you need to have plans that are flex enough, flexible enough to be able to effectively deal with part of your infrastructure and part of your response being compromised. We can also talk about major instance being compensated and uncompensated. Compensated means uh I've got enough resources to deal with it and I can effectively manage it. Uncompensated means I've thrown everything I have at it, but I still can't cope. The reality, however, is that major incidents are normally a bit of both. They'll start start off uncompensated at the beginning, but as I find more resources and push them forward, they'll gradually become compensate and therefore easier uh to deal with and manage. an uncompensated natural disaster, yeah, is probably going to be a mass cal and we're going to be in the realms of um disaster medicine. And certainly if you think about tsunamis, Japan, yeah, earthquakes, volcanoes, floods, that's the type of thing. And it's important to find the definition of the difference between major instant and mass cal or mass casualty. Um, mascal is a major incident in which there is an excessive disparity between the number of casualties and the locally available medical resources available or the medical capacity. It is a case probably where you will most definitely need mutual aid not only from elsewhere in your country but probably from outside of your country to be able to effectively manage and deal with it. So we will look throughout this course at different types of incidents that have occurred uh from uh large numbers of casualties to smaller number of casualties but with more complex circumstances that make the extraction of those casualties to a place of treatment difficult to manage. And what we're probably hopefully going to teach you is a uh set of principles and a method a methodology. Yeah. that will manage all of those types of incidents if you apply them effectively. We will in other words be giving you an allhazards approach to being effectively managing the incident. that systemic uh approach um or systematic approach to be fair should be able to cover such instance as marauding terrorist attacks such as Mumbai in 2008 and it will also cover uh more domestic yeah industrial accident um multiple casualty incidents that you might expect to find on a more daily basis. It will become no surprise as you we will be teaching you a couple of different acronyms to effectively manage that. You will become familiar throughout this C course with both CSCAT and scatter. Yeah. And we will talk in detail about what both of those stand for. In general, CSCAT stands for command and control, safety, communications, assessment, triage, treatment, and transport. And it's really broken down into two sections. management items, things that you have to do out of that to be able to effectively manage the incident and support items. Support items are the handson physical things that you do to patients. You have to physically triage a patient. You have to physically treat one and you have to physically transport them in order to resolve the situation. with the exception of one one item yeah in both the acronyms fits into both and that is triage because as a clinician people think of triage as something you have to do to a patient to find out how quickly you need to assess treat and transport that patient but as a commander triage is an assessment tool. It tells you very quickly what the size of the problem is. Yeah. and therefore what decision processes you're going to need to make to be able to effectively manage it. We're going to show you hopefully throughout this process that the predominant reason that triage needs to be done early uh as part of a systematic approach is to get a handle on the size of the problem to be able to manage it. We'll look at command and control. What things do you need to put in place to have effective command and control? And actually command and control covers more than that. It's command, control, communication and coordination. We have a tendency to think in singular agencies and singular organizations. But if you're going to manage a major incident effectively, you need to work cooperatively. Yeah. And handin glove with the other responding agencies that going. Now that will vary from country to country. In mine, it tends to be police, fire, and ambulance. Yeah. In general terms. But the roles that are carried out Yeah. no matter where you go will always need to be carried out. It may be a different organization carrying them out than what you would expect. For as an example, in Germany, paramedics tend to be invested with the fire service, whereas in the United Kingdom, they're invested with the ambulance service, but the role that they carry out is going to be exactly the same. We're going to teach you some acronyms to help you get through a process um of dealing with as a checklist to yourself as a commander that you're moving in the right direction. One of those acronyms we're going to talk about is called the five C's and we'll look in more detail of that under safety when we get there. We're going to look at safety itself in terms of safety of yourself, safety of the scene, safety of the survivors. Yeah. How you're going to effectively put the systems in place to manage those three uh different populations at risk. We're going to look at communications and we're going to look at critical message structures and we're going to be uh looking at an acronym that we use called methane. uh and why it's important that not only as medical personnel you have an understanding of methane but actually methane is a joint service approach for getting situational awareness and for passing situational reports between agencies. Yeah. In order to ensure that you're all singing from the same sheet and you have the same information available to you to make your joint decision process. We'll be talking about assessment of the scene. How do you assess a scene? What principles will you use? How do you share that information? And how quickly do you need to do it? We will talk about triage both primary and secondary and the critical part that they play yeah within the major incident uh management system. Um whilst um different countries may have different methodologies of triage, we will only teach you one method of primary triage, one method of secondary triage because it's the one that we're going to use throughout the course. Uh we are not saying in any way whatsoever that you have to use this. What we are saying is you will need a method of primary triage and you will need a methodology of secondary triage. And everybody in your organization, yeah, and health economy needs to be using the same systems, whatever they may be. We look at transport. What problems will we have with transportation? Yeah. Will we be using frontline evidence or will we have to consider other types of vehicle movement such as helicopter, such as patient transport vehicles, such as coaches or buses? When are they appropriate to use? What are the risk assessments that need to be done in order to do that? Because what you'll find as we go through this is most of this is about assessing risk. Yeah. And doing what is for the greater good at that particular point in time. Your normal dayto-day rules tend not to apply. Yeah. You will have a commander's discretion to make quick, rapid, and effective decisions, but you need to justify them. We will particularly be looking at that. You need to make those decisions in a combined way with your other emergency services. Yeah. So, you shouldn't be at odds, yeah, with another service that is responding to that instance. Your priorities should all be the same and should be working together to have an effective response. And in general, the um combined strategic priorities of almost any emergency service are to save life, to prevent the escalation of the incident, to relieve suffering, to protect the environment, to protect property, um to rapidly restore normality, and bigger and bigger to facilitate inquiries. Yeah. About that incident or the people involved in it. What you'll find with most major incident plans is actually they focus on rapid restoration of normality, which seems odd because you'd think well surely they should be focusing on saving life and relieving suffering and the other good things that we do. But what you'll find is that if you do a rapid restoration of normality then you will save life. You will prevent escalation of the instant. you will release suffering because what you got to remember is whilst you have a major incident, the day job does not stop. Mrs. Miggins is still going to have a heart attack. Johnny's still going to nick cars from the council state and bang him into lamp posts and you're expected to respond to it uh in an effective way uh without compromising um your day job. The principles we're going to talk about cross international boundaries and they cross the uh civilian military divide. So they will work uh in almost any environment. However, what I will say that in some cases the principles will be applied differently. So we will talk about cordons somewhere on this course. Um and there will be different types of cordons. In civilian life, you'll be a bit of colored plastic tape. In military life, it may well be a person with a weapon pointing outward, providing force protection. Yeah. In order for you to allow you treat, there's still cordance. Yeah. So, the principle applies in both environments, just the application may be slightly different. So hopefully you'll have uh an interesting time doing the major incident uh practice and support course. Uh and you'll have an ability to ask us questions uh at the end of each module and then to test your own knowledge as you go through.
The part of the course is presented by Justin Bert Jones, who has extensive experience as a combat medical technician in the British Army, a medical support officer, and later an emergency planner and resilience trainer in the UK Ambulance Service. He has worked at tactical and strategic levels and been involved in incidents such as Alton Towers and the Bosley Mill explosion.
The course is designed to be interactive, encouraging participants to share their experiences, since different agencies and countries approach incidents in varied ways. The aim is to provide the knowledge, skills, and structures needed to manage major incidents effectively and to integrate with statutory emergency services.
Course Content
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Online manual, lectures, skill stations (triage, radio work), workshops, tabletop and practical exercises, and assessments.
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Assessment includes command tasks, radio communication, casualty clearing station set-up, staff briefing, and triage systems.
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Realistic scenarios based on actual incidents are used.
Definition of a Major Incident
A major incident is when the number, severity, type, or location of casualties requires special procedures beyond day-to-day operations. Key considerations:
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Number depends on available resources, not a fixed figure.
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Severity of casualties affects demand on the health system (e.g. terrorist attacks may produce many high-priority patients).
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Type (e.g. burns) can overwhelm specialist resources.
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Location (urban vs. rural) impacts response capacity.
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Must involve live casualties (as opposed to fatalities).
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May require special procedures or escalate to international casualty regulation.
Challenges and Planning
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Major incidents may occur more frequently due to reduced resources in services.
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Plans must cover children (not just small adults, with different needs) and consider both trauma and medical incidents (e.g. pandemics, chemical releases).
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Incidents may be natural or man-made, simple or compound, compensated or uncompensated, and can escalate into mass casualty (MASCAL) situations requiring mutual aid.
Frameworks and Principles
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Course teaches systematic, all-hazards approaches applicable to different scenarios.
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Acronyms such as CSCAT (Command & Control, Safety, Communications, Assessment, Triage, Treatment, Transport) and METHANE (for structured communication) are used.
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Emphasis on command and control, cooperation between agencies, safety, triage, communication, transport logistics, and risk assessment.
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Strategic priorities: save life, prevent escalation, relieve suffering, protect environment/property, restore normality, and support inquiries.
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Importance of rapid restoration of normality to keep day-to-day services functioning alongside incident response.
International and Civil-Military Relevance
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Principles apply across borders and military/civilian contexts, though implementation may differ (e.g. cordons set with tape vs. armed personnel).
Conclusion
The course will provide both theoretical and practical tools to manage incidents, supported by exercises, workshops, and assessments, ensuring participants can apply a systematic, collaborative approach in real emergencies.
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