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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Safety
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Right now we're going to discuss safety. So the objectives here are to understand the all hazards approach at the scene of an incident. Understand uh in better detail the role of a safety officer. look at something called the five C's approach which will help you understand an approach to safety at the scene and understand the need for joint appreciation of risk that you at a scene can't necessarily uh make a risk risk assessment in isolation uh without reference to other agencies. So all hazards approach then what we mean by that is the principles used um can be applied to any type of incident. Now if we look at the incident management roles which we've already discussed and said well in most cases they are predefined. We know what we're going to need etc etc. Have a look at where the safety officer sits. He is supportant too but very much on the wing of the tactical commander um or the silver commander. Um and whilst in most cases uh I like my command support officers to be in my command support bubble the safety officer for me is one of those that I will allow to run free to either colllocate with safety officers from other services. So I find it quite useful to put you know the safety offers all together in one lump. Yeah. Or to be able to walk the scene. Yeah. To ensure that the policies and processes um in terms of PPE wearing risk assessments in fact have actually been carried out. So I tend to give them a fair amount of free reign to do that business. Well, we talked about the five Cs. So the five C's were originally invented by um the explosive ordinance department from the British military for dealing with um explosive devices and potential secondary devices at the scene of an incident. But what we found is from a safety point of view, we can also apply them to any instant. So, I'm going to go through the five C's as a they were originally intended by um the bomb disposal experts and then show you how you can also apply them to your own scene that may not have any explosives in it at all. So, from an explosive point of view, confirm confirm that you've actually got something suspicious. Yeah. That constitutes a device that constitutes a threat to you. Clear? Having confirmed that you think this is a threat, clear an appropriate distance based on the size of the device. As commanders, I don't expect you to know that, but you will have a subject matter expert like a tactical adviser which will be able to inform you it's the size of a car mate, so therefore we need 150 m, etc., etc. Having cleared the area, have it cordoned off. Having had it corded off, control access and egress to the scene to minimize any threat or danger to personnel on scene. Having done that, check for secondary devices and we'll talk a bit about um how to check for devices in a second. So, let's have a look at that in terms of a conventional incident that has no explosives involved in it at all. Confirm. Confirm you got an incident that actually needs dealing with. I mean, quite often we get telephone calls, come quick, multiple vehicle RTC, motorway X. We arrive and they're all exchanging insurance details on the hard shoulder. Well, clearly we've got nothing to do. We can move along. Yeah, confirmed you got an incident to actually deal with. Having decided you've got an incident to deal with, clear a space appropriate to the size of the incident that will allow you to set up your command support and your medical support areas, i.e. casualty clearing, route in, route out parking. Having cleared the area, have it cordoned off. Having cordoned it off, control access and egress to the site. check whether there are any secondary hazards at scene which will impact your ability to deliver management to the scene. So actually we're still going through confirm clear accord and control check and if you want to argue you can probably say that there's a sixc which in both cases having done all of that you'll have contained the incident and prevented it from getting any worse. Safety self we've discussed. Yeah. Don't add to the problem by becoming a casualty yourself. Ensure that your responders don't add to the problem by becoming casualties, especially in their enthusiasm to treat casualties. Scene we've already discussed. Yeah, scenes are dangerous places don't add to the numbers. Survivors not a medical problem, a witness, police problem. So, let's have a look at the safety officer's responsibilities then. So ensure suitable PPE and decontamination if needed. So suitable PPE should be done on a recognized risk assessment depending upon what the threat is. Yeah. To determine the level of PPE required which can vary from something as simple as a surgical mask to full-blown um extended duration breathing apparatus. But again, you'll need to ensure that the personnel you're giving the PPD to are appropriately trained in it uh and have them checked on a regular basis. One of the big officers um responsibilities for me for a safety officer is to monitor the fatigue and stress yeah of all those on scene and decide when people need relieving. Yeah. Or resting. And one of the worst people Yeah. for not monitoring fatigue and stress is yourself as the commander. Yeah, we are very very bad at going I need to rest. Yeah, I need to be replaced. So I have recognized that I'm really bad at that as actually so were my compadre. So we came up with a system where on the way to the scene we would ring our opposite numbers in the service and to look at the time and go right 6 hours from now mate you're going to be my relief and we would actually before I'd even arrived on scene have planned the relief if the job was still running that means it's done it's out of the way before you've got embroiled yeah in the vagrancies of whatever that incident is going to bring to you. Um, organized relief. Yeah, relief is an interesting thing because it's never the same because it will depend on when the instant is, you know, does it clash with shift change over times? Is it nowhere near shift changeover times etc. So that's actually quite a planning process. I tend to leave that with the safety officer providing he knows what the rem is in terms of the resources required to identify and I would say along with other services the hazard risks and threats at the scene. Some of those you won't even recognize and you'll only get by having the conversation with other services that we mentioned earlier. And I'll give you a good example. One early Sunday morning after a Saturday night, I got called out to a fire at a um waste recycling recycling tip in on the edge of Birmingham by the Aston Express A38. And I did go into the job thinking, why am I here? What's my purpose? There's no wider population at risk here. There's no estates around it. It's just a fire on a recycling plant in the middle of nowhere, which is odd because it was in the middle of an urban area, but it was just a massive disused industrial site. So, I did the usual thing, got dressed, went down to the command post, found the fire officer and go, "Mate, what's going on here?" And listened into my first joint briefing. So at this point I suddenly realized my purpose in life because apparently black smoke from fire intermixed with electrical pylons causes the national grid to short out within the area. The pylons going through the middle of that recycling plant happened to feed the feed the Queen Elizabeth Hospital in Birmingham. very quickly I clearly had something to do which I hadn't realized I would have had to do when I've been but didn't come to that assessment until I'd actually been and assess the risk in line with other services you always learn stuff always pay attention to what other people are telling you and think so what how is that going to impact on my organization you then need to apply control measures so in this case my control measures was get hold of the emergency planning officer from the hospital and say you need to run your generators up mate okay and therefore you know Saturday night A&E large metropolis. Don't want that going down. Yeah. Um leers with the other agent safety officers. I've already said that colllocating the safety officers together is a useful task and they will learn off each other. The other thing I use them for is to assist with staff briefings. It's not the military. People don't arrive on mass in one lump as a regiment or a a formed junior and go we're here sir. What do you want? Yeah. They arrive in dribbs and drabs, which means your briefing process happens in dribbs and drabs all the time time as new people arrive. If you're the commander, you haven't got the time to do that yourself. So, get the safety officer to do it as people arrive or use decent technology. Uh, one of the reasons I had a large TV screen placed in the outside of my command truck is I put a rolling PowerPoint um, briefing slide set on it that's blank and just filled it in for each instance. So when troops arrived, they read the screen till they got back to the point they started at, went to the hatch and go, "What do you want me to do, boss?" Because they now got it because we've briefed them all about the site and the mapping and everything is already on there. That say somebody standing there and going, "Welcome to the scene all over again." So joint appreciation of risks first of all you got to identify the hazards. Having identified hazards you're going to do need a dynamic risk assessment on them. We'll talk a little bit about what the depth of dynamic risk assessment is. Um but in general general terms it's based on your experience and whatever else is the experience of the other services there based on that out of that will become tasks that need to be done and they may be simple tasks or they may be complex tasks. Examples in some cases might be downwind plume. Yeah. You might need to get additional information request for further information as to what is the content of the plume. Yeah, because you'll need to know whether or not you're going to have to evacuate downwind or not, or whether you can just do a stay indoors, shut your doors and windows advice, etc. Apply control measures. And control measures should be applied in a hierarchy. Um, and we'll talk a bit about that later on, but basically you either eliminate a hazard or a risk, put the fire out. Yeah. Uh, or you control it. Don't go there. It's dangerous. Yeah, have it cordoned off even to your own staff. Yeah, feed all that in and it becomes part of the integrated response plan with the other services. So, we're all talking about risk assessment from the same page. All of these are key decisions and therefore need to be recorded. And the bit that needs to be recorded are what do we know at this particular point in time? How did we assess it? What was our decision? And ideally where risk is concerned and safety all three services need to sign up to that. So dynamic risk assessment then what's it actually look like? Analyze the situation or the task. For a lot of them you'll have a safe system of work that already in place for you. Uh an SOP or a policy or procedure that covers that off. If you don't, you need to dynamically assess a system of work and how it goes. So, let's have a look at that before we just run through the rest of this circle and put that into context. What does that mean? So, we might be familiar with the Alton Towers Smiler Crash, which is a roller coaster um at uh a theme park uh in the West Midlands. The problem with this is in reality if you analyzed it, it was a minibus crash but at height. And the height was the significant factor here because actually although they were only 25 m off the ground, by the time you'd gone into the pit, which is underneath, it's actually about 75 m to the bottom of the carriage. seriously injured people up the top need to get medical support to them because it's going to be a long extraction process. We didn't have a safe system at work that would allow us to take a senior clinician i.e. a doctor to height to be able to work on the priority one casualties wasn't a conclusion we'd ever had. We'd always thought you know what heart will deal with all that stuff. It's a special operations area. They'll do it. But actually, heart wasn't going to be enough. It needed a senior clinician up there to do it if we were going to save life. So, problem there. How do we get a clinician to 75 m in the air? Well, between Hart, the fire and rescue service and the um high rope access team. Basically we strapped a doctor between two experienced climbers took them up and I think most of my guys time in heart was spent don't step back sir. Yeah. While they dealt with the patient now didn't have a policy or procedure to deal with that have now because we've learned from the experience. Yeah. And now we can take a non-professional who's reasonably physically fit up to height should that clinical inter intervention be required. So sometimes you learn and it becomes a new SOP as part of the process. Are the control measures employed adequate to manage the identified risk? Taking the Towers one. Yeah, probably they are. Okay. If there was answer was no or I have doubts go back reassess the dynamic system of work. Are they now suitable? Yes, they are. Carry out the task. Yeah. Review. Is it working? Yeah. is it still safe on a regular basis by analyzing the situation and how it's progressing. So that's basically dynamic risk assessment in a nutshell where you're doing the dynamic and you're making the stuff up as you go along. Some people might refer to as a back of a [ __ ] packet or rest of things but actually it does have a professional world word. It is called commander's operational discretion. What it means is as the commander based on your experience and the knowledge of the hand, you can improvise and adapt new procedures providing you log. Okay? So, you'd have to log your rationale etc etc. That wasn't the only um new uh system that was invented on that day of the race. Uh on that day of the race, we also had a new policy born about giving blood at scene which we didn't have before. Yeah. So one instant produced two new SOPs and policies uh for future reference. So direct risk assessment helps drive your policy changes as well. So hazard management we talked about um that there was a hierarchy of dealing with um threats, risks and hazards. The first of these as I said was eliminate in other words put the fire out. The second is reduce. So reduce the risk. Put a shield between the fire and the subjects working. Yeah. It's reducing the risk. Yeah. Isolate. Cordon off. Don't go there. Yeah. Control access. Unless you're qualified or you've been authorized, don't go there. Yeah. Use the appropriate PPE based upon the risk assessment by trained personnel. apply discipline. Yeah, you will wear your hat. You will wear your high fluorescent jacket. Boom. And that whole process is known as Eric PD, which is the easy way to remember it. Yeah. And remember that eliminate is the first thing that you try and do. Always try and eliminate a risk rather than reduce it rather than isolate it, etc., etc. People that are very good at this tend to be fire service because they um work with hazard and risk all the time. So, if you're doing safety, work very closely with a fire service safety officer and you won't go too far wrong. So, what about joint hazard and risk assessment? This looks like a bit of a complex and messy slide. Um, but um actually it works very well as a process. So, you report on arrival and you go, "Hello, control, I'm here." You go along to the command point and as part of your um assessment process you will identify hazards. First thing provide the sit rep because the situation has changed back to your control room. Apply guess what the safety 123 process selfseene and survivors. Next question to yourself is are there any casualties within the inner accord with the presence of hazards? Well, if the answer to that is no, back to business as normal. Set up a casualty clearing point. Get rid of the casualties and move on. If the answer is yes, jointly agree with the other services what the hazards actually are. Work together to find out what the um safe systems of work might be. Control the scene. Identify the safe arrival routes, rendevous points, and additional resources that you may require to be able to implement those safe systems of work. Are there any casualties unable to walk requiring rescue from the hazard area? No. Walk to me, mate. Come away from the danger. Yep. Treat the casualties. Evacuate. Yes. Undertake the agency specific dynamic risk assessment and do a risk versus benefit analysis. Apply the control measures. Are the control measures adequate? And does the benefit outweigh the risk? Great. undertake rescue with minimal personnel with the appropriate PPE timing and constraints, extract them, treat the casualties, and evacuate. And actually, as a a little tiny flowchart as a commander, that is probably worth sticking to the back of your notebook. Yeah. Because it'll help guide you through that process and keep you on track. It's very easy sometimes to become distracted and forget what your main task is. Having little amens like this is a very useful way of doing it. What about hazardous chemicals or a CBRN environment? So we've had safety 123 didn't we self-seen survivors and I said on the initial one we would talk about steps one two three which applied to a CBR in area. So step one casualty incapacitated for no obvious reasons single casualty. Yeah. Approach using standard protocols. In other words, your normal caution and safety methodologies of approach at any scene. Two casualties unconscious, not responding to you in the same location. H approach with caution. Use your protocols. Report on arrival and update control. This is probably the time that if you've got a specialist response team, two people in one place, this is bit on the suspicious size in terms of the mechanism of injury, etc. I will probably call out the hazards area response team because it sounds like you're going to need them. More than three casualties in close proximity, approach with caution, plus use a CBRN first responder flowchart, which we'll talk about in a minute, but basically the basic principles here are evacuate the casualties, communicate and advise, disrobe and decontaminate. This is a system in this country that's called I initial operating response. Yeah, for chemical or CBR in instance. And it means that even with very limited responders, you don't need specialist responders to come do decontamination at scene because your frontline staff can do it by getting the casualties to decontaminate themselves. And where they can't decontaminate themselves, i.e. they're unconscious, you can use fire and rescue service in breathing apparatus and send them forward to carry out the decontamination and the rescue. So you don't have to wait long periods of time to have specialist responders arrive and set up mass decontamination and all that. And actually works in a very uh simplistic method. You just need to do control a large number of people. Yeah. Usually with three people. One person speaks and they're the mouthpiece from your organization to the people being decontaminated. this side. Um, safety officer or compliance officer. He's scanning the crowd, watching for anybody. Yeah. That is not complying or not doing as you're telling. You red jumper. You're not doing told. Listen in. Do what the rest are doing. Yeah. On the other side, the demonstrator. The person that is physically turning what you're saying into, right? Rub the towel against your head. Yeah. Then do your face. Take off your glasses. Put them down to one side. Yeah. He's demonstrating that whilst you're saying it because do remember that the primary language particularly in metropolitan areas may not be English. Right? So having you saying in English but also having someone demonstrate the requirement helps overstep that mark. Okay. Um the IR process can be taught very very quickly. Um, I found that actually with a good team, you can get them to understand it and do it in about 15 minutes flat. Yeah. And then they're actually pretty slick at it. Uh, it's some of the minor details have to be worked out. Um, things we've learned. Don't throw individual pieces of um, tissue or blue roll at people in light winds. It's very funny to watch, but it doesn't actually hit the target. Throw the whole roll to the end person. Ask them to take an arm's length of tissue off and pass it down to the next person on the row. Yeah. dead easy. So, we talked about methane, but where there's a hazard or risk that might be chemical or CBRN, it becomes methane plus. And the plus means signs and severity of the symptoms. Yeah. So, what are the patients demonstrating the way of signs and symptoms? What's the weather? Particularly, what is the wind direction? You'd think that would be obvious because we don't want to be downwind of anything that is nasty, etc., etc., but even professionals manage to get it wrong on occasions. Um, what's the environment telling you? You know, what is the environment in terms of, you know, is it wet? Is it dry? Is it hot? Is it cold? Is it night? Is it day? Um, believe it or not, the difference between uh night and day, particularly for stuff like chlorine leaks, is phenomenal. Yeah. So chlorine goes miles and miles and miles further at night. Yeah. Than it does during the day. Uh something to do with the temperature. Evidence. What can you actually see? Are there people with signs and symptoms coughing and spitting? Yeah. Yeah. Grabbing their throat and going, "I can't breathe." That's evidence. Yeah. Uh is there any canisters there or anything else that might be done? The trouble with signs of symptoms on their own, by the way, as part of the evidence trail here, is that if you tell people they've been gassed and exposed to something, they will assume that they have been, and there will therefore automatically produce the signs of symptoms. I do remember going to a job in Tipton in the West Midlands where somebody had apparently run into a McDonald's um with a canister and a balaclava mask on and uh sprayed the entire population that were eating their burgers and ran out again and jumped on a bike and gone off and they're going, "Oh, terrorist attack. We've all been attacked by chemicals." Yeah. Some local hoodie with a can of air freshener. But of course, we didn't know that at the time, but every single patient there displayed signs and symptoms. You don't know it's real. You have to treat it's real until you can prove otherwise. So bear in mind signs and symptoms are not a definitive uh methodology of understanding. Are the perpetrators still present? Are they there? Yeah, because that will again affect your risk assessment and how you're going to approach it is probably the most important bit because it's the bit in the log you're going to have to justify. What were the risks? What were the benefits? What were the control measures? Why did you decide to do what you were going to do? That's the bit that needs to be in your log. Wet decontamination, which is a traditional way of doing stuff, is not actually evidence-based at all in any way, shape or form. In fact, we have proved that wet decontamination actually makes the situation worse, not better. And so warm water opens up the pores of the skin and the rinse, wipe, rinse processes that were being employed is pushing the chemical through the dermal layer. So in fact it's a contamination process not a decontamination process. Dry contamination is far more effective in a sort of blockbang rub process working from the head downwards to the areas that were exposed at the time. So in other words as I am standing at the moment the pe the bits that need to be focused on for me are the head and the lower arms because actually I'm wearing this and I'm pretty much protected unless I'm actually soaked in the stuff. Yeah. from any chemicals clearly. Um, for you two, yeah, you've got long sleeves, so you're only talking about hands and head rather than Yeah. So, be very aware of what they're doing. So, take the outer clothing off, do the decontamination process, and it's much more patient centered, much faster process of waiting for specialists, and you can teach people to do it very, very quickly. Do remember that you need to be uphill and upwind. Don't be on the downwind side of the incident. The problem with um that initial operating response that dry decontamination method is it is time critical. So after about 15 or 20 minutes it becomes much less effective on a sliding bell curve. So no matter what, it should be implemented at the earliest stage without even thinking about it. To be perfectly honest, contaminated, try decontaminate them because you're going to lose nothing by doing it. You're only going to gain. And if it turns out you didn't need the decontamination, well, so what? You've had a nice little exercise. You run your patience through it. And we've all had a little practice, haven't we? But we haven't made the situation worse. Golden rule is commander. try not to make the situation any worse than it was when he arrived. So in terms of safety, self one, two, three, five C's. Do dynamic risk assessments, record your actions and outcomes, work with other agencies to have a situational awareness.
Safety at Major Incidents: All-Hazards Approach
Aim: Apply a consistent safety framework to any incident, define the Safety Officer’s role, use the Five C’s, and conduct a joint appreciation of risk with partner agencies.
Safety Officer (Silver/Tactical Support)
- Supports the Silver (tactical) commander with freedom to walk the scene and co-locate with other services’ safety officers.
- Verifies PPE selection and use, risk assessments and decontamination measures.
- Monitors fatigue and stress; plans rest/relief early and manages rolling briefings (use visual aids/screens where possible).
The Five C’s (adapted from EOD)
- Confirm the incident/credible threat.
- Clear appropriate space/stand-off.
- Cordon the area.
- Control access/egress and flows.
- Check for secondary hazards (then effectively contain).
Joint Appreciation of Risk (JAR)
- Identify hazards with all agencies; no service assesses risk in isolation.
- Integrate controls and routes/RVPs into a single plan; record what was known, decisions made, and sign-off.
Dynamic Risk Assessment (DRA)
- Analyse task → consult SOPs (or create a safe system dynamically).
- Apply controls → if inadequate, reassess and adapt.
- Execute and review repeatedly; document Commander’s Operational Discretion when improvising.
Control Hierarchy — ERIC-PD
- Eliminate → Reduce → Isolate → Control → PPE → Discipline (enforce procedures).
CBRN / Hazardous Chemicals
- Step 1-2-3: 1 casualty (caution); 2 co-located (caution + alert HART); 3+ (initiate Initial Operational Response).
- IOR: Evacuate, communicate/advise, disrobe, dry decontaminate (upwind/uphill). Start early—effectiveness drops after ~15–20 minutes.
- Avoid wet decontamination (may increase dermal absorption).
- Use METHANE-Plus: add signs/severity, weather/wind, environment (day/night), evidence, perpetrator status, and recorded risk–benefit–controls.
Key Principles
- Self–Scene–Survivors: don’t add to casualties; manage the scene; coordinate witnesses with police.
- Record actions and outcomes; keep multi-agency situational awareness; brief continuously.
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