Casualty Transport in Major Incidents

In the CSCATTT framework, triage and treatment prepare casualties for evacuation, but the incident only truly begins to resolve when we address the transport phase. Moving casualties away from the scene safely and efficiently is what starts to make the problem smaller.

The Role of Transport in Major Incident Management

Transport is the final stage in the hierarchy of support: triage, treatment and transportation. The aim is to move:

“The right patient, to the right place, at the right time – the first time, every time.”

To do this effectively, we must understand:

• How the scene is organised to optimise casualty transport.
• How vehicles are selected and why.
• How evacuation decisions are made for individual casualties.
• What factors can hinder or delay transportation decisions.

Casualty Flow and Vehicle Flow

At a major incident scene, there are two key flows to manage:

• Casualty flow: movement from the point of wounding → triage → Casualty Clearing Point / Casualty Clearing Station (CCP/CCS).
• Vehicle flow: ambulances and other vehicles entering through the outer cordon → parking → moving forward to loading → exiting the scene to receiving facilities.

Casualties can be selected for evacuation at different points along these flows. For example:

• Inviting those who can walk to “come to me if you’re injured” immediately identifies P3 (walking wounded) for separate management or early movement.
• Others may pass through full triage and treatment at the CCP/CCS before being loaded.

In practice, a blended approach is often used, depending on the layout, risk and available resources.

Management of the Deceased

Deceased casualties found at the scene should remain in situ, as they form part of the forensic evidence. They are not moved to a body holding area by the ambulance service.

Typically:

• Those who die at the CCP/CCS are transferred to a body holding area.
• The body holding area is under police control as representatives of the coroner.
• A medical officer (doctor) is required to assist with certification of death.

Managing P3 Casualties

There are two main approaches to handling P3 (minor) casualties:

1. Send P1 and P2 through the CCP/CCS, while P3 bypass the CCS and go directly to a receiving hospital.
2. Create a separate on-scene area for P3 and:
   • Assess them with a view to discharge from scene, avoiding unnecessary transport.
   • Or move them off scene by coach or similar transport to a more distant facility.

The chosen method will depend on the scene, geography and system capacity. Often, a combination of both approaches is used. Discharging suitable P3s from scene reduces pressure on transport and prevents unnecessary hospital crowding.

Priority 1 and 2 Casualties – Secondary Triage and Evacuation

P1 (immediate) and P2 (urgent) casualties must be:

• Re-triaged using a secondary triage system (such as TRTS).
• Graded for evacuation to determine order of transport.
• Moved to the loading point for dispatch to hospital.

As an ambulance service, casualty regulation aims to “spread the load”:

• Distribute casualties across as many suitable hospitals as possible.
• Avoid simply “moving the scene” to the front door of a single hospital.
• Protect the wider health economy by balancing demand.

Geography may limit options. In areas with fewer receiving hospitals, the nearest hospital may temporarily act as a de facto casualty clearing station, with secondary transfers arranged later.

The Expectant Category – Order of Evacuation

The “expectant” category (P4) is politically sensitive and rarely used in the UK, but if applied, it has an important place in evacuation planning.

Intuitively, some might assume the order of evacuation is 1–2–3–4. However, if P4 is in use, the recommended order is:

1 – 4 – 2 – 3

Rationale

• P1: Need surgery within ~60 minutes to survive. They go first to major trauma centres.
• P4 (expectant): If not categorised as expectant, many would have been P1, meaning they still have a potential for survival if resources allow.
• P2: Can typically wait 2–4 hours for definitive care.
• P3: Minor injuries and walking wounded; lowest immediate clinical priority.

Hospitals use damage control surgery in major incidents:

• Short operations (~20–30 minutes) to do the minimum necessary to keep the patient alive.
• Further surgery is done in stages over subsequent days.

This approach:

• Improves survival by reducing physiological stress.
• Increases theatre throughput, allowing more patients to be treated in less time.

Vehicle Selection – Capacity, Availability and Suitability

When choosing vehicles for casualty evacuation, three main factors must be considered:

• Capacity – How many casualties can the vehicle carry safely?
• Availability – How quickly can the vehicle be brought into use?
• Suitability – Is it clinically appropriate for the casualty’s condition?

Typical Allocation by Priority

• P1: Frontline emergency ambulances, possibly with advanced capability.
• P2: Stretcher PTS (Patient Transport Service) vehicles where appropriate.
• P3: “Anything on wheels” that is safe and suitable – e.g. buses or coaches for bulk movement.

Most frontline ambulances are designed to carry one stretcher patient. In exceptional circumstances, and under gold commander authorisation, this may be flexed (e.g. two stretcher patients on one vehicle) if:

• Travel times are short.
• The clinical risk is justified by overall benefit.

Air Assets – Helicopters and Military Support

Helicopter Emergency Medical Services (HEMS)

• Designed for polytrauma patients with onboard critical care capability.
• Can land in tight urban spaces (e.g. roads, car parks).
• Flight time is usually around 60 minutes, including load/unload.

Use HEMS for:

• Specialist-to-specialist transfers – e.g. head injuries to neurosurgical centres, major burns to burns units, paediatrics to children’s hospitals.
• Longer distances where road travel would exceed 60 minutes.

If the journey by road is less than 60 minutes, a land ambulance is often quicker overall once loading and unloading are taken into account.

Military Support Helicopters

• Much larger than HEMS aircraft with greater range (e.g. Scotland, Northern Ireland, mainland Europe).
• Do not come with medical equipment or clinical staff.
• Require you to provide both equipment and personnel, plus a plan to bring those staff home.
• Typically mobilised via Military Aid to Civil Authority (MACA / MKA) and may take ~90 minutes to deploy.

They are extremely valuable in large-scale or prolonged incidents with high casualty numbers and long distances involved.

Other Transport Options

Depending on the incident and geography, additional transport options may include:

• Voluntary ambulance services – e.g. St John Ambulance, British Red Cross.
• Buses and coaches – suitable for walking wounded or seated casualties.
• Ferry services and hovercraft – for island communities or coastal incidents (e.g. Isle of Wight).
• Airport “bendy buses” – can be adapted as mobile casualty clearing stations to move casualties from aircraft to hospitals.
• Trains – in very specific circumstances, can offer rapid mass evacuation to a suitable receiving hospital.

Always consider:

• Vehicle suspension and ride quality – rough transport (e.g. agricultural trailers) can worsen injuries.
• The ability to provide or maintain in-transit care, particularly if multiple stretcher patients are loaded closely together.

Secondary Transfer Burden

Even with good casualty regulation, some incidents inevitably create a secondary transfer burden. Examples include:

• Burns incidents: there are limited burns centres in the UK; patients may initially go to local hospitals, then be transferred to specialist units within ~72 hours.
• Events with national or international attendees: casualties may later need repatriation to their home region or country.

Good practice is still to aim for the right place first time, as every secondary transfer adds complexity, risk and workload.

Why Evacuation May Not Be Strictly in Priority Order

Although priority category and tools like TRTS guide evacuation, real-world constraints mean that:

• Vehicles, skills and equipment do not always line up perfectly.
• A P2 may board a stretcher PTS vehicle ahead of a P1 if that is the only suitable vehicle currently available.
• It is usually better for a P1 to wait for the correct vehicle and clinical capability than be sent off on inappropriate transport to the wrong destination.
• P3 casualties may leave the scene first, not because they are clinically prioritised, but in order to clear space and simplify on-scene management.

Operational Constraints on Transport Decisions

Several factors can significantly affect casualty transport:

• Road conditions: traffic, weather and road closures influence journey times.
• Time of day: many air assets may not operate at night, changing available options.
• Security and escorts: some convoys may require police escort or protected routes.
• Blue light routes and motorway management: collaboration with police and Highways England (e.g. using lane closures/red “X” lanes) can improve flow.
• Limited communication capacity: hospitals may only receive brief updates such as “5 P1s – 20 minutes”, rather than detailed clinical information.

Always check that your major incident transport plan works 24/7, and that specialist centres can receive casualties around the clock.

Key Learning Points

• Transport is the phase where a major incident starts to resolve as casualties are evacuated from the scene.
• Effective casualty regulation aims to spread demand across appropriate hospitals.
• Evacuation order is guided by triage, but real-life constraints mean strict sequencing is rarely possible.
• Vehicle selection must balance capacity, availability and suitability.
• Air assets and non-standard vehicles can add huge value but require careful logistics and planning.
• Always aim for “right patient, right place, right time, first time” to reduce secondary transfers and improve outcomes.