Working in the midst of a major incident: first-hand experience from A&E

With five London hospitals, Imperial College Healthcare NHS Trust needs to be ready to respond to a major incident at any time. Since the middle of March 2017, the Trust’s hospitals have been ‘stood up’ for three major incidents – the Westminster and London bridge attacks and the Grenfell Tower fire. Dr Alison Sanders, the Trust’s clinical director of urgent care and emergency medicine, explains what happened when a major incident was declared at St Mary’s, one of the capital’s four major trauma centres, on 22 March.

In emergency medicine we are used to dealing with ill and injured patients in high-pressure situations. We are also used to dealing with the unexpected. When a major incident alert goes out, you don't know how things are going to unfold. There is often quite limited information early on, some of it fact and some it rumour, and you don't know much about what you are going to be dealing with in the early stages.

At 15:23 on Wednesday 22 March, London Ambulance Service called to put St Mary’s Hospital on standby for a major incident. We had already seen and heard that an incident was taking place in Westminster with potentially multiple casualties in a situation that was beginning to unfold on our TV screens. Although we had not been officially declared as a receiving centre at this point, it was evident that the proximity and nature of this incident made it highly likely we would receive casualties.

When the red phone started to ring in the emergency department a few minutes later, to let us know that we were going to receive casualties and to give us the details, we began to implement our well-rehearsed major incident plan. Our actions are guided by this comprehensive plan that has been tested and refined over a number of years. It is a plan that is designed to get the whole hospital rapidly working in a different way from our business as usual. It means that we can clear the emergency department within minutes and create large numbers of trauma teams with pre-arranged equipment and unique hospital numbers to ensure that we can provide high quality care to a large number of people with traumatic injuries. It also means we can provide surgeons, theatres and intensive care beds.

The hospital has action cards that detail the different roles that we need to fulfil in a major incident. It’s important to stick to your role and work as part of a team. Many of us are used to being the leader in our day to day practice – in a major incident you have to fulfil the role you are allocated and not try to lead everything!

Your role as an emergency department consultant may be leading a trauma team, running an area of the department, or being a trauma team member. During the Westminster incident, my role was to run the majors area which meant rapidly clearing the existing patients to another area of the hospital safely and creating multiple trauma teams ready to receive patients.

Along with the other emergency department consultants in charge of specific areas I reported to the consultant in charge of the emergency department, Miss Nicola Batrick. She is our major incident lead and has run many major incidents at St Mary’s. Nicola was responsible for coordinating the care of all our patients, and for prioritising those who needed urgent operations or intensive care to make sure everyone got the best clinical care.

As soon as a major incident is declared your mindset changes. Whatever you were doing gets put on hold unless it is critical. At this point there is usually minimal information and the accuracy of that information is often unknown in the early stages.

We work as part of a pan-London trauma network where the response to an incident is coordinated across all the pre-hospital services, major trauma centres and trauma units. Each of us plays a part, whether that is to receive casualties directly from scene, support other hospitals in the network, or just to carry on with the important job of managing the rest of the emergency workload. Our workload does not stop just because there is a major incident – of course, fewer people come to our emergency departments, but people still have strokes and heart attacks, and we need to make sure that they also get the best care.

When you get the call for a major incident it's important to complete your personal checklist in the time before the first casualties arrive, as you don't know how long the incident will last and your mind will be totally focussed on the major incident. Phone your partner to say you’re safe, go to the toilet, make sure someone’s picking your children up from school. From then on, the focus is entirely on playing your part in a big team whose aim is to save lives and minimise any long-term impact of injuries.

You often don’t get to find out much more about the incident you’re involved in until it’s all over. There are a few facts, and some rumour and then you step up and deliver the clinical response with very little awareness of what is going on outside. During the Westminster incident, I didn’t really know what had happened until I finished work much later that evening and watched it on the news.

We’ve had a huge response from staff going over and above every time we have been stood up for a major incident, even when the incident has been in the middle of the night as with London Bridge and the Grenfell Tower fire. Westminster was during normal working hours and so we had most of the staff we needed on site already. Whatever the incident it's important to have a clear plan from early on for establishing sensible work shifts. Our response to an incident may need to continue for many hours and we also need to ensure we can continue to care for all of our other patients and return to business as usual as quickly as possible. So whilst it’s easy to think that we just call everyone in, we in fact need to think carefully about making sure we have some back up for the night shift and the following day. The system is under incredible pressure day to day and the response to a major incident is like stepping up another whole gear, on top of something that feels as if it is already working at maximum.

In a major incident one of the first tasks is to create bed capacity, including in intensive care, and also to ensure we have theatre capacity and surgeons since many patients will need urgent damage control surgery. Patients who definitely need to stay in hospital will stay, but there will be some who can be transferred to another of our hospitals not directly involved in the incident or occasionally to another trust. There may be patients who are due to go home later that day who can be discharged safely a little earlier. We might also have patients who have come in for non-urgent surgery who can be postponed until another day.

We received a total of eight patients from the Westminster incident. All patients from the incident and any other blue light ambulances arrive in the emergency department through a single entrance. They are triaged by a senior clinician and given a unique hospital number pre-prepared for this purpose. Once the patient has been prioritised according to their injuries, they are cared for by one of the major trauma teams that has rapidly formed in the resuscitation room or in majors. Wherever the patient needs to go – imaging, intensive care, theatres, major trauma – their trauma team stay with them. This helps us maintain good continuity of care and good documentation and enables us to build a strong relationship with the patient to support and reassure them at an incredibly difficult time.

You can never underestimate how frightening a major incident is for our patients. They are often separated from their family or friends and, if conscious, are trying desperately to make sense of what has happened to them. During the Westminster incident, many of our patients were from overseas, adding an extra level of complexity in relation to a language barrier or next of kin being a long way away.

Our training and major incident planning enable us to take the same actions in these situations regardless of the cause. One of the most important things is to follow the well thought out plan, whilst of course thinking on your feet and adapting to what can be a rapidly changing situation. Whatever the nature of the incident we remain focused on providing safe, compassionate and effective care for our patients. It’s when we finally step away and put it into context that the significance and scale of the event often really sinks in.

Once London Ambulance Service confirms that we will not be receiving further casualties and we are able to care for the patients we do have as normal, we will look to ‘stand down’ from the major incident. We will always have a ‘hot’ debrief to identify any immediate actions and ensure staff have the support they need. A ‘cold’ debrief will follow some time later, when we really focus on critiquing what happened and refining our major incident response for the next time.

We try to go back to business as usual as quickly as possible. The emotional impact of recent incidents on our staff is difficult to quantify. It can take time to process the facts and emotions associated with being part of something like this and it is challenging to do that when the emergency workload continues at a sustained pace.

Whether it’s one patient or many, treating severe injuries has an impact. It can take time to get over the experience and everyone has to have their own strategy for dealing with that. We have a team strategy too – involving talking and debriefing, both in a structured and a non-structured way. We’ve learnt a lot in my specialty about the importance of recognising the emotional as well as the physical pressures of our work. It’s a sad reality of the past few months that many more colleagues – as well as our patients and their families – have had to do the same.