The content you’re about to read or listen to is at least two years old, which means evidence and guidelines may have changed since it was originally published. This content item won’t be edited but there will be a newer version published if warranted. Check the new publications and curriculum map for updates

Author: Mehrad Ramazany / Editor: Nikki Abela / Codes SLO8, XC1 / Published: 30/06/2020

I remember the day very well.

I was on a night shift, in a major trauma centre, still an ST3 at the time. We were actually having a nice night shift in not so cold weather. There was still a little flow of patients, we had some room in resus and our minors area was pretty empty. Some may even brave the “Q” word.

It was around 6am when the phone rang, ambulance dispatch warning us a tram had derailed, it was not a major incident declared situation yet, but “stay alert”. Basically it was Major incident Standby.

I was lucky enough to work in a place that had a consultant on the shop floor 24/7, so myself and the other reg ran to him for advice, which was, to call back and get more details and inform all the senior team on the shop floor including the nurse coordinators and ward/bed managers. So everyone got given a task. Mine to begin with was to grab the action cards (probably because I had declared myself to be a keen runner).

As my MRCEM exam was coming soon, the METHANE mnemonic was fresh in my mind:


By the time I got back with all the ED action cards in my hand, the Ambulance Services had officially Declared the Major Incident.

The nurse in charge had already informed the waiting room about the situation and literally all patients left (there weren’t many).

Switchboard was informed and cascaded the information to the SpRs from different specialties about the incident.

The nurse in charge of resus liaised with theatre.

It was just amazing to see how it all was flowing nicely.

We expected to see the first patient in less than an hour with the potential to receive at least 8 P1s (requiring immediate care). This ignited another search between the tired brain cells at 6ish in the morning, the triage category in mass casualty,:

P1 Immediate care

P2 Urgent care

P3 Delayed care

P4/0 Dead

I also remembered triage Sieve and Sort.

Fig 1- Triage Seive ( National Ambulance Resilience Unit)

And then Triage Sort was more complicated, evidence based and a reliable tool.

Fig 2- Triage Sort ( National Ambulance Resilience Unit )

After reviewing all these details in my head, I noticed we are having a quick debrief.

We were also trying to clear the department of the patients already there before the major incident patients arrived. ICU had taken two of the patients very quickly from Resus, the Acute Medical unit took another two and we had pretty much empty resus too.

Theatres were ready, SpRs from different specialties called their bosses, surgeons who were on their way. A few of our consultants were on their way in and we would hand over anyway at 7:30 am.

So at the debrief, we had most of the ED team with ward managers, bed managers and some registrars from other teams, with the addition of the security team to prevent any sort of Media wanting to squeeze in inappropriately.

Allocated to P3s, I tried to show off to the consultant in the little time we had by asking “so what type of injuries we are expecting”. I was definitely not expecting CBRN( Chemical, Biological, Radioactive and Nuclear) so we did not need Decontamination to be ready. He gave me a decent look and told me “we have it ready just in case, we have recently practiced using it and it is all ready to go if we need to”. Ok man no need to have Atropine, Pralidoxime in the side pocket.

So I had the whole minors area to myself, with a separate entrance for patients coming in, rooms ready for them to go in, two nurses with me and two SHOs ready, I had it handled ready to go like a boss, with a little help from the Action card.

Meanwhile in Resus, trauma teams were assembling , ready to go.

The first few patients arrived, got triaged by the senior SpR as P2, a couple went to resus as P1. They were all getting Major Incident Hospital Numbers at the time of booking in.

I think this was one of the most memorable experiences I have had generally. Major incidents are (luckily) rare events so any practice for learning is important:

  • Acronyms for Major incidents : METHANE or CHALET
  • How to triage in a mass casualty : Triage SIEVE and Triage SORT
  • More importantly how quickly, swiftly the whole ED and the hospital came together to yet again prove how good we are.

Dont forget if you are stuck in a major incident Communicate, communicate and communicate.


1 www.england.nhs.uk

2 naru.org.uk

3 www.rcemlearning.co.uk reference triage in mass casualty

4 em3.org.uk

Image courtesy of cyberrescue