HMC Ambulance Service

Major Incident Response

Guide
 HMC Ambulance Service
Major Incident Response Guide

Version Control Document

Document/Plan: HMC Ambulance Service Major Incident Response Guide
First Draft Author: Philip de Bruyn, Assistant Executive Director: Ambulance Service
Configuration Owner: Brendon Morris, Executive Director: Ambulance Service

Version History
Version* History Author Date
0.1 First Draft P. de Bruyn 01.02.2013
0.2 Second Draft P. de Bruyn 17.09.2013
1.0 Final Version P. de Bruyn 09.01.2014
2.0 2016 Updated Version N. Pullian 12.05.2016

*Version Control Note: All documents in development are indicated by minor versions i.e. 0.1,
0.2, etc. The first version of a document to be approved for release is given major version 1.0.
Upon review the first version of a revised document is given the designation 1.1, the second 1.2,
etc. until the revised version is approved, whereupon it becomes version 2.0. The system
continues in numerical order each time a document is reviewed and approved.

Authorisation
Version Name Signature Date
1.0 Dr. Robert Owen 09.01.2014

2.0 Mr. Brendon Morris 15.10.2016

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Major Incident Response Guide

Preface
The title of this document is HMC Ambulance Service Major Incident Response Guide. This
manual is published by the Hamad Medical Corporation Ambulance Service (HMCAS). The HMC
Ambulance Service Major Incident Response Guide is intended as the primary reference and
guideline for training, guidance and assistance of first responders and medical control personnel
in the management of major incidents. It is recommended that a copy of this Guide be kept in a
readily accessible location in every HMC Ambulance Service Supervisor’s Unit, Manager’s and
Executive’s and other Command Vehicles; at each Ambulance Service ‘Hub’ and ‘Spoke’ Station,
the National Command Centre (NCC), and in hospital emergency departments.

To request additional copies of the Guide; or to submit questions, comments, or suggestions

please contact:

Hamad Medical Corporation Ambulance Service

P.O. Box 3050

Doha

Qatar

Telephone: +974 4439-3524

Facsimile: +974 4439-3526

Email: [email protected]

Web Site: http://as.hamad.qa

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Scope and Purpose

The HMC Ambulance Service Major Incident Response Guide is intended to address techniques
in field operations that must be employed when the number of patients exceeds immediately
available resources. In addition, this Guide may also serve as the basis for routine operations.
This Guide standardises operations during major incidents. It is intended to be an “all hazards”
guide to meet the needs of any major incident regardless of what caused the incident. If
necessary, these procedures can be modified based on the number of patients, the cause or
severity of injuries, the nature and/or complexity of the incident, and special circumstances
involved in the incident.

The initial response will be determined by the number of patients involved. The first arriving
unit must estimate what ambulance service resources will be needed as part of the initial scene
size-up. Additional supervisory resources may also be needed to establish the Incident
Command System and should be called for as required by local procedures.

The Hamad Medical Corporation Ambulance Service strongly encourages this plan be exercised
in conjunction with the local Emergency Operations Plan.

*Every effort has been made to include the most up-to-date and current listings of resources.
Should additions, deletions or revisions be necessary, please contact the Specialised Emergency
Management Office.

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Major Incident Response Guide

Table of CONTENTS
Chapter 1: General Concepts and Considerations p9
Introduction p9
The Incident Command System & Major Incident Management p9
Scene Safety & Security p10
Personnel Accountability p11
Major Incident Definition p11
Significant Incidents p11
Multiple Simultaneous Incidents p12
Chapter 2: Major Incident Levels p13
Concept of Major Incident Levels p13
Definition of Major Incident Levels p13
Key Concepts p13
Major Variables p13
Levels of Response p13
Considerations p14
Complexity of Incident p14
Response Matrix p14
Major Incident LEVEL 0 p15
Major Incident LEVEL 1 p15
Major Incident LEVEL 2 p16
Major Incident LEVEL 3 p16
Contaminated Patients p16
Requesting Additional Resources p16
Chapter 3: Basic Principles p18
Major Incident Management Goals p18
Overview of the Response – Critical Tasks p19
Chapter 4: Command Structure p21
GOLD – Strategic Level p21
SILVER – Tactical Level p21
BRONZE – Operational Level p21
LEVEL 0 p22
LEVEL 1 p22
LEVELS 2/3 p23
Executing Command p25
Gold Command p26
Gold Command Suite p26
Gold Commander Role, Functions & Responsibilities p26
Gold Strategic Intent p26
Gold Coordination Meetings p27

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Silver Command p27

Silver Coordination Meetings p27
Silver Command Roles p28
Bronze Command Roles p30
Chapter 5: Communications p37
Pre-Determined Attendance p37
Initial Actions of NCC p37
Emergency Department/Hospital Notification p38
Major Incident Standby p38
Significant Incident Notification p39
Major Incident Declared p39
Ongoing Actions of NCC p39
Closure Actions of NCC p40
Incident Control p40
Silver Control During an Extended Incident p42
Texting/Paging p43
Radio Communications p43
Talk Groups p44
Call-signs & Radio Channels p44
Inter Service Communications p46
Chapter 6: Ambulance Service Initial Actions p47
Safety Triggers for Emergency Personnel (‘STEP’) p47
First Arriving Unit Responsibilities p47
First Ambulance or Response Driver p48
First Ambulance or Response Attendant p48
Second Ambulance Crew or Responder Attendant p49
Subsequent Ambulance Crew or Responder Attendant p49
Other Considerations p50
Establishing Incident Command p51
Request Additional Resources p51
Chapter 7: Triage p52
Introduction p52
Triage Levels p52
Triage Methods: Primary & Secondary Triage p53
Primary Triage p53
Adult Primary Triage (>140cm) Algorithm p54
Paediatric Primary Triage (<140cm) Algorithm p55
Expectant Category p56
Triage in CBRNe (Hazardous Materials) Incidents p57
Secondary Triage p58
Secondary Triage Evaluation Chart p58

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Triage Tags p59

Special Major Incidents p60
Conclusion p60
Chapter 8: Emergency Management of Uncontaminated Patients p61
First Arriving Unit Actions p61
The Incident Scene p61
The Treatment Area p63
The Transportation Area p64
Scene Layout p65
Chapter 9: Emergency Management of Contaminated Patients p66
First Arriving Unit Actions p66
Designation of Hot, Warm, and Cold Zones p67
Incident Zoning Diagram p68
Decontamination p69
The Incident Scene p70
The Treatment Area p72
The Transportation Area p73
Packaging Radiologically Contaminated Patients for Transport p74
Transport Considerations p74
Scene Layout p75
Chapter 10: Response Plans - Command & Control Structure p76
LEVEL 0 p76
LEVEL 1 p77
LEVEL 2 p78
LEVEL 3 p79
DECONTAMINATION p80
Chapter 11: Response Plan – Incident Layout p81
LEVEL 1 – Illustration p81
LEVEL 1 – Site Plan p82
LEVEL 2 – Illustration p83
LEVEL 2 – Site Plan p84
LEVEL 3 – Illustration p85
LEVEL 3 – Site Plan p86
DECONTAMINATION - Illustration p87
DECONTAMINATION – Site Plan LEVEL 1 p88
DECONTAMINATION – Site Plan LEVEL 2 p89
DECONTAMINATION – Site Plan LEVEL 3 p90
Chapter 12: Casualty Management Shelters Layout p91
RED SHELTER p91
YELLOW SHELTER p92
GREEN SHELTER p93

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Chapter 13: Hospital Communications and Patient Distribution p94

National Command Centre to Emergency Department Comms p94
Patient Distribution p94
Receiving Facility Major Incident Notification Matrix p95
Coordinating ED Communication Responsibilities p95
Medical Emergency Response Incident Team (MERIT) p96
HMC Strategic Command Centre p97
Chapter 14: Aero-medical Operations p98
Introduction p98
Use of Aeromedical Resources p98
Activation of Aeromedical Support p99
Communications p99
Airspace Restrictions p100
Weather Restrictions p100
Landing Zones/Helicopter Operating Sites p101
GPS Coordinates p101
Patient Destinations p101
Chapter 15: Production Services p102
Production Department p102
Preparedness p102
Initial Actions of Production p102
Ongoing Actions of Production p104
Closure Actions of Production p104
Incident Control, Roles & Responsibilities p105
Production Major Incident Response Flowchart p106
Chapter 16: Post Incident Activities p107
Operational Activities p107
Debriefing p107
Post Traumatic Activities p108
Peer Support p108
Trauma Risk Management p108
Recovery from Major Incident p108
Staff Clinic p109

Appendix A: Major Incident Pre-determined Attendance p110

Appendix B: Major Incident Action Cards/Job Checklists p114
Appendix C: Pre-hospital Major Incident Forms p171
Appendix D: Major Incident Resource Distribution p179
Appendix E: Major Incident Resource Inventory Lists p180
Appendix F: Glossary p192
Appendix G: References p199

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Chapter 1: General Concepts and Considerations

Introduction
The HMC Ambulance Service Major Incident Response Guide is intended as the primary
reference and standard operating procedure for training, guidance and assistance of first
responders and medical control personnel in the management of Major Incidents. In addition, it
serves as the basis for routine operations; the HMC Ambulance Service Major Incident Response
Guide is also intended to address techniques in field operations that must be employed when
the number of patients exceeds immediately available resources. The HMC Ambulance Service
strongly encourages each agency to be familiar with their respective Emergency Operations Plan
and its procedures.

The Incident Command System and Major Incident Management

HMC Ambulance Service efforts in a Major Incident will begin with the first arriving unit and
expand to meet the needs of the incident. The first arriving unit should establish Incident
Command. That unit is responsible to assess scene Safety, conduct a scene Size-up and Send
that information to the National Command Centre (NCC), begin to set up the triage and
treatment areas, and begin to triage victims using the PRIMARY and SECONDARY triage
methods.

The three priorities of incident management are:

1. Life Safety (Access to Effective Care)

2. Incident Stabilisation
3. Property Conservation

The Incident Command structure will expand or contract as needed based on the size and
complexity of the incident, and in order to maintain the span of control. Only those
functions/positions that are necessary will be filled and each element must have a person in
charge.

In most major incidents the following functions/positions must be staffed as a minimum:

Command, Staging, Triage, Treatment and Transportation roles. In a small scale incident, one
person may assume more than one function, i.e. triage and treatment may be done by the same
person or transportation and staging can be handled by the same person. In a larger incident,
the Incident Commander may establish a Medical Sector (SILVER MEDICAL) to oversee some or
all of the above functions.

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HMC Ambulance Service must be capable of managing greater numbers of patients without
mutual aid because of the geographic location of the State of Qatar and the subsequent time
and complexity involved in obtaining mutual aid (which will have to come from other GCC
countries). Some incidents may be so large, or the sense of danger so pervasive (such as a
terrorist incident), that victims may not wish to remain on the scene and will self-refer to known
medical facilities.

During such incidents, ambulance service triage and treatment resources may have to be co-
located at hospitals, assembled at multiple locations, and/or situated a great distance away
from the initial scene location to ensure the safety of first responders and victims. In an effort
to assist the Incident Commander, the concepts of Major Incident Levels have been integrated
into this Guide. The definition of the Major Incident Levels can be found in Chapter 2 p13.

Scene Safety and Security

Scene safety is always the first consideration in a Major Incident of any level. Responder safety
must be consistently monitored throughout the event. A Safety Officer must be appointed by
the Incident Commander in accordance with the Major Incident Command structure.

Recent history has proven that first responders have become choice targets for domestic and
international terrorists. Due to the potential for the presence of secondary devices or people
targeting first responders, operations should be carried out in such a way as to assure the
security of both first responders and victims. First responders must be alert for the presence of
secondary devices and the presence of people who don’t fit into the scene picture. All
suspicious items, devices, or people must be immediately reported to the Incident Commander.
In addition, all first responders should adhere to the prudent safety rule which is, “If you did not
bring it into the scene with you, then don’t touch it!”

HMC Ambulance Service personnel must also be aware that one or more of the victims resulting
from a suspicious or terrorist incident may actually be the perpetrator of the crime and
therefore pose a threat to first responders, the victims, patients and the public. HMC
Ambulance Service personnel must be on the alert for the presence of armed and possibly
violent victims or patients.

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Personnel Accountability
A personnel accountability system must be implemented at Major Incidents to help ensure the
safety or first responders and efficient operations. The HMC Ambulance Service will have overall
responsibility for the medical personnel accountability system. It will be the responsibility of the
Incident Commander to assure that all medical personnel on site of the incident are accounted
for in accordance with local Standard Operating Procedures (SOPs).

Major Incident Definition:-

Any incident or event which, due to its size, nature and/or complexity, is likely to cause serious
disruption to services and would potentially overwhelm the Ambulance Service or one or more
of HMC’s hospitals as a result. Such an incident requires a coordinated response from multiple
agencies including HMC (as well as corporate departments), other healthcare services and
hospitals. Major incidents may be external to HMC or internal to HMC.

Major Incidents will require a heightened response above the normal means of the HMC
Ambulance Service and HMC hospital system at varying levels (local; national; international).

Major Incident Levels are described in Chapter 2 p13.

Serious Incidents
Incidents involving multiple victims that can be managed with heightened response (including
local mutual aid, if necessary), by the HMC Ambulance Service agency or HMC healthcare
system.

Serious incidents typically do not overwhelm the hospital capabilities of the State of Qatar
and/or region, or any one or more hospitals within a locality.

There is usually a short, intense peak demand for health and medical services, unlike the
sustained demand for these services typical of mass casualty incidents.

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Major Incident Response Guide

Multiple Simultaneous Incidents

The resources needed to mitigate multiple simultaneous incidents are dependent on the size
and complexity of incidents as well as their location.

Expected mutual aid resources may not be available or they may be significantly delayed.

Providers must be prepared to sustain their patients for long periods.

Non-traditional modes of transportation and alternate patient transport destinations will need
to be considered.

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Chapter 2: Major Incident Levels

Concept of Major Incident Levels
Each defined Major Incident Level provides the Incident Commander with a suggested minimum
number and type of resources that should be requested as part of their initial dispatch matrix.
These Major Incident Levels are based upon the number of high acuity (‘RED’ and ‘YELLOW’
tagged patients), not just the total number of victims involved. Ultimately, the type and number
of resources requested is dependent on the nature and location of the incident.

Definition of Major Incident Levels

 Key Concepts
o The management of Major Incidents must be separated from normal business.
o Levels of response are used as indicators to determine what initial pre-
determined attendance is required and also what command and control
structures need to be implemented.
o Escalation processes must be in place to respond to identified and/or growing
needs on scene, or to deal with multiple incidents simultaneously.
o Organisations must have structured processes in place involving all departments
in preparation for dealing with major incidents.
 Major Variables
o The total time to respond to the incident from onset to conclusion.
o The complexity of the incident.
o The number of high acuity patients.
 Levels of Response
o The four Major Incident Levels are defined as shown in the table below.
o A list of recommended minimum resources is provided for each Major Incident
Level; as per Appendix A p110.
o These lists serve as a guideline from which to begin requesting additional
resources.
o Lists are also included for putting additional resources on ‘alert’ in case the
Major Incident needs to be escalated to the next level requiring further
resources; as per Appendix A p110.

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 Levels of Response

ESCALATION IMPACT DESCRIPTION SIGNIFICANCE

LEVEL 0 MINOR Serious Incident LEVEL 0 Routine/none
LEVEL 1 MAJOR Major Incident LEVEL 1 Local Level
LEVEL 2 MAJOR Major Incident LEVEL 2 National Level
LEVEL 3 MAJOR Major Incident LEVEL 3 International Level

 Considerations
o Impact on HMC Ambulance Service resources - what effect will this incident
have on overall operational capacity (capacity to cope with total demand).
o Emergency Service Agencies involvement (how many agencies and to what
extent).
o Impact on Core Business (how the incident will affect our ability to deal with
routine emergencies).
o Frequency of Incidents (how often such incidents are likely to occur).

 Complexity of Incident
o How complex an incident presents in terms of unfamiliarity; size; technical
difficulty and access/egress difficulties.
o To be assessed and considered by the Operations Officer: Communications
based upon the METHANE report.

 Complexity Levels

COMPLEXITY LEVELS DESCRIPTION

High Not routine or it is an infrequently used procedure (e.g. CBRNe,
airport emergency, etc.).
Moderate Multi-agency (e.g. Police, Fire, etc.) or large numbers of personnel
are deployed.
Low Access to patients is difficult due to hazards, environmental or
security factors.
None Unobstructed access to and egress from patients

 Response Matrix
o A scoring matrix used to identify the levels of response required to an incident.
o The predominant deciding factors are the number of high acuity patients
(‘RED/YELLOW’), the complexity of the incident as well as the duration.

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 Response Matrix

RED (P1) & YELLOW ESCALATION LEVEL

(P2)
Number of High
Acuity Patients

>100 LEVEL 3 LEVEL 3 LEVEL 3 LEVEL 3 LEVEL 3

51-100 LEVEL 2 LEVEL 2 LEVEL 3 LEVEL 3 LEVEL 3
21-50 LEVEL 2 LEVEL 2 LEVEL 2 LEVEL 3 LEVEL 3
11-20 LEVEL 1 LEVEL 1 LEVEL 2 LEVEL 2 LEVEL 2
6-10 LEVEL 0 LEVEL 1 LEVEL 1 LEVEL 2 LEVEL 2
3-5 LEVEL 0 LEVEL 0 LEVEL 1 LEVEL 1 LEVEL 2
Complexity Level None Low Moderate High High
Time <1hr 1-2hrs 2-4hrs 4-8hrs >8hrs

Severity of Incident

Major Incident LEVEL 0

All medical incidents are prioritised according to Medical Priority Dispatch System (MPDS)
criteria. The HMC Ambulance Service has established a Response Matrix to determine the
appropriate response to emergency calls based upon the call categorisation. Response matrices
include ‘X-Ray’, ‘Yankee’ and ‘Zulu’ activations.

Major Incident LEVEL 0 implies ‘Business-as-Usual’ and does not require any escalation of the
HMC Ambulance Service Major Incident Response Guide. This level of operation is therefore not
deemed to be classified as a Major Incident and it is expected that the HMC Ambulance Service
is able to cope with all ‘routine’ day-to-day emergency calls within planned daily capacity and
capability limits.

LEVEL 0 Major Incident Response should be sufficient to deal with Routine ‘Business-as-Usual’
Incidents and/or small-scale Serious Incidents below the LEVEL 1 response threshold.

Major Incident LEVEL 1

Major Incident LEVEL 1 is the first level of activation of a Major Incident and will be deemed to
have a major impact on local HMC resources and infrastructure. A medical incident of this
magnitude will frequently require the activation of HMC Ambulance Service resources from two
of the local operational ‘Hubs’.
The HMC Ambulance Service may be capable of handling incidents less than 11 ‘RED/YELLOW’
Tagged patients without necessarily implementing the HMC Ambulance Service Major Incident
Guide or requesting mutual aid resources. The decision to declare a Major Incident LEVEL 1 is
left to the Incident Commander.

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Major Incident LEVEL 2

Major Incident LEVEL 2 is the second level of activation of a Major Incident and will be deemed
to have a disastrous impact on national HMC resources and infrastructure. A medical incident of
this magnitude will frequently require the activation of a national response. Declaration of a
Major Incident LEVEL 2 will require the establishment of a Gold Command Centre to manage the
coordination of response on a national level; and expansion of the Incident Management
Structure to include the Planning, Logistics, Human Resources, Media Liaison and/or Finance
and Administration Sections.

Major Incident LEVEL 3

Major Incident LEVEL 3 is the third and final level of activation of a Major Incident and will be
deemed to have a catastrophic impact on national HMC resources and infrastructure. A medical
incident of this magnitude will frequently require the activation of an international response.
Declaration of a Major Incident LEVEL 3 will require the establishment of a National Strategic
Command Centre to manage the coordination of response on an international level; and
expansion of the Incident Management Structure to include the Planning, Logistics, Human
Resources, Media Liaison and/or Finance and Administration Sections.

Contaminated Patients
If the victims of the Major Incident are contaminated, or potentially contaminated with a
chemical, biological or radiological agent or materials, CBRNe Response Teams will need to be
activated. Refer to Chapter 9: Emergency Management of Contaminated Patients p66 for
additional information.

Requesting Additional Resources

 Additional resources must be requested as soon as a potential need for them has been
identified. Appendix A identifies ambulance resources and specialty teams that may be
requested to respond to a Major Incident LEVELS 0 & 1. These levels of response are
deemed to have an operational impact on a ‘local’ level only (i.e. North/South);
generally having an impact on all local services and infrastructure in the immediate
vicinity.
 Appendix A identifies ambulance resources and specialty teams that may be requested
to respond to a Major Incident LEVEL 2. This level of response is deemed to have an

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operational impact on a ‘national’ level (i.e. Qatar-wide) generally having an impact on

healthcare systems and infrastructure across the country.
 Appendix A identifies ambulance resources and specialty teams that may be requested
to respond to a Major Incident LEVEL 3. This is deemed to be the maximum level of
resource available on a national scale and will likely require the additional assistance of
international mutual aid; as determined and coordinated by the National Strategic
Command Centre. This level of response is deemed to have an operational impact on an
‘international’ level (i.e. World-wide) generally having an impact on healthcare systems
and infrastructure across the World.
 For all Major Incidents LEVEL’S 1-3 all local and national resources must be requested
via the National Command Centre. The Gold Command Centre will be responsible for
coordinating the provision of all resources necessary to enable the NCC to respond to
the requests of assistance from the Major Incident as well as for the requirement to
service routine emergency (999) responses across the Country.
 The requirement for additional resources which most likely will have to be achieved
through mutual aid on an international level must be put to the National Strategic
Command Centre via the Gold Command Centre.

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Chapter 3: Basic Principles

Major Incident Management Goals
There are three primary goals of Major Incident Management:

 Do the greatest good for the greatest number. The primary concern must be to save as
many lives as possible with the resources available, while protecting the first responders
and bystanders.
 Manage scarce resources. In a resource limited environment heroic resuscitative
efforts are not appropriate. These heroic efforts take too much time, require too many
people to perform, and require the use of supplies and equipment that should be used
for salvageable patients. In normal day-to-day circumstances four or more providers
may work on a single patient. In mass casualty incidents this provider to patient ratio is
reversed. Scarce resources management recognises that you do not have enough
providers, equipment, vehicles, or time to provide the normal level of pre-hospital care.
Providers must focus their efforts on salvaging as many patients as possible while
waiting for the arrival of additional resources.
 Do not relocate the disaster. Do not relocate the incident by transporting all of the
patients to one hospital. Providers must use triage to determine patient prioritisation
for transport. The first arriving HMC Ambulance Service Units may never transport a
single patient, often it is better to establish a treatment area and wait for more units to
arrive and provide patient transportation. Communications must be established with
the Coordinating Emergency Department via the Bronze Hospital Officer through Gold
Command. Effective scene to hospital communications, combined with triage will
ensure that patients will be distributed to the appropriate receiving hospital, in the
correct order and quantity.

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Overview of the Response – Critical Tasks

The primary concern must be to save as many lives as possible with the resources available,
while at the same time protecting the first responders and bystanders. To accomplish this, the
HMC Ambulance Service personnel should respond to the incident and perform the sequential
critical tasks as per the CSCATT mnemonic below:

C – Command

 Appoint a Silver Commander, Triage Officer and Parking Officer as quickly as possible

S – Safety A, B, C

 A - Ensure the safety of yourself

o Don Personal Protective Equipment (PPE)
 B - Safety of the scene
o Using cordons/cordon tape
 C – the survivors
o Remove to place of safety

C – Communications

 Instigate communications including control vehicles, radios, etc.

A – Assessment

 Carry out an assessment of the incident – requesting your required resources through a
METHANE report to Control (NCC)

T – Triage

 Instigate the PRIMARY Triage system as soon as possible

T – Treat

 Commence extended treatment of patients as soon as the SECONDARY Triage is

complete

T – Transport

 Consider the capability, availability and suitability of types of transport

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 Overview of the Response – Sequential Critical Tasks

Command - STRUCTURE

Safety – SELF, SCENE, SURVIVORS

Communications -
INFRASTRUCTURE
Assessment – METHANE &
RESOURCES

Triage

Treatment

Transport

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Chapter 4: Command Structure

The system of Command and Control has been designed to provide all responding agencies with
a clear operating framework which promotes safe and efficient systems of work.

The response can be divided into four levels: Bronze (Operational), Silver (Tactical), Gold
(Strategic), and Platinum (National Strategic Command). The requirement to implement one or
more of these levels will depend upon the nature of the incident and the associated escalation
level implemented. The HMC Ambulance Service will only implement the first three of these
levels initially upon declaration of a Major Incident. The Platinum Level Command Structure will
be implemented by the Hamad Medical Corporation Executive Team upon declaration of a
LEVEL 2 and/or LEVEL 3 Major Incident only.

It should be noted that Command positions are always role rather than rank orientated and
more senior ranks should not automatically assume a Command Post; however they remain
accountable for advice provided to more Junior Managers.

GOLD – Strategic level

The Gold Commander is the most appropriate Officer who has Executive authority. This is the
executive tier of management required to make strategic decisions, usually based within the
Gold Command Centre. On occasions the Gold Commander (Call-sign: GOLD COMMAND) may
be based with senior officers of the other Emergency Services or the health authority.

SILVER – Tactical level

The first member of the HMC Ambulance Service at the scene of the incident will become the
Silver Commander (Call-sign: SILVER COMMAND). It is usual for the role of the Silver
Commander to be handed over to a more senior ranked Officer as they arrive. The Silver
Commander will not directly be involved in casualty treatment. Their role is to determine
priority in allocating resources; planning and co-coordinating tasks and obtaining other
resources as required.

BRONZE – Operational level

Those staff who are managing the operational work at the incident site. Each is responsible to
SILVER COMMAND.

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 Command & Control Structure

LEVEL 0

Silver
Silver Command Commander

Bronze Bronze Bronze Bronze

Bronze Officers Medical Operations Support Specialised

Triage & Decon &

Forward & Parking &
Bronze Roles Casualty
Clearing
Safety Loading
Specialised
Access

LEVEL 1

Gold
Gold Command Commander

Silver
Silver Command Commander

Silver Roles Medical Operations Support Specialised

Bronze Bronze Bronze Bronze

Bronze Roles Triage Forward Parking Decon

Bronze Bronze Bronze

Bronze
Bronze Roles Casualty
Clearing
Safety Loading Specialised
Access

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LEVELS 2/3

Gold
Gold Command Commander

Silver
Silver Command Commander

Silver Silver Silver Silver

Silver Officers Medical Operations Support Specialised

As below As below As below As below

Bronze Roles (next page) (next page) (next page) (next page)

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 Command & Control Structure - Silver & Bronze Medical

Silver
Medical Roles Medical

Bronze Bronze Bronze

'PRIMARY 'SECONDARY Bronze
'CASUALTY 'DOCTOR'
TRIAGE' TRIAGE' CLEARING'

 Command & Control Structure - Silver & Bronze Operations

Silver
Operations Roles Operations

Bronze Bronze Bronze Bronze

'FORWARD 1' 'FORWARD 2' 'FORWARD 3' 'SAFETY'

 Command & Control Structure - Silver & Bronze Support

Silver
Support Roles Support

Bronze Bronze Bronze Bronze

'PARKING' 'LOADING' 'EQUIPMENT' 'PRODUCTION'

 Command & Control Structure - Silver & Bronze Specialised Operations

Silver
Specialised Roles Specialised

Bronze Bronze Bronze Bronze

'DECON 1' 'DECON 2' 'SAT 1' 'SAT 2'

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Executing Command

A Gold or Silver Commanders’ ability to perform their role effectively depends on them being in
a location where they have:
 Knowledge of the circumstances and the available intelligence
 The ability to communicate effectively with others
 Advice available from advisors
 A suitable environment from which to exercise their command function.

All command should be executed using the HMC Ambulance Service approved decision making
model as below:

 Decision-making Model

Information/Intelligence Received

Review
Threat/Risk
Actions/Effects
Assessment

Actions

Policy &
Tactical
Procedures
Options

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Gold Command
The GOLD COMMANDER is responsible for the Strategic Command of a Major Incident and will
ensure that service policy is adhered to. Decisions at this level will be made in liaison with
senior officers from other emergency services and communicated via the command structure
for implementation by the Silver Commander. The Gold Commander must take into account the
normal workload of the Service and if necessary invoke the necessary HMC Ambulance Service
Business Continuity Plan.

Gold Command Suite

Gold Command Suite is the location from which the Gold Commander and the Gold Team will
manage any significant Major Incidents (LEVEL’S 2 & 3). Gold-suite must have enhanced
communication facilities so that the Gold Commander can maintain an overview of the Service.
Gold Command should be opened by a Communications Manager in preparation for the Gold
Team when a Major Incident has been declared.

Gold Commander Role, Functions and Responsibilities

Gold Commander will either be the Chief Operations Officer of the HMC Ambulance Service or a
suitably qualified member of the Executive Team. Gold Medical will deploy to the Gold
Command Suite and, having established that a Silver Medical Officer has been appointed will
then be responsible for liaising with the Gold Commander and designated hospitals on strategic
matters.

Gold Strategic Intent

 Preserve and protect lives.
 Mitigate and minimise the impact of the incident/event to the wider Healthcare System.
 Inform the public and maintain public confidence.
 Ensure sufficient assets are available to manage both the incident(s)/events(s) and core
activity to maintain service delivery to national standards.
 Assist an early return to normality (new normality).
 Maintain the reputation of the Organisation with the public and partner agencies.

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Gold Coordination Meetings

The Gold Team will meet at a location detached from the scene with suitable communications
and meeting facilities. In general, the nature and difficulties of the incident will govern the
frequency of Gold meetings.

The Gold Coordinating Team meetings will follow the standard template which is provided in the
Gold Command Suite. The group will determine the strategic issues relevant to the incident.

In addition, the group may provide liaison with governmental and other bodies and ensure that
sufficient support and resources are available to the incident.

Gold meetings will also take place on a multi-agency basis. A Gold representative for HMC
Ambulance Service will attend and report back to HMC Ambulance Service Gold Command.

Silver Command
The SILVER COMMANDER is responsible for the Tactical Command of a Major Incident and will
ensure that service policy is adhered to. Decisions at this level will be made in liaison with
Senior Officers from other Emergency Services and communicated via the Command Structure
for implementation by the Silver and Bronze Officers. The Silver Commander must take into
account the normal workload of the Service and if necessary invoke the necessary HMC
Ambulance Service Major Incident Escalation Procedure and Mutual-aid Agreements.

Silver Coordination Meetings

The Silver Coordinating Group will consist of all the Partner Agencies attending and will meet
close to the scene.

The Silver Commanders will call an initial meeting of the Silver Coordinating Group at the
earliest reasonable opportunity.

The agenda should be based around the following:

 Safety
 Situation reports
 Priorities
 Future developments

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The HMC Ambulance Service should briefly describe the situation as it affects its own operations
and mention those matters for which it requires the assistance or co-operation of others.

Silver Command Roles

a) Silver Commander (Call-sign: SILVER COMMAND)

The nominated HMC Ambulance Service representative with the overall

responsibility for the Command and Control of the work of the HMC Ambulance
Service at the scene of a Major Incident. He/she will be clearly identifiable by
wearing a high visibility vest bearing the words “Silver Commander”. On arrival
he/she will assume Command of all HMC Ambulance Service/medical operations on
the scene. He/she will be located at the Silver Command Point through which
personnel, technical and material support will be requested as required. Silver
Commander is a Tactical Role and directs all ambulance resources at the scene as
required.

The Silver Commander will be assisted by a Silver Control Team (SCT) from
Communications (NCC). This Team will consist of a Communications Manager,
Distribution Team Leader (DTL), Case Controller and an Ambulance Service Medical
Dispatcher. The Case Controller will act as radio operator, telephonist and loggist;
they will keep a log of all communications and actions.

b) Silver Tactical Advisor (Call-sign: SILVER TACTICAL)

This role is assigned to a Specialised Emergency Manager. The duties of the Silver
Tactical Advisor are to tactically advise the Silver Commander of any specialist
personnel or equipment that may be necessary to assist in the management of a
Major Incident, provide advice and support on matters relating to emergency
planning and other HMC Ambulance Service or Hamad Medical Corporation
requirements. This Officer is also available to offer advice regarding the
employment of outside agencies e.g. MOI, Military, Industrial and site specific
information. In the event that the Silver Commander is unavailable, it will usually be
the Silver Tactical Advisor that will Command the incident.

A Silver Tactical Advisor will be available to provide advice on matters relating to the
Major Incident Plan and the required response of the HMC Ambulance Service if
appropriate.

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c) Silver Medical (Call-sign: SILVER MEDIC)

Qualified and experienced Senior HMC Ambulance Service Clinician or managerial

equivalent with overall responsibility for clinical effectiveness functions and all staff
assigned to ‘Medical’ posts at the scene of a Major Incident.

d) Silver Operations (Call-sign: SILVER OPS)

Qualified and experienced HMC Ambulance Service Officer with overall

responsibility for clinical access and safety functions and all staff assigned to
‘Operations’ posts at the scene of a Major Incident.

e) Silver Support (Call-sign: SILVER SUPPORT)

Qualified and experienced HMC Ambulance Service Officer with overall

responsibility for all production/logistical support functions and all staff assigned to
‘Support’ posts at the scene of a Major Incident.

f) Silver Specialised (Call-sign: SILVER SPECIAL)

Qualified and experienced HMC Ambulance Service Officer with overall

responsibility for specialised access (Special Access Team), CBRNe decontamination
functions and all hazardous operations at the scene of a Major Incident; as well as
all staff assigned to ‘Specialised’ posts at the scene of a Major Incident.

g) Silver Control (Call-sign: SILVER CONTROL)

The nominated HMC Ambulance Service representative responsible for managing

the Silver Control Unit (SCU) on site. A prime area of responsibility is to ensure, in
liaison with the NCC, that the most effective communications network is available
for all medical personnel on site.

h) Silver Staff Officer

A suitably trained representative of the HMC Ambulance Service who will be utilized
by the Silver Commander to respond to and send radio messages and answer and
make telephone calls on behalf of Silver Command; as well as carrying out any
requests or instructions by Silver Command as may be required.

i) Loggist

A suitably trained representative of the HMC Ambulance Service who will be utilised
by the Commanders/decision-makers at Silver and Gold level to log the decision-
making processes and outcomes.

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Bronze Command Roles

a) Bronze Forward (Call-sign: BRONZE FORWARD 1/2/3)

The nominated HMC Ambulance Service representative responsible for a

smaller incident site within the main incident site. An incident site may be
divided into many sectors and thus there may be many different Sector Officers
within an incident.

The Bronze Forward Officer(s) will manage the scene under the direction of the Silver
Commander. The duties of the Bronze Forward Officer include:

 Management and co-ordination of all HMC Ambulance Service and

mutual aid personnel forward at the actual site
 Ensuring that liaison is ongoing with other agencies at Bronze Level

If the incident covers a large area it can be divided into Sectors. Each Sector can be
identified either by a number or a point of the compass. The Officer appointed to take
charge of a Sector will take the Call Sign, “Bronze Forward” suffixed with the number or
point of compass/landmark (e.g. "Bronze Forward 1"" or “Bronze North”). If more than
one Major Incident is being dealt with all call signs will include a suffix indicating the
location of the incident
 The important point is that all are aware of the method to be used.

b) Bronze Primary Triage (Call-sign: BRONZE PRIMARY)

The nominated HMC Ambulance Service representative at the site responsible

for the initial PRIMARY Triage of all casualties and for organising patient removal
to the SECONDARY Triage Area.

The Bronze Primary Triage Officer will co-ordinate the PRIMARY Triage of casualties at
the incident site. Other duties of the Bronze Primary Triage Officer include:

 Ensuring all casualties receive a PRIMARY Triage survey

 Ensuring only basic airway management is performed
 Ensuring all casualties are correctly tagged

c) Bronze Secondary Triage (Call-sign: BRONZE SECONDARY)

The nominated HMC Ambulance Service representative at the site responsible

for the SECONDARY Triage of all casualties arriving at the SECONDARY Triage
Area and for distribution of casualties to the appropriate Casualty Clearing
Station for treatment.

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The Bronze Secondary Triage Officer will ensure that the SECONDARY Triage of
casualties is carried out at the Casualty Clearing Station. Other duties of the Bronze
Secondary Triage Officer include:

 Ensuring all casualties continually receive a SECONDARY Triage survey

 Ensuring all casualties are correctly labeled

d) Bronze Clearing (Call-sign: BRONZE CLEARING)

The nominated HMC Ambulance Service representative who, in liaison with the
Silver Medical (Clinical Effectiveness) Officer and/or Bronze Primary Triage and
Bronze Secondary Triage Officers, ensures an efficient patient throughput at the
Casualty Clearing Station.

The Bronze Clearing Officer will co-ordinate the treatment and evacuation of casualties
to the receiving hospitals through the triage process. Other duties of the Bronze Clearing
Officer include:

 Arranging the siting and setting up of a Casualty Clearing Station

 Ensuring that casualties held at the Casualty Clearing Station are triaged by
a Bronze Secondary Triage Officer
 Ensuring that patient documentation has commenced
 Handing over patients to Bronze Loading

e) Bronze Doctor (Call-sign: BRONZE DOCTOR)

Hamad Medical Corporation Ambulance Service Doctors with responsibility for

assisting with the treatment and/or the assessment, and discharge of low acuity
(‘GREEN’) patients from scene; reporting to Silver Medical (Clinical
Effectiveness) Officer.

The Bronze Doctor will assist with clinical treatment of patients as required and
task any medical teams as required.

f) Bronze Loading (Call-sign: BRONZE LOADING)

The nominated HMC Ambulance Service representative responsible for ensuring

that suitable access and egress is available to the Ambulance Loading Point, for
organising patient movement in priority order with documentation and
maintaining a supply of appropriate transportation.

The Bronze Loading Officer will organise the Ambulance Loading Point(s) which should
be located near to the Casualty Clearing Station. They are responsible to the Silver
Commander. The duties of the Bronze Loading Officer include:

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 Liaison with the Ministry of Interior to ensure ingress and egress routes
exist
 Ensuring liaison with the Parking Officer is commenced and is ongoing
 Ensuring that all casualties have been triaged and are labeled prior to
transportation to hospital
 Instructing crew staff which hospitals to convey their patients to

NCC will provide a Silver Control Team (SCT) to support this Officer.

g) Bronze Parking (Call-sign: BRONZE PARKING)

The nominated HMC Ambulance Service representative responsible for

marshalling both staff and types of vehicle arriving at the parking areas, in
liaison with the Silver Commander, ensures the most appropriate use of such
resources.

The Ambulance Parking Officer will be responsible for ensuring that HMC Ambulance
Service resources are correctly parked and ready to proceed to the Loading Point as
directed. The duties of the Bronze Parking Officer include:

 Ensuring attending crews are wearing Personal Protective Equipment

(PPE)
 Maintenance of records of staff and vehicles attending
 Ensuring liaison with the Loading Officer is commenced and is ongoing
 Management of keys and call signs of vehicles attending
 Instructing crew staff what equipment to take to the scene (e.g. triage
cards etc.)
 Briefing crews on the nature of the incident

h) Bronze Equipment (Call-sign: BRONZE EQUIPMENT)

The nominated HMC Ambulance Service representative who is responsible for

supplying and maintaining all of the equipment production requirements in
liaison with the Silver Commander.

The Bronze Equipment Officer will be responsible for the issue and recovery of all
Service equipment at the scene. Other duties of the Bronze Equipment Officer include:

 Liaison with the Ambulance Liaison Officer (ALO) to arrange for

specialist hospital equipment to be brought to the scene as required
through Silver Command
 Arranging for refreshment points to be set up at scene for HMC
Ambulance Service staff

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 Consideration of the need for requesting the attendance of additional

HMC Ambulance Service Major Incident Vehicles/pods
 Liaison with Silver Production for further equipment required from
Stores

i) Bronze Safety (Call-sign: BRONZE SAFETY)

An HMC Ambulance Service Officer responsible for ensuring that the

environment and working practices of the HMC Ambulance Service staff, Hamad
Medical Corporation and support staff are not placed at undue risk.

The Bronze Safety Officer will be responsible for the overall safety of all HMC
Ambulance Service and Hamad Medical Corporation staff at the scene and must ensure
that the environment and working practices at the scene do not place any staff at undue
risk. Other duties of the Bronze Safety Officer include:

 Identification of specific Hazards

 Liaison with the Multi-agency Safety Officers
 Ensuring that the correct PPE is worn
 Identification of stress/fatigue in staff
 Monitoring rest and refreshment periods

j) Bronze Production (Call-sign: BRONZE PRODUCTION)

The nominated HMC Ambulance Service representative who is responsible for

arranging the supply of all HMC Ambulance Service and Mutual-aid Resource
requirements in liaison with the Silver Commander.

The Bronze Production Officer will be responsible for the production of all additional
ambulance and/or other resources required at the scene, constantly maintaining a
minimum number of available ‘pool’ ambulances at the staging area ready for
deployment. Other duties of the Bronze Production Officer include:

 Liaison with the Scheduling Department to agree how many additional

ambulances need to be produced using HMC Ambulance Service staff
on overtime
 Liaison with Mutual-aid Commanders on scene to request Mutual-aid
Resources as and when required
 Ensuring that staff receive adequate rest breaks during the operation
 Ensuring that staff who are stood down on rest breaks are replaced by
available staff to maintain minimum cover

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k) Bronze Hospital – Hospital Liaison Officer (HLO) (Call-sign: BRONZE HOSPITAL)

The Bronze Hospital Officer’s primary responsibility is to liaise with the Hospital
Coordination Team to maintain communications with Gold Command.

The Bronze Hospital (HLO) is the second HMC Ambulance Service Officer to be deployed
to each hospital on Major Incident declaration. This will normally be a Medical Officer
nominated by the Medical Director. The Bronze Hospital Officer’s primary responsibility
is to liaise with the Hospital Control Team. Other main tasks and duties include:

 Ensuring that liaison has commenced with the Hospital Control Team, the
Ministry of Interior representative/s at hospital and the Ambulance Liaison
Officer (ALO)
 Assisting the Ambulance Liaison Officer (ALO) with the arrangement of
specialist hospital equipment that is required at scene
 Organising the assistance of MERIT Teams as required

l) Bronze Ambulance Liaison Officer (ALO) (Call-sign: BRONZE ROMEO)

The Bronze Romeo Officer’s primary responsibility is to liaise with Silver

Command to coordinate the flow of patients and with ambulance crews at
hospital to ensure rapid patient transfer and quick ambulance turnaround.

Each hospital that has been placed on Major Incident Alert will have an Ambulance
Liaison Officer (ALO) appointed to it. This will normally be the Bronze Romeo assigned
to that specific hospital, or a substitute Production Supervisor. The Bronze Ambulance’s
prime responsibility is for ambulance crew welfare and collation of patient numbers.
Other main tasks and duties include:

 Maintaining a log of vehicle details and patients arriving

 Ensuring that triage tags are used
 Ensuring that assistance is provided with the decanting of patients
 Ensuring that ambulance equipment is released from the hospital as quickly as
possible
 Arranging specialist hospital equipment that is required at scene
 Providing equipment and consumables to restock vehicles
 Ensuring that crew staff update their status with NCC







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m) Special Access Team (SAT)

Special Access Team (SAT) is a Specialised Team of service staff who have been trained
to administer life-saving medical care in hostile environments such as Industrial
Accidents, Natural Disasters, Terrorist Incidents and CBRNe incidents. They are capable
of delivering this care whilst using a range of Personal Protective Equipment (PPE) which
is not normally available to HMC Ambulance Service Personnel.

FUNCTION

The function of the Special Access Team (supported by technical and scientific advice) is
to provide a rapid response to:
1. Any CBRNe incident
2. Any Major Incident (non-CBRNe) which requires a combined response from all three
Emergency Services and where the assessment, incident and casualty management is
within a potentially Hazardous area
3. Any intelligence led operations which would, under normal circumstances, remove
core resources to be deployed away from normal duties
4. Any pre-planned event requiring a tactical CBRNe response to support the overall
multi-agency incident plan

The role of the Special Access Team is to provide:

• Health input to the initial assessment of the scene
• Undertake a scene assessment directly related to the needs of the ambulance
and other health services
• In collaboration with partners identify the ‘Inner Cordon’ and the ‘Hot Zone’
• Initial triage and immediate life-saving treatment
• Hazard Identification
• Casualty confirmation
• Estimation of the resources required
• Command & Control in a CBRNe ‘Hot/Warm’ Zone, overseeing
o On-going resource requirements
o Ambulance/Health resource management
o Casualty management
o Evacuation

* Special Access Team (SAT) subject to future planning & development.*

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n) Bronze Decontamination (Call-sign: BRONZE DECON)

The nominated HMC Ambulance Service representative who has responsibility

for the management of the HMC Ambulance Service Decontamination Team
and decontamination of contaminated casualties.

The Bronze Decontamination Officer is located in the ‘Clean Area’ and reports to the
Silver Commander. Duties include:
 Liaison with Bronze Doctor and the CBRNe tactical advisor
 Liaison with Ministry of Interior and Civil Defence Commanders
 Ensuring that sufficient resources have been mobilised and arrangements made
for their reception
 Inspection of all Decontamination Operators that are to enter the ‘Warm Zone’
to ensure that the CPPE is donned correctly
 Ensure appropriate comms/radios are available for all Ambulance
Decontamination Team operators
 Ensuring the health and safety of all Ambulance staff in the ‘Warm Zone’

o) CBRNe Tactical Support Officer - (Call-sign: BRONZE TACTICAL)

The CBRNe Tactical Support Officer’s (TSO) main function is to advise the Silver
Commander on decontamination issues. The CBRNe Tactical Officer will be
decontamination trained and will have experience in managing
decontamination incidents at this level.

p) Production Department

In the event of a Major Incident the role of the Production Department is to

provide additional equipment, drugs, disposable blankets, medical gasses and
consumables as requested by Silver Command. In addition, Production
Managers will liaise closely with suppliers and procurement to place emergency
orders and ensure stocks are replenished.

In the event of a prolonged incident, the Department will arrange refreshments for
operational staff.
The on-call Production Director (GOLD PRODUCTION) will have overall responsibility for
co-ordinating the Production response and if instructed will report to the Gold
Command Suite. The on-call Senior Production Manager (SILVER PRODUCTION) will
coordinate all production activities from the HMC Ambulance Service Headquarters. The
Production Manager will delegate tasks to relevant Production Supervisors (BRONZE
PRODUCTION) as necessary.

 Please Refer to Chapter 15: Production Services p102

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Chapter 5: Communications
The Communications Centre is an integral part of any Major Incident Management System. The
initial call will be received at the National Command Centre (NCC) who will dispatch HMC
Ambulance Service resources. The early identification of Serious Incidents or potential Major
Incidents is of paramount importance.

Pre-determined Attendance (PDA)

There is a pre-determined response for major incidents or incidents where the number or type
of casualties threatens to overwhelm the service.
On receipt of such a call where the HMC Ambulance Service are put on Major Incident Standby
or have confirmation of a major incident, NCC will immediately dispatch sufficient resources to
match Major Incident LEVEL 1 requirements initially. This response will be deployed upon
identification of the incident or incidents, without waiting for reports from the scene.
Consideration will also be given to the deployment of Silver Control Units (SCU’s) with a Silver
Control Team (SCT).
The Pre-determined Attendance (PDA) for a major incident activation (LEVEL 2) consists of Alpha
Units, Charlie Units, Delta Units, Mike Officers, Major Incident Units, and a Silver Control Unit
(SCU) with Silver Control Team (SCT), an Incident Command Unit, Green Buses, Mass Casualty
Ambulances and possibly LifeFlight. Ambulance Liaison Officers and Hospital Liaison Officers
should also be deployed to the appropriate hospitals.

 Please refer to Appendix A: Major Incident Pre-determined Attendance

p110

Initial Actions of NCC

The Operations Officer on duty will assume overall responsibility for the NCC response to a
Major Incident and ensure that the following initial actions have been taken, not necessarily in
the sequence detailed:

• Dispatch Pre-determined Attendance (PDA) of ambulances and officers, according to the

requirements for a LEVEL 0 and/or LEVEL 1 response initially and subsequent escalation
requirements for declared LEVEL 2 and LEVEL 3 incidents.
• Ensure that a log of all messages and actions has been commenced.
• Ensure the entry and capture of all Units dispatched on the Computer-aided Dispatch
(CAD) System to record resource movements; including a log of all Mutual-aid Units
deployed in addition.
• Ensure that a METHANE report has been requested and received from the first resource
on scene and that the crew is told to carry out the procedure listed on their Major Incident
Action Cards.

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• Initiate the Major Incident Console as soon as possible.

• For LEVEL 2 or 3 responses, dispatch a Silver Control Team (SCT) to the incident comprising
of one Distribution Team Leader (DTL), a Case Controller and an Ambulance Service Medical
Dispatcher.
• Commence notification instructions for all managers and executives as appropriate.
• Instruct all resources deployed to the incident to switch their radios to the designated
channels.
• Check existence of relevant locality information and contingency plans for the location of
the incident.
• Ensure the appropriate Officer(s) proceed to the scene(s) to act as Silver and/or Bronze
Commanders.
• Inform the Ministry of Interior and Civil Defence.
• In consultation with the Silver Commander, dispatch or alert specialist resources.
• Notify appropriate hospital(s) as below.
• Nominate a Silver Medical Officer and instruct him/her to report to the Silver Commander.
If Medical Emergency Response Incident Team (MERIT) is required by the Silver
Commander, notify the appropriate hospital listed to supply a team.
• Dispatch Green Bus and Patient Transport Service (PTS) vehicles to the scene for early
evacuation of walking casualties. The Silver Commander may wish to consider the use of
private buses.
• NCC Manager on call/on duty to initiate the Goldsuite for Major Incident declared LEVEL 2
& LEVEL 3.

Emergency Department/Hospital Notification

When the HMC Ambulance Service identifies a Major Incident, either during the handling of a
999 call or upon Units arriving on scene and activating a Major Incident, it is the responsibility of
Operations Officer (OSCAR NCC) or in his/her absence the Distribution Team Leader (DTL), to
task the Clinical Team leader (CTL) to notify hospitals in accordance with the matrix below.

The CTL is responsible for completing the notification and filling out the ‘Hospital Major Incident
Notification Log’. When done the checklist should be handed in to the OSCAR NCC on duty or in
his/her absence the DTL.

 MAJOR INCIDENT STANDBY

When HMC Ambulance Service is aware of an incident that has the potential to result in large
numbers of serious (‘YELLOW’) or life-threatened (‘RED’) patients, but has not yet completed a

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preliminary assessment, it will notify all HMC hospitals via their dedicated ‘HOTLINE’ with the
message “MAJOR INCIDENT STANDBY”, followed by a brief description where available.
This is a system-wide notification.
This message will normally be followed by the message “MAJOR INCIDENT TERMINATED” when
the incident does not materialise or will result in escalation to a ‘SERIOUS INCIDENT
NOTIFICATION’ (for a specific hospital) or one of the ‘MAJOR INCIDENT ACTIVATED’ levels.

 SERIOUS INCIDENT NOTIFICATION

When preliminary assessment of the incident indicates that the incident is not a Major Incident,
but still warrants notification of individual hospitals, HMC Ambulance Service will notify
individual HMC hospitals via their dedicated ‘HOTLINE’ with the message “SERIOUS INCIDENT
NOTIFICATION”, followed by a brief description where available.
This is a hospital-specific notification.
Examples of where this would be used include significant numbers of patients inbound who
have minor injuries or illness (‘GREEN’), small numbers of serious (‘YELLOW’) or life-threatened
patients (‘RED’) inbound or patients inbound with unusual presentations such as burns or
poisoning.

 MAJOR INCIDENT ACTIVATED

When preliminary assessment of the incident indicates that large numbers of serious (‘YELLOW’)
or life-threatened (‘RED’) patients are resulting, HMC Ambulance Service will notify all hospitals
via their dedicated ‘HOTLINE’ with the message “MAJOR INCIDENT ACTIVATED”, followed by a
“LEVEL 1, 2 or 3”.
See Table: Receiving Facility Major Incident Notification Matrix p95 for description of each level.
This is a system-wide notification.
Following this notification, HMC Ambulance Service will notify individual hospitals as to whether
they are designated as a ‘CATEGORY A, B or C’ Receiving Facility. See Table: Receiving Facility
Major Incident Notification Matrix p95 for description of these designations.

Ongoing Actions of NCC

• Update the Ministry of Interior, as appropriate, giving the names of receiving hospitals.
• Dispatch Officers if necessary to fulfil all the key roles at the scene and at the receiving
hospital(s).
• Mobilise the required resources for the incident.
• Maintain liaison with Gold Command Suite.
• Notify the Scheduling Department requesting them to retain personnel who volunteer
their attendance. Ask Scheduling to tell staff not to self-respond.

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• Update receiving hospitals and the Emergency Bed Service (EBS) of relevant scene reports,
obtaining revised patient intake numbers.
• Notify appropriate fleet managers and workshop supervisors to facilitate the operation of
vehicles during long term incidents.
• Give regular comprehensive briefings to the gold meetings.

Closure Actions of NCC

• Give "Scene Evacuation Complete" messages at the appropriate time to all participating
hospitals. These messages should include known/expected number of patients still en route
• Inform other agencies of HMC Ambulance Service "Scene Evacuation Complete ".
• Ensure that all NCC staff involved are available for a NCC ‘Hot’ debrief immediately after
the incident.
• Re-stock and prepare the Major Incident Console to ensure it is in a state of readiness.
• Collate all documentation and Incident Logs.
• Prepare a report for the Operations Manager: Specialised Emergency Management.

Incident Control
The Major Incident and Event Consoles are the dedicated consoles within NCC which
support the Silver (tactical) tier during incidents, operations and events. These are
responsible for:

• Controlling deployment of resources to the incident

• Allocating ambulances their destination hospital
• Communication with hospitals and external organisations
• Primary logging duties
• Escalation notification procedures
• Facilitating requests of additional resources, equipment and personnel to scene

There is a degree of flexibility surrounding the functionality of the Major Incident Console.
The concept of operations allows for the use of the ‘Event Console’ as an expansion of the
Major Incident Console should additional capacity be required.
The Operations Officer: Communications has a responsibility to ensure that the Major
Incident or Event Console is opened at the earliest opportunity once a serious incident or
large event has been identified. The Major Incident Console should be staffed with sufficient
people to manage the incident, if necessary at the expense of NCC staffing.

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The following NCC staff should be deployed during an incident – suggested in the following
progressive order:

LEVEL 1 Control Team – for LEVEL 1 Major Incidents or Events

A LEVEL 1 Major Incident or event will be managed by the routine management

infrastructure within NCC; however with the following exceptions:-
NCC will open and operate either the Major Incident Console or the Event Console
depending on the type of incident, and staff such operating desk with an Ambulance Service
Medical Dispatcher.
The Operations Officer (OSCAR NCC) will remain responsible for overseeing the incident as
well as routine business simultaneously. One DTL will be assigned to lead the operation for
the Significant Incident or Event whilst the remaining DTL will focus on routine service
delivery only.
The on-call NCC Manager must be notified of the event or incident operation for
information only and will not be required to mobilise initially to NCC unless specifically
requested to do so by the Silver Commander or Executive Director on-call.

LEVEL 2/3 Control Team – for Level 2 & 3 Major Incidents or Events

Once the Director on call confirms escalation to a LEVEL 2 or LEVEL 3 Major Incident
response, the following NCC Command structure must be implemented; in addition the a
LEVEL 1 response:-

Incident Commander
Responsible for the management of the NCC Control team and NCC's initial actions during
the incident.

Radio Operator/Dispatcher
Responsible for dealing with all radio communications and recording vehicle movements.

Telecoms Officer (changes to Primary Telecoms Officer if required - see below)

Responsible for dealing with and logging of telecommunications throughout the duration of
the incident.

Tactical Advisor
A Specialised Emergency Management Advisor responsible for advising the Incident
Commander and the Silver Control Team.

Critical Incident Loggist

Responsible for maintaining the Critical Incident Log. This log is a list of critical entries taken
from the overall incident log requiring urgent action.

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Gold/EOC Liaison
Responsible for liaison between NCC, the Major Incident Console and Gold Command Suite.
This member of staff is based in NCC.

Tertiary Telecoms
Responsible for dealing with and logging of telecommunications throughout the duration of
the incident.

Silver Control during an Extended Incident

The HMC Ambulance Service has mobile Silver Control Units (SCU), staffed by Silver Control
Team (SCT) members, which may be activated for response to an incident.

Each vehicle has radio sets programmed to ambulance frequencies, hand portables, Tetra
radio sets, maps and other sources of information. They also have the facility to set up a
direct line telephone link between the emergency services at the scene of an incident. Each
vehicle may link into Ooredoo telephone lines and has a variety of mobile phones available.

The role of the Silver Control Unit is to:

• log all communications at the site of the incident
• manage all resources at the incident in conjunction with the Major Incident Console
• set up a Joint Emergency Services Control Centre (JESCC) with the other services on
scene
• act as a focal point for ambulance, medical, and nursing staff and other Emergency
Services at the scene

All UHF/TETRA radio resources will be controlled from the NCC, but an effective radio net on
scene ensures that communication is maintained. The TETRA hand portables can be used for
setting up this radio net.

All messages should follow the appropriate Chain of Command, ensuring that Control is
maintained, i.e. any messages for ALO’s at hospitals from Bronze Officers at scene should
pass through the SCU then on to the appropriate Hospital Officer.

The Incident Command Unit will act as a conference facility for the Silver Commander and is
not designed for controlling the incident.

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Texting/Paging
On receipt of a Serious Incident or a Major Incident activation, NCC must ensure that the
texting/paging instruction has been instigated and followed.

Each text/pager message will have one of three colour coded prefixes:

GREEN: ALL ROUTINE / INFORMATION ONLY MESSAGES

AMBER: PREPARE A STATE OF READINESS/INCIDENT MESSAGES

RED: ACTIVATION REQUIRED

Radio Communications
Members of the Command Structure will have a TETRA radio. When a Silver Control Team
(SCT) responds to the scene, they will manage the pool of TETRA radios on the Silver Control
Unit (SCU), ensuring there are sufficient radios for the on-site Command Structure.

A minimum of two radio nets will be established using different TETRA channels. TETRA will
provide the Command Channel for Silver, Sector and Bronze Officers. TETRA will also
provide a resource channel between vehicles moving to and from scene, NCC Control, Silver
Control, Goldsuite, ALOs and HLO’s and the Production Team.

NCC Control will be responsible for all communications outside of Incident Command
infrastructure dealing with all resources that are involved in the incident but not in
attendance on scene; e.g.:

 Deploying resources to scene

 Controlling resources becoming available from hospital
 Liaise with Bronze Ambulance to provide updates on the number of remaining
casualties
 Communicate with Silver Control to obtain situation reports (SITREPS)

The Silver Control Team will be responsible for controlling all resources that are in
attendance at the scene, e.g.:

 Control all resources available on scene

 Liaise with NCC Control for further resourcing requirements
 Provide NCC Control with situation reports (SITREPS)
 Pass urgent/important messages to all incident commanders (e.g. safety alerts)

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Silver Control will seek acknowledgement of any information/action messages passed e.g. if
the Silver Commander reports the number of remaining casualties. Silver Control will relay
the message to NCC Control who will then seek acknowledgement from ALOs.

 The following Talk-groups will be used to manage and control Major Incidents
and events:-

Talk-group AS MAJOR AS EVENT 1 AS EVENT 2

Control Major Control Event 1 Control Event 2

Gold Major Gold Event 1 Gold Event 2
Silver Major Silver Event 1 Silver Event 2
Silver Medical Major Silver Medical Event 1 Sector Medical Event 2
Silver Ops Major Silver Ops Event 1 Sector Ops Event 2
Channels

Silver Support Major Silver Support Event 1 Sector Support Event 2

Silver Special Major Silver Special Event 1 Sector Special Event 2
Bronze Medical Major Bronze Medical Event 1 Bronze Medical Event 2
Bronze Ops Major Bronze Ops Event 1 Bronze Ops Event 2
Bronze Support Major Bronze Support Event 1 Bronze Support Event 2
Bronze Special Major Bronze Special Event 1 Bronze Special Event 2
Production Major Production Event 1 Production Event 2
Auxiliary Auxiliary Auxiliary

 The following call signs will be used at Major Incidents:-

CALL-SIGNS & RADIO CHANNELS

DESIGNATED ROLE CALL-SIGN LOCATION RADIO CHANNEL
NCC
Incident/Event Control NCC CONTROL 1/2 NCC Control Major/Event
Mobile Control SILVER CONTROL 1/2 Incident location Control Major/Event
GOLD COMMAND
Gold Command Suite GOLDSUITE NCC Gold Major/Event
Gold Commander GOLDSUITE NCC Gold Major/Event
Gold Doctor GOLDSUITE NCC Gold Major/Event
Gold Tactical GOLDSUITE NCC Gold Major/Event
Gold Staff GOLDSUITE NCC Gold Major/Event
Gold Loggist GOLDSUITE NCC Gold Major/Event

SILVER COMMAND

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CALL-SIGNS & RADIO CHANNELS

DESIGNATED ROLE CALL-SIGN LOCATION RADIO CHANNEL
SILVER COMMAND
Silver Commander SILVER COMMAND Incident location Silver Major/Event
Silver Tactical SILVER TACTICAL Incident location Silver Major/Event
Silver Medical SILVER MEDICAL Incident location Silver Major/Event
Silver Operations SILVER OPS Incident location Silver Major/Event
Silver Support SILVER SUPPORT Incident location Silver Major/Event
Silver Specialised SILVER SPECIAL Incident location Silver Major/Event

CALL-SIGNS & RADIO CHANNELS

DESIGNATED ROLE CALL-SIGN LOCATION RADIO CHANNEL
SILVER COMMAND
Silver Staff SILVER STAFF Incident location Silver Major/Event
Silver Loggist SILVER LOGGIST Incident location Silver Major/Event
BRONZE COMMAND
Bronze Forward BRONZE FORWARD Incident location Bronze Ops
1/2/3 Major/Event
Bronze Doctor BRONZE DOCTOR ½ Incident location Bronze Medical
Major/Event
Bronze BRONZE DECON Incident location Bronze Special
Decontamination Major/Event
Bronze Tactical BRONZE TACTICAL Incident location Bronze Special
Major/Event
Bronze Primary Triage BRONZE PRIMARY Incident location Bronze Medical
Major/Event
Bronze Secondary BRONZE SECONDARY Incident location Bronze Medical
Triage Major/Event
Bronze Clearing BRONZE CLEARING Incident location Bronze Medical
Major/Event
Bronze Loading BRONZE LOADING Incident location Bronze Support
Major/Event
Bronze Parking BRONZE PARKING Incident location Bronze Support
Major/Event
Bronze Equipment BRONZE EQUIPMENT Incident location Bronze Support
Major/Event
Bronze Safety BRONZE SAFETY Incident location Bronze Ops
Major/Event
Bronze Production BRONZE PRODUCTION Incident location Bronze Support
Major/Event
Bronze Hospital (HLO) BRONZE HOSPITAL (HLO) Receiving Silver Major/Event
Hospital/s Gold Major/Event
PRODUCTION

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CALL-SIGNS & RADIO CHANNELS

DESIGNATED ROLE CALL-SIGN LOCATION RADIO CHANNEL
PRODUCTION
Gold Production GOLD PRODUCTION NCC Production
Major/Event
Silver Production SILVER PRODUCTION AS HQ Production
Major/Event
Bronze Production BRONZE STORES/FLEET Stores/Fleet Production
Major/Event
Bronze Ambulance ROMEO 1/2/3 Receiving Control Major/Event
(ALO) Hospital/s Silver Major/Event

Inter Service Communications

Robust communication links must be established as soon as possible. There are several
technological solutions available for this, but these are no substitute for frequent Silver
meetings along with well-established working practices.
There is an interoperability Talk-group available through the TETRA system. This facility
should be requested via NCC who will designate the appropriate Talk-group.

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Chapter 6: Ambulance Service Initial Actions

Safety Triggers for Emergency Personnel (‘STEP’)
In order to assist HMC Ambulance Service staff to remain in a safe environment and to identify a
possible chemical incident/attack, the ‘STEP 1-2-3’ system should be adopted when attending
emergency calls. This should be supplemented by the use of the METHANE report as soon as
practical.

To be used when the cause is unknown

STEP 1 ONE casualty Approach using normal procedures

STEP 2 TWO casualties Approach with caution, consider all options

Report on arrival and update control

STEP 3 THREE casualties DO NOT approach the scene

Withdraw

Contain

Report

Isolate yourself

SEND FOR SPECIALIST HELP

First Arriving Unit Responsibilities

It is the responsibility of the First Arriving Unit to establish Command and to perform the Initial
Scene Size-up using the METHANE mnemonic and reporting the information to their Dispatcher:

M - MAJOR INCIDENT DECLARED at appropriate LEVEL 1/2/3

E - EXACT LOCATION with map reference if possible

T - TYPE OF INCIDENT with details of structure and/or vehicle types, size, number

H - HAZARDS present and potential

A - ACCESS ROUTES and suitable Rendevous Point (RVP)

N - NUMBER OF PATIENTS and severity

E - EMERGENCY SERVICES present and required, including equipment

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First Ambulance or Response Driver

On arrival at the scene, the driver of the First Ambulance or Response will assume the role of
Silver Control (Call-sign: SILVER CONTROL) and will adopt the following procedures:

 Park as near to the scene as safety permits and do not leave your vehicle.
 Don high visibility clothing and safety helmet (take a short time to reflect on the
situation).
 Leave the flashing Emergency lights and Hazard warning lights on the ambulance ‘ON’ to
signify Ambulance Control Point until relieved.
 Maintain a communications link between your attendant and the HMC Ambulance
Service Communications Centre (NCC).
 Provide a METHANE report to the HMC Ambulance Service Communications Centre
(NCC) from the vehicle base radio if possible.
 Request additional resources as required.
 Hold all staff at your vehicle until briefed by SILVER COMMAND (your attendant).
 Ensure that all arriving staff wear high visibility clothing, safety helmets, and bring their
triage packs to the Ambulance Control Point.

If the first ambulance attendant on scene is alone (single crewed) then he/she will be responsible
for carrying out the Attendant duties described below.

First Ambulance or Response Attendant

On arrival at the scene, the Attendant of the First Ambulance or response will assume the role of
Ambulance Incident Officer (Call-sign: SILVER COMMAND) and will adopt the following
procedures:

 Don high visibility clothing and safety helmet.

 Carry out reconnaissance of the incident site and report back to the Ambulance Service
Communications Centre (NCC) using the METHANE mnemonic.
 Activate a Major Incident based on the criteria in the definition and the Emergency
Response Plan Levels of Escalation (LEVEL 1/2/3).
 Think Command and Control – designate appropriate roles as per Major Incident Action
Cards; starting with Bronze Parking (call-sign: BRONZE PARKING) and Bronze Primary
Triage (call-sign: BRONZE PRIMARY) roles.
 Instruct the second arriving crew to assist with Triage.

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 In liaison with other Emergency Services identify and establish:

o Access and egress routes to and from the incident site
o Ambulance Casualty Clearing point(s)
o Ambulance Control point
o Ambulance Parking point
o Ambulance Loading point(s)
 Consider potential Hazards when designating the above.

The first crew on scene should not attempt to rescue or treat casualties until relieved of their
initial “First on Scene” roles by Ambulance Supervisors or Managers.

Second Ambulance Crew or Responder Attendant

On arrival at the scene, the Second Ambulance Crew will adopt the following procedures:

 Park as near to the Ambulance Control Point as safety permits (first arriving ambulance
with emergency lights flashing).
 Switch ‘OFF’ your vehicle’s flashing emergency lights unless required for scene safety
illumination but do not use Hazard warning lights regardless.
 Don high visibility clothing and safety helmet (take a short time to reflect on the
situation).
 Keys to remain with the vehicle, radio sets to be turned to ‘low’ volume and the driver’s
window to be left marginally (¼) open.
 Be prepared to take a Command Role in the initial stages of the incident. You may be
designated Bronze Parking (call-sign: BRONZE PARKING) and Bronze Primary Triage (call-
sign: BRONZE PRIMARY) roles.
 Obtain a briefing from SILVER COMMAND.
 Do not attempt to rescue or treat casualties until relieved by Ambulance Supervisors or
Managers.

Subsequent Ambulance Crew or Responder Attendant

On arrival at the scene, the Third and Subsequent HMC Ambulance Service Crews will adopt the
following procedures:

 Proceed as instructed by the HMC Ambulance Service Communications Centre (NCC),

normally to the parking /staging point.
 Report arrival to the HMC Ambulance Service Communications Centre (NCC) on R/T.

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 Report arrival to BRONZE PARKING if designated, if not report to Ambulance Control

Point indicated by flashing Emergency lights and Hazard warning lights.
 Switch ‘OFF’ your vehicle’s flashing Emergency lights unless required for Scene Safety
illumination but do not use Hazard warning lights regardless.
 Keys to remain with vehicle, radio sets to be turned to ‘low’ volume and driver’s window
left marginally (¼) open.
 Don high visibility jackets and safety helmets.
 Take Major Incident Response Pack to required location.
 As directed carry out Primary Triage, labeling, management and movement of
casualties.

Other Considerations
Staff should be aware that there are Contingency Plans for specific ‘high risk’ sites throughout
Qatar. These plans should be carried on all vehicles and should be available to staff prior to
attending an incident. Staff should familiarise themselves with the content of their Contingency
Plans.

Staff should be issued with Major Incident Action Cards to remind them of their roles on arrival.
Staff should make themselves familiar with their contents.

In order to provide sufficient initial equipment for the treatment of patients prior to the arrival
of Major Incident Response (MIR) Units, it may be appropriate for crews to strip the First and
Second Ambulances of their equipment.

Any ambulance crew that conveys a patient MUST advise the BRONZE LOADING Officer and the
HMC Ambulance Service Silver Control of the following information:

 Casualty numbers
 Patient classification (code ‘RED’; code ‘YELLOW’; code ‘GREEN’)
 Patient sex and approximate age

It should be noted that during a Major Incident there is no requirement for Serious Incident
Notifications – simply the use of code updates will suffice. BRONZE LOADING will advise crew
staff of the receiving hospital.

Within the assessment for required resources at the scene of the incident it may be appropriate
to request the use of a coach or bus for transportation. Where possible staff should request
buses/coaches via the HMC Ambulance Service Silver Control.

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Establishing Incident Command

The senior crewmember on the first arriving unit must assume the role of the Attendant – Silver
Commander (Call-sign: SILVER COMMAND) and reports that they have Command to their
Dispatcher.

The person will remain in charge until Command is transferred to a higher authority. It is the
responsibility of the Silver Commander (SILVER COMMAND) to perform the initial scene size-up
using the “METHANE” mnemonic.

Request Additional Resources

Once the initial Scene Size-up has been completed the Silver Commander (SILVER COMMAND)
must request additional resources based on his/her assessment of the incident and available
resources.

The Silver Commander’s request for additional resources should be accompanied by the
identification of the Incident Parking/Staging Area(s).

The Major Incident Pre-determined Attendance (PDA) Resource Sheets found in Appendix A
provides a list of recommended resources for each Major Incident level.

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Chapter 7: Triage
Introduction
Triage is derived from the French Trier, meaning ‘to sort or sieve’. In pre- hospital emergency
medicine, to sort and to sieve is the process of sorting patients in order of priority for receiving
treatment, evacuation and transportation. Triage may take many different forms, and can
operate at a number of different levels; however, the aim is to give the right patient the right
care and treatment at the right time in the right place. In certain circumstances, this may also
mean ‘doing the most for the most”.
As the patient’s condition changes so too does the need for medical intervention change; this
change in the patient’s condition will cause a change in the triage category. To reflect this
change the triage process must be regularly repeated.
The purpose of triage is to assign treatment and transportation priorities to patients by
separating the victims into easily identifiable groups; it should be fast, reliable and reproducible,
easy to use and easy to teach. The following triage categories are used to prioritise patients:

 Figure 1 – Triage Categories

URGENCY PRIORITY COLOUR DESCRIPTION

Immediate P1 Red Life-threatening
Urgent P2 Yellow Serious
Delayed P3 Green Minor
Dead P0 White Not breathing
Expectant P4 Blue Potentially un-survivable injuries

Triage Levels:
 RED: A patient who requires immediate treatment due to their life being in immediate
danger; e.g. a patient with an airway problem or with severe breathing or
haemorrhaging problems.
 YELLOW: A patient who is not in immediate danger but requires urgent medical or
surgical intervention, within 2 to 4 hours; e.g. a patient with multiple complicated
fractures.
 GREEN: A patient with minor injuries that will require treatment, i.e. a delayed urgency;
e.g. a patient with minor lacerations and abrasions.
 WHITE: A patient that is not breathing with no pulse.
 BLUE: A patient that has severe and extensive injuries and cannot be saved with the
resources available. The BLUE category is regarded as the most challenging both from
an emotional and ethical view.

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Triage Methods: Primary and Secondary Triage

When faced with a Major Incident there are two types of triaging that will be done:-

Primary Triage:
 Done at the scene of the incident.
 Done by HMC Ambulance Service Paramedics on scene of a Major Incident.
Secondary Triage:
 Done when patients are taken to the Casualty Clearing Station.
 Done by a senior clinician (Critical Care Paramedic).

The ideal person to do the initial triage (Primary Triage) will be the second or subsequent HMC
Ambulance Service Responder (Ambulance Paramedic) that arrives on scene.
The method of initial field triage to be used is the Primary Triage method for adult patients
(>140cm) and paediatric patients (<140cm). This will be followed up by a Secondary Triage
completed at the triage area.
Patients who have been exposed to various CBRNe agents may need to be triaged using
guidelines that are specific to the agent to which they have been exposed. Patients who have
been exposed to certain CBRNe weapons may have different triage needs than trauma patients.

The Primary Triage method is used by assessing the patient’s ability to walk, airway patency,
breathing rate and the patient’s pulse rate. Primary Triage uses the parameters of less than 10
(<10) or greater than 30 (>30) breaths per minute to classify abnormal breathing. Primary
Triage also categorises the pulse rate of >120/min for ADULT or >140/min for PAEDS to RED due
to a pulse rate being a good physiological indicator of the presence of shock.

 Primary Triage
The initial triaging of victims must begin right where the patients lay. The HMC Ambulance
Service Provider must begin to triage patient’s right where they enter the scene and then
progress in a deliberate and methodical pattern to ensure that all of the victims are triaged.
When using the Primary Triage method all ambulatory patients are initially directed to a
designated ‘GREEN’/Minor treatment area where they will be assessed and further triaged as
personnel become available. It is appropriate to provide these patients with self-care kits, if
available, so that they may begin treating themselves while awaiting the arrival of HMC
Ambulance Service providers. For all remaining patients, Triage personnel must quickly triage
each patient and apply the appropriate color-coded triage ribbons.
The initial triage of the victims establishes the order in which non-ambulatory patients will be
moved to the treatment area. ‘RED’ Tagged/Critical victims should be moved first, ‘YELLOW’
Tagged/Serious second. All ‘GREEN’ Tagged/Non-serious patients should already be in the
Treatment Area as outlined above by moving ambulatory patients first. Deceased victims
(‘WHITE’ Tagged/Deceased) are left where they are found unless they must be moved to gain
access to living patients or if the remains are in danger of being destroyed.

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 Adult Primary Triage (>140cm) Algorithm

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 Paediatric Primary Triage (<140cm) Algorithm

The paediatric version of the Primary Triage Algorithm uses the same physiological parameters
as the adult algorithm however the values differ due to the child’s length (<140cm). This is due
to a child’s length being proportional to its weight, which is proportional to its age.

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The first step in PRIMARY Triage: Get up and Walk!

The first step in PRIMARY Triage is to tell all the people who can get up and walk to move to a
specific area. If patients can get up and walk, they are probably not at risk of immediate death.
In order to make the situation more manageable, those victims who can walk are asked to move
away from the immediate scene to a specific designated safe area. These patients are now
designated as code GREEN minor injuries.
If a patient complains of pain on attempting to walk or move, do not force him or her to move.
The patients who are left in place are the ones on whom you must now concentrate.

The second step in PRIMARY Triage: Begin Where You Stand

Begin the second step of PRIMARY Triage by moving from where you stand. Move in an orderly
and systematic manner through the remaining victims, stopping at each person for a quick
assessment and tagging. The stop at each patient should never take more than one minute.

REMEMBER: Your job is to find and tag all patients with the appropriately coloured ribbon so
that other rescuers can see which remaining casualties have already been triaged, and which
haven’t. Examine each patient, correct life-threatening Airway, Breathing and Circulatory
problems, and tag the patient with the appropriately coloured ribbon and MOVE ON!

When conducting PRIMARY Triage in the dark (at night or in dark areas/tunnels), for all code
RED patients, place a ‘RED Glow Stick’ on top of the patient for easy identification by rescuers.
The first priority is to have all code RED patients – those who require immediate attention –
moved to the SECONDARY Triage Area.

Expectant Category
The Expectant Category is only used following the authority of the Gold Commander. This
situation arises when there are such large numbers of patients that the ability of the HMC
Ambulance Service to respond to the clinical needs of every individual is compromised. Patients
with potentially un-survivable injuries will not be treated. These patients are treated the same
as the dead. This allows the HMC Ambulance Service to “do the best for the most patients”.

Expectant patients must be triage tagged as “Expectant Category” which is BLUE in colour.
These patients are left in the position they are found and are not treated. Once all ‘RED’ and
‘YELLOW’ code patients have been removed from the incident site, BLUE code patients are re-
assessed finally. If they still show signs of life, only then will treatment be attempted.

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Triage in CBRNe (Hazardous materials) Incidents

During a CBRNe Incident responders must protect themselves from injury and contamination.
The single most important step when handling any hazardous materials incident is to identify
the substance(s) involved.

IF THERE IS ANY SUSPICION OF A HAZARDOUS MATERIALS SPILL:

 Follow the ‘STEP 1-2-3’ procedure.
 Call for specialised help.

Unless you have received training in handling hazardous materials and can take the necessary
precautions to protect yourself, you should keep far away from the contaminated area or “Hot
Zone”.

Once the appropriate protection of the rescuers has been accomplished, triage in CBRNe
Incidents has one major function – to identify victims who have sustained an acute injury as a
result of exposure to hazardous materials. These patients should be removed from the
contaminated area, decontaminated by trained personnel, given any necessary emergency care,
and transported to hospital.

REMEMBER: Contaminated patients will contaminate unprotected rescuers!

Emergency treatment of contaminated patients who have been exposed to hazardous materials
is usually aimed at supportive care, since there are very few specific antidotes or treatments for
most hazardous materials injuries. Because most fatalities and serious injuries sustained in
hazardous materials incidents result from breathing problems, constant re-evaluation of the
patients code YELLOW and GREEN is necessary so that a patient whose condition worsens can
be moved to a higher triage level.

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 Secondary Triage
Secondary triage is the first step in patient treatment. Every patient is brought from the scene
to a single point where one of the most medically qualified people on scene will conduct a
secondary triage of patients, making a determination of what triage colour category the patients
should be placed in for treatment, and ensure that the HMC Ambulance Service Triage Tag is
applied to the patients. Secondary Triage is a more in-depth assessment of each patient and is
based on the clinical experience and judgment of the provider, using the ‘SECONDARY’ Triage
Evaluation Chart below:

 ‘SECONDARY’ Triage Evaluation Chart

Measured Score Measured Score

Physiological
Value Value Insert Score
Variable
ADULT PAEDS
10 – 29 4 10 – 24 4
> 29 3 25 – 35 3
Respiratory Rate 6–9 2 > 35 2 A
1–5 1 < 10 1
None 0 None 0
≥ 90 4 > 90 4
76 – 89 3 70 - 90 3
Systolic Blood
50 – 75 2 50 - 69 2 B
Pressure
1 – 49 1 < 50 1
No BP 0 No BP 0
13 – 15 4 14 – 15 5
9 – 12 3 11 – 13 4
Glasgow Coma
6–8 2 8 – 10 3 C
Scale
4–5 1 5–7 2
3 0 3-4 1
Triage Revised Trauma Score A+B+C
PRIORITY PRIORITY ADULT PAEDS
Priority 1 Immediate 1 - 10 2 - 11
Revised Trauma
Priority 2 Priority 2 11 12
Score
Priority 3 Priority 3 12 13
Priority 0 Priority 0 0 1

Fig.3

Ongoing Triage is then performed periodically thereafter depending upon the patient’s
condition. Additional triage assessments must be performed during transport to and again
upon the patient’s arrival at the Emergency Department.

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Triage Tags
Once a triage category has been established on a patient, the Secondary Triage Officer must
label the patient accordingly, to prevent confusion, and the triage process being duplicated.
Each label should have an identifying number, they should also allow for any changes in the
patient’s condition when further triaging is done. The triage labels should annotate the
patient’s clinical information and the correct colour triage shown. Triage labels should at all
times remain with the patient even if a new label is started.

 Triage Tag Example

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Special Considerations for Major Incidents

Today’s Ambulance Service providers can expect to face specifically challenging major incidents
resulting from a man-made biological event (e.g. anthrax attack), a natural occurring pandemic
disease event (e.g. influenza), or a natural disaster or other event resulting in a large number of
victims becoming ill.

Massive system-wide infrastructure damage may result from these types of incidents and may
also result in the loss of hospitals, physician’s offices, dialysis centres, other healthcare facilities
and home healthcare services. Patients who live with controlled chronic illnesses and conditions
may suddenly find themselves separated from their existing family members/care givers, and/or
their normal healthcare system. Many of these patients may be unable to obtain needed
medications, oxygen, dialysis, cancer treatments, etc. due to the destruction or disruption in the
healthcare system. This situation will exacerbate their medical conditions forcing many of these
patients to turn to the Ambulance Service system for care. The principles of triage still apply
during these incidents and serve to assist providers by prioritising patient care and
transportation.

Conclusion
When a Major Incident occurs, the rapid assessment and treatment of the causalities involved
should remain the most important, and Triage being the most important tool that is used when
faced with a Major Incident, ensures that resources are effectively used when casualties are
faced with life-threatening injuries.
Triage tools are only as effective as the Triage Officer and Triage Teams using them. It is
therefore imperative that Emergency Care Providers familiarise themselves and become
proficient in using the Primary Triage and Secondary Triage methods of triaging patients within
HMC Ambulance Services.

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Chapter 8: Emergency Management of

Uncontaminated Patients
First Arriving Unit Actions
The First arriving unit on a potential Major Incident must restrain themselves from rushing
into the scene. The first arriving unit should use the “METHANE” mnemonic to properly assess
the scene and report the information to their Control Centre. This step is vital to initiate a
response appropriate to the size of the Major Incident.

Emergency Departments MUST be notified immediately that a Major Incident has been
declared, according to the Hospital Notification Procedure (p38).

If this is a LEVEL 2 or 3 Major Incident, consider requesting the appropriate Mutual-aid at this
time.

The Incident Scene

Primary Triage must be conducted at the incident scene if it is safe to do so.

 All injured victims must be rapidly triaged using the Primary Triage Cards (Adult &
Paediatric).
 Make certain that triage ribbons are applied.
 Only Basic Life Support intervention must be applied by HMC Ambulance Service
personnel during the Primary Triage, and only where and when such intervention is
deemed necessary as a life-saving procedure.
 Examples are basic airway procedures such as applying C-Collars, inserting OP Tubes and
placing patients lateral in the recovery position; also controlling exacerbated
haemorrhaging by the application of pressure bandages and tourniquets.
 No intravenous fluid resuscitation (IV therapy), Cardio-Pulmonary Resuscitation (CPR),
or any other invasive and/or labour intensive treatment is to be performed on any
patient during the Primary Triage stage.

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All Survivors of a Major Incident who are uninjured and require no treatment must be directed
to a safe place as soon as one is identified.

 Survivors should be asked to assist other patients if they are able to do so.
 Survivors must undergo a Secondary Triage at the Secondary Triage Area in order to
confirm that they are uninjured.
 Following Secondary Triage, survivors should be directed to a Survivor Reception
Centre/Area where they must all be accounted for and their personal identification and
contact details, as well as details of their relatives and/or friends, collated and
forwarded on to the relevant authorities.
 The Ministry of Interior should be responsible for establishing a central ‘Incident Contact
Centre’ for concerned families and friends to call should they wish to establish the
welfare of their relatives and/or friends.
 Arrangements should be made for survivors to be collected or transported home from
the Survivor Reception Centre once the Ministry of Interior and relevant authorities
have obtained the necessary personal identification and contact details, details about
their relatives and/or friends, as well as any statements required about the incident (if
required and necessary at this stage).

Ambulatory (‘GREEN’ Tagged) patients must be directed to a safe place as soon as one is
identified.

 Self-treatment kits or supplies should be distributed to patients in the ‘GREEN’ section

of the treatment area.

Non-ambulatory patients (‘RED/YELLOW’ Tagged) are removed from the scene to the Treatment
Area by stretcher bearers. Ministry of Interior Officers can assist in these roles, to include the
Police, Internal Security Forces (ISF) and Civil Defence as well as Military Officers (where
available).

Deceased victims (‘WHITE’ Tagged) are left where they are found, unless they must be moved to
gain access to living patients or if the remains are in danger of being destroyed.

All incident victims must be accounted for. This includes victims who may be uninjured,
trapped, or who have been rescued or extricated.

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The Treatment Area

 Secondary Triage

‘BLUE’ coloured tarpaulins will be placed outside the entrance of the Triage Shelters for use
in designating Triage Areas. The tarpaulins are intended to be used as the initial Triage
Areas whilst the Triage Shelters are being erected and equipped. Be aware that the Triage
Area required will easily exceed the size of the shelters and/or tarpaulins.

Responders must expand and/or relocate the Triage Area during an incident to
accommodate increasing space requirements.

A more in-depth assessment method, known as Secondary Triage, must be conducted on all
patients arriving at the Treatment Area from the incident scene. Each patient will have a
HMC Ambulance Service Triage Tag applied upon their entry into the Treatment Area.

 Continual Evaluation

Patients in the Treatment Area must be continuously reevaluated (re-triaged) throughout

their stay in the treatment area.

 Designating Treatment Area Sections

Patients are placed in the Treatment Area and emergency medical care is provided on the
basis of the triage priority. If needed, separate areas may be created in the Treatment Area
for ‘RED’ Tagged, ‘YELLOW’ Tagged, and ‘GREEN’ Tagged patients. Personnel, equipment
and supplies are allocated to patients based on their Triage Priority.

Designate a separate, secure and isolated area for the Incident Morgue. The Incident
Morgue is for the placement of victims who die in the Treatment Area (this area should be
secured by the Ministry of Interior not HMC Ambulance Service providers).

 Treatment Area Space Requirements

It is important to provide enough space between patients to allow providers room to place,
treat and move safely between patients. Each patient should have at least 1 meter of open
space on three sides of the patient as shown in Chapter 12: Casualty Management Shelters
Layout (‘RED’, ‘YELLOW’ & ‘GREEN’ Treatment Shelters p91). ‘RED’, ‘YELLOW’ and ‘GREEN’
coloured tarpaulins will be placed outside the entrance of the Treatment Shelter for use in
designating Treatment Areas. The tarpaulins are intended to be used as the initial
Treatment Areas whilst the Treatment Shelters are being erected and equipped. Be aware
that the treatment area required will easily exceed the size of the shelters and/or tarpaulins.

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Responders must expand and/or relocate the Treatment Area during an incident to
accommodate increasing space requirements.

The Transportation Area

The NCC will notify HMC HGH Switchboard, the Nursing House Supervisors for each hospital, the
on-call SWICC Incident Commander and HMC Hospital Emergency Departments that a major
incident has been activated. The NCC will also allocate the receiving status based on the major
incident level according to the number of each category of patient.

Once the SWICC is operational it will take control of all HMC co-ordination and communication
with the NCC. The Ambulance Service will initially determine which patients will be sent to
which hospitals, as per the ‘Receiving Facility Major Incident Notification Matrix’ p102. The HMC
Ambulance Service Gold Command Centre (Goldsuite) will maintain constant contact with the
HMC SWICC to liaise on hospital coordination decisions.

The HMC Ambulance Service Gold Commander, through NCC, will contact the HMC SWICC
Liaison Officer in order to obtain bed availability information to assist with the appropriate
distribution of patients to various Emergency Departments, hospitals, and/or other medical
facilities.

Transportation resources are assigned based on Triage Priority.

Patients are moved from the Transportation Area to the appropriate vehicle by the
collecting/receiving ambulance crew.

Patients are transported to the most appropriate medical facility by the most appropriate means
available. Emergency medical care is continued en route to the hospital. At a minimum all
medical care must be documented on the HMC Ambulance Service Tag. If time and resources
allow medical care may also be documented on the Pre-hospital Patient Care Record (PCR).
Patient transports to receiving Emergency Departments are documented on the Major Incident
Patient Tracking Forms.

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Scene Layout
It is important for responders to establish an orderly flow of patients from the incident scene
through the Transport Area. The uncontaminated patient flow diagram shown below provides a
sample diagram of just one way to organise the scene. Ultimately the way a scene is organised
will depend on scene security and location, terrain, weather, the number of patients, and
numerous other factors.

Survivor
Receptio

 Scene Diagram: Uncontaminated Patients

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Chapter 9: Emergency Management of Contaminated

Patients
First Arriving Unit Actions
In order to assist HMC Ambulance Service staff to remain in a safe environment and to identify a
possible HAZMAT incident, the ‘STEP 1-2-3’ system should be adopted when attending
emergency calls. This should be supplemented by the use of the METHANE report as soon as
practical.

To be used when the cause is unknown

STEP 1 ONE casualty Approach using normal procedures

STEP 2 TWO casualties Approach with caution, consider all options,

report on arrival and update control.

STEP 3 THREE casualties DO NOT approach the scene

Withdraw

Contain

Report

Isolate yourself

SEND FOR SPECIALIST HELP

The first arriving unit on a potential CBRNe incident must restrain themselves from rushing
into the scene by remaining uphill and upwind of the incident.

The successful initial management of a CBRNe incident is based upon the first arriving unit using
the “METHANE” mnemonic to properly assess the hazard and report the information to the
Communications Centre (NCC). This step is vital to the safety of all first responders, victims, and
the community alike.

Request the Civil Defense CBRNe Team and the HMC Ambulance Service HAZMAT team to
respond. If this is a LEVEL 2 or 3 Major Incident and/or involves a large number of contaminated
victims, advise the Communications Centre when the request is made to enable other CBRNe
Teams to be called in from other providers (e.g. Ministry of Interior, Military and Qatar
Petroleum).

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The First Arriving Unit should also make an effort to control the scene by designating a
“Danger/Hot Zone” and a “Safe/Cold Zone’, this must be done in conjunction with Civil Defence.
Consult Fig 9.1 p68 for initial isolation distances.

Designation of the Hot, Warm, and Cold Zones

Upon arrival the HMC Ambulance Service HAZMAT Team will assess the incident scene and
designate a ‘Hot Zone’, ‘Warm Zone’ and a ‘Cold Zone’, in conjunction with Civil Defence.

 Hot Zone

The ‘Hot Zone’ is the area that immediately surrounds a CBRNe incident. The Hot Zone
normally extends out in a 360 degree radius around the incident scene. The Hot Zone is also
referred to as the ‘exclusion zone’ or ‘restricted zone’ in other documents.

 Warm Zone

The ‘Warm Zone’ is the area where personnel and equipment decontamination and Hot
Zone support takes place. The Warm Zone has access control points which assist in reducing
the spread of contamination. This is also referred to as the ‘decontamination’,
‘contamination reduction’, or ‘limited access zone’ in other documents. The Warm Zone will
often be the first place that patients will be decontaminated, receive antidotes and other
lifesaving treatments. Once patients have been decontaminated, they will be transferred
into the care of HMC Ambulance Service providers in the ‘Cold Zone’.

Note: The administration of life-saving treatments takes precedence over decontamination

for radiologically contaminated patients.

 Cold Zone

The ‘Cold Zone’ serves as the ‘Control Zone’ for a CBRNe incident. The Cold Zone contains
the Incident Command Post and other incident support facilities. This zone is also referred
to as the ‘clean zone’ or ‘support zone’.

In some cases victims may remove themselves from the contaminated area. It is important
to channel these victims into a hasty decontamination corridor consisting of the flush, strip,
and flush activities. This action may be necessary to save lives and protect first responders
before a more formal contamination reduction corridor has been established.

 Figure 9.1 Incident Zoning Diagram

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The above diagram shows the zoning of CBRNe incidents and is intended to serve as a guide
for the Incident Commander.

 Distance between the release and the Hot Zone boundary will be at least 30 meters;
however it could be more depending on the material and quantity involved.

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 Contamination Control (decontamination area) is the distance between the Hot Zone
boundary line and the Warm/Cold Zone boundary line. This area will be at least 45
meters long.
 The distance between the hazardous materials release and the Command Post must be
at least 75 meters.
 The Cold Zone is the clean area where the command post and rest and rehabilitation
areas are located.
 The Parking Area is located off-scene but nearby. It is the assembly area for Mutual-aid
Departments and other resources.
 A Parking Officer must be appointed to oversee activities.
 Zones must be marked and access restricted to essential personnel only!

If the victims of the Major Incident are contaminated, or potentially contaminated with a
chemical, biological or radiological agents or materials, activate the Civil Defense Hazardous
Materials (CBRNe) Team and the HMC Ambulance Service HAZMAT Team.

Decontamination
Patient decontamination, if required, should be carried out in the Warm Zone by properly
trained personnel wearing appropriate chemical-protective clothing and respiratory equipment
(i.e. Civil Defense CBRNe Team; HMC Ambulance Service HAZMAT Team).

Refer to established protocols to:

 Determine the potential for secondary contamination and the necessity for, and extent
of, decontamination.
 Select appropriate personal protective equipment to be worn by personnel in the Warm
Zone.
 Decontaminate patients when the exposure is to an unidentified gas, liquid, or solid
material.
 Provide emergency decontamination for patients with critical injuries and illness
requiring immediate patient care or transport.
 Identify and consider crime scene related issues such as the preservation of evidence,
chain of custody, etc.

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 Sequential Critical Tasks – Contaminated Patients

Blot (if chemical)

Wet (if biological or radiological)

Remove clothing, jewelry, etc.

Shower the patient

Provide covering

Provide medical treatment

The Incident Scene

Primary Triage must be conducted at the incident scene if it is safe to do so.

 All injured victims must be rapidly triaged using the Primary Triage Ribbons (Adult &
Paediatric).
 Make certain that Triage Ribbons are applied.
 Only Basic Life Support intervention must be applied by HMC Ambulance Service
personnel during the Primary Triage, and only where and when such intervention is
deemed necessary as a life-saving procedure.
 Examples are basic airway procedures such as applying C-Collars, inserting OP Tubes and
placing patients lateral in the recovery position; also controlling exacerbated
hemorrhaging by the application of pressure bandages and tourniquets.
 No intravenous fluid resuscitation (IV therapy), Cardio-Pulmonary Resuscitation (CPR),
or any other invasive and/or labour intensive treatment is to be performed on any
patient during the Initial (PRIMARY) Triage stage.

All survivors of a Major Incident, who are uncontaminated, uninjured and require no treatment
must be directed to a safe place as soon as one is identified.

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 Survivors must undergo a Secondary Triage at the Secondary Triage Area in order to
confirm that they are uninjured.
 Following Secondary Triage, Survivors should be directed to a Survivor Reception
Centre/Area where they must all be accounted for and their personal identification and
contact details, as well as details of their relatives and/or friends, collated and
forwarded on to the relevant authorities.
 The Ministry of Interior should be responsible for establishing a central ‘Incident Contact
Centre’ for concerned families and friends to call should they wish to establish the
welfare of their relatives and/or friends.
 Arrangements should be made for Survivors to be collected or transported home from
the Survivor Reception Centre once the Ministry of Interior and relevant authorities
have obtained the necessary personal identification and contact details, details about
their relatives and/or friends, as well as any statements required about the incident (if
required and necessary at this stage).

Ambulatory (‘GREEN’ Tagged) patients must be directed to a safe place as soon as one is
identified.

 Self-treatment kits or supplies should be distributed to patients in the ‘GREEN’ section

of the treatment area.

Non-ambulatory patients (‘RED/YELLOW’ Tagged) are removed from the scene to the Treatment
Area by stretcher bearers. Ministry of Interior officers can assist in these roles, to include the
Police, Internal Security Forces (ISF) and Civil Defence as well as Military Officers (where
available).

Contaminated patients should be decontaminated prior to leaving the incident scene and
before arriving in the Treatment Area.

Deceased victims (‘WHITE’ Tagged) are left where they are found, unless they must be moved to
gain access to living patients or if the remains are in danger of being destroyed.

All incident victims must be accounted for. This includes victims who may be uninjured,
trapped, or who have been rescued or extricated.

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The Treatment Area

 Secondary Triage

‘BLUE’ coloured tarpaulins will be placed outside the entrance of the Triage Shelters for use
in designating Triage Areas. The tarpaulins are intended to be used as the initial Triage
Areas whilst the Triage Shelters are being erected and equipped. Be aware that the triage
area required will easily exceed the size of the shelters and/or tarpaulins.

Responders must expand and/or relocate the Triage Area during an incident to
accommodate increasing space requirements.

A more in-depth assessment method, known as Secondary Triage, must be conducted on all
patients arriving at the treatment area from the incident scene. Each patient will have a
HMC Ambulance Service Triage Tag applied upon their entry into the Treatment Area.

 Continual Evaluation

Patients in the Treatment Area must be continuously reevaluated (re-triaged) throughout

their stay in the treatment area.

 Designating Treatment Area Sections

Patients are placed in the Treatment Area and emergency medical care is provided on the
basis of the triage priority. If needed, separate areas may be created in the Treatment Area
for ‘RED’ Tagged, ‘YELLOW’ Tagged, and ‘GREEN’ Tagged patients. Personnel, equipment
and supplies Are allocated to patients based on their triage priority.

Designate a separate, secure and isolated area for the Incident Morgue. The Incident
Morgue is for the placement of victims who die in the Treatment Area (this area should be
secured by the Ministry of Interior not HMC Ambulance Service).

 Treatment Area Space Requirements

It is important to provide enough space between patients to allow providers room to place,
treat and move safely between patients. Each patient should have at least 1 meter of open
space on three sides of the patient as shown in Chapter 12: Casualty Management Shelters
Layout p91 (‘RED’, ‘YELLOW’ & ‘GREEN’ Treatment Shelters). ‘RED/YELLOW’ and ‘GREEN’
coloured tarpaulins will be placed outside the entrance of the Treatment Shelter for use in
designating Treatment Areas. The tarpaulins are intended to be used as the initial
Treatment Areas whilst the Treatment Shelters are being erected and equipped. Be aware
that the treatment area required will easily exceed the size of the shelters and/or tarpaulins.

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Responders must expand and/or relocate the Treatment Area during an incident to
accommodate increasing space requirements.

The Transportation Area

The NCC will notify HMC HGH Switchboard, the Nursing House Supervisors for each hospital, the
on-call SWICC Incident Commander and HMC Hospital Emergency Departments that a major
incident has been activated. The NCC will also allocate the receiving status based on the major
incident level according to the number of each category of patient.

Once the SWICC is operational it will take control of all HMC co-ordination and communication
with the NCC. The Ambulance Service will initially determine which patients will be sent to
which hospitals, as per the ‘Receiving Facility Major Incident Notification Matrix’ p102. The HMC
Ambulance Service Gold Command Centre (Goldsuite) will maintain constant contact with the
HMC SWICC to liaise on hospital coordination decisions.

The HMC Ambulance Service Gold Commander, through NCC, will contact the HMC SWICC
Liaison Officer in order to obtain bed availability information to assist with the appropriate
distribution of patients to various Emergency Departments, hospitals, and/or other medical
facilities.

Transportation resources are assigned based on Triage Priority.

Patients are moved from the Transportation Area to the appropriate vehicle by the
collecting/receiving ambulance crew.

Patients are transported to the most appropriate medical facility by the most appropriate means
available. Emergency medical care is continued en route to the hospital. At a minimum all
medical care must be documented on the HMC Ambulance Service Tag. If time and resources
allow medical care may also be documented on the Pre-hospital Patient Care Record (PCR).
Patient transports to receiving Emergency Departments are documented on the Major Incident
Patient Tracking Forms.

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Packaging Radiologically Contaminated Patients for Transport

Do not withhold lifesaving treatment from a patient solely because they are contaminated with
radiation. In this instance the rendering of life-saving treatment takes precedence over
decontamination. Unstable ALS patients requiring immediate transport can be “packaged” to
reduce the likelihood of spreading contamination to providers, the ambulance or the hospital.

A properly packaged radiologically

1. Cover ground or floor up to location of patient. contaminated patient.
2. Place two sheets on a clean (uncontaminated)
ambulance cot/stretcher.
3. Bring in the clean ambulance cot/stretcher.
4. Transfer the patient to the new ambulance
cot/stretcher.
5. Wrap one sheet around patient, then the
other.
6. Perform radiological monitoring of the
ambulance cot/stretcher and wheels to reduce
the spread of contamination.

Transportation Considerations
Clinically unstable, radiologically contaminated patients must be transported via ground
ambulance to Hamad General Hospital Emergency Department. These patients should be
packaged as outlined in the above paragraph and the receiving Emergency Department must be
notified that they will be receiving a contaminated patient.

Air ambulances will NOT transport contaminated patients of any kind. If there are any questions
as to whether or not a patient is safe to fly, consult with the pilot of the responding air
ambulance. The pilot has the final authority as to whether or not the patient will be accepted.

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Scene Layout
It is important for responders to establish an orderly flow of patients from the incident scene
through the Transport Area. The contaminated patient flow diagram shown below provides a
sample diagram of just one way to organise the scene. Ultimately the way a scene is organised
will depend on scene security and location, terrain, weather, the number of patients, and
numerous other factors.

Survivor
Reception
Centre

 Scene Diagram: Contaminated Patients

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Chapter 10: Response Plans – Command & Control

Structure
LEVEL 0

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LEVEL 1

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LEVEL 2

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LEVEL 3

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DECONTAMINATION

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Chapter 11: Response Plans – Incident Layout

LEVEL 1 - Illustration

TRIAGE SECONDARY

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LEVEL 1 – Site Plan

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LEVEL 2 - Illustration

TRIAGE
SECONDARY

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LEVEL 2 – Site Plan

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LEVEL 3 – Illustration

TRIAGE
SECONDARY

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LEVEL 3 – Site Plan

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DECONTAMINATION - Illustration

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DECONTAMINATION – Site Plan LEVEL 1

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DECONTAMINATION – Site Plan LEVEL 2

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DECONTAMINATION – Site Plan LEVEL 3

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Chapter 12: Casualty Management Shelters Layout

RED SHELTER

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YELLOW SHELTER

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GREEN SHELTER

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Chapter 13: Hospital Communications and Patient

Distribution
National Command Centre to Emergency Department Communications
During a Major Incident, routine ambulance-to-Emergency Department communications are
suspended. This means that Hamad Medical Corporation Ambulance Service will not provide
priority status messages for every Code Red patient transported from the incident scene.
Initially Goldsuite will notify the receiving Emergency Departments and hospitals of the number
and priority of patients, via the Hospital Liaison Officer (HLO). Once the HMC SWICC becomes
operational it will decide the optimal care location of Major Incident patients who require
transfer and communicate this to Goldsuite accordingly.

The early notification of Emergency Departments is vital to the preparation of the Emergency
Department to receive patients.

The HMC Ambulance Service will contact Hamad General Hospital (HGH) immediately after a
major incident has been identified. The HMC Ambulance Service must advise HGH of the
incident, incident location, the approximate number of patients, possible types of injuries
involved, and the presence or absence of chemical, biological or radiological contamination.
Once HMC SWICC is operational all HMC Ambulance Service communication will go via the
SWICC.

Early Emergency Department notification allows Emergency Departments and hospitals time to
move, release, or postpone the care of less acute patients to make room for patients arriving
from the major incident scene. It also gives the Emergency Department some time to begin
calling in additional staff members.

Patient Distribution
Following initial Major Incident notification, until the HMC SWICC becomes operational, HMCAS
will notify individual hospitals directly as to whether they are designated as a ‘Primary’,
‘Secondary’, or ‘Support’ Receiving Facility. See the table below for description of these
designations.
Hamad General Hospital (HGH) will always be designated a ‘Primary’ Receiving Facility in the
event of a major incident. Although the designation of other health care facilities will depend
largely on the size and complexity of the incident, as a guide, the general hospitals are likely to

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be designated ‘Secondary’ Receiving Facilities and all other healthcare facilities within HMC and
appropriate facilities outside HMC would be designated ‘Support’ Receiving Facilities.
Although HGH will receive the majority of the life-threatened and serious patients in a major
incident, in the event that the incident involves HGH or is of such a magnitude that HGH is at risk
of being overwhelmed, facilities designated ‘Secondary’ and ‘Support’ Receiving Facilities must
be prepared to receive life-threatened or serious patients.

 Receiving Facility Major Incident Notification Matrix

Level Anticipated Yellow Receiving Facility Patient Distribution

or Red patients Category
Primary ≤20 Red/Yellow patients.
No Green patients.
Secondary ≤4 Yellow patients1.
1 6-20
Multiple Green patients.
Support Multiple Green patients.

Primary ≤50 Red/Yellow patients.

No Green patients.
Secondary ≤10 Yellow patients1.
2 21-100
Multiple Green patients.
Support Multiple Green patients.

Primary Initially as described for Level 2.

Following consultation, HMCAS Gold
Secondary Command/SWICC may manage
3 p>100
system capacity by distributing higher
Support acuity patients to Secondary and
Support facilities as necessary.
1
Except in the event of overwhelming numbers of patients, these yellow patients will generally have
isolated injuries or pathologies that can be treated at general hospitals without Level 1
Trauma/Emergency facilities.

Coordinating Emergency Department Communication

In the early stages of the incident, SWICC will be established to coordinate coordinating all
general hospital activity to assist in dealing with the incident.

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Once SWICC has been established the coordination of activities and responsibilities involving all
general hospitals must be communicated to the HMC Ambulance Service Goldsuite via the
SWICC Communications Officer.

This information will assist the HMC Ambulance Service in determining appropriate patient
distribution requirements depending on hospital capability and capacity status.

Hospital Teams: Medical Emergency Response Incident Team (MERIT)

The Ambulance Service (Silver Commander and Silver Medical) has the responsibility within the
initial stages of the incident to determine the need for a MERIT to be mobilized to a Major
Incident.
The MERIT must consist of at least two Consultant Doctor and Senior Nurse Teams. The MERIT
staff will be collected from the Hamad General Hospital Emergency Department by the
Ambulance Service and transported directly to the scene. Upon arrival the MERIT staff must
report directly to the Bronze Doctor and will work under the command of the Ambulance
Service at all times.
Any and all communications required between the MERIT staff and the Hamad General Hospital
Emergency Department must be conducted via Silver Medic (using Silver Control) through to
Gold Command. Gold Command will then liaise with the Emergency Department on MERIT’s
behalf, and will provide the necessary feedback accordingly along the same communications
route.
The role and function of the MERIT is to provide support to Ambulance Service staff in the triage
of predominantly category ‘YELLOW’ and ‘GREEN’ patients.
The main aim of the MERIT will be to determine the disposition of certain YELLOW category
patients, to advise as to whether or not they must be transported to a ‘Primary’ receiving
hospital.
The category ‘GREEN’ patients can be assessed to determine the need for them to be taken to
an emergency department at a ‘Secondary’ or ‘Support’ receiving hospital; or to decide on any
other destinations that may be appropriately suitable alternative destinations (such as Primary
Health Care Centres).
Furthermore, the MERIT Consultant must assist in determining which patients are suitable for
assessment, possible treatment and discharge from the scene of the incident, so that they are
not transported to any healthcare facility unnecessarily.
In very rare situations a specialist Surgeon or other speciality may be required to assist in
specific treatment, such as performing an amputation. In such instances a very specific request
will be made to Hamad General Hospital, and the appropriate MERIT staff collected and
transported to the scene along with their required equipment. This will not be a standard
procedure for major incident alerts and associated requests for MERIT assistance.

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HMC Strategic Command Centre

In the event of Major Incident LEVEL 2 or Major Incident LEVEL 3 incidents the Hamad Medical
Corporation Ambulance Service (HMCAS) will establish a National Strategic Command Centre to
be located at Ambulance Headquarters.

The National Strategic Command Centre will serve as the venue for the National Strategic
Command Committee for the purposes of determining the strategy for a national health
response including the response and coordination of all health resources required.

The National Strategic Command Committee will also be responsible for arranging and
coordinating international aid as and when required.

The National Strategic Command Centre will be staffed by HMCAS Managing and Executive
Directors and possibly representation from the Ministry of Health.

The Chief Executive Officer of the HMCAS will facilitate the National Strategic Command Centre
function.

The Managing Director of Hamad Medical Corporation will Chair the National Strategic
Command Committee.

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Chapter 14: Aero-medical Operations

Introduction
The use of helicopters in Major Incident responses, although complex in nature add substantial
value and options to the management of these incidents. Their potential roles can extend
beyond just treating and transporting patients. It is important to be aware that it is possible that
not all helicopters involved in MIR’s will necessarily fulfill a medical function. These helicopters
may impact Aeromedical operations.

When establishing an airborne Major Incident response, the same key components of the
ground plan should be employed in the air. For example, all helicopters routing to the incident
should be initially responded to a holding/staging area which may not necessarily be on the
ground.

From a Command and Control perspective, the complexities and uniqueness of airborne
operations at MIR’s are best coordinated by individuals experienced in aeromedical operations.

Use of Aeromedical Resources

Aeromedical resources should be considered when any of the following requirements exist:

Minimising patient transport time from the incident to hospital

Providing or supplement Critical Care provision on scene

Requirement for rapid transport of specialised medical or command resources

Overcoming access or egress limitations to the incident

Evacuation of patients

Incident assessment

Distribution of patients

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Activation of Aeromedical Support

Authorisation is required before any helicopter fulfills any medical task at a Major Incident. The
diagram below outlines the respective individuals that are permitted to authorize the various
types of airborne resources.

RESOURCE AUTHORISING AUTHORITY

Executive Member
Senior Operational Manager (Mike Callsign)
LifeFlight
Clinical Team Leader
Incident Commander
Military Helicopters Executive Member
SOM: Special Services
Civilian Helicopters Executive Member

Military and Civilian helicopters will still require internal authorization from their respective
services.

Communications
Communications are of paramount importance, not only from a safety perspective but also to
ensure effective and efficient airborne operations. The ability to communicate can vary from
being able to maintain two way traffic (e.g. LifeFlight) to communication being limited to a
message before takeoff with no ability to contact the aircraft during flight to send information
updates.

As a result, all airborne resources should be aware of the various radio frequencies in use for the
incident and the different forms of communication that will be used. In addition, at dispatch, all
airborne resources should be advised of any particular routing, reporting points and helicopter
operating sites in use.

Aircraft and National Command Centre

Communications between LifeFlight and the NCC will be on the AirMed 1 channel. It is difficult
to change frequencies in the aircraft, therefore it is best that a single frequency is used to
ensure adequate flight following.

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Aircraft and Air Traffic Control

Whilst in controlled airspace, the pilot/s will remain in contact with Air Traffic Control. In Qatar
the vast majority of the airspace at the lower heights is uncontrolled necessitating co-ordination
between pilots.

Aircraft to Aircraft

With multiple aircraft operating at an incident an operational (air to air) frequency should be
established. This frequency will be in the aviation band and all airborne resources responding
should be advised of the frequency. As a dedicated frequency is yet to be assigned, the first
arriving pilots can assign a frequency provided it does not impact any other aviation frequency.

Aircraft and the Operating Site/ Landing Zone

Communications between the operating site and LifeFlight will be achieved over the Airmed 1
frequency. Communications with non-company traffic are best accomplished via hand signals or
use of the airband frequency.

Airspace Restrictions
The LifeFlight pilot will be able to assist on whether an incident is in a Restricted or Dangerous
Area. In addition, Air Traffic Control and/ or the QCAA may assign the area around the MIR as a
temporary restricted flying zone.

Weather Restrictions
Adverse weather conditions can ground helicopter operations. In addition, weather conditions
must be above the minimum required levels for flight for the entire flight i.e. clear weather at
the scene and poor weather enroute may prohibit helicopter involvement. As a general rule,
LifeFlight requires 2km visibility to operate during the day and 5 km at night. The pilots will
advise whether current weather conditions are suitable for flight.

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Landing Zones/ Helicopter Operating Sites

In addition to the standard helipad requirements (size 30 metres by 30 metres, flat, free of
obstructions and debris and upwind of a Major Incident) the following should also be
considered.

One landing zone is required per helicopter on the ground at any one time i.e. if only 2
landing zones are available; only 2 helicopters may land at any one time. Additional
helicopters may remain airborne until such time as a landing zone becomes available.

Access to the landing zones by medical teams shall be limited. A holding area for
patients should be established near the landing zone, with due consideration for the
effects of the aircraft downdraft on patients. Patients should be readied for flight prior
to arrival of the aircraft.

The Landing Zone Officer is responsible for coordinating all movement around the
landing zone.

Hospital Landing Zones

It is important to note that none of the hospital helipads currently in use have direct access to
the emergency room/ trauma unit and none are capable of accommodating multiple aircraft
simultaneously. As a result there is an additional step in the transfer process and reliance on
ground based units. In order to mitigate a possible backlog of patients proactive attempts
should be made to ensure that measures are in place to accommodate them. One solution to
ensure a rapid turnaround time of airborne resources is to request deployment of hospital staff
to the various helipads for patients to be endorsed by the flight crew on the helipad.

At Hamad General Hospital two (2) helipads currently exist.

GPS co-ordinates
GPS Co-Ordinates provide the ability to route an aircraft to an incident as soon as it is deemed
suitable to use air resources. They should be provided to everyone in a common format. Landing
Zones should be assigned names to limit confusion.

Patient destinations
Due to the ability to almost always fly in a straight line, coupled with the speed at which they fly
at, helicopters can be used to bypass closer hospitals and deliver patients to hospitals that are
further away, thereby distributing the patient load. The Clinical Team Leader is responsible for
determining, distributing and advising receiving hospitals of patients.

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Chapter 15: Production Services

Production Department
In the event of a Major Incident the role of the Production Department is to provide and set-up
all shelters and equipment required as part of the Predetermined Attendance (PDA) as well as
resourcing any additional staff, equipment, drugs, disposable blankets, medical gasses and
consumables as requested by the on scene commander. In addition, production staff may have
to liaise closely with suppliers and procurement to place emergency orders and ensure stocks
are replenished.
In the event of a prolonged incident, the department will arrange refreshments for operational
staff.

Preparedness
The Production Directorate fulfils a critical role in preparedness for any Major Incident.
Responsibilities include:
 Training all HMC Ambulance Service staff according to MIR training plan and assist in
facilitating any simulated incident drills.
 Ensure operational units (Alpha, Delta and Oscar) and Mike units have an appropriate
Triage pack.
 Serviceability and stock currency of all MIR vehicles (Green buses, multi-patient
ambulances, MIR trucks and containers).
 Store and maintain all MIR technical equipment.
 Prepare a reserve pool of ambulances, equipment and disposables to cope with the
initial phases of any MIR.
 Maintain a call out plan and process to increase staff numbers or relieve staff during an
MIR.

Initial Actions of Production

Upon the declaration of a Major Incident the following actions should be undertaken by the
production directorate:

 The PDA will require the dispatch of the closest Green Bus and Major Incident Unit to
any potential multiple patient incident.
 The Management Notification Process (MNP) will be followed when a Major Incident is
activated: Silver Command requests Mike Papa to be informed. Mike Papa will inform
the following:
 Stores Manager

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 Senior Production Manager

 Scheduling Manager
 Production Supervisors at relevant hubs are informed to prepare and dispatch the Major
Incident Truck/s to scene.

At the incident:

 Set up the Triage ‘SORT’ Shelter.

 Set up the CODE ‘RED’ Casualty Management Shelter according to the ‘RED’ shelter
layout plan.
 Set up the CODE ‘YELLOW’ Casualty Management Shelter according to the ‘YELLOW’
shelter layout plan.
 Set up the Casualty Loading Shelter.
 Set up the CODE ‘GREEN’ Casualty Management Shelter according to the ‘GREEN’
shelter layout plan.
 Set up the Survivor Reception Centre.
 Set up the CODE ‘WHITE’ Temporary Mortuary.
 Set up the AS Staff Rehabilitation shelter during protracted incidents.
 Additional water supply prepared and transported to scene from HQ.

The Stores Manager is responsible for activating additional Ambulance Assistants and arranging
additional stores for the following activities:
 2 additional AA to HGH to assist in make ready and turn-around times
 Packing of additional pre-packs (according to incident type) and to meet regular
demand.
 Preparation and transport of additional pool units to HGH as required
 Deep cleaning and pool unit turn around at stores.
 Dispatching additional supplies as per the Bronze Production on scene

The Scheduling Manager will confirm with Silver Command if additional staff are required and
will activate the call out process (developed with communication). For long duration Major
Incidents the shift change process will be activated to relieve staff on duty.

 Deploy all required Major Incident Units.

 Deploy all required Green Buses.
 Prepare all triage packs for distribution.
 Prepare all spinal immobilization boards for distribution.

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Ongoing Actions of Production

 Maintain adequate supplies of all medical equipment and supplies required to keep
equipment boxes fully replenished at all times.
 Maintain adequate supplies of additional equipment and supplies required such as
blankets, water, hazardous waste containers, fuel for generators, etc.
 Provide refreshments for HMC Ambulance Service personnel to include water and food
for prolonged incidents.
 Arrange provision of additional ambulance staff and units as required both for the major
incident as well as routine business.
 Maintain adequate emergency lighting as and when required.
 Bronze Production on scene will request the activation and establishment of a staff
refreshment and rest area for prolonged scene times (in consultation with Silver
Command).
 Silver Command will request through Gold Production for the activation of required
mutual aid support services in the event these are required.

Closure Actions of Production

Following the termination of the Major Incident by the Silver or Gold Command the production
directorate is responsible for:

 Clearing the scene including packing up the treatment areas, collecting all unused
medical equipment and disposables and returning all to the stores department.
 The Stores Department is responsible for the following in order:
 Deep cleaning and restocking operational Alpha units to restore
operational capacity to normal.
 Cleaning and restocking Green Buses and return to designated Hub.
 Cleaning and restocking the MIR Units and return to designated Hub.
 Cleaning and restocking the Major Incident trucks and containers.
Checking all treatment shelters for damage and cleanliness, preparing
all pre-packed treatment boxes and cleaning all MIR stretchers. All
equipment is packed into the MIR containers, which are then returned
to their designated Hub.

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Incident Control, Roles and Responsibilities

The on-call Senior Production Manager will have overall responsibility for co-ordinating the
Production response. The on-call Senior Production Manager will continue to have overall
responsibility until the Director of Production takes charge (for LEVEL 2 & 3 incidents). The
Production Managers in Charge of the Production Department will delegate tasks to relevant
Production staff as necessary.
For LEVEL 2 and LEVEL 3 incidents the Director of Production will report to the Gold Command
Suite.

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 Production Major Incident Response Flowchart

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Chapter 16: Post Incident Activities

Operational Activities
Post incident, HMC Ambulance Service will ensure that staff have access to appropriate
support and welfare services. We also have a duty to ensure that operational procedures
are carried out to restock and maintain the fleet. Debriefing is a very important process
in order for the HMC Ambulance Service to gain from lessons learnt, make
recommendations for change to our partners and adapt service protocols if needed. It is
therefore the Specialised Emergency Management Department who have the
responsibility on behalf of the Gold Commander to organise, chair and administer Major
Incident debriefs - monitoring the progress of actions as necessary.

Post incident the HMC Ambulance Service has a responsibility to ensure that the
following procedural and administrative activities are carried out:

• A "hot debrief" immediately after the incident chaired by the Silver Commander
and to include the circulation of welfare information
• The re-stock of HMC Ambulance Service resources including control rooms, Major
Incident vehicles, and operational vehicles
• "Stand down" time for all HMC Ambulance Service staff involved
• Feeding of staff where necessary
• The collation of all paperwork and voice recordings to form a primary transcript
record
• All members of staff receive a debrief pro-forma
• All operational and NCC command officers to submit a report to the Specialised
Emergency Management Department
• An internal HMC Ambulance Service NCC debrief
• An internal HMC Ambulance Service Major Incident debrief
• Lessons learnt and debrief actions to be allocated

Debriefing
The HMC Ambulance Service internal debriefing process should be followed at an early
opportunity by a joint medical service debrief involving representatives from all the
medical organisations involved in the incident. The joint medical service debrief should
be organised by the HMC Ambulance Service who should also supply the Chair and
secretarial support.

Information gathered from these debriefings can then be presented where appropriate,
to the Joint Services debriefing, usually organised by the Ministry of Interior. This will
review the response overall, identify any lessons learnt and any revision required to the
existing plans.

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It must be remembered that the notes taken at debriefing sessions are essential for
inclusion in incident reports for recording purposes and may potentially be useful as
learning points that can be included in corrective action plans.

Post Traumatic Activities

Post incident HMC Ambulance Service will give due consideration to staff's psychological
needs after exposure to a potentially traumatic incident. The use of peer support is good
practice and should be encouraged for those who need support after an incident. HMC
Ambulance Service HR/welfare services will coordinate the support of staff post incident.

Peer Support (Listening, Informal, Non-judgemental, Confidential peer

support)
Peer support is a network for all and is an integral part of staff support. It is therefore
particularly relevant following a Major Incident.
The aim of peer counseling is to promote physical, psychological and emotional well-being
of staff. The scheme is there to support any member of staff. This is regardless of gender,
age, ethnicity, disability, religion, culture, sexual orientation, role within the service, or rank.
Peer support provides a confidential listening service.
Peer support workers are not trained counsellors and do not aim to ‘solve’ all situations.
They are there to listen, support and if necessary advise on other relevant sources of help.

 Trauma Risk Management

Some incidents in which staff are involved can be distressing regardless of previous
experience. It can help to talk the experience through and normalise reactions to such
incidents. Peer support workers are available to support staff following an incident, either
by listening or meeting in the role of a Trauma Risk Management practitioner.

Recovery from Major Incident

• Consider early release of operational staff and vehicles from scene if near to “scene
evacuation complete” declaration.
• Amalgamate resources if multi-site incident is near to closure for the HMC Ambulance
Service on scene.

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• The Production Department to view in collaboration with the Gold Commander, rota
changes due to core cover versus incident cover.
• Service Business Continuity Plan to be viewed in relation to return to normality through
the whole of the HMC Ambulance Service.
• Welfare aspects of all staff to be viewed in regard to what action to take over the
following days/weeks.
• Hot de-brief actions to be implemented.
• Service de-brief dates to be viewed in collaboration with other supporting agencies and
Emergency Service partners.

Staff Clinic

Post incident personnel that have been referred by a peer support worker will initially be
offered a professional counseling service through the staff clinic.
In the event that the HMC Ambulance Service peer support worker system is saturated post
incident, the staff clinic will instigate a support system for the “debriefing” of staff.

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Appendix A: Major Incident Pre-determined Attendance

(PDA)
For a LEVEL 0 Response – Deploy all resources as per the following sheet
and put listed resources on standby:-

LEVEL 0 – RESOURCES DISPATCHED

HMCAS OFFICERS Qty HMCAS RESOURCES Qty
Operations Officer (Access) X1 Alpha Units X6
Operations Officer (Effectiveness) X1 Charlie Units X1
Delta Units X1
MIR Level 0 Resources: X1
 MIR Unit Set
 Logistics Unit
 CBRNe Unit (if required)
**MIR Level 1 Resources instead of X1
Level 0 if: Set
 NEARER to scene
 Major Incident Standby
Green Bus X1
LifeFlight (Dispatch Zone Dependent) X1
MUTUAL AID OFFICERS Qty MUTUAL AID RESOURCES Qty
NONE NONE
LEVEL 0 – RESOURCES ON STANDBY
HMCAS OFFICERS Qty HMCAS RESOURCES Qty
Silver Tactical X1 Alpha Units X3
Bronze Tactical Forward X1 Charlie Unit X1
Bronze Tactical Advisor (SEM) X1 Delta Unit X1
Bronze 1 X1 PTS Units X2
Silver Communications X1 Command and Control Unit X1
Bronze Aeromedical ( if x2 LF X1 LifeFlight X1
helicopters Activated) MIR Level 1 Resources: X1
 MIR Container Set
 LOGISTICS Container
 CBRNe Container (if required)
MUTUAL AID OFFICERS Qty MUTUAL AID RESOURCES Qty
None Civil Defence Water Tanker if a CBRNe X1
incident is reported. (Dispatch Process)

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For a LEVEL 1 Response – Deploy all resources as per the following sheet
and put listed resources on standby:-

LEVEL 1 – RESOURCES DISPATCHED

HMCAS OFFICERS Qty HMCAS RESOURCES Qty
Senior Operations Manager X1 Command & Control Unit X1
Operations Manager (Communications) X1 Alpha Units X12
Operations Officer (Access) X1 Mass Casualty Ambulance Units X2
Operations Officer (Effectiveness) X1 Charlie Units X2
Prod. Supervisors (ALO – Romeo) HGH X2 Delta Units X2
Production Manager (Stores) X1 Green Buses X2
CCP Managers (incl. Consultant PM) X2 LifeFlight X1
Major Incident Unit MCI Container X1
Major Incident Unit Logistics Container X1
MUTUAL AID OFFICERS Qty MUTUAL AID RESOURCES Qty
NONE NONE
LEVEL 1 – RESOURCES ON STANDBY
HMCAS OFFICERS Qty HMCAS RESOURCES Qty
Director (Access) X1 Alpha Units X6
Director (Communications) X1 Charlie Unit X1
Operations Manager (Access) X1 Delta Unit X1
Operations Manager (Effectiveness) X1 PTS Units X4
Operations Manager (Communications) X1 CCPs (Effectiveness) Off-duty X6
Delta Supervisor (Access) X1

MUTUAL AID OFFICERS Qty MUTUAL AID RESOURCES Qty

None Red Crescent Ambulances X4
ISF Ambulances X2
QP Ambulances X2

** As long as the number of casualties exceeds the number of ambulances on scene (at the
parking area), always maintain the minimum number of ambulances at the parking area. **
 deploy mutual aid ambulance resources to backfill shortfalls;
 re-deploy HMCAS ambulances assigned to the Major Incident once they become
‘AVAILABLE’ at hospital.

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For a LEVEL 2 Response – Deploy all resources as per the following sheet
and put listed resources on standby:-

LEVEL 2 – RESOURCES DISPATCHED

HMCAS OFFICERS Qty HMCAS RESOURCES Qty
Director SILVER (Access) X1 Command & Control Units X2
Senior Operations Managers X2 Alpha Units X24
CCP Managers (incl. Consultant PM) X4 Mass Casualty Ambulance Units X4
Operations Managers (Comms) X2 Charlie Units X4
Operations Officers (Access) X2 Delta Units X3
Operations Officers (Effectiveness) X2 Green Buses X4
Delta Supervisors (Access) Off-duty X8 LifeFlight X2
Production Managers (Stores) X2 Major Incident Unit MCI Containers X2
Production Supervisors (Incident) X4 Major Incident Unit Logistics Container X2
Chief Executive Officer (CEO) X1 CCPs (Effectiveness) Off-duty X8
Chief Operations Officer (GOLD Comm) X1 PTS Units X4
Director COMMS (Goldsuite) X1
MEDICAL Director (Goldsuite) X1
Director PRODUCTION (Goldsuite) X1
Director BUSINESS SERVICES (Goldsuite) X1 MUTUAL AID RESOURCES Qty
Supervisor (ALO – Romeo) Al Wakra X1 Red Crescent Ambulances X8
Supervisor (ALO – Romeo) Al Khor X1 ISF Ambulances X4
MUTUAL AID OFFICERS Qty ISF Mass Casualty Ambulance X1
Bronze Officer from each agency X1 QP Ambulances X4
LEVEL 2 – RESOURCES ON STANDBY
HMCAS OFFICERS Qty HMCAS RESOURCES Qty
Operations Manager (Comms) X1 Alpha Units X12
Delta Supervisors (Access) X3 Charlie Units X2
Operations Officer (Access) X1 Delta Units X2
Operations Officer (Access) Off-duty X4 PTS X12
Operations Officer (Effect.) Off-duty X4 Major Incident Unit MCI Container X2
CCPs (Effectiveness) Off-duty X12 Major Incident Unit Logistics Container X2
CCPs (Effectiveness) Off-duty X12 LifeFlight X1
MUTUAL AID OFFICERS Qty MUTUAL AID RESOURCES Qty
Bronze Officer from each agency X1 Red Crescent Ambulances X4
ISF Ambulances X2
ISF Mass Casualty Ambulance X1
QP Ambulances X2
Military Ambulances X2
Karwa Buses X2
Hems (Helicopter) QP X1

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For a LEVEL 3 Response – Deploy all resources as per the following sheet
and put listed resources on standby:-

LEVEL 3 – RESOURCES DISPATCHED

HMCAS OFFICERS Qty HMCAS RESOURCES Qty
Director SILVER (Access) X1 Command & Control Units X3
Senior Operations Managers X3 Alpha Units X36
CCP Managers (incl. Consultant PM) X8 Mass Casualty Ambulance Units X4
Operations Manager (Comms) X3 Charlie Units X5
Operations Officer (Access) X4 Delta Units X5
Operations Officers (Effectiveness) X4 Green Buses X6
Delta Supervisors (Access) Off-duty X12 LifeFlight X2
Production Managers (Stores) X2 Major Incident Unit MCI Containers X3
Production Supervisors (Incident) X6 Major Incident Unit Logistics Container X3
Chief Executive Officer (CEO) X1 CCP’s (Effectiveness) Off/Duty X18
Chief Operations Officer (GOLD Comm) X1 PTS Units X8
Director COMMS (Goldsuite) X1 MUTUAL AID RESOURCES Qty
Medical Director (Goldsuite) X1 Red Crescent Ambulances X12
Director PRODUCTION (Goldsuite) X1 ISF Ambulances X6
Director BUSINESS SERVICES (Goldsuite) X1 ISF Mass Casualty Ambulances X2
Supervisor (ALO – Romeo) Al Wakra X1 QP Ambulances X6
Supervisor (ALO – Romeo) Al Khor X1 Military Major Incident Ambulance X1
MUTUAL AID OFFICERS Qty Karwa Buses X4
Bronze Officer from each agency X1 Hems (Helicopter) QP X1
LEVEL 3 – RESOURCES ON STANDBY
HMCAS OFFICERS Qty HMCAS RESOURCES Qty
Operations Manager (Comms) X1 Alpha Units X12
Operations Officer (Access) Off-duty X6 Charlie Unit X1
Operations Officer (Effect.) Off-duty X6 Delta Unit X1
Delta Supervisors (Access) Off-duty X6 PTS X4
Major Incident Unit MCI Container X1
Major Incident Unit Logistics Container X1
LifeFlight X1
CCPs (Effectiveness) Off-duty X12
MUTUAL AID OFFICERS Qty MUTUAL AID RESOURCES Qty
Bronze Officer from each agency X1 Red Crescent Ambulance X4
ISF Ambulance X2
QP Ambulance X2
Military Ambulance X2
Military Major Incident Ambulance X1
Karwa Buses X2

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Appendix B: Major Incident Action Cards/Job Checklists

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Appendix C: Pre-hospital Major Incident Forms

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Appendix D: Major Incident Resource Distribution

Associate with HUBs

CALL SIGN LOCATION

MIR 4.1 Abu –Baker HC
HAZMAT 4.1 (Honda Pilot) Hub 4
MIR 2.1 Hub 2
MIR 6.1 Hub 6
T-HAZMAT 5 Mesameer H/C
T- MIR 5 Mesameer H/C
T- Logistics 5 Mesameer H/C
Greenbus 0 New Hub 1

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Appendix E: Major Incident Resource Inventory List

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Appendix F: Glossary
AMBULANCE CONTROL POINT:
A point at which a specially equipped vehicle (Command & Control) is sited, at the scene of a
Major Incident, to operate as an Ambulance and or Medical Control Point. It provides a
reporting, co-ordinating and communications centre for ambulance, medical, nursing and
voluntary aid personnel. This point will be established in close proximity to the Police and Fire
Service Control vehicles subject to radio interference constraints.
AMBULANCE EQUIPMENT OFFICER:
An Officer responsible for the mustering, issue and collection of all patient care equipment on
site. He/she will maintain control of the Emergency Support Vehicle’s equipment and will
replenish on site stocks as necessary. He/she will direct, in liaison with the Silver Commander,
the on-site distribution of stretcher bearers assembled at this point.
AMBULANCE FORWARD INCIDENT OFFICER:
An Officer who, under the direction of the Silver Commander, co-ordinates health care
resources at Forward Control Point(s).
AMBULANCE SILVER COMMANDER:
The Officer in overall control of Ambulance operations at the site.
AMBULANCE LIAISON OFFICER (ALO):
An Officer responsible for providing liaison with ambulance crews and hospital receiving staff
from a Major Incident. The officer is based at the hospital.
AMBULANCE LOADING OFFICER:
An Officer responsible for the management of the Ambulance Loading Point. He/she will ensure
that casualties are documented and evacuated in priority order. He/she will maintain control
over vehicle access/egress and personnel operating within this area.
AMBULANCE LOADING POINT:
An area, preferably on hard standing and in close proximity to the Casualty Clearing Station,
from where casualties are evacuated in order of priority.
AMBULANCE PARKING OFFICER:
An Officer responsible for the management of the Ambulance Parking point. He/she will direct
vehicles and staff forward to the Ambulance Loading Point as required.
AMBULANCE PARKING POINT(s):
Point(s) designated at the scene of a Major Incident where incoming Ambulance resources
report and are held in readiness for forward deployment, thus avoiding congestion at the
entrance to the site or at the Ambulance Loading Point.
AMBULANCE SAFETY OFFICER:
An officer appointed to ensure the safety of all AS & medical staff working within the incident
boundary and that they are correctly dressed in PPE.
AMBULANCE TACTICAL ADVISOR:
An Emergency Planning Advisor appointed to assist and advise the Silver Commander on Major
Incident protocol.

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CASUALTY CLEARING OFFICER:

An Ambulance Officer who, in liaison with the Medical Incident Officer, supervises
assessment/labeling of casualties for evacuation in accordance with triage priorities.
CASUALTY CLEARING STATION:
An area set up at a Major Incident by the Ambulance Service in liaison with the Slver Medical
Commander to assess, treat and triage casualties and direct their evacuation.
CASUALTY EVACUATION COMPLETE:
Term used to indicate that treatment and removal of casualties from the scene is complete.
CBRNe:
Chemical, Biological, Radiological, Nuclear & explosive incidents.
COLD ZONE:
The control zone for a hazardous materials incident; contains the Incident Command Post and
other incident support facilities. Also referred to as the clean zone or support zone.
CO-ORDINATING GROUP:
The Gold/Silver Commanders of the emergency services who convene to consider/review
strategy/tactics relating to the co-ordination of activity at a Major Incident.
COMMAND:
The act of directing, ordering, or controlling by virtue of explicit statutory, regulatory, or
delegated authority.
COMMAND STAFF:
(Officer) In an incident management organisation, the Command Staff consists of the Incident
Commander and the special staff positions of Public Information Officer, Safety Officer, Liaison
Officer, and other positions as required, who report directly to the Incident Commander. They
may have an assistant or assistants, as needed.
COMMUNICATIONS UNIT:
An organisational unit in the Communications Department responsible for providing
communication services at an incident or an EOC. A Communications Unit may also be a facility
(e.g., a trailer or mobile van) used to support an Incident Communications Centre. .
CRITICAL CARE TRANSPORT:
An ambulance transport of a patient from a scene or a clinical setting whose condition warrants
care commensurate with the scope of practice of a Critical Care Paramedic, a qualified physician
or registered Intensive Care Nurse (e.g., capable of providing advanced airway techniques, use
of ventilators, hemodynamic support & monitoring, infusion pumps, advanced skills, therapies,
and techniques).
EMERGENCY CONTROL VEHICLE (ECV):
Specially equipped communications vehicle sited at the scene of a Major Incident to operate as
the Ambulance Control Point.
EMERGENCY OPERATIONS CENTRE:
Operations Console/Room which receives, collates and co-ordinates all demands for the
Emergency Service in the geographical area covered by the Ambulance Service and allocates
resources accordingly.

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EMERGENCY SUPPORT VEHICLE (ESV):

Vehicle equipped with specialist patient care equipment, Major Incident stocks of stretchers,
blankets, patient care backpacks, inflatable tents, emergency lighting etc.
EQUIPMENT/STRETCHER BEARER POINT:
Point where bulk supplies for First Aid equipment, blankets and stretchers are available. Point
where able-bodied persons are assembled to assist with the on-site transfer of casualties by
stretcher, to the Casualty Clearing Station or the Ambulance Loading Point.
ESTIMATED TIME OF ARRIVAL (ETA):
The estimated time it will take for a unit (vehicle), Officer, staff member, equipment or patient
to arrive at a destination.
FORWARD AMBULANCE CONTROL POINT:
A selected point, near or at the scene, where the Silver Commander/Forward Incident Officer
can direct the operation. There may be a requirement for more than one Forward Control.
Forward Control(s) will maintain a communications link with the Ambulance Control Point.
FORWARD CONTROL TEAM:
A radio operator trained member of NCC staff who assists the command team with radio
communications and records the Silver Commander log.
FUNCTION:
Function refers to the five major activities in an Incident Command System: Command,
Operations, Planning, Logistics, and Finance/Administration. The term function is also used
when describing the activity involved, e.g., the planning function. A sixth function, Intelligence,
may be established, if required, to meet incident management needs.
GENERAL STAFF:
A group of incident management personnel organized according to function and reporting to
the Incident Commander. The General Staff normally consists of the Medical Sector
Commander, the Operations Sector Commander, the Support Sector Commander, and
Hazardous Operations Sector Commander.
HOSPITAL LIAISON OFFICER (HLO):
An officer responsible for providing liaison with the hospital control team staff during a Major
Incident. The officer is based at the hospital.
HOT ZONE:
The area that immediately surrounds a CBRNe incident; normally extends out in a 360 degree
radius around the incident scene and far enough to prevent adverse effects from hazardous
materials release to personnel outside the zone. Also referred to as the exclusion zone or
restricted zone.
INCIDENT ACTION PLAN (IAP):
An oral or written plan containing general objectives reflecting the overall strategy for managing
an incident. It may include the identification of operational resources and assignments. It may
also include attachments that provide direction and important information for management of
the incident during one or more operational periods.

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INCIDENT COMMAND POST (ICP):

The field location at which the primary tactical-level, on-scene incident command functions are
performed. The ICP may be located with the incident base or other incident facilities and is
normally identified by a green rotating or flashing light.
INCIDENT COMMAND SYSTEM (ICS):
A standardised on-scene management construct specifically designed to provide for the
adoption of an integrated organisational structure that reflects the complexity and demands of
a single or multiple incidents, without being hindered by jurisdictional boundaries. ICS is the
combination of facilities, equipment, personnel, procedures, and communications operating
within a common organisational structure, designed to aid in the management of resources
during incidents. It is used for all kinds of emergencies and is applicable to small as well as large
and complex incidents. ICS is used by various jurisdictions and functional agencies, both public
and private, to organise field-level incident management operations.
INCIDENT COMMANDER (IC):
The individual responsible for all incident activities to include the development of strategies and
tactics and the ordering and the release of resources. The IC has overall authority and
responsibility for conducting incident operations and is responsible for the management of all
incident operations at the incident site.
INNER CORDON:
Surrounds the immediate scene and provides security for it.
JOINT EMERGENCY SERVICES CONTROL CENTRE (JESCC):
The point from which the management of the incident is controlled and co-ordinated. All
Emergency Services are represented at this location.
LIAISON OFFICER:
A member of the Command Staff responsible for coordinating with representatives from
cooperating and assisting agencies..
LINC WORKER:
Listening, Informal, Non-judgmental, confidential peer support.
LOCAL AUTHORITY EMERGENCY PLANNING OFFICER:
Co-ordinator of a local authority’s response to Major Incidents etc.
MAJOR INCIDENT:
Major Incidents are incidents which present a serious threat to the health of the community
and/or cause disruption to the service by becoming protracted in their management, either as a
result of their size and/or complexity, or by exceeding or overwhelming the capabilities of the
Ambulance Service and hospitals.
MAJOR INCIDENT CANCELLED:
The term used to cancel a Major Incident Alert.
MAJOR INCIDENT DECLARED – ACTIVATE PLAN:
The term used to prefix messages to confirm a Major Incident.

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MAJOR INCIDENT STANDBY:

The term used to prefix messages indicating that an incident may have or has occurred which
could result in a large number of casualties.
MARSHALLING AREA:
Area to which resources and personnel not immediately required at the scene, or being held for
further use, can be directed to stand by.
MASS CASUALTY INCIDENT:
An incident resulting from man-made or natural causes resulting in injuries that exceed or
overwhelm the Ambulance Service and hospital capabilities of a locality, jurisdiction or region. A
mass casualty incident is likely to impose a sustained demand for health and medical services
rather than a short, intense peak demand and for these services typical of multiple casualty
incidents.
MEDIA CENTRE:
Central contact point for media enquires, providing communication and conference facilities
and staffed by spokespersons from all agencies involved.
MEDIA LIAISON OFFICER:
Officer responsible for the initial release of information from the scene of the incident and
liaison with other Services at the Medical Centre.
MEDIA LIAISON POINT:
Rendezvous and initial holding area, at or near the scene, designated for use by accredited
media representatives prior to establishment of a media centre.
MEDICAL INCIDENT OFFICER (MIO):
The medical officer with overall responsibility, in close liaison with the Silver Commander, for
the management of the medical resources at the scene of the Major Incident. He/she should not
be a member of any mobile team.
MOBILE EMERGENCY RESPONSE INCIDENT TEAM (MERIT):
A medical team who will attend the incident site to assist the triage and treatment of casualties.
The ambulance service will alert and organise transportation for the team to the incident site.
MULTIPLE CASUALTY INCIDENT:
An incident involving multiple victims that can be managed, with heightened response (including
mutual aid, if necessary), by a single ambulance service agency or system. Multi-casualty
incidents typically do not overwhelm the hospital capabilities of a jurisdiction and/or region, but
may exceed the capabilities of one or more hospitals within a locality. There is usually a short,
intense peak demand for health and medical services, unlike the sustained demand for these
services typical of mass casualty incidents.
NATIONAL COMMAND CENTRE (NCC):
Multi-agency Emergency Communications Centre including Ambulance Service Emergency
Communications.
OUTER CORDON:
Seals off an extensive area to which unauthorised persons are not allowed access.

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OPERATIONS SECTION:
The section responsible for all tactical incident operations. In the Incident Command System this
section will normally include subordinate departments, sections, and/or units.

PERSONNEL ACCOUNTABILITY:
The ability to account for the location and welfare of incident personnel. It is accomplished
when supervisors ensure that ICS principles and processes are functional and that personnel are
working within established incident management guidelines.
POST TRAUMATIC STRESS DISORDER (PTSD):
Stress caused as a direct result of a traumatic event causing both physical and psychological
symptoms.
PRIMARY TRIAGE OFFICER:
Officer responsible for the co-ordination of the triage sieve of casualties at the incident site.
PRODUCTION:
Providing resources and other services to support incident management.
PRODUCTION SECTION:
The Section responsible for providing facilities, services, and material support for the incident.
PUBLIC INFORMATION OFFICER (PIO):
A member of the Command Staff responsible for interfacing with the public and media or with
other agencies with incident-related information requirements.
RECEIVING HOSPITAL:
Any hospital listed as having facilities to receive and treat patients who are seriously injured or
critically ill resulting from a Major Incident, on a 24 hour basis. Should have facilities for
provision of Bronze Doctor and MERIT at request of ambulance service.
RENDEZVOUS POINT(S):
A point usually nominated by the Police, as a safe area to which all vehicles and personnel must
report before proceeding to the incident site or parking points. A Rendezvous Point (RVP) will
generally be identified at any high risk location for the initial mustering of Emergency Service
Vehicles (Airport, COMAH site etc.).
SAFETY OFFICER:
A member of the Command Staff responsible for monitoring and assessing safety hazards or
unsafe situations and for developing measures for ensuring personnel safety.
SECONDARY TRIAGE OFFICER:
Officer responsible for the triage sort of casualties at the Casualty Clearing Station.
SECTOR:
(Commander) The organizational level having responsibility for a major functional area of
incident management, e.g., Medical, Operations, Support, Hazardous Operations. The sector is
organizationally placed between the tactical level (Bronze) and the Incident Command.

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SIEVE (PRIMARY) TRIAGE:

The initial prioritisation of casualties in respect of their injuries right where the patients lay (are
found) on scene. On this basis an effective casualty evacuation plan will be implemented.
SORT (SECONDARY) TRIAGE:
The second stage in the prioritisation of casualties in respect of their injuries, completed at the
Casualty Clearing Station. This is a more comprehensive assessment of each casualty and
becomes the first step in the treatment of patients.
SPAN OF CONTROL:
The number of individuals a supervisor is responsible for, usually expressed as the ration of
supervisors to individuals. (Under the National Incident Management System (NIMS), an
appropriate span of control is between 1:3 and 1:7).
STAGING AREA:
Location established where resources can be placed while awaiting a tactical assignment. The
Operations Section manages Staging Areas.
SURVIVORS RECEPTION CENTRE (SRC):
Secure premises to which those who have been directly involved in the incident and are
uninjured can be taken.
TRANSPORT UNIT:
An ambulance capable of transporting patients from the scene. Minimum staffing will be at least
two Basic Life Support (BLS) qualified staff one of which is released as an Attendant In Charge.
TRIAGE:
The prioritising of casualties in respect of their injuries. On this basis an effective casualty
evacuation plan will be implemented.
TRAUMA CENTRE:
A specialised hospital facility distinguished by the immediate availability of specialised surgeons,
physician specialists, anaesthesiologists, nurses, and resuscitation and life support equipment
on a 24-hour basis to care for severely injured patients or those at risk for severe injury.
TRiM:
Trauma Risk Management Scheme offered to staff via the Peer Support Worker scheme.
WARM ZONE:
Area where personnel and equipment decontamination and hot zone support takes place;
includes control points for access corridor. Also referred to as the decontamination,
contamination reduction, or limited access zone.
WEAPONS OF MASS DESTRUCTION (WMD):
Weapons that can kill and bring significant harm to a large number of humans and/or cause
great damage to man-made structures (e.g. buildings), natural structures (e.g. mountains), or
the biosphere (sum of all ecosystems) in general.

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Appendix G: References
1. Southwest Virginia Emergency Medical Services (EMS) Council, January 2011.
Southwest Virginia Mass Casualty Incident Response Guide.
Southwest Virginia EMS Council, Inc., 306 Piedmont Avenue, Bristol, VA 24201.
https://www.southwest.vaems.org

2. Emergency Preparedness Unit, December 2007.

Major Incident Plan, “Preparing the LAS for incident response”.
London Ambulance Service NHS Trust, 18-20 Pocock Street, London, SE1 OBW.
https://www.londonambulance.nhs.uk/

3. Special Operations and Mass Casualty Planning Unit.

State Major Incident & Disaster Plan.
Queensland Ambulance Service, GPO Box 1425, Brisbane, 4001 Qld, Australia.
https://ambulance.qld.gov.au/

4. Lee Waller & Joe Cuthberston, September 2011.

PST3210 Pre Hospital Perspectives in Emergency Management, Module 5 Notes –
Disaster Triage.
Edith Cowan University, 270 Joondalup WA 6027, Australia.
https://[email protected]

5. Resilience Manager, South Western Ambulance Service NHS Trust, January 2010.
South Western Ambulance Service NHS Trust Major Incident Plan.
Resilience Department, SWAS, NHS Trust Headquarters, Abbey Court, Eagle Way, Exeter,
EX2 7HY.
https://www.swast.nhs.uk/

6. Peter Brown, Resilience Manager, Great Western Ambulance Service NHS Trust, March
2012.
Great Western Ambulance Service Major Incident Plan, Version 6.0.
Resilience Department, GWAS, NHS Trust Headquarters, Abbey Court, Eagle Way,
Exeter, EX2 7HY.
https://www.swast.nhs.uk/

7. Australian Emergency Management Institute, Commonwealth of Australia 2011.

Australian Emergency Management Handbook Series, Disaster Health, HANDBOOK 1.
Attorney-General’s Department, 3-5 National Circuit, Barton Act, 2600.
https://www.ema.gov.au

8. Paul Holman, Operations Manager, July 2010 presentation.

Emergency Management – The Role of Ambulance Victoria.
Ambulance Victoria, 375 Manningham Road, Doncaster, Victoria, Australia.
http://www.ambulance.vic.gov.au/index.html

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 HMC Ambulance Service
Major Incident Response Guide

9. Cone, C.D., Serra, J. and Kurland, L. 2011.

Comparison of the SALT and Smart triage Systems using a virtual reality simulator with
paramedic students.
www.ncbi.nlm.nih.gov/pubmed/21451414

10. Jenkins, J.L., Mcarthy, M.L., Sauer, L.M., Green, G.B., Stuart, S., Thomas, T.L. and Hsu,
E.B. 2008.
Mass Casualty Triage: Time for an Evidence Based Approach.
www.ncbi.nlm.nih.gov/pubmed/18491654

11. Navin, M. and Waddel, B. 2005.

A Disaster doesn’t have to be a Disaster.
www.ncbi.nlm.nih.gov/pubmed/16274178

12. Smith, W. 413 CME Nov/Dec 2012 Vol. 30 No.11.

Triage in Mass Casualty Situations.
www.ajol.info/index.php/cme/article/download/83802/73811

13. Montgomery County Fire & Rescue Service.

Hazardous Materials MCFRS Annual Re-certification, Version 10.3 lrs.
Montgomery County Fire & Rescue Training Academy, 9710 Great Seneca Highway,
Rockville MD. 20850.
www.montgomerycountymd.gov

14. Department of Human Services, April 2007.

Decontamination Guidance for Hospitals.
State Government of Victoria, 50 Lonsdale Street, Melbourne.
http://www.londonccn.nhs.uk/_store/documents/decon-guidance-for-hospitals.pdf

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