How to declare a Major Incident. St.Emlyn’s

Recent attacks in Manchester, London and around the world have heightened our awareness of the possibility of a major incident being declared at any time of day or night. As emergency physicians (and all specialities really) we need to think hard about how we prepare and organise ourselves for how we might respond.

This blog builds on the experience in Manchester and London regarding alerting procedures for major incidents. In Manchester the bomb at the Ariana Grande concert exploded at about 22:35. At that time we typically have 2-3 consultants on duty between the adult and children’s emergency departments. That’s not enough to cover a major incident response and so we need to call people in, but how?

The traditional method is the telephone cascade. Someone (switchboard or the onsite consultant) gets an up to date list of colleagues and then starts phoning or paging them in from the top of the list until they have enough people to come in.

This system is based on old style phones or pagers1 and really does not reflect how we communicate in the modern world. The traditional method is slow, phone numbers may be out of date and it’s difficult to know who has reponded and how.

Unsurprisingly then new communication methods such as WhatsApp have been mooted as the solution (Ed – you could also use other systems like Slack, Yammer, or many others, but we have most experience with whatsapp). Despite some concerns about confidentiality it’s abundently clear that many, if not most, clinical groups are now using some form of closed messaging system to keep in touch. WhatsApp is secure, easy to use and easy to modify and it’s no surprise that it was used in the UK during the recent terrorist attacks. You can read more about how it worked in London on Helgi’s BMJ blog here.

There is more detail on his personal blog here2.

So here’s a few thoughts on how to set yourself up so that it works well.

  1. Set up a dedicated group for major incidents. This is important as you want to let people know when it’s a major incident and not just a regular chit-chat routine message. How to set up a group chat (aka whatsapp group)
  2. Set a different ring tone for the major incident group. You will find that certain tones can trigger memories and anxieties if you think it’s a major incident every time someone sends a whatsapp message. So choose something unique.How to change a ring tone for a whatsapp group
  3. Set some ground rules about what goes on this group. Basically keep it for major incidents or other time critical, highly important messages. By all means have a different group for general banter.

What about actually using whatsapp during an incident? Well it’s not perfect as we found in Manchester. Some people quite rightly have their phones turned off at night, or are away on holiday, or have family commitments which mean they cannot repond. You can never get away from that, but it’s still better than most traditional systems.

We also need to be mindful that the person who is actually in the department will not want to be spending all their time replying to whatsapp messages as they will be busy doing other stuff.

So here are a few tips that might help.

  1. If you are the person declaring the major incident try and use a structured message at the beginning of the message thread. As a an author of  HMMIMS and an advocate of MIMMS 3 I suggest you could use the METHANE message that should come from the prehospital teams as a model. The METHANE structure looks like this
    1. MAJOR INCIDENT DECLARED (or standby)
    2. EXACT LOCATION (e.g. MEN Arena)
    3. TYPE OF INCIDENT (e.g. bomb explosion at pop concert)
    4. HAZARDS (known or suspected) (e.g. potential chemical contamination of casualties)
    5. ACCESS this is mostly prehospital, but for hospitals could include likely transport methods (e.g. no aircraft, police vehicles on site with P3 now, ambulances expected in next 10 minutes to paed and adult departments)
    6. NUMBER and SEVERITY of casualties (e.g. 200 casualties, 30 P1, 25 P2, 100 children)
    7. EMERGENCY SERVICES REQUIRED what response you require of colleagues and the department – how many need to come in now (e.g. we have two consultants, 3 middle grades and 5 juniors present: We require 6 additional consultants now, and double our junior numbers if possible).
  2. Once declared someone else in the group should volunteer to collate and respond to other colleagues. Essential tasks are.
    1. Determine who can respond
    2. Determine how quickly they can respond
    3. Identify how many need to come in now.
    4. Identify who needs to not come in in order to manage the workload over the next 24-48 hours.
  3. Consider that all communications made via whatsapp would likely be releasable at a later date as part of an investigation into the incident. In part this is excellent as it gives a timed log of events and what happened with an electronic time stamp. Just be mindful that you stay professional and sensible at all times.

And that’s it really. It should not be complex and it should not be difficult to do. It’s not perfect as it still requires you to have your phone on, whatsapp alerts on and for you to be available. It’s clearly a better system than call-in lists by phone and recent experiences in the UK suggest that it was effective4.

You may be concerned that whatsapp might be compromised and your communications eavesdropped upon. In reality that’s extremely unlikely as the security on whatsapp is very secure. Technically I think some parties may suggest that you cannot do this for antiquated IT rules, but these are interesting and worrying times and we need to be prepared. The usual social media rules apply – don’t be an idiot5.

In the last 24 hours the threat level in the UK has been raised to critical and all NHS organisations have been asked to ensure that they are prepared. My final thought is therefore to set up your whatsapp groups now (unless you have something better already) as making it up on the night really does not work.

vb

S

Useful links and references.

How to set up a group chat (aka whatsapp group)

How to change a ring tone for a whatsapp group

1.
Old technology: NHS uses 10% of world’s pagers at annual cost of £6.6m. the Guardian. https://www.theguardian.com/society/2017/sep/09/old-technology-nhs-uses-10-of-worlds-pagers-at-annual-cost-of-66m. Published 2017. Accessed September 16, 2017.
2.
WhatsApp doc. traumagasdoc. https://traumagasdoc.wordpress.com/2017/07/23/whatsapp-doc/. Published 2017. Accessed September 16, 2017.
3.
Major Incident Medical Management and Support: Hospital. ALSG. http://www.alsg.org/uk/HMIMMS. Published 2017. Accessed September 16, 2017.
4.
Should doctors use WhatsApp to bypass archaic NHS tech? . The Guardian. https://www.theguardian.com/healthcare-network/views-from-the-nhs-frontline/2017/jun/05/should-doctors-use-whatsapp-to-bypass-archaic-nhs-tech. Published 2017. Accessed September 16, 2017.
5.
Doctors’ use of Facebook, Twitter, and WhatsApp is the focus of 28 GMC investigations. BMJ. http://www.bmj.com/content/358/bmj.j4099. Published 2017. Accessed September 16, 2017.

8 Comments

  1. Luke Regan

    Top post. We have a dedicated whatsapp group for the ED Consultants in Inverness as we regularly have multicasualty traumas which are frequent enough to need a reliable alerting system for extra staff but unpredictably timed enough to remain forever outside the remit of regular staffing. Our prehospital team here trialled a similar group for communicating within majax exercises. The first time it was amazing as formed an effective event log at scene and was invaluable when the radios went down. The second time no one used it as scene was close to CCS was close to transport point so phones seemed superfluous. Then after the event realised much info lost that whatsapp group had safeguarded in the previous one…

    Reply
    1. Simon Carley (Post author)

      Great point Luke. Past major incidents have really struggled to keep a log of events. This may we’ll help.

      Also worth remembering that smart phones have voice recorders that you can use to keep contemporaneous notes. Again these are time and date stamped electronically.

      S

      Reply
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  4. Rob Willmore

    Interesting post. To add to A of METHANE I find teaching “Access & Egress” engages the thought process for both pre-hospital and in-hospital teams about flow of casualties. Prehospital we need transport in and out – clogging the one way street with emergency vehicles can cause many problems when casualties need transport to hospital. Additionally it highlights the need to decide which centres are going to be recieving casualties on a gross scale.

    In hospital I think it’s useful to think about egress in terms of early movement of non-critical patients from our emergency departments, theatres and wards. Where will critically injuries patients ‘egress’ from ED to?
    Great post though.

    Reply
    1. Simon Carley (Post author)

      Agree Access is about in and out and that’s what we teach on HMIMMS/MIMMS

      S

      Reply
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  6. Oliver Fröhlich (@docfr0ehlich)

    Don’t know the technical details but as far as I know parts oft the mobile nets are turned off during terrorist attacks. Does this matter for whatsapp?

    Reply

Thanks so much for following. Viva la #FOAMed

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