Major Incidents. Major incidents. Tim Fotheringham The Royal London Hospital. London bombings 7 th July Lessons learnt Discussion

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Victoria Cook
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1 Major Incidents Tim Fotheringham The Royal London Hospital Major incidents London bombings 7 th July 200 My day What happened at RLH Lessons learnt Discussion

2 7/7/ Power surge LUG Approx 09:0 LFB declare major incident 09:16 LAS declaration Multiple incidents? up to 8 scenes?

4 The Pre Hospital Response

5 Liverpool Street 080 Circle line train from Liverpool Street to Aldgate Second carriage of train 8 people dead King s Cross 080 Piccadilly train from King s Cross to Russell Square First carriage of train 27 people died

6 Edgware Road 080 Circle line train heading towards Paddington Second carriage of train 7 people dead Tavistock Square 0947 Number 30 bus from Marble Arch to Hackney. Exploded at junction of Tavistock Square & Upper Woburn Place Upper level of bus towards rear 14 people dead

7 The Royal London Hospital A&E Department 00 Patients in A&E average day:- 10 Majors 20 Minors/Walk In 1 Resus 70 Paediatric 2-3 Trauma Calls

A&E patients 2 back to back CT scanners Team leader A&E Cons/Reg Anaesthetist & ODA A&E SHO

8 A&E and Orthopaedic X-ray Dept Staff radiographers 2 X-ray rooms bay resus room with overhead tube and US machine 1 paediatric emergency room Provide service for orthopaedic and A&E patients 2 back to back CT scanners Team leader A&E Cons/Reg Anaesthetist & ODA A&E SHO 2 Nurses Neuro SHO scribe Surgical SHO Orthopaedic surgeon 2 Radiographers 1 Radiologist Trauma team

9 Trauma call RLH Trauma team assemble in resus ATLS protocol Pelvis Lat C-Spine CXR FAST and Chest US - radiologist Further plain films if indicated Transfer CT, theatres, ITU, angio My day Working at home Called on mobile by a trainee at 0930 major incident, possible bomb, everyone at St Bartholomews Set off on bicycle 20min ride Traffic gridlocked by buses miles out Weaving around city to get to RLH

10 My day Arrived at 10 am Went to collect lead apron from angio Joined a team in resus Dealt with 2 majors Left work at approx pm MIP activation RLH X-ray MIP recently rehearsed! At 08.6 on 7 th July 200 a MI was declared All departments and wards were cleared of noncritical patients All outpatient work cancelled Equipment and rooms prepared for a large influx of causalities

Co-ordination of plan Lead Superintendent sets plan inaction in A&E Staff allocated to key areas Key staff given action cards:- Radiologist Radiographer A&C staff Radiographer allocation There were

11 Co-ordination of plan Lead Superintendent sets plan inaction in A&E Staff allocated to key areas Key staff given action cards:- Radiologist Radiographer A&C staff Radiographer allocation There were 33 Radiographers at work on July 7 th 7 went home to allow them to cover the night. (3 already allocated to work the night) Remaining 2 worked on a rolling rota system Extra staff allocated to shifts the following nights and weekend 6 Student Radiographers Our biggest staffing issue was that we had no idea how long the MI would last and how many casualties there would be.

12 Radiologists Very few on site Many at board meeting the other side of the city at St Bartholomews Addhoc dissemination of incident No plan of how to get to RLH In the event no shortage of staff What we were told 8.2am Power surge between Liverpool Street and Aldgate underground 9.26am Major Incident Alert from LAS: bombs at Aldgate East, Liverpool Street, and Praed Street. Casualties unknown. RLH first receiving hospital. 9.40am Incidents at Liverpool Street, St Pancras and Aldgate. 1 dead at Liverpool Street and 10 injured. Media reports that a power surge caused the incidents. 9.2am 7 bombs on underground and hundreds dead. Later that day Police report times of four blasts as 8.1 Liverpool Street (7 dead), 8.6 King s Cross (21 dead), 9.17 Edgware Road (7 dead) and 9.47 Tavistock Place (2 dead more likely).

13 ER Response bed resuscitation room 1 Majors cubicles Minors and adjacent walk-in centre Major Incident declared 10.0 First Priority 1 patient Resuscitation room capacity reached First Priority 1 patient to theatre A&E arrival of Priority 1&2 Patients

14 A+E Response Cntd Hospital phones overwhelmed 12.3 Reopened to Majors + Ambulance pts Major incident stood down A+E reopened to all pts Hospital debrief The major incident just beginning for the rest of the hospital The Operating Theatre Response

AT 0930 9 10 11 12 13 14 1 16 17 18 19 20 21 22 Theatre 1 Theatre 2 Theatre 3

15 AT Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre Theatre 6 Theatre 8 Theatre 9 Theatre 10a Theatre 10b Theatre 11 Available

16 At Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre Theatre 6 Theatre 8 Theatre 9 Theatre 10a Theatre 10b Theatre 11 Available 6 9 At Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre Theatre 6 Theatre 8 Theatre 9 Theatre 10a Theatre 10b Theatre 11 Available

17 At Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre Theatre 6 Theatre 8 Theatre 9 Theatre 10a Theatre 10b Theatre 11 Available At Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre Theatre 6 Theatre 8 Theatre 9 Theatre 10a Theatre 10b Theatre 11 Available

18 At Theatre 1 Theatre 2 Theatre 3 Theatre 4 Theatre Theatre 6 Theatre 8 Theatre 9 Theatre 10a Theatre 10b Theatre 11 Available Injuries Body Region Number Av AIS Head & Neck Facial Chest Abdominal Pelvis/Limbs External

19 Primary Operations Number of Patients Fasciotomy Amputation Laparotomy Thoracotomy Craniotomy Debridement/closure wounds Ex-fix ORIF K-wire Globe Upper Limb Lower Limb AKA BKA Thru Knee Upper Limb Lower limb Upper limb Number RLH Average ISS 10 ISS 1 17 Min ISS 0 ISS >1 8 Max ISS 34 Unknown 2 Median ISS

bays AMX4 mobile machine serving 2 bays A further

20 Blood Usage by time RESUS 10 radiographers 10 radiologists 4 US machines Overhead gantry serving 2 bays AMX4 mobile machine serving 2 bays A further AMX4 mobile was positioned outside resus Film processor in resus

RESUS Buddy system used:- 2 radiographers and 2 radiologists to each resus bay Co-ordinating radiologist and radiographer casualty ID and report Extra lead aprons, film cassettes and lead

21 RESUS Buddy system used:- 2 radiographers and 2 radiologists to each resus bay Co-ordinating radiologist and radiographer casualty ID and report Extra lead aprons, film cassettes and lead markers Teams of 18 radiographers working 2 hours on 1 off Imaging performed in RESUS 8 patients treated in resus Between and CXR 3 Pelvis 4 CSP/TSP/LSP 4 Upper limb 8 Lower limb 10 FAST

18 CXR 12 Lower limb 11 Upper limb 1 AXR 4 Facial Views 8 ST views Spine views CT 3 Scanners fully

22 A&E X-ray Minor walking wounded casualties 4 members of staff deployed All staff changed in theatre scrubs Student radiographers based here. 63 X-rays performed. 18 CXR 12 Lower limb 11 Upper limb 1 AXR 4 Facial Views 8 ST views Spine views CT 3 Scanners fully staffed including our 1 week old lovely 64 slice scanner! 7 patients on the 7th 1 Abdomen 3 Brains 3 Brain/Face/Orbits Many follow up CTs performed

23 Imaging performed outside A&E Main X-ray rooms not used Theatres received their first patient at All 11 theatres in use, provisions were made for up to 2 operating areas 6 Mobile chest x-rays performed in theatre MR not utilised Lower limb angiography performed in theatre PATIENT NUMBERS The hospital received 208 patients. 26 were admitted 49 kept in A&E 19 discharged By 19.4, 27 remain in RLH 7 on ITU 19 In-patients 1 Died in theatre

After Stand Down Stood down from major incident at 12.40 ER re-opened to all patients by 13.30 Hospital wide debriefing at 14.00. Radiology debriefing at 1.30 Liquid debriefing 17.

24 After Stand Down Stood down from major incident at ER re-opened to all patients by Hospital wide debriefing at Radiology debriefing at 1.30 Liquid debriefing The After Effects Many ITU Patients required spine clearance the following day 18 CT scans needed the throughout the following week Extra staff to cover the weekend. 7 patients still on ITU In the 2 weeks following the MI there were 64 theatre cases Catch up of elective patients Death during ITU transfer

25 19 in-patients 7 in ITU 1 in HDU 8 on Trauma Ward 3 on other wards As of 8 th July The Aftermath Twice-daily meetings Tertiary survey of all in-patients Frequent return to OR for relook at wounds

26 2 Deaths in total As of 21 st July 7 in-patients 2 in ITU 0 in HDU on open wards As of 7 th September 1 in-patient on Trauma ward Average LOS days (0-62) (of 27 admitted patients)

27 Good clinical outcome was a result of: Early adequate amputation led by experienced trauma surgeons. Twice daily MDT Trauma meetings, ensuring early effective intervention. Effective wound cover, limiting ITU stay.

28 Communication Problems Patient documentation/identification Early re-opening of A+E Capacity reached despite fortuitous timing Knowledge and adherence to MI plan Afterwards Visitors attending the hospital looking for relatives Visits from the Queen and The Mayor of London Staff support through individual meetings Staff counselling offered Hospital reviewed plan

29 Hospital wide problems indentified Communication Chemical, biological and radiation hazard not considered by hospital staff. It was assumed that patients would be decontaminated before entering hospital. Travelling home Little public transport for most of the day No support lines set up until later in the day No specific press location press surrounded the hospital cordon Communication Staff members where not reliably contacted by department when incident was announced Mobile and landlines swamped by 10am ACCOLC and GTPS not used Hospital telephones and bleeps swamped

30 Telecommunications Mobile network Access Overload Control Scheme ACCOLC Cell based SIM card determines ACCOLC (1-1) 1-10 normal use priority 1 network use Landline GTPS 1 telephone exchange 2 10% community responsibilty 3 all other

31 Personal reflections Very impressed by hospital response Very unsettling wanted to be kept active TV reports key source information Unable to reassure family Debriefs important Hospital worked as one team Glad to be on holiday at WE

32 Department of imaging Ensure all staff can be contacted Group text Plan how you will get to work Avoid arranging meetings at non ER site Move equipment US machines to AE resus Reports must be available on EPR Walkie talkies Department of imaging In ER Hot report plain films FAST/Chest Advise on further imaging/intervention In CT Hot reporting Advise on intervention Co-ordinate reporting to be available on EPR

33 Major Incident Review

Strong Medicine Interview with Alik Farber, 16 June JOAN ILACQUA: [00:00] All right, so today is June 16 th, 2014.

Strong Medicine Interview with Alik Farber, 16 June 2014 JOAN ILACQUA: [00:00] All right, so today is June 16 th, 2014. This is Joan Ilacqua, and I m here with Alik Farber at Boston Medical Center. We