Bus-versus-train collision, 40 casualties expected — disaster preparedness, incident command and surge

Declare the mass casualty incident and activate the Hospital Incident Command System (4 marks). I, as the consultant in charge, declare the mass casualty incident and assume the role of Incident Commander, or hand it to the on-call executive if present. I activate HICS at full activation given the scale. I do NOT treat patients — my role is to coordinate. I stand up the command structure: I appoint the Command Staff — a Public Information Officer (single voice to media), a Safety Officer, a Liaison Officer (to coordinate with ambulance, police and other hospitals), and Medical-Technical Specialists as needed; and I confirm the four General Staff sections — Operations (runs patient care, security and facilities), Logistics (staff, supplies, blood, communications), Planning (situation status and the Incident Action Plan) and Finance/Administration. I document the activation on the incident-briefing form, set the operational period per the hospital HICS guide, and establish a single incident communication channel with redundancy (radios plus mobile and landline back-up, and runners if the network overloads). I notify the hospital executive, the on-call management, and through Liaison the regional ambulance service and the receiving hospitals for mutual aid. I brief the ED team on the situation, the scale, and the roles. I communicate the event in PICE terms — root word, three columns, likelihood-of-outside-help stage — so ambulance control, the executive and the receiving hospitals hear the same picture.^[8][1]

Surge capacity strategy in the first hour (4 marks). I move the hospital from conventional to contingency capacity using the three levers — Staff, Stuff, Structure/Space — and I free inpatient capacity by reverse triage. Staff: recall off-duty ED, surgery, anaesthetics and nursing staff; redeploy from elective and non-clinical areas; fast-track credentialing for any borrowed or volunteer clinicians under the mutual-aid memorandum. Stuff: activate the massive transfusion protocol and the blood bank, bring forward the surgical and airway trolleys, confirm oxygen and ventilator availability, and open the disaster pharmaceutical stock. Structure/Space: clear the existing ED patients by rapid disposition (discharge the safe, transfer the ward-ready, defer the non-urgent); open additional treatment areas — resus overflow, corridors, the waiting room, the day-case unit; prepare theatre for damage-control surgery and ICU for the ventilated. I track resource burn-rate through Logistics and the Planning section produces the Incident Action Plan for the next operational period. I recognise that the first casualties to arrive are usually the least-injured walking wounded who self-present; the seriously injured and entrapped arrive later by ambulance, so I prepare for the peak that follows. If demand exceeds contingency I would, with executive authority, declare crisis standards of care under the pre-vetted regional framework, applied by a separate triage team — not a bedside decision.^[5][8]

Triage system on arrival (4 marks). I deploy SALT (Sort, Assess, Lifesaving interventions, Treatment and Transport), the proposed national mass casualty triage guideline of Lerner and the expert panel, because it works for adults and children and it includes the lifesaving-intervention step that START lacks. The triage team first performs the global sort: ask casualties to walk (initially Minimal/Green), to wave or show purposeful movement (initially Delayed/Yellow), and assess first those who are still or have an obvious life threat (initially Immediate/Red). Then for each casualty the triage provider performs the lifesaving interventions — control catastrophic haemorrhage, open the airway (chin lift, recovery position), decompress tension pneumothorax if trained — before assigning the category: Immediate (Red) if any assess criterion fails (obeys commands, peripheral pulse, respiratory distress, haemorrhage controlled); Expectant (Grey) if unlikely to survive given resources; Delayed (Yellow) and Minimal (Green) if criteria pass; Dead if apnoeic after interventions. Triage sets the order of treatment and transport — Immediate first, Expectant given comfort care, Minimal last and often self-evacuating. The Expectant category is the ethical hardest and reflects the shift to the population standard of care — the greatest good for the greatest number. Continuous reassessment is mandatory: the casualty who deteriorates moves category. The two errors I guard against are over-triage (which overwhelms the red bay and degrades the whole response) and under-triage (which harms the individual).^[2]