MIMMS Principles

SILVER (OUTER) CORDON
• The 'warm' zone that defines the safe boundary within which activity supporting the incident is managed.

SILVER COMMAND POST
• The command and control point for all activity within the Silver cordon.

BRONZE (INNER) CORDON
• Referred to as the ‘hot' zone. It is a high threat environment that requires expert risk assessment.

BRONZE SECTORS
• The Bronze cordon may be divided into sectors to improve control.

BRONZE COMMAND POST
• The incident command and control point for all Bronze Commanders.

CASUALTY CLEARING STATION
• A temporary medical treatment facility that provides life saving medial treatment prior to evacuation to definitive medical care.

SURVIVOR RECEPTION CENTRE
• A location within the Silver cordon where personnel with no obvious or very minor injuries are managed.

AMBULANCE PARKING POINT
• The location where vehicles required for casualty evacuation are parked.

CASUALTY LOADING POINT
• Located at the rear of the Casualty Clearing Station. Casualties are loaded onto suitable transport for evacuation to definitive medical care.

Key locations can be seen in schematic view here

SILVER COMMANDER (SC)

• Responsible for command and control of the response within the Silver cordon.
• Coordinates assets and resources in support of the medical response.
• Liaises with the strategic (Gold) Commander.

SILVER MEDICAL COMMANDER (SMC)

• Responsible for command and control of all medial assets at the scene.
• Coordinates triage, treatment and transport of casualties to definitive medical care.

BRONZE COMMANDER (BC)

• Responsible for command and control within the Bronze cordon.
• Liaises with the Bronze Medical Commander and directly with the Silver Commander.

BRONZE MEDICAL COMMANDER (BMC)

• Responsible for command and control of all medical assets within the Bronze cordon.
• Liaises with the Bronze Commander and Silver Medical Commander.

PRIMARY TRIAGE OFFICER (PTO)

• Manages the triage of casualties within the Bronze cordon.

CASUALTY CLEARING OFFICER (CCO)

• Responsible for the command and control of medical assets within the CCS.
• Coordinates the secondary triage, treatment and transport of casualties.
• Liaises directly with the Silver Medical Commander, the Bronze Medical Commander and the Casualty Loading Officer

MEDICAL TEAM LEADER

• The senior clinician within the CCS responsible for coordinating the medical care of casualties within the CCS.

SECONDARY TRIAGE OFFICER (STO)

• Triages and logs casualties on arrival at the CCS.

CASUALTY LOADING OFFICER (CLO)

• Responsible for coordinating the safe transport of casualties to appropriate definitive medical care. Liaises with the CCO and SMC.

AMBULANCE PARKING OFFICER (APO)

• Controls and coordinates the movement of all evacuation platforms within the Silver cordon.

COMMAND

• Command is organised in three tiers.
  • GOLD – Not at the incident but in a control room or strategic headquarters, supporting the incident as well as other operations within the AOR.
  • SILVER - Overall Command of operations within the Silver Cordon, supporting operations within Bronze, liaising with strategic or 'Gold' command.
  • BRONZE – Command of operations within the Bronze Cordon.

Command moves vertically between the tiers with defined command functions within each tier.

Within each tier, there will be Commanders with differing skill sets (Medical, Force Protection etc.)

• These commanders must Co-locate, Coordinate and Communicate together to jointly understand the risk and share situational awareness (see JESIP).

MEDICAL COMMAND

• Medical command focuses on managing the medical assets at the incident.
• It coordinates the triage, treatment and evacuation of the casualties to definitive medical care.
• Medical command is organised within the command tiers.
• See the aide memoir for further detail.

CONTROL

• During the initial stage of an incident the 4 C''s (see Aide Memoir) are used:
  • CONFIRM
  • CLEAR
  • CORDON
  • CONTROL
• Control is achieved by the establishment of a Bronze and Silver cordon.
• Control of the BRONZE cordon is the responsibility of the Bronze Commander.
• However, an “all hazards” approach may require initial control and risk assessment by a subject matter expert such as a bomb disposal expert.
• A large Bronze cordon may require the use of sectors to improve control within the cordon.
• The Silver Commander is responsible for the control and coordination of all assets within the SILVER cordon in order to optimise the major incident response.
• The Silver Medical Commander is in control of the medical assets on scene and is responsible for coordinating the medical response.

Safety is organised using the following approach:
SELF – SCENE – SURVIVORS

Self

The tactical situation will dictate safety measures required by the individual. This can involve using military skills and tactics and selection of appropriate PPE such as body armour, helmets, gloves etc.

In a permissive (safe) environment appropriate PPE will be dictated by the location, for example at the CCS PPE would include masks, gloves and aprons.

Scene

The nature of the incident will dictate safety measures required to mitigate any hazards, such as EOD teams to deal with unexploded ordnance, firefighting teams to deal with fires, force protection/QRF to deal with hostile action, Engineers to deal with unstable structures etc.

If HAZMAT/CBRN is present, then special measures will be required.

Survivors

Survivors will need to be managed, particularly if there is a threat from hostile action, the weather, secondary devices or additional hazards.

For further details on managing safety, refer to the Aide Memoire

Communications between the key command roles and locations within a major incident must be effectively established using the most appropriate available means.

Options available include;

• FACE TO FACE
• RADIO
• LANDLINE
• RUNNERS
• TANNOY
• LOUDSPEAKER
• HAND SIGNALS

The use of universal message structures such as METHANE and ATMIST are vital for communications to be effective.

All communications must be logged. (See reference section)

The JESIP principles

Co-locate, Coordinate, Communicate, Joint Understanding of risk and Shared situational awareness will improve communication between Commanders at the scene.

Further information on these JESIP principles can be found in the reference section

COMMUNICATION FORMATS

My Call Sign, Name or Designation

M Major Incident Standby or Declared

E Exact Location. Grid or GPS where available

T Type of incident.  Wind direction for CBRN or HAZMAT

H Hazards – Actual or Potential

A Access / egress routes. HLS

N Number, type and severity of casualties

E Emergency support present and required.
CBRN or HAZMAT consider on decontamination

Early scene assessment is vital on order to establish the magnitude of the incident and the resources required to respond to the situation.

Assessment is a dynamic process and should be conducted regularly to maintain situational awareness and refine the response plan.

The initial assessment is usually conducted by the first on scene.

Subsequent assessments are conducted by key commanders at the scene, typically the:

• Silver Commander
• Silver Medical Commander,
• Bronze Commander
• Bronze Medical Commander.

Assessment tools such as ETHANE for an initial assessment and CSCATTT for a detailed assessment reduce the likelihood that key information is overlooked.

See the Aide Memoire in the reference section for a more detailed description.

INITIAL SCENE ASSESSMENT

E - Exact Location. Grid / GPs. If CBRN or HAZMAT. Wind direction if on scene.
T - Type of incident or types of casualties ( blast, frag, blunt, burn…)
H - Hazards – actual and potential . Suggestion mitigation measures.
A - Access routes to scene / casualties. Potential vehicle parking and HLS sites
N - Number and severity (if known) of casualties involved
E - Emergency support on scene and required. If CBRN / HAZMAT consider on scene decontamination requirements

GENERAL SCENE ASSESSMENT

• C - Are command and control measures in place?
• S - Consider hazards and mitigation measures. Is special PPE required?
• C - Communication plan, shared situational awareness (JESIP)
• T - Triage
  • Number / types of casualties
  • Number and composition of triage teams required
  • Equipment required
• T - Treatment
  • Personnel and equipment required
• T - Transport
  • Number of stretchers required
  • Vehicles – capacity, suitability, accessibility
  • Vehicle circuits within Silver cordon
  • Distance / time to receiving medical facilities

BRIEFING FOR DUTY

❑ Ground layout ( sketch where possible)
❑ Situational brief - what has happened
❑ Confirm chain of command (C2)
❑ Confirm tasks and sub-tasks
❑ Identify hazards, access and egress points,
evacuation procedure, PPE required
❑ Additional equipment required
❑ Communication plan
❑ Assessment – consider the medical resources
and infrastructure required (if relevant to task)
❑ Triage system (if relevant to task)
❑ Treatment plan (if relevant to task)
❑ Reporting procedure - who, when, where

• Triage prioritises casualty evacuation from the point of injury and treatment at the casualty clearing station (CCS)
  • It identifies those casualties that require life saving interventions and prioritises their care.
• The choice of appropriate triage system is critical in ensuring the right casualty receives the right treatment at right time.
• Once the Bronze cordon area has been made safe, the Primary Triage Officer coordinates triage of all the casualties within the cordon.
• Secondary triage is carried out on arrival at the casualty clearing station by the Secondary Triage Officer using an appropriate triage method and clinical judgement.
• The toolboxes contains the triage sieve and triage sort algorithms.
• Paediatric casualties will be over triaged using the adult triage sieve and sort algorithms.
  • A paediatric triage tool such as the paediatric triage tape should be used.
• Detailed information about triage can be found in the Aide memoire.

The availability of medical personnel, equipment and local infrastructure may place constraints on the level of treatment that can be delivered to casualties at the scene of a major incident.

• At the point of injury, (during the initial triage) treatment is focused on control of catastrophic bleeding and airway opening manoeuvres.
• Advanced treatment may be provided in very specific circumstances such as casualty entrapment.
• The Casualty Collection Station (CCS) is located using CCS siting tool.
  • It should be laid out to optimise casualty treatment and flow through the facility.
• The Secondary Triage Officer (STO) will re-triage all casualties at the entrance to the CCS to determine their treatment priority.
• Medical treatment teams will deliver the medical care necessary to stabilise and sustain the casualties for evacuation to an appropriate medical treatment facility.
• Treatment will be overseen by the medical team leader(s) in accordance with CGOs treatment guidelines.

Follow the links below to CGOs for guidance on specific treatments or care pathways

• Catastrophic haemorrhage management
• C- spine management
• Airway management
• Breathing management
• Circulation management
• Splintage and fracture management [Guidance missing]
• Amputation [Guidance missing]
• Pelvic fracture [Guidance missing]
• Fragmentation injury [Guidance missing]
• Blast injury
• Blunt trauma
• Chemical / biological exposure

An efficient flow of casualties from the point of injury through the CCS and onwards to a medical treatment facility requires careful coordination by the SMC, the BMC and the CLO.

• The Casualty Loading Officer (CLO) is responsible for ensuring that the right casualty is moved to the right medical facility in the right timeframe.
• They must liaise regularly with the SMC to maintain situational awareness of the receiving medical facilities.
• A range of transport platforms, both dedicated and improvised should be considered according to their capacity, availability and suitability.
• Detailed specification can be found in the CGOs transport section.
• The Incident log found in the reference section should be used for casualty tracking.
  • Casualty tracking is a critical process that ensures casualties reach their correct destination and are accounted for.

The basic MIMMS principles, planning and execution apply to all special situations.

Applying an “all hazard” approach to risk assessment, a subject matter expert will advise on the necessary modifications required to safeguard the responders.

Follow the links below for guidance on specific situations.
• HAZMAT [Guidance missing]
• CBRN
• Building collapse [Guidance missing]
• Road traffic collision [Guidance missing]
• IED [Guidance missing]
• IDF [Guidance missing]

Command and Control

• Start a log and record time of arrival
• 4Cs
  • Confirm
  • Clear
  • Cordon
  • Control

Safety

• Prioritise Self – scene - survivors
• Confirm hazards and mitigate
• Consider appropriate PPE

Communication

• Send initial report
• Use a METHANE format
• Co-locate with other emergency services

Assess

• Assess the scene
• Consider location of command posts and medical laydown

Notes

• Do NOT carry out any triage or treatment at this stage
• Continue to assess and communicate as details become available
• Continue duties of the Commander until relieved

❑ Ground layout ( sketch where possible)
❑ Situational brief - what has happened
❑ Confirm chain of command (C2)
❑ Confirm tasks and sub-tasks
❑ Identify hazards, access and egress points,
evacuation procedure, PPE required
❑ Additional equipment required
❑ Communication plan
❑ Assessment – consider the medical resources
and infrastructure required (if relevant to task)
❑ Triage system (if relevant to task)
❑ Treatment plan (if relevant to task)
❑ Reporting procedure - who, when, where

❑ Ground – hard standing
❑ Building / permanent structure (protection)
❑ Life support (heat, light, water, sanitation)
❑ Upwind of potential airborne hazards
❑ Safe proximity from incident point
❑ Easy access and egress for evacuation
platforms (air/land/sea)