Crash course in emergency medicine


A mock-up of a ‘major incident’ in Dublin last week showcased Irish emergency services at their best

WITH OVERCROWDED emergency departments and trolley counts, emergency medicine in Ireland is rarely out of the news for all the wrong reasons.

At lunchtime last Thursday, a car crashed through the barriers at the Docklands railway station in Dublin city centre. It later transpired the driver had suffered a major heart attack.

As the car veered out of control and on to the train tracks, the driver of an oncoming commuter train did not have enough time to stop and collided with the car.

There were 17 passengers on board the train who suffered a range of injuries, from minor to life-threatening.

The driver of the car and a train passenger died at the scene. One passenger in the car survived, but had to be cut out of the wreckage.

Irish Rail immediately called 999 and a number of teams from the Dublin Fire Brigade (DFB) and the National Ambulance Service (NAS) of the HSE were deployed.

Although this was a demonstration exercise for delegates of the 2012 International Conference on Emergency Medicine, the mock-up was an opportunity to showcase emergency medicine in Ireland and the co-operation between the agencies, involved, namely Irish Rail, the DFB and the NAS.

This was the first time the world’s largest international emergency medicine conference had come to Dublin. The three-day biennial event attracted more than 2,000 delegates and numerous expert speakers in emergency and disaster medicine from around the world.

Before the exercise, the 19 “casualties”, all of whom were volunteers from the Tipperary Red Cross, were given instructions on their individual injuries. These ranged from serious conditions such as head injuries, internal bleeding and punctured lungs to broken ribs and fractured limbs.

Injuries such as open wounds from protruding shards of glass were realistically reconstructed with make-up and fake blood. Those in pain cried out for help in a most convincing fashion, with many performing to Oscar-winning standards.

At that stage, a major incident was declared. According to Dr Niamh Collins, consultant in emergency medicine in Dublin, the definition of a major incident is when “demands exceed resources”.

Once the fire service declared the scene safe, paramedics from the NAS were then permitted to board the train where they assessed and triaged casualties, prioritising those with life-threatening injuries.

Meanwhile, members of the fire brigade used cutting equipment to free the dead driver and badly injured passenger from the car, which lay upturned on the track in front of the train.

Paramedics then escorted the walking wounded off the train and brought them to the casualty clearing station, which was set up a safe distance away in front of the station’s ticket office.

They returned for casualties who could not walk and brought them on spinal boards to the clearing station. Once in the station the injured were reassessed and any emergency interventions that were needed were carried out, before they were prioritised for transport to local hospitals.

An incident command unit was also established with incident officers from the DFB, NAS and Irish Rail.

Dr Cathal O’Donnell, medical director with the National Ambulance Service HSE, says in a major emergency where you have more patients than you can deal with at that moment, medical personnel try to “do the most for the most”. This means identifying those casualties who are most seriously injured and most time critical. This is done by a process called triage.

All of the casualties of last week’s incident were labelled by the paramedics with different tags, which O’Donnell says is part of the triage process.

“We . . . triage them into four different categories: red, yellow, green and white. Red is immediate, yellow is urgent, green is delayed – these are patients who can wait – and white is dead. It then allows us to prioritise the red patients. They are the ones who need treatment at the scene and also need to be prioritised for transport to hospital,” he says.

The four months of planning for last week’s demonstration by O’Donnell and the conference’s local organising committee paid off. The event was carried out expediently and with an impressive level of interagency co-operation, expertise and skill.

While the event was primarily designed to showcase emergency medicine in Ireland to delegates of the international conference, O’Donnell says it also presented an opportunity to carry out a simulated exercise with other agencies that might be involved in similar real-life events.

“While we all plan and train for these ourselves it is also important to train with the other agencies that would be involved in the event . . . The principles are: if you are working together, you should train together,” he says.

Although last week’s incident at the Docklands train station was only a mock-up, O’Donnell says the emergency services in Ireland tend to see one major incident a year. He cited the 2011 air crash at Cork airport, which claimed six lives, as one of these.

According to Collins, the mock-up event also highlighted Ireland’s expertise in emergency medicine to the public.

“I think we have an obligation in Ireland to tell people what we do well. We have a tendency, and it is quite easy, to tell people what we do badly, but we do an awful lot of stuff very well here and the public aren’t aware of that . . . We have got great service, fabulous personnel, we have got good organisations and structures, and we need to build on those strengths,” she says.