Take home points from an HMIMMS course

23 Jan

(Updated August 2017 with some added bits for the FRCEM revision)

Before christmas I finally got another one of the alphabet courses under my belt – The Hospital Major Incident Medical Management & Support course. Or HMIMMS for short.

To be perfectly frank major incidents weren’t exactly on my radar – I like to describe emergency medicine in Ireland as one long protracted major incident so there’s a little bit of incredulity involved in actually planning for some major disaster when we can’t even manage the day to day.

Having done the course I now see why it’s considered as mandatory for training in emergency medicine. Emergency physicians will always be front and central in such scenarios, and the more senior you are the more important the management bits will be. The clinical stuff is easy but making sure your patients and staff get to where they need to be is a whole different story.

The table top exercises are some kind of cross between Monopoly and Settlers of Catan so it allows to unleash your inner geek a bit too.

Below are a few scribbled notes I took during the course and from reading the manual (which of course @EMManchester is an author of… that guy gets everywhere…)

Major incident

  • events that owing to the number, severity, type or location of live casualties require special arrangements to be made by the health services.
  • can also be put as “major incidents occur when the resources available are unable to cope with the workload from the incident”
  • A major incident can remain “uncompensated” when still unable to manage despite mobilisation of additional resources


M – Major incident declared

E – Exact location

T – Type of incident

H – Hazards

A – Access

N – Number & Type of casualties

E – Emergency Services Present and Required

7 main principles (abbreviated as the fairly unpronounceable CSCATTT)

  1. command
  2. safety
  3. communication
  4. assessment
  5. triage
  6. treatment
  7. transport

Phases of a major incident

  • pre hospital
  • reception
  • definitive care
  • recovery

The Collapsible Heirarchy

  • still not sure if i like the term
  • refers to the system used to delegate staff
  • roles can be coloured red yellow green in order of importance
  • some folk may fill multiple roles until further help arrives
    • for example at 2am the only surgical doctor in the hospital may be the poor surgical SHO who will assume the role of “senior surgeon” (in charge of entire surgical response) until someone more senior arrives and the SHO can go and change his underwear, or perhaps even his career.

Essential clinical roles that need filled ASAP

  • medical coordinator
  • senior EP
  • senior MLSO(lab)
  • senior surgeon
  • senior physician (often overlooked as we assume all major incidents are traumatic when they’re not – they can be toxicological or environmental


  • the most important thing is that the expectant cases are low down the list. A resuscitative thoracotomy may not be appropriate when your resources are over stretched
  • start with a triage sieve, so simple you don’t need to be clinical to use it. For example if you can walk then you’re immediately a lower priority.
  • a triage sort is a bit more detailed that involves some physiologic variables (GCS, HR, RR) to determine your level of priority (which is essentially which physical space you are assigned to in the ED).

There are some specific Irish documents available online looking at this in the Irish context. Your hospital will of course have it’s own major incident plan. it is no doubt dusty and out of date somewhere…

[Featured Image: Nuclear Explosion – Wikimedia Commons, CC License]

2 Replies to “Take home points from an HMIMMS course

  1. Hi

    I’ve long thought about the current situation in EM in (at least parts of) the UK as a long, drawn-out major incident: too many patients/ too little space/ staff/ resources. So I’m interested, have you found that you’re using lessons from HMIMMS on a typical day?

    • can’t say i do. certainly the need outstrips resources but it’s not like there’s that many who need a life saving intervention in the first 5mins. As a result the response from the hospital is slightly under whelming.

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