Manual ETS BEN 080507 Highpxl PDF

MANUAL
EMERGO TRAIN SYSTEM (ETS)
2008-05-07
version 2.3

Preface
Disaster medicine is a young discipline within the medical profession. There is a growing inte-
rest for this discipline as well as a growing understanding of its importance. Consequences of
disasters and major incidents tend to have a greater impact on the society than ever. Experience
has shown that disasters, even if occurring in seemingly remote places, can have a worldwide
impact. Although recognising this we must be aware of that disaster response often starts at
local level with sometimes a single ambulance. In this broad spectrum the discipline of disaster
medicine must develop, and so must the educational systems within this field. The Emergo Train
System (ETS) is a pedagogic tool for teaching and training in disaster medicine.
The Centre for teaching and training in disaster medicine and traumatology now introduces the
Emergo Train System, version 2. A lot of emphasis has been put into the importance of evalua-
tion as a tool to convert “lessons observed to lessons learned”. In order to achieve this an edu-
cational program for teachers using the system has been developed. It is considered mandatory
to have proper training when using the system. The concept of senior instructors has developed
from this idea.
We are now happy to introduce the first manual of the ETS that we believe will serve as an
important guiding tool for all users of the system and as a promoter in the process of spreading
knowledge in disaster medicine and disaster management, all for the good of the patient.
Linköping 2005-11-30

Editors
Hornwall, Johan johan.hornwall@lio.se

Nilsson, Heléne helene.nilsson@lio.se
Rüter, Anders anders.ruter@lio.se
Vikström, Tore tore.vikstrom@lio.se
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Abbreviations
AMB Ambulance
AN Anastetic – nurses or doctor
BI Basic instructor
BIC Basic Instructor Course
CPR Cardiac Pulmonary Resucitation
ECC Emergency Call Centre
EM Emergency – nurses or doctor
ER Emergency room
ETS Emergo Train System
GCS Glasgow Coma Scale
HR Heart Rate
ICU Intensive Care Unit
KMC Katastrofmedicinskt Centrum. ��
Centre for Teaching and Research in
Disaster medicine & Traumatology
MD Medical Doctor
METHANE Structure of first report from scene
MIMMS Major Incident Medical Management and Support
MMT Mobile Medical Team
OBS Observer
OR Operation room
PI Performance Indicator
POL Police
SI Senior Instructor
SIC Senior Instructor Course
TT Trauma Team
TT1 Trauma Team one

Content
Preface 2
Editors 3
Abbreviations 4
1. Introduction 8
2. General description of the Emergo Train System 10
2.1 History of the Emergo Train System 10
2.2 Emergo Train System; technical simulation exercise
characteristics
2.2.1 Learning with Emergo Train System 11
2.2.2 Target group 12
2.2.3 Scope of Emergo Train System 12
3. ETS simulation exercise techniques and evaluation 13
3.1 Time 13
3.2 Process stages in Emergo Train System 13
3.2.1 Roles in the Emergo Train System 14
3.3 Dynamics 15
3.4 Interventions 15
3.5 Evaluation 16
3.5.1 Knowledge 16
3.5.2 Aims, goals and objectives 16
3.5.3 Indicators 17
3.5.3.1 Patient outcome indicators 17
3.5.3.2 Performance indicators 17
4. Description of the ETS material 23
4.1 The ETS material 23
4.1.1 Staff symbols 24
4.1.2 Vehicles 24
4.1.3 Signs 24
4.1.4 Patient and management cards 25
4.1.4.1 Patient bank 25
4.1.4.2 Management cards 25
4.1.4.3 Trigger patients 26
4.1.4.4 Hospital patients 26
4.1.5 Markings 27
4.1.6 Preventable death/complications 28
4.1.7 Categories 28
4.1.8 Other ETS material 28
4.1.8.1 Resources, conditions 29
4.1.8.2 Maps 29
4.1.8.3 Reports 30
4.1.8.4 Photos 30
4.2 How to use the ETS material 31
4.2.1 Staff symbols 31
4.2.2 Vehicles 31
4.2.3 Signs 31
4.2.4 Patients and management cards 31
4.2.4.1 Patient bank 31
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4.2.4.2 Management cards 32
4.2.4.3 Trigger patients 32
4.2.4.4 Hospital patients 32
4.2.5 Markings 32
4.2.5.1 Markings for treatment 32
4.2.5.2 Markings for triage 33
4.2.5.3 Markings for command 33
4.2.5.4 Markings for indicating special circumstances 33
4.2.5.5 Markings for unfavourable outcome 33
4.2.6 Preventable death/complications 33
4.2.7 Categories 34
4.2.8 Other ETS material 34
4.2.8.1 Resources, conditions 34
4.2.8.2 Maps 35
4.2.8.3 Reports 35
4.2.8.4 Photos 35
4.3 Example of set ups of the whiteboards 36
4.3.1 Board one: Resources 36
4.3.2 Board two: Arrival time 39
4.3.3 Board three: Incident site 41
4.3.4 Board four: First Aid Post 43
4.3.5 Board five: Resources for transport 45
4.3.6 Board six: Hospital Emergency Department 47
4.3.7 Board seven: Hospital Surgery 49
4.3.8 Board eight: Hospital ICU 51
4.3.9 Board nine: Arriving staff 53
5. Scenario guidelines 55
5.1 Introduction 55
5.2 Scenario guideline minibus 57
5.3 Scenario guideline hazard 60
5.4 Scenario guideline fire 63
5.5 Scenario guideline triage 68
5.6 Scenario guideline stadium 75
6. Basic Instructor course 85
6.1 Basic Instructor 85
6.2 Basic Instructor program 85
7. ETS Doctrine 87
7.1 Introduction 87
7.2 Basic outlook in management 87
7.3 Components and roles 89
7.4 Communication, alerting plans, reports 91
7.5 Guideline decisions in medical management 92
7.6 Laws, regulations and liaison 94
7.7 Additional reading about management 95
8. Emergo Train System Concept 96
Introduction 97
Roles and responsibilities 98
ETS Quality control board 100
License concept 102
Action process to implement a license 106
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9. Copyrights 108
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1.Introduction
1.1 Description of the system
Emergo Train System (ETS) is a pedagogic educational simulation system used in
several countries around the world.
The system is simple to use and does not require any sophisticated equipment. It is
based on magnet symbols on white boards representing patients, staff and resources,
movable markers indicating priority and treatment and a large patient bank with
protocol giving results of treatment based on trauma score.
The ETS is an educational tool for training and testing the preparedness and
management of major accidents and disasters. It is not a course in disaster medicine
itself and not a concept that tells how to handle a major incident. This means that it
does not compete with any educational concept or doctrine but it is a tool that can be
used in a variety of educations, from basic to advanced level, in the field of disaster
medicine in any country.
Organisations dealing with disaster managements must have a line of regulations and
rules to follow. These rules must be accepted and wide spread within the organisation.
If not, there is a risk of chaos, unfavourable results and it will be impossible to evaluate
performances. ETS can be used with any kind of doctrine. It can also be used to point
out the need for a doctrine and of course to teach various doctrines or to test the
effect of using different doctrines. The content of the chosen doctrine must always be
understood by all participants in a course and that is the responsibility of the senior
ETS instructor.
For practical reasons there is an ETS doctrine available as an example. The theoretical
background to this comes from the Viable System Model; a model that has been the
foundation when designing line of regulations for different emergency services in
different parts of the world.
The most relevant data regarding results from disasters and major incidents is the
patient outcome. Patient outcome is the ultimate indicator on how a situation was
managed. It is therefore crucial that this is reflected in the simulation system. The ETS
way of addressing this is by including performance indicators for management including
logistics and for each and every patient symbol in the system. If defined measures are
not performed within defined time frames the patient may risk unfavourable outcome.
The introduction of performance indicators could provide new ways of approaching
disaster medicine both as a quality tool and scientifically, in education and also in real
life.
The need of training as a key element of the preparedness and management in

major incidents and disasters is today generally agreed upon. The use of pedagogic
educational simulation systems for this purpose is non controversial.
- The ETS is a well -recognised system for these purposes.
- It is adaptable to any organisation or way of working and does not implicate or

change any methodology, but still gives an objective result that can be used for
further development of the own organisation.

- It is based on extensive clinical experience , giving a sense of realism. One strength
is the large patient bank with the connected programme, which is the core of the
system.

2. General description of the Emergo Train System
2.1 History of Emergo Train System
Emergo Train System was developed by Prof. Sten Lennquist in the early 1980s. The
first version of ETS was based on simple magnetic ‘buttons’ with different colours
symbolising what staff it was. Orange for a paramedic, black with white dot was a
fireman and black with yellow spot a fire officer. The ambulances, police cars and fire
brigades were symbolized by using laminated photos of such vehicles.
The patients were magnetic ‘buttons’ with a number on the front side. The user of
the system then had to look at a paper to see the description of the patients. Using
triangle-shaped magnetic symbols added next to the patients, they could be prioritised.
Today ETS look very different from its early days but the basic idea is still the same,
magnetic symbols, which are simple to use when running both small and large
simulation exercises.
ETS was in the beginning used on courses at the Centre for Teaching and Research
in Disaster Medicine and Traumatology. It was an easy and cost-effective way to use a
whiteboard with magnets when demonstrating for example the incident site of a large-
scale accident or medical organisation of a first aid post. Since ETS showed to be a
very good pedagogic tool it was spread both in Sweden and internationally and is today
used in several countries.
Over the last decade, Emergo Train System has been proven as a useful tool for
training organisations on the international arena (in particular with a medical focus) in
dealing with major incidents. The total Emergo Train System concept is best described
as a system for simulating the organisation of above all the medical emergency
services chain in the repression phase at operational-tactical level in the event of
major incidents. In its current form, therefore, it is a simulation system dealing with the
organisation and coordination of multidisciplinary emergency medical care.
The vision of Emergo Train System is that training and practising the organisation of
emergency medical care for major incidents is only worthwhile if based on realistic
data. The reality content of Emergo Train System is reflected by the real time and
interactive character of the simulation, working with realistic resources (available
personnel, equipment and facilities) and the scientifically accurate pool of patients,
based on realistic physiological parameters. As a consequence, participants in the
simulation session are actually required to cooperate, communicate and take decisions
based on the resources available to them. In addition, the decisions taken will have
consequences for the situation of other participants.
Fig 1 Staffsymbols first version of ETS Fig 2 Vehicles first version of ETS
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2.2 Emergo Train System; technical simulation exercise
characteristics
The Emergo Train System is a simulation focused on contingency planning and
disaster medicine. The simulation has been developed to support participants in
learning to deal with major incidents. Emergo Train System covers the entire medical
‘chain’ from pre-hospital right through to hospital treatment. In addition to these
characteristics, Emergo Train has a number of further specific technical, simulation
exercise characteristics, namely:
• Emergo Train System as a simulation framework

this means that ETS is a very flexible game simulation. A number of components are
fixed, and together represent the Framework or backbone of ETS. This framework
can where necessary be supplemented with additional components. In this way,
ETS can be tailor-made to specific development, learning or change requirements
from the organisations involved.
• Emergo Train as a linear simulation

ETS is a simulation tool based on a linear scenario. This means that the participants
work through a consecutive chain of activities. This is unlike cyclic scenarios,
whereby participants work through a repetitive chain of activities.
• Emergo Train as an interactive simulation

Emergo Train facilitates and promotes dialogue between the participants. Together,
they ‘generate’ the dynamics in this game simulation. This makes Emergo Train a
particularly powerful tool. In addition to content-based learning experiences and
learning experiences at process/procedure level, the participants will also learn
about the way in which they cooperate/interact in difficult situations. Within this
setting, the participants experience ‘live’ whether the choices made and decisions
taken were effective and/or efficient.
• Emergo Train System is not a normative game situation

This means that the system provides no job-specific guidelines or doctrines for the
actions of the emergency services representatives.
2.2.1 Learning with Emergo Train System

ETS can be broken down into a pre-hospital, a hospital component and medical and/
or ambulance coordination component. The pre-hospital component deals with the
management of the accident, from the first incident report. The hospital component is
focused on dealing with the incident following the first incident report, within hospitals.
The hospital and ambulance coordination component deals with alerting, alarming
transport resources and the distribution of patients to correct facilities.
ETS can be flexibly deployed, depending on the learning targets of the participating
group. ETS facilitates exercising with:
• procedures/doctrine
• triage methods
• multidisciplinary pre-hospital cooperation
• (multidisciplinary) hospital cooperation
• priority setting
• handling the effects of (the lack of) time and/or resources
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• interaction between parties involved
• cooperation by parties involved
• fulfilling the individual role within the chain
• dealing with high-pressure and hectic situations
• dealing with disruptions and incidents
2.2.2 Target group

Participation in ETS is possible, on the basis of the following conditions. The
participant:
• is conversant with the basic processes, procedures and officers involved in dealing
with a major incident
• has the knowledge necessary to be able to adequately perform his own professional
tasks in the event of the occurrence of a major incident
Note: sufficient medical knowledge in disaster medicine and disaster management

must be available within the participant group.
2.2.3 Scope of Emergo Train System

ETS is focused on the medical chain in dealing with major incidents, and can at present
be deployed in one of three ways:
• as a demonstration tool: facilitating either a pre-hospital or hospital consultation/
discussion session, based on materials
• as a total simulation: interactive simulation whereby the pre-hospital and hospital
components are integrated
• as a part simulation: interactive simulation of either the pre-hospital or hospital
component
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3. ETS simulation exercise techniques and evaluation
This paragraph contains a description and analysis of the game-technique aspects of
ETS. The following aspects will be discussed:
• Time
• Processes
• Roles
• Dynamics
• Interventions
• Indicators
In the analysis, an observation is made of the consistency of the game techniques and
the effects of the choices made on learning.
3.1 Time
In Emergo Train, time runs according to the clock (real-time). All the activities of the
participants also last as long as they would in reality. For example, if in reality it takes
10 minutes to transfer a victim from the wreck to the treatment post, this will also be
the case in Emergo Train System. People and resources are necessary for moving
this victim and for these 10 minutes transport time, the equipment and personnel are
not available for other activities. Time is usually not accelerated to shorten the duration
of the simulation. However, to move the clock can be used as an intervention (see
chapter 3.4).
3.2 Process stages in Emergo Train System

Emergo Train System can in general be broken down into a pre-hospital section and a
hospital section. In addition, the ETS also have the components ECC, dispatch. If the
decision is made to deploy the full ETS (the total chain), ETS starts simultaneously for
the two components. For these components, during the course of the simulation, the
dynamics will vary considerably.
The participants in the pre-hospital component are very active right from the first
incident report. The first group of participants that are active are those simulating
dispatch alert and ambulance coordination. They are confronted with the chaotic
situation immediately following the incident and are required to establish, coordinate
and implement the entire handling of the incident.
The first incident report puts the participants in the hospital coordination component
in a state of preparedness where early decisions on the distribution of patients will be
done.
The last group of participants is usually those at the receiving hospitals. However
interventions (see chapter 3.4) such as walking wounded arriving at hospitals may in
fact cause a very early start at the hospitals.
The ETS simulation broadly speaking passes through the following process stages:
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Prehospital:
• 1st incident report
• arrival at incident site
• first series of actions
• triage
• start of casualty transport
• actions in further treatment
• shutdown actions at incident site
Hospital:
• initial announcement by control room or trauma team
• arrival of 1st spontaneous patient
• influx of hospital staff involved
• arrival of 1st planned patient
• reception at Emergency department
• transfer through hospital
• dispatch
• ambulance coordination
• hospital coordination
• harmonisation between hospitals
The discrepancy in dynamics matches the real life situation and allows the participants
to experience the effect of uncertainty (in the hospitals) and underlines the importance
of sound communication.
One major disadvantage is the lengthy calm period for participants in the hospital
component. They have little work which can result in ‘out of simulation’ behaviour: e.g.
discussions of their own reality.
3.2.1 Roles in the Emergo Train System

Depending on aims and target group some of these roles will be played by instructors.
Overview of the possible players in ETS:
• Paramedic 1st ambulance

• Driver 1st ambulance
• Paramedic ambulance X
• Driver ambulance X
• Head of Casualty cluster
• MMT physician
• Duty Medical Officer
• Coordinator for Casualty transport
• Dispatch
• Ambulance loading officer
• Ambulance coordinator
• Fire brigade senior officer
• Police coordinator incident site
• Emergency physician(s)
• Emergency nurse(s)
• Duty specialist(s)
• Emergency department secretariat
• Hospital coordinator
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• Head of admissions
• Head of ICU
• Head of operating theatres
• Ambulance coordination centre
• Dispatch
• Hospital coordination centre
3.3 Dynamics
The dynamics within ETS can be described on various levels.
Between players
Dynamics between the players will take place at content, procedure and interaction
level. At each of these three levels, discussions will take place and choices must
be made. On a continuous basis, players will be confronted with the relevance and
consequences of a particular choice (e.g. treatment) for the implementation of tasks by
other colleagues.
Between the players and instructors

The instructors act at various moments as points of release and critical sounding
boards for the participants. During timeouts, the instructors will allow players to reflect
and assist them in their processes of reflection.
3.4 Interventions
An intervention in a simulation exercise is an inject event that can be fired in three
principally ways. Firstly it could be fired by the game itself, i.e. when running a
simulation there are certain pre-programmed events that will happen in a sequential
order on special times. Secondly participants can make interventions. By this we mean
that the interactions between the participants in a simulation can trigger reactions
and/or actions that might not have been anticipated. The third type of interventions is
the ones that are done by the instructor. This is the type that we will focus on in this
paragraph.
An intervention is something that is done or created by the instructor in order to trigger

a reaction or certain behaviour of the participant(s). Interventions must have a purpose,
an adequate timing, a pre-planned way of execution, and a pre-planned way of how the
reaction should be evaluated. There must also be a preparedness of what the next step
(intervention) could be if reactions anticipated do not occur.
When interventions are planned you should always address the issues of:
Why? When? How? Evaluate? What if? And of course the issue of documentation.
Never make
1) interventions that have no or minimal relevance.
2) interventions with purpose to throw participants off the track.
3) interventions where results cannot be evaluated
Plan as much of your interventions ahead and try to minimise ad-hoc solutions.
However, it is understandable that there may be times when participants behave in an
unpredicted manner and an intervention that is not pre-planned is needed to put them
back on track.
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3.5 Evaluation
Why evaluate?
Evaluation is the key to how lessons observed could be lessons learned. Without an
adequate evaluation there is an obvious risk that the same behaviour and performance
will be repeated in incident after incident. A good evaluation, however, will stimulate
the learning process and give students a clue as to what was good and what needs to
be improved. Since the aim of teaching often is to change behaviour there are certain
aspects that the teacher and/or instructor need to consider. The following points should
be regarded as our view of what a senior instructor need to know in order to evaluate
an Emergo train session. These suggestions are conclusions from years of Emergo
train experience but do not aspire to be the results of pedagogic research or expertise.
3.5.1 Knowledge
Know your group of students
This might sound un-necessary to point out. Of course every teacher knows in what
group he/she is teaching. There are always, however, students that know more, have
special interest or for other reasons do not fit into what is expected from a certain
group. Let it be ambulance technicians, paramedics, physicians or other groups.
If possible, read the applications forms that the students have filled in and look for
specialists in different fields. By knowing the student group in advance you as an
instructor can be better prepared for questions that might arise and you can also have
a clue to whom you can redirect certain issues if brought up.
Know the students level of knowledge
This is a difficult subject that needs to be treated with finesse. Often people that
come to training in disaster medicine are quite convinced that they already know what
there is to know. This can create a problem when running simulation exercises in
simulation mode since these often require that students actually have a certain level of
knowledge. If a student holds a position in a simulation mode exercise and obviously
does not have the required knowledge this can create a situation where this person
could become very upset or a situation where the simulation exercise is more or less
ruined. This must, of course, be avoided. Be aware of that there is different levels
knowledge and make sure that the student group have the level for which you have
designed the simulation. For example: if you want to test an organisation or disaster
plan and there is no knowledge in the group about the disaster plan in question this
will create a problem during evaluation. Do you evaluate the knowledge of the plan or
the plan itself? Or do you evaluate the knowledge in disaster medicine? Remember:
evaluation is the key to turning lessons observed into lessons learned and therefore the
issue of level of knowledge is important already when designing your exercise.
3.5.2 Aims, goals and objectives

Set aims
One of the first issues that you need to address before designing your simulation
exercise is the aim or the aims of the exercise. The aim should be the answer to the
question “why” you do something. The aim can therefore never be to train or to teach.
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Often setting aim/s is a process that addresses on the core questions. Therefore it is
advisable always to start with formulating aim/s in process. After all, if the question
“why” cannot be answered properly there is really no reason to start teaching or training
at all! Examples of aims in relation to goals are shown later.
Goals
Goals describe what you overall want to achieve. The goal is something that is desired
to be accomplished at the end of simulation. Goals cannot be an activity, for example
“to train or to test”. If an activity like training would be a goal, you will always reach your
goal, which of course is not true. The goals must be related to aim/s. The goal/s must
be one mean to fulfil, or come closer to the aim.
Objectives
An objective is a goal that can be measured. By setting your objectives you take a step
closer to being able to record observations that can be compared. If something can
be measured, statistics can be used to demonstrate differences. Measurable goals
are something that so far has been quite sparse in the field of disaster medicine but is
more and more asked for. Measurable observations are one of the tools in changing
disaster medicine more into an analysing science and not only an observing one.
3.5.3 Indicators
In a good simulation, indicators have been elaborated, which provide the players with
an insight into their performance (during the simulation). This allows the players to hold
well-considered discussions on the problems they are experiencing and the way they
wish to solve those problems. Good indicators generate objective feedback for the
players on the effect of the choices made on their performance.
3.5.3.1 Patient outcome indicators

At present, ETS offers two measurable indicators related to outcome of patients:
• risk of preventable deaths
• risk of preventable complications
These indicators provide an insight into the effect of the choices made. In this respect,
the instructor can opt to ‘mark’ patients who enter these categories in a simulation (this
is the preferred option) or to wait until the end of the simulation to mark these patients.
These indicators should be evaluated with regard to the evaluation of the performance
indicators.
3.5.3.2 Performance indicators

Here is where you decide what is good or bad! A performance indicator is the level of
measurable goal that you think is good standard. To be able to decide on this you must
have subject matter expertise immediate available. Introducing performance indicators
may cause emotions and the senior instructor must be able to defend the ones chosen.
At the same time, the instructor must be aware that all yours performance indicators
may not be accepted. This must not stop you from using them, for it is important that
you as an instructor can give feedback as what you consider good or bad after a
simulation exercise. This is maybe the most important lesson that students get. By
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using performance indicators the evaluation will have a better chance of not being
emotional. Besides this, the instructor can always show the indicators in advance so
that students know what is good standard. If the chosen performance indicators are
challenged, this discussion is easier to have in beforehand than after a simulation
exercise.
Result
This is what the students have achieved when you sum up all performance indicators.
Make sure that you are able to record the result. Stick to the results when evaluate
Evaluate
By using your performance indicators as a template you can compare them to the
results and get an overall picture of the simulation exercise. You can use scoring
systems ( 1 pt, 2pts 3pts etc.) and decide whether the student/s passed or not.
Regardless of which, you have the possibility to give the students information what
was good and was less good. Remember, you can only be as precise as your chosen
performance indicators.
Give feed back, document
After training give feed back. Use the indicators and let students discuss results. These
discussions will often focus on the process that led to different decisions and thereby
will create another possibility for the students to learn. Document all results as well as
your sets of performance indicators. Often the students initiate the process of analysis
of why certain performance indicators were met and others not. As an instructor your
task is to facilitate this process, when needed.
Analyse results, change training or send to competence centre
This is a very important step in improving knowledge in disaster medicine. We are

aware of that this may not be the interest of all education or training centres, but
still, there is a need for these processes to be done. If you yourself cannot or do
not have possibilities to analyse results, do not hesitate to call your national service
centre or the Competence centre in Sweden. It is by analysing results and studying
shortcomings we have the opportunity to improve both simulation exercises but also
the Emergo train system itself. Results from training must also be compared to results
from real incidents. It is our belief that if this process of evaluation must be continued
by application on real incidents this could create a new and possibly more scientific
approach to the subject of disaster medicine. And furthermore it is by analysing results
that you can get clues on how to improve your training.
Remember….
Always start your next exercise by reviewing the results from your last. Make sure that
also you learn lessons and not only observe.
Example that demonstrates relation between: aim, goal, objective and performance
indicator.
Aims, goals, performance indicators and objectives.
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Intended training: Secondary triage on-scene
Aim: To ensure optimal treatment for patients involved in major incident
Goal: Students should know the principles of secondary triage
Objective: 1) Number of avoidable deaths

2) Number of victims without life threatening complications

Performance indicator:
15 points or more according to decision template for strategic management, prehospital
command and control
Patient outcome indicators:

• No avoidable deaths
• No avoidable complications
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Performance indicators
Prehospital Command & CONTROL
GROUP:
Correct 2 pts
Measurable Within ….min from arrival Partly correct 1 pt
indicators on scene Incorr./Omitted 0 pt
Putting on tabard Directly

First report to dispatch 2 min
Content of first report METHANE
Formulate guidelines for 3 min

response
Establish contract with 5 min

strategic level of command
Liaison with fire and police 5 min
Second report from scene 10 min
Content of second report Verifying first report Indicating

first patient transport
Establish level of medical 10 min
ambition
First patient evacuated 15 min
Information to media on 30 min

scene
TOTAL
Approval level > 11 pts
Fig 3 performance indicator prehospital command and control
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HOSPITAL MANAGEMENT
GROUP:
Correct 2 pts
Measurable Partly correct 1 pt
Within ….min from alert
indicators Incorr./Omitted 0 pt
Decide on level of 3 min

preparedness
Formulate guidelines for 15 min
hospital response
Inform media 15 min
Give information about 25 min

resources to strategic level
Ensuring that there is a 30 min

medical officer in
Emergency
Operation
Estimate need of ICU beds 45 min
First information to staff 60 min
Estimate endurance of staff 90 min
Evaluate and report 120 min
estimated shortage of own
capacity
Evaluate influence on the 120 min
daily hospital activities
Information plan for patients 180 min

with postponed
appointments and
operations
TOTAL
Fig 4 performance indicator hospital management
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STRATEGIC MANAGEMENT
GROUP:
Correct 2 pts
Measurable Partly correct 1 pt
Within ….min from alarm Incorr./Omitted
indicators 0 pt
Declaring major incident 1 min

Deciding level of 3 min
preparedness
Decision on additional 3 min
resources to scene
Deciding on receiving 5 min
hospitals
Establishing contact with 10 min

incident officers at scene
Deciding on guidelines for 10 min
referring hospitals
Brief information to media 15 min
Formulate general 15 min
guidelines in accordance
with guidelines from scene
Make sure there is 20 min
information for definitive
referral guidelines
Evaluated if capacity of own 30 min
organisation is sufficient
Notify guidelines on 40 min

referring hospitals
TOTAL
Fig 5 performance indicator strategic management
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4. Description of the ETS material
Emergo Train System is a simulation for the actual provision of emergency services in
the event of major incidents or disasters in real time. The entire emergency services
chain – from the scene of the incident right through to the treatment department in the
hospital – participates in the situation, without even a single emergency vehicle having
to leave the premises.
The basis of Emergo Train is an extensive database with realistic reference figures,
including those from the ambulance support plan and the casualty distribution plan
for the participating organisations. The system also contains a patient bank of patient
symbols with realistic information about their condition, recommended treatments and
expected developments over time. The patients belongs to a certain cathegory with a
certain outcome.
The exercise is simulated on whiteboards with magnetic symbols: patients, emergency

services workers, police, triage team and hospital resources. The markers show the
current state of affairs on the disaster site and in the hospitals, and visualizes the
decisions of the exercise participants.
The description of material in this manual is based on version 2 of Emergo Train

System. Version 2 was released autumn 2005.
4.1 The ETS material

The Basic set consists of material used for setting up a pre-hospital exercise; a patient
bank including patient management cards, signs, staff symbols, vehicles, markings etc.
The Hospital set consist of material for setting up one large hospital; signs, markings,
staff symbols with different specialities of doctors and nurses in a hospital and special
patients for hospital. The Introduction set consists of parts of the Basic set; some of the
patients, markings and scenario guidelines. This set is to be used when running pre-
hospital exercises.
Described in this manual are the standard symbols for ETS. The symbols can be
customized and special symbols be made by the ETS Competence centre upon
request. A more detailed list of content for the standard Basic and Hospital sets can be
viewed on ETS website www.emergotrain.com
23
4.1.1 Staff symbols
A number of magnetic staff symbols are included in the ETS material. The pre-hospital
part contains for example ambulance paramedics, triage teams, police and rescue
symbols and the hospital set consists of doctors and nurses with different kinds of
specialities.
Fig 6 Staff symbol nurse triage team

Fig 7 Staff symbol rescue officer
Fig 8 Staff symbol ambulance/paramedic Fig 9 Staff symbol doctor anestesiology
4.1.2 Vehicles
The Basic set consists of a number of magnetic vehicles used in a pre-hospital setting,
for example ambulances, police cars, helicopters, fire brigade, band wagons.

Fig 10 Vehicle symbol ambulance Fig 11 Vehicle symbol fire brigade
4.1.3 Signs
In the Basic and Hospital sets are a number of signs included. There are large, small
and triangle shaped signs.
Fig 12 Sign large Fig 13 Sign triangle shaped Fig 14 Sign small
24
4.1.4 Patients and management cards
There are three different types of patients in the ETS; patients with different injuries
included in the patient bank, trigger patients and hospital patients.
4.1.4.1 Patient bank

The patient bank includes 369 magnetic patient symbols and 299 magnetic patient
management cards. Each patient has a number that is its identity.
The patient has text on both the front- and backside. On the front is information what
you can see or hear from a distance. For example the patient is lying down, being
quiet. On the backside, is information that you find when you examine the patient. This
text is in concordance with the ATLS® program, A=Airway, B=Breathing, C=Circulation,
D=Disability, and E=Exposure.
Fig 15 Patient frontside Fig 16 Patient back side
4.1.4.2 Management cards

The management cards have also a front- and backside. A number on the front side
relates to the patient number. For example patient management card number 12 is
connected to the patient with the same number. On the front side of the management
cards is written sex and age of the patient, health history (if known) and what treatment
the patient is given at the emergency department. If the patient needs surgery or ICU
this information is described on the backside of the management card.
Fig 17 Patient management card frontside Fig 18 Patient management card back side
25
4.1.4.3 Trigger patients
There are also patients called “trigger patients” who have ‘normal’ everyday injuries
not related to the disaster. There are a total of 12 different kinds of trigger patients.
To separate them from the other patients, they have a letter in there face instead of a
number.

Fig 19 Trigger patient Fig 20 Trigger patient management card
4.1.4.4 Hospital patients

The hospital patients have a front- and backside. On the front side is information of
the patient (sex, age) and a short description of the injury. On the backside is written
where the patient should be placed (ER, OP or ICU) and how long time the patient
needs treatment on these departments. There are patients for Emergency department,
Surgery and different types of ICU departments.
There are a total of 45 hospital patients. They have no number or letter and do not
have any management card. These patients are included in the hospital set.
Fig 21 Hospital patient
26
4.1.5 Markings
There are five different kinds of markings included in the ETS.
1. treatment of the patients

2. triage
3. command markings
4. markings placed on the patients by the instructor before the exercise indicating
special circumstances (hypothermia, trapped)
5. unfavourable outcome
Fig 22 Marking analgesia (1) Fig 23 Marking oral/nasopharyngeal tube (1)
To know the time it takes to treat the patients, a time schedule is available with
treatment times for each measure.
Fig 24 Time schedule measures
Fig 25 Marking for command (3) Fig 26 Marking for trapped (4) Fig 27 Hypothermia (4)
Fig 28 Marking preventable complication (5) Fig 29 Marking preventable death (5)
27
4.1.6 Preventable death/complications
A template for preventable death/complications helps the instructor to see the outcome
of the patients. On the template, preventable death has a black frame and preventable
complications a red frame.
Fig 30 Template preventable death/complications
4.1.7 Categories
The unfavourable outcome (death or complication) is related to a template where all
patients are divided into 22 different categories (see fig 30). All patients within the same
category needs the same measures in order to avoid unfavourable outcome.
On the front side, down right of the magnetic patient, is the number for which category
the patient belongs to.
Fig 31 Category of patient
4.1.8 Other ETS material

There are a number of symbols and material used for visualising the incident site,
which can be of help when setting up a simulation exercise. Examples of such symbols
are houses and trees. It can also be paper printouts like photos and maps.

Fig 32 Building
28
4.1.8.1 Resources, conditions
A number of tables in Excel are included in the ETS material where information about
resources, transportation time, weather conditions etc. can be written and printed out
on paper.
Fig 33 Transportation tim
Fig 34 Resources hosptial
4.1.8.2 Maps
There are maps made in Power Point, which can be used as they are or the instructor
can remake them after the real geography for the exercise.

Fig 35 Map county Fig 36 Map town
29
4.1.8.3 Reports
Templates for METHANE, verifying- and up-date reports are included in the ETS
material.
Fig 37 Template METHANE report
4.1.8.4 Photos
To make the exercise more realistic a real photo of an accident can be printed out
and added on the whiteboard. In the ETS material are photos of common accidents
included.
Fig 38 Photo accident
There are also realistic photos of patients with injuries included in the ETS material.
The victims’ injuries on the photos correspondent with the patient symbol 1 to 40. The
photos are in a power point presentation. Under the photo is the same text written as
the one on the magnetic patient symbols front- and backside.
Fig 39 Photo injuries
30
4.2 How to use the ETS material
This chapter describe how to use the material viewed in chapter 4.1.
4.2.1 Staff symbols

An important factor in a large accident/disaster is the number of staff you have
available to work on the scene (ambulance staff, triage team, rescue) or in the hospital
(doctors/nurses). In ETS one magnetic staff symbol symbolizes one person/staff. For
example, if there is not a surgeon staff symbol available, it is not possible to perform
any surgery.
It is the ETS instructor who decides, when planning the simulation exercise, the
resources of staffs that are available at the moment of the accident and how many that
can be available within a certain number of times.
4.2.2 Vehicles
During an exercise, one symbol symbolizes one vehicle. An ambulance can transport a
patient if there is staff available who can drive the ambulance.
The vehicles are in the beginning of the simulation exercise on the resource whiteboard
showing the number of resources of rescue, police and medical in the area (see fig
41). During the exercise, the symbols are moved together with the staff symbols, to the
whiteboard where they are used.
4.2.3 Signs
To set up a simulation exercise on a whiteboard, the signs can be used to get a better
overview and structure of the board. The signs have different meaning.
• made-up names of towns (Middletown, Smalltown etc).

• marking out a crucial place or a crucial happening (Site of incident, Rendevouz
point, State of preparedness)
• used to visualise a whiteboard so it is easier to work with it even for someone who
have never seen ETS before (Op-theatre, Theatre blocked until)
• used to indicate when a rescue unit is alarmed and leave the station (Alarm (time),
Leaves (time))
4.2.4 Patients and management cards

There are three different types of patients in ETS.
• patients in the patient bank with different injuries used in the simulation exercises
and for evaluation
• trigger patients with injuries from other accidents and used by the instructor during a
simulation exercise
• Patients that are on the hospitals before the exercise begin
4.2.4.1 Patient bank

All the patients in the patient bank are sorted in 22 categories. Each category has its
special patient outcome although the specific injuries of the patients can be different
within a category. For example, bleeding from spleen or liver will regime the same
treatment as for internal abdominal bleeding. The number of which category a patient is
included is written discreet on the front side, down right of the patient. This information
31
is important for the ETS instructor since the category of a patient is related to the
outcome of the patient.
The patients can be given treatment by adding markings, which can easily be attached
on the magnetic symbols. Treatment can be given on scene, during ambulance
transport or at the hospitals. Read more in chapter 4.2.5.1.
4.2.4.2 Management cards

The management cards are used only at the hospitals. During a simulation exercise the
patient is moved from the on-scene whiteboard to the transportation whiteboard and
the symbol remains there during the time of transport. When arriving to the designated
hospital, the patient is moved to the hospital whiteboard together with the management
card.
On the management card is presented how long time the patient will be treated at
the emergency department of a hospital. The time for x-ray is included in this time. If
the patient needs surgery and/or ICU, time for this is written on the backside of the
management card. In the time for surgery it is included time for transport between ER-
OR-ICU.
If it is noted that the patient should be treated 20 minutes at the emergency

department, the patient occupies an emergency room with staff for 20 minutes. If a
patient needs one-hour surgery, the patient will occupy an operation theatre with staff
for one hour. If a patient needs a ventilator for 4 days, he/she will occupy a ventilator
with staff for the same amount of time.
This means that it is necessary to have the correct staff to treat the patients. It is also
necessary to have available emergency rooms at the emergency department and
available op-theatres/ventilators at surgery/ICU. If not, the patients will not be treated
and will risk unfavourable outcome.
4.2.4.3 Trigger patients

The trigger patients can be used as interventions during a simulation exercise. For
example if the instructor during an exercise wants to put extra pressure on a hospital,
he/she can send in trigger patients. The trigger patients also have a management card
and need treatment in the same way as the other patients.
They are also categorised in the same way as the other patients.
4.2.4.4 Hospital patients

The instructor should when planning and setting up a simulation exercise, add special
hospital patients on the hospital whiteboards. The hospital patients have ‘normal’
injuries and are the type of patients a hospital normally would get an average day. They
occupy resources and it is up to the participants in the simulation exercise to decide
which patients who can be moved or not.
This will add extra pressure on the hospitals. How much pressure the instructor
decides.
4.2.5 Markings
4.2.5.1 Markings for treatment
The patients can be treated for their injuries. When treating a patient in ETS a marking
(sticker) symbolising the treatment is added on the patient symbol. There are markings
32
for all the common treatments, i.v. fluid, analgesia, stiff collar, intubation, prone position
etc.
There are also markings for material like blanket and stretcher.
Time is a crucial factor in ETS. To treat a patient, a staff symbol (symbolizing a

paramedic, doctor or nurse) will be occupied with that patient during the time the
treatment takes. How long time is depending on the kind of treatment given.
For this purpose a time schedule (fig 24) for the measures is made for each treatment.
This schedule is made from studying students and hospital staff in their daily work. For
example, setting an i.v. needle take 4 minutes for an experienced staff or under optimal
conditions. The same treatment will take 8 minutes for an less experienced staff or
under sub-optimal conditions. Giving i.v. fluid to a patient will take 2 minutes for an
experienced staff but 3 minutes for an less experienced staff. The instructor decides in
forehand if the times for experienced or less experienced staff will be used. If decided
to use experienced staff, it would in this example means that one staff is occupied with
a patient for 6 minutes setting i.v. needle and giving i.v. fluid (4 minutes + 2 minutes).
4.2.5.2 Markings for triage

When triage will be made, there are markings in the colour of red, yellow, green and
black to be used and added on the patient symbol.
4.2.5.3 Markings for command

Command markings are available for rescue service, police and medical care. These
markings are added on the staff symbol in command.
4.2.5.4 Markings for indicating special circumstances

Markings can also be used by the instructor and added on the patient before the
simulation exercise starts. The instructor might want to simulate an accident where
some of the patients are trapped in for example a car wreck. A marking for trapped
attached on the patient symbol means this patient cannot be moved before the rescue
service can open the car wreck and take out the patient. The instructor decides when
the marking will be taken off. There are also markings symbolising hypothermic
patients.
4.2.5.5 Markings for unfavourable outcome

If the patient is dead or got a complication, the instructor can add a marking for
preventable death or preventable complication on the patient.
4.2.6 Preventable death/complications

Risk of preventable death/complications is the result of the outcome of the patients.
The patients die or risk complication on consequence of stipulated treatment or
measures not being performed within the timeframes.
Type of treatment is the markings added on the patient symbol like i.v. fluid, fracture
stabilisation, chest drain etc. It can also be if the patient has arrived to the surgery or
ICU at a hospital.
Time is calculated from the time when the incident occurred.
33
4.2.7 Categories
During or after a simulation exercise, the instructor looks at the category number on the
patient symbols and checks the outcome by using the preventable death table (fig 30).
If for example, a simulation exercise have been going on for 2 hours and a patient in
category 1 is not treated with any kind of measures, the patient will be dead. As seen
in figure 30, patients in category 1 needs to be treated by being in a prone position, get
a nasopharyngeal tube and oxygen within 1 hour after the accident or he/she will die.
The same patients also need a rigid cervical collar within one hour or he/she will get a
preventable complication.
If the patient is dead or got a complication, the instructor can add a marking for
preventable death or preventable complication on the patient. There is also a template
for preventable death where the instructor or facilitators during the exercise can check
preventable death/complications and also write down at what place in the chain it
happened. Was it during ambulance transport, at the hospital etc. This template is
useful during an evaluation after an exercise.
4.2.8 Other ETS material

4.2.8.1 Resources, conditions
When the instructor is designing an exercise it can be a good idea to decide
parameters for the simulation exercise that the participants need to know or might ask
about. It can also be of importance when setting up the whiteboards. For example what
day of the week will the simulation exercise occur in the exercise? If it is a Saturday,
less staff will be available on the hospitals since most people work on weekdays. Is it
day or night? Time of the year; summer, winter? How are the weather conditions, rainy,
cold, warm? An excel sheet named conditions is available where the instructor can
write all those facts and print out on paper and add for example on a whiteboard.
It is also necessary to decide by forehand how the surroundings of the accident

looks like. How many hospitals is it in the area? How many available ambulances,
fire brigades? What is the distance between the hospitals and the accident? This
information can be written in the excel file resources in sheet facts and be printed
out. The circulation times (the time it take for the ambulances to drive from the scene
of accident to hospitals and back to the scene) is already calculated in the excel file
(depending on the distance written in the excel file) and just to print out. It is of course
also possible to calculate your own circulation times and fill it in the table.
The information of resources is also useful when setting up the resource whiteboard.
The person (instructor or facilitator) who set up the whiteboard can easily see what
number of resources (ambulances, fire brigades, staff symbols or ambulance, triage
teams etc.) that should be set up.
When planning and setting up a hospital whiteboard, a similar excel file is available
called resources hospital. In the sheet named Facts the instructor fill in the information
that is necessary to have on the whiteboards:
• Type of hospital; University hospital, County Hospital or Regional Hospital

• The name of the town where the hospital is located
• Distance between the hospital and the scene of accident´
• Total number of ER rooms at the Emergency department and how many of those
who are occupied
34
• Total number of OP theatres at the Surgery and how many of those who are
occupied
• Total number of ventilators at ICU and how many of those who are occupied
• Total number of other beds at ICU and how many of those who are occupied
• Total number of ventilators at Post-op and how many of those who are occupied
• Total number of other beds at Post-op and how many of those who are occupied
In the same excel file the instructor can also fill in the number of doctors and nurses of
different specialities that is working and are available at the hospital. These doctors and
nurses symbols should be added on the whiteboard at the different departments.
At a disaster more staff will be called in to work at the hospital. The instructor can
decide before the simulation exercise how many staff of different specialities that will
be called in and who will be arriving within 30 minutes, 60 minutes and 2 hours. These
symbols are added on another whiteboard and are moved to the hospital whiteboard
during the exercise.
4.2.8.2 Maps
Many participants and also the facilitators and instructors are helped during an exercise
if they have a map over the geographic area where the simulation exercise is taken
place. The area can be for example a county or a town. A simulation exercise can be
designed after real geography or made up. The maps can be simple just showing the
different cities where the hospitals are and distances or be more detailed with names of
streets. It is a good idea to print out the maps on paper and give to the participants. In
the ETS material maps are available made in power point. These maps can be used as
they are or the instructor can remake them after the real geography for the exercise.
4.2.8.3 Reports
Available reports in ETS are METHANE-, verifying- and up-date reports. The reports
are congruent to the performance indicators. These reports are useful if the instructor
during the simulation exercise also wants to train the participants in reporting from
scene of accident.
4.2.8.4 Photos
To make the exercise more realistic a real photo of an accident can be printed out and
added on the whiteboard. This photo can be useful also when the participant during
an exercise will give the first report of what he/she sees on the accident. In the ETS
material are photos of common accidents included.
There are also realistic photos of patients with injuries included in the ETS material.
The victim’s injuries on the photos correspondent with the patient symbol 1 to 40. The
photos are in a power point presentation. Under the photo is the same text written as
the one on the magnetic patient symbols front- and back side.
35
4.3 Example of set ups of the whiteboards
To use the Emergo Train System it is recommended (but not necessary) to use
magnetic whiteboards. The material can also be used placed on for example tables.
But to get a good overview and be user-friendlier we recommend white boards.
This chapter will describe the whiteboards, how to use them and how to set them
up. This document relates to a single possible set up and is an example of how the
whiteboards can look like. There is no rule how a whiteboard should look like or be set
up. The standard setting shown here are for the whole chain of a large-scale exercise.
Most simulation exercises are smaller and maybe only using a few of the whiteboards
shown here.
The number of whiteboards to a hospital depends on the size of the hospital. A large
hospital might need three whiteboards, a small only one. In a Hospital set is material
available to set up a large hospital.
In this example we have used the setting for a large hospital with three whiteboards.
It is also important to know that all the material (signs etc.) shown in this example
is not necessary for performing an exercise. Sometimes it is easier to just write
with a whiteboard pen on the whiteboard. The Senior instructors have free hands to
experiment and set up the exercises after their own needs.
4.3.1 Board one: Resources (see fig 41)

Purpose of this board:
• to provide all participants, instructors and facilitators a overview of the geographic
are of the incident
• to provide all participants, instructors and facilitators the number of resources in the
area
Users of this board:

Dispatch, rescue service, police
Material for this board:

• excel file resources
• excel file conditions
• staff symbols, vehicles, signs
• maps
On this board, the incident site is represented and names of places surrounding the
incident. Resources of vehicles, ambulances, fire brigades, helicopters etc. are added
in each town. The number of vehicles set up on the whiteboard is the number of
vehicles that will be used during the exercise.
The vehicles need staff as drivers. Next to each vehicle is added the available staff at
the moment the exercise starts. Paramedics should therefore be placed next to the
ambulances, which will be available when the exercise starts. The ambulance with no
staff is not available before staffs have been called in. The same with rescue and police
personnel. If there is to little space on the whiteboard to put up all the symbols, the
available number of staff can be written with a white board pen (see fig 40 for detailed
example of a town).
36
Fig 40
On this board it is also good to set up the print outs for weather condition, time of
accident and photo of the incident.
When the exercise starts, the different rescue services, ambulances etc are alerted. To
get a good overview of what units and when they where alerted, the triangle shaped
alarm signs can be added next to the units and then write the alarm time with a white
board pen next to the sign. The same procedure with the sign Leaves, when the unit is
leaving.
37
RESOURCES
MIDDLETOWN
38
COUNTY
NORTH CITY HOSPITAL
UNIVERSITY TRIAGE TEAM

HOSPITAL
TRIAGE TEAM WESTFIELD
CLOSE HILL
RENDEVOUZ POINT EASTFIELD
DARKWOOD
SMALLTOWN
REGIONAL CARE VALLEY SOUTHFIELD

HOSPITAL
LONG RANGE
AIRBASE
PRIMARY CARE
TRIAGE TEAM CENTER
Fig 41 board resources

4.3.2 Board two: Arrival time (see fig 42)
• to provide all participants, instructors and facilitators an overview of the personnel
and equipment on site

Dispatch, rescue service, police

• staff symbols, vehicles, signs
• maps
When the different units have been alarmed, the magnetic symbols (vehicles and staff)
are taken from the resource board to the arrival time board and added in the column for
unit. In the column for checkpoint is written the time when the unit expects to arrive to
check point. When the unit is expected to arrive on the scene is written in the on scene
column. The instructor can decide these times in forehand.
The arrival time board is not necessary to use in all exercises. In a small exercise a
paper can replace the board and the instructor just write the times while the symbols
are moved from the recourse board directly to the board for incident site.
39
ARRIVAL TIME
40
RESCUE SERVICE POLICE AMBULANCE TRIAGE TEAM
UNIT AT R.V.P SITE OF UNIT AT R.V.P SITE OF UNIT AT R.V.P SITE OF UNIT AT R.V.P SITE OF
INCIDENT INCIDENT INCIDENT INCIDENT
15.12 15.27 15.30 15.40
Fig 42 board arrival time

4.3.3 Board three: Incident site (see fig 43)
• to provide all participants, instructors and facilitators a visual overview of the
patients, personnel and equipment on site on the incident site

1st ambulance driver, 1st ambulance, triage teams, rescue service, police

• patients, markings, staff symbols, vehicles, signs
• maps
• photo of incident
On the incident site board is all the patients added. It is a good idea to have this board
covered before the exercise starts so the participants don’t know how many casualties
that are involved. A cardboard model of for example a train if the exercise is a train
accident can be built with the patients hidden underneath. If the cardboard is removed
in sections at fixed times, the victims emerge. This to some extent simulates the time it
takes to release the victims.
The patients can be given treatment on this board. When making a large scenario
it is a good idea to treat the patients on the board for first aid post and instead just
doing triage on this board using the priority markings. To do treatment or triage, the
paramedic must have arrived to the incident site. This is represented by adding the
paramedic staff symbols on the board. It might be necessary to have the rescue service
moving the patients. This can only be made if there is enough rescue staff symbols on
the board or if the instructor decides so.
When the patients are triaged and ready for treatment, the symbols are moved to the
first aid post.
41
42
INCIDENT SITE
Main road
COMMANDING PLACE
SCENE OF INCIDENT
Park
NON-INJURED
DEAD
Park Avenue
Fig 43 board incident site
4.3.4 Board four: First aid post (see fig 44)
• patients receiving treatment
• columns showing times that patient arrive at casualty cluster and time for treatment

1st ambulance driver, 1st ambulance, triage teams, ambulance loading officer

• patients, markings, staff symbols, signs
When the patients are moved from incident site board to first aid post board an
participant (or facilitator) sort the patients with regard to their priority and put them
under respectively sign “Waiting for stabilisation”. Patients that do not need treatment
or have been given necessary treatment on the incident site but need to be transported
in ambulance or other transportation, will be sorted and put to the column Directly to
ambulance loading point.
When a patient is ready for stabilisation the patient symbol is put in the column for
Patient. Stabilisation can only be made if there are available staffs. Therefore, the
necessary staff symbols shall be put in the column for Medical staff. These staff can
only treat and is occupied with one patient. The participant writes the time when the
stabilisation starts and adds the necessary markings for treatment on the patient.
When the markings are added, he/she calculate (please see chapter 4.2.5 Markings)
how long time the treatment takes and write that time in the column for Treatment time
(total). He/she also write what time the stabilisation is finished in column Stabilisation
finished. The time shall be written in real time. The staff will be frozen until the
stabilisation is finished and can then be used for the next patient.
When the patient is treated and ready for transport, the symbol is moved to the column;
Waiting for transport. If it is a large exercise with a lot of patients, it is a good idea to
have a participant or facilitator who decides which patients are most urgent to send to
a hospital. The patients are therefore sorted under red, yellow and green signs while
waiting for transport.
43
AVAILABLE
STAFF
44
FIRST AID POST
WAITING FOR STABILISATION TREATMENT TIME STABILISATION MEDICAL WAITING FOR

PATIENT (TOTAL) FINISHED
STABILISATION STARTED STAFF TRANSPORT
11.00 0.15 11.15
WAITING FOR WAITING FOR

STABILISATION TRANSPORT
WAITING FOR WAITING FOR

STABILISATION TRANSPORT
SORTING
AMBULANCE LOADING
POINT
DIRECTLY TO
AMBULANCE LOADING POINT
DIRECTLY TO
DIRECTLY TO
Fig 44 board first aid post

4.3.5 Board five: Resources for transport (see fig 45)
• to provide an overview of the logistic processes of personal and equipment in the
surrounding region
• to organise the transportation of the patients to the hospitals

Ambulance loading officer, facilitator

• patients, patient management cards, vehicles, staff symbols, signs
• map
• excel file resources
To move the patients from the incident site to the hospitals or elsewhere vehicles
is needed (ambulances, helicopters, buses). The time when the ambulances and
helicopters are on the scene of the incident is written in the column Site of the incident
on the Arrival time board (please see chapter 4.3.2 Arrival time.
When the units arrive, the symbols for ambulances and helicopters are moved from
the arrival time board to this board and added in column Transport. All the resources
of ambulances and helicopter on the site are illustrated on the transport whiteboard.
These are the resources that have arrived. However, it doesn’t mean that they are
ready to use. The vehicles cannot transport patients without a crew. If the crew from
the ambulances are occupied with treating patients on the first aid post, the ambulance
will remain still. This is a decision to make, do we use the staff on the first aid post or
transporting the patients. One patient can be transported in each ambulance and it
needs two paramedics to drive to the hospital. The helicopters can take two patients
and need two paramedics to accompanying the patients. When an ambulance is
ready to go to a hospital the necessary staff symbols are added next to the ambulance
vehicle. The patient is taken from the first aid post board and put in the column Patient.
Next to the patient can the management card with the same number as the patient be
added. The patient management card will be brought to the hospital together with the
patient.
The distance between the site of incident and the different hospitals is made up before
the exercise starts. The facilitator calculate and write destination, time of departure
and arrival time in the different columns by using the print out of the transportation
times which can be added on the whiteboard. He/she also writes when the ambulance
is back on scene and ready to use for next transportation in the column Available. If it
takes 1 hour to transport a patient from the incident site to a hospital, the ambulance
will not be available again until after 2 hours.
45
RESOURCES FOR TRANSPORT
46
TRANSPORT DEPARTURE PATIENT DESTINATION ARRIVAL AVAILABLE
11,00 North City 12,00 13,00
12,45
11,30 North City 12,00 12,30
11,45 Smalltown 12,00 12,15
Fig 45 board resources for transport

4.3.6 Board six: Hospital emergency department (see fig 46)
• to provide all participants, instructors and facilitators an overview of the activities in
the Emergency department

Head of Emergency department, trauma physician

• patients, patient management cards, staff symbols for hospital, signs, markings
• excel file resources hospital
The front of this board shows the Emergency department of a hospital, including
personnel and patients. This may on the one hand be dictated by the script/scenario,
and on the other hand by the actions of the players. In addition, patients (hospital
patients, please see chapter 4.2.4.4) are already present at the start of the exercise.
The instructor can also have so-called trigger patients from another site or wild
evacuation from the actual scene arrive at the emergency department.
The patient arrives to the emergency department with the ambulance brought from
the resources for transport board to the emergency department board. The person
working on the emergency department board put the patient and management card
under the signs for arriving patient. He/she decides which patient is most urgent to give
treatment. When decided, the patient is moved to a free emergency room. To give
treatment at the emergency department, it is necessary to have free emergency rooms
and staff (EM nurses/doctors). Doctors who are available on the hospital is put under
the sign Doctor.
The patients shall be treated according to what is written on the management card. If
the management card say it take 20 minutes on the emergency department, the room
and staff will be occupied during this time. The time is written in the columns on the
board. If the patient needs surgery, the patient symbol and management card is put
under the signs Waiting for surgery.
47
STATE OF DISASTER WAITING FOR SURGERY
EMERGENCY DEPARTMENT
STATE OF INCREASED
48
PREPAREDNESS

STATE OF PREPAREDNESS ARRIVING PATIENTS WAITING FOR SURGERY
INJURED INJURED INJURED

TRIAGE TEAM WAITING FOR SURGERY
PSYCHOLOGICAL
MANAGEMENT GROUP PHYSICIAN
X-RAY
EMERGENCY TEAM
1 2 3 4
NURSE
PHYSICIAN
PATIENT
ARRIVAL
10,30
DEPARTURE
10,50
Fig 46 board hospital emergency department
4.3.7 Board seven: Hospital surgery (see fig 47)
the Surgery department

Head of operation theatres, assistant

• patients, patient management cards, staff symbols for hospital, signs
The front of this board shows the Surgery department of a hospital, including personnel
and patients. This may on the one hand be dictated by the script/scenario, and on
the other hand by the actions of the players. In addition, patients (hospital patients,
please see chapter 4.2.4.4) are already present at the start of the game simulation. The
instructors can also use so-called trigger patients from another incident site that is in
need for operation.
The patient arrives from the emergency department to surgery by moving the magnetic
symbols. To perform a surgery it is necessary to have a surgeon, a Op-nurse and/or
AN-nurse/AN-doctor. It is also necessary to have free op-theatres.
Staff available is added in the column for OR-team and Surgeon. The person working
at the board write how long time the patient will occupy the op-theatre by reading on
the patient management card.
49
DOCTOR IN CHARGE NURSE IN CHARGE
SURGERY
50
OP-THEATRE
1 2 3 1
OP-TEAM
SURGEON
PATIENT
THEATRE
BLOCKED UNTIL:
OP-THEATRE
2 1 2 3
OP-TEAM
SURGEON
PATIENT
THEATRE
BLOCKED UNTIL:
Fig 47 board hospital surgery department

4.3.8 Board eight: Hospital ICU (see fig 48)
the ICU

Head of ICU, assistant

• patients, patient management cards, staff symbols for hospital, signs
The front of this board shows the ICU department(s) of a hospital, including personnel
and patients. This may on the one hand be dictated by the script/scenario, and on
the other hand by the actions of the players. In addition, patients (hospital patients,
please see chapter 4.2.4.4) are already present at the start of the game simulation. The
instructors can also use so-called trigger patients (see 4.2.4.3) from another incident
site that will occupy the ICU department.
The patient arrives from the emergency- or surgery department to ICU by moving the
magnetic symbols. It has to be free ventilators, beds and available staff (ICU nurses,
doctors) at the ICU to move the patients to this board. One ICU nurse can take care of
two patients. The staff available is added next to the patients.
51
ICU
52
INTENSIVE CARE UNIT POST-OP ICU, THORAX
DOCTOR IN CHARGE NURSE IN CHARGE DOCTOR IN CHARGE NURSE IN CHARGE DOCTOR IN CHARGE NURSE IN CHARGE
1 1 1 1 1 1
2 2 2 2 2 2
3 3 3 3 3
4 4 4
5
Fig 48 board hospital ICU
4.3.9 Board nine: Arriving staff (see fig 49)
• to provide all participants, instructors and facilitators an overview of the amount of
arriving staff and time when they are available

Persons who are working at the other hospital boards, facilitators

• staff symbols for hospital, signs
The arriving staff is the personnel that are free but can be called in. The instructor
before the simulation exercise sets up the arriving staff board. He/she decides the
amount of personnel (doctors/nurses) of different specialities and what time they will be
available at the hospital. The staff will arrive from that there have been a decision made
to call in extra staff.
53
ARRIVING STAFF
54
ON DUTY WITHIN ON DUTY WITHIN ON DUTY WITHIN
30 MIN 60 MIN 120 MIN
PHYSICIAN
NURSES
Fig 49 board arriving staff

5. Scenario guidelines
5.1 Introduction
The Emergo Train system is an excellent tool for creating different simulation exercises
about medical management on scene, at the strategic level and in a hospital. It all
depends on the aims and goals and on the learning objectives that you have decided
upon.
However it can be difficult at the start to do your own set up with different exercises.
In this set of material we have already provided the user with five different simulation
exercises that are easier to start with. They are possible to use in different countries as
they are or with only small adjustment to your own procedure and protocols- doctrine.
The exercises give emphasis to the importance of the first, second and third report
from the scene. The knowledge is that recourses must be alerted in right time and that
hospitals must be given the most possible time to prepare.
In the evaluation of the exercise it’s very useful to emphasis on the performance
indicator that comes with the ETS.
The scenario guideline is a guide how to prepare, run and evaluate a part simulation
exercise and total simulation exercises were the hospital is included. A Basic instructor
can do all these exercises.
The guideline provides you with a scenario, geography, timetable and with a detailed
instruction how to do it. The performance indicators must be used in the evaluation.
Learning objectives
To demonstrate the ability to achieve the efficient mobilization of adequate
recourses by give
-“Through the windshield report” according to METHANE
- Complete second report with the right content
To demonstrate the ability to perform on- scene initial action by working in the different
roles as Ambulance incident Commander and Medical Incident commander.
In these exercises the participants will work in groups of 4 with 1 instructor. This can be
done in different stations (rooms) but can easily be done in one lecture room provided
that only 4 people work in front of the white board at the same time.
Preparation
Prepare the different boards with scenario A /B -D and triage consisting of the Emergo
Train System. Cover with sheet so that the participants only can see one scenario at
the time.
Give some minutes to the group to get familiar with the radio / walkie-talkie before you
give the alert.
Give them template for METHANE and second report as a guide.
55
To run the exercise
Start the exercise when you give the alert to the first ambulance crew, paramedic and
nurse. The other pair will be taken into the exercise as 2’nd ambulance or as a Mobile
medical team. The timetable is a great help when you guide the participants into the
exercise.
• The alarm comes from dispatch and now it’s time for the first ambulance to act.
• First of all they look at a photo (a picture of what they will see when they park there
ambulance), “through the windshield”. They are now supposed to give their first
report.
• After the first report they are allowed to see the board and they will be able to give
the second verifying report to dispatch (instructor)
• The instructor receives the report on the radio and will respond back as the dispatch
center. (See timetable)
• The instructor can also play the role as fire and police.
• Let the other pair (second ambulance) enter the scene. What happens now?
At scenario Fire and Triage it’s more adequate to let the last pair out be the mobile
medical team and see what will happen with the medical responsibilities. Who will be
Medical incident officer now?
At scenario Fire the instructor has prepared the board with only 2 patients that has
jumped out on the sidewalk. The rest of the patients are carried out by fire (instructor)
during the hole exercise. It’s important that the participants feel the uncertainly which is
present when your dealing with fire accidents and that the scenario easily can change
into a complete inferno.
The patients with burn injuries are carried out at last.
At the triage exercise it’s important that they have the possibility to prioritize and treat
the patients. Use the tags for priority and measures that comes with the ETS system.
Focus on the decisions about the level of medical ambition and how it has an impact on
the outcome of triage.
The instructor has to know the whole scenario well so the exercise will run smoothly.
Emphasis on the importance of giving an early report and of a early efficient
mobilization of adequate recourses. Focus on the learning objectives and on the
performance indicators.
Remember that this is an exercise and that you are not skilled until you have practiced!
Material
Scenario Minibus, Hazard, Fire or Triage with Emergo Train patients.
White-boards
2 walkie- talkies
Tabards or west coats for the different roles
Templates for METHANE and the second verifying report
Priority and treatment tags.
56
5.2 Scenario guideline minibus
ALARM
A Traffic accident at Uphill crossing (6 km from the city)
A minibus has crushed it to a rock at the free highway.
Driver is trapped. Uncertain if more people are involved
Fire and police are alerted.
2 ambulances alerted.
“Trough the windshield report”:
M Major incident - NO
E Uphill crossing
T Singel traffic accident involving a minibus
H No
A Highway strait ahead

N 1
E No
Second verifying report:

• 1 injured
• Trapped
• Stable vital signs
• Extrication by rescue
• All area searched.
• No additional recourses needed
• Transport to City hospital in … minutes
57
Time table scenario minibus
Time Reply and answers

Ex.
+-2min ALARM: Traffic accident involving a
minibus at Uphill crossing. One person
trapped. Uncertain if more people are
involved. Fire and police at place within 2
min.
++-0 1’st ambulance arrives METHANE-

REPORT?
The Chief of rescue talks to the Ambulance - Scene is safe to
Incident Officer: enter. The driver is
trapped with both legs.
We will prepare for
rapid extrication.
Is there something
you want to do before
we start?
+10?? If no report: Second

Dispatch Centre calling: verifying
Number? Injuries? Additional recourses? report?
+10 POLICE: - We have control over

the traffic situation
-We have secured the
area.
+ 12 2’nd ambulance arrives:
Totally: 2 ambulances
58
Panorama patients minibus
Nr Category What you see What you hear A B C D E
Sever
227 10 Sitting No visible injuries Speaks normally OK OK HR 80 GCS=15 pain in
the back
59
5.3 Scenario guideline hazard
ALARM
Traffic accident at Long bridge (10 km from the city)
Collision between a chemical track and a Volvo station wagon.
Potential hazard situation, dangerous goods.
Driver trapped, Rescue on their way
2 ambulances alerted
1 medical team from County Hospital are alerted
”Trough the windshield report”:(suggestion)
M Potential Major incident

E 1 km from Long bridge
T Traffic accident A truck and a single vehicle
H Dangerous goods NR= Petrol 33
120
A Road strait a head from Long Bridge
N 5 (unknown)
E Need of 4 ambulances and a medical team.
Second verifying report (suggestion):

2 Red (T1) and 1 green (T3) Totally 3
One with chest injury, fractured femur and one unconscious and trapped.
Driver of the tank is in psychological chock
All area secured
Additional recourses Total of 3 ambulances and let the medical team arrive.
Requires a key for transport?
The first transport estimated at ….
60
Time table scenario hazards

Ex.
-2min ALARM: Traffic accident at Long Bridge.
Collision between chemical truck and a
Volvo station wagon. Hazard- dangerous
goods. Several people injured.
Rescue in place in 1 minute.
2 ambulances on their way
A mobile medical team from hospital
alerted.
++-0 1’st ambulance arrived METHANE-

REPORT?
Chief of rescue talks with the Ambulance -The truck is full with
Incident commander: gasoline and we have
a big leakage at the
tap. We are foaming
the road just now. –
The driver of this tank
is sitting here nearby
and is chocked and
trembling. We have
secured the area
around the Volvo and
two people are
trapped inside.
- You decide who we
can extricate first.
+5 2’nd ambulance arrive Second

verifying
report?
+10 Only if no report : - We have control over
Dispatch calling: the traffic situation
Up-dated: Hazard? Number? Type of -We have secured the
injuries? Additional recourses? area.
+ 12 Dispatch calling the Ambulance incident

officer:
1 ambulance arriving in 10min with a
mobile medical team
Key for transport: All 3 goes to County
Hospital
+ 12 3’rd ambulance arriving with the medical

team from County Hospital
+ 20 POLICE: - An outer cordon is

made and traffic are
lead out the opposite
way through Forest
road.
Totally: 3 ambulances
61
Panorama scenario hazards
Suspected
Rapid femur
228 7 Sitting No visible injuries Moaning OK respiratory HR 120 GCS=13 fracture
rate bilat. Chest
pain
Crush-injury
229 1 Lying down No visible injuries Quiet OK OK HR 80 GCS=7 right lower
limb
Irregular, No visible
230 21 Lying down Bleeding from mouth Quiet OK HR 130 GCS=3
shallow injuries
62
5.4 Scenario guideline fire
Scenario- FIRE
ALARM
Heat road number 5 , fire in a apartment on 3’rd floor.
No numbers of casualities yet.
A lot of smoke is coming out from the 3’rd floor, there is fire.
3 ambulances on roll
”Trough the windshield report”:(suggestion)

M Potential major incident
E Heat Road 5 2’nd and 3’rd floor
T Fire

H Smoke and fire
A Access Heat Road through High Street
N Unknown
E Additional resources_? Ambulances_? Mobile medical team_?

Second verifying report (suggestion):

• Number of 15-20
• Major trauma, smoke inhalation, burn injures
• The area is not secured
• Need of ex.15 ambulances, helicopter and 2 mobile medical teams
• The firs transport in 5 min to County Hospital
• Require: Key for transportation.
63
Time table scenario fire

Ex.
+-2min ALARM: Fire in a apartment on Heat Road
number 5
A lot of smoke is coming out from a
window. Fire services are at place. No
number of casualties yet. 3 Ambulances on
roll.
+-0 (1) 1’st ambulance on scene METHANE-

REPORT?
The chief of rescue reports to the - There is a large
Ambulance Incident Officer: fire going on at
(Played by the instructor) third floor. We are
concentrated on
evacuation and
life saving.
- It’s not clear how
many that is inside
this building.
- We have two
sectors: Inside/
Outside
- It’s not safe inside
yet but you are
free to work on the
outside
- We have a person
that has jumped
out, badly injured
on the
sidewalk.
- My suggestion is
to carry out to the
square and make
a temporary first
aid point there.
- Our commanding
place will be here.
+1 (2) 2’nd Ambulance arrives
+10? If no report to dispatch or strategic level We are waiting for Second

of command: your report… County report:
Dispatch: Hospital in Fire City
are calling and want to
know if they are going
to receive any patients
64
+10 Dispatch calling the Ambulance Incident The medical co-
Officer: ordination centre is
at County Hospital
in Fire City. They
are the strategic
management.
Here are the first
preliminary key for
transport:
You can send:
Burn injury to Big City
with helicopter
-Fire City is prepared
to take all---red (t1)
and yellow (T2)
Green (T3) goes to
Primary Care Centre
in town
+10 (3) 1 ambulance with a Mobile medical Medical officer in Level of
team (doctor and nurse) from the County charge? medical
Hospital in Fire City arrives. ambition?
(4) 1 ambulance
+15 (5, 6, 7,8) 4 ambulances arrive with a - An outer cordon is

Mobile medical team (doctor and nurse) made and traffic are
from the County Hospital in Fire City. lead out the opposite
way through Forest
Medical Co-ordination Centre: road.
The two hospitals in Fire City and Big City
are ready to receive
Patients at following definite key for
transportation:
-Fire City- Totally 10 Red

(T1) and
10 yellow (T2)
-Trauma Centre in Big City- Totally 4 Red
(T1) Burn injuries
-All greens to the Primary Care Centre near
by.
+15 POLICE:( Played by the instructor) - We have control over

the traffic.
+20 Helicopter arrives if requested from
Long Range Airbase
+25 (9, 10,11,12) 4 ambulances from other
counties.
65
Panorama scenario fire
Lying Rapid respiratory
231 4 Soot around face Hacking cough OK HR 120 GCS=13 No visible injuries
down rate, cyanosis
Lying
232 4 Soot around face Hacking cough OK Forced HR 80 GCS=15 No visible injuries
down
Lying
down
Lying Snoring
4 Soot around face Hacking cough Forced HR 80 GCS=13 No visible injuries
234 down sounds
Psychological
235 18 Sitting Cough Speaks normally OK OK HR 70 GCS=15
shock
Psychological
shock
Psychological
shock
Psychological
shock
Psychological
shock
Dislocation of right
Lying
240 15 Cough Speaks normally OK OK HR 80 GCS=15 lower arm and right
down
lower limb
Laceration to
241 18 Sitting Cough Speaks normally OK OK HR 70 GCS=15 forehead with glass
splinters
Swollen and
Lying
242 15 No visible injuries Speaks normally OK OK HR 80 GCS=15 tenderness right
down
knee
Cough, blood on Contaminated
243 16 Sitting Speaks normally OK OK HR 70 GCS=15
face laceration on chin
Holding on to right Bruises and swollen
244 15 Walking Speaks normally OK OK HR 70 GCS=15
arm over the right elbow
Swollen left wrist,
Cough, blood on
245 18 Sitting Speaks normally OK OK HR 70 GCS=15 soft tissue wound
hand
on hand
66
Cough, blood on Glass splinters in
246 18 Walking both arms and Moaning OK OK HR 80 GCS=15 face and on both
face hands
Burnt
Lying
247 8 clothes/sooty on Moaning OK OK HR 90 GCS=15 Severe pain
down
both legs
Burns to both
Speaks
248 16 Walking hands and right OK OK HR 80 GCS=15 Severe pain
normally
lower limb
Burns to both
Lying
249 9 arms and legs, Moaning OK OK HR 120 GCS=13 Severe pain
down
thorax and head
Severe bleeding Speaks Contaminated open
250 15 Walking OK OK HR 90 GCS=15
left hand normally hand wound
67
5.5 Scenario guideline triage
Learning objectives:
To demonstrate the ability to do primary triage
To demonstrate the ability to perform secondary triage and move patients to
appropriate treatment areas
To demonstrate the ability to manage all activities within the treatment area (advanced
medical post)
To demonstrate the importance of a decision about the medical level of ambition
Preparation
• Scenario - Triage T1 - T65 is prepared on a white board. Divide the bus in to two
sections and cover it with sheets of paper. Let some (10) of the patients be outside.
• Explain and show the group how to work with the material and how to count the
time.
• The instructor plays the role as Medical Incident officer and appoints a Triage
officer. Let the group start the triage outside the bus and open up each sector as the
exercise goes on
• Use the priority tags that follow with the ETS material.
• The MIO (instructor) can give a decision about -No CPR or intubations are aloud at
this moment until more personnel arrives.
• If there is a MD in the group, appoint him/her to be the Triage officer.
This exercise can be done without walkie-talkies.
Material:
• 1 Whiteboard
• Scenario- Triage
• Patients Triage
• Priority tags and tags for measure
68
Triage- Information
Information given by the instructor before start.
You are called out to a traffic accident. A tourist bus has crushed into a concrete
bridge and has tipped over into a ravine. You have arrived to the scene as ambulance
personnel/ mobile medical team. The Medical Incident officer (instructor) tells you that
the bus is lying on the right side in the ravine and the rescue /fire service are securing
the area and there is safe for you to be outside the bus at this moment. People are
lying outside and many are still trapped inside the bus. He is expecting three more
medical teams within 40 min The MIO appoints one to be Triage officer and gives you
order to count and to do primary triage. -Triage officer report back to me!
You have to work with these priority tags and you can do treatment. Treatment takes
time in reality and also in this scenario, so you have to follow the time schedule fore
measures.
Use whiteboard pencils and write down the time for each patient. This patient is now
“frozen” that actual time.
Location: Small town Hospital 10 km. County Hospital 30 km and the University
Hospital 180 km.
69
Panorama triage
Cate-
Nr What you see What you hear A B C D E
gory
Lying Rapid
1 11 Abdominal injury Quiet OK HR 130 GCS=13 Penetrating abdominal injury
down respiratory rate
Lying Amputation right
2 15 Moaning OK OK HR 110 GCS=15 Pain left hip, chest pain
down limb
Lying
3 18 Blood on face Quiet OK OK HR 80 GCS=15 Minor face wound
down
Holding on to Speaks
4 18 Walking OK OK HR 80 GCS=15 Pain right wrist
right arm normally
Lying Bleeding from
5 7 Quiet OK OK HR 120 GCS=13 Wound left thigh
down left femur
Lying Bleeding from Snoring
6 3 Moaning OK HR 100 GCS=13 Large facial injury
down face sounds
Bleeding from Speaks
7 15 Walking OK OK HR 90 GCS=15 Open fracture left lower arm
right arm normally
Respiratory
distress,
No visible Chest pain and a bruise on
8 5 Sitting Quiet OK diminished HR 90 GCS=13
injuries left side of the chest
breath sounds
left side
Lying No visible Left leg shortened, angled to
9 15 Quiet OK OK HR 100 GCS=15
down injuries the left
Bleeding from
10 18 Sitting Quiet OK OK HR 80 GCS=15 Soft tissue injury ear
right ear
Lying Open abdominal Open abdominal wound,
11 11 Quiet OK Irregular HR 120 GCS=7
down injury intestine visible
12 18 Walking Bleeding left ear Quiet OK OK HR 90 GCS=15 Soft tissue injury left ear
Lying
13 2 Blood on face Quiet Obstruction OK HR 80 GCS=7 Laceration to forehead
down
14 16 Walking Hand injury Crying OK OK HR 80 GCS=15 Open fracture left hand
Lying Rapid Impaled object in the
15 11 Abdominal pain Quiet OK HR 140 GCS=13
down respiratory rate abdomen
70
Cate-
gory
Lying Laceration on Snoring
16 3 Moaning OK HR 90 GCS=15 Soft tissue injury to face
down face sounds
Lying
17 15 Bleeding left leg Crying OK OK HR 90 GCS=15 Open fracture left lower limb
down
Blood on right Rapid Pain from right shoulder,
18 18 Sitting Crying OK HR 100 GCS=15
shoulder respiratory rate chest pain
19 16 Walking Blood on face Quiet OK OK HR 80 GCS=15 Penetrating injury left eye
20 15 Sitting Blood on left arm Crying OK OK HR 80 GCS=15 Open fracture of the left wrist
Lying Open fracture
21 15 Quiet OK OK HR 130 GCS=13 Open fracture left lower limb
down left lower limb
22 18 Walking Blood on left arm Quiet OK OK HR 90 GCS=15 Laceration to left arm
Lying Burnt
23 21 Quiet OK Irregular HR 90 GCS=9 90 % TBSA burn
down clothes/sooty
Lying Open abdominal Rapid Open abdominal wound, intestine
24 11 Quiet OK HR 130 GCS=13
down injury respiratory rate visible
Lying Open wound left thigh, absent
25 14 Bleeding left leg Crying OK OK HR 130 GCS=13
down distal pulses
Blood on both
26 15 Sitting Quiet OK OK HR 80 GCS=15 Lacerations to both arms
arms, face
Lying Bleeding right Open fracture femur, absent distal
27 7 Quiet OK OK HR 140 GCS=13
down leg pulses
Lying Soft tissue injuries to face and
28 2 Blood on face Quiet OK OK HR 80 GCS=9
down right arm
Lying No visible
29 10 Moaning OK OK HR 120 GCS=13 Abdominal pain
down injuries
Lying Dislocated left
30 15 Crying OK OK HR 90 GCS=15 Dislocation left ankle
down lower limb
Lying
31 16 Child Blood on face Crying OK OK HR 110 GCS=15 Large soft tissue injury to face
down
Lying Blood on left
32 15 Moaning OK OK HR 90 GCS=15 Open fracture left lower limb
down leg
Blood on both
33 16 Walking Quiet OK OK HR 70 GCS=15 Open fracture left middle finger
hands
Blood in the
34 18 Walking face and on left Crying OK OK HR 100 GCS=15 Face injury, severe pain
arm
71
Cate-
gory
35 16 Walking Blood on face Crying OK OK HR 90 GCS=15 Nose bleed
Irregular and
Sucking chest wound right
36 5 Sitting Chest injury Quiet OK rapid respiratory HR 100 GCS=13
side
rate
Irregular and
37 5 Walking No visible injuries Moaning OK rapid respiratory HR 90 GCS=15 Chest pain and coughing
rate
Lying
38 16 Child Blood on face Moaning OK OK HR 130 GCS=15 Penetrating injury to left eye
down
Blood on face and
39 12 Sitting Quiet OK OK HR 90 GCS=15 Laceration wound to skull
both hands
Lying
40 2 No visible injuries Quiet Wheezing Irregular HR 70 GCS=7 No visible injuries
down
Lying
41 2 Head injury Quiet Wheezing OK HR 70 GCS=13 Bruises to forehead
down
Lying
42 10 Child Blood on face Quiet OK Shallow HR 150 GCS=13 Chest and abdominal pain
down
Lying Big haematoma and severe
43 7 No visible injuries Moaning OK OK HR 110 GCS=15
down pain left femur
Lying Blood on both
44 1 Quiet OK OK HR 80 GCS= 9 Lacerations to both arms
down arms
Lying Blood on left leg
45 15 Quiet OK OK HR 110 GCS=13 Open fracture left lower limb
down and face
Lying
46 1 Child No visible injuries Quiet OK OK HR 70 GCS= 7 No visible injuries
down
Lying Rapid
47 10 No visible injuries Moaning OK HR 140 GCS=13 Chest pain when breathing
Lying Dislocated right
48 14 Moaning OK OK HR 120 GCS=15 Severe pain in the right knee
down lower limb
Lying
49 21 Child No visible injuries Quiet OK Irregular HR 100 GCS=3 No visible injuries
down
Lying
50 10 No visible injuries Quiet OK OK HR 120 GCS=15 Chest and abdominal pain
down
72
Cate-
gory
51 12 Sitting Blood on face Crying OK OK HR 80 GCS=15 Laceration to lower lip
Paradoxical
52 5 Sitting No visible injuries Moaning OK HR 90 GCS=13 Coughing
movement
Blood on lower Speaks Soft tissue injury to lower
back normally back
Lying Severe pain in lower
down abdomen
Lying
55 12 Child No visible injuries Quiet OK OK HR 90 GCS=13 No visible injuries
down
Rapid
56 0 Walking No visible injuries Quiet OK HR 90 GCS=15 Abdominal pain
respiratory rate
Lying
57 7 No visible injuries Moaning OK OK HR 80 GCS=15 Severe pain left thigh
down
Lying Bilateral paralysis below the
58 13 No visible injuries Crying OK OK HR 70 GCS=15
down navel
59 15 Walking Child Sitting Moaning OK OK HR 70 GCS=15 Wound right lower limb
Lying Rapid
60 10 Child No visible injuries Moaning OK HR 120 GCS=13 Severe abdominal pain
Lying Rapid
61 10 No visible injuries Moaning OK HR 140 GCS=13 Abdominal pain
Lying
62 2 Child No visible injuries Moaning OK OK HR 70 GCS=13 No visible injuries
down
Lying
63 12 No visible injuries Quiet OK OK HR 100 GCS=9 No visible injuries
down
Lying
64 10 Child No visible injuries Moaning OK OK HR 110 GCS=13 Minor lacerations to face
down
Lying
65 13 No visible injuries Quiet OK OK HR 80 GCS=15 Pain when moving head
down
73
Cate-
gory
Speaks
320 19 Walking No visible injuries OK OK HR 70 GCS=15 Psychological shock
normally
Speaks
normally
Speaks
normally
Speaks
normally
Speaks
normally
Speaks
325 20 Walking No visible injuries OK OK HR 70 GCS=15
normally
Speaks
326 20 Walking No visible injuries OK OK HR70 GCS=15
normally
Speaks
327 20 Sitting No visible injuries OK OK HR70 GCS=15
normally
Speaks
328 20 Sitting No visible injuries OK OK HR70 GCS=15
normally
Speaks
329 20 Walking No visible injuries OK OK HR70 GCS=15
normally
Bruises over chest and
Lying Blood on both No
345 22 Quiet No breathing GCS=3 abdomen, open left femur
down arms and legs pulse
fracture
Lying No
346 22 No visible injuries Quiet No breathing GCS=3 Bruises over the pelvis
down pulse
Lying Thrown Blood on both No
347 22 Quiet No breathing GCS=3 Laceration to head
down out arms and legs pulse
Lying Blood on both No
348 22 Quiet No breathing GCS=3 No visible injuries
down arms and legs pulse
Lying No Haematoma over chest,
349 22 No visible injuries Quiet No breathing GCS=3
down pulse abdomen and pelvis
74
5.6 Scenario guideline stadium
Example of different learning objectives:
To demonstrate the ability to achieve the efficient mobilization of adequate recourses in
a Major Causality Accident
To demonstrate the ability to perform on- scene initial action
To demonstrate the ability to manage and coordinate all medical personnel and
resources responding to the incident
To demonstrate the ability to perform secondary triage and move patients to
appropriate treatment areas
To demonstrate the ability to manage all activities within the treatment area (advanced
medical post)
To demonstrate the ability to distribute patients to the appropriate hospitals/health care
facilities
To demonstrate the ability to arrange appropriate transportation of patients to hospitals/
health care facilities
Material
• A minimum of 4-7 Whiteboards in a large room
• Scenario- guideline E
• Patient 230-249, 257-286 from the ETS patient bank, maps, time- schedules,
patient treatment time
• Different equipment, for all the different roles in this exercise, prepared in plastic
bags.
• Minimum of 3 walkie- talkies
For example…
1’ st ambulance the bags contain tabards as ambulance incident officer and medical
incident officer, templates for reports, tags for measures (iv-fluid, needle, oxygen and
priority tags) material that usually arrives with the ambulances. Walkie- talkies, with the
right frequency and pencils for Whiteboards.
Preparation
Prepare all the 4-7 whiteboard before the exercise as follow.
1. The scene
This is the scene of the accident. A football stand has collapsed and there is a fire
going on at the left stand. You can by simple drawing visualise the stand with the left
and the right side and also the entrance, which is blocked. Put up the entire Scenario-
E with all its ETS patients and cover the left and the right side with a paper.
The first ambulance crew should only be able to look at the photo of the scene and
then give their first report. Here the scenario starts and the first preliminary triage will
take place.
The ambulance incident- and medical officer works here in liaison with the
commanders of rescue and police. (Can be played by instructors)
2. Sort and sieve (First aid point)

This is a white board with one or two patients from the scene. The rescue (the
instructor) has started to carry out patients to this preliminary first aid point. This is
an area with no facilities. At this board the participants can work with the preliminary
triage and do treatment by putting on tags and count the time it takes to do measures.
75
Remember to use real- time. Participants can easily count the time by them selves
but it can also be done by a facilitator or by an instructor. Prepare the board with time-
table for measures.
Arriving ambulance and medical personnel will be working at this board.
3. Triage area (Advanced medical post)

The board will visualize the advanced medical post and will be established after
running the scenario for 20 minutes or when the instructor decides so. Participants
must organize this place with sorting (triage) at the entrance and appropriate treatment
areas. The participants perform treatment by using the tags for measure. Remember
to count the time. Prepare the board with timetable for measures. Triage teams and
ambulance personnel will be working here.
4. Ambulance loading point

The arriving ambulances will appear at this board. An ambulance officer must be
appointed to work here. The purpose of this board is to organize the transportation of
patients to different hospitals. Transportation time is prepared on a template but can
easily be created by the instructor.
5. Dispatch (can be excluded)

On this board the instructor prepares all the resources available for the dispatch such
as, ambulances, helicopter services, rescue services, and police services.
The different hospitals and the distance to the accident. Available medical team and
other health care service.
The role as dispatch could be played by a participant or by the instructor. The time
table for dispatch is a good help.
6.Smalltown Hospital (can be excluded)

This board visualizes the emergency department, operation and ICU at Smalltown
hospital.
Preparing plastic bags
The exercise will be better if the different boards are placed with a distance in the room
so the participants have to walk between them. (See example of how to rearrange the
room)
Running the exercise
TIME FRAME:
Information 15 min
Running Exercise 45-90 min
Briefing and evaluation 30 min
The participants are sitting in a separate room. They will be informed and briefed by the
instructor about the learning objectives (see information).
Everyone receives a plastic bag with all the equipment they need in this exercise.
Let the participants divide between them selves which role they want to play. The
dispatch gives the alarm call and starts the exercise.
Time is actual day and actual time.
76
EVERYONE WALKS IN TO THE EXERCISE- ROOM AT THE SAME TIME but only the
first ambulance starts to work. The other participants can now sit down for a while and
will be alarmed according to schedule. Remember that this is a learning process and
no one benefits from standing behind a door and wait.
• Dispatch alerts the first ambulance

• The first ambulance crew starts with looking at a photo that describes what they will
encounter when they arrive on the scene.
• Ambulance incident officer gives the first report to the dispatch.
• The ambulance incident officer and medical incident officer start to work. The role as
chief of the rescue and police can be played by the instructor or by a participant.
• More personnel arrives at the scene after they been alerted by the dispatch and it is
important that they will be guided were to work.
• Try to use walkie- talkies or other types of radios in the communication. It makes it
more realistic.
• Everyone must be activated in this exercise. The incident officers must instruct all
personnel were to work and to use all the different boards. Otherwise they will all
stand in front of the scene and the other boards will not be used.
• The instructor or facilitator must move the patients by playing carriers from the
rescue services ex. from the scene to the advanced medical post.
• Performance indicators are important in this exercise. All the different instructors
must try to fill in the template before the evaluation.
• The evaluation will be easier if you as an instructor can focus on these indicators.
Try to focus on critical decisions and let everyone in the group be heard.
• Don’t let the group leave this exercise feeling that they did everything wrong.
A tip…
You can easily do this exercise with your own setting with geography and distance.
77
Ex.
+-2min Alarm: 1’st ambulance to dispatch over?
A football stand has collapsed during a
football game in the City of Smalltown.
There is fire.
People are panicking. There are people

caught and trapped at the main entrance
Fire services and police are at place.
+-0 1:a ambulance crew on scene - We are trying to METHANE-

Ambulance Incident Officer talks to the cut the fence and we REPORT?
Chief of rescue … have started saving
lives. Many people
are trapped and
several injured. We
are beginning to take
control over the fire at
the west stand. It’s not
safe to go there.
I suggest that this is
our commanding place
Police Incident Officer…
- We are trying to
move the crowd
towards Parkstreet
and to the open park.
We have no control
over the traffic
situation yet.
+5 2:a ambulance crew from Smalltown

arrives at the scene
+10? We are waiting for

If no report to dispatch or strategic your report…
level: Hospitals in Smalltown Second
Dispatch: are calling and want to report:
know if they are going
to receive any patients
+10? 3:e ambulance with If hospitals
1 Mobile medical team from Smalltown are included
hospital arrives at the scene in the
exercise:
(Chief of rescue give takes away the sheet Wild
that covers the right stand) evacuation:
(10+5
patients to
Middletown
5+5 to
Smalltowm
comes by
their own)
78
+12 Dispatch calling the Ambulance Incident The medical co-
Officer in charge: ordination centre is
at County Hospital in
Middletown.
They are the strategic
level of command and
control.
Here are the first
preliminary key for
transport: You can
send:
5 Red (T1), to
Middletown
3 Red (T1), to
Smalltown
All green (T3) to
Primary care Centre in
Smalltown.
+20 Chief of rescue… - We have now control
over the fire, so it’s
safe to go in to the left
stand.
My men are doing
CPR on some people-
shall they continue?
+20 (4, 5) 2 ambulances from Smalltown on If hospitals are
scene included in the
1-2 Mobile medical team from Smalltown exercise:
arrives Wild evacuation:
(10+5 patients to
Medical Co-ordination Centre call to Middletown
Ambulance incident officer 5+5 to Smalltowm
or to Chief medical officer : ( Dispatch or comes by their own)
instructor))
The two hospitals in Smalltown and
Middletown are ready to receive patients at
following key for transportation:
Smalltown Totally 5 Red (T1) and 10 yellow
(T2)
Middeltown Totally 10 Red (T1) and 10
yellow (T2)
Traumacenter in Bigtown 5 Red (T1) by
Helicopter
+22 (6, 7) 2 ambulances from Middletown - We have control over

arrives� the traffic.
+26 (8, 9, 10, 11) 4 ambulances from different
counties arrives on scene
+29 2 helicopters on scene from Long Range

Airbase
+35 (12,13,14,15) 4 ambulances from
Smalltown and Middletown arrives on
scene
+ 45-60 End of exercise
79
Fig 50 boards and roles scenario stadium
80
Panorama stadium
Cate-
gory
Lying Bleeding from Irregular,
230 21 Quiet OK HR 130 GCS=3 No visible injuries
down mouth shallow
Rapid
Lying
231 4 Soot around face Hacking cough OK respiratory rate, HR 120 GCS=13 No visible injuries
down
cyanosis
Lying
down
Lying
down
Lying Snoring
234 4 Soot around face Hacking cough Forced HR 80 GCS=13 No visible injuries
down sounds
Speaks
235 18 Sitting Cough OK OK HR 70 GCS=15 Psychological shock
normally
Speaks
normally
Speaks
normally
Speaks
normally
Speaks
normally
Lying Speaks Dislocation of right lower
240 15 Cough OK OK HR 80 GCS=15
down normally arm and right lower limb
Speaks Laceration to forehead with
241 18 Sitting Cough OK OK HR 70 GCS=15
normally glass splinters
Lying Speaks Swollen and tenderness
242 15 No visible injuries OK OK HR 80 GCS=15
down normally right knee
Cough, blood on Speaks Contaminated laceration on
243 16 Sitting OK OK HR 70 GCS=15
face normally chin
Holding on to Speaks Bruises and swollen over
right arm normally the right elbow
81
Cate-
gory
Cough, blood Speaks Swollen left wrist, soft tissue
hand normally wound on hand
Cough, blood on
Glass splinters in face and
246 18 Walking both arms and Moaning OK OK HR 80 GCS=15
on both hands
face
Burnt
Lying
247 8 clothes/sooty on Moaning OK OK HR 90 GCS=15 Severe pain
down
both legs
Burns to both
Speaks
248 16 Walking hands and right OK OK HR 80 GCS=15 Severe pain
normally
lower limb
Burns to both
Lying
249 9 arms and legs, Moaning OK OK HR 120 GCS=13 Severe pain
down
thorax and head
Lying
257 10 No visible injuries Moaning OK OK HR 120 GCS=13 Severe pain in the abdomen
down
Rapid
258 5 Sitting Rapid breathing Quiet OK HR 110 GCS=15 Unstable chest
respiratory rate
Lying Blood around Snoring GCS=13-
259 2 Moaning OK HR 100 Multiple maxillofacial injuries
down face sounds 9
Lying Bilat. Tibia fracture and
260 15 No visible injuries Crying OK OK HR 90 GCS=15
down fracture of elbow
Rapid Multiple rib fracture. Chest
261 6 Sitting No visible injuries Moaning OK HR 90 GCS=15
respiratory rate stable
Speaks Rapid
262 10 Sitting Rapid breathing OK HR 120 GCS=15 Severe chest and back pain
normally respiratory rate
Lying Snoring Rapid
263 21 No visible injuries Quiet HR 140 GCS=3 No visible injuries
down sounds respiratory rate
Lying Severe bleeding Snoring
264 3 Quiet Forced HR 100 GCS=13 Multiple maxillofacial injuries
down from face sounds
Lying Rapid
265 10 No visible injuries Quiet OK HR 110 GCS=13 Severe abdominal pain
Severe chest pain when
266 5 Sitting No visible injuries Moaning OK Forced HR 120 GCS=15
breathing
82
Cate-
gory
Severe chest pain when
267 6 Sitting No visible injuries Quiet OK Forced HR 90 GCS=15
breathing
Bleeding from left Laceration to left hand,
268 18 Walking Quiet OK OK HR 70 GCS=15
hand severe bleeding
Lying
269 12 No visible injuries Quiet OK OK HR 70 GCS=9 No visible injuries
down
Lying Pelvic unstable. Severe
down abdominal pain
Speaks
271 10 Sitting No visible injuries OK OK HR 80 GCS=15 Severe pain in the back
normally
Rapid Suspected femur fracture

272 7 Sitting No visible injuries Moaning OK HR 120 GCS=13
respiratory rate bilat. Chest pain
Lying
273 1 No visible injuries Quiet OK OK HR 80 GCS=7 Crush-injury right lower limb
down
Lying Speaks Dislocation of right lower
274 15 Cough OK OK HR 80 GCS=15
down normally arm and right lower limb
Speaks Laceration to forehead with
275 18 Sitting Cough OK OK HR 70 GCS=15
normally glass splinters
Lying Speaks Swelling and tenderness to
276 15 No visible injuries OK OK HR 80 GCS=15
down normally right knee
Cough, blood on Speaks Contaminated laceration to
face normally chin
Holding on to Speaks Bruises and swollen over
right arm normally the right elbow
Cough, blood on Speaks Swollen left wrist, soft tissue
hand normally wound on hand
Cough, blood on
Glass splinters to face and
280 18 Walking both arms and Moaning OK OK HR 80 GCS=15
on both hands
face
Blood on both Speaks Glass splinters to both
hands normally hands. Severe bleeding
83
Cate-
gory
Severe pain in Speaks
282 18 Walking OK OK HR 60 GCS=15 Glass splinters in left eye
left eye normally
Bleeding from left Speaks Glass splinters in the sole of
foot normally the foot
Speaks
284 18 Sitting Cough OK OK HR 70 GCS=15 No visible injuries
normally
Speaks
normally
Speaks
normally
84
6. Basic Instructor course
6.1 Basic instructor
A basic instructor in Emergo Train:
• Is a professional within the healthcare system

• Has knowledge enough to teach or instruct in disaster medicine according to local or
regional requirements
• Has successfully completed an Emergo Train basic instructor program
• Can summarize and report results as decided upon by responsible senior instructor
• Is qualified to attend the senior instructor course
6.2 Basic instructor program
• Is the responsibility of the national service centre

• Can be performed by suggested schedule, or by other method of training
• Successful completion of Basic instructor course
• Can, if asked for, be subject to evaluation from competence centre
85
Basic Instructor schedule Day 1
Time Subject
Introduction
08.00-08.15
Aims, goals and objectives
Disaster Medicine
08.15-09.00
Research Training Evaluation
09.00-09.30 Emergo Train system
09.30-10.00 Coffee
Demonstration of simulation: Minibus, Hazard,
10.00-12.00
Fire and Triage
12.00-13.00 Lunch
13.00-13.30 Demonstration simulation: Stadium
13.30-15.00 How to prepare and run an exercise
15.00-15.30 Coffee
15.30-16.00 Responsibility of an ETS instructor

How to follow learning goals and performance
16.00-17.00
indicators in evaluation
17.00-17.15 Closing
Basic Instructor schedule Day 2

Time Subject
Preparation and setting up simulation: Minibus,
08.00-09.30
Hazard, Fire and Triage
09.30-10.00 Coffee
Running simulations
10.00-12.00
½ group as students ½ group as instructors
12.00-13.00 Lunch
13.00- 14.00 Preparation and setting up simulation: Stadium
14.00-16.00 Examination by Running simulation: Stadium

16.00-17.00
Closing
86
7. ETS Doctrine
Suggestions on doctrine to use in an ETS-exercise. This paragraph should serve as
help and is recommended only in case that there is no existing or functioning doctrine
within the organization.
7.1 Introduction
We all work accordingly to some sort of doctrine. By this we mean that there is always
a line of regulations, which is followed within an organization when dealing with disaster
and crisis management. This doctrine may be more or less expressed in strategic
tables and more or less known or rehearsed; but it is constant. The outcome of
performance should be evaluated accordingly to the doctrine and its norm. Deficiencies
in the doctrine and following its regulations, can lead to difficulties in connecting with
the management. It is often mentioned that adequate information is the most important
thing for achieving success when in command during major incidents and disasters.
This is by all means true, but even more essential is that the information is handed
over to the right Commander at the exact time and in the right way. Also important is
that the recipient knows what he or she is to do with the information. This is a part of
the line of regulations, the doctrine. Emergo Train system is entirely dependent on the
use of a doctrine, but independent on which doctrine that is used. When it comes to
the evaluation of carried out simulation exercises, focus have to be apparent. It is not
the doctrine that is to be evaluated, but the students’ performance. The entire idea
with “Performance indicators”, rely on the existence of a comprehensible policy. To
help users of Emergo Train system, we present this doctrine. It is both internationally
and nationally suited and can be carried out by Health and medical care as well as the
Rescue service or Police service. This doctrine is to be thought of as a proposal from
which a line of regulations can be formed. Naturally it is the present senior instructor
who is to decide if this doctrine is to be used, and to what extent. We hope that this
doctrine will assist you when carrying out the exercises with Emergo Train system. As
all other Emergo Train material, this doctrine will regularly be revised.
7.2 Basic outlook in management

Management - Leadership
Management is something that is constantly carried out regardless if the people
exposed to the leadership are conscious about it or not. Leadership has a conscious
effect on people and a specific purpose. The chief in charge is intended to direct
within the area of his or hers authority, but there can also sometimes appear informal
leaders inside organisations. The latter may occur when the chief in charge fails doing
his job. What we call leadership is the capability to affect other people. Being a part
of a management requires a number of qualities that characterizes a good leader.
One of these qualities is knowledge of leadership, that is to say, an administrative
competence. A part from this, a good knowledge about the subject matter within the
actual organisation is required. This does not mean that the chief of the organisation
as a whole is the best “operator within the field”. A good leader is a person with ability
to establish requirements that the different “operators” need to achieve satisfactory
results, and at the same time having the best interest in mind for each co-worker.
87
Management: Administrative competence
Leadership: Knowledge and qualities in
guiding other people.
Aim
The aim is the answer on the question –“Why”. It must be clear why a certain activity
is performed, and who benefits from it. It should always be the patient that obtains the
advantages from a functioning management. To be able to fulfill the aim, we must have
the perspective of the patient in mind. When we are dealing with disaster scenarios,
we also have to consider what is best for all wounded as a whole group, and what will
benefit a majority of the group. If we cannot motivate our actions and our management
in having the best interest in mind for the patient, we are not working within the area in
which the Health and Medicare has authority. All decisions made by the management
shall at all times benefit the individual patient and the rescue performance as a whole,
so that the purpose is carried out correctly. We who work in health and medical
services should always provide the indispensable patient perspective.
The aim for the medical management

must be
“Patient perspective”
Goal
– ”If we don’t know were we are going it doesn’t matter were we end up.”
Often when we review our efforts we come to the conclusion that everyone did the
best they could, and even if our actions had been different, the outcome would still
have been the same. How do we know if our work is good or bad? How can you tell
if a management fulfills all expectations? To be able to answer these questions a
set of goals are needed. To create goals for a management may be difficult but not
impossible. What we need to think through when we do this is that our aim is relevant,
reachable but still challenging for the actual activity. Goals must be apparent and
comprehensible. Each person of the organization should understand the purpose of the
aim and work accordingly to it.
Goals should be…

Relevant
Reachable
Challenging
Apparent
Measurable
88
The person responsible for clear and comprehensible goals is also the person
responsible for the organisation as a whole. It is within that management that goals are
to be formulated and the ones carrying out the activity must fulfil the purpose of these
goals. There are a number of important events and decisions that can be registered,
timed and put up against goals, which can be measured. For example when the
first report from a major incident is sent out or when decisions are made to increase
preparedness.
7.3 Components and roles

Components
In a system of medical management, as well as in other management systems, we
can identify three components: normative, strategic and operative. Each component
exists in the different levels in a hierarchy within the system, but can be more or less
prominent. The hierarchy can be similar in different systems and have different names
in different countries. It is up to the senior instructor to define and explain the hierarchy
within the actual exercise.
Normative component
The normative component deals with issues concerning the organisation. This
component translates laws and regulations and decides what the responsibilities are
and what the organisation must and can do.
Strategic component
The medical management on scene has a big interest in being connected to the
level that has the strategic component. This component deals with issues concerning
mobilisation of more recourses. It can also redistribute recourses to the scene of an
accident that has a lack of recourses. This level have to receive the reports coming
from the scene and need to give a fast response on were to send the wounded. The
strategic level must have a “helicopter prospective” of how to use the resources in the
best possible way. This component must always be available and must be able to make
decisions at once.
Operative component
The operative component is the “doing” part. In medical management on scene this
component is most prominent.
Roles
A role has responsibilities that you shoulder when you arrive at the scene of an
accident. One person can have more than one role during the process and can also
hand over that role to someone else, for example when more personnel resources are
arriving. The person who has a specific role is responsible for that all tasks within that
role are being fulfilled.
Prehospital roles
• Ambulance incident commander
• Medical incident commander
• Staff
• Care provider/Care giver
89
Ambulance incident officer
The ambulance incident commander arrives in first the ambulance on scene. This role
has responsibilities about security and safety for all arriving ambulances and medical
personnel, logistics and communication and also the one who liaison with the Fire
officer and with the Polis incident officer. Conditions and environment must be as good
as possible so that the medical management can be as efficient as possible.
Medical incident officer

The person with the highest medical education must be the medical incident officer.
This role must be handed over when for example the medical doctor arrives, or when
an officer of a higher rank arrives to the scene. The responsibility of this role is all the
tasks that has to do with medical decisions about the victims, and their treatment and
also the transportation to hospitals.
Staff
The role as staff is a person who supports the ambulance incident officer or medical
incident officer.
Care provider or Caregiver

The role as care provider is a person who priorities patients and give hem treatment.
Regional level of management

This hierarchy level is also in the literature refereed to as “strategic level” and “gold
level”
The level that takes the decision to declare a major incident is different in different
countries.
Regardless of where in the hierarchy this level is, it is important the reports that come
from the scene goes to this level of management. It can be located together with
the Emergency call centre or dispatch or connected to other function with adequate
authority and responsibility within the organisation. The importance is that this function
is available immediately at all times. There must be no delay in declaring a major
incident or disaster.
In this doctrine the strategic management is the one that has an overview and thereby
also have the mandate to take decisions about how to request medical resources that
are not within own organisation.
Medical management on scene

Medical service on scene is never isolated from any other medical service. We must
always maintain a comprehensive picture of our efforts, and cannot consider our own
organisation or activity isolated from any other medical service.
The important thing is not only the number of

wounded that arrive at the hospital, but also
the number of patients that leaves the hospital
without complications.
90
At certain points we will always have a lack of resources when we are dealing with a
major accident. With the exception of a “minor accident”, that we handle in our every
day lives; work at major incidents always means a shortage of resources. This shortage
may count for personnel as well as material resources. This does not necessarily
mean that the subjected receive poorer care. By changing our way of working during
lack of resources, we can achieve equally results through good management.
Naturally we may be forced to lower the medical level of ambition because of different
circumstances. This requires a high-quality management at the scene. Fire and rescue
services arrive at the scene as a closely held together group where leadership and
command are clear and the group well co-ordinated. People working at the scene have
perhaps not worked together previously and it cannot be predicted which unit or which
commander that will arrive first. It is important that the medical management is built on
roles and functions and not on people.
Appliance��
of roles
��
at a scene
Even at a small accident where only one ambulance is engaged, equal responsibility
and efforts are essential. If the event is of larger scale and several ambulances are
at the scene, it is crucial to establish who the commanders are. Strive for as few
exchanges of commanders as possible.
Distribution of medical personnel

Medical personnel arriving at the scene are to report their presence to the ambulance
incident officer. It is very important that the ambulance incident officer is informed of
who is at the scene and at what time. Another reason for this is that the ambulance
incident officer is the one from the medical services that co-operates in liaison and has
access to information coming from rescue and police. For example; if the area can
be set foot upon. The ambulance incident officer is also the one dividing the medical
personnel into his or hers task, but the basis of this division comes from the medical
incident officer.
7.4 Communication, alerting plans, reports

Communication
Good communication is very important when it comes to effectiveness and good
management. Responsible for this is the ambulance incident officer. There should
be prearranged routines of how communication should be solved technically, and
there should always exist systems for back-up. These routines are to be tested and
performed regularly. Good and functional communication from the scene to the regional
level (strategic level/gold level) is one of the important success factors.
Alerting
Initial alerting and dispatching of ambulances, rescue service, police etc is in several
countries done by an Emergency call centre. The dispatching of resources is done by a
person who activates and follows special alerting plans at special events.
91
Structure of communication for the medical management at the scene
Other place Regional level/Strategic level/Gold level

Dispatch or Emergency Coordination centre
or Hospital Coordination centre
At the scene
Reports from Distribution

different sectors Officer
Medical Ambulance
incident officer incident officer
Police Chief of
incident officer Rescue
Reports
We know that in a major incident or disaster the first reports from the first arriving
personnel is crucial.
The ambulance incident officer has the responsibility of making these reports and
to send them to the function that can dispatch recourses. This reports must be in a
structured form and not something you have to invent each time. This is something
you, as ambulance personnel, must have lot training in and do every day.
In this doctrine we offers you examples of these three fist reports. The first “trough the
windshield report” is according to METHANE used by the MIMMS- group.
7.5 Guideline decisions in medical management

People who possess the role as ambulance incident officer and the role as medical
incident officer make decisions in on guidelines for the medical management. The
purposes with these decisions are to bring about a picture of what are the most
important duties of the medical services. All decisions made within the disaster area
should be handed over to the strategic component, so that further decisions can be
made. All decisions of management should be reviewed when necessary.
92
Guideline decisions in management should include…
1. What should be dealt with now

2. What should be dealt with later
3. What should be dealt with in the long run
Guideline decision for response

The most important decision in management at the scene is made by the ambulance
incident officer very early. This is the decision for the effort as a whole, and is made
after or in association with establishment of liaison. This decision is to make sure that
each organisation is working accordingly to the same idea of what is most important
under the circumstances. The decision should contain how the work is to be formed
and where to start all based on the facts that are available now. One example is;
Decision about a rapid evacuation of victims from the area. Liaison is of great
importance for this decision.
Guideline decision for medical level of ambition

By medical level of ambition we mean; what is the actual level of ambition, and what
medical priorities should be made at the scene. The medical incident officer who also
communicates with the ambulance incident officer makes decisions of this nature. The
decisions about the level of medical ambition concern all personnel that are giving
treatment to patients. That includes all personnel from the rescue and police services
too. It is the ambulance incident officer that has to pass on this decision to the other
chiefs in command. The first medical decision in management should be made at
an early stage and should be reviewed as you go along. The reason for this is that
conditions change when additional transport resources and more competent medical
personnel arrive at the scene. It is important that the strategic level is updated so that
they will have a clear picture of what is happening. They have to be well informed of
possible changes if it is required to deviate from normal demands of medical quality.
All decisions in management should to be:

• Documented
• Communicated
• Reviewed
93
7.6 Laws, regulations and liaison
Laws
Different organisations (medical, fire, police) follow different laws and regulations.
Issues involving several organisations and laws must be solved through good
cooperation and liaison. Within every country (sometimes region) there are laws and
regulations that regulate the prehospital organisations. To achieve good results when
carrying out simulation exercises in ETS it is important that the senior instructor has
knowledge of which rules that should be followed.
Liaison
By liaison we mean the process when different organisations who have different laws,
are to solve a task together. As we earlier discussed at the scene of an accident or
disaster, the medical, fire and police have the same goal – to save lives and decrease
damage. For good cooperation certain requirements are needed. For example; there
can only be one commanding post at the scene at which the commanders from the
different agencies should be available. Everyone should recognize the commanding
post, and the commanders must be clearly marked so that it is easy to identify their
functions. A chequered tabard often identifies the commanders, for the ambulance
green and white, for the fire red and white and for the police blue and white.
Media and information

The ambulance incident officer is responsible for handing over information to all
medical personnel, as well as to the other involved agencies. He or she is also
responsible for what medical information that is given to the media. Which authority
that has the complete responsibility varies from country to country, and sometimes
even between regions. The media and the public always have a great interest in
major incidents and disasters. They always arrive early to the scene taking pictures
and seeking information of what has happened. Sometimes the media knows about
the situation even before any ambulance or medical personnel have been alerted.
We must always count on having to communicate with representatives from media,
and if we don’t hand over information it will be obtained in other ways. There is a risk
that the information given to the public by the media is inaccurate. Consequences of
this are not only irritation among organisations but trouble with the management. The
emergency organisations often have problems with lack of time to inform the media. A
stressful situation makes it difficult to deliver exact information, and the chance that you
might break some laws about secrecy makes it even more stressful. - “If we don’t tell
them, someone else will.”
94
7.7 Additional reading about management
Health disaster management. Guidelines for evaluation and research in the Utstein
style. Sundsnes K-O, Birnbaum M L. Prehospital and disaster medicine. Volume 17/
supplement 3.
Information sharing in out-of-hospital disaster response: The future role of information

technology.
Arnold J et.al. Prehospital and Disaster Medicine 2004;19:201-207
Major Incident Medical Management and Support. The practical approach. Advanced
Life Support Group. BMJ books. Fourth impression 2000.
Performance Indicators for Major Incident Medical management- A Possible Tool for
Quality Control.
Rüter A, Örtenwall P, Wikström T. International Journal of Disaster Medicine 2004;2:52-
55.
Diagnosing the system of organizations. Stafford Beer, 1985.
95
Emergo Train System®
Concept
Contact information:
Johan Hornwall
Manager
KMC – Centre for Teaching and Research in Disaster Medicine & Traumatology
Emergo Train System
University Hospital, S-581 85 Linköping, Sweden
Telephone: +46-13-227490
Cell-phone: +46-768-197490
E-mail: johan.hornwall@lio.se
Website:
www.emergotrain.com
www.lio.se/kmc
96
Introduction
Emergo Train System® (ETS) is a pedagogical simulation system that can be used in
training and education in disaster- and emergency medicine. The ETS can be used
for creating awareness, teaching, testing and quality control of aspects on
preparedness and management of accidents, major incidents and disasters on
different levels.
ETS can be used by health care system, ambulance services, rescue services, fire
brigade, police, military, NGO, Civil protection and other organisations involved in
disaster response and management.
The Emergo Train System consists both of material mainly comprising magnetic
symbols and current knowledge in disaster medicine and management. The
fundamental part is the patient bank that allows performance to be evaluated in
relation to patient outcome.
Continuous development of the ETS is the responsibility of the ETS Competence

Centre in cooperation with ETS license holders.
2008-03-12 97
Provider concept
Emergo Train System® is a registered trademark
Emergo Train System® (ETS) is a pedagogical simulation system that can be used in
training and education in disaster- and emergency medicine. The system can also be
used for testing and evaluation of disaster preparedness regarding both
contingencies planning and testing of organisations.
ETS can be used by health care systems, ambulance services, rescue services, fire
brigade, police, military, NGO, Civil protection and other organisations involved in
disaster relief, response and management.
Roles and responsibilities
ETS Competence Centre
The ETS Competence Centre is:

- the Centre for Teaching and Research in Disaster Medicine and Traumatology
(KMC), University Hospital, Linköping, County of Östergötland, Sweden
- responsible for development and upgrading of the ETS
- the licenser
ETS provider
An ETS provider is an organisation or institution that holds an ETS license. In this

context it will be referred to as license holder.
ETS Senior Instructor (SI)
An ETS Senior instructor:

- is an instructor with teaching experience in Disaster Medicine or other related
fields (Ambulance, Civil protection, Rescue Service, Fire Brigade, Police,
Military, Administration).
- has participated successfully in a Senior Instructor Course and thereby is
certified (see paragraph Senior instructor course).
- is responsible for setting up the aims, goals and objectives and for conducting
and evaluating an ETS simulation exercise.
- can purchase the ETS material
2008-03-12 98
ETS Educator (EE)
An ETS Educator:
- is a certified Senior Instructor
- has participated successfully in a ETS Educator course (see paragraph ETS
Educator course)
- is a teacher in a Senior Instructor course
- is responsible for setting up the Senior instructor course-program according to
a plan given by ETS Competence Centre or National ETS faculty (see
paragraph faculty)
- can together with other ETS Educators start a faculty (minimum 4 persons)
within a license agreement with the ETS Competence Centre and conduct
Senior Instructor courses
ETS Director (ED)
An ETS Director:
- is appointed by the license holder
- can be national or regional according to license agreement (see paragraph
license)
- is responsible for using the ETS in the licensed area
- is the contact person to the ETS Competence Centre
ETS Medical Director (ETSMD)
An ETS Medical Director:

- is appointed by the national/regional director
- can be national or regional according to license agreement
- is responsible for the subject matter expertise in the use of ETS within the
licensed area
- is a trained ETS Educator and a part of the faculty
ETS Faculty
An ETS faculty:
- can be national or regional according to license agreement
- conducts Senior Instructor courses
- is responsible that the courses are held according to the standards given by
ETS Competence Centre
- comprises a minimum of 4 ETS Educators
- must have an ETS medical director (ETSMD)
2008-03-12 99
ETS Quality control board
The ETS quality control board is a body that comprises representatives from ETS
competence centre and from all ETS license holders. The ETS quality control board
serves as a reference group for ETS updates and can also propose development
projects both regarding subject matter and pedagogic issues.
License
An ETS license:
- can be national or regional
A national license:
- is valid for a country and is exclusive
- gives the right to conduct Senior instructor courses
- gives the right to translate, customise and re-sell the ETS material within the
licensed area
- gives the right to start a national faculty and appoint a national director
- gives the right to appoint one member to the ETS Quality control board
A regional license:
- is valid within a country that does not have a national license and is not
exclusive
- gives the right to conduct Senior instructor courses
- gives the right to translate, customise and re-sell the ETS material within the
licensed area
- gives the right to start a regional faculty and appoint a regional director
- will not be renewed if a national license has been signed
Senior Instructor Course (SIC)
The national or regional faculty can conduct Senior Instructor courses and educate
Senior Instructors. The course must follow the course plan given by ETS
Competence Centre for a maximum of 20 students. The content of the course can be
adapted/customised to the country after approval from the ETS Competence Centre.
The ETS Competence Centre provides lecture material (in English). After each
course, a complete course report form must be sent to ETS Competence Centre.
ETS Educator Course (EEC)
The ETS Educator course is a continuation course of the Senior instructor course.
Approval of the course results in a certification as an ETS Educator and gives, within
2008-03-12 100
a license agreement, the right to run Senior instructor courses. The ETS Educator
course is given on request by the ETS Competence centre.
Certificates
ETS Educators and ETS Senior Instructors receive a certificate from the ETS
Competence Centre. Certificates will be valid according to agreement with license
holder.
Material
The ETS material:

- can be ordered by the national or regional director from the ETS Competence
centre
- can be re-sold by the national or regional director only to certified Senior
instructors
Annual report
An annual report regarding use of ETS, development etc. will be requested from the
ETS Competence Centre.
2008-03-12 101
License concept
Emergo Train System® (ETS)
Emergo Train System® is a registered trademark
There are two types of ETS licenses, national and regional. A national license is
exclusive and valid for one country and gives the license holder rights to implement
and re-sell the Emergo Train System. A national license holder is an organisation or
institution that represents a whole country within the field of training in emergency
and/or disaster medicine.
The regional license is valid within a country or parts of a country and does not give
exclusive rights. A regional license holder is an organisation within the field of
emergency and/or disaster medicine that is not considered representing the whole
country. There can be more than one regional license within a country, but a regional
license cannot exist within a country that has a national license holder.
Within a license agreement an ETS Director is appointed. The ETS Director is the
contact person between the license holder and the ETS Competence centre. It is the
license holder who appoints the ETS Director.
License rights
A license gives the right to purchase and re-sell the ETS material, use Emergo Train
System and conduct Senior Instructor courses. In order to conduct Senior Instructor
courses, it is required you have an ETS faculty with ETS Educator competence.
It is possible to have a license without forming a faculty if the license holder is
interested in using the ETS system but not conducting Senior Instructor courses.
ETS Faculty
An ETS faculty consists of a minimum of 4 persons with ETS Educator competence.

One of the faculty members is the ETS Medical director.
Within a license agreement there must be an appointed ETS Director, who is the
contact person between the license holder and the ETS Competence centre. The
license holder appoints the ETS Director.
Senior Instructor Course
The Senior Instructor course is conducted according to a course plan given by the
ETS Competence Centre. After each course, a course report is sent to the ETS
Competence centre who issues the certificates.
2008-03-12 102
ETS material
A national/regional license gives the right to re-sell the ETS material with the
requirement that it is only sold according to guidelines set by the ETS Competence
centre. The material is purchased from the ETS Competence centre who gives a
discount to a license holder.
A Senior Instructor in a country without an ETS license has the right to purchase ETS
material from the ETS Competence centre.
A license holder can have the ETS material customised in order to local or national
standards. Prices for customisation is agreed upon within the license. The material
may be translated to domestic languages.
The national or regional director has the responsibility within the licensed area to
ensure that the material is sold and used according to license agreement.
License fee and royalty
License fee
An annual licence fee is charged from the ETS Competence centre and will be paid
in order for the licence to apply. The licence fee is invoiced annually from ETS
Competence centre.
Royalty
For each Senior Instructor course (maximum 20 students) that is conducted, a royalty
to the ETS Competence centre is transferred.
All other use of the ETS for educational purposes will be subject to a royalty
procedure according to license agreement.
2008-03-12 103
Copyright, customisation and modification
Copyright
Emergo Train System® is a proprietary trademark owned by the County of

Östergötland and is administered by the Centre for Teaching & Research in Disaster
Medicine and Traumatology (KMC).
Emergo Train System cannot be used by individuals or entities for their goods and
services without prior written approval by the KMC.
Customisation
Customisation means necessary adaptations made in order to make ETS a

functional educational system within own licensed area, for example; new colours,
new signs, new terminology. Customisation products are, if developed in the licensed
area, the property of the license holder.
Customisation does not include what is specified as modifications
Modifications
Modification means a change in the ETS system that alters the intellectual concept
and can have influence on other parts of the ETS, for example; adding of new patient
measures, changes in the victim bank, changes in the patient outcome.
Modifications must be approved by the Quality control board and are the property of
KMC. Approved modifications can be used freely within the license area in which
they are developed. In other areas, ETS Competence centre has the exclusive right
to decide if the modifications should be used or not.
2008-03-12 104
Description of the ETS Concept
ETS Competence centre has the exclusive rights to:
- Conduct Senior Instructor courses to all persons outside a licensed area

- Conduct Educator program (only to license holders; national or regional)
- Charge a royalty fee from license holders in relation to number of simulations exercises and
number of students within the licensed area
License holder has the right to:
- With trained ETS Educators conduct Senior Instructor courses within the licensed area
- Purchase and re-sell ETS material within the licensed area
- Have the ETS material customised (for national license holders this is included in license fee)
Charge a royalty fee from all programs conducting ETS simulation exercises within licensed
area
Senior Instructors:
- The Senior Instructors within a licensed area can purchase the ETS material from license
holder and conduct ETS simulation exercises
- Senior Instructors outside licensed area can purchase ETS material from ETS Competence
Centre and conduct ETS simulation exercises
Quality Control board has the right to:
- Approve modifications
2008-03-12 105
Action process to implement a
national license
1 Contact ETS Competence Centre at KMC* in Linköping to receive information
about license and procedures
2 Organise ETS administration at home
3 ETS Senior instructor course
4 The forming of a National faculty
5 ETS Educator Course **
6 Running domestic ETS Senior instructor courses
7 Development of training concepts according to domestic needs
8 Training of users
1+2 3+4+5 6 7 8
0 1 2 3 4 5 6 7 8 9 10 11 12 Months
Time schedule is arbitrary.
*) KMC, Centre for Teaching and Research in Disaster medicine and Traumatology
**) After ETS license agreement with ETS Competence Centre
2008-03-12 106
Action process to implement a
regional license
1 Contact ETS Competence Centre at KMC * in Linköping to receive information
about license and procedures
2 Organise ETS administration at home
3 ETS Senior instructor course
4 The forming of a Regional faculty
5 ETS Educator Course **
6 Running domestic ETS Senior instructor courses
7 Use of ETS according to domestic needs
1+2 3+4+5 6 7
0 1 2 3 4 5 6 7 8 9 10 11 12 Months
Time schedule is arbitrary.
*) KMC, Centre for Teaching and Research in Disaster medicine and Traumatology
**) After ETS license agreement with ETS Competence Centre
For more information, please visit www.emergotrain.com
2008-03-12 107
9. Copyrights
Copyright © 2005 by the Centre for Teaching and Research in Disaster Medicine
and Traumatology, Linköping, Sweden
All rights reserved. This manual is protected by copyright. No part of it may be

reproduced, stored in a retrieval system or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording or otherwise, without
written permission from the Centre for Teaching and Research in Disaster
Medicine.
Emergo Train is a proprietary trademark owned by the County Council of

Östergötland/Centre for Teaching & Research in Disaster Medicine and
Traumatology and cannot be used by individuals or entities for their goods and
services without prior written approval by the Centre for Teaching & Research in
Disaster Medicine and Traumatology.
108

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MANUAL

EMERGO TRAIN SYSTEM (ETS)

Hornwall, Johan johan.hornwall@lio.se

The need of training as a key element of the preparedness and management in

- The ETS is a well -recognised system for these purposes.

- It is adaptable to any organisation or way of working and does not implicate or

• Emergo Train System as a simulation framework

• Emergo Train as a linear simulation

• Emergo Train as an interactive simulation

• Emergo Train System is not a normative game situation

2.2.1 Learning with Emergo Train System

2.2.2 Target group

Note: sufficient medical knowledge in disaster medicine and disaster management

2.2.3 Scope of Emergo Train System

3.2 Process stages in Emergo Train System

3.2.1 Roles in the Emergo Train System

• Paramedic 1st ambulance

Between the players and instructors

An intervention is something that is done or created by the instructor in order to trigger

Know the students level of knowledge

3.5.2 Aims, goals and objectives

3.5.3.1 Patient outcome indicators

3.5.3.2 Performance indicators

Give feed back, document

Analyse results, change training or send to competence centre

This is a very important step in improving knowledge in disaster medicine. We are

Aim: To ensure optimal treatment for patients involved in major incident

Goal: Students should know the principles of secondary triage

Objective: 1) Number of avoidable deaths

Patient outcome indicators:

Prehospital Command & CONTROL

Putting on tabard Directly

Formulate guidelines for 3 min

Establish contract with 5 min

Second report from scene 10 min

Content of second report Verifying first report Indicating

Information to media on 30 min

Approval level > 11 pts

Fig 3 performance indicator prehospital command and control

Decide on level of 3 min

Give information about 25 min

Ensuring that there is a 30 min

Information plan for patients 180 min

Approval level > 11 pts

Fig 4 performance indicator hospital management

Declaring major incident 1 min

Establishing contact with 10 min

Notify guidelines on 40 min

Approval level > 11 pts

Fig 5 performance indicator strategic management

The exercise is simulated on whiteboards with magnetic symbols: patients, emergency

The description of material in this manual is based on version 2 of Emergo Train

4.1 The ETS material

Fig 6 Staff symbol nurse triage team

Fig 8 Staff symbol ambulance/paramedic Fig 9 Staff symbol doctor anestesiology

4.1.4.1 Patient bank

Fig 15 Patient frontside Fig 16 Patient back side

4.1.4.2 Management cards

4.1.4.4 Hospital patients

Fig 21 Hospital patient

1. treatment of the patients

Fig 22 Marking analgesia (1) Fig 23 Marking oral/nasopharyngeal tube (1)

Fig 24 Time schedule measures