Episode 34 – Claire Park – 10 Second Triage & The UK Approach to Mass Casualty Events

Jon Becker: My guest today is Dr. Claire Park. Claire is a consultant in the prehospital emergency medicine for London HEMS and anesthesia and critical care medicine at King's College Hospital in London. She's also an army consultant and retired lieutenant colonel with over 20 years of deployed military experience.

Claire is the medical advisor to the specialist firearms teams of the Metropolitan Police Service and has worked closely with all of the emergency services in London on developing the joint response to high threat incidents. In particular, following the attacks of 2017. She's the chief investigator of a UK nationally funded research grant looking at evidence for improving patient outcomes in the hot zones of major incidents.

I'm excited to have Claire on the show because she has a unique combination of real world experience in combat theaters and practical experience and research in civilian tactical law enforcement. She's also been at the forefront of the UK's new approach to mass casualty events called ten second triage.

My name is Jon Becker.

For the past four decades, I've dedicated my life to protecting tactical operators. During this time, I've worked with many of the world's top law enforcement and military units. As a result, I've had the privilege of working with the amazing leaders who take teams into the world's most dangerous situations.

The goal of this podcast is to share their stories in hopes of making us all better leaders, better thinkers, and better people.

Welcome to The Debrief!

Claire, thanks so much for being here today! I'm really excited to have this conversation.

Claire Park: Thanks so much for advising me! Jon, I'm really excited to be talking to you about it as well!

Jon Becker: So I think context probably matters more in this conversation than it does typically in one of my interviews, because your experience and the experience of the United Kingdom informed of, ultimately, the ten second triage system that you create. So why don't we go back and let's talk about kind of your background and history a little bit. Why did you decide to become a doctor?

Claire Park: Okay, so that's quite a long time ago. I actually almost joined the army before I became a doctor, but I decided to become a doctor because I was super interested in how people work in the human body, and I figured that life was probably quite important, so trying to sustain life seemed quite an important thing to be doing.

So I decided to go to medical school and then really wasn't even sure if I'd enjoy it, but absolutely loved looking after patients and then realized I could be in the army and be a doctor. So just before I graduated from medical school, I joined the army, planning to join for six years and 23 years later, I was still in until last year now when I left.

So I specialized in end up specializing in anesthetics, intensive care and pre-hospital emergency care trauma, which is my kind of main area of work. But started off in the army as a GP. Working with an infantry battalion in Iraq was the first place we deployed to where I spent six months with them and then came back and studied specialist training in anesthetics and critical care medicine, which then took me to the pre hospital care world, where when I deployed again to Afghanistan, I deployed with the medical emergency response team, which is essentially the sort of helicopter version on the Met in the Chinooks, and we would go out to treat the soldiers from the battlefield on the way back through camp bastion.

And then I do the equivalent of that job in the UK, where we call it Hems, or helicopter emergency medical services. And in London, we have a team that work for a service called London Hems, where we do exactly the same. We essentially take the emergency department to the roadside, where we do resuscitation procedures and examine and decide what patients need at multiple trauma scenes across London and the surrounding area.

Jon Becker: So you spent the last 23 years dealing with people who are in trauma in the field, not just treating people in emergency rooms, but between your work in the army and your work in the Hems program, like you're flying in on a helicopter to almost every patient you see.

Claire Park: Yeah, either on a helicopter or in the car when the weather's too rubbish. But we. Yeah, essentially, I guess we're, in a way, I see it as being pretty lucky to see patients at that really early phase of their injury trajectory, something that often people in hospital don't see. And sadly, some people were not able to save, and those people never get seen by the people in hospital. But we have the opportunity to see what we maybe could do to save people, and we also understand what it's like to try and manage people at the scene.

And I think that sort of that element of working within an emergency scenario and within the scene is something that brings me into the work I've been doing with the police, and particularly police officers in tactical environments. Understanding the situation they're working in is something very different to people who work within.

Jon Becker: Yeah. And I think it's not, you know, it's not wasted on me that the 23 years you spent in the army were 23 of the most eventful years for trauma medicine, for the way we treat our injured soldiers. How many times did you deploy in the time you were in?

Claire Park: I guess that it was a total of. So it was in Iraq for six months. I went to Afghanistan three times for three or four months each time. And then I also deployed with small surgical forward teams that support our SOF units to North Africa. And during that time spent a lot of time, obviously, in training for those different varying roles with the military.

So probably particularly Afghanistan, Washington, really busy in terms of casualties, sadly, ISAF casualties that we saw, all of the international security forces, both UK, American, Dutch and everyone else that was deployed with us, as well as the Afghan casualties that we came across.

So, yeah, those few years were particularly busy and really glad to say that by the time we left, at least it was less busy than when we started and we were seeing less people badly injured. There was certainly a lot of bad injuries during that time.

Jon Becker: Yeah. But I think it's for your later life. I think it's fantastic preparation. Right. Like between the him's work that you've done of seeing people who are in car crashes and all kinds of traumatic injuries, to the time spent in Iraq and Afghanistan and dealing with gunshot wounds and frag wounds and concussion wounds and all those kinds of things, it kind of lays a foundation that then makes this, makes you perfectly qualified to do what you're now doing.

Claire Park: Yeah, I think it does. It focuses your mind a lot when you're there trying to save people. And if you're passionate enough about it, you really, really want to understand what it is that we could do to make a difference and seeing the injury patterns, trying to understand what's happening.

And I think now my other job, which is in hospital, as well as working for the pre hospital services, I work in hospital based in the emergency department, running trauma calls and in the intensive care department, looking after people on life support machines, essentially helps me understand that whole injury process and what we expect to happen and what's possible to happen for people that we do the right stuff for. And then in the pre hospital world, we see the people that sometimes we can't save and we look at what we need to learn to do better.

Jon Becker: Yeah, I think it's the US they talk about the golden hour of trauma and it seems just in reading your bio and talking to you and preparing for the interview, it seems that you've spent the last two decades living in that golden hour with everybody from soldiers to cops to just average UK citizens.

Claire Park: Yeah, arguably it's not an hour. I think I know you've probably heard people say that, now there's the golden hour. But actually, for some people, it's five minutes. For some people, there's no time at all, and then for some people there's longer, but there's definitely, I think, a shift. And what we know is that probably the peak time to death, certainly from bleeding pre hospitally, is 30, 35 minutes.

So in some people, you have a really short time to try and do something, and other people who are bleeding from injuries to different parts of their body, you have longer. So I think our aim is really to get there as quickly as possible to make the decision about what they need.

And that decision is actually sometimes all we do, sometimes it's interventions, but sometimes it's just knowing, okay, actually, we just want to go with this patient, and in other patients, it's no, we need to stay and do something to try and get them relying.

Jon Becker: Yeah. I recently interviewed Kevin Menes, who was one of the doctors that responded to the Las Vegas shootings. And Kevin put it better than anything I've ever heard. He said, when somebody is injured in a traumatic injury, they have x amount of time to live, and that might be five minutes, it might be 2 hours, it might be the rest of their life. But if you do not intervene and stop what is killing them in the time that they have, they're going to die.

And, you know, I had never thought about the role of, especially the first physician that's treating as extending that time. But it's really, in reading your work and listening to interviews with you, that's really kind of the focus of a lot of your work, is trying to get there as quickly as you can to stop the dying process as quickly as you possibly can.

Claire Park: Yeah, and I think one of the procedures we started doing in London, which is something called riboa, it's essentially an internal tourniquet. So it's a resuscitative endovascular balloon. Occlusion of the auto. It's a long term for it, but basically you put a tube into the femoral artery and inflate the balloon in the aorta to stop bleeding below it. And we brought that in really, because we were seeing patients dying on the streets that we could resuscitate to get the hospital alive. We wanted to do something different.

So that process of essentially, because you can't compress that, that's non compressible bleeding that's inside the body as a piece of the stuff that you can put a tourniquet on or you can pack, then we needed to do something different. So as a service in London, we, even though it's fairly complicated. We realized that we needed to do something and we certainly had some patients and the complications of it, but we've had some patients who survived to hospital and done really well as a result of having that put in.

So we're still learning about it, we're still trying to push boundaries with who we can make it work for. And the sicker the patient, the harder it is to get it in. But we're constantly looking at what we can do differently and not accepting that there isn't something we can do.

Jon Becker: Yeah, I want to talk about some of the areas you're currently researching. I think, first, it may not be a bad idea to give context to our listeners, the difference between the UK and the US, as far as policing ambulance service, because you guys have a different approach than we do.

Claire Park: Yeah, I guess certainly from a policing point of view, it's unusual, or more unusual for our police officers to carry guns then it is not. And we've had one, actually had one American doctor work with us, but he was like, I can't get over it. I can't understand how police don't. More than half your police don't have guns on the street.

So for me, when I say that I work with our armed police unit, that most of our police in London are not armed, and there's a small unit of smallish unit of armed police in London, more in London than anywhere else. But that's probably the biggest difference.

Jon Becker: Which of the specialist firearms officers, if I remember correctly.

Claire Park: So we've got two levels, if you like, of armed policing in general. I mean, they're split into specialist areas, but the main armed response vehicles, as we call them, ARVs or armed firearms officers, standard firearms officers are the normal guys, the guys we work with day to day on the streets. They'll be driving around London in cars and they often go to stabbings and shootings that we go to with them. The specialists, the counter terrorist specialist firearms officers, or CTSFOs, are a little bit more like the specialist intervention units.

So a bit like GSG nine or raid or probably a high level SWAT team, more sort of special forces trained. And they have extra skills for hostage rescue and the more complicated jobs, and they would do more undercover stuff, both crime and counter terrorist work. And we have quite a few teams in London and I've worked quite closely with them as their medical adviser.

And then I guess some of the other differences we have in the pre hospital world is that our fire and ambulance services are split. So unlike in the US where often you would one day maybe be doing fire job and the next day be on an ambulance. We have totally separate fire and rescue service to ambulance service. And they're not interchangeable roles.

Jon Becker: So the firefighters are firefighters, they're not firefighter paramedics.

Claire Park: Yeah.

Jon Becker: And the paramedics rescue EMS or their own discipline.

Claire Park: Yeah. So we have – The fire rescue service tends to be the kind of fire and they have a rescue role. So their role in sort of high threat incidents or terrorist attacks would be, other than dealing with fire, to be the sort of extrication and rescue people, particularly, although they have some first aid training as well, and the EMS or the ambulance service would be providing the medical response.

Jon Becker: Got it. Yeah, that makes sense. And the other thing is, it's common to have a doctor in the US. We think in terms of, you're going to get a paramedic who's going to get you to a hospital, to a doctor, but you guys forward deploy your doctors much more than we do.

Claire Park: Yeah, I think it's pretty standard across the UK. Not lots of doctor teams, not as many as they have in France. But in most areas of the UK, we will have a doctor paramedic team available to deploy to a scene to provide that kind of hems response, that emergency department response by the roadside. And it's been increasing. So it's probably 30 years ago. London Hems has been going for, I think, just over 30 years now, 34 years or so.

And certainly when we started, a lot of people said, this is ridiculous, why would doctors going to the scene? And it's kind of become an accepted kind of part of our response now, which is to have that enhanced sort of medical team going to the scene. Bizarrely, it's the one place that's not so accepted is in tactical situations or high threat environments. And I think my understanding that the reverse is the case in the US, where the only place physicians really seem to deploy to the scene is with a tactical team in some places.

Jon Becker: Yeah, it's not. It's not uncommon in the US for a medical director to, you know, be embedded with a team. At a minimum, you know, you'll have highly trained tactical emergency medicine specialists, but. But it is not unusual for teams to take a team doctor with them. And, yeah, you're right, that is the one place that we for deploy our doctors. Although, you know, I think as we go into this, we'll find that probably both sides could, could stand to move the doctors a little forward in a mass casualty. Talk to me about interoperability there's a little bit of difference in the way you guys interoperate. Police, fire, rescue.

Claire Park: Yeah, I think it's probably standard for us in the UK. So we have a thing called Jessup, which is a joint emergency services interoperability principles. So for any scene, and most of our emergency scenes on multi agency to a certain extent, where we'll have an RTC, fire will come and secure the vehicles, while ambulance will sort of deal with the casualties and then police will secure the scene.

So most of our scenes involve at least two, if not three, of the emergency services. And we have a standard way of bringing those services together with principles of joint understanding of risk and situational awareness and the commanders all coming together in a huddle to make those decisions. And in principle it works really well.

And on the smaller scenes it definitely does and will have repeated land huddles between the three commanders just to kind of update, particularly on slightly more complicated scenes. It doesn't work if people don't come together in some of the more complicated, bigger major incidents. That's one of the issues we've had.

But I think in general it actually works really well. And we have specific interoperability liaison officers for each of the services that are specifically trained to pass the knowledge of their service onto the other emergency services they're working with. I think it does work quite well to bring our teams together and see and augment. Everybody's working together.

Jon Becker: Yeah. And I think that's kind of a good segue to talk about stuff that's interesting to you right now, because I know that you're doing research, you're involved in a lot of things. What's got your attention right now? What are the things that you are working on, are trying to move forward.

Claire Park: So I've spent probably the last few years at least, looking specifically, as I've kind of alluded to, higher threat responses, but also major incidents in general, whether that's a train crash or car crash or a fire, a big fire in a building, and from a sort of London air ambulance, London hems point of view, lead on that.

And it particularly looks at incidents across the world and how people have responded to that. As I kind of alluded to, I've been thinking quite a lot about what we could do differently to save lives. And what I've noticed at a lot of these scenes is that people talk about process and they talk about numbers of casualties and they maybe even talk about triage categories, but no one really talks about what's wrong with the casualties and how much, therefore, how much time we have to save them. And actually, that's probably because we don't have a lot of really good evidence on that.

So I spent quite a lot of time thinking about what is it that's killing people, how long do they have to survive with all of the various different injuries, and everyone responds a bit differently, and then who is there at which phase of their response to try and fix that, and trying to bring all of that together to the sort of chain of survival which we think do quite well for medical cardiac arrest, but we probably do less well for traumatic injuries.

So I've been looking specifically at a research project to look at all of the deaths from terrorist attacks in the UK, and supplementing that with stabbings and shootings and similar type of mechanisms since 2000 to look at specifically bringing in multi agency data.

So using police data to join with health data and with the coroner data to look at the time to death, how long did they survive or not death on the certificate, but how long it took till they went into cardiac arrest, what their injuries actually were, which we get more detail from in the post mortem report, and then what anyone who was there was able to do, and also the time of who responded, at what point in time, with what skill set.

So then we know who might have the ability to do something, so we can look at all of that data and pull it together, and we're still doing that now, but to look at potential survivability as well. And if a patient had an injury that is potentially survivable, who would we need to get there and what timeframe to fix it, and then translate that into exercising as well.

So that when we actually exercise these things, we have people playing casualties who act out in the way that the casualties would present, so that it's more realistic than having mannequins and people who are having a bit of a laugh, because it's quite funny to pretend to be a casualty. So trying to make it as realistic as possible, having casualties acting in the right way, presenting in the way the casualties would.

So people learn that and then deteriorating if they don't get the right intervention. So that by the end of the exercise, you have outcomes that say this number of people died, these patients might have survived if something different had happened at this time. So we can get better learning out of the training we do, which often is expensive and time consuming, and quite often we don't think as much out of it as we could.

Jon Becker: But you start really hitting the human effects kind of the human factors of training by increasing pressure and doing other things.

Claire Park: Yeah, absolutely. And the knowledge and the technical skills is one thing, but the human factors is almost a whole other kind of element of training that we spend quite a lot of time training in sort of small teamwork, which is kind of understanding what it is that prevents us maintaining that situational awareness. So simple concepts, I'm sure lots of people who are listening to this understand and train anyway.

But the idea of sort of bandwidth being the amount of head spare, the amount of spare headspace you have to take in new information and process it and make decisions. And if your task focused on something, how that bandwidth narrows to focus on the thing you're doing, and by default, then your peripheral vision and your peripheral hearing go. And so you miss stuff that's coming in. And if you become really, really task focused, you really don't focus on anything other than what you're doing, but you probably don't notice that at the time, so then you lose your situational awareness.

So a lot of the training we do is to train things like motor programs. So, for instance, when you drive, most of us, I certainly often drive and probably couldn't tell you what I was doing to drive. If I had to teach someone else to drive, I'd have to really think about it, because it's so ingrained in me that I just do it automatically. Even driving a route home that you drive every day, you don't think about it a lot of the time unless you're driving for a job where you're taking note of everything that's around you.

So that idea that you've embedded and rated program that then doesn't take up your headspace. So you've got more headspace to notice what's going on around you. To not become task focused and to maintain your situational awareness means that you're much more effective, particularly when there's a high threat situation. But even on a normal job, when we go to a scene, people become quite stressed by everything that's going on, and that also narrows their bandwidth because they're not used to taking it in.

So being used to turning up to scenes like that and then also focusing on how we respond to each other and noticing it in a teammate. So if my paramedic sees that I'm a bit focused on something, they can offload me and take some information or take something off me to give me a little bit more bound.

Constantly doing that as a team or keeping one person step back with the eyes out with someone else who's task focused and then switching between those two things allows us to maintain as a team that sort of situational awareness and is often the way we are able to make the skills and the decision making work and push the scene forwards. We spend quite a lot of time focusing on that and also in our training, breaking down the skills to focus on those bits as well.

Jon Becker: Well, it's interesting because we tend to think of the initial response to an active shooter or that kind of a situation, and we tend to train that a great deal. Teams will work on active shooter protocols and all that, and they'll work on tactical medicine, but they don't tend to necessarily work on them together where you're dealing with not just a patient, but a dozen patients, and having to choose where you're going to pay attention.

And I think it is an area that could use a great deal of augmentation for training. And we don't think about the overwhelming nature that happens to the medic too, you know, if you're lucky enough to have a doctor there, the doctor, because that's – It's not just an unusual circumstance for the team, it's an unusual circumstance for everybody involved.

Claire Park: Absolutely. I mean, this is, you know, we train for this all the time, but it's not the kind of thing you go through all the time at all. And there's a lot to do. You know, if you've got one sick patient, you could do so much for one sick patient.

When you've got multiple sick patients, having all of those sick patients there, you've got to have some way of starting and actually doing the immediately important stuff first, and have a sort of framework to approach that scene and having that framework to approach the scene, but also keeping one person, maybe even back, to stop people getting sucked into doing too much for each casualty forest before they've got around and done all of the immediate stuff is a really important part of making that scene work and is certainly a lot of the consideration that we put into a new triage tool that we've developed, particularly for those kind of tactical scenarios, but for all of our emergency services in the UK.

Jon Becker: Yeah. Which is ten second triage, which I want to get to, I think, before we move to ten second triage, why don't we give context? Because the UK had a series of events in 2017 that not only identified the issue with triage response, but also, I think, gave the political will to the public and provided the funding to do the research and all of that. Why don't we start? I guess it's probably March of 17, right, is the Westminster Bridge incident, if my memory serves me correctly. Car versus pedestrians.

Claire Park: Absolutely. It was March 2017, and it was 02:00 in the afternoon, and it was a car that had driven into pedestrians on Westminster Bridge and then drove into the barrier outside the palace of Westminster, which is our houses of parliament. And then the attacker ran around to the gate of the houses of parliament and attacked a police officer that was on duty there.

And sadly, that police officer was killed in the attack along with four other people. That was the first of the terrorist attacks we had had for quite a while. And actually what you learn about these kind of incidents is that corporate memory phase quite fast. In the sort of nineties, we had lots of IRA attacks in London. And then in the early two thousands, we had the seven. Seven bombings, but we hadn't had anything for quite a long time.

So a lot of people actually responding to that attack didn't necessarily know that it was a terrorist attack initially, certainly not the car vested pedestrian. That was one of the first vehicle attacks we'd had. And so. But it then became very rapidly clear what was happening since the police responded to the attacker at the palace of Westminster.

And there was – See, there's, as with all of these events, there was all of the distraction calls and the concern that there were multiple attackers and other things happening. And for that reason, even though it was, we now know in hindsight easily, that it was a single attacker, there was a lot of reticence to deploy teams to the scene because of the safety and because it was technically a hot or a warm zone.

And then that event followed by some other events in 2017 with some of the similar themes. But actually what happened, well, in that event was that the patients got really good care on the bridge because most people didn't know it was a terrorist attack. And when it does become known to be that, actually the response gets delayed because people worry about the safety.

Jon Becker: Yeah. So you've got, at Westminster, you've got 49 people injured, five killed. But, yeah, it initially presents as a car crash. Like somebody just lost control of their car and hits a crowd. And so people are running into the scene and you're getting help, and it's not, you know, there isn't this immediate shutdown of, okay, it's a terrorist attack, shut it down. It's a hot zone, so you have better response.

Claire Park: And it was kind of split. So you almost had. It was very obvious what was happening at the palace of Westminster, that that was an attack. But the people who responded to the south side of the bridge that that kind of took a little while to filter, certainly from an ambulance point of view.

And I mean, quite quickly it became clear. But I think you still, by the time people had responded and were there already, the police who knew that it was a terrorist attack, went, if I stop people responding now, I'm going to stop a response that needs to happen.

So I'm going to take a risk and let them carry on, because we know that the one attacker we had is now secured. And that's happening in a different area, which is different to something like London Bridge, where there were multiple attackers and there were thought to be more, and then that whole area is kept hot or warm for a long period of time.

Jon Becker: Yeah. So why don't we skip, because London Bridge is the third in a series of attacks, but let's jump to London Bridge. So that's the 3rd June 3 attackers. Vehicle as a weapon.

Claire Park: Correct. 3 attackers, but thought to be four for quite a long time. A van used as a weapon over London bridge to go into multiple patients on the bridge and then crash that van into the corner of a pub, believe in the back of the van, there were Molotov cocktails that were intended to be thrown into borough market to use fire as a weapon.

And then the attackers got out with knives strapped to their hands and ran through the market area, which was 10:00 on a Saturday night. So sort of super busy time and a really busy small alleyway area of London.

Jon Becker: Stabbing everybody. They see her, basically.

Claire Park: Yeah. Essentially running around everyone they can get to through the market. And the police response was really pretty quick. It was, I think, eight minutes from the initial call to the air response vehicle turning up outside the other side of the market and shooting them. But at that point, they had fake IED vests on the IED vests that they didn't know were fake at the time.

So that was then a sort of slight further delay in securing that area or allowing people into that area. But from that point, the three attackers were killed. I pretty much together, and there was thought to be a fourth. And so all of those buildings in that area were searched sort of the next 8 to 10 hours.

Jon Becker: Yeah. It's fascinating how often in these events the count is always off high. I'm not aware. In thousands of debriefs, I'm not aware of a single case where they thought there was three guys and there turned out to be four. It's always they thought there were three and there were two, Vegas being a perfect example where you have a single attacker and they were getting multiple reports of, you know, oh, there's three guys, there's four guys.

Claire Park: Yeah, yeah. And you know, the same thing happened in Manchester where there was one attacker, he blown himself up. We'll go on to that. But the same thing with wounds that look like gunshot wounds which are actually fragmentation wounds and people running away with those wounds and people going, oh, no, that they're being shot in the car park because they're now in the car park with those wounds having escaped.

Jon Becker: Yeah. So London Bridge is 48 injured, three killed. Similar. Eight killed. Sorry, killed. So 48 injured, eight killed. So similar effect size as to what you saw in Westminster Bridge with 49 and 5. And then between those two, 22nd May you have the Manchester arena bombing, which in the US is the Ariana Grande concert. It was interesting because as I started to dig into Manchester, I had no idea the scope of that event. Like it was reported as a bombing and it was not, you know, I mean, it got coverage as a bombing at an Ariana Grande concert, but 66 pound bomb, TATP bomb, if I remember correctly.

Claire Park: Yes, correct. And I. I think you probably don't work in kilos, but about 30 kilos. That is, I think 66 pounds of CACP and fragments, loads and loads of nuts, bolts, metal fragments that he put into it.

Jon Becker: And that is an injury scale. That is, I've seen a variety of numbers here, 22 killed, but the injury counts that I've seen have been as high as 1000 on scene. What was the, you know, give us some scale here.

Claire Park: So I think the reason the numbers are difficult to know is that quite a lot of people who were injured actually took themselves away from the scene if they weren't that badly injured that they couldn't get away from the scene. I've certainly, as part of the research we're doing, have interviewed people who've. Who survived lots of these events. And there was one lady who got in a car and drove herself to Wales because she was told no one was going to come and look after her in Manchester.

But yeah, I think in the room, the city room where the bomb went off, there were maybe 337 people kind of notably badly injured in there. But yeah, we put up to a thousand people injured, some with minor injuries. But I think we're talking about kind of. I think somewhere between three and 600 had decent injuries. The numbers will be different from everyone. And then, as we know, 22 who died, two of whom, two or three of whom made it to hospital but died either on the way or just after arriving in hospital.

Jon Becker: Yeah, but I mean, whether it's 300, 600 or 1000, it is a scale that is just ridiculous. It's similar to what we saw in the Vegas incident, where it's hundreds of patients and some of them are minor injuries and some of them are major injuries. And, you know, one of the things that, in talking with you and in doing the research, part of the problem is figuring out whether somebody is legitimately, you know, is this an injury they're going to survive, or is this an injury that we've got to treat them right now or they're not?

Claire Park: Yeah, I think it's in that very first instance of responding, you have to limit what you do. But there's knowing over the initial response of life saving intervention, of dealing with catastrophic hemorrhage and opening an airway. What is it that's killing people? And it's kind of obvious if someone's got an amputated leg, I think it's more obvious, and that's why, actually, some of the blast injuries that we saw in Afghanistan were easier to understand. I actually think blunt trauma to a certain extent, and blunt trauma where the blast has thrown you against something, it's fragmentation injury.

So you don't have an obvious amputation, but you've got those metal fragments that have gone through vessels in your legs that aren't, obviously your legs not off, but you're bleeding inside your leg. That's more difficult to understand how sick the patient is, I think. And so one of the things with bleeding patients, at least one of the things we focus on is trying to understand what a bleeding patient looks like in terms of their physiology.

So how do they present? They often pale, they often really shut down, often sweaty. You can't feel a radial pulse. Their breathing rate might be fast because they haven't got enough blood going around, so they're trying to get more oxygen to the blood that they have.

But using kind of simple things to try and understand if a patient is bleeding or not, as well as the injuries that you see is what you need to do for the people that have internal injuries that you can't obviously see a bleeding out. And that goes for whether it's bleeding into limbs. And that's important because for the limbs, you can put a tourniquet above it, but if it's what we call non compressible bleeding.

So one of the things I try and tell my medics is about this is blood on the floor, and floor more so. There's essentially four other places you can bleed into. One is your chest cavity, one is the abdomen, one is the pelvis, and the other is what we call long bones. But it's particularly the femurs. You can lose kind of two liters of blood into a broken femur that's expanding into the space where it's broken.

So those sort of four places, if you like, are places that you need to worry about someone bleeding and dying from that bleeding. And a femur, whether it's because of the femur, if it's because of blood vessels in the leg that are damaged, that bleeding can cause you to die. And if you can get a tourniquet above, it will splint the limb that's broken.

Then there's stuff you can do on scene to try and limit that bleeding, which is really important, because it might just limit it enough, even if they're bleeding from somewhere else as well, to get them to hospital alive. If they're bleeding into that abdomen or chest, there's not a lot you can do about that before you get to hospital.

There's a couple of things we might do as an enhanced team, and maybe if there's a couple of patients, we can try and do that. But if there's multiple patients, those are the patients that really need to go. If it's a pelvis, it is important that you might want to splint it, because you can, again, limit that bleeding.

So I guess it's about understanding where you can't do anything else, and you want those patients to just go to hospital and where the stuff that you can splint or stop bleeding to do it, because the longer you leave it, the more problems they'll be in when they get to hospital.

Jon Becker: Well, I think that's kind of a good transition for us, because. So in the wake of the Manchester bombing, they put together a blue ribbon panel to look at the incident, to look at the response. Produced a fantastic, lengthy report that we'll link to in the show notes. And I would encourage people to go in and at least read the executive summary of. But you at that point, are brought in to assist as an expert on the review, right?

Claire Park: Yes, I was involved in it from a couple of points of view. I was initially brought in as an expert witness to look at one of the patients who died. And that meant looking at all of the footage and all of the reports in terms of the response and what it looked like initially and what she looked like and how she presented from a clinical point of view with the body worn footage and CCTV footage. And that was extensive discussions about her injuries and what may or may not have happened to her.

But then the next bit after that was that I was asked to comment on what the chairman of the inquiry called the care gap, which is essentially based on something we published on a couple of years before called the therapeutic vacuum, or at least that's what we called it, which is this concept of a vacuum, or this gap in treatment for people who were injured at any scene, but particularly at something like a terrorist attack or an active shooter attack, where it's not safe initially for people to immediately run in.

And there's always going to be a delay in healthcare getting to see in anyway, but particularly in these instances where they may be kept outside because of a worry about safety, that delay in first responder, what I call first responder interventions, or bystander interventions. So the CNA or the m and a of march, those are the things that kill people in the first ten minutes. External catastrophic hemorrhage and opening an airway are things that need to be done by someone next to you or someone very quickly there, and that not happening for that first ten minutes.

And then the delay in healthcare getting in there, the delay in getting the patients out to definitive care quickly. And by definitive care, I mean ultimately to a hospital and if they need it in operation, and then delay actually in the final bits as well, that's not relevant so much at the scene. Actually, when we look at some of these inquiries, they happen four, five, six years later.

So we're not getting really quick learning of all of the things that we need to learn from, even though they go into huge amounts of depth and they're really complicated. Getting that multi agency, honest learning between different agencies, and the learning from the post mortem reports, which certainly in the UK are not that easily accessible, are things that we could still do better in the future.

So that's a long way of saying that this care gap that the chairman focused on, he asked me to look at what I thought could be done differently in terms of narrowing or filling that care gap and where we could make a difference for the future.

Jon Becker: So if we think of it in terms of, take the analogy we previously had, the minute you are injured, the bomb goes off, patient x has x amount of time until they're going to die. Let's just say it's 30 minutes. The care gap is the amount of time we are wasting out of that 30 minutes, because we cannot deliver care immediately, which obviously, there's always going to be a care gap right. No matter what, there's – Unless you have the medical team standing by immediately, there's always going to be a care gap.

But obviously, the more of that 30 minutes we spend trying to get paramedics there, trying to get doctors there, trying to get ambulances there, or in the case of hot zone, waiting for the scene to be secure, that care gap is spending that 30 minutes that that person has. And if we spend 15 minutes of that, then we're down to 15 minutes to save their life.

Claire Park: Yeah, absolutely. And, you know, those initial interventions don't need a. A paramedic to do them. Anyone can do them if they're trained to do them, I think is the key bit. And I have certainly seen exercises in the UK a few years ago where there would be CTSFOs and armed response police standing. They've moved the casualties, they've put them all in an area to keep them protected in the hot zone, or made a warm zone in the middle of the hot zone and just stood watching them die, because the training is not or wasn't to provide a immediate interventions for them.

And like in the military, where every soldier is trained to provide buddy buddy aid for the person next to them. And if their mate is blown up, the first thing they do once they've returned the firefight, if they're in a firefight or made sure it's safe to approach them, is to chuck them a tourniquet, push them on their front and try and tighten that tourniquet for them.

So that kind of idea of the person next to you trying to help you is possible. I know in Afghanistan, because I know on the back of the met, the people that came on are alive to me, their mate put the tourniquet on. The people that didn't come on alive didn't have their mate put in a tourniquet on. So I know it's possible to do. It's just about putting it into practice in a way that you can do while you maintain your situational awareness of what else is going on.

Jon Becker: Well, I think there's been a big move, both in the military and at least in US law enforcement, to push down kind of those basic levels of hemorrhage control. And I recently interviewed an agency that'll be an episode later in the season that was. They had a team go into a bank robbery and six of their officers were shot immediately and two or three. Three femoral wounds. And those guys were alive because the patrol officers that responded had medical supplies, they had tourniquets, they had gauze they had bandages and knew what to do with them.

And so you went from, there was a single medic for the team, but instead of doing the interventions now, he was describing to patrol officers what to do, and you could see how the system works and how you layer the response.

But that's, you know, in the case of a mass casualty, in the case of very serious injuries, half the time the problem is that initial response and how complicated so many of the algorithms are. And I think that that's kind of one of the things that emerged from your research with Manchester. Right?

Claire Park: Yeah. So if we're looking at a framework for people to walk into that room, and everyone describes the overwhelming nature of walking into a bomb having just gone off, and we could see it from the CCTV, there's the alarms going off, the noise, the smell, the destruction, the body bits, all of those things that even if you know exactly what to do, you're struggling to remind yourself, to kick yourself into where you start.

So assuming as an operator, it's secured and you're not doing another job of securing the area, and you're just going in and you're faced with a casualty, is how do you know where to start with each of the casualties? How do you stick to just looking at them and dealing with Cambridge and airway and moving on to the next one, rather than getting stuck on everything else, or not even knowing where to start, because it's too overwhelming.

So one of the things that we'd actually developed before Manchester, but it was an opportunity to present it and suggest that this was something that we think would work for all of the emergency services, which is ten second triage as a way of having a framework to walk in and have some very simple questions to ask when you get to each casualty that allow you to just think about these things that are going to kill them in the first ten minutes, deal with that and move on to the next one, while prioritizing them at the same time with a P1, 2, or 3 tag.

Jon Becker: So one of the things that struck me when I first started reading ten second triage and looking at the system and listening to interviews about it, was that there was an underlying belief, and I guess was demonstrated in Manchester, that the existing algorithms were too complicated.

Claire Park: Yeah, absolutely. And I think a lot of current triage tools, and there's something like about 20 at least, published a few years ago. When we started working on this, there were 20 primary different scene triage tools. Almost all of them, in fact, all of them require some form of physiology to be measured.

And by physiology, I mean feeling for pulse and counting it, measuring a respiratory rate, feeling for what we call capillary refill time, so pressing on the skin and seeing how quickly the blood flow comes back, those things really, really take up your bandwidth and narrow you, your focus and prevent you being able to have any situational awareness.

And I certainly never count respiratory rate or count pulse rate. I feel if it feels stronger or not, but feeling for a pulse and someone who's bleeding is really difficult because it's weak. And if you've got tactical gloves on, you're sweating, your pulse is racing, it's dark, you've got a load of other stuff going on. It's really not an easy thing to do, even in a well patient, but particularly not in a sick patient. And what does it actually mean?

Because in a lot of the research, when you look at the triage systems that have been developed and what they've been compared against, liberty as well, writes down that pulse rate and that respiratory rate of that patient at that point in time when they've just been injured, they get written down when the ambulance is in a position to record the heart rate or the ambulance crew are in a position to record the heart rate in the respiratory rate, and that's much later on down the line. So not only do we not really have good data from that early physiology to tell us that it means anything anyway, we know that it probably doesn't mean anything.

If you're bleeding to death, your heart rate can be slow or fast, so it doesn't necessarily tell us anything. And if you've just watched your daughter be killed, your heart rate is probably not going to be slow. Or if you're in loads of pain, your heart rate is not going to be slow, and your breathing rate is not going to be slow.

So actually, in that early phase, in those first few minutes of an attack, where we want people to have a really simple way of working out what to do, it's too complicated to measure those things, and then you have to remember what the respiratory rate is and which category they go in, all of which, again, it's not necessarily that helpful.

So what we wanted to do is take away anything that's not going to be helpful and anything that's going to make it too difficult for someone to put this into practice and replace it with simple questions that essentially ask about the, what we call the end organ effect of the physiology.

So what happens to you if you're bleeding a lot? If you've bled a lot. You're not going to have enough blood flow going to your brain, so you're not going to be able to talk properly over that. You're not going to be able to walk. If you've not got enough blood flow going around your body to be able to keep all of your muscles while walking, then the first step is you won't be walking. The next step is you won't be talking. So ask those questions rather than try and find a pulse.

Jon Becker: Yeah. So why don't we walk through? What struck me the first time I read it is like I'm far from a doctor and I'm an attorney and the tactical gear guy and I looked at it and thought, I can answer these questions. There's zero medical knowledge required as you look at the questions. It struck me as very simple and very quick to apply and, like, you could do most of it in legitimately in 10 seconds.

So why don't we walk through? We'll put up on the screen and also include in the show notes a graphic for this, but walk me through the questions I'm going to ask.

Claire Park: So the flow chart starts with are they walking? And I know that there are some. The reason we started with that is just as a simple way to get rid of some people out of the way. If you're walking, walk out. Direct them out, because obviously some people who are walking could collapse. But if you're walking, walk out. And then we come to the next question of, is there any severe bleeding?

The reason that we didn't put it the other way around is if you focus on the severe bleeding first, you've got more people to try and assess. So go into the walking. If they collapse, then they can be assessed. If someone. One caveat with that is we tell people to use their common sense. So if they're walking and they've clearly got an arm hanging off or they've clearly got a big hole in the front of their chest, then sit them down and treat them as if they're not walking because they won't be for very long.

But you can't afford to assess everyone who's walking out, otherwise you get completely swamped. If there's really thousands of people, the next question is, so if they're walking, if you want to tag them, they get a green tag, which is a P3. P3. Priority three is basically anyone that's walking. The next question is, do they have any severe bleeding? And that terminology, people will notice has changed from catastrophic hemorrhage in some of the triage tools to severe bleeding.

And the reason for that, we had a lot of discussion about it, but severe bleeding, a lot of people perceive, and certainly we've seen in training, that catastrophic hemorrhage has to be spurting up the wall to be catastrophic hemorrhage, and it sometimes is, but a lot of the time it isn't. A lot of the time, it just seeps into clothing. Even if it's an arterial bleed, it seeps into clothing. Seeps into the floor, particularly if it's dark clothing and the dark floor and it's dark, you won't see it's burning.

And what we don't want is for people to miss that. And then later, which we know, too, there's been two preventable deaths in Manchester. The findings were that two people died. Certainly one of them died from compressible lower limb hemorrhage, and he was young and fit otherwise, and he died at an hour and a quarter, I think, off to the. After the bomb had gone off, because he didn't have torn the case put on, because it wasn't obvious that it was splitting out. So that terminology has been changed to say, if there's severe bleeding, then manage the bleeding.

So however, you know how to do whatever you've got available to you. The little. There's a little diamond action box, which is the blue action box that says pressure packing or tourniquet. So if it's compressible with a tourniquet, put one on. If you can't or you don't have one pressure, and if you can pack it, even if you don't have specialist kind of hemostatic packing agents to pack it with anything, pack it with a t-shirt. It's about getting pressure on the base of the wound that's bleeding to stop it bleeding.

If you've dealt with them, they become a P1 automatically because they've got something that needs to be done, but also because they're obviously sick, so they become a P1 or a red tag. Then you go to the next question, which is, are they talking? And as I've sort of explained, are they talking? Is a really simple question. You can answer it quite quickly, are they talking to me or not? If there's a little bit more training time for people, we can nuance that a little bit more and say, are they talking normally? Because actually that will pick up. If you're not quite got enough blood going to your brain or you've got a head injury and you're a bit agitated, you won't be talking normally.

And those, again, are people that we would want to pick up to get out early. So in that way, for people with a bit more training time, you can nuance it to pick up some of the other sicker patients. But actually, if you have no training at all, the simple question of, are they talking or not? Will pick up someone, they're not talking, something's wrong, and then they become a P1.

The other question in that little bit of the algorithm is, do they have any penetrating injury? And this is the bit where I think the kind of stop the bleed campaign has kind of missed a few of the patients. And I think I listened to your interview with Kevin, and I know he spoke a lot about the kind of the bleeding that needs to get to a surgeon and those type of injuries from Las Vegas, where you've got penetrating trauma. But the bit that has been shown from quite a few of the recent events, from a lot of the Paris attack patients, and also from Las Vegas, and from quite a few other places, and from London Bridge, where we've had patients who've had stab wounds or gangstock wounds in that area between the neck and navel, essentially, where it's either gone through a vessel there or could have gone into blood vessels inside, or you can't compress it.

Those patients have a risk of non compressible central hemorrhage, and they need to be, ideally on an operating table with a surgeon rather than by the side of the road. We can try and do something for them as a sort of pre hospital doctor team. Preferably. They'll do better than a hospital. So we want to pick up those patients as being a priority one, and get them out over the people that have, don't have that non compressible hemorrhage, essentially.

So the question at that point is, do they have penetrating injury anywhere in that box? And the diagram shows you the area that you're looking at. And if they do, they become a P1 rather than a P2. Then we move on to the final question, which is, are they breathing? But you have to be able to open the airway to make sure they're breathing.

So there's a little reminder to open the airway if you're able to. And that's because it's for anyone, whether you know how to do a jaw thrust, which is ultimately the best way of opening an airway, or whether all you know how to do is put someone in a recovery position to maintain that airway, whatever you do, open the airway, if they're breathing, then they get a P1 tag. And if they're not breathing, they get a not breathing tag.

And that's quite a big change from other triage tags wherever trio systems where at that point people get a dead tag. That was important for a couple of reasons. One, because we want it to be applicable to every responder, and certainly in the UK, we don't want to put the pressure on. And it's not appropriate for police officers and firefighters to be pronouncing someone dead. Clearly, if they're cut in two and their bodies apart from their head, then that's different.

But in most of these patients, they may be resuscitable, and we're not asking those people to make that decision. And secondly, certainly for us in our inquiries and inquests and for our patients, in some people, resuscitation is appropriate because maybe they've only just gone into cardiac arrest and maybe you don't have that many patients.

And if the mechanism is something like a crush injury, like we had at our hillsborough incident, what they need is CPR. Now, if you've got huge numbers of patients, you can't afford to do CPR. So it only says do CPR if resources allow, and that would be dependent on the situation, on the threat, on the number of casualties.

But all we're saying is don't just automatically put a dead tag on at that point in 10 seconds without properly assessing whether they're assessable or not, and then someone will come back and reassess them. And if you haven't got the resources to do CPR, they just go on their front in the recovery position as well. The same as a P1C. But the P1 s get prioritized to go out because they're more likely to survive if they're breathing than the people that aren't.

Jon Becker: Yeah, it's really. I mean, it sounds like a lot when you look at it in context, but let's just walk back through it again. So are they walking? If yes, walk out your P3. If not, then P1.

Claire Park: Essentially P1. You could do that. If they're not walking their p, if they're walking their P3.

Jon Becker: If they're nothing, you're moving down the algorithm.

Claire Park: Are they bleeding? If they're bleeding, they're a P1. If not, are they talking? If they are talking and they don't have penetrating injury, they're a P2. Doesn't really matter if they don't get a P2 tag. But that's just to differentiate the people that need to go with a slightly more priority than the people that are talking and don't have penetrating injury and don't have bleeding.

So are they walking, are they talking, do they have any severe bleeding? And are they breathing? Those are the four questions. And you can, you know, someone's walking past you, if they're sat there talking to you, that's all you need to know. And you can't see any bleeding anywhere, then you've done it and you can move on. And when we say looking for penetrating injury, it's literally just picking the top up and having a quick look. We're not saying strip them off naked and leave them.

So some patients, you can literally do in 2 seconds, some patients will take a bit longer, and I think the other important bit about it. So there's two reasons why the tagging is useful. One is to start that casualty flow. So put a tag on so you know the P1s and they want to go out first. So if they're not breathing, they get left a little bit later because they're less likely to survive. And if they're a P2, they get left to a bit later.

So when you've got limited people to evacuate and take P1s out first, and that optimizes your casualties to start moving, you've also started this whole process of who's going to go out first. You're not waiting for health to get in there to do that. You started it. And then it stops people going over the same work. Because what I would see before we had tags was that people wouldn't use.

But in the UK, police and fire went talk to triage before this. So we had a thing where previously it was said that only ambulance would triage. So we had to wait till ambulance got there for this to happen, which was adding to that delay. So where anyone that gets there can now start triaging, that started and people can start to be moved out.

But you would see people going over the same work because they couldn't see who'd been treated, because there was no marker to say they'd been treated. When they get tagged on, people see, all right, they tag. I'll just go past them and start working on the next person that I can see who hasn't got a tag until everyone's been tagged, and then you can start moving them out.

And in that process, what you're also doing is managing those life saving or providing these life saving interventions. So while you're tagging, almost more important than the tagging is providing that hemorrhage control and opening the airway. Because even if you didn't have tags, if you had the flow chart and you went around everyone and all you did was go, are you bleeding? Okay, I'm going to stop it.

Is your airway open? No, I'm going to open it, put you in a recovery position. I'm going to move on. Because the problem is when people have some medical training, the temptation is to get them and start doing everything they know. They start taking clothes off, putting chest seals on. Chest seals never saved anyone's life. In the first few minutes, they start trying to, you know, prettily bandage wounds. None of that matters because that's not going to save anyone's life. In the first few minutes, you want to get to the people that might be around the corner bleeding to death, then you can come back and do all the rest of it.

Jon Becker: Yeah, it's interesting because when you hear, you think about it, you think about it in a series of layers. There's that kind of initial. And I mean, triage by definition, is filtration. Right. That's what you're doing, is filtering people. And so right away, let's get rid of anybody that is going to be a P3, because that's just noise to the initial life saving process. Trying to get to the P1 patients who you can help. The P3 patients have a long, you know, their clock is longer. Right?

Their countdown timer is much longer. So really what we're trying to do is initially look for people that have, you know, a ten minute countdown timer on them or less, and get them as quickly as possible to treatment. So it's kind of like the first step is get rid of the P3s, and then from there, try to get down to the treatable P1s is kind of the way that it strikes me.

Claire Park: Absolutely. And what I would expect any medical people to do. So that's for anyone in that initial wave. So we would have whoever turns out five police enamorants doing that. We're also now pushing to have our kind of, if you like, physicians or enhanced paramedics, getting as far forward as possible to then work out between those P1s. So you've got a load of P1s, which ones are basically what we call P1 classes or the P1ERs. P1s, which ones are going to die now as opposed to P1. Est P1s.

Jon Becker: That's the quote of the day, the P1. Est P1s.

Claire Park: So we want to know which ones need something? Either to get them away from hospital alive, or they just need to go. So then we try. It's that whole casualty flow in keeping casualties moving. So we don't want anyone delaying one scene, but we want the right ones going first. If you have the option, if you've got loads of people to carry them out, just take more lap. Don't let anyone get stuck. Stuck in there.

What we've seen in the past, and this is one of my slight soapbox things about major incidents, is this concept of a casualty clearing station that we have, certainly in the UK, where people, I think, see it a bit like a field hospital, and people just get stuck there and everyone has a clipboard, people start writing down observations.

Meanwhile, there's ambulances on the other side of it waiting to take people to hospital. But there's a process they have to go through. So they sit here and the whole point is not to do that, but to just keep people moving to what they need. That's fine. If they're P3 and they're fine, and they've got some minor cuts, they can sit in the casualty clearing station. They don't need to go to hospital, but the P1s needs to go.

Jon Becker: Yeah. And I think that one of the things that I walked away from my interview with Kevin Menes about was that a lot of the reason that people survived in Vegas was because they didn't wait for medical to come in, they didn't wait to clear the hot zone. They literally were flagging down cars and filling them with bodies, just telling him to take him to the nearest hospital. There were a lot of people that ended up getting to hospital because a particular police officer who had traffic just started putting people in cars and said, go, take them to the hospital. Take them to hospital.

So you had patients coming in taxis and limos and police cars and all kinds of stuff. And it strikes me here is the same thing. We get the P1s to the hospital as quickly as possible. Trying to filter out the people who have the shortest timer certainly is challenging.

And the more complicated the algorithm, the less likely it is to be applied, and the longer we have to wait for expertise to get there. To go back to that concept of a care gap, anytime we're waiting for expertise, we're in that care gap, and we're spending time on everybody's clock.

Claire Park: Absolutely. I mean, we're starting from a much later point. If you wait for health response to arrive, if everyone who's there already is just sitting, waiting for that to happen, all that stuff, and there isn't time, you know, anyone that needs, certainly the external hemorrhage stopping and the airway opening, that's got to be done in ten minutes, otherwise it's too late anyway. So that has to be done straight away.

And then you want to start moving people out and there may be some people who. What they need is for you to take over their breathing because they've got a really bad chest injury. They're not bleeding as much, but something's fallen on their chest and they just need you to take over their breathing. We can do that in the casualty clearing point. We can do that at the scene with inherent care. What we want to do is pick up the ones that are bleeding that we can't fix and need to go.

So that becomes the kind of more complicated bit that we do further on. But we don't want to wait to get in there to work out who that is. If those people are already being brought out to us, then they're already on their way. And what we certainly seen with our police starting to do this is they started to nest patients, so they would go in, deal with the threat, secure it, then start to.

All the next people responding would come in behind them while the armed police are dealing with a threat, and they would come in and start to do this and they would do the ten second triage walk through. Everyone put the tags on, see someone's tags, go to the next one, go to the next one. Once everyone has tags on that aren't walking, then they start to nest them. So they start to move them to an area where they're closer to the door or you're optimizing your resources, even if it's not safe to take them out. Because rather than protecting people in every corner of a building, if you can drag them all to one corner, you need less people to stand around and protect them.

You've got all of your resources and your kit together, and then you can move them out and you can see which are the P1s. Take the P1s in one area and take them out first, and then the P2s, and then you're not breathing. Someone can come in and assess them later. So you're optimizing your resources and your casualty flow by making your life easier and splitting them into sort of triaged areas, but also getting everyone together.

Jon Becker: So this has now been adopted as a national standard, right, by the UK?

Claire Park: Yeah. So this is now being trained this year. So by April this year, we started training in April last year across all of ambulance, police and fire. So by April this year, we've given everyone a year to train it. We expect to see all of the emergency services using ten second trailers and it's been written into our joint operating procedures for maoridding terrorist attacks.

So whereas before those operating procedures said only ambulance would triage, they now say any emergency service can triage as long as they're using their NHS England recommended tool, which is ten second triage. And the benefits of having everyone doing the same thing is what we saw when we did the testing for it, which is not only more people are doing it and so it starts happening quicker, but people work together much better and you suddenly get a much better sort of shared mental model of what's happening. Because all of the services, when they say a P1, they know what they mean rather than people using different terms to describe a sick patient. And that terminology starts to be passed out sooner.

So if health ambulance are delayed, the message comes to them, oh, we've got 20 P1s. That means much more than we've got 20 casualties. Because of the 20 casualties there's P3s. You've got a bit more time and you maybe need less resource, so you immediately have some better communication in terms of understanding the number of casualties and how sick they are.

Everyone's working together, people understand what the priority is and we get that casualty flow happening much sooner because they're already tagged, they've already had the life saving intervention. So by the time you get the next step happening, either people are moving them out or at least they're on a process that starts to move them out.

Jon Becker: Yeah, I mean, what you've done by teaching it at a national level is you've created common nomenclature. So if I say P1, you know exactly what I mean by P1. Whereas if I say, oh, this guy's really bad like that, that doesn't mean anything really bad to me. Might mean, you know, I spent 20 years as a medic in Afghanistan and this guy's going to be dead in 30 seconds or I've never seen somebody injured and he's got a toe that's been cut off. Yeah, exactly. And like I'm. By defining a common triage tool and then giving nomenclature, now everybody speaks the same language and a P1 is a P1 and we know exactly.

Claire Park: What to do with it and it's still. The other triage tools use the same nomenclature. P1, P2, P3. But I think they're too complicated for people to actually use. And as you sort of suggested earlier on, the ones that need all of the other stuff where it's not as straightforward, people know about it, but they just don't do it.

Whereas with this one, we've tested it, we've given the flow chart to people who've not had any training and just said, here's some scenarios. What do you think? What category are they? And they just go, yeah, and they pretty much get 90% correct. So the point is, we want something that people are going to use and practically is going to help them maintain their bandwidth and actually know what to do, rather than walk in and be like, oh, s***, where do I stop? And we've certainly had it used on smaller scenes.

Some of the people that did our initial training have taken the card away before we brought it in, but they've used it on scenes. And I know a few of the police in London have used it where they've got to a multi patient RTC or a multi patient stabbing with quite sick, you know, four or five sick patients, one dad and some. Okay, and they've just gone, okay, let's get this card out.

And it's just allowed them to spend that first few minutes when they're there on their own, one of two of them knowing how to approach it, knowing what to do, not to get caught up in what should I do? But just do those simple steps. Even without the tags, I know that I'm looking for. Are they walking? Have they got any severe bleeding? Are they talking? Are they breathing? Move on to the next one. And then by the time they've done that, other people have arrived to come and help them and they've already gone. Right, well, that's the sickest one because those are the P1s that are there. So you go to those and have a look.

Jon Becker: So the placement fireman, everybody's literally carrying a card with ten secondary on it in their wallet or in their pocket.

Claire Park: Yeah. So we've designed. The flow chart is on. Is accessible to anybody, so it's on the NHS England website. But all of our services are being issued with little laminated cards and they'll have that on them and then they get a set of tags for their medic bag and some of them will get individual issue, and we've got lots of different police forces and fire services across the UK, so everyone will do something slightly different.

But essentially they'll have the tags available and they'll have the flow charts available so that, yes, you can remember it, but we don't want people to have to worry about remembering. The idea is that it's really. There's not too much on it when we designed it, so it should be quite easy to get it out and just look at it and it should be clear enough that you can quickly follow it without having to think too much.

Jon Becker: Yeah, that makes a lot of sense. And we'll link to the NHS website and the charts and everything in the show notes so that people can go and find it.

Claire Park: Yeah, and there's some training on there as well. Actually, if people, anyone could take that stuff. We've written some PowerPoint and some training points, so if anybody wanted to look at that, it's all kind of openly available on that website, too.

Jon Becker: That's fantastic. So moving past TST, like Claire, you've been involved in response to a lot of events, you've looked at a lot of events, you've done a lot of research. I would love to get your lessons learned or your kind of soapbox thoughts on mass casualty events and the way we're responding. What are we getting wrong?

Claire Park: So that's a really interesting question. I think there's lots. What's interesting, I think, is that when you look at a lot of the reports and learning, there are a repeated things that seem to be commented on. And I. I guess it's because they're complicated things to address. One of the first things I would say is that in general, a lot of people try and make the plan work.

So for major incidents, mass casualties, ambulance services have. They have saps. And one of the faults, I think of some people is that they try to make the SAP work, whatever the situation. I think that's probably less the case for police and policing and operators, and I think people are more used to making it work.

But certainly one of the things that we sometimes see is people not thinking outside the box and just going, well, we just want to make this plan work, whatever, and not understanding that every situation is different. You can't write a plan for every situation, so you've just got to try and make something work. But if we look at specifics, things that often are commented on, the comms don't work is something that multiple people say.

Jon Becker: That's every debrief, everything I have ever attended, I've been to a thousand plus debriefs, and every single one of them has started with the comms didn't work.

Claire Park: Yeah. And to a certain extent, what do you do about it? I hear people say, we're gonna get different comms, different radios, whatever. Basically I would say to people, assume they're not gonna work and then have a plan for what's gonna happen when they don't. So work on face to face comms, work on people running with messages, if you really want to make sure you're passing messages reliably or work on pieces of paper, but have a plan, because they probably won't work with everybody on the same radio net turns up to the same place and they're all trying to work and they're all overloaded anyway.

So that's one point that I would say that we should plan to overcome, as opposed to be surprised when it doesn't work. The second one is kind of linked to the sort of concept of the joint emergency services principles of getting joint command, or unified commands, as I think it's sometimes called in the US, getting everyone together to that command huddle, which is great in principle and easy on a fairly small scene, but actually much more complicated.

Certainly when you have different control rooms, different services, all responding on different radio nets, actually getting the point where people come together to get that shared mental model and shared understanding of what's happening and understanding what each other are doing. So the sort of spending time trying to understand not just your aim and what you want to make happen, but having the respect and the understanding and trust of other services there so that you understand they. They are trying to do and you all work together to achieve that is really important.

And I kind of say that because that links me into the higher threat stuff where one of the things that I think works really well, and one of the things that works well in the military and works well in services where they have embedded medical response within their tactical response, is everyone being on the same Agnet, if it works, and everybody having understood what the plan is and understanding both sides of it.

Social instance at the battle clan, where the raid went in with their two doctors, who went in with their tactical response, they trained this so many times that they got there and six minutes later they all went in together and the two doctors went in and triaged everybody in the orchestra pit. While the terrorists were still being held hostage in the corners of the Bataclan. Their operators knew what they needed to do.

Two of them provided them cover while they triaged everyone out, while they came up with a plan for what they were going to do for the terrorists. They could only do that because they trained it over and over again, because they were integrated within that response and they all understood what was happening. That wouldn't work for anyone that wasn't fully embedded in the response.

And the same thing happened for us in the military. If I deployed, I got the security information from my infantry team in Iraq, I knew what was safe, what wasn't safe. They were there to support, to protect me. And that speeded up all of that stuff happening. It's a long way of saying, I think, that having the best option is to have people integrated, but most of the time that's not possible.

So if you've got multiple agencies and multiple people, really get to know the people in your area, really get to know the people you work with, really get to trust them, so that when you get to the scene, you know who it is, you know how they're going to work and what they want, even if there's a different service in a different agency to optimize that working together, because that's the way that you're going to achieve what you really need to achieve for the best outcome for the people involved.

Stretches is something that often comes out in debriefs, and certainly the battle clan and Manchester both had everybody carried out on barriers, and I don't know if you've seen the pictures, but both of those were quite big events where every single casualty was carried out on some sort of kind of crowd barrier or advertising hoarding. And that takes like ten people to carry people out. And some stretchers take up lots of space, but small carry sheets don't take up much space.

So it's a bit of a soapboxing in mind. But I say to people, just have a big bag of carry sheets so that two people can carry people out on a carry sheet. If you're going to keep casualty flow going, have some way of getting carry sheets out, rather than trying to take ten people to carry a barrier because it's not going to work. That's three. So comms command together stretches and then probably the other key thing is, I think, people not really understanding this fog of war idea and decision inertia.

So it's easy to criticize in hindsight when all of the information is available. And it wasn't at the time. But a concept that I try and get across to a lot of our teams is the idea of not needing all the information to make a decision. So 40% of the information is probably too little, but 70% of the information, if you're getting past that, you've probably got too much and you need to have made the decision, because there is always risk involved in the jobs that we do. And every second you delay someone might die.

So making a decision about doing something going in, don't go in and get yourself killed, obviously, if it's really unsafe, but not delaying too long to be really sure it's safe, because that's what we've seen in quite a few of our events, and that often comes back as a debuff point afterwards, certainly from a health point of view.

Jon Becker: I like the term decision or inertia. I think that's – If you look at the Uvalde tragedy, that is a perfect example of decision inertia. Nobody wants to make a decision. No one has taken command. And it's interesting, I heard a trauma doctor talking about, actually, is it? ER doc was talking about the difficulty in making decisions and I didn't. It was a post Uvalde debrief that I watched. And one of the things he said is, you know, I can tell you, when somebody calls code blue in the hospital, I can tell you how old the patient is by how many people are in the room.

And he said, you know, if I walk in the room and there's one or two people, I know it's an old person and they're trying to save them, they're doing the best they can. He said, if I walk in the room and there's 30 people, I know it's a kid. And he said, the difference between the one or two people and the 30 people is the 30 people are frequently not doing anything because they're afraid to make a mistake. And there begins to be so much weight to decisions that it becomes easy to not make decisions. And it's exactly what you're saying. It's just decision inertia. And it is trying to break that decision inertia and get decisions made quickly.

Claire Park: There's all the, you know, the worry, the things that you've had put in your head in training, like the. Is there a secondary device? Is this a CBRN incident? Is this this, is this this? And you have to have all that awareness of the possible threats, but you've also got to go, in reality, how many attackers are still unseen when people turn up to these events?

If you're worried about another attacker, in reality, how often is this likely to, where's the. I mean, where's the zebra and where's the horse or the dog or whatever the common animal is, as opposed to the one from Africa that doesn't come into the UK? So what is common? What's not common, what's likely? What's not likely, what information do we have? And just accept that you're going to have to make a decision with as much information as you'd like.

Jon Becker: Realistically, the time you're taking. Going back to the care gap. Right. There's also a decision gap, the time that you're taking to make a decision. Everyone's clock is running.

Claire Park: Exactly. And that's my, I think the final thing is, I would say for the care gap, do that, avoid that delay, try to get someone doing something. Have kits available, like equipment for bystanders who are often going to be the people that can do that initial response, because often trained off duty people in these public scenarios where things happen, who could do something. So just try to ensure that that stuff is available and people know where it is that something like ten secondary age or the life saving interventions is trained to people so that they know to start doing stuff. Because often it's the not knowing.

Most people want to help. It was really clear to me from watching people in the Manchester footage, everybody in that room desperately wanted to help, but they just didn't know where to start. So they just did what they knew how to do, which was talk to people trying off of the water or do CPR if that's what they knew how to do. But they didn't know about stopping bleeding, they didn't know about opening airways.

Jon Becker: Yeah. And what we learned with the San Bernardino incident was literally rolling people on their sides. Save people's lives. Like it is. It is in that first ten or 15 minutes. Really simple stuff can, can make you huge a difference. So one last topic I'd like to pick up with you. Claire, you know, has spent a lot of time embedded with tactical units, with sofa units. You're currently affiliated with the counterterrorism specialist firearms officers, which is the tier one response for the meth metropolitan Police in London.

If you're the czar of the universe and you're training tactical teams and working with them, what do you want your teams to know? What are those critical points that if you're a guy listening to this that's on a team, what do they need to take home from this conversation?

Claire Park: Okay, so I'll try and keep it. I've got ten points, but I'll keep them brief, clear points kit. Keep it simple. Ideally the same kit in the same position, like if you're carrying tourniquets, put it on the same position on each other, so in the dark, you know where to get it off your mate. And that motor program idea of just being able to get it without taking up headspace so have the same kit. Keep it simple. Don't go for all the Gucci complicated kicks because it's only going to make your life more complicated.

Secondly, do the basics well. So even though it seems really simple, stopping, bleeding and opening and airway save people's lives and drill the motor programs of doing those things. Don't over under rate them because they're really important. But remember those things, do the basics well and be able to do it in the dark and maintain your focus to do other things. So if you drilled them enough, you know how to do that.

The third thing would be a lot of the stuff we've talked about today, understanding what kills people so and the stuff that you can do about it. So understanding what kills people in the first ten minutes is the external bleeding and opening an airway that's obstructed. If you can fix those things, you can save their life. And then pick up the people that have non compressible hemorrhage, the people that might be bleeding into their chest, abdomen or pelvis or long bones, and get them out with a priority.

And understand that there isn't something apart from splinting limbs that you can do on scene for those patients. So if, particularly if it's penetrating trauma, the ambulance service is not going to do anything different. You just need to get them to somewhere, either to an ambulance that can take them or to hospital.

The next bit was again, making your life simple. So talking about the ten second triage stuff, nest your casualties if you can, so that you can order them. Keep them in one area, don't have them split over everywhere so that you're spreading your team. Keep them in one area and then put them into areas of P1, 2S and 3S so that you make your life more simple. Bye. Separating them and knowing which ones are which.

So don't make it complicated by having them higgledy piggledy all over the place. So nest them, keep them in areas and then your evacuation will be easier. And actually, if you can move that nest to walk closer towards the exit or the hospital, you're starting that casualty evacuation process.

So thinking about where you're going to put them, don't take them back upstairs. I'm sure people would, but it's just simple process of thinking. The closer they are to getting into a vehicle, to getting to hospital, the better. And if you are going to put them in a vehicle and use your vehicle as a Kasovac vehicle, think about preparing it.

So I know that a lot of my teams would have said, oh, yeah, we'll put them in a vehicle and take them. But they haven't actually thought, who's got the keys? Are the keys in the vehicle? Is the back of the vehicle down? Is it filled with kit? So if you're going to do an operation and plan to use that vehicle, think about preparing it and having a proper plan.

Next one would be about having a medic team leader along. The idea of them maintaining bandwidth, if you've got enough people, so you'll have a tactical team leader, but if you have someone who's a medic, maybe don't have them doing the stuff, but have them as a person standing back.

Everyone will have the basic medic skills, so have them standing back, keeping everyone else and you can directing what needs to happen, because that allows them to keep the bandwidth. It's what I would do. If I go to a scene with the guys, I'll try to do nothing. I'll just go around everyone, make a quick decision and direct them what I want them to do, rather than getting stuck in doing stuff myself, because then I lose my observation.

And that's where you see the person that hasn't been treated or the person that's deteriorating. So having someone to take that kind of overview medic team leader role is really useful, particularly when it comes to charging multiple casualties and keeping people in check for adjusting the basics and carrying on.

Jon Becker: So almost like a medical incident commander.

Claire Park: Yeah, essentially just someone who's kind of got the overview. So the multiple casualty event, you know, you're more likely to see someone in a vehicle that someone hasn't searched or stepped behind a door. If you standing back, just keeping an overview over everything, and there's a temptation and we've seen it in the testing and training as a tool people want to get stuck in and help people more particularly relatives and stuff there, it's about going, no, don't start doing that. Just airway, breathing airway, cat hemorrhage, move on until we've got around everyone.

So that kind of sense check, keeping everyone pulled back. The 7th one would be just most of the time, I think they can do everything and they should start to move people out. A time where they might want medical help forward is where they're stuck with multiple P1s and the ability to only evacuate one at a time.

So the situation that I would see is like a maritime situation. So for us, if we've got a vessel off the coast or on the Thames, and you can only evacuate a few at a time by boat or air. Then somehow you've got to choose who goes and what order. And that's where really ten secondary edge doesn't give you enough. There's not enough knowledge there. You need someone with more medical training to do that, to pick up the one that's a P1 is that really needs to go.

So that's where you might want to think about taking your medical care with you forward or bringing them forward if there's a siege and you've got a whole load of people stuck, a bit like the guys did in the battle clan, to decide who went out next. Otherwise DTS team just start moving them out rather than wasting time trying to get people in, because they're not going to do anything different in that immediate sort of seeing.

And the final few points are probably stuff that I think tactical operators are certainly high level tactical operators are really good at doing anyway, but maybe just don't acknowledge that they do. Debriefing really well, as you will be very well aware, but debriefing to understand why you did something.

So experts tend to do something without knowing why they did it. Malcolm Gladwell's book Blink, that talks about the unconscious, unconscious decisions we make because we're doing something from learning about it before we do it, because we know it's the right thing to do without clocking why we did it. And I have only learned why I do stuff by debriefing it in detail afterwards and going, oh, that's why I decided to do that and then logging it for next time.

So it reinforces my decision making for the future. So the debriefing in the sort of honest, why did you do something? Let's try and learn that for the future way. And then along with that, the idea that everyone has a different black box recording of the event.

So an example I have is of one of my forced protection from Afghanistan, who got off the back of the helicopter to triage the casualties. He was so focused on getting that triage right because he got it wrong the last time we debriefed it, which may be my fault for not leading the debrief well, but he was so focused that he didn't notice that the Taliban were firing past him one way and the force protection were firing past him the other way and he was in the middle of it. I honestly thought he wasn't going to get back onto the back of the helicopter.

And it wasn't until we got back and debriefed, he still didn't believe us that that was the case until we got the air crew and the force protection in to reinforce that. Because his black box recording was of Australia during the casualties, he didn't see or hear it because his hearing went.

So just reinforcing that idea and that's a bit of an extreme view, but reinforcing the idea that when you debrief, understand that other people might not have seen and heard stuff that you saw and heard. But I listening to them will bring the whole story together and then you will really learn what happened and understand it.

And again, I think operators are really, really good at doing that and being really honest about what happened and trying to learn from it. Much better than medical people sometimes. And the final point, which maybe they're slightly less good at, is it being okay to be upset about something? I think we all do this job and we all see stuff that probably affects us. And most people deal with it by talking amongst their teams. And that certainly talking to someone who understands what you've been through and processing it is a way of dealing with it and moving on, definitely.

But sometimes there's just one thing that gets you, particularly if it's treating a casualty that you didn't manage to save, or treating one of them worse, treating one of your team that you didn't manage to save. And it's okay to be upset about that. And it's normal. There doesn't need to be any bravado about being obsessed about that.

And the only way you'll deal with it is to be upset about it, talk about it and accept that that's a normal response than anyone. Dealing with them, whether they're medical, tactical or otherwise, would feel the same. And I think that's how people process it and move on. And I think people are really good at doing that mostly. But sometimes that kind of alpha mindset doesn't allow you to accept that it's okay to be like that. And that's probably my final point.

Jon Becker: Yeah, I think that's a really valid point. Claire, I can't thank you enough for doing this. It's really interesting! We'll link to all this stuff in the show notes and make sure that people get it. And where can people find your work? What is the best way for people to contact you or to learn about what you're doing?

Claire Park: So they're welcome to email me if they want to email me. I can put that in a link to the show as well, if that's the best way to do it. Or you can google some of the papers that we published and yeah, I guess that's probably the best way to do it. I have some links to the CTech group in America as well, so there's a few people that have contacts for me. But email out if people wanted to get hold of me or find me on LinkedIn or Twitter.

Jon Becker: That's great!

Claire Park: Excellent work!

Jon Becker: We'll include that in our show notes. Claire, thank you so much! I really appreciate you being on the debrief with me!

Claire Park: Thank you so much, Jon! It's been an absolute pleasure talking to!