"CRUCIFORM"^® Emergency Documentation

ACTION BY FIRST ATTENDER AT THE SCENE OF A LARGER INCIDENT

Any incident where numbers of victims are high and which may be declared a Major Incident

Remember :- If there are no other rescuers or services present, the most important action is to provide the relevant control centre with information. First attenders/responders should not engage in rescue or life-saving activities until there are more rescuers on scene to assist.

• When it is possible to go into the scene, take a box of Cruciform® cards. Use the Triage Sieve inside the box lid to remind yourself of the triage criteria. Use the card to quickly “sieve” victims. All rescuers should identify the victim’s physical location with the large numbered tag/sticker for subsequent police investigation. Stick the relevant CBRN-E “Flag” on the outside of the plastic sleeve, if victim may have been contaminated.
• Place the elastic cord over the necks of those victims who appear to be most seriously injured, using the Triage Sieve criteria, or attach it to the most convenient part of the victims or clothing.

Ignore the least injured and the dead at this stage (though they can be labelled if time permits.)

Do not waste time writing down anything on the card but apply the wrist band to link victims and card and take a numbered tag for your own records.

Utilise the Colour Module only. Writing information and/or making adjustments to priority colour can be undertaken later, when more rescuers are available.

• As the most seriously injured are identified, keep track of how many victims have been found, by taking off a number tag from the number strip before you leave each victims. You can also use the Casualty Numbers & Initial Priority on the reverse of the Triage Sieve. After this initial assessment is completed, the Incident Control can be advised that the initial estimate has identified - n - number of priority 1 victims. These are the most important from all services' points of view, and will be the ones for whom most resources are mobilised. Other priority victims’ information can be given, if available. The completed Casualty Numbers & Initial Priority should be given to your service’s Incident Controller so that total numbers of victims can be established (in conjunction with incident controllers from other services.) The victims’ numbers side of the card can be scanned/copied and/or faxed if facilities are available and copies given to the other relevant agencies.
• When more rescuers arrive and the scene starts to become organised, the remaining victims can be identified and the Incident Controllers advised.

It is important that the dead are labelled as early as possible, to prevent waste of medical time. As the scene is, forensically, a crime scene, the police may also wish to leave the dead in situ to take measurements or photographs, and a "dead" label will ensure that bodies are not unnecessarily disturbed. When the necessary information relating to the body has been filled in, the card can be sealed in its plastic sleeve. The police may also wish to use their own labelling system for the dead in addition to the Cruciform®.

• As time becomes available and/or more paramedic rescuers or medical teams arrive, proper assessment of injuries can start. The Casualty Assessment Module can be utilised for this purpose, and will provide a convenient check-list of injuries found and treatment given. This may the start of the “sort” phase.

Entering information on the card can be done without removing the card from the victims' neck. Push the plastic sleeve up and make whatever notes or alterations are necessary. Ensure that the sleeve is always replaced over the card to hold it together and protect it from inclement weather, blood, oil etc.

• The Casualty Details Module should be filled in as soon as practicable. Lay volunteers or any available person can be used to extract this information. Each medic/ambulance/nurse/police/fire officer rescuer or volunteer should identify himself/herself on the card and peel off a number from the strip for their own records and/or to, for instance, identify fluid bags/bottles given, bag of possessions, associated child etc. This will enable subsequent evaluation of treatment given and/or to provide the police and legal authorities with continuity information about who dealt with that victim. The police can also use the tear-off the numbered overlay sheet on the Casualty Details Module to assist them with their Casualty Bureau duties and to identify those who had been involved with the victims prior to arrival at hospital. It will also significantly assist the coroner’s officers, if any victim has died away from the scene, either in transport or at the hospital.

All persons involved with the victims may at a subsequent stage be called forward to give evidence, and it is vital that everyone is identified. This module gives a convenient place for that information to be written down. All persons have a legal obligation to HM Coroner (in the UK) to provide evidential continuity of the handling of a victim who dies, from its location at the incident through its recovery to the post mortem examination The unique number/bar code will also assist rescuers in identifying specific victims after the incident or to clarify which victim had gone to which destination.

• The Trauma Score Module may be utilised for the traumatically injured victims.
• Do not attempt to use it unless trained. This is the only way to ensure that the information recorded is accurate.

Medical staff, offshore medics, nurses and paramedic ambulance or military staff will have no difficulty with this module, which will provide the receiving medical staff with a definitive and time based set of parameters specific to that victims' reaction to injury.

Seriously injured victims should have their trauma score checked on several occasions. The Trauma Score Module allows this to be done on up to ten occasions. Ensure that the time each score was taken is recorded in the space provided.

After scoring the victims, the information gained may enable attention to be focused on those aspects of the victims' condition, which could be deteriorating. The information gained may lead to unsuspected injuries or suggest a change in the destination to which the victim should be transported. The control centre should be consulted regarding any changes recommended.

The Trauma Score Module can be used to record oxygen saturation, if the necessary equipment is available to measure it, as well as changes to pulse rates and pupil reaction.

If the Trauma Score Module is used up, seal the card and put another onto the victim to continue trauma scoring.

Victims scoring consistently at 3 or below are least likely to survive, regardless of the degree of medical intervention they receive. If choices have to be made on which victims are to be conveyed or treated first, preference may be given to injured victims scoring 4 - 12.

Victims scoring consistently at 3 or less may be classed as "expectant" and identified visually by folding the corners of the green/delayed page in to show red "flashes" underneath. This will differentiate them from victims who are classed as green/delayed because their injuries are comparatively minor.

The green/delayed panel can also be used as follows:

Fold the green page in to show white "flashes" - for victims considered dead by rescuers but who need confirmation of death by legally qualified personnel.

Fold the green page in to show yellow "flashes" - for those uninjured victims, who may be infested, infected or contaminated and could benefit from specialised transport. These victims’ plastic sleeve should also be “flagged” using the appropriate CBRN-E stickers.

Use the Additional Observations/Treatment given/Comments Module provided to document any additional information not catered for elsewhere, for example, known or suspected medical conditions, personal effects, suspected contaminant (plus action taken to alleviate) or next of kin etc.

• Any pen or pencil can be used on the card, though pen should be used for permanence. As nearly all writing is on the white sections of the card, any type of ink or pencil mark will show up. The destination of the victim should ideally be written in black pen or felt tip to show up on the coloured panels.
• Victims arriving in hospital with the card already attached and filled in, can have the original card left on until they arrive at their final destination or ward. The in-hospital priority for theatre, X-ray or other procedures can be determined by utilising the card panels, particularly if there are a number of victims arriving from the incident, which may be congesting the emergency or other departments.

The information contained can be utilised for subsequent treatment purposes, and the card itself could be the first entry into the victims' file. Naturally, the Trauma Score Module can also be utilised by hospital based medical and nursing staff, if desired and a number from the strip entered on hospital records to permanently link the Cruciform® card to the victim’s record.
The card should, in any event, be retained with the victims' file for subsequent analysis and continuity purposes and as a permanent legal record of injuries found, action taken and the names of persons involved in dealing with that victim before admission.

• The police will want to utilise information from the card for Casualty Bureau purposes, and close liaison between the medical and police personnel at hospital will be necessary to ensure that information on the card is appropriately shared, initially by giving the police the numbered overlay sheet. If any victim should die, the police and other legal authorities will require the card itself for their own procedures and enquiries.

The card is identified with a unique sequential number strip with bar code, which should enable the movement of the victims to be logged through the various agencies and personnel involved and should provide the necessary verification and evidential continuity. The wrist-band will ensure that card, victim and possessions remain linked and will link rescuers to the victim, if required, so they could be traced for health screening if the victim was later discovered to be infected or contaminated.
The card modules can be scanned and the details transferred electronically to any relevant agency.

• Restock with Cruciform® cards and other relevant supplies at the earliest opportunity.

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