Hong Kong is a highly developed territory with a population around 7 520 000. It is only a very small city of about 1 100 square kilometers. It is also one of the most densely populated places in the world. In view of the geographical features, natural disaster seldom occurred in Hong Kong. In recent years, incidents require full emergency response is rare. However, traffic accidents, vessel collisions or great fires involving multiple casualties occasionally happened.

Overall disaster response apporach Preparedness and response

In the disaster management cycle, the preparedness and the response are the two essential elements considered more important than the recovery and the mitigation.If preventive measures and the emergency actions are taken in an effective manner, the damages to life and property will be minimized^[1].The Fire Services Department (FSD) and the Hospital Authority (HA) are the two main frontline departments responding for emergencies in Hong Kong. The Security Bureau (SB) is an administrative arm represents the Hong Kong SAR Government for the overall disaster management as well as to monitor/support the execution of the response actions carried out by individual departments.

The Security Bureau

For any emergencies, the SAR Governmen must ensure to respond to the scale and extent of the situation in the most efficient and effective manner. Hence, it must have not only the capability to respond to large-scale emergencies, but also the experience to judge the most appropriate level of response to any emergencies. For example, the SB has to make decision for reinforcement of supporting departments or the arrangement of additional manpower from volunteer agencies.

In connection with this, the SAR Governmen has developed a bottom up approach to emergencies. The policy is to keep the emergency response as simple as possible by—

•limiting the number of involved departments and agencies

•limiting the levels of communication within the emergency response system

•delegating necessary authority and responsibility to those at the scene of an emergency

In extreme situations, there is likely to be a need for direct overall SAR Government involvement and the SB will represent the government to monitor the development of the incident. Below is the SAR Government Three Tier Emergency Response System.

Tier one response

At this level, the emergency forces perform the operations entirely under the direction, monitoring and supporting by their own commands. In general, simple accidents normally involve three departments. They are the Hong Kong Police Force (Police), the FSD and the HA. The usual means for the public to request emergency assistance is through the Police 999 emergency call centre. Reports of fire and accident will be immediately relayed to the Fire Services Communication Centre (FSCC) of the FSD. In Hong Kong, the emergency ambulance services are under the command of the FSD.

Tier two response

There are standing instructions for the Police and the FSD to alert the Duty Office (DO) of SB about incidents which may need the attention of the SAR Government. Incidents under this category are those where the scale is likely to grow in terms of threats to life, property and security, and which may require a more complex emergency response operation. For example, explosion occurred in the underground transportation system or the airport. At this level, the senior government officials will closely monitor the incident through the Emergency Support Unit (ESU) in the SB.

Tier three response

In extreme emergency situations involving widespread threats to life and where extensive government emergency response operations are required, the Tier Three Response will be activated. The Emergency Monitoring and Supporting Centre (EMSC) will be manned with the participation of emergency/supporting departments. The EMSC will monitor the situation and provide timely support to the frontline emergency forces by mobilising all the resources within the government or even from outside agencies. Other committees (e.g. the Aviation Security Committee) may be convened as necessary. The EMSC is also responsible to brief the senior government officials on the progress and disseminate government policy decisions to those parties concerned.

In order to manage different emergency situations, the government has developed comprehensive contingency plans specifying all the actions to be taken by different departments and agencies.For example, early in 1990s, the SB compiled a Daya Bay Contingency Plan to cope with the nuclear emergency occurred near Hong Kong^[2].The plan also lists out those swimming pools to be modified as monitoring centres for decontamination. The related documents are regularly updated and uploaded to the SB website for the information of the public. Other contingency plans include aircraft crash, natural disasters, maritime/aeronautical search and rescue, and et al.

In fact, the vast majority of emergencies in Hong Kong, casualties can be effectively handled by the FSD and the HA.

Fire Services Department

Other than firefighting, the FSD is also responsible for the provision of emergency ambulance services for the sick and the injured in Hong Kong. The ambulance services are free of charge for HK citizens. The Ambulance Command of the FSD operates 383 ambulances, four Mobile Casualty Treatment Centres (MCTC), 41 Emergency Medical Assistant (EMA) Motorcycles and three Rapid Response Vehicles^[3].In 2018, FSD ambulances responded to 748 777 emergency calls, representing an average of 2 051 calls in a day.94.6% of the calls were responded within the 12 minutes target response time. Frontline firemen are also trained as first responders to provide basic life support treatment before the arrival of ambulance crews. In 2017, the first responders turned out for 40 298 cases. In average, 110 cases in a day^[4].

For accidents occurred within Hong Kong water, FSD fire boats will carry out the search and rescue operation.Sometime, GFS helicopters will give help in remote areas operations.Casualties will be conveyed to the nearby berth for onwards transfer to hospital or directly by a helicopter to hospital.

The FSD ambulance crews are neither doctors nor nurses. They are paramedics qualified under special EMA Ⅰ/Ⅱ provider training programmes. Same as other paramedics in USA or UK, they can carry out some medical procedures and administrate certain types of medications for urgent cases. For examples, laryngeal mask airway for artificial ventilation, defibrillator for cardiac arrest, intravenous infusion of Dextrose 10% for hypoglycemia and Normal Saline for blood loss/shock, Adrenaline (intravenous/intraosseous) for cardiac arrest/anaphylaxis, Nitroglycerin for chest pain, Nacoxone for narcotic overdose, Entonox for pain relieve, and et al.Furthermore, qualified ambulance officers can use portable ultrasound sonography in handling trauma cases to determine intra-abdominal bleeding for direct transfer to a designated trauma centre^[4].

There are strict protocols for each DMA procedure. Regular reviews will be made to related cases to ensure high standard services provided to each client in accordance with the laid down instructions. An A & E consultant from the HA will update the EMA guidelines from time to time. FSD ambulance crews are required to have their DMA revalidation every three years. For those assigned the duties of advanced airway management and advanced protocol treatment will be reassessed every six months. Similar as other medical professionals, a continuing medical education scheme is applied to upkeep the proficiency of each crew member.

Hospital Authority

Hospital Authority is a statutory body established in the year 1990 to manage all public hospitals in Hong Kong.It operates 43 public hospitals and institutions, of which 18 of them provided Accident & Emergency (A & E) services^[5].The number of all hospital beds is 28 928. In the year 2018, the total figure for A & E attendance was 2 157 617.That means 5 911 per day in 18 A & Es.The fee for each attendance in the A & E is HK＄180 and for a day of hospitalisation is HK＄120 for Hong Kong citizens. The fee covers medications, treatments and operations.Only a limited number of special drugs and medical equipment are under the self-financed items requiring patients to responsible for extra payment.

Taking into account factors including the nature of the incidents and the number of casualties, same as the SAR Government, HA will activate three response levels to deal with different types of emergencies^[6].

Level one

Day-to-day emergencies will be responded by individual hospitals according to standing guidelines/instructions.For example, there are well established operational orders and plans such as mobilising extra manpower to support the A & E or carrying out decontamination outside the A & E.

Level two

MCIs will bring to the attention of the SB, so DO of HA Head Office will also be notified. At this level, the Mass Incident Control Centre (MICC) will be set up in the HA Head Office to liaise with SB ESU and the concerned hospitals. Emergency Medical Teams (EMTs) will be dispatched to provide emergency medical treatment on-the-spot. If there is a need to make further coordination related to casualty conveyance and medical resources, a Medical Command Officer (MCO) will also be deployed^[7].

Level three

At this level, the HA Head Office MICC will be fully manned to keep close connection with the EMSC and other departments. Internally, the MICC will coordinate the operations of all A & Es. Individual hospitals may set up their own MICCs for better communication. Special committees will be chaired by HA senior officials to handle different types of incidents. As and when necessary, HA Head Office MICC will make arrangements of manpower, hospital beds and medical resources to cope with the emergency situation.

Handing of multiple casualty incidents

In a MCI (whenever eight casualties or more are involved in a single incident or a fire upgraded to No.3 and first casualty confirmed) occurred, the typical operational responses can described as bellows.

•Upon receiving an emergency accident call, the Police will immediately relay the information to the FSCC.

•Ambulances in the nearby depots will be immediately mobilised.

•The officer-in-charge of the first ambulance will quickly assess the situation. For a MCI, he will ask reinforcement through the FSCC.

•Additional ambulances and/or the MCTC will be deployed.

•An ambulance officer will act as the Ambulance Control Officer (AIO) to oversee all the casualty treatment activities.

•A Triage Point together with the Red, Yellow and Green casualty treatment areas will be identified.For easy operation, colour mats are used to differentiate the treatment areas. For prolonged operation or during inclement weather, tents will be set up.

•A temporary mortuary will be arranged aside to hold the dead bodies.

•At the same time, the FSCC will notify the HA Head Office MICC to send EMTs (one doctor and one nurse in a team) and/or the MCO (from another hospital) to render assistance.

•The volunteers of the AMS and/or the St. John may be asked for reinforcement.

•Another ambulance officer will act as a Triage Officer to work with other medical personnel to prioritize casualties into four categories-Red, Yellow, Green and Black.

•Casualties evacuated should go through the triage process and then be carried to the appropriate area for treatment.

•The Simple Triage and Rapid Treatment (START) model will be applied in setting casualty priority.

•Casualties who are obvious death (Black) should be moved to the temporary mortuary.

•AMS/St.John volunteers will be assigned to different areas to take care of the casualties or the non-juried persons.

•The AIO/MCO will monitor the situation and keep close connection with the FSCC/MICC.

•According to the pre-set quota or the instructions given by the AIO or the MCO, casualties in priority will be conveyed to different nearby receiving hospitals as appropriate by the FSD/AMS/St. John ambulances.

•An Ambulance Loading Point (ALP) should be set up and manned by an Ambulance Loading Officer (ALO).

•Ambulances should be orderly parked at the ALP and the traffic flow should be smoothly maintained.

•Casualties' numbers should be carefully counted and clearly recorded and documented.

•The FSCC, MICC and EMSC will keep close connection with each other. Updated information will be relayed to the communication centres concerned by the AIO from time to time.

•After the last casualty has been conveyed to hospital, the AIO will announce the stand-down message in consultation with the FSD commander.

Remarks

•The FSD will set up the Mobile Command Unit (MCU). It is the overall command of the whole operation.

•The MCTC has its surgical instruments and emergency medications. Urgent operation can be performed by the EMTs in this special vehicle.

•The normal pre-set quota for a large-scale hospital is 2 Red cases + 12 Yellow/Green cases. For a non-large scale hospital is 1 Red case+12 Yellow/Green cases^[8].

•If the number of casualty is more than the pre-set quota or a receiving hospital is overloaded, the MCO will further discuss with the MICC and/or individual hospitals to make alterative arrangements.

•Subsequent to the admission of the first two Red cases, the large-scale hospital will only accept the 6th and 7th Red case in the second round.

•Traumatic cases should be directly conveyed to the designated trauma centres and burn cases to the relevant burns facilities.

•If the conditions of those traumatic and burn cases are clinically unstable, they will be first sent to the nearest hospital.

Pearls and pitfalls

Experience on the past incidents have given practical knowledge for individual parties in making improvements to the MCI operations. It can be based on the four Cs-command, control, coordination and communication to look into these.

Command MCU and AIO

The FSD will set up a MCU as the overall command centre. Departments which involve in the field operation should send their liaison officers on duty in the MCU. Direct instructions can be given to individual department representatives immediately by the FSD commander.

The AIO plays an important role and he should take the command to make sure all rescue parties are in smooth coordination and good communication. One of his important duties is to ensure that all casualties are quickly triaged, properly treated and safety conveyed to the appropriate medical facilities as fast as possible^[9].

Control Casualty conveyance

All ambulances should be parked in a location that can be easily controlled. A smooth traffic flow should be ensured. An ALO will give instructions to each ambulance in the conveyance of casualties according to the priority and the pre-set quota without any mistakes.

Ambulance crews

Ambulance crews should be divided into small teams and directed/controlled by senior officers.Even they are experienced in handling casualties, however in a MCI, they need to flexible in the application of their knowledge under the casualty START model.In case of doubt, the HA EMTs can give advice.

Volunteers

AMS/St. John volunteers sometime will be called for assistance.They have the similar problems same as the EMTs.They are not familiar with the MCI field operation arrangements.Volunteers should be assigned the duties to tally with their abilities.Their team leaders should take up this important role.Furthermore, close supervision to volunteers should be strengthened to avoid any mistakes.As far as possible, it is best for volunteers to work together with the FSD ambulance crews.

Coordination MCO

The MCO should be a senior A & E doctor and he should keep close liaison with the AIO and the EMTs.In case of need, he will contact the MICC at hospital level to adjust the pre-set quota to meet with the operational needs as well as to request for additional medical resources from the HA Head Office MICC. If required, he can coordinate the EMTs in casualty treatment.

Casualty Flow

Upon the announcement of a MCI, there will be many different parties working together at the same time at the incident site, which will affect the normal casualty flow^[10].In order to strengthen the flow process, the AIO should immediate direct his subordinates to set up the Triage Point and the different colour casualty treatment areas.The START model should be quickly carried out in the Triage Point by the Triage Officer and his counterparts. The ALP should be manned by an ALO to convey casualties to hospitals in a controlled manner.

Training to EMTs

The incident site is a complete different place comparing to the in-house working condition for the HA doctors and nurses in hospitals. For example, it is difficult to intubate a casualty lying down on a triage mat even you are kneeing down. Inclement weather, inadequate lighting together with the chaos at the scene are difficult situations needed to be overcomed.

It is recommended that other than the regular drills and exercises, practices on some medical procedures should be carried out in similar conditions. For example, doctors should try the intubation using a simulator putting on the ground or even on a stretcher in the compartment of a moving ambulance. As far as possible, doctors and nurses should be given a better environment for carrying out the complex procedures. It will be more convenient for them to perform resuscitation in the MCTC or to place a casualty on a high up ambulance trolley to perform intubation.

In fact, there are some physique requirements for the above works. Members of the EMT should upkeep their physical fitness to maintain their outdoor operation capacity. The FSD ambulance crews should work closely with the EMTs and give a helping hand if required.

Logistic supports to EMTs

The EMTs should have a set of uniform outfits with protective gears for outdoor duty. HA EMTs will wear red colour vests with the wordings of 'HA Doctor' or 'HA Nurse'.One technician will accompany an EMT to the incident site with the conveyance of a FSD ambulance. They will bring with them the necessary medical equipment and drugs. The equipment and drugs are clearly classified and packed in waterproof carrying bags well in advance. All the items should be checked regularly and the bags should be kept in a visible place in the A & E store room for easy pick up at any time.

Communication Radio telephone system

A radio communication system must be established and has been proved its' reliability in remote areas, places surrounded by high buildings and even during inclement weather situations.The use of new digital trunked radio systems by the FSD in recent years has ensured the effective communication among the FSD personnel at the incident sites.Other than that, the MCO and all EMTs, volunteer team leaders should be equipped with their own communication devices so that internal communication can be easily done to exchange information without delay. The technical aspects of a hand-held radio transceiver as well as the manner in radio telephone communication should be learned and regularly practiced.

Debriefing

Debriefing sessions normally chaired by the FSD will be arranged for some special incidents. Problems will be identified and suggestions will be discussed. It is essential to record the details showing all the important points for attention. Actions to be followed up by individual departments with timeframe should be documented. The concerned departments should report the progress of the remedial actions to the Chairman in written. After all the actions have been done, all information should be compiled in a report for future reference. In case of need, the related contingency plans as well as the operational orders should be amended accordingly.

Conclusion

The FSD ambulances rapidly respond to accidents as the FSCC has a computerised mobilising system for immediate dispatch of ambulances in the nearby depots. The system can also monitor the real time ground movement of all ambulances and keep in touch with them with a reliable radio communication network all the time.

Furthermore, ambulance crews are equipped with the appropriate EMA skills to render treatment to casualties on-the-spot and enroute to hospitals. The mechanism of running emergency ambulance services by paramedics in Hong Kong has been proved effective and efficient. Upon the expansion of the administration of more drugs and the use of certain types of advanced medical equipment, the efficiency of casualty care has marked improvements in recent years.

With the support from HA EMTs, the FSD has demonstrated its capacity in handling different types of MCIs. Furthermore, the new Fire and Ambulance Services Academy opened in 2016 had significantly provided more opportunities for the fire and ambulance personnel to be trained together, thereby enhancing their responses and co-ordinations in emergencies.

Without doubt, Hong Kong is one of the safest cities in the Asia-Pacific Region. Citizens receive high standard and comprehensive pre-hospital care even in MCIs.