Incident Management and Mass-Casualty Incidents

Nancy Caroline’s Emergency Care in the Streets, Eighth Edition Chapter 47: Incident Management and Mass-

Casualty Incidents

© 2018 Jones & Bartlett Learning, LLC, an Ascend Learning Company 1

Chapter 47

Incident Management and Mass-Casualty Incidents

Unit Summary

The paramedic has operational roles and responsibilities in establishing command under the

incident command system (ICS) in order to ensure patient, public, and personnel safety. Upon

completion of this chapter and related course assignments, students will be able to explain the

purpose of medical incident command in the ICS and describe the major components of the

National Incident Management System (NIMS). They will be able to describe how START and

JumpSTART triage methods are performed and discuss triage principles, resource management,

and the need for retriage. Students will also be able to discuss the specific conditions that define a

situation as a mass casualty incident (MCI), including the role and purpose of critical incident

stress management (CISM) in an MCI.

National EMS Education Standard Competencies

EMS Operations

Knowledge of operational roles and responsibilities to ensure patient, public, and personnel

safety.

Incident Management

Establish and work within the incident management system. (pp 2335-2344)

Multiple Casualty Incidents

Triage principles (pp 2345-2347)

Resource management (pp 2335-2340)

Triage (pp 2345-2351)

• Performing (pp 2347-2350)

• Retriage (pp 2346)

• Destination decisions (p 2351)

• Posttraumatic and cumulative stress (p 2351)

Knowledge Objectives

1. Explain the federal requirements for the minimum entry-level certifications of

paramedics and other emergency personnel in incident command system (ICS) training.

(p 2334)

2. Describe the National Incident Management System (NIMS) and its major components.

(pp 2334-2335)


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3. Describe the purpose of the ICS and its organizational structure, and the role of

emergency medical services (EMS) response within it. (pp 2335-2339)

4. Describe how the ICS ensures the safety of responders, people injured or threatened by

the incident, volunteers assisting at the incident, and the media and general public who

are at the scene. (pp 2339-2340)

5. Describe the role of the paramedic in establishing command under the ICS. (pp 2340-

2341)

6. Explain the purpose of EMS operations within incident management. (pp 2341-2344)

7. Describe the specific conditions that would define a situation as a mass-casualty incident

(MCI), including some examples. (p 2344)

8. Describe what occurs during primary and secondary triage, how the four triage categories

are assigned to patients on the scene, and how destination decisions regarding triaged

patients are made. (pp 2345-2348, 2351)

9. Explain the need for retriaging of patients during MCIs. (p 2346)

10. Describe how the START and JumpSTART triage methods are performed. (pp 2348-

2350)

11. Describe the purpose of critical incident stress management. (p 2351)

Skills Objectives

1. Demonstrate how to perform triage based on a fictitious scenario that involves an MCI.

(pp 2345-2351)

Readings and Preparation

• Review all instructional materials including Chapter 47 of Nancy Caroline’s Emergency

Care in the Streets, Eighth Edition, and all related presentation support materials.

• Visit the Federal Emergency Management Agency (FEMA) website for information to

direct students as they review the National Incident Management System.

• Several articles available on the EMS World website provide information and examples

surrounding multiple casualty incidents.

- “Mass Casualty Incident Management” by R. Duckworth

- “Kid Care During Disaster Response” by J. Busch

- “EMS Consequence Management: The ICS Elephant in the Room” by J. H. Logan

Support Materials

• Lecture PowerPoint presentation

• Case Study PowerPoint presentation

• The FEMA website can be used as a resource to assist students in understanding how

comprehensive the NIMS system is in the management of disasters and the impact it has


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had on multiple agency responses. Direct students to the information sheets, brochures, or

frequently asked questions located on the website.

• Obtain copies of your local EMS agency’s hazardous response or MCI plan. Make sure

that students are able to familiarize themselves with their role if this occurs during a

clinical assignment.

Enhancements

• Direct students to visit Navigate 2.

• Contact the closest fire department that has a hazardous response team. Ask if one of the

members is available to speak to the class on the role of EMS in a hazardous response.

• Contact the local fire department to determine if there is a CISM certified professional

available in your area. If so, contact them about sending someone to speak to the class

about the role of CISM after an MCI.

Content connections: Students should be encouraged to review the importance of personal well-

being as outlined in Chapter 2 of Nancy Caroline’s Emergency Care in the Streets, Eighth

Edition. MCI events can bring additional stress and it is essential that the paramedic have healthy

ways to deal with these incidents.

Remind students that NIMS has impacted how EMS communicates with other public safety

agencies by implementing a “plain English” radio language and discontinuation of use of codes.

Encourage them to discuss whether the EMS agency they work with has become NIMS

compliant.

Cultural considerations: Pediatric and older adult patients are particularly vulnerable during an

MCI and may require additional considerations for appropriate triage and transport. Remind

students to take this into consideration when assessing these patients.

Patients who do not speak English may pose a challenge in an MCI if access to a translator is not

immediately available. Encourage students to consider the population of the community in which

they will be working and what resources are available to assist with bridging these potential

communication barriers. Have students identify technological resources that may be beneficial in

an MCI environment.

Teaching Tips

• While some students may have completed a Hazardous Materials Awareness course, do

not assume that all students are aware of the proper procedures for responding to a

hazardous materials incident. Consider locating a local HazMat Awareness class offered

by area fire departments and encourage students to complete the course.

• Survey your students to determine if they have completed the FEMA ICS 100 and ICS

700 courses that are required by most states for emergency personnel. If they have not

completed these courses, encourage students to visit the website to register and complete

these online: training.fema.gov/is/nims.asp

Unit Activities


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Writing activities: Most students will have heard about large-scale MCI events that have

involved multiple agencies and large numbers of fatalities. Assign an event for students to

research and identify the role that EMS played in the management of the event. Ask that students

consider long-term effects of the event on responding providers. They should submit a paper

summarizing their findings.

Student presentations: Assign students a hazardous material to research and identify its

classification, threat to humans, threat to the environment, type of response and control efforts,

and long-term effects. Ask that students present their findings in a brief report to the class.

Group activities: Assign three to five students to a group. Provide each group with a START or

JumpSTART triage tag. Ask that they identify types of patients and conditions that would be

assigned to each designation. Encourage them to discuss how they would deal with assigning a

patient to the expectant category. Have groups consider the role of CISM in dealing with the after

effects of this responsibility.

Visual thinking: Assign three to five students to a group and provide them with a poster board or

large sheet of newsprint. Have each group construct a visual representation of the ICS structure

for a large-scale event. Have them identify each sector and officer, as well responsibilities, that

will take part in the event. When completed, have each group discuss which areas EMS might

play a role and why.

Pre-Lecture

You are the Paramedic

“You are the Paramedic” is a progressive case study that encourages critical-thinking skills.

Instructor Directions

1. Direct students to read the “You are the Paramedic” scenario found throughout Chapter

47.

2. You may wish to assign students to a partner or a group. Direct them to review the

discussion questions at the end of the scenario and prepare a response to each question.

Facilitate a class dialogue centered on the discussion questions and the Patient Care

Report.

3. You may also use this as an individual activity and ask students to turn in their comments

on a separate piece of paper.

Lecture

I. Introduction

A. Incident types

1. Disasters and mass-casualty incidents (MCIs)

a. A disaster is declared by local, county, state, or federal government for purposes of

providing additional resources and funds to those in need.

b. An MCI is declared when the number of patients and severity of injuries suggest that

available community resources could be overwhelmed.


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i. Mutual aid response is required.

2. Multiple-casualty incident

a. Any situation with more than one patient, but that will not overwhelm available

resources

3. There is no set numerical cutoff at which a multiple-casualty incident becomes a mass-

casualty incident.

B. National Incident Management System (NIMS)

1. System designed to improve efficiency in the management of incidents, regardless of size

or complexity

2. NIMS courses may offer certifications that can be prerequisites, corequisites, or part of

an entry-level course.

C. Incident command system (ICS)

1. Prepares responders to provide a coordinated effort during an incident

2. As a paramedic, you will typically be assigned to work within the EMS/medical group

under an ICS, but you also may be asked to function in other areas.

II. The NIMS

A. The National Incident Management System (NIMS) was implemented in 2004 to

provide a consistent nationwide template to promote effective and efficient

emergency response.

1. Used to prepare for, prevent, respond to, and recover from domestic incidents

a. Regardless of cause, size, and complexity

2. Flexibility, standardization, and interoperability are key principles of NIMS.

a. The organizational structure must flexibly and quickly adapt for use in any type of

incident.

b. NIMS provides standardization in terminology, resource classification, personal

training, and certification.

c. Interoperability allows agencies of different types or from different jurisdictions to

communicate with each other.

3. Through interoperability, a common incident communications plan is developed and

facilitates interoperable communications.

a. All resources must be able to work using a similar framework.

B. Major components of NIMS

1. Command and management

a. Incident management is standardized for all hazards across all levels of government.

b. Command structure is based on:

i. ICS

ii. Multiagency coordination systems

iii. Public information systems

2. Preparedness


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a. Institutes procedures for all responders to include in their systems in preparation to

respond to any event at any time

3. Resource management

a. Sets up systems that describe, inventory, track, and dispatch resources before, during,

and after incident

b. Creates standard procedures to recover equipment that was used

4. Communications and information management

a. Enables the necessary functions needed to provide interoperability

5. Ongoing management and maintenance

a. A NIMS Integration Center will be created to provide strategic direction and

oversight of the NIMS.

III. The Incident Command System

A. Using common language and “clear text” ensures better communication among

various agencies.

B. The ICS creates a modular organizational structure.

1. The goal is to make the best use of resources to manage the environment and treat

patients.

2. Follow local standard operating procedures to establish the ICS.

3. The ICS is designed to control duplication of effort and freelancing.

a. Freelancing: Individual units or agencies make independent decisions about next

steps

4. The ICS limits span of control.

a. Keeps the supervisor-to-worker ratios at one supervisor for three to seven workers

b. A supervisor who is overseeing more than seven people must delegate tasks and

supervision.

5. Organizational divisions can include:

a. Sections

b. Branches

c. Divisions and groups

d. Resources

6. Some areas have emergency operations centers.

a. Operated by the city, state, or federal government

b. Usually only activated in large emergencies, with hundreds of patients and that

continue for days

7. Responders in an MCI or disaster should use the ICS. Find out from your service:

a. Does ICS exist?

b. Who is in charge?

c. How is it activated?

d. What will be your role?

C. Incident command system roles and responsibilities


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1. The general roles within the ICS include command, finance, logistics, operations, and

planning.

a. Command functions include:

i. Public information officer (PIO)

ii. Safety officer

iii. Liaison officer

2. Command

a. The incident commander (IC) evaluates the incident and creates a plan of action

based on strategic objectives and priorities.

i. The number of duties the IC is responsible for depends on the size of the

incident.

(a) Small incidents often mean the IC will do it all.

(b) Incidents of medium size or complexity often mean the IC will delegate

some functions but retain others.

(c) In a complex incident, the IC may appoint team members to all command

roles.

b. A unified command system is used when an incident requires multiple organizations

or jurisdictions.

i. Plans are made in advance by all organizations that take on responsibility in

decision making.

ii. The plan assigns the lead and support agencies.

(a) For example: HazMat team takes the lead during a chemical leak where the

medical team would take the lead in a multivehicle car crash.

iii. Agencies bordering each other should regularly practice together in preparation

for an incident.

c. A single command system is one in which one person is in charge.

i. Generally used with incidents in which one agency has the majority of

responsibility for incident management

ii. Ideally used for short-duration, limited incidents

d. For small-scale incidents that are not anticipated to increase in complexity, IC may

be located somewhere on the fringes of a scene that is clearly identifiable.

i. Know who the IC is, where the command post is located, and how to

communicate with the IC.

e. For large-scale incidents or incidents with several injured responders, it may be

reasonable for the IC to be located a short distance from the scene.

i. Decreases distractions, improves flow of vital information, and helps ensure

safety of those in command from secondary attacks

f. Transfer of command: IC transfers command to a more experienced person in a

critical area.

i. This transfer is to be done in an orderly manner and ideally face to face.

ii. Your agency should have standard operating procedures (SOPs) that direct the

transfer of command.

g. At the conclusion of an incident there should be a termination of command.

i. Demobilization procedures should be implemented as the situation de-escalates.


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3. Operations

a. Manages the tactical operations job at a large incident

b. At a complex incident, the operations chief oversees the responders working at the

scene.

i. Often have managerial experience within a fire department

4. Finance

a. Responsible for documenting all expenses at an incident that should be reimbursed

i. Not always necessary at smaller incidents

ii. Tracks and reports personnel hours and cost of materials and supplies at meetings

b. The finance chief will help your organization receive reimbursements if eligible.

c. The roles of the finance section are:

i. Time unit

(a) Keeps a daily record of personnel time and equipment use

ii. Procurement unit

(a) Deals with vendor contracts

iii. Compensation/claims unit

(a) Deals with claims regarding incident and injury compensation

(b) Collects, analyzes, and reports costs

5. Logistics

a. Responsible for:

i. Communications equipment

ii. Facilities

iii. Food and water

iv. Fuel

v. Lighting

vi. Medical equipment and supplies

b. In large incidents many people may coordinate logistics, but only one reports to the

IC.

6. Planning

a. Solve problems as they arise during the MCI.

b. Typically four units associated with the planning section: resources, situation,

demobilization, and documentation

c. Use data from the current incident to analyze the previous plan and predict next steps

for the new plan.

c. Work closely with operations, finance, and logistics.

d. Call upon technical experts to help with planning process.

e. Set plan for demobilization.

f. Develop an incident action plan.

i. Written at the beginning of a response by the chief with input from other

departments

ii. Continuously revised as the response continues


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iii. The degree of detail included depends on the complexity and size of the

response.

7. Command staff

a. Safety officer

i. Continually monitors the area for any hazards to responders and patients

ii. Possibly will interact with environmental health and HazMat teams

iii. Has the authority to stop an emergency operation when a rescuer is in danger

b. Public information officer (PIO)

i. Presents information to the public and media

ii. Takes post away from incident to keep media safe from the emergency and keep

distractions to a minimum

iii. May work in conjunction with other organizations in a joint information center

(JIC)

iv. May be responsible for providing a message that will help a situation, prevent

further panic, and provide evacuation directions

c. Liaison officer (LNO)

i. Relays information between command, general staff, and other agencies

D. Communications and information management

1. Communications should be integrated so all agencies can communicate easily and

quickly by radio.

a. Allows for:

i. Accountability throughout the incident

ii. Instant communication

2. Maintain professionalism on all radio communications.

3. Communicate clearly, concisely, and using clear text.

E. Mobilization and deployment

1. Once an incident is declared and additional resources and personnel are requested, they

are mobilized and deployed at a staging area.

2. The steps of mobilization and deployment are:

a. Check in with the IC upon arrival at a small-scale incident or with the resource unit at

a large-scale incident.

i. Allows you to be assigned to a supervisor for job tasking

ii. Allows for personnel tracking

iii. Allows for precise tracking of costs, pay, and reimbursement

iv. Provides accountability regarding who is present at the incident should

something go wrong

b. Check in with your supervisor for an initial briefing about the incident and job

responsibilities.

c. Keep records as a way to document items that may need to be reimbursed.

d. Keep your supervisor up to date on your location, actions, and completed and

uncompleted tasks (accountability).


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i. Advise your supervisor of the tasks that you have been unable to complete and

what tools you need to complete them.

e. Once the incident is controlled the IC will decide on demobilization of resources.

IV. EMS Response Within the Incident Command System

A. Preparedness

1. Decisions and basic plans are made before an incident occurs.

a. Includes plans for all natural disasters that are most likely to happen in a particular

area

b. Allow for some flexibility for unique circumstances

2. Each EMS agency generally has a written disaster plan.

a. Usually located at each EMS station, as well as on each EMS vehicle

b. You may have a checklist of supplies that need to be at your station, which may

include:

i. Water

ii. Batteries

iii. Cots

iv. Other items for the personnel who will be staffing the station

v. Medical supplies that you must have on hand in sufficient quantities

3. You should have your own disaster plan in place for your family in the event that you

need to respond to a disaster.

a. Your EMS agency may have an assistance program for families of EMS responders.

4. Make sure you have all necessary immunizations.

a. Influenza

b. Hepatitis A and B

c. Tetanus

5. Training is one of the most crucial components of preparedness.

a. Mock scenarios with multiple agencies working together should be practiced

monthly.

b. Continuous, realistic training and updated planning are crucial to performance during

an actual emergency response.

B. Scene size-up

1. Dispatch will inform you if the MCI scene is safe or unsafe.

a. Do not hesitate to request more resources early on if dispatch information suggests

the need.

2. When you arrive on the scene, ask yourself two basic questions:

a. What do I have?

i. Check for hazards and warn other responders of safety concerns such as

hazardous materials, fuels spills, and electrical hazards.

ii. Confirm the location of the incident.

iii. How many casualties are there?


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iv. Report findings to dispatch.

b. What do I need?

i. Determine the resources you will need.

(a) You may need EMS responders, ambulances, or other forms of

transportation.

(b) A rescue unit and fire department may be needed if extrication is required.

(c) The hazmat team should be called at once if there are any hazardous material

issues.

(d) There may be specialized MCI units and mobile emergency rooms that are

called upon if there are a lot of patients.

C. Establishing command

1. Establish command early on.

a. Preferably by the first-arriving, most experienced public safety official

2. Evaluate scene then return to your post.

3. If working as the IC, retain the mindset that you are there to serve as command.

a. Do not become distracted with patient treatment and other tasks.

D. Communications

1. Communications is often a key problem at an MCI or a disaster.

2. To limit radio traffic, always use face-to-face communication when possible.

3. If you are communicating by radio, do not use codes or signals.

4. There are typically radio channels specified as emergency command channels.

5. The communication equipment you are using should be reliable, durable, field tested, and

have backups.

a. There should always be a “Plan B” for communication.

V. Medical Incident Command

A. Medical incident command is also known as the medical branch of the ICS.

1. A medical branch director is appointed during incidents that call for a large amount of

medical attention.

a. Oversees primary roles of medical team

i. Triage

ii. Treatment

iii. Transport

b. Makes sure that EMS units are working within the ICS

c. Assigns each medical unit with tasks prior to working at the scene

i. Prior to instructions all medical responders should stay in the staging area.

d. Depending on the size of the incident, EMS may be its own command or work under

the logistics section.

B. Triage unit leader

1. Counts and prioritizes patients at the incident


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2. Ensures each patient receives an initial assessment

a. Triage paramedics transfer patients to the correct treatment section.

3. Treatment on patients must not begin until every patient is triaged.

C. Treatment unit leader

1. Locates and sets up the treatment area with a tier for each priority of patient

2. Sees that each patient has secondary triage and that each gets enough care

3. Assists with moving patients to transportation area

4. Communicates the request for sufficient quantities of supplies, including:

a. Bandages

b. Burn supplies

c. Respiratory supplies

d. Patient packaging equipment

D. Transportation unit leader

1. Coordinates the transportation and distribution of patients to appropriate hospitals

a. Communicates with area hospitals to decide which will receive certain patients

2. Tracks and records the number of vehicles transporting, patients transported, and the

destination of both

E. Staging area manager

1. Assigned when a situation calls for multiple emergency vehicles or agencies

2. Designates an efficient location for the staging area away from the incident

3. Plans for access and exit from the site

4. Prevents traffic congestion among responding vehicles

5. Releases vehicles and supplies when needed

F. Physicians on scene

1. Provide secondary triage decisions

a. Decide the priority of patients to be transported

2. Provide on-site medical direction and treatment

G. Rehabilitation group leader

1. Creates a rehabilitation area where responders can come to rest, eat and drink, and get

protection from the elements during an incident that will last for a while

a. The rehabilitation area is set up away from the incident, crowds, and media.

2. Monitors EMS personnel for stress signs.

a. Fatigue

b. Altered thinking

c. Collapse

H. Extrication and special rescue

1. An extrication task force leader or rescue task force leader may need to be appointed if

there is a need for search and rescue or extrication of patients.

2. The supervisor coordinates the equipment and resources needed.


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3. The supervisors will usually function as a specialty group under the operations group of

the ICS because extrication and rescue are medically complex.

I. Morgue unit leader

1. In an incident where many victims have died, a morgue supervisor is appointed.

a. Works with the medical examiners, coroners, disaster mortuary assistance, and law

enforcement

b. Coordinates removal of bodies

2. The deceased should be left untouched until removal and storage plans are made.

a. This will also help in identifying victims in an MCI or crime scene investigations.

3. If a morgue area is created it should be out of sight so there is no further psychological

trauma to living patients and responders.

VI. Mass-Casualty Incidents

A. An MCI may overwhelm available resources.

1. Mutual aid response: Neighboring EMS systems respond to MCIs in each other’s regions

when there aren’t enough local resources

2. Examples of MCIs include:

a. Bus or train crashes

b. Earthquakes

c. Residential building fire

d. Loss of power to a hospital or nursing home

3. Response to the MCI will vary depending on location and how spread out the patients are

B. Identify an MCI as an open incident or a closed incident.

1. Open incident

a. Unknown amount of casualties when you first answer a call

b. Patients may need to be searched for and treated in multiple locations.

c. Possibly an incident that is ongoing, for example, a tornado or school shooting

2. Closed incident

a. Number of patients is not expected to change

b. Patients are triaged and treated as they are removed

c. May turn into an open incident

C. When deciding what qualifies as an MCI, regions will use varying standards and

protocols.

1. Previous experience will help determine the status of the incident.

2. Regular use of the ICS and participating in disaster planning drills, table-top MCI

exercises, and other trainings will better prepare you for an incident.

3. Having a solid understanding of the roles of an MCI and regular use of the ICS and

NIMS will help the keep the incident responders organized and efficient.

4. The following questions will help you determine whether an incident is an MCI:

a. How many injured or ill patients are on scene?


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b. What resources are available?

c. How long will it take for additional help to arrive?

d. Where should these patients be transported?

5. Never initiate transport of patients if there are unattended patients present who are sick or

wounded.

a. This could be considered abandonment.

b. If there are multiple patients and not enough resources to handle them without

abandoning victims, request additional resources and initiate the ICS and triage

procedures.

6. Consider relocating patients to a smaller area to initiate treatment on the critical patients

while continuing to observe those who are less injured.

7. If needed, use your resources and delegate tasks to your partner or responders from other

agencies, such as police officers.

8. Always follow local protocol.

VII. Triage

A. Triage is sorting patients by severity of their conditions and prioritizing them for

care accordingly.

1. The goal is to do the greatest good for the greatest number.

a. Triage should be brief.

b. Categories that patients are placed in should be basic.

2. Primary triage is used to rapidly categorize patients.

a. Focus is on speed.

b. Work on locating all patients and determining initial priority.

3. Patients may be identified with a triage tag in primary triage.

a. Each tag will have a unique number and a triage category.

4. After primary triage, the team leader will report to the medical branch director:

a. The total number of patients

b. The number of patients in each triage category

c. Recommendations for extrication and movement of patients to the treatment area

d. The resources that are needed to complete triage and begin the movement of patients

5. Secondary triage is retriage in the treatment group.

a. The category of a patient can change suddenly and can be upgraded or downgraded

due to patient condition.

i. Frequent reevaluation of patients will help quickly identify changes.

b. Avoid spending too much time assessing a single patient.

B. Triage categories

1. Four common triage categories can be remembered using mnemonic IDME:

a. Immediate (red)

b. Delayed (yellow)

c. Minimal (green)


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d. Expectant (black)

2. Immediate patients are first priority.

a. Need immediate care or transportation

b. These patients may have problems with the ABCs, head trauma, or shock.

3. Delayed patients are second priority.

a. Will need care or transport, but it can be delayed

b. These patients may have bone, joint, or back injuries (not spinal cord).

4. Minimal patients are third priority.

a. Need little to no on-scene treatment

b. Patients are known as the “walking wounded.”

c. Usually suffer from soft-tissue injuries

i. Contusions

ii. Abrasions

iii. Lacerations

5. Expectant patients are the last priority.

a. Either already dead or have little chance to survive

i. Cardiac arrest

ii. Open head injury

iii. Respiratory arrest

b. These patients only get treated if all other patients are helped.

6. A new, fifth triage category—the orange-tag category—may be added.

a. Represents an intermediate category between the critical (red-tag) and noncritical,

nonambulatory (yellow-tag) categories

b. There may be ambulatory patients who require prompt evaluation and treatment for

medical comorbidities that are not acute traumatic injuries associated with the initial

event.

C. Triage tags

1. It is important to label, track, and record a patient’s conditions no matter what system is

used.

2. A triage tag should have these characteristics:

a. Weatherproof

b. Easy to read

c. Color coded

d. Clearly shows triage category

i. In case a responder may be color-blind use both symbols and colors.

3. This tag will be added to a patient’s medical record and may have a tear-off receipt.

a. Tracks a patient’s location

b. Identifies a patient if they are unresponsive

4. Digital photos are sometimes used in identification of victims.

5. Another method of tracking patients is to use bar-code scanners and triage tags that have

bar codes.


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a. With adequate training, this method allows for real-time tracking of patients from the

initial triage to the destination hospital.

6. Whatever labeling system is used, it is imperative for the transportation supervisor to be

able to identify:

a. Which patient went by which unit and to which destination

b. The priority of the patient’s condition

D. START triage

1. Staff at Hoag Memorial Hospital in Newport Beach, California, created a simple form of

triage named Simple Triage and Rapid Treatment (START).

2. Uses a limited evaluation of a patient

a. Ability to walk

b. Respiratory status

c. Hemodynamic status

d. Neurologic status

3. First step of the START system

a. When you first get to the scene, call out, guiding patients who can hear you to an

identifiable landmark.

i. These injured patients are considered the “walking wounded.”

ii. Categorized as minimal priority, or third-priority patients

4. Second step of START

a. Evaluate the nonambulatory patients.

b. Check the respiratory status.

i. If a patient is not breathing, open the airway using a simple manual maneuver.

(a) If the patient does not begin breathing, categorize as expectant (black).

ii. If the patient starts breathing, quickly estimate their respiratory rate.

(a) Faster than 30 breaths/min categorize as immediate priority (red)

(b) Fewer than 30 breaths/min, continue assessment

iii. Check for radial pulse to evaluate the hemodynamic status.

(a) Absent radial pulse suggests the patient is hypotensive and should be

categorized as immediate priority.

(b) If radial pulse is present continue assessment.

iv. Check the neurologic status.

(a) Ask the patient to follow simple commands (eg, “Show me three fingers”).

(b) If they don’t understand the command and are unresponsive, categorize as

immediate priority.

(c) A patient who understands commands is categorized as delayed.

E. JumpSTART triage for pediatric patients

1. Lou Romig, MD, created JumpSTART to address the developmental and physical

differences children have from adults.

a. The system is used to assess children younger than 8 years old or who appear to

weigh less than 100 pounds (45 kg).

2. First, identify the “walking wounded.”


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a. Infants and children not developed enough to walk are taken to the treatment area for

immediate secondary triage.

3. JumpSTART triage differs slightly from START triage.

a. If a pediatric patient isn’t breathing, check for a pulse.

i. If there is no pulse the patient is labeled as expectant.

ii. If there is a pulse, open airway with a manual maneuver.

iii. Give five rescue breaths if the patient still isn’t breathing.

iv. If the patient doesn’t respond they are labeled as expectant.

b. The most common cause of cardiac arrest in children is respiratory arrest.

4. Next check the approximate rate of respirations.

a. A child who is breathing fewer than 15 breaths/min or more than 45 breaths/min is

categorized as immediate.

b. If respirations are within a range of 15 or 45 breaths/min, continue assessment.

5. Assess the hemodynamic status.

a. Check for a distal pulse.

b. If there is no distal pulse the child is labeled as immediate.

c. If the child has a distal pulse, continue assessment.

6. Assess neurologic status.

a. A child’s responses will vary depending on their age and development.

b. Use a modified AVPU score.

i. Alert

ii. Verbal

iii. Pain

iv. Unresponsive

c. A child who is unresponsive, not understandable in voice, or cannot locate their pain

is labeled as immediate.

d. A child who is alert or can pinpoint their pain is labeled as delayed.

F. SALT triage

1. SALT stands for Sort, Assess, Lifesaving interventions, and Treatment and/or Transport.

2. This triage system begins by prioritizing order in which patients are assessed.

a. Patients who lie still or have obvious life-threatening injuries

b. Patients who are unable to walk but demonstrate purposeful movement or the ability

to follow verbal commands

c. Patients who are ambulatory and can follow commands to walk to a designated area

3. SALT method allows for limited rapid interventions, including the following steps:

a. Bleeding control

b. Opening the airway (including two rescue breaths for children)

c. Needle decompression for tension pneumothorax

d. Auto-injector antidotes

4. As you progress through the assessment, you will assess:

a. Airway


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b. Mental status

c. Perfusion

d. Respiratory status

e. Bleeding control

5. The SALT method is also unique in that there are five patient categories.

a. Black tags are assigned to patients who are dead and should not be moved from the

point of injury.

b. Gray tags are assigned to patients who are not expected to survive given the available

resources.

c. The other three categories are similar to most triage schemes, with immediate,

delayed, and minimal categories.

G. Triage special considerations

1. Patients who are hysterical and disruptive to rescue efforts may need to be made an

immediate priority and transported out of the disaster site, even if they are not seriously

injured.

a. This type of behavior could create panic for other patients and rescuers.

2. Do not hesitate to have the “walking wounded” assist you with simple tasks.

3. An injured or sick responder should be categorized as immediate and transported away

from the scene so other responders do not lose morale.

4. If hazardous materials or weapons of mass destruction are present, the HazMat team must

categorize patients as contaminated or uncontaminated before regular triage can begin.

5. Some incidents will require multiple teams or areas of triage if patients are spread out.

H. Destination decisions

1. Using the 2011 American College of Surgeons Committee on Trauma (ACS-COT) field

triage decision scheme, refer patients to trauma centers using criteria including:

a. Physiologic criteria

b. Anatomic criteria

c. Mechanism of injury

d. Special considerations

i. Age

ii. Underlying health conditions

2. The guidelines help prehospital responders identify individuals who will benefit from

transportation to a trauma center.

3. Consider which hospital has the appropriate means to help a patient.

a. Some hospitals can become overwhelmed by a large number of patients.

i. Most have hospital surge capacity plans to accommodate for this.

(a) May include deployed mobile units that can be quickly set up on site

b. Some patients may require specialized care.

i. Burn centers

ii. Pediatric centers

4. Given hundreds of patients, not all of the critical trauma patients will go straight to a

single trauma center.


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a. Patients may be transported to a hospital that is not ordinarily capable of accepting a

trauma patient.

i. The physicians can work to stabilize the patient before arranging transfer to an

appropriate facility.

b. Some patients may require specialty centers.

5. Transport patients that are categorized as immediate by ambulance or air ambulance.

6. You can transport walking wounded by bus if needed in large situations.

a. These patients should be taken to a hospital farther away from the scene so as not to

overwhelm the hospital.

b. At least one EMT or paramedic must ride on the bus.

c. An ambulance should follow.

d. The EMT should notify the receiving hospital immediately if a patient’s condition

worsens during travel.

7. Transport immediate patients two at a time.

8. Transport delayed two or three at a time.

9. Transport slightly injured last.

10. Expectant patients are treated once all patients have been transported.

11. Dead victims are handled and transported according to the SOP for the area.

VIII. Critical Incident Stress Management

A. An MCI response is incredibly stressful.

1. There are few things more emotionally wrenching than discussing triage and

management of an MCI.

2. Suicide rates have increased among EMS workers, firefighters, and police officers.

3. Debriefing with others who responded to the event may be beneficial.

a. Debriefing with family or others who did not respond to the event can be unhelpful

and may create additional issues.

4. Reach out to colleagues struggling with the emotional toll of an incident.

5. Within your department’s disaster plan there should be a resource for debriefing or

defusing of responders before, during, and after an MCI.

a. Depends on service director’s and medical director’s views

6. Critical incident stress management (CISM) should be available to all responders.

a. Participation is encouraged but not required.

7. All responders should have access to coping mechanisms.

a. Employee Assistance Program (EAP)

b. Mental health professionals

c. Peer counselors trained in CISM debriefing

8. These services should always be available.

a. Some effects may not set in until much later.

9. The psychological impact on responders should be included in the postincident

evaluation.

B. After-action review


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1. All agencies participate in a review after an incident ends.

2. For future events, include what worked and what didn’t work.

3. All observations should be written down for future review.

4. Never accuse someone of doing something wrong during the incident.

a. All MCIs are different, and all reactions will be different.

Post-Lecture

This section contains various student-centered end-of-chapter activities designed as

enhancements to the instructor’s presentation. As time permits, these activities may be presented

in class. They are also designed to be used as homework activities.

Assessment in Action

This activity is designed to assist the student in gaining a further understanding of issues

surrounding the provision of prehospital care. The activity incorporates both critical thinking and

application of paramedic knowledge.

Instructor Directions

1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the

end of Chapter 47.

2. Direct students to read and individually answer the quiz questions at the end of the

scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class

review and dialogue of the answers, allowing students to correct responses as may be

needed. Use the quiz question answers noted below to assist in building this review.

Allow approximately 10 minutes for this part of the activity.

3. You may wish to ask students to complete the activity on their own and turn in their

answers on a separate piece of paper.

Answers to Assessment in Action Questions

1. Answer: A. Assume incident command and call for additional resources.

Rationale: As the first arriving emergency responder, you will serve as incident

commander. You may choose to pass this role to a more qualified or more experienced

responder once he or she arrives on scene. Remember that this transfer of command

should occur in a face-to-face meeting during which you communicate your findings and

particular details of the scene. In a situation like this, calling for additional resources

early is an absolute must.

2. Answer: B. Unified command

Rationale: With this type of incident, you are likely to have many different agencies

responding to the scene. You should expect to have representatives from each agency

involved in some way in the command center. Remember the definition for a unified

command is a command system used in larger incidents in which there is a multiagency

response or multiple jurisdictions are involved.


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3. Answer: B. Open

Rationale: There are multiple areas where patients could be located. It is important to

remember that you may want to request enough resources to cover the number of patients

that are identified from the initial triage plus additional resources in case more patients

are located in the water or inside one of the boats. You do not want to discover more

patients and not have resources to treat them.

4. Answer: C. Transport and treatment

Rationale: As the first arriving unit, you have occupied the role of triaging the entire

scene. While you may need additional help triaging the scene, your partner should be

assisting you. The next available units arriving on scene should be able to swiftly move to

set up a treatment and transport sector. This will be important as patients are brought by

other responders away from the scene of the incident.

5. Answer: B. START

Rationale: The START triage system provides a simple method of categorizing patients

at an MCI based upon the patient’s ability to walk, respiratory status, hemodynamic

status, and neurological status. JumpSTART is a triage method that is meant for use in

children under age 8 years or who appear to weigh less than 100 pounds (45 kg).

6. Answer: D. Immediate

Rationale: The patient should be triaged as immediate (red). The presence of profuse

bleeding could be distracting as you attempt to triage your patients. However, following a

START or SALT triage method, you would recognize that the patient meets the criteria

for immediate treatment and transport.

7. Answer: A. Number of patients in each triage category

Rationale: Upon completion of primary triage, the team leader should communicate the

following information to the medical group leader: total number of patients; number of

patients in each of the triage categories; recommendations for extrication and movement

of patients to the treatment area; and resources needed to complete triage and begin

movement of the patients.

8. Answer: Accurate triage will help to ensure that precious resources are utilized

efficiently. If the patient is undertriaged, the responder has missed some component of

the patient’s injury or illness, and the patient is at risk for sudden decompensation or a

delay in treatment and transport to the appropriate facility. If the patient is overtriaged,

the patient is likely to receive rapid treatment and transport to a specialty center (eg,

trauma center, burn center). This will not negatively affect the patient who has been

overtriaged. It is important to remember that situations surrounding a mass-casualty

incident will limit the availability of critical resources. The patient who has been

overtriaged may take up one of the limited spots at the specialized center. This could

negatively impact another patient’s ability to receive the specialized care that he or she

desperately needs. Do your best to perform an accurate triage and remember to retriage

patients once they reach the treatment area.

9. Answer: Training is an excellent opportunity to stress your predetermined mass-casualty

response plans. Run it through the paces and determine strengths and weaknesses.

Reformat your plan based on the performance during the training exercise. While current

training scenarios are becoming more realistic, there is no test for a response plan like an

actual incident response. After-action reviews allow you to analyze each part of the


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response. However, this is not a place to make personal accusations about weaknesses

discovered during the response. Be constructive in your criticism.

10. Rationale: As a paramedic, you and your coworkers will be subjected to repeated

significant stressors above and beyond what the general public will ever experience.

Responding to a mass-casualty incident is no exception. Pay attention to yourself and

your fellow responders before, during, and after the event. Signs of emotional stress may

be obvious or they may be difficult to detect. There are multiple resources to investigate

if you or a coworker needs a formal or informal debrief. Remember that you are a part of

a large family of responders. Take care of one another.

Assignments

A. Review all materials from this lesson and be prepared for a lesson quiz to be

administered (date to be determined by instructor).

B. Read Chapter 48, Vehicle Extrication and Special Rescue, for the next class session.

Documents

Incident Management and Mass-Casualty Incidents