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An Approach to Mitigating a Multiple Casualty Incident
MEDICAL INCIDENT COMMAND
MEDICAL INCIDENT COMMAND
Disasters and MCI’s are challenging situations
Why?
Large number of patients Lack of specialized equipment or help
MEDICAL INCIDENT COMMAND
Systemic approach to manage incident efficiently
MEDICAL INCIDENT COMMAND
Incident Command System (ICS)
Try to do the greatest good for the greatest number!
MEDICAL INCIDENT COMMAND
National Incident Management System (NIMS)
Created to promote efficient coordination
Disasters
Critical Infrastructure can be damaged
a) Electrical power gridb) Communication systemc) Fuel for vehiclesd) Watere) Sewage Removalf) Foodg) Hospitalsh) Transportation systems
Disasters
Disaster Management Requires planners to take a broad
look at:1) Preparedness2) Planning3) Training4) Response5) After-action review
Multiple Casualty Incident
1. Number of patients exceeds resources available to the initial responders
2. ICS will help Paramedics work efficiently and effectively
Open Incident
Number of casualties not yet located
Rescuers may have to search for patients
Ongoing situation that produces more patients
Closed Incident
Situation that is not expected to produce more patients than initially present
a) Triaged and treated as they are removed
b) May suddenly become an open incident
INCIDENT COMMAND SYSTEM
OVERVIEW
INCIDENT COMMAND SYSTEM
Terminology
Common terminology and “clear text” communications
INCIDENT COMMAND SYSTEM
Modular Organization Structure
a) Built on size and complexity of incident
b) Designed to control duplication of effort and freelancing
INCIDENT COMMAND SYSTEM
SPAN OF CONTROLa) Limited by ICSb) Keeps supervisor/worker ratio at:
One(1) Supervisor for three(3) to seven(7) workers
INCIDENT COMMAND SYSTEM
Organizational Division
May Include:1) Sections2) Branches3) Divisions4) Groups
See Figure 47-3) Page 47.6
INCIDENT COMMAND SYSTEM
Emergency Operations Center1) In some regions2) Usually operated by city, state or
Federal3) Only activated in large catastrophic
event that may go on for days
ICS Roles and Responsibilities
General Staff includes:1. Command2. Finance3. Logistics4. Operations5. Planning
Incident Command
LogisticsFinanceOperations Planning
Incident Commander
Person in charge of overall incident Assesses incident Establishes strategic objectives and
priorities Develops a plan to manage incident Number of Command duties varies
by the size of the incident such as Public information, Safety and Liaison
Unified Command System
Required in large MCI’s Multiagency or multijurisdiction
response Plans drawn up in advance by all
cooperating agencies that have shared responsibility for decision making and cooperation
Designate lead and support agencies in several kinds of MCIs
Single Command System
One person in charge Generally used with incidents in
which one agency has majority of responsibility for incident management
Short duration, limited incidents
Transfer of Command
IC may turn over command to someone with more experience in a critical area
Orderly, face to face Termination of command Demobilization procedures—workers
relieved as incident is mitigated
Finance
The Finance Section Chief is1. Responsible for documenting all
expenditures at an incident for reimbursement
2. Responding agencies and organizations may be eligible for some types of reimbursement
3. Trained in process of assessing expenditures with eye to reimbursement long before an actual event
Logistics (1 of 2)
The Logistics Section Chief isa) Responsible fori. Communications equipmentii. Facilitiesiii. Food and wateriv. Fuelv. Lightingvi. Medical equipment and supplies
Logistics (2 of 2)
Local standard operating procedures will list medical equipment needed for incident
See Table 47-1 MCI Equipment and Supplies
Trained to find food, shelter and health care for responders at the scene of MCI
Operations
The Operations section Chief 1. Responsible for managing the
tactical operations job at a large incident
2. Supervises the people working at the scene of the incident
Planning
The Planning Section chief1. Solves problems as they arise
during the MCI2. Obtains data, analyzes the previous
incident plan, and predicts what or who is needed to make the new plan work
3. Responsible for demobilization when needed
Command Staff—Safety Officer
Monitors scene for conditions or operations that may present a hazard to responders and patients
May need to work with environmental health and hazardous materials specialists
Authority to stop an emergency operation whenever a rescuer is in danger
Command –Public Information Officer
Provides public and media with clear and understandable information
Positioned well away from incident command post
Must keep media safe and prevent them from becoming part of the incident
May work in cooperation with PIO’s from other agencies in a joint information center(JIC)
Command –Public Information Officer
Disseminates messages aimed at helping a situation, preventing panic, and /or providing evacuation directions
Liaison Officer (LNO)
Relays information and concerns among command, the general staff, and other agencies
If any agency is not represented in the command structure, questions and input should be given through the LNO
THE NIMSNATIONAL INCIDENT MANAGEMENT SYSTEM
NIMS--Overview
1) President directed Secretary of Homeland Security to implement in March 2004
2) Provides consistent nationwide template to enable Federal, state and local governments as well as private-sector and nongovernmental organizations to work together effectively and efficiently
NIMS--Overview
3) Prepare for, prevent, respond to and recover from domestic incidents, regardless of cause, size or complexity, including acts of catastrophic terrorism
4) Underlying principles Flexibility: rapid adaptation Standardization Interoperability: agencies of
different types can communicate with one another
NIMS—Major components
Command and Managementa) Incident management is
standardized for all hazards and across all levels of government
b) ICS, mulitagency coordination systems and public information systems are the three key constructs
NIMS—Major components
Preparednessa) Establishes measures for all
responders to incorporate into their systems in preparation to respond to all incidents at any time
NIMS—Major components
Resource Managementa) Mechanisms to describe, inventory,
track and dispatch resources before, during and after an incident
b) Defines standard procedures to recover equipment used during the inciden
NIMS—Major components
Communications and Information management
a) Critical aspect of domestic incident management
b) Enable essential functions needed to provide interoperability
NIMS—Major components
Supporting Technologiesa) Promotes national standards and
interoperability for supporting technologies to successfully implement NIMS
b) Provides structure for the science and technology used in incident management
NIMS—Major components
Ongoing Management and Maintenance
a) U.S. Department of Homeland Security will establish a multijurisdictional, multidisciplinary NIMS integration center
b) This will provide strategic direction for and oversight of NIMS, supporting routine maintenance and continuous improvement of the system in the long term
EMS RESPONSE WITHIN THE ICS
Preparedness
1) Decision making and basic planning are done before an incident occurs
2) EMS agency should have written disaster plans
3) Disaster supplies for at least 72-hour period of self-sufficiency
4) Mutual Aid agreements with surrounding organizations
5) Assistance program for families of EMS
Scene Size-UP
1) Unsafe scene a. Stay away b. Get close enough only to make
an assessment2) Three Basic Questions a. What do I have? b. What do I need to do? c. What resources do I need?
Establishing Command
1) After scene size-up, establish command
2) Command system ensures resources are effectively and efficiently coordinated
3) Establish early
Communications
1) Often key problem at an MCI or disaster
2) Problems should be worked out before a disaster happens
a) Designate channels strictly for command
b) Ensure equipment is reliable, durable and field-tested, and that there are backups in place
MEDICAL INCIDENT COMMAND
Overview
Known also as Medical (EMS) branch of ICS
Medical group leader a. supervises primary roles of
medical group (triage, treatment and transport of injured)
b. Ensures EMS units are working within ICS
c. See Figures 47-7 and 47-8
Triage Unit
Triage Officera) Counts and
prioritizes patientsb) Makes sure every pt.
receives initial assessment and moved to appropriate treatment sector
c) Don’t begin treatment until all patients are triaged
TASKS Triage and tag all pts. Ensure adequate staff
to accomplish tasks Ensure safety of all
members Communicate with
EMS branch on progress of operations
Establish initial morgue Document activities of
triage area.
Treatment Officer
1) Locates and sets up treatment area
a. tier for each priority of patient
b. secondary triage of patients
c. assist with moving patients to transportation area
2) Communicates with medical group leaders
TASKS1) Separate patients by
priority 2) Responsible for safety
of all members working in area
3) Ensure sufficient supplies and personnel
4) Maintain security of area
5) Document activities6) Provide updates to
EMS Branch Director
Transportation Officer
1) Coordinates transportation and distribution of patients to appropriate receiving hospitals
2) Communicates with area hospitals3) Documents and tracks number of
vehicles transporting, patients transported, and the facility destination of each vehicle and patient
Staging Officer
1) Scenes requiring numerous emergency vehicles or agencies
a. vehicles cannot and should not drive into the scene without direction from the staging officer.
2) Area established away from the scene
3) Locates area to stage equipment and responders, track unit arrivals, and send out vehicles as needed
Physicians On Scene
1) Some area plans are in place for physicians on scene
a. Enormity of situation may require physicians sent to scene
b. Ability to make difficult triage decisions
c. Secondary triage decisions in the treatment sector (priority for transport)
d. On-scene medical direction
Rehabilitation Officer
1) Extended Periods2) Establishes a Rehabilitation Section a. area providing protection for
responders from the elements and the situation
b. Located away from exhaust fumes and crowds and out of view of scene
c. Responder’s needs for rest, fluids, food and protection from elements are met
d. monitor for signs of stress e. Defuses and debriefs team
Extrication and Special Rescue
Extrication Officer (rescue officer)a) Determines type of equipment and
resources needed for situationb) Victims may need to be extricated
or rescued before triage and treatment
c) Functions under EMS branced) Crew safety is of utmost importance
Morgue Officer
1) Dead patients2) Works with medical examiners,
coroners, disaster mortuary assistance teams and law enforcement agencies to coordinate removal of bodies and body parts
3) Attempts to leave dead victims in location found until removal and storage plan determined
4) If morgue area necessary
TRIAGE
OVERVIEW
1) Triage means “to sort” based on severity of injuries
2) Primary triage---done in field3) Secondary triage---done in treatment area4) Rapid and accurate triage will help bring order to
the chaos of the MCI scene5) After primary triage report a. total number patients b. number of patients in each category c. recommendation for extrication and
movement of patients to treatment area d. resources needed to complete triage and
begin movement
Triage Categories
Four common triage categories 1. Immediate (red tag)—First priority2. Delayed (yellow tag)—Second
priority 3. Minimal (green tag)—Third priority 4. Expectant(black tag)—Last Priority
Immediate
Usually have problems with ABC’s, head trauma, or signs and symptoms of shock
Delayed
Usually have multiple injuries to bones or joints, including back injuries with or without spinal cord injury
Minimal
They may require no field treatment, “walking wounded” or soft-tissue injuries (contusions, abrasions and lacerations)
Expectant
These are patients who are dead or whose injuries are so severe they have a minimal chance of survival (cardiac arrest, open head injury, or respiratory arrest)
TRIAGE TAGS
Tagging patients assist in tracking them
Helps keep accurate record of condition
Tag will become part of patient’s medical record
START Triage
1) Simple triage and rapid treatment2) Limited assessment of patient’s
ability to walk, respiratory status, hemodynamic status, and neurologic status
START Triage
Steps 1) Call out “If you can hear my voice and are
able to walk…”(identifies walking wounded)2) Assess respiratory status and open airway is
needed(black if not breathing, red if breathing)
3) Assess the hemodynamic status by checking for a radial pulse (if no pulse, red tag)
4) Assess neurologic status by ability to follow simple commands (red tag if unconscious, yellow tag if conscious)
JumpSTART Triage for Pediatric Patients
1) Children younger than 8 or who appear to weigh less than 100 pounds
2) Respiratory status assessment 1. If child not breathing and has no pulse,
label as expectant 2. If patient is not breathing but has pulse,
open airway, give five rescue breaths; if child does no begin to breathe label as expectant
3. Approximate rate of respirations: less than 15 breaths/min or more than 45 tagged as immediate
JumpSTART Triage for Pediatric Patients
3) Hemodynamic status—no distal pulse, immediate priority
4) Neurologic status a. responses will vary based on
development b. unresponsive or responding to pain by
posturing or with incomprehensible sounds or unable to localize pain in an immediate priority
c. alert or able to localize pain is a delayed priority
Triage Special Considerations
1) Hysterical and disruptive patients a. immediate priority to be
transported out of the disaster site b. Panic breeds panic2) A sick or injured rescuer a. immediate priority to be
transported3) Hazardous materials and weapons
of mass destruction incidents
Transportation of Patients
1) Immediate (red) or delayed (yellow) should be transported by ambulance
2) With extreme situations, “walking wounded” are transported by bus
3) Immediate priority patients are transported two at a time until they are all transported
4) Delayed are transported two or three at a time
5) Slightly injured are transported6) Expectant patients who are still alive would
receive transport and treatment
Critical Incident Stress Management
1) Responders may become overwhelmed
2) Stress management should be available but not imposed
After-Action Reviews
All agencies involved in response should participate in effort to improve future reactions to disasters
Discourage finger pointing
Summary
1) Disasters and mass-casualty incidents
2) Incident command3) Emergency Response within the ICS4) Triage
Class Assignment
Read Assessment in Action and then answer questions to discuss in class
Answer Challenging Question Read Points to Ponder. Answer
questions and be prepared to discuss in class
Fill out Organization chart for ICS