MEDICAL INCIDENT COMMAND. Disasters and MCI’s are challenging situations Why? Large number of patients Lack of specialized equipment or help

An Approach to Mitigating a Multiple Casualty Incident

MEDICAL INCIDENT COMMAND


Disasters and MCI’s are challenging situations

Why?

Large number of patients Lack of specialized equipment or help


Systemic approach to manage incident efficiently


Incident Command System (ICS)

Try to do the greatest good for the greatest number!


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


Terminology

Common terminology and “clear text” communications


Modular Organization Structure

a) Built on size and complexity of incident

b) Designed to control duplication of effort and freelancing


SPAN OF CONTROLa) Limited by ICSb) Keeps supervisor/worker ratio at:

One(1) Supervisor for three(3) to seven(7) workers


Organizational Division

May Include:1) Sections2) Branches3) Divisions4) Groups

See Figure 47-3) Page 47.6


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


Preparednessa) Establishes measures for all

responders to incorporate into their systems in preparation to respond to all incidents at any time


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


Communications and Information management

a) Critical aspect of domestic incident management

b) Enable essential functions needed to provide interoperability


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


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


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