2. Virginia MASS Casualty Incident Management Lieutenant Jeff Lawson Roanoke County Fire & Rescue Department

3. Course Objectives Complete initial response actions to MCI Triage using START Use correct triage ribbons Accurate casualty count Complete Virginia Triage Tag

4. The Problem Geographic Location Population Centers Transportation Routes Unique Hazards

5. There is potential for an incident With large numbers of patients that overwhelms any EMS system

6. MASS CASULTY INCIDENT Overwhelms resources available in a system or area Places great demand on resources: Personnel, Equipment, & Hospital Facilities

7. MCI TYPES -TECHNINCAL HAZARDS Building Collapse High Rise Incidents Major Industrial Accidents Transportation Accidents Hazardous Materials Incidents

8. MCI TYPES - CIVIL/POLITICAL Civil disobedience Criminal or terrorist incidents Military attack on the United States

9. Incident Management System Allows effective control, direction, coordination of response resources Communications and information gathering Improved interaction with other agencies

10. Influencing Factors Magnitude of the event Available resources

11. Magnitude How big is the incident –N–Number of patients –a–area –b–boundaries: open or closed

12. Resources Response and support personnel Apparatus Facilities (Hospital’s, Temporary Shelters, & etc.

13. Categories of MCI’s Expanded Medical Incident Major Medical Incident Disaster Catastrophe

14. Expanded Medical Incident Produces multiple casualties - a multiple vehicle accident Pre-hospital resources adequate Hospital capacity adequate

15. Major Medical Incident Produces a large number of casualties - the World Trade Center bombing Multi-jurisdictional and regional EMS response Regional allocation of patients to hospitals

16. Disaster Mass casualties - a major earthquake Overwhelms local, multi- jurisdiction, and regional mutual aid Assistance from State, interstate, or Federal resources.

17. Catastrophe Overwhelm local, multi- jurisdictional, regional, State resources Interstate and Federal resources needed - as in Hurricane Andrew Local resources are concentrating on their own survival

18. Goals of MCI Management Greatest good for greatest number Scarce resource management Don’t relocate the disaster

19. Do the Greatest Good Make the best possible use of available resources Salvage the most patients possible Heroic resuscitation not appropriate Concentrate on those we can save!

20. Resource Management Call for needed resources early! Be prepared for delays Use command –to coordinate with other hospitals –to coordinate transportation decisions

21. Don’t Relocate the Disaster Transport patients to facilities based on: –P–Predetermined plan –a–ability of facility to receive types and numbers of patients –D–Don’t move the incident to the hospital

22. 5S - Safety Assessment Fire Electrical Hazard Flammable Liquids HAZ-MAT Other Life Threats and Hazards to Rescuers

23. 5S -Scene Safety Type of incident Approximate number of patients Severity of injuries Area involved and access

24. 5S - Send Information Contact dispatch with survey information Request resources and mutual aid Notify command hospital (MED-COM @ RMH)

25. First EMS Provider Establishes Medical Group Directs triage of all patients Assigns resources as available to get key functions running

26. 5S - Set Up Medical Group Supervision Triage Treatment Medical Communication Transportation Extrication Staging Medical Supply

27. Transportation Decisions Patient prioritization Destination facilities Transportation resources

28. START Simple Triage and Rapid Treatment

29. Triage From French word “to sort” Separates patients needing rapid care Reduces urgent burden on capabilities Provides rational casualty distribution

30. Triage Problems Reliance on specific diagnosis to put patients in categories Too slow a process

31. START does these things

32. Ideal Triage System Simple No Advanced Skills No Specific Diagnosis Easy to do Rapid and simple life-saving intervention Easy to teach and learn

33. Triage Ribbon Concept Red –IMMEDIATE (highest priority) –respiration, perfusion, mental status, severe burns

34. Yellow –DELAYED (second priority) –burns,major or multiple bone or back injuries Triage Ribbon Concept

35. Green –M–Minor (third priority) –M–Minor painful, swollen deformities, minor soft tissue injuries

36. Black –D–DEAD (lowest priority) –D–Deceased or non-salvageable

37. Start First Steps Begin where you stand Move all who can walk –away from the site –use GREEN ribbons

38. Start - First Steps Move in orderly pattern through patients Assess using START and put ribbons on

39. Start - First Steps Keep a count of casualties Give only minimal treatment –open the airway –stop gross bleeding

40. Start - First Steps Keep moving

41. Respiration Assessment Not Breathing? Open Airway! –Still not breathing - BLACK (DEAD) –Starts to breath - RED (immediate)

42. Respiration Assessment Breathing >30 breaths per minute - RED <30 breaths per minute - Next Step Maintain airway any way you can

43. Perfusion Assessment Radial pulse absent?RED (immediate) Radial pulse present - NEXT STEP Stop any gross hemorrhage

44. Mental Status Assessment Ask patient to do something simple Does not follow command - RED Able to follow command - YELLOW

45. Treatment Functions Purpose –Identify specific injury –Categorize patients and give care –Prioritize for transport

46. Treatment Functions Start depends on three simple observations –Respiration –Perfusion –Mental Status

47. Treatment Functions Reassessment and tagging –on way to treatment or (in small incidents) at the site –in treatment area –in ambulance

48. Treatment Functions MCI’s will require two triage stages Reassessment in treatment is secondary triage –more subjective –based on specific condition and experience

49. Secondary Triage RED (Immediate) –L–Life threatening injury –H–High probability of survival –c–can be stabilized –r–risk of asphyxiation or shock present or imminent

50. YELLOW (Delayed) –Potentially life threatening injury –Severely debilitating injury –Can stand a delay in treatment and transport

51. Secondary Triage GREEN (Minor) –Non life threatening injuries –Minimal care with minimal risk

52. Secondary Triage BLACK (Deceased or non- salvageable –Unresponsive with no circulation –Deceased at the site en route to treatment in treatment

53. Summary MCI’s can overwhelm you - go for the goals: –greatest good for greatest number –scarce resource management –don’t relocate the problem

54. Summary Fist responders take first steps - the 5-S’s: –Safety –Survey –Send –Set-up –START

55. Summary START sorts large number of patients Treatment phase requires secondary triage as in-depth assessment Triage Tag IMS expands to meet the needs of response