1. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Marin County Multiple Patient Management Plan Training Module June 2013

2. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time This training presentation is intended for use by EMS, hospital and law enforcement personnel in Marin County, California. It may not be used without expressed permission from the Marin County EMS Agency.

3. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Introduction Marin Countys guide for managing MCIs has been the 1999 Emergency Medical Response Plan The Multiple Patient Management Plan (MPMP) replaces the EMRP effective July 1, 2013 The MPMP integrates guidance from: –FIRESCOPE Field Operations Guide 420-1 (aka FOG Manual) –California Public Health and Medical Emergency Operations Manual (aka EOM)

4. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time References National Incident Management System (NIMS) Standardized Emergency Management System (SEMS) Incident Command System (ICS) Simple Triage and Rapid Treatment (START) and JumpSTART FIRESCOPE FOG 420-1 California Master Mutual Aid Agreement California Government Code California Emergency Services Act Marin County Fire Service Mutual Aid Plan California Public Health and Medical Emergency Operations Manual California Patient Movement Plan (TBD) County of Marin Emergency Operations Plan County of Marin Medical and Health Annex County of Marin ACS Plan County of Marin FTS Guide (TBD) This Plan meets the standards of the following by reference or incorporation and may be used for guidance when required:

5. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time EMRP vs. MPMP EMRP Uses START triage Incident organization based on FIRESCOPE model 4 response levels Hospital most distant from the incident is assigned as the Coordinating HospitalMPMP Uses START triage Incident organization based on FIRESCOPE model Local MCI plus 3 response levels Level III Trauma Center is the Coordinating Hospital Integrates with States Public Health & Medical Emergency Operations Manual

6. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time MCI Activation Levels in MPMP Local MCI Level III Level II Level I

7. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Local MCI (6-15 patients*) Example: Multiple vehicle collision involving 15 patients requiring transportation. Operational Focus is on incident management including the use of resources necessary to mitigate the problem (scene safety, security, specialty response, on-scene triage, patient transportation, etc.). Managed with local jurisdiction (i.e., ALS zone) resources EMS system modifications may be implemented. (e.g. canceling diversions, using private ambulances for 9-1-1 calls, amending dispatch criteria, etc.) * Guideline only – actual number of patients may vary

8. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Level I (16-30 patients*) Example: Aircraft collision, skilled nursing facility evacuation, large motor vehicle collision, involving 20-30 patients. Operational and Strategic Focus shifts from individual incident management to maintaining the Countys EMS system and a possible transition from focused patient care to population based care. In-county mutual aid from other ALS zones will be requested. EMS system modifications to be implemented. * Guideline only – actual number of patients may vary

9. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Level II (31-100 patients*) Example: Large aircraft collision, hospital facility evacuation, isolated natural incident, involving 80 patients. Operational and Strategic Focus is on scene management, resources necessary to mitigate the incident and maintain the Countys EMS System. This includes a transition from focused patient care to population based care. The use of out-of-county mutual aid resources is anticipated. Modifications to the daily 9-1-1 system are made to support the incident and stability of the system. * Guideline only – actual number of patients may vary

10. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Level III (> 100 patients*) Example: Significant natural disaster or other incidents involving more than 100 patients. Operational and Strategic focus is on scene management, resources necessary to mitigate the incident and maintain the Countys EMS System. This includes a transition from focused patient care to population based care. The use of out-of-county mutual aid resources from regional, state and federal partners is anticipated. Activation of Operational Area Patient Distribution Center likely Includes significant modifications to support the incident and maintain 9-1-1 response. * Guideline only – actual number of patients may vary

11. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time MCI Alert & Activation The IC may initiate either an ALERT or an ACTIVATION –ALERT: Notifies all EMS system participants of a potential multi- casualty event –ACTIVATION: Notifies all EMS system participants of a multi- casualty event in progress –Alert or Activation should be cancelled when no longer needed Marin County Communications is responsible for sending the alert/activation/cancellation to EMS system participants

12. Patient Distribution MPMP allows for immediate transport of patients to local hospitals prior to a communications link being established with the Coordinating Hospital For a Local MCI, Marins hospitals will accept: –1 Immediate Delayed –1 Delayed –2 Minor –Trauma Triage Tool may still be considered For a Level 1 or higher, Marins hospitals will accept: –2 Immediate Delayed –2 Delayed –4 Minor

13. MPMP Forms MPMP includes several forms that may be used by on- scene personnel: –Patient Routing Worksheet for Local MCI & Level I –Patient Routing Worksheet for Levels II & III –ICS 214 Unit Log –ICS 206 Incident Medical Plan –Transportation Group Supervisor Worksheet –ICS 255 Patient Status Sheet (for Marin) –Job Action Checklists

14. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Incident Command First-arriving unit will establish Incident Command Then: –Initiate an MCI Alert or Activation –Assign ICS roles as needed –Identify incident command post and staging area(s) –Request tactical radio frequencies as needed –Order additional resources Incident Command Post

15. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time MCI Organization Incident Commander Operations Section Medical Group Triage Unit Single Resources Morgue Treatment Unit Immediate Delayed Minor Patient Transport Unit Medical Communications Coordinator Ground Ambulance Coordinator Air Ambulance Coordinator Fire Group Extrication Unit Staging Coordinating Hospital (Adapted from FIRESCOPE Field Operations Guide 420-1)

16. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Broad Street MCI Incident Staging Ambulance Staging Minor Immediate Delayed Morgue To Hospital MCI Scene Eastern Street Broad Street

17. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time S.T.A.R.T. Review Verbally direct walking wounded patients to one area –These are patients For each remaining patient assess: –Respirations (<30/min.) –Perfusion (Cap refill <2 sec.) –Mental Status (follows commands) Tag if any of above not met Tag if 30 – 2 – Can Do MINOR IMMEDIATE DELAYED

18. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Triage Tag Marin EMS providers use a triage tag similar to the one shown Remove contaminated strip if not applicable Remove all colored triage strips below the one selected Attach tag to arm, leg or neck Front Back

19. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time MCI Trailers (50 pts) Marin County maintains three trailers stocked with equipment and supplies for an MCI Each can manage about 50 patients Trailers may be ordered by the IC MCI Trailer

20. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time MCI Trailers (25 pts) Eight low-profile trailers are strategically located throughout Marin Each can manage about 25 patients. Low Profile MCI Trailer

21. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Air Operations Ordering air ambulances is at the discretion of the IC Air ambulance transportation will be directed by the Air Ambulance Coordinator Air ambulances will generally be used to transport immediate patients to hospitals outside Marin County

22. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Dispatch Center Marin County Communications Center will: –Notify hospitals, providers, law enforcement, and EMS Agency of a multi-casualty incident –Assign radio frequencies as needed for the incident –Dispatch additional incident resources as requested by the IC 9-1-1 Communications Center

23. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Coordinating Hospital The Coordinating Hospital will: –Initiate an MCI using ReddiNet ® –Coordinate patient distribution with the Medical Communications Coordinator (MedComm) –Use ReddiNet ® to track all patients from an incident Level III Trauma Center (Marin General Hospital) is the coordinating hospital for MCIs Marin General Hospital

24. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time EMS Agency Marin County EMS Agency will: –Be notified of all MCI alerts or activations –May send an Agency Rep to the incident scene if requested –Activate an Operational Area Patient Distribution Center if large numbers of patients must be transported outside Marin

25. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time OA Patient Distribution Center Large numbers of patients to be transported out of Marin may require activation of an OAPDC OAPDC works with Coordinating Hospital, MedComm, nearby OAs, Region II and State to distribute patients to medical facilities outside Marin Directed by the MHOAC (Medical Health Operational Area Coordinator) and staffed by EMS Agency

26. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Reno Championship Air Races Crash September 16, 2011

27. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time The Venue

28. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Minutes Before

29. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Milliseconds Before

30. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time The Impact

31. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time The Scene A highly-modified P-51 Mustang flown by veteran pilot, James Jimmy Leeward, suddenly dives directly into a VIP grandstand packed with spectators Initial response includes four ALS ambulances The pilot and 6 spectators are dead on arrival

32. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time The Aftermath 54 patients are triaged and transported in 62 minutes: –25 Immediate –18 Delayed –11 Minor –7 Dead 4 patients later die in the hospital

33. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Now assume this incident has just occurred at Gnoss Field in Novato, and you are on duty…

34. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time Questions 1.What would the initial dispatch of resources likely include? 2.When would you request an MCI activation? 3.Discuss the ICS organization needed for this incident. 4.How would you handle all the walking wounded? 5.What level MCI would this incident fall under according to the MPMP?

35. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time More Questions 6.How many ambulances will you need for this incident? Who orders them? 7.How many air ambulances? 8.Which ICS role handles patient distribution with the Coordinating Hospital? 9.How many patients can be sent to Marins three acute hospitals right away? 10.How will patients be tracked from the scene to the hospital?

36. Marin County Emergency Medical Services Excellent Care – Every Patient, Every Time For a copy of Marin Countys Multiple Patient Management Plan or this training presentation please go to: www.MarinEMS.org Copyright © 2013 All rights reserved by Marin County EMS Agency