1. Incident Command at a Mass Casualty Incident
Chris Goliver, M.D.
Chief Resident
St. Vincent’s Mercy Medical Center

2. Incident Command System
Designed for all kinds of emergencies
Applicable from single jurisdiction to multiagency incidents
Applicable to both small day to day operations as well as very large and complex incidents

3. Design Requirements
Structure must be able to adapt to any type of emergency
Must be applicable to users of diverse backgrounds
Should be readily adaptable
Must be able to expand
Must be able to avoid CHAOS

4. CHAOS
C - Chief
H - Has
A - Arrived
O - On
S - Scene

5. ICS Terminology Apparatus Command Command Post Communications Center
Sector
Staging Area

6. ICS Operations
Common Terminology - All communications should be in plain English (NO Codes)
Modular Organization
Manageable Span of Control - In general from 3 to 7
Unified Command Structure

7. Command Post Location from which all operations are directed
Should only be one command post
All appropriate authorities should be at the command post

8. Staging Area
Established for temporary location of equipment and personnel
Status Conditions - Assigned, Available, and Out of Service

9. Major Incident
An event for which available resources are insufficient to manage the number of casualties
Consider in cases which require more than two ambulances, hazardous materials or specialized equipment

10. Preparing for a Major Incident
Phase 1 - The Preplan
Phase 2 - Scene Management
Phase 3 - Post Disaster Follow-up

11. FEMA Incident Command System
Federal law requires the use of ICS for hazardous materials incidents
Ideal to use the ICS as standard operating procedure on all incidents

12. ICS Organization Built around five major components Command Planning
Operations
Logistics
Finance / Administration

13. Command Function
Command should belong to one person who can coordinate a variety of emergency activities
Command should be established immediately
The Incident Commander must be clearly identified

14. Types of Command
Singular Command - One individual is responsible for the entire operation
Unified Command - Specialized organizations are identified and personnel unify to compliment command

15. Example of Unified Command
Incidents that affect more than one jurisdiction
Incidents involving multiple agencies within a jurisdiction

16. ICS Organization
The Incident Commander will base decisions to expand the ICS Organization based on three major incident priorities:
Life Safety
Incident Stability
Property Conservation

17. Planning Section
Provides past, present, and future information about the incident and the status of resources

18. Operations Section
Directs and Coordinates all emergency scene operations
Ensures safety of all operational personnel
Operations Section Chief is in charge of the actual scene

19. Logistics Section Supports the logistical needs of the incident
Primary function is to provide gear and support to the incident responders

20. Finance/Administration Section
Seldom used on small scale incidents
Accounts for costs and accounting of personnel

21. Establishing Command
Generally the first arriving unit starts the Incident Command System
Unification of EMS command with fire and police may become necessary

22. Scene Assessment
First unit on scene should make a quick and rapid assessment of the situation: Type of incident, Number of patients, Additional resources needed
Scene assessment must be continually updated

23. Obtaining Resources
Should have a written Standard Operating Procedure already in place for requesting additional resources
Use of staging to ensure timely response of resources

24. Task Force
Any combination of resources put together for a specific assignment

25. Strike Team Set number of resources of the same kind and type
Examples: Ambulances, Engine companies

26. Extrication Sector
Responsible for managing entrapped patients at the scene
Patient care activities should only include assessment and treatment of life threatening injuries

27. Treatment Sector
As patients are delivered they are categorized according to their medical needs
Provides advanced care and stabilization until the patients are transported to a medical facility

28. Rehabilitation Sector
Usually set up in a location outside the operational area
Monitors personnel and ensures proper rest and hydration
Works with logistics to ensure proper hydration, nutrition and supplies

29. On-Scene Physicians Medical Direction for EMS personnel
Use at treatment area to make secondary triage decisions
Emergency Surgery to facilitate extrication

30. Disposition of the Deceased
Assisting in the establishment of an appropriate and secure area for a morgue
Working with the medical examiner, law enforcement and other appropriate agencies to coordinate disposition

31. Transportation Sector
Communicates with the receiving hospitals, ambulances and aeromedical services
Must work closely with the treatment sector to determine appropriate destinations for the injured

32. Staging Sector
Required for large incidents to prevent vehicle congestion and delays
All emergency vehicles should report to staging for further direction

33. Support Sector
Coordinates the gathering and distribution of equipment and supplies for all other sectors
May be responsible for obtaining medical supplies, rescue equipment, etc.

34. Sector Identification
Radio communications use operation titles instead of personal or unit names
For example EMS sector to Command

35. Radio Communications
Preplanning includes identifying a radio frequency to be used in a major incident
All responding units should have multi-channel radios
Separate frequencies for EMS, Fire, Police, Etc.

36. Radio Communications
Sector Officers should have radios that allow direct communication with Command
Radio traffic MUST be in clear, concise and plain English
Avoid use of radio codes and signals

37. Principles of Triage
A method used to categorize patients for priorities of treatment
Assessment of patient severity is based on: Abnormal vital signs, Obvious anatomic injury, Concurrent disease factors that might affect prognosis

38. Primary vs. Secondary Triage
Triage is a CONTINUOUS process

39. Primary Triage
Used to rapidly categorize patient condition for treatment
Label patient with triage labels, tags or tape
Focus on speed to sort patients quickly
No care other than immediate lifesaving interventions

40. Secondary Triage Used at Treatment area
Patients are triaged and labeled according to their present physiological status

41. START Triage
Simple Triage And Rapid Treatment. Uses a 60 second assessment
Focuses on the patient’s:
Ability to Walk
Respiratory Effort
Pulses / Perfusion
Neurological Status

42. 30 - 2 - Can Do Respiratory Rate >30 or <10
Capillary Refill < 2 seconds or Positive Carotid with Negative Radial Pulses
Altered Mental Status or Inability to Follow Commands

43. START Triage Assessment used to classify victims as: Urgent Delayed
Dead or Dying
Critical

44. START Triage
Allows rescuers to quickly identify victims at greatest risk of early death
Advise other rescuers of the patient’s need for stabilization by tagging the patient with color coded disaster tags

45. START Triage
Repositioning the airway and controlling severe hemorrhage are the only initial treatment efforts in the primary triage

46. Triage Labeling Many Variations of tags, tape and labels are available
Immediate - Red - Priority 1
Delayed - Yellow - Priority 2
Hold - Green - Priority 3
Deceased - Black - Priority 4

47. Purpose of Tagging Identify the priority of the patient
All tags and labels should be easy to use, rapidly identify patient priority, allow for easy tracking, allow room for documentation and prevent patient from being re-triaged

48. Tracking System
A destination log that integrates the triage tagging system must be maintained by the transportation officer
Triage log must contain: Patient ID, Transporting unit, Patient priority, and Hospital destination

49. Transportation of Patients
Method of transportation determined by triage priority and situation
Air ambulances are usually reserved for critical patients
Buses should be considered for transporting large number of priority 3 patients

50. Critical Incident Stress Management
A potential hazard for rescue personnel
Should be part of the post disaster SOP
Monitor personnel for signs of stress
Develop pre-designated resources