Mass Casualty Management First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman.

Mass Casualty Management First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Learning Objectives At the end of the session the participants will be able to: Explain the concept of Mass Casualty Define Mass Casualty Management System Describe Field Management Elaborate the management of victims Elucidate the concept of transfer organization Be familiarized with the concept of Surge Capacity

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Produces several patients As few as six or as many as several hundred Affects local hospitals Patients are greater than resources of the initial responders Overview of Mass Casualty Mass Casualty Incident 3

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Pre-planning and training are critical Establish guidelines and procedures Early implementation of Incident Command First five minutes will determine next five hours Overview of Mass Casualty Preparation for Mass Casualty 4

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Mass Casualties can occur in a variety of ways Effect on emergency response and community impact Include transportation, violent crimes and building collapse Overview of Mass Casualty Response Categories for Mass Casualties 5

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Hazardous materials incidents Civil disturbances Natural disasters Major fires Terrorist attacks Overview of Mass Casualty Categories of Mass Casualties 6

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Incident Command Location of the Command Post Communication and coordination between agencies Overview of Mass Casualty ‘Critical’ in Mass Casualty Incidents 7

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Perimeter establishment delayed or not done at all Large crowds of people Media involvement Political involvement Inadequate resources Overview of Mass Casualty Challenges of Mass Casualty Incidents 8

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing Mass Casualty Management System 9

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Objective: to minimize loss of life and disabilities Mass Casualty Management Establishing a Mass Casualty Management System 10

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Mass Casualty Management System The group of Units, Organizations, Sectors which work jointly during a mass casualty event Based on: - Pre-established procedures - Maximization of use of existing resources - Multi-sectoral preparation and response - Strong pre-planned and tested coordination 11

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Different Approaches to MCI 1.“Scoop and Run” 2.Classical Approach 3. Mass Casualty Management System 12

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Scoop and Run Most common Does not require specific technical ability from rescuers Justified for small numbers occurring near a hospital May just transfer problem to the hospital 13

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Classical Approach First responders are trained (basic triage and field care) Disregard the receiving hospitals from the field Quickly result to chaos 14

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Mass Casualty Management Approach Most sophisticated approach includes pre- established procedures for: a. resource mobilization b. field management c. hospital reception 15

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Mass Casualty Management Approach Training of various level of responders Incorporates links between field and health care facilities Command Post Multi-sectoral Response Dependent on the availability of large amounts of human & material resources 16

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Problems in Developing MCM Limited human resources limited material resources –facility –transport –communication Poor communication –topography –isolation Political

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Field Management Definition: Encompass procedures used to organize the disaster area in order to facilitate the management of victims Components Alerting Process Pre-identification of Field Areas Safety/ Security Command Post Search and Rescue Field Care Evacuation (EMC) Emergency Management Center

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman RESCUE CHAIN---SECTORAL *SEARCH* *RESCUE* *First Aid* Impact Zone Command Post Triage Stabilization Evacuation Traffic Control Regulation of Evacuation CP / AMP Pre-Hospital OrganizationHospital Organization ER or A&ED Establishing a Mass Casualty Management System 19

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Field Organization Alerting Process Definition: Sequence of activities implemented to achieve the efficient mobilization of adequate resources Aim: - Confirm the initial warning - Evaluate the extent of the problems - Ensure that appropriate resources are informed and mobilized 20

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Field Organization Alerting Process Dispatch Center: Core of the Alerting Process (Operation/Communication Center) Functions: – receives all warning messages (radio/phone) – mobilize a small assessment team (Flying Team) from police, fire or ambulance services 21

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Precise location of the event Time & type of the event Estimated number of casualties Added potential risk Exposed population Resources needed Establishing a Mass Casualty Management System Initial Assessment 22

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Safety Best practice technique to protect victims, responders & exposed population: immediate/potential risk Measures: Direct action: - risk reduction - fire fighting - contain hazardous material - evacuation of exposed population Preventive actions: establish field areas - primary- impact zone - secondary- rescue/ICP/AMP - tertiary-“buffer zone”; tri-media 23

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Safety Personnel: fire services; specialized units hazardous materials & explosives (bio-nuclear and radioactive materials) experts, etc., airport manager, chemical plant expert 24

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Command Post ( CP / or ICP) Multi-sectoral control unit to: Coordinate sectors involved in field/scene management Linked w/ back-up system: provide information & mobilization resources Supervise victim management REQUISITE: radio communication network: main criterion to be effective Purpose: coordination / communication hub of people who don’t work routinely (pre-hospital setting) Location: external boundary of restricted area (impact zone) close to AMP/ Evacuation Area/ accessible/easily identified * should accommodate: com./visuals/maps/boards 25

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System High ranking officer (government police, fire, health, defense) - plant manager/ airport manager/ chief security, etc… - fire officer / police officer skilled in ICS / MCM Identified by name/position, coordinator / commander May depend on what type of incident Must be familiar with each other’s roles during previous meetings/ drills/ simulation exercises (policy) This core group cooperate with volunteer organizations Personnel 26

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System The communication / coordination hub of the pre- hospital organization. By constant re-assessment, CP will identify needs to increase / decrease resources: o organize timely rotation of rescue workers exposed to stressful/exhausting conditions in close coordination w/ back-up system o ensure adequate supply of equipment / manpower o ensure welfare / comfort of rescue workers o provide info to back-up system, other officials, and tri-media thru an Information Officer o release as soon as situation allows “E” staff and re- establish normal operations o determine termination of field operations METHOD 27

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Search & Rescue - locate victims - remove victims from unsafe locations – collecting area - assess victim’s status (on-site triage) - provide first aid, if necessary (no CPR on-site in MC Event) - transfer victims to AMP thru entry triage (medical triage) - under supervision of the CP/ IC/ or Commander/Coordinator - may in special situation, require medical personnel (trained) - to stabilize/resuscitate/amputate (trapped) victim before extrication. MANAGEMENT OF VICTIMS 28

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Management of Victims Field Care - Pre-established capabilities / inventory: pre-planning - Integrated community plan: practiced w/ policy support - The “Golden Hour” Principle 29

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Establish AMP with specially skilled /trained ---- “disaster field medical teams” - good triage / stabilization capacity - specifically trained / up-skilled medical teams - good (radio) communications between the field scene & medical facility “ Don’t transfer chaos in the scene, to the hospital……” Recent progress in pre-hospital emergency / disaster medicine 30

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Basis: urgency (victim’s status) survival (chance or likelihood) care resource availability and capability Objectives: Quick identification for immediate stabilization for life-saving (measures) and surgery Levels: On-site–----- ‘where they lie’ Medical ----- at Advance Medical Post Evacuation --- transport TRIAGE 31

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman On-site T:Acute Non-acute Medical T:Red Yellow Green Black Evacuation T - transport: Red Yellow Green Black Red: transferred as soon as possible to tertiary facilities in an equipped ambulance with medical escort Yellow: after evacuation of Red, without life-threatening problem Green: ‘walking wounded’-to AS/OPD Black: to morgue Forensic Services Public Health & Psycho-Social interventions to relatives/kin Establishing a Mass Casualty Management System 32

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Personnel: – volunteers, fire, police staff, special units, EMT’s, and medical personnel Location: – on-site, before moving victim – at collecting point/ area in an unstable environment. – “Green Area” of “AMP” – ambulance in transit to facility Action: – primarily to transfer with consideration of the ABC’s order of priority First Aid 33

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Purpose: reduce loss of life & limb - save as many as possible in the context of existing & available resources/ situation victim’s status; chance of survival; resources Location: 50-100 meters from Impact Zone (walking distance ) direct access to: Evacuation Road. / Command Post Clear Radio-Com Zone… and SAFE (Upwind) tent / bldg / open / mobile field hospital..?? Advance Medical Post (AMP) 34

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Role: Provide “entry” medical triage Effective stabilization for victims of a MCI/Situation – intubation, tracheostomy, chest drainage, – shock mgt, analgesia, fracture immobilization – fasciotomy, control external bleed & dressing Convert red to yellow category as maybe possible Organize patient transfer to designated care facility/ties AMP 3-T principle: Tag – Treat – Transfer…. Personnel: ER (A&ED), physicians/ nurses (trained & skilled) support: Anesthetists / Surgeons / EMT’s / Nurses / Aiders, etc. Advance Medical Post (AMP) 35

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman COLLECTION AREA TRIAGE AREA TREATMENT AREA PRIORITY IIPRIORITY I (color tagging of victims) T R A N S P O R T A R E A PRIORITY III COMMAND POST Establishing a Mass Casualty Management System 36 (in unstable condition) (management and stabilization) 1st 2nd 3rd

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Field Management Plan: Diagram Working Area Triage Impact Zone Evacuation AMP Command Post Strictly Restricted Restricted Access Route Traffic TrafficTraffic ControlControl Establishing a Mass Casualty Management System 37

Victim Flow : “Conveyor Belt” Management Diagram 3-T Tag Treat and Transfer Triage Treatment Triage Evacuation Impact Zone Collecting Point AMP TRANSFER HOSPITAL Victims FlowTransport Resource Flow Establishing a Mass Casualty Management System

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Establishing a Mass Casualty Management System Situation Assessment Report to Central Level Work Areas Pre-identification Safety Primary Area: Impact Zone Secondary Area Units: CP/AMP/EVAC/TRANSFER Radio Communications Crowd & Traffic Control Search and Rescue Triage & Stabilization Controlled Evacuation Field Organization Checklist 39

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Thank you

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Incident Command System

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Performance Objectives Discuss the advantages of using the Incident Command System Discuss the two types of command Discuss the Incident Command Process Discuss Incident Priorities 42

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman Performance Objectives Discuss the components of the Incident Command System Discuss the Incident Command System organization Discuss the use of the Incident Command checklist 43

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 44 Incident Command System Developed in the 1970’s during the California wildfires Business management practices of planning, directing, organizing, coordinating, delegating, communicating and evaluating 44

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 45 Framework necessary to manage resources, personnel and equipment Designed to be flexible and can be used in large or small incidents Creates a safe environment for all involved 45 Incident Command System

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 46 Benefits of Incident Command Common terminology Position titles and Chain of Command for decision making Responder accountability 46

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 47 Basic Command Types Single Command Unified Command 47

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 48 Single Command Based on first arriving emergency units Initial Incident Commander begins assessment of incident Rescue, Triage, Treatment, Transport 48

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 49 Basic Command Structure Single Command 49

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 50 Unified Command Incidents that involve jurisdictions or agencies involved in the decision making and planning process Ensures plan is communicated and supported by all resources assembled 50

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 51 51

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 52 Overview of Incident Command Process Process is based on: Size up Setting Incident Priorities Predicting incident course and harm Strategic goals and tactical objectives 52

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 53 Size Up Rapid mental evaluation of factors influencing an incident Must continue throughout incident with ongoing evaluation Incident situation, incident cause and incident status 53

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 54 Incident Situation May be one or combination of: Biological Nuclear Fire Chemical Explosion or natural event Natural disaster with MCI 54

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 55 Incident Cause Incident Cause is important because additional or specialized resources may be needed The Incident Commander must determine if the incident was accidental or intentional 55

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 56 Incident Status Is the incident: In a somewhat controlled state or Does it remain uncontrolled 56

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 57 Setting Incident Priorities After size up of the incident a course of action is determined High priority is life safety for the public and responders Incident stabilization Protection of critical systems 57

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 58 Estimating Potential Incident Course and Harm Responder is making a prediction on what will likely occur during the incident Based on available information Responder’s experience 58

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 59 Strategic Goals Broad general statements of desired outcome of the incident Example: mass casualty overturned school bus - extrication, triage, treatment, transport 59

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 60 Incident Command System Comprised of two major categories which assist in organizing functions into an effective design: - Command Staff - General Staff 60 Organization

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 61 Command Staff Consists of the : Incident Commander Safety Officer Liaison Officer Public Information Officer 61

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 62 62 Incident Commander

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 63 Incident Commander First person on the scene with communications capability Remains in command until transferred or incident is terminated Complete authority and responsibility 63

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 64 Incident Commander Must assume and announce command, rapidly evaluate incident, identify resources on hand, request additional resources and establish incident action plan 64 Fill command staff and functional areas Must approve all information releases to the media 64

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 65 Transfer of Command Based on the initial responders experience and comfort level Higher ranking officer does not need to assume command Transfer procedures should be predetermined Detailed briefing is required Face to Face is best method Include: current status, strategies and tactics employed, progress, safety, accountability and resources assigned or needed 65

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 66 General Staff Consists of: Operations (includes staging) Planning Logistics Administrative/Finance 66

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 67 Operations Section

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 68 Operations Section Operations officer functions under direction of the Incident Commander Deploys tactics to control and resolve the incident Responsible for execution of the incident action plan Makes recommendations for changes to plan based on incident status Oversees and is in direct contact with the staging manager Task supervisors report to Operations not Incident Command 68

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 69 Planning Section 69

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 70 Responsible for collection, evaluation, distribution and use of information about the incident Forecast and develop plans to contain and resolve incident Communicates with logistics section 70 Planning Section

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 71 71 Logistics Section

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 72 Responsible for providing facilities, services and materials in support of incident Includes equipment, personnel and associated materials and tools Support branch and Services branch 72 Logistics Section

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 73 Administrative / Finance Section 73

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 74 Administrative/Finance Section Generally not located at incident site Responsible for financial, administrative and cost analysis Divided into four units: time, procurement, compensation/claims and cost 74

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 75 Summary Incident Command created to deal with any incident in an organized manner Manages resources, personnel and equipment to mitigate the incident Builds from first responder Expandable to manage hundreds Implementation is critical for safe and effective operation Allows for multi-agency operations and response based on incident type 75

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 76 Thank you 76

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 77 CRITICAL INCIDENT MANAGEMENT 77

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 78 Performance Objectives Discuss critical incident stages Discuss decision making in a critical incident 78

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 79 Demands a coordinated response to prevent incident from getting worse This includes unresolved element of danger such as additional bomb, a threat to citizens and responders or an unusual incident Often random in nature and disrupt normal life Terrorist organizations use opportunity as a tool for civil disturbance A mass casualty is a critical incident 79 Critical Incident Management Characteristics

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 80 Mass Casualty Incident Overview Produces several patients As few as six or as many as several hundred Affects local hospitals Patients are greater than resources of the initial responders 80

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 81 Preparation For Mass Casualty Pre-planning and training are critical Establish guidelines and procedures Early implementation of Incident Command First five minutes will determine next five hours 81

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 82 Functional Systems Approach Three levels of function: strategic, tactical and task (operation) Management is strategic Team leaders are tactical Resources not involved in supervision are task 82

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 83 Critical Incident Stages They consist of: Initial Response Incident Control using the Six Step Response Recovery Stage 83

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 84 Initial Response Stage Ability to establish command and control Faced with confusion and panic Crucial to develop a team and place a plan in action Protecting citizens and rescue of victims Limit incident growth Protect arriving responders Identify ingress and egress routes 84

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 85 Initial Response Objectives As soon as possible: Gain control of the scene Restore order Prevent target opportunities 85

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 86 Incident Control Using The Six-Step Response The Six-Step response is based on the Incident Command System. It includes: 1.Assume Command, 2.Situation Assessment, 3.Identify and Set Perimeters, 4.establish Command Post, 5.assign Safety Officer and 6.establish Staging Area and assign a Staging Officer 86

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 87 # 1 – Assume Command Must advise incoming responders of incident location Secure tactical frequency Request supervisory support 87

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 88 # 2 – Situation Assessment Size up of the incident that includes the type of threat, approximate number of injured, size of threatened area and possibility of secondary event. 88

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 89 # 2 – Situation Assessment In simple terms the assessment describes: What do you have What are you doing What do you need 89

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 90 # 3 - Identify and Set Perimeters Divide the incident into manageable divisions (geographical areas) Allows command to provide resources where they are needed Critical incidents have three standard perimeters. All perimeters are divisions Expand perimeters based on weather Perimeters are the hot zone, inner perimeter and outer perimeter 90

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 91 The Hot Zone Area in which the incident has occurred May be a street corner or spread over a large area Secured by placing responders in positions of controlling ingress and egress 91

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 92 Inner Perimeter Protects responders in hot zone Uniformed personnel only Used as decontamination area, treatment area and evacuation area for walking wounded 92 Outer Perimeter Provides last line of defense from internal incident acceleration Provides first line of defense from external acceleration Secure area for command post, resources and control of the media

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 93 Perimeter Placement Illustration 93

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 94 # 4 – Establish Command Post Typically begins at first responders vehicle Incident dynamics will require Incident Commander to shift to a fixed command post Must be away from hot zone The command post will ensure support for field personnel, create a controlled environment and improve communications 94

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 95 # 5 - Establish Safety Officer Should be filled as soon as possible Officer selected on operational experience and ability to recognize acceptable and unacceptable risk Operations can be stopped or modified 95 # 6 - Establish Staging Area Effective tool in correct and safe deployment of resources Staging Supervisor must track, rotate and relieve resources as appropriate Area established within inner or outer perimeter. Avoid congestion

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 96 Inter Agency Planning Failure to include all agencies during planning process may compromise responders Identify and establish liaisons with all agencies and coordinate tactical operations 96 Secondary Incidents May be more destructive and damaging than initial incident World Trade Center crashes were primary incident with collapse of the towers as secondary incidents claiming more lives

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 97 97 Recovery Stage Begun when aggressive threats of incident are neutralized Incident is not over when last patient is transported Recovery must be managed aggressively Planning Section of incident command is responsible for initial recovery Typically the longest and most poorly managed part of the incident May require months to years 97

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 98 Goals in the Recovery Stage Most important goal is document collection Information can assist in Post Incident Analysis, cost recovery and tracking responder injuries or deaths Provide critical incident stress management for responders Collect and properly dispose of used medical supplies and biohazard waste from the incident 98

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 99 Post Incident Analysis Critical for operational review. Benefits include: Operational performance Organizational needs Procedure modification Additional training 99

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 100 Summary Critical Incident Management can place a heavy burden on responders Requires a coordinated response from all agencies involved Mass casualty incident is a critical incident, terrorist related or not Identifying critical stages will give the responder a better chance of dealing with the incident Six – Step response is a tool for incident management Humanitarian Assistance 100

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 101 9-11-01 101 9-11-01

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 102 TRIAGE 102

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 103 This lesson provides participants with methods of prioritizing care delivery in mass casualty situations. The decision- making process is explored with the goal being the maximum positive effect for the greatest number of patients. 2 Description

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 104 QUESTION 1 What is the meaning of Triage ? What is the basis of triage ?

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 105 QUESTION 2 In the MCMS, how many times do you triage and where ?

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 106 Describe the basic concepts of sorting and allocating treatment to patients in a triage situation Demonstrate the decision-making process in determining priority of care 3 Objectives Describe the basic concepts of sorting and allocating treatment to patients in a triage situation Demonstrate the decision-making process in determining priority of care 3

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 107 What is Triage ? French word meaning to “Sort” Utilized to identify treatment priorities Process by which a decision is made on which victim receives treatment and which does not Four basic priorities of patient treatment and transport 107

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 108 Priorities Highest Priority Patients that require immediate care and transportation Patients receive treatment at the scene for life threatening injuries First to be sent to available medical facilities 108 Intermediate Priority Patient treatment and transport can be delayed

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 109 Priorities Delayed or Low Priority Referred to as “walking wounded” Injuries require medical care at some point Treatment and transport can be delayed Monitor patients and reassess Lowest Priority Patients have either died or are near death If still alive they have suffered severe or serious injuries with little chance of survival When resources are limited, patients must be ignored 109

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 110 Initial Triage Officer Must size up situation Ensure safe approach and scene survey Activate additional resources o Number of victims o Size of the incident o Better off requesting more equipment and personnel than not enough 110

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 111 Simple Triage and Rapid Transport System This system focuses on three areas : 1. Respirations 2. Pulse Rate and Quality 3. Mental Status System requires first responders to have tags, ribbons or tape in four colors Priority One (Highest Priority ) Red – Immediate care : Life threatening injuries 111

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 112 Simple Triage and Rapid Transport System Priority Two (Intermediate Priority)  Yellow – Urgent care: delay treatment and transport up to one hour Priority Three (Delayed or Low Priority)  Green – Walking wounded: delay treatment and transport up to three hours 112

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 113 Simple Triage and Rapid Transport System Priority Four (Lowest Priority) Black – No care required: patient is dead or near death Hardest priority to deal with emotionally Necessary for others to survive 113

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 114 Simple Triage and Rapid Transport System First Step is to make an announcement for all people able to get up and walk to specific area Allows responder to focus on injured People who successfully move should be tagged “Green” Tell people to look out for each other and notify responders of any significant changes 114

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 115 Simple Triage and Rapid Transport System Second step is to conduct an orderly survey of remaining victims Decide how to move through area Perform quick assessment on each person and label or tag No more than 10 seconds per patient 115

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 116 Simple Triage and Rapid Transport System Correct life threatening : airway or breathing problem and profuse bleeding The objective is to: locate, identify and tag priority one patients who require immediate care and transportation 116

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 117 Respiration Assess breathing rate Greater than 30 per minute, patient is priority one and tagged red Less than 30 per minute, move on to assessing pulse and mental status 117 Patient Assessment

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 118 Not Breathing Quickly make sure mouth is clear Open airway with head tilt method During mass casualty incident, cervical spine immobilization may not be able to be done Open patients airway and position so it remains open If patient does not start to breath with simple airway maneuvers, tag priority four - black 118 Patient Assessment

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 119 Patient Assessment Pulse Rate and Quality Check radial pulse No more than 5 second check Pulse is weak or irregular - Red Tag Priority One If pulse is strong, move on to assess mental status If there is NO pulse, Black tag priority four 119

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 120 Patient Assessment Mental Status Breathing and pulse should have already been checked Have patient respond to simple commands such as “open your eyes” or “squeeze my hand” If patient can perform this function, is breathing and has a pulse, yellow tag priority two If patient is unresponsive and cannot follow simple commands, red tag priority one 120

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 121

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman

First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman 123 Thank You

Mass Casualty Management First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman.

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Mass Casualty Management First National Course on Public Health Emergency Management 12 – 23 March 2011. Muscat, Oman.

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