27 Introduction to Multiple-Casualty Incidents, the Incident Command System, and Triage

Objectives Define the common causes, criteria and the EMR role in a mass casualty incidents. Explain the ICS system Explain the principles of triage and the START triage system continued on next slide

Multiple-Casualty Incidents Multiple-Casualty Incident (MCI) Any emergency that involves multiple victims and overwhelms first responding units Multiple vehicles Earthquakes Floods Large explosions Building collapses Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

Multiple-casualty incidents require the resources of many agencies. First priority when arriving on scene is to notify of the MCI

Multiple-Casualty Incidents Low-Impact Incidents Manageable by local emergency personnel High-Impact Incidents Stresses local EMS, fire, and police resources Disaster, Terrorism Incidents Overwhelms regional emergency response resources Discussion Question: Do all terrorism incidents result in an MCI?

INCIDENT COMMAND SYSTEM

Incident Command System Model tool for command, control, coordination of resources at scene of large-scale emergency involving multiple agencies Procedures for organizing personnel, facilities, equipment, and communications Talking Point: The first formal incident command systems was formed as a result of a mandate from Congress to analyze the aftermath of a devastating series of wildfires in Southern California in the early 1970s.

Incident Command System Incident Commander Responsible for all aspects of an emergency response Modules in Incident Command System Command Operations Planning Logistics Finance Talking Point: The Incident Commander is the first person (could be the EMR) to arrive on scene until other, more qualified individuals, can assume command.

Incident Command System National Incident Management System Developed so that federal, state, local, and tribal resources can respond more efficiently to natural disasters and emergencies Teaching Tip: Remind students that FEMA offers several free online instructional courses pertaining to both the incident command system and NIMS. continued on next slide

Incident Command System National Incident Management System Teaches unified approach to incident management, standard command and management structures Emphasizes preparedness, mutual aid, resource management, common terminology among agencies SPAN and CONTROL for any supervisor is between 3 and 7 subordinates, and optimally does not exceed 5 subordinates Discussion Questions: How might common ICS terminology improve the management of a large-scale incident? Do the agencies you interact with (police, fire, EMS) use common terminology on a routine basis? How do operations on a daily basis affect how well events are managed during an unexpected large-scale incident?

Incident Command System The Medical Branch Branch of ICS Designates and coordinates three functional areas or groups Triage Treatment Transport Talking Point: The Medical Branch is a branch of ICS within which EMRs will commonly function. Each group (triage, treatment, and transport) has a group leader. The group leader reports to the medical group supervisor who reports to the medical branch director.

Incident Command System Triage Group Determines location of triage areas Conducts primary triage and sorts using local triage protocol The triage group leader sends resource requirements to the medical group supervisor. Sorts for movement of patients into treatment area for prehospital care Teaching Tip: Discuss the triage system used in your area (e.g., START, SMART). continued on next slide

Incident Command System Treatment Group Determines treatment group location Coordinates with triage group to move patients from triage to treatment areas Maintains communications with medical group supervisor Reassesses patients Conducting secondary triage to match patients with resources Directs movement to transport group Critical Thinking: Why is it important for the treatment group to have red, yellow, green, and black flags or tarps as markers? continued on next slide

Incident Command System Transport Group Coordinates transportation and accountability of victims to appropriate hospitals Designates ambulance staging area Works with treatment group to establish adequately sized, easily identifiable patient loading area Maintains communication with medical group supervisor Critical Thinking: How important are communications between treatment, transport, and staging to the overall facilitation of patient movement? Are procedures in place in your area to ensure that multiple agencies can communicate on one frequency?

Incident Command System Medical Staging Designates easily located site for resources to stage near incident area Determines whether staging will need to be relocated as situation evolves Discussion Questions: Why is it important that medical staging be at an easily located site? Are there procedures in place in your area that ensures communication of the staging area to responding units?

Think About It You are first on scene of a MVC involving 20 patients who have been ejected into the median after a bus overturned. Should you immediately begin triage? Do you have other immediate responsibilities?

Triage Method of sorting patients for care and transport based on severity of injuries or illnesses Used in hospital emergency departments, battlefields, or emergencies when there are multiple victims and limited medical resources Critical Thinking: Why is it important to sort and prioritize patients by condition when dealing with a large number of patients?

At the scene of a multiple-casualty incident, triage is the system used to identify victims who are most in need of immediate medical care. EMRs First on scene Must be able to triage patients and initiate care rapidly

Triage Serious medical or trauma related problems should be transported quickly. Heart attack Shock Major injuries Heat stroke

Triage START Triage System Simple Triage And Rapid Treatment Based on rapid assessment of patients using three criteria Respirations Perfusion (Peripheral pulses) Mental status 60 seconds or less per patient Do not begin treatment during triage. Teaching Tip: Discuss alternate Triage Systems if the one used in your area differs from START. continued on next slide

Triage START Triage System Patients classified into one of four categories and tagged with denoted color-coded tag indicator Immediate (red) Delayed (yellow) Minor (green) aka Hold Deceased (black) Teaching Tip: Distribute Triage Tags for each student to examine.

Examples of standard triage tags, front and back.

Start Triage Guide

Triage Primary triage Secondary triage When patient is first identified and triaged Secondary triage When patient is relocated to treatment area, they will immediately be re-triaged by treatment team. Class Activity: Using patient volunteers or manikins and the START system (or triage system used in your area); provide an MCI scenario and direct students to demonstrate the ability to properly categorize patients.

START TRIAGE

Triage JumpSTART Pediatric Triage System For patients from one to eight years of age Assessment categories for JumpSTART system are the same as for START system. Respirations Perfusion (peripheral pulses/cap refill) Mental status (AVPU) Class Activity: Using patient volunteers or manikins, and the JumpSTART system (or pediatric triage system used in your area); provide an MCI scenario involving children and direct students to demonstrate the ability to properly categorize patients.

Triage JumpSTART Pediatric Triage System The Smart tape is also Assessment categories for JumpSTART system are the same as for START system. Respirations Perfusion (peripheral pulses) Mental status (AVPU) The Smart tape is also a pediatric triage tool. Class Activity: Using patient volunteers or manikins, and the JumpSTART system (or pediatric triage system used in your area); provide an MCI scenario involving children and direct students to demonstrate the ability to properly categorize patients.

Multiple-Casualty Incidents Terrorism Role of EMS Personal Safety Provide Patient Care Initiate ICS Assist with Ops 1993 WTC Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

Multiple-Casualty Incidents Terrorism Safety Personal First priority Appropriate PPE Scene Size Up Time, Distance, Shielding for protection Emergency responders are targets Dangers of the secondary attack Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

Multiple-Casualty Incidents Terrorism Patient Keep patient informed of your actions Protect from further harm B-NICE Biological Nuclear Incendiary Chemical Explosive Greater good for any delay Treating terrorists/criminals Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

Multiple-Casualty Incidents Terrorism 360 degree Assessment Scene Size Up Outward signs and characteristics of terrorist incidents Outward signs of WMD incident Outward signs and protective actions of B-NICE weapons Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

Multiple-Casualty Incidents Terrorism Determine number of patients Use MCI protocols as necessary Additional Resources Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

Multiple-Casualty Incidents Terrorism EMS ops during WMD/terrorist incident All hazard safety approach Initial distance from scene Ongoing Scene size up/Secondary events Communicate with Law enforcement of an armed attack Initiate ICS Perimeter use to protect public and rescuers Escape Plan and mobilization Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

Multiple-Casualty Incidents Terrorism Care of Emergency Responders at WMD/terrorist incident Safe use of auto injectors for peers and self Safe disposal of auto injectors after use Discussion Question: Can a five person event and a fifty-person event both be considered an MCI? (MCI is also known as a Mass Casualty Incident).

Triage Patient Priority examples Immediate Airway and breathing difficulties Uncontrolled or severe bleeding Decreased mental status Patients with severe medical problems Shock Severe burns Class Activity: Using patient volunteers or manikins, and the JumpSTART system (or pediatric triage system used in your area); provide an MCI scenario involving children and direct students to demonstrate the ability to properly categorize patients.

Triage Patient Priority examples Delayed Hold, Minor Deceased Burns without airway problems Major or multiple bone/joint injuries Back injuries without spinal damage Hold, Minor Minor painful swollen deformed limbs Minor soft tissue injuries Deceased Class Activity: Using patient volunteers or manikins, and the JumpSTART system (or pediatric triage system used in your area); provide an MCI scenario involving children and direct students to demonstrate the ability to properly categorize patients.

Triage Tagging/Labeling International agreement on color-coding and priorities Immediate- Priority 1, P-1 Delayed- Priority 2, P-2 Hold, Minor- Priority 3, P-3 Deceased- Priority 0, P-0 Class Activity: Using patient volunteers or manikins, and the JumpSTART system (or pediatric triage system used in your area); provide an MCI scenario involving children and direct students to demonstrate the ability to properly categorize patients.

Triage Be aware of your mental and physical stress levels. Critical Incident Stress Debriefing (CISD) Point to Emphasize: CISD could be made available, but should not be mandated.

SUMMARY

Summary While rare, Multiple-Casualty Incidents (MCIs) can easily overwhelm first responding units at scene. First unit on scene notify of MCI and request additional resources Begin to establish command over incident.

Summary Triage Sorting of patients based on severity of injuries or illnesses Goal is to save as many patients as possible using available resources.

Summary Triage Categories Immediate Delayed Minor Deceased Most critical but salvageable patients Delayed Less critical but still in need of care Minor Ambulatory at scene Deceased No signs of life

Summary START System Simple Triage And Rapid Treatment Uses respirations, perfusion, and mental status assessments to categorize patients into one of four treatment categories continued on next slide

Summary JumpSTART Variation of START Triage System designed specifically for pediatric patients Takes into account unique needs and presentation of pediatric patients END SUMMARY