Mass Casualty Incidents Curtis Mattoon

Objectives n Be able to define an MCI n Be able to identify causes of an MCI n Demonstrate knowledge of the importance of scene safety n Demonstrate knowledge of Triage processes n Demonstrate knowledge of special hazards situations in MCI incidents

What is an MCI? n An MCI is technically defined as any incident involving more than one patient n Another definition is an incident that places a significant strain on the available resources n A more realistic definition is an incident where casualties outnumber the responders.

Causes of an MCI n Natural Disasters n Plane crashes n Bus/train accidents n Terrorism n Structure Collapse n Industrial Accidents n HAZMAT situations

“Curiosity did not kill the cat… … impulsivity did!”

Scene Safety 1. YOUR Safety n Priorities: 2. Your team’s safety 3. The safety of other ES personnel 4. Safety of any bystanders 5. The patient’s safety n Why? n What happens when you become a patient?

Scene Safety n Be sure to adhere to posted warnings n Listen to briefings, remember hazards mentioned n Always be alert for hazards that weren’t mentioned n Use all of your senses – not just sight. Which taught you that the grill was hot?

Keep your eyes open for hazards! n Spilled chemicals n Downed electrical wires n Unstable vehicles n Secondary explosions n Bloodborne pathogens n Violent persons n Too many people n Any scene you can’t control

Perceived hazards are only the “tip of the iceberg” Do I need backup? Police? Fire? EMS? HAZMAT? Advanced Rescue? Do I need backup? Police? Fire? EMS? HAZMAT? Advanced Rescue? Can I control this situation?Can I control this situation? Do I have the proper equipment and training to handle this situation?Do I have the proper equipment and training to handle this situation? Am I prepared to handle this incident if it deteriorates?Am I prepared to handle this incident if it deteriorates? What else can go wrong?

Do I need help? Don't be afraid to call for backup! Its better to cancel your backup en-route than request it when it’s too late.

PAY ATTENTION!!

Casualty Collection Point n As the name implies, the CCP is a point where casualties are collected for: n Triage n Treatment n Transportation

Triage n The process of evaluating the gravity of victim’s injuries, so that they can be treated properly. n Primary Triage n Secondary Triage n Developed by Military for use in situations where time is critical, there are limited resources, and/or the casualties outnumber the responders

Triage

Triage n “If you can walk, get up and move to the green area.” (‘Voice Triage’) n If they can walk and talk - they’re okay for now (walkie-talkies) n Sorts out Reds/Blacks/severe Yellows from Greens/Whites/minor Yellows n Save Yellow, Green, White for Secondary Triage n Continue with Primary Triage

Primary Triage n Mainly dealing with Reds and Blacks n Check pulse; if there is no pulse, they are Black n Check breathing; no breathing after one attempt to open airway? Black. n Sort out deceased from critical. n Move on to Secondary Triage

Significant MOI and Critical Conditions n Fall from >20 ft (or 2x-3x pt. height) n Vehicle Crash: –Greater than 40 mph –Ejected from vehicle –Rollover –Death in same passenger compartment –Motorcycle crash at >20 mph with separation of rider and bike –Prolonged extrication time of >20 minutes n Airway problems n Breathing problems n Circulation problems n Unconsciousness/Decreased LOC n Hypothermia n Others (Severe burns, abdominal complaints, several/major fx.)

Secondary Triage n These are your “walking wounded”. Many have already gone to the hospital, therefore there are fewer beds for the more critical patients. n Sort out based on criteria on Triage Tags n Depending on availability of resources, the treatment/transportation phases may be initiated at this point

5 n Patients with no injury n Refusals

n Transport not required n Have absolute last priority for transport if they want to be taken to a hospital to be checked out n Generally will not be transported in a large- scale incident, but may be transported in a smaller incident, such as an MVC.

n Minor fractures n Minor controlled injuries n People that can walk (Why waste stretchers and personnel if they can walk?) n If they can walk and talk (walkie-talkies) - they’re okay for now. Assign stretchers and cots to those that need them. n Re-assign greens after the initial assessment (i.e. assign stretchers and cots, then move green’s to their proper area.)

n These are your “walking wounded”. Most have left the scene after the initial incident to seek medical attention for themselves. n Therefore, the hospitals are over-staffed with them already - we do not want to send them to the hospital and take beds from the more critically injured people.

n Head injury - conscious n Loss of distal pulse - extremity n Severe burns n Unconscious n Spinal injuries n Moderate blood loss

n Receive “prompt” transport, when and if it is available n This group tends to either stabilize and get moved to green, or they get worse and go to red

n Unconscious n Open chest or abdominal wounds n Severe medical conditions n Uncorrected resp. problems n Severe/uncontrolled bleeding n Severe shock (hypoperfusion) n Several major fractures n Resp. burns

n Have first priority transport n High percentage end up black

n Definitive signs of death: –Rigor Mortis –Dependent Lividity –Obvious mortal wounds (major open head trauma) –Purification n Pulseless / Apenic (Cardiac arrest) n Not breathing after attempting to open airway and ventilate once

While no transport is given, action should be taken to place fatalities away from the triage area, at least out of view of the public and other patients. Reasonable measures to ensure privacy should be taken if the incident is expected to last for any period of time, or it is a large-scale incident.

Contaminated Personnel n If a disaster situation involves radiation or other hazardous materials, a special category goes into effect. n This category takes priority over any other - requiring rapid containment and decontamination. n They must be moved away from other patients, emergency personnel, hospitals, etc. so that they do not cause further contamination

Treatment n Typically left up to EMS personnel. n If there is time, equipment, etc on scene, treatment may be initiated on scene. n Otherwise, treatment will be en-route, or at a medical facility

Treatment Area Considerations n Patients should be lined up “head-to-toe” in an alternating fashion. n Adequate space between stretchers to work around, including room to pick up and move patients. n Easy communication between workers in each area, including between areas. n Easy access from treatment area to transportation area n Easy access from one triage category to the next, in case of pt. status changes.

Transportation n Move patients according to priority (Red, Yellow, Green, White, Black) n Trans. tags work like firefighter’s accountability tags

Transportation n In its own way, transportation is yet another breakdown of the concept of triage. n Where should the patient go? That depends: –The specific illness or injury –Severity of the illness or injury –Availability of local resources at the time –Local rules and protocols

Transportation n Sending the patient to the right care facility is almost as important as the treatment they will receive –Trauma center? –Burn center? –Pediatric care facility? – Special equipment needed? –Life flight / StatMedevac transport? Do we need an LZ?

Final Notes n Remember to keep the morgue (Black) area away and out of sight from the treatment area. n Keep in mind the mental status of the people you will be dealing with. (and I’m not talking about the ES personnel!) n All patients must be accounted for, even if they are not injured! (Triage tags)

Special Considerations for Terrorist Incidents n Be aware of NBC conditions. Proper PPE is required, such as HAZMAT suits, respirators, SCBA’s, etc. n Many suicide bombers are injected with highly infectious diseases such as HIV, Hepatitis, etc. before they set out on their mission.

Special Considerations for Natural Disasters n Disasters such as hurricanes, tornadoes, floods, etc. can cause hazmat situations due to overturned trucks, gasoline spills, chemical exposure (i.e. fertilizers, insecticides, etc.) n These chemicals can cause other hazards, by causing explosions, fires, etc.

Special Considerations... n Make sure you have the proper training and equipment necessary to safely accomplish the task n BE SAFE! n Don’t be afraid to call in for assistance

Resources n HAZMAT, Fire suppression, etc. n Remember, there is now a HAZMAT situation in addition to the already-existing MCI, therefore we need more personnel. n Do we take these personnel away from triage and assign them to the HAZMAT situation-for decontamination of patients? Or should we call in for more backup? How long will that take? How many people will die in that time?

More Information n HAZMAT sources –NFPA standard #479 –OSHA standard # –FEMA guidelines for coping with HAZMAT situations –2000 Emergency Response Guidebook » /eastern.htm /eastern.htmhttp://hazmat.dot.gov/erg2004 /eastern.htm –Jane’s Series »Chem.-Bio »Pre-hospital »Others

Summary n Be able to define an MCI n Be able to identify causes of an MCI n Demonstrate knowledge of the importance of scene safety n Demonstrate knowledge of Triage processes n Demonstrate knowledge of special hazards situations in MCI incidents

Questions?