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

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

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

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

ICS Terminology Apparatus Command Command Post Communications Center Sector Staging Area

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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.

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

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

Primary vs. Secondary Triage Triage is a CONTINUOUS process

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

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

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

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

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

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

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

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

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

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

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

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