1. 30 Special Operations Instructor Preparation
Always prepare for lectures by reading the text and reviewing presentations.
As an instructor, it is very important that you familiarize yourself with the information in the text and the presentation. You must be familiar with the flow of the slides in order to advance through the lecture without getting ahead of the presentation.
Be prepared to engage your students by asking them questions and encouraging creative discussion.

2. OBJECTIVES DIRECTORY
Objectives for this chapter can be referenced on pages 726 and 727 of your textbook.
The objectives for this chapter meet and exceed the National EMS Education Standards for the EMR level. Briefly introduce the objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

3. TOPICS Hazardous Materials Multiple Casualty Incidents (MCI) Triage
Extrication
Aeromedical Rescue
Planning Your Time
Plan 85 minutes for this chapter as follows:
Hazardous Materials (20 minutes)
Multiple Casualty Incidents (MCI) (10 minutes)
Triage (20 minutes)
Extrication (20 minutes)
Aeromedical Rescue (15 minutes)
Note: The total teaching time recommended is offered as a guideline only.

4. INTRODUCTION Situations requiring special operations Hazmat
Multiple casualty incident
Aeromedical evacuation
Talking Points
A special operations situation is any incident where you may encounter hazardous materials, multiple casualties, or critical patients who require aeromedical evacuation to a trauma center for treatment.
Many times you will face a scene, such as a severe motor vehicle collision, that will require all three of these services.

5. THE CALL Dispatch Called to busy intersection for a MVC
18-wheeler tanker truck struck minivan
Heavy damage to the minivan
You size up the scene from a safe distance
Tanker is intact with no damage
Placard reveals truck is carrying gasoline
You ask dispatch for fire and hazmat
You move upwind and uphill
Case Study Discussion
What should you do if there is gasoline leaking from the truck?
Is the action taken thus far appropriate?

6. Hazardous Materials Teaching Time 20 minutes Teaching Tips
Invite a hazardous materials technician to class. Have him discuss his role and the role of his specialized team.
Demonstrate that not all hazardous materials are found in tanker trucks. Visit the janitor’s closet and review material safety data sheets. Review any NFPA 704 placards in your area.
Hand out Emergency Response Guidebooks. Discuss the placard system.
Describe a hazardous materials response. Discuss “hot,” “warm,” and “cold” zones. Use real examples if possible.
Discussion Question
Discuss what hazardous materials you might find in your immediate area. What resources might you need to respond to an incident involving these hazards?

7. Talking Points
We come across hazardous materials every day of our lives. The DOT regulates not only how hazardous materials are transported, but also how they are reported, documented, and identified. This system is designed to provide those who work with or near the hazardous material warning of the dangers.
The established standards are referred to as hazardous materials communication (HazCom) and they define the requirements for shipping papers, documentation, labeling, and placarding of vehicles carrying hazardous materials.
Points to Emphasize
Hazardous material is defined as “any substance or material incident in a form which poses an unreasonable risk to health, safety, and property when transported in commerce.”
The DOT placard system is a standardized labeling system used when transporting hazardous materials.
Use the DOT Emergency Response Guidebook to identify and reference information on hazardous materials labeled with the DOT placard system.
The NFPA 704 uses numbers and colors on a sign to indicate the basic hazards of a specific material being stored.
NFPA 704 placards display information on a substance’s health hazard, flammability hazard, reactivity hazard, and any other special hazards.
Hazardous materials incidents are divided into “hot,” “warm,” and “cold” zones. Never enter a warm or hot zone without specialized training and equipment.

8. U.S. Department of Transportation Placard System
Materials classified into nine categories
Four-digit identification number
Additional sources of information
Shipping papers
Bills of lading
Placards are not always displayed
Talking Points
A diamond-shaped sign called a placard is required when hazardous materials are being transported.
The DOT classifies materials into nine classes. Numbers on the placard may show the division of the class of hazardous material.
Placards have a four-digit number. You can reference the placard and ID number in the DOT Emergency Response Guidebook. There you will find information on the material and on safety measures in the event of a spill or release.
Obtain additional information from invoices, shipping papers, and bills of lading. Often these documents are stored in the wheelhouse of a water-going vessel, in a truck cab, or with the engineer of a train.
Remember that a hazardous material may not have a placard if it does not meet the weight or class requirements for displaying one. Always err on the side of caution when approaching any scene.
Discussion Question
Describe how a hazardous material might be labeled, using the DOT placard system and the NFPA 704 system. What information might be obtained by examining both types of warning devices?

9. Example of an NFPA 704 Placard
Talking Points
The National Fire Protection Association (NFPA) has developed a system to alert emergency responders to the characteristics of hazardous materials stored in stationary tanks and facilities. This system known as the NFPA 704 uses a combination of colors and numbers to indicate the basic hazards of a specific material present.
The NFPA is diamond shaped and divided into four quadrants:
Left quadrant (blue)—Contains a numerical rating of the substance’s health hazard on a 0–4 scale.
Top quadrant (red)—Contains substance’s flammability rating on a 0–4 scale.
Right quadrant (yellow)—Contains the substance reactivity, or its susceptibility to release energy. This quadrant is also rated from 0-4.
Bottom quadrant (white)—Contains information about any special hazards that may apply using three possible codes: OXY (oxidizer), W (reacts with water), or tri-blade “propeller” symbol (radioactive).
Knowledge Application
Describe a NFPA 704 warning placard and create a response scenario. Have students discuss response strategies.

10. Material Safety Data Sheets
Employers are required to maintain current MSDS
Attempt to retrieve MSDS if it is safe to do so
Talking Points
Employers are required to maintain a current material safety data sheet (MSDS) from the manufacturer for every hazardous chemical in the workplace.
Attempt to retrieve the MSDS if it safe to do so. If you are able to retrieve the MSDS, give it to EMS personnel who will be transporting the patient to the hospital.
Class Activity
Have a hazmat scavenger hunt. Tour the campus or area where you hold your class. Identify hazardous materials (using MSDS sheets, placards, and so on) and discuss response strategies.
Critical Thinking Discussion
How might you identify a hazardous materials incident without placards or warning signs? What warning signs might indicate that a hazardous material is involved?

11. Hazardous Materials Incident Safety
Zones of a hazmat incident
Hot zone
Warm zone
Cold zone
Talking Points
A hazmat incident is divided into three zones:
Hot zone—Area directly around the incident where hazardous materials have breeched their container.
Warm zone—Area surrounding the hot zone. Hazmat technicians dress in level A or B suits to prepare to enter the hot zone. These suits are designed to resist chemicals and incorporate self-contained breathing apparatus. Decontamination of the patient also occurs here.
Cold zone—Area surrounding the warm zone. No contaminants are present and no special equipment is needed. Decontaminated patients are brought to the cold zone for triage and transport.
Only specially trained hazmat technicians should handle incidents involving hazardous materials.
Knowledge Application
Use photographs of a hazardous materials incident (or use a tabletop simulation). Have students identify the hot, warm, and cold zones.

12. THE RESPONSE Two additional fire companies arrive and secure the scene
Chief of the fire company designates you as the triage officer
Driver of the truck is holding a bill of lading as you approach
He tells you the minivan ran a red light, and he hit it
Several people in the minivan need help
Knowledge Application
Display pictures of DOT hazardous materials placards. Have groups of students use the DOT Emergency Response Guidebook to identify the hazard and to create response plans. Discuss.

13. THE RESPONSE Six patients are in the minivan The driver is pinned
You realize that you have an MCI and call for three additional units
You begin to use the START triage system to sort the patients
Case Study Discussion
Read on to understand the START triage system. How will you determine which patients are a priority for immediate care?
Considering this scenario, what additional resources are necessary to effectively treat the patients?

14. Multiple Casualty Incidents (MCI)
Teaching Time
10 minutes
Points to Emphasize
A multiple casualty incident (MCI) is an event that overwhelms the resources of the responders at the scene.
An MCI might mean a large number of patients, but it might also mean a small number. This classification truly depends on the immediate resources that are (or are not) available.
Teaching Tips
Use real examples of multiple casualty incidents (MCIs). Discuss small incidents, such as multiple vehicle collisions (MVCs), and compare them to large-scale incidents.
Discuss local resources and describe how certain situations might overwhelm them to create an MCI.
Discussion Questions
Define an MCI. Describe how both a five-person situation and a fifty-person situation could both be considered MCIs.
Consider responding to an multiple vehicle collision with four patients involved. How might this situation be considered an MCI?
Critical Thinking Discussion
You respond by yourself to a serious motor vehicle crash. You find two patients: One is bleeding severely from a neck wound, and the other is complaining of head pain. Which patient do you treat first? Is this situation an MCI?

15. Multiple Casualty Incident
Incident that overwhelms the resources of the responders on scene
Work as a team
Quickly and effectively triage, treat, and transport patients
Talking Points
MCIs bring to mind terrorist attacks, severe storms, and large scale disasters. By definition an MCI is any incident that overwhelms the resources of the responders on scene. A simple MVC involving a school bus full of children can quickly tax the resources of any EMS system. Effective management of an MCI is achieved by using the incident command system (ICS) model.
No matter what your role is on an MCI, work as a team to deliver the most care to the largest number of patients. The goal to managing an MCI is quickly and effectively triaging, providing emergency care, and transporting all patients to the most appropriate medical facilities.
Knowledge Application
Use programmed patients to create small-scale MCIs (for example, incidents involving four or five patients). Train students to think in the framework of an MCI, even in smaller situations.
Discuss how an EMR might begin to build an ICS structure to deal with an MCI. What would be the initial components?

16. Triage Teaching Time 20 minutes Teaching Tips
If an EMR is involved in an ICS structure, it likely will be in the triage section. As such, students should have at least a basic understanding of triage concepts.
START and JumpSTART triage systems are simple, but they require practice. Be sure to provide adequate review time.
Class Activity
Have a class MCI hand out injury cards to students and take turns practicing triage.

17. Points to Emphasize
Triage is the sorting of patients by the severity of their injuries so that the most severely injured patients receive treatment first. The standard system used nationally is the Simple Triage and Rapid Treatment (START) triage system.
START triage assigns a triage category based on an assessment of breathing, perfusion, and mental status.
Discussion Questions
Discuss why triage is important in an MCI situation. What does proper triage achieve?
Describe how you would use the START and/or the JumpSTART triage system to sort patients at an MCI.

18. Examples of the Use of START Triage
Simple Triage and Rapid Treatment (START)
Accomplished with no equipment and minimal training
Jump START triage for pediatric patients
Talking Points
The Department of Homeland Security chose the START triage system to be the national model and incorporated it into the National Incident Management System (NIMS). Utilize the START and JumpSTART triage systems to do the most good for the most patients.
The START triage system can be accomplished with no equipment and minimal training. The START triage system is designed for use on adult patients and the JumpSTART triage system on pediatric patients. Patients are tagged by the triage officer on scene.
Begin with sorting the “walking wounded” to secondary triage; ask all patients who can walk to come to a designated area. Be sure other EMRs are there to provide care and begin secondary triage.
The START triage system differs from the normal primary assessment. Assess breathing and then move to perfusion and finally mental status.
Knowledge Application
Work in small groups. Write injury information on balloons and create MCI scenarios. Have teams simulate response and triage.
Use triage tags routinely. Have students triage patients even in scenarios that would not be considered an MCI.

19. Section Opener: Patient #2—A lot of patients
Recall the Section 7 Opener discussion on pages of your textbook on the types of patients you may encounter.
Critical Thinking Discussion
Considering the scene pictured in the slide, please discuss how you would utilize the START triage system to prioritize the patients.

20. JumpSTART System Designed for use on pediatric patients
Allows for rescue breaths to “jump start” breathing in pediatric MCI patients
Talking Points
JumpSTART triage is designed for pediatric patients ages 1–8 and differs slightly from START for the adult patient.
Airway problems are the primary cause of cardiac arrest in pediatric patients, so the JumpSTART system allows the rescuer to provide rescue breaths to the child to “jump start” breathing.
Critical Thinking Discussion
You are the first and only immediate responder to an MCI involving twenty patients. As you arrive, you see patients strewn all over the scene. Should you immediately begin triage, or might you have other more immediate responsibilities? If so, what would those responsibilities be?

21. JumpSTART System
If patient is not breathing after airway opening, check for a peripheral pulse.
If there is no pulse, tag the patient deceased/nonsalvageable.
Talking Point
Review the assessment steps outlined on the slide.

22. JumpSTART System
If there is a peripheral pulse, give five ventilations.
If apnea persists, tag the patient as deceased/nonsalvageable and move on.
If breathing resumes after the “jump start,” tag the patient as immediate
Talking Point
Review the assessment steps as outlined on the slide.

23. Extrication Teaching Time 20 minutes Teaching Tips
Invite an extrication technician to class to discuss the process and tools of extrication.
Discuss safety and appropriate PPE for extrication.
Class Activity
Attend an extrication demonstration. Use appropriate PPE and train with a local fire department or extrication squad.
Critical Thinking Discussion
You and your partner witness a motor vehicle collision. As you approach, you see that the vehicle is on fire. The patient is awake and yells that the door is jammed. Your partner notes that you probably could just break the window and extricate the patient, but you do not have PPE. Discuss your immediate actions.

24. Photo: © Ray Kemp/911 Imaging
Points to Emphasize
Safety is always the most important priority. Always use proper PPE in extrication situations.
Extrication is the process of disentangling a patient from wreckage or debris so that care and transport can be rendered.
Extrication from a vehicle involves stabilizing the vehicle and gaining access to the patient inside. Access may be gained simply (as in unlocking a door) or technically (as in using a hydraulic tool to remove the roof).
If you must break a window to gain access, use a center punch and break the window on the side of the car that is opposite from the patient.
Discussion Questions
Describe how a vehicle might be stabilized.
Describe a scenario in which extrication might be necessary. Discuss local extrication resources.
Describe methods to gain access to a patient in an extrication scenario. Discuss simple and technical methods.
Photo: © Ray Kemp/911 Imaging

25. Vehicle Stabilization
Personal protective equipment (PPE)
Pinned
Entrapment
Cribbing
Talking Points
While extrication is taking place, wear personal protective equipment including helmet, gloves, NFPA-approved coveralls or firefighter’s coat and pants (bunker gear), and steel-toed boots.
First determine if the patient is truly pinned or just entrapped.
Pinned means that a part of the patient’s body is entangled in the wreckage. You must remove the wreckage before removing the patient.
Entrapment means that the patient is free inside of the vehicle, but due to the damage to the vehicle the patient cannot be accessed or safely removed from the wreckage.
Stabilize unstable vehicles prior to extrication using cribbing. Cribbing material is often made from wood blocks of treated lumber cut into various shapes and sizes. Place cribbing under the vehicle between the frame and the ground to provide stability. Once the vehicle is stabilized, the true work of extrication can begin.
Knowledge Application
Use a programmed patient and a vehicle to simulate motor vehicle crash scenarios. Discuss stabilization and simple extrication.

26. Gaining Access “Try before you pry” Center punch
Halligan tool or pry bar
Hydraulic tools
Only done by qualified personnel
Talking Points
Sometimes accessing a patient is as easy as opening a door of the vehicle. Try all of the doors of the vehicle before resorting to tools. “Try before you pry” should be practiced on every call when access is initially thought to be prevented by damage to the vehicle.
If you find a patient who is unresponsive or unable to communicate effectively with you and the car doors are locked, use a center punch, a spring-loaded punch used to break the glass of a car window. Once the window is broken, clear away the glass taking care not to cut yourself. Unlock the car door to access the patient.
Occasionally damage to the vehicle will be too extensive to allow you to open a door. In those cases, use a Halligan tool or pry bar to force doors open and gain access to the patient.
Hydraulic extrication tools commonly called “jaws of life” are used in place of manual pry bars and other tools to access patients. These hydraulic tools are designed to easily cut most metal found in today’s vehicles and give the rescuer the advantage of both speed and power when it comes to extrication.
Patient extrication should only be performed by qualified extrication personnel as serious injury can result from anyone else operating the equipment.
Knowledge Application
Review and don PPE associated with extrication.

27. Aeromedical Rescue Teaching Time 15 minutes Teaching Tips
Contact your local aeromedical transport service for assistance in teaching this lesson.
Discuss local protocol for activation of aeromedical transport.
Discuss the risks of aeromedical transport. Review crashes and describe a cost-benefit analysis in choosing air transport.
Tour the local aeromedical service. Review aircraft safety procedures.
Discussion Questions
Describe the benefits and risks of aeromedical transport. Discuss how an EMR would make the decision to call for a helicopter.
Discuss common indications for aeromedical transport. Review local protocols and regulations regarding aeromedical activation.
Describe an appropriate landing zone (LZ) for a helicopter. Describe how you would identify the LZ.

28. Talking Points
The use of helicopters for the transport of critical patients from a scene owes its origins to the Korean War. Soldiers were flown to MASH units to receive surgical care for their wounds. This use of aeromedical transport greatly decreased the casualty rates as compared to World War II. This led to the development of helicopter transport for civilian use, improving the outcome of trauma patients in modern times.
Points to Emphasize
Aeromedical transport can be dangerous. To choose this mode of transport, the benefit to the patient must outweigh the risk.
A patient who may require immediate lifesaving surgical intervention could be considered a candidate for aeromedical transport.
An appropriate landing zone (LZ) for a helicopter should be a flat area, free of utility lines, of at least 100 by 100 feet. The slope of an LZ should not be greater than eight degrees.
Never approach the aircraft from the rear around the tail rotor.

29. Indications for Aeromedical Transport
Head trauma
Spinal trauma
Chest trauma
Abdominal trauma
Heart attack
Stroke
Talking Points
Using a helicopter to transport a patient to a trauma center does have risks to the patient and the flight crew.
Weigh the risks versus the benefit for the patient. Patients who should be considered for aeromedical transport include those with head trauma, spinal trauma, chest trauma, abdominal trauma, heart attack, and stroke.
Knowledge Application
Describe various scenarios. Have students discuss the most appropriate mode of transport for each. Include an aeromedical cost-benefit discussion.
Critical Thinking Discussion
Discuss local protocol for activating aeromedical transport. Is it appropriate in your area for an EMR to call for a helicopter?

30. Landing Zone (LZ) Flat area 100 feet by 100 feet
Slope not greater than eight degrees
Free of utility lines
Radio exact location and LZ description
Terrain
Landmarks
Major hazards
Talking Points
When choosing a landing zone (LZ), find a site at least 100 feet by 100 feet. The best choices are large parking lots free of lampposts.
The slope of the LZ should not be greater than eight degrees, allowing for clearance of the rotors of the aircraft and the ground.
Be sure that the area is free of utility lines. If utility lines are present, clearly mark their location with lighting or a piece of apparatus. Keep in mind that lines are very difficult to see from the air as they blend in with the ground beneath them.
Radio the exact location of the LZ and include information about:
Terrain—“Your LZ is a large field with several large oak trees to the south of the field.”
Landmarks—“There is a large water tower to the west of the LZ. The LZ is marked with fire apparatus to either side of the LZ.”
Major hazards—“There are utility lines marked with the tanker to the top of the LZ. Three police cars with blue lights mark the LZ.”
Knowledge Application
Review the area around your classroom. Choose and mark a landing zone. Simulate relaying information to an incoming helicopter.

31. Approaching the Aircraft
Always approach from the front with direct view of the pilot
Never approach from the rear around the tail rotor
Talking Points
Once the aircraft has landed, approach the aircraft from the front in direct view of the pilot to assist with loading gear or the patient.
Never approach the aircraft from the rear where the tail rotor is located.
Class Activity
Tour a local aeromedical service. Review aircraft safety procedures.

32. TRANSITION
All patients are extricated except for the driver who remains pinned
You manually stabilize the cervical spine as the team prepares for extrication
The vehicle is stabilized
The windshield is removed and the posts holding the roof are cut
The roof is flapped back to allow access

33. TRANSITION The dashboard is rolled back and the patient is freed
The patient is moved onto a long backboard and secured
She is moved to an ambulance for transport to the LZ
Paramedics ask you to begin BVM ventilations

34. TRANSITION
Paramedics place an advanced airway into the patient’s trachea
You arrive at the LZ, and the paramedic gives report to the flight crew via radio
The aircraft lands 200 feet from the ambulance
You assist in loading the patient as the aircraft is still running
You watch as the helicopter flies off
Case Study Discussion
Why would you choose to have this patient flown to a trauma center?
What are the advantages and disadvantages of aeromedical evacuation?
In addition to the preceding questions, consider how the ICS allows all of the various resources to work together. How do EMRs fit within this structure?

35. REVIEW Define the following terms: Placard Material safety data sheet
Multiple casualty incident
START system
Extrication
Pinned
Entrapment
Aeromedical transport
Definitions
Placard—Diamond-shaped sign placed on certain containers when hazardous materials are being transported
Material safety data sheet—Manufacturer’s information about the chemicals contained in the product
Multiple casualty incident—Event that overwhelms the resources of the responders on scene
Simple Triage and Rapid Treatment (START) system—Triage system designed to be accomplished with no equipment and minimal training
Extrication—Process of disentangling a patient from wreckage or debris that prevents access to render care and transport
Pinned—Part of the patient’s body is entangled in the wreckage and will require removal of the wreckage before the patient can be removed
Entrapment—Patient is free inside the vehicle but cannot be accessed due to damage to the vehicle
Aeromedical transport—Use of a helicopter to provide quick transport of a critically ill or injured patient to a trauma center

36. STOP, REVIEW, REMEMBER The U.S. DOT defines a hazardous material as:
a poison or chemical that could harm you.
any substance or material in a form that poses an unreasonable risk to health.
a substance that must be marked with a placard to be shipped or stored.
a poison or chemical that is not harmful to you.
Answer: B
Have students justify their answers.

37. STOP, REVIEW, REMEMBER
The National Fire Protection 704 system is used to mark buildings for _____ with a multicolored diamond sign.
occupancy
hazards
flammable materials
chemical materials
Answer: B
Have students justify their answers.

38. STOP, REVIEW, REMEMBER The term triage means to: separate. sort.
categorize.
count.
Answer: B
Have students justify their answers.

39. STOP, REVIEW, REMEMBER
The START triage system begins with an assessment of:
level of consciousness.
airway.
breathing.
pulse.
Answer: C
Have students justify their answers.

40. REVIEW
Discussion
Describe common locations and situations in which hazardous materials are encountered.
Discuss the sources of information on hazardous materials.
Discuss what an appropriate landing zone should include.
Discussion Answers
Have students justify their answers.
Examples include fires, motor vehicle collisions, train derailments, and plane crashes.
Sources include placards, material safety data sheets, and the National Fire Protection Agency 704.
An appropriate landing zone should include a flat area 100 X 100 feet, a slope not greater than eight degrees, and an area free of utility lines. Radio the exact location and landing zone description (terrain, landmarks, major hazards).