1. 27
Introduction to Multiple-Casualty Incidents, the Incident Command System, and Triage

2. 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
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3. 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).

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

5. 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?

6. INCIDENT COMMAND SYSTEM

7. 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.

8. 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.

9. 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.
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10. 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?

11. 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.

12. 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).
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13. 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?
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14. 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?

15. 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?

16. 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?

17. 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?

18. 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

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

20. 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.
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21. 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.

22. Examples of standard triage tags, front and back.

23. Start Triage Guide

24. 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.

25. START TRIAGE

26. 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.

27. 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.

29. 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).

30. 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).

31. 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).

32. 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).

33. 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).

34. 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).

35. 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).

36. 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.

37. 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.

38. 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.

39. 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.

40. SUMMARY

41. 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.

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

43. 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

44. Summary START System Simple Triage And Rapid Treatment
Uses respirations, perfusion, and mental status assessments to categorize patients into one of four treatment categories
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45. Summary
JumpSTART
Variation of START Triage System designed specifically for pediatric patients
Takes into account unique needs and presentation of pediatric patients
END SUMMARY