Ch47 Incident Management and Multiple-Casualty Incidents.docx

Chapter 47 Incident Management and Multiple-Casualty Incidents Unit Summary The paramedic has operational roles and responsibilities in establishing command under the incident command system (ICS) in order to ensure patient, public, and personnel safety. Upon completion of this chapter and related course assignments, students will be able to explain the purpose of medical incident command in the ICS and describe the major components of the National Incident Management System (NIMS). They will be able to describe how START and JumpSTART triage methods are performed and discuss triage principles, resource management, and the need for re-triage. Students will also be able to discuss the specific conditions that define a situation as a multiple casualty incident (MCI), including the role and purpose of critical incident stress management (CISM) in an MCI. National EMS Education Standard Competencies EMS Operations Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety. Incident Management Establish and work within the incident management system. (pp 2200-2207) Multiple-Casualty Incidents Triage principles (pp 2209-2213) Resource management (pp 2207-2208) Triage (pp 2209-2213) • Performing (pp 2209-2213) • Retriage (pp 2210-2212) • Destination decisions (p 2213) • Post-traumatic and cumulative stress (p 2213) Knowledge Objectives Explain the federal requirements for the minimum entry-level certifications of paramedics and other emergency personnel in incident command system training. (p 2199) Describe the National Incident Management System (NIMS) and its major components. (pp 2199-2200) Describe the purpose of the incident command system (ICS) and its organizational structure, and explain the role of EMS response within it. (pp 2200-2203) Describe how the ICS assists the EMS in ensuring both personal safety and the safety of bystanders, health care professionals, and patients during an emergency. (pp 2203-2205) Describe the role of the paramedic in establishing command under the ICS. (p 2204) Explain the purpose of medical incident command within the incident management system, and describe its organizational structure within ICS. (pp 2205-2207) Describe the specific conditions that would define a situation as a multiple-casualty incident (MCI), and give some examples. (pp 2207-2208) Describe what occurs during primary and secondary triage, how the four triage categories are assigned to patients on the scene, and how destination decisions regarding triaged patients are made. (pp 2209-2213) Describe how the START and JumpSTART triage methods are performed. (pp 2211-2212) Explain the need for retriaging of patients during multiple-casualty incidents. (pp 2210-2212) Describe the purpose of critical incident stress management. (p 2213) Skills Objectives Demonstrate how to perform triage based on a fictitious scenario that involves a multiple-casualty incident. (pp 2199, 2201, 2204, 2210, 2214-2216) Readings and Preparation • Review all instructional materials including Chapter 47 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials. • Visit the Federal Emergency Management Agency (FEMA) web site for information to direct students as they review the National Incident Management System: http://www.fema.gov/national-incident-management-system • Several articles available on the EMS World web site provide information and examples surrounding multiple casualty incidents. “Mass Casualty Incident Management” by R. Duckworth: http://www.emsworld.com/article/10616426/mass-casualty-incident-management-part-1 “Kid Care During Disaster Response” by J. Busch: http://www.emsworld.com/article/10725221/caring-for-kids-when-disaster-strikes-qa-with-lou-romig-md-faap-facep “EMS Consequence Management: The ICS Elephant in the Room” by J. H. Logan: http://www.emsworld.com/article/10318995/ems-consequence-management-the-ics-elephant-in-the-room Support Materials • Lecture PowerPoint presentation • Case Study PowerPoint presentation • The FEMA web site can be used as a resource to assist students in understanding how comprehensive the NIMS system is in the management of disasters and the impact it has had on multiple agency responses. Direct students to the information sheets, brochures, or frequently asked questions located on the web site: http://www.fema.gov/national-incident-management-system • Obtain copies of your local EMS agency’s hazardous response or MCI plan. Make sure that students are able to familiarize themselves with their role if this occurs during a clinical assignment. Enhancements • Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at http://www.paramedic.emszone.com for online activities. • Contact the closest fire department that has a hazardous response team. Ask if one of the members is available to speak to the class on the role of EMS in a hazardous response. • Contact the local fire department to determine if there is a CISM certified professional available in your area. If so, contact them about sending someone to speak to the class about the role of CISM after an MCI. Content connections: Students should be encouraged to review the importance of personal well-being as outlined in Chapter 2 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition. MCI events can bring additional stress and it is essential that the paramedic have healthy ways to deal with these incidents. Remind students that NIMS has impacted how EMS communicates with other public safety agencies by implementing a ‘plain English’ radio language and discontinuation of use of codes. Encourage them to discuss whether the EMS agency they work with has become NIMS compliant. Cultural considerations: Pediatric and elderly patients are particularly vulnerable during an MCI and may require additional considerations for appropriate triage and transport. Remind students to take this into consideration when assessing these patients. Patients who do not speak English may pose a challenge in an MCI if access to a translator is not immediately available. Encourage students to consider the population of the community in which they will be working and what resources are available to assist with bridging these potential communication barriers. Have students identify technological resources that may be beneficial in an MCI environment. Teaching Tips • While some students may have completed a Hazardous Materials Awareness course, do not assume that all students are aware of the proper procedures for responding to a hazardous materials incident. Consider locating a local HazMat Awareness class offered by area fire departments and encourage students to complete the course. • Survey your students to determine if they have completed the FEMA ICS 100 and ICS 700 courses that are required by most states for emergency personnel. If they have not completed these courses, encourage students to visit the website to register and complete these online: training.fema.gov/is/nims.asp Unit Activities Writing activities: Most students will have heard about large-scale MCI events that have involved multiple agencies and large numbers of fatalities. Assign an event for students to research and identify the role that EMS played in the management of the event. Ask that students consider long-term effects of the event on responding providers. They should submit a paper summarizing their findings. Student presentations: Assign students a hazardous material to research and identify its classification, threat to humans, threat to the environment, type of response and control efforts, and long-term effects. Ask that students present their findings in a brief report to the class. Group activities: Assign three to five students to a group. Provide each group with a START or JumpSTART triage tag. Ask that they identify types of patients and conditions that would be assigned to each designation. Encourage them to discuss how they would deal with assigning a patient to the expectant category. Have groups consider the role of CISM in dealing with the after effects of this responsibility. Visual thinking: Assign three to five students to a group and provide them with a poster board or large sheet of newsprint. Have each group construct a visual representation of the ICS structure for a large-scale event. Have them identify each sector and officer, as well responsibilities, that will take part in the event. When completed, have each group discuss which areas EMS might play a role and why. Pre-Lecture You are the Medic “You are the Medic” is a progressive case study that encourages critical-thinking skills. Instructor Directions Direct students to read the “You are the Medic” scenario found throughout Chapter 47. • You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. • You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. Multiple-casualty incidents (MCIs) and disasters can be overwhelming due to the amount of patients you are faced with and the lack of specialized supplies or personnel. B. It is important to respond to an MCI systematically, using the principles of the incident command system (ICS). 1. Paramedics normally work under the EMS/medical branch under an ICS. a. May be asked to function in other areas C. The National Incident Management System was created to encourage well-organized emergency response from the regional, state, and national levels. 1. Homeland Security Presidential Directive (HSPD-5) requires students to: a. Complete entry-level certifications in FEMA IS-100 and IS-700 training b. Have a complete understanding of NIMS II. The NIMS A. The National Incident Management System (NIMS) was implemented in 2004 to provide a consistent nationwide template to promote effective and efficient emergency response. 1. Used to prepare for, prevent, respond to, and recover from domestic incidents a. Regardless of: i. Cause ii. Size iii. Complexity 2. Flexibility, standardization, and interoperability are key principles of NIMS. a. The organizational structure must flexibly and quickly adapt for use in any type of incident. b. NIMS provides standardization in terminology, resource classification, personal training, and certification. c. Interoperability allows agencies of different types or from different jurisdictions to communicate with each other. B. Major components of NIMS 1. Command and management a. Incident management is standardized for all hazards across all levels of government. b. Command structure is based on: i. ICS ii. Multiagency coordination systems iii. Public information systems 2. Preparedness a. Institutes procedures for all responders to include in their systems in preparation to respond to any event at any time 3. Resource management a. Sets up systems that describe, inventory, track, and dispatch resources before, during, and after incident b. Creates standard procedures to recover equipment that was used 4. Communications and information management a. Enables the necessary functions needed to provide interoperability 5. Supporting technologies a. Encourages national standards and interoperability among all technologies b. Provides structure for the science and technology used in incident management 6. Ongoing management and maintenance a. A NIMS Integration Center will be created to provide strategic direction and oversight of the NIMS. III. The Incident Command System A. Using common language and “clear text” (plain English, not 10-codes) ensures better communication between various agencies. B. The ICS creates a modular organizational structure. 1. The goal is to make the best use of resources to manage the environment and treat patients. 2. Follow local standard operating procedures to establish the ICS. 3. The ICS is designed to control duplication of effort and freelancing. a. Freelancing: Individual units or agencies make independent decisions about next steps 4. The ICS limits span control. a. Keeps the supervisor-to-worker ratios at one supervisor for three to seven workers b. A supervisor who is overseeing more than seven people must delegate tasks and supervision. 5. Organizational divisions can include: a. Sections b. Branches c. Divisions and groups d. Resources 6. Some areas have emergency operations centers. a. Operated by the city, state, or federal government b. Usually only activated in large emergencies, with hundreds of patients and that continue for days 7. Responders in an MCI or disaster should use the ICS. Find out from your service: a. Does ICS exist? b. Who is in charge? c. How is it activated? d. What will be your role? C. Incident command system roles and responsibilities 1. The general roles within the ICS include command, finance, logistics, operations, and planning. a. Command functions include: i. Public information officer (PIO) ii. Safety officer iii. Liaison officer 2. Command a. The incident commander (IC) evaluates the incident and creates a plan of action based on strategic objectives and priorities. i. The number of duties the IC is responsible for depends on the size of the incident. (a) Small incidents often mean the IC will do it all. (b) Incidents of medium size or complexity often mean the IC will delegate some functions but retain others. (c) In a complex incident, the IC may appoint team members to all command roles. b. A unified command system is used when an incident requires multiple organizations or jurisdictions. i. Plans are made in advanced by all organizations that take on responsibility in decision making. ii. The plan assigns the lead and support agencies. (a) For example: HazMat team takes the lead during a chemical leak where the medical team would take the lead in a multivehicle car crash. iii. Agencies bordering each other should regularly practice together in preparation for an incident. c. A single command system is one in which one person is in charge. i. Generally used with incidents in which one agency has the majority of responsibility for incident management. ii. Ideally used for short-duration, limited incidents d. Your IC should be at or near the incident to be able to communicate with all responders at the scene. i. Know who and where your IC is and where the command post is. (a) The IC may be wearing a piece of identifying clothing. (b) If a vehicle is acting as command post location it should be easily identifiable. ii. Your supervisor or the IC should be knowledgeable of all plans before they are initiated. e. Transfer of command: IC transfers command to a more experienced person in a critical area i. This transfer is to be done in an orderly manner and ideally face to face. ii. Your agency should have standard operating procedures (SOPs) that direct the transfer of command. f. At the conclusion of an incident there should be a termination of command. i. Demobilization procedures should be implemented as the situation de-escalates. 3. Finance a. Responsible for documenting all expenses at an incident that should be to be reimbursed i. Not always necessary at smaller incidents ii. Tracks and reports personnel hours and cost of materials and supplies at meetings b. The finance chief will help your organization receive reimbursements if eligible. c. The roles of the finance section are: i. Time unit (a) Keeps a daily record of personnel time and equipment use ii. Procurement unit (a) Deals with vendor contracts iii. Compensation/claims unit (a) Deals with claims regarding incident and injury compensation (b) Collects, analyzes, and reports costs 4. Logistics a. Responsible for: i. Communications equipment ii. Facilities iii. Food and water iv. Fuel v. Lighting vi. Medical equipment and supplies b. In large incidents many people may coordinate logistics, but only one reports to the IC. 5. Operations a. Manages the tactical operations job at a large incident b. At a complex incident, the operations chief oversees the responders working at the scene. i. Often have managerial experience within a fire department 6. Planning a. Solve problems as they arise during the MCI. b. Use data from the current incident to analyze the previous plan and predict next steps for the new plan. c. Work closely with operations, finance, and logistics. d. Call upon technical experts to help with planning process. e. Set plan for demobilization. f. Develop an incident action plan. i. Written at the beginning of a response by the chief with input from other departments ii. Continuously revised as the response continues iii. The degree of detail included depends on the complexity and size of the response. 7. Command staff a. Safety officer i. Continually monitors the area for any hazards to responders and patients ii. Possibly will interact with environmental health and HazMat teams iii. Have the authority to stop an emergency operation when a rescuer is in danger b. Public information officer (PIO) i. Presents information to the public and media ii. Takes post away from incident to keep media safe from the emergency and to keep distractions to a minimum iii. May work in conjunction with other organizations in a joint information center (JIC) iv. May be responsible for providing a message that will help a situation, prevent further panic, and provide evacuation directions c. Liaison officer (LNO) i. Relays information between command, general staff, and other agencies D. Communications and information management 1. Communications should be integrated so all agencies can communicate easily and quickly by radio. a. Allows for: i. Accountability throughout the incident ii. Instant communication 2. Maintain professionalism on all radio communications. 3. Communicate clearly, concisely, and using clear text. E. Mobilization and deployment 1. Once an incident is declared and additional resources and personnel are requested, they are mobilized and deployed at a staging area. 2. The steps of mobilization and deployment are as follows: a. Check-in with the finance section upon arrival at an incident. i. Allows you to be assigned to a supervisor for job tasking ii, Allows for personnel tracking iii. Allows for precise tracking of costs, pay, and reimbursement b. Check-in with your supervisor for an initial briefing about the incident and job responsibilities. c. Keep records as a way to document items that may need to be reimbursed. d. Keep your supervisor up to date on your location, actions, and completed and uncompleted tasks. e. Once the incident is controlled the IC will decided on demobilization of resources. IV. EMS Response Within the Incident Command System A. Preparedness 1. Decisions and basic plans are made before an incident occurs. a. Includes plans for all natural disasters that are most likely to happen in a particular area 2. Written disaster plans are regularly practiced, and a copy should be located in every EMS vehicle. 3. EMS facilities are stocked with supplies to last for a minimum of 72 hours. 4. Mutual aid agreements are made with nearby organizations in case additional resources are needed quickly in an emergency. a. All organizations should regularly practice emergency plans with smaller simulated situations. b. Resource inventory should be shared among organizations for easy accessibility. c. EMS organizations should create an assistance program for families of responders so they can be sure of their safety and focus on their job. 5. You should have your own disaster plan in place for your family in the event that you need to respond to a disaster. 6. Make sure you have all necessary immunizations. a. Influenza b. Hepatitis A and B c. Tetanus B. Scene size-up 1. Dispatch will inform you if the MCI scene is safe or unsafe. 2. When you arrive on the scene, ask yourself three basic questions: a. What do I have? i. Check for hazards and warn other responders of safety concerns such as hazardous materials, fuels spills, and electrical hazards. ii. Confirm the location of the incident. iii. Is the incident open or closed? iv. How many casualties are there? v. Report findings to dispatch. b. What do I need to do? i. Safety is the first priority. (a) This includes yourself, your partner, and other rescuers first, then patients and bystanders. ii. Isolate or stabilize the incident. iii. Preserve property and environment. c. What do I need? i. Determine the resources you will need. (a) A rescue unit and fire department may be needed if extrication is required. (b) The HazMat team should be called at once if there are any hazardous material issues. (c) There may be special MCI units and mobile emergency rooms that are called upon if there are a lot of patients. C. Establish command 1. Notify other responders and request necessary resources. 2. Establish command early on. a. Preferably by the first-arriving, most experienced public safety official D. Communications 1. To limit radio traffic, always use face-to-face communication when possible. 2. If you are communicating by radio do not use codes or signals. 3. There are typically radio channels specified as emergency command channels. 4. The communication you are using should be reliable, durable, field tested, and have backups. a. There should always be a “Plan B” for communication. V. Medical Incident Command A. Medical incident command is also known as the medical branch of the ICS. 1. A medical branch director is appointed during incidents that call for a large amount of medical attention. a. Oversees primary roles of medical team i. Triage ii. Treatment iii. Transport b. Makes sure that EMS units are working within the ICS c. Assigns each medical unit with tasks prior to working at the scene i. Prior to instructions all medical responders should stay in the staging area. d. Depending on the size of the incident, EMS may be its own command or work under the logistics section. B. Triage supervisor 1. Counts and prioritizes patients at the incident 2. Ensures each patient receives an initial assessment a. Triage paramedics transfer patients to the correct treatment section. 3. Treatment on patients must not begin until every patient is triaged. C. Treatment supervisor 1. Designates an area where patients are treated by their priority. 2. Sees that each patient has secondary triage and that each gets enough care. 3. Assists with moving patients to transportation area. 4. Communicates the request for sufficient quantities of supplies, including: a. Bandages b. Burn supplies c. Respiratory supplies d. Patient packaging equipment D. Transportation supervisor 1. Coordinates the transportation and distribution of patients to appropriate hospitals a. Communicates with area hospitals to decide which will receive certain patients 2. Tracks and records the number of vehicles transporting, patients transported, and the destination of both E. Staging supervisor 1. Assigned when a situation calls for multiple emergency vehicles or agencies 2. Designates an efficient location for the staging area away from the incident 3. Plans for access and exit from the site 4. Prevents traffic congestion among responding vehicles 5. Releases vehicles and supplies when needed F. Physicians on scene 1. Assist with triage decisions. a. Also decide the priority of patients to be transported 2. Provide on-site medical direction and treatment. G. Rehabilitation supervisor 1. Creates a rehabilitation area where responders can come to rest, eat and drink, and get protection from the elements during an incident that will last for a while. a. The rehabilitation area is set up away from the incident, crowds, and media. 2. Monitors EMS personnel for stress signs. a. Fatigue b. Altered thinking c. Collapse H. Extrication and special rescue 1. Extrication or rescue supervisors are appointed when there is a need for search and rescue or extrication of patients. 2. The supervisor coordinates the equipment and resources needed. 3. Typically these supervisors work under the EMS branch of the ICS because the removal of a patient may be medically difficult. I. Morgue supervisor 1. In an incident where many victims have died, a morgue supervisor is appointed. a. Works with the medical examiners, coroners, disaster mortuary assistance, and law enforcement. b. Coordinates body removal 2. The deceased should be left untouched until removal and storage plans are made. a. This will also help in identifying victims in a MCI or crime scene investigations. 3. If a morgue area is created it should be out of sight so there is no further psychological trauma to living patients and so there is no theft from deceased victims. VI. Multiple-Casualty Incidents A. A multi-casualty incident is defined as a call having three or more patients, an incident that puts stress on resources and requires a mutual aid response, or any incident that has the potential to create one of those situations. 1. Mutual aid response: neighboring EMS systems respond to MCIs in each other’s regions when there aren’t enough local resources. 2. Examples of MCIs include: a. Bus or train crashes b. Earthquakes c. Residential building fire d. Loss of power to a hospital or nursing home 3. Response to the MCI will vary depending on the size, location, and how spread out the patients are. B. Identify an MCI as an open incident or a closed incident. 1. Open incident a. Unknown amount of casualties when you first answer a call b. Patients may need to be searched for and treated in multiple locations. c. Possibly an incident that is ongoing, for example, a tornado or school shooting. 2. Closed incident a. Number of patients is not expected to change. b. Patients are triaged and treated as they are removed. c. May turn into an open incident C. When deciding what qualifies as an MCI, regions will use varying standards and protocols. 1. Previous experience will help determine the status of the incident. 2. Regular use of ICS and participating in disaster planning drills, table-top MCI exercises, and other trainings will better prepare you for an incident. 3. Having a solid understanding of the roles of an MCI and regular use of ICS and the NIMS will help the keep the incident responders organized and efficient. 4. The following questions will help you determine whether an incident is an MCI: a. How many seriously injured or ill patients can you care for effectively and transport? b. What happens when you have three patients to deal with? c. How long will it take for additional help to arrive? d. What do you do when a school bus crashes, resulting in eight critically injured patients and you only have three ambulances available? 5. In most situations your team will not be able to help all of the patients alone and will need assistance from other responders and equipment. 6. Never leave patients without other responders present at the scene. a. This could be considered abandonment. 7. Declare an MCI if there are more patients than resources. a. Start ICS and triage procedures. 8. Always follow local protocol. 9. Large EMS systems may send specialized MCI units or mobile emergency rooms if there are numerous patients to be treated. VII. Triage A. To triage is to sort patients by the seriousness of their injuries. 1. The goal is to do the greatest good for the greatest number. a. Triage should be brief. b. Categories that patients are placed in should be basic. 2. Primary triage takes place at the scene of the incident. 3. Secondary triage takes place in the treatment areas. 4. Patients may be identified with a triage tag that is created in primary triage. a. Each tag will have a unique number and a triage category. 5. After primary triage, the team leader will report to the medical branch director: a. The total number of patients b. The number of patients in each triage category c. Recommendations for extrication and movement of patients to the treatment area d. The resources that are needed to complete triage and begin the movement of patients 6. Secondary triage is a reassessment of remaining patients. a. The category of a patient can change suddenly and can be upgraded or downgraded due to patient condition. i. Continuous evaluation of patients will help quickly identify changes. B. Triage categories 1. Four common triage categories can be remembered using mnemonic IDME: a. Immediate (red) b. Delayed (yellow) c. Minimal (green; hold) d. Expectant (black, likely to die, or dead) 2. Immediate patients are first priority. a. Need immediate care or transportation. b. These patients may have problems with the ABCs, head trauma, or shock. 3. Delayed patients are second priority. a. Will need care or transport, but it can be delayed. b. These patients may have bone, joint or back injuries (not spinal chord). 4. Minimal patients are third priority. a. Need little to no on scene treatment. b. Patients are known as the “walking wounded.” c. Usually suffer from soft-tissue injuries i. Contusions ii. Abrasions iii. Lacerations 5. Expectant patients are the last priority. a. Either already dead or have little chance to survive i. Cardiac arrest ii. Open head injury iii. Respiratory arrest b. These patients only get treated if all other patients are helped. C. Triage tags 1. It is important to label, track, and record a patient’s conditions no matter what system is used. 2. A triage tag should have these characteristics: a. Weatherproof b. Easy to read c. Color-coded d. Clearly identify triage category. i. In case a responder may be color-blind use both symbols and colors. 3. This tag will be added to a patient’s medical record and may have a tear-off receipt. a. Tracks a patient’s location b. Identifies a patient if they are unresponsive 4. Digital photos are sometimes used in identification of victims. 5. Alternatively, you can track and account for patients by assigning 20-25 tags at a time with a scorecard to mark how a patient is triaged and their priority. a. Tracks the amount of patients b. Helps command create a response plan c. Identifies if more resources are needed 6. The transportation supervisor should know how and where a patient was transported, their priority, and who transported them. D. START triage 1. Staff at Hoag Memorial Hospital in Newport Beach, California, created a simple form of triage named Simple Triage and Rapid Treatment (START). 2. Uses a limited evaluation of a patient a. Ability to walk b. Respiratory status c. Hemodynamic status d. Neurologic status 3. First step of the START system a. When you first get to the scene, call out, guiding patients who can hear you to an identifiable landmark. i. These injured patients are considered the “walking wounded.” ii. Categorized as minimal priority, or third-priority patients. 4. Second step of START a. Evaluate the nonwalking patients. b. Check the respiratory status. i. If a patient is not breathing, open the airway using a simple manual maneuver. (a) If the patient does not begin breathing, categorize as expectant (black). ii. If the patient starts breathing, quickly estimate their respiratory rate. (a) Faster than 30 breaths/min categorize as immediate priority (red). (b) Fewer than 30 breaths/min, continue assessment. iii. Check for radial pulse to evaluate the hemodynamic status. (a) Absent radial pulse suggests the patient is hypotensive and should be categorized as immediate priority. (b) If radial pulse is present continue assessment. iv. Check the neurologic status. (a) Ask the patient to follow simple commands (eg, “Show me three fingers.”) (b) If they don’t understand the command and are unresponsive, categorize as immediate priority. (c) A patient who understands commands is categorized as delayed. E. JumpSTART triage for pediatric patients 1. Lou Romig, MD, created JumpSTART to address the developmental and physical differences children have from adults. a. The system is used to assess children under 8 years old or who appear to weigh less than 100 lbs. 2. First, identify the “walking wounded.” a. Infants and children not developed enough to walk are taken to the treatment area for immediate secondary triage. 3. JumpSTART triage differs slightly from START triage. a. If a pediatric patient isn’t breathing, check for a pulse. i. If there is no pulse the patient is labeled as expectant. ii. If there is a pulse, open airway with a manual maneuver. iii. Give five rescue breaths if the patient still isn’t breathing. iv. If the patient doesn’t respond they are labeled as expectant. b. The most common cause of cardiac arrest in children is respiratory arrest. 4. Next check the approximate rate of respirations. a. A child who is breathing fewer than 15 breaths/min or more than 45 breaths/min is categorized as immediate. b. If respirations are within a range of 15 or 45 breaths/min continue assessment. 5. Assess the hemodynamic status. a. Check for a distal pulse. b. If there is no distal pulse, the child is labeled as immediate. c. If the child has a distal pulse, continue assessment. 6. Assess neurologic status. a. A child’s responses will vary depending on their age and development. b. Use a modified AVPU score. i. Alert ii. Verbal iii. Pain iv. Unresponsive c. A child who is unresponsive, not understandable in voice, or cannot locate their pain is labeled as immediate. d. A child who is alert or can pinpoint their pain is labeled as delayed. F. Triage special considerations 1. A hysterical or disruptive patient may be categorized as immediate despite their condition. a. This type of behavior could create panic for other patients and rescuers. 2. An injured or sick responder should be categorized as immediate and transported away from the scene so other responders do not loose morale. 3. If hazardous materials or weapons of mass destruction are present, the HazMat team must categorize patients as contaminated or uncontaminated before regular triage can begin. 4. Some incidents will require multiple teams or areas of triage if patients are spread out. G. Destination decisions 1. Using the 2011 American College of Surgeons Committee on Trauma (ACS-COT) field triage decision scheme, refer patients to trauma centers using criteria including: a. Physiologic criteria b. Anatomic criteria c. Mechanism of injury d. Special considerations i. Age ii. Underlying health conditions 2. The guidelines help prehospital responders identify individuals who will benefit from transportation to a trauma center. 3. Consider which hospital has the appropriate means to help a patient. a. Some hospitals can become overwhelmed by a large number of patients. i. Most have hospital surge capacity plans to accommodate for this. (a) May include deployed mobile units that can be quickly set up on site. b. Some patients may require specialized care. i. Burn centers ii. Pediatric centers 4. Transport patients that are categorized as immediate by ambulance or air ambulance. 5. You can transport walking wounded by bus if needed in large situations. a. These patients should be taken to a hospital farther away from the scene so as not to overwhelm the hospital. b. At least one EMT or paramedic must ride on the bus. c. An ambulance should follow. d. The EMT should notify the receiving hospital immediately if a patient’s condition worsens during travel. 6. Transport immediate patients two at a time. 7. Transport delayed two or three at a time. 8. Transport slightly injured last. 9. Expectant patients are treated once all patients have been transported. 10. Dead victims are handled and transported according to the SOP for the area. 11. Notify hospitals as early as possible during an MCI, so they are prepared to receive patients. a. EMS should know the hospital surge capacity. VIII. Critical Incident Stress Management A. Emergency workers may suffer from psychological impact of an MCI. 1. There is no shame in using debriefing resources. 2. Within your departments disaster plan there should be a resource for debriefing or defusing of responders before, during, and after an MCI. a. Depends on service director’s and medical director’s views 3. Critical incident stress management (CISM) should be available to all responders. a. Participation is encouraged but not required. 4. All responders should have access to coping mechanisms. a. Employee Assistance Program (EAP) b. Mental health professionals c. Peer counselors trained in CISM debriefing 5. These services should always be available. a. Some effects may not set in until much later. 6. The psychological impact on responders should be included in the postincident evaluation. B. After-action review 1. All agencies participate in a review after an incident ends. 2. For future events, include what worked and what didn’t work. 3. All observations should be written down for future review. 4. Never accuse someone of doing something wrong during the incident. a. All MCIs are different, and all reactions will be different. IX. Summary A. Major incidents require the involvement and coordination of multiple jurisdictions, functional agencies, and emergency response disciplines. B. The National Incident Management System (NIMS) provides a consistent nationwide template to enable federal, state, and local governments, as well as private-sector and nongovernmental organizations, to work together effectively and efficiently. C. The major NIMS components are command and management, preparedness, resource management, communications and information management, supporting technologies, and ongoing management and maintenance. D. The purpose of the incident command system (ICS) is to ensure responder and public safety, achieve incident management goals, and ensure the efficient use of resources. E. Using the ICS gives you a modular organizational structure that is built on the size and complexity of the incident. F. Preparedness involves the decisions made and basic planning done before an incident occurs. G. Your agency should have written disaster plans that you are regularly trained to carry out. H. General ICS staff roles include command, finance, logistics, operation, and planning. I. At incidents that have a significant medical factor, the incident commander should appoint someone as the medical branch director who will supervise triage, treatment, and transport of injured patients. J. A multiple-casualty incident refers to any call that involves three or more patients, any situation that places such a great demand on available equipment or personnel that the system would require a mutual aid response, or any incident that has a potential to create one of the previously mentioned situations. K. The goal of triage is to do the greatest good for the greatest number. This means that the triage assessment is brief and patient condition categories are basic. L. The four common triage categories are immediate (red), delayed (yellow), minimal (green), and expectant (black; likely to die or dead). M. It is vital to tag each patient during triage to help keep an accurate record of their condition. Triage tags become part of the patient’s medical record. N. START triage (Simple Triage And Rapid Treatment) uses a limited assessment of the patient’s ability to walk, respiratory status, hemodynamic status, and neurologic status to quickly and efficiently triage patients. O. JumpSTART triage modifies the START triage system to take into account the physiologic and developmental differences of pediatric patients. It is intended for use in children younger than 8 years or who appear to weigh less than 100 pounds. P. Consider critical incident management before, during, or after an event. It is normal to sometimes feel overwhelmed. Recognize the need for assistance in yourself as well as for others on the scene. Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities. Assessment in Action This activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of paramedic knowledge. Instructor Directions 1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 47. 2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity. 3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper. Answers to Assessment in Action Questions 1. Answer: C. promote more efficient coordination of a multiple-casualty incident. Rationale: The National Incident Management System (NIMS) was created in 2004, and was the product of a directive from the president to the Secretary of Homeland Security. The purpose of NIMS is to provide a consistent nationwide template to enable federal, state, and local governments, along with the private-sector and nongovernmental organizations, to work together effectively and efficiently. 2. Answer: D. Unified command system Rationale: A unified command system is utilized during large MCIs requiring involvement from multiple agencies or jurisdictions. With a unified command system, plans are drawn up by all cooperating agencies that assume a shared responsibility. This prevents miscommunication and duplication of efforts during the event. 3. Answer: B. Logistics Rationale: The logistics section is responsible for procuring communications equipment, facilities, food and water, fuel, lighting, and medical equipment and supplies for patients and emergency responders. The finance section is responsible for documenting all expenditures at an incident for reimbursement. Operations have the responsibility for managing the tactical operations jobs. Finally, the planning section is tasked with obtaining data about the incident, analyzing the previous plan, and predicting who is needed to make the new plan work. 4. Answer: C. transportation supervisor. Rationale: Coordination of transportation and distribution of patients to appropriate receiving hospitals is the responsibility of the transportation supervisor. In addition, the transportation supervisor documents and tracks the number of vehicles transporting, patients transported, and the facility destination of the each vehicle and patient. 5. Answer: B. START Rationale: The START triage system provides a simple method of categorizing patients at an MCI based upon the patient’s ability to walk, respiratory status, hemodynamic status, and neurological status. JumpSTART is a triage method that is meant for use in children under the age of 8 years or who appear to weigh less than 100 pounds. 6. Answer: A. surge capactity. Rationale: The capabilities of a hospital to handle a large number of patients is known as its surge capacity. Knowledge of the surge capacity of receiving facilities in your area is critical as this information will help planning and effectively transporting patients during an MCI. 7. Answer: D. All of the above Rationale: The National Trauma Triage Protocol was designed to facilitate the transport of trauma patients to an appropriate facility. Patient criteria used in this protocol include the mechanism of injury, anatomy of the injury, and the patient’s physiological status. 8. Answer: B. The number of patients in each of the triage categories Rationale: Upon completion of primary triage, the team leader should communicate the following information to the medical group leader: total number of patients; number of patients in each of the triage categories; recommendations for extrication and movement of patients to the treatment area; and resources needed to complete triage and begin movement of the patients. 9. Answer: C. Staging supervisor Rationale: The responsibility of releasing vehicles and resources when ordered by the incident commander falls to the staging supervisor. Additional Questions 10. Rationale: Taking the initiative to explore ways in which you can be an active part of disaster planning will give you a better understanding and perspective of how the process works and how you can help facilitate it. Contact the local Emergency Operations Center, Red Cross, or fire departments and inquire about opportunities to get involved. There may be a local Community Emergency Response Team that can use your expertise, or this may be the perfect time to form one. Get creative, and enlist the help of fellow coworkers. You can make a difference! Assignments A. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by instructor). B. Read Chapter 48, Vehicle Extrication and Special Rescue, for the next class session. Unit Assessment Keyed for Instructors 1. Discuss the introduction of NIMS and the principles for implementation in public safety. Answer: The National Incident Management System (NIMS) was established in 2004 in an effort to provide flexibility and standardization for public safety agencies responding to major incidents. Major incidents include catastrophic events such as terrorist attacks, as well as hazardous materials incidents. The NIMS is designed to provide a standardized and consistent nationwide template that will allow all federal, state, and local governments, as well as private and non-governmental agencies to work together in planning for, preventing, responding to, and recovering from these types of events. Included in this standardization are terminology, resource classifications, training, and certification. (pp 2199-2200) 2. What are the benefits of using the ICS for managing events? Answer: In order for the ICS to function properly, it is essential that all participants understand the language, roles, and responsibilities of each member of the system. The system is intended to provide a modular structure that can accommodate incidents of all sizes. If each member understands their role in the system, there is less likelihood of duplication of efforts or freelancing by an agency or responder. Each person in the ICS structure has a limited span of control to ensure that each component functions in the manner in which it was intended. This prevents one supervisor from being responsible for too many personnel and tasks. Depending on the size of the incident, divisions may include sections, branches, divisions and groups, as well as resources. In some cases, there may be an emergency operations center (EOC) to assist in overall coordination of the event response. There may also be command functions such as a public information officer (PIO), safety officer, and liason officer. (p 2200) 3. What are the the primary roles and responsibilities in the ICS? Answer: Under the command responsibility, the incident commander (IC) is the person in charge of the overall incident. Depending on the size of the incident, the IC may be the only command function or this position may delegate out other command functions. This position is responsible for assessing the incident, establishing strategic objectives and priorities, and developing a plan to manage the incident. In a major incident, the IC may appoint members to all of the command roles. The IC should be on scene or very close to the scene with all members able to identify this individual and their location. The financial section chief is responsible for documenting all expenditures at an incident for reimbursement, including personnel hours and materials and supplies. The logistics section or section chief is responsible for overseeing communications equipment, facilities, food and water, lighting, fuel, and medical equipment and supplies as outlined by standard operating procedures (SOPs) for the incident. The operations section is responsible for the tactical operations of the incident. The operations section chief will be responsible for supervising personnel working at the scene of the incident. The planning section is responsible for solving problems as they arise at the incident. They are also responsible for developing the incident action plan for use during the response. Command staff assists the general staff and IC. They include the PIO responsible for providing the public and media clear and understandable information about the event. The safety officer is responsible for monitoring the scene for conditions or operations that may present a hazard to patients or responders. The liason officer relays information and concerns among general staff, the IC, and other agencies. (pp 2200-2203) 4. Outline and explain how EMS functions within the ICS. Answer: Every EMS agency should have a written disaster plan in place before an incident occurs. It should include natural disasters as well as other types of disasters. EMS agencies should have supplies adequate to support operations for 72 hours on hand. Mutual aid agreements should be in place to offer support and relief during the disaster so that requests for assistance are expedited. Scene size-up is an important component of preparedness. All scenes should be assessed for safety and the potential presence of hazards. The responding EMS unit should determine if the incident is not safe for entry to the scene, confirm the location of the scene, and notify appropriate resources. If possible, the number of casualties should be estimated. The paramedic assumes command until relieved by a more appropriate person. Three main priorities should be considered: safety, incident stabilization, and preservation of property and environment. These priorities may prevent the ability to access and provide care to patients until additional assistance is available. The medical branch of the ICS is typically where EMS plays a significant role. Within the medical branch, it will be necessary to establish triage, transportation, and treatment responsibilities, with supervisors assigned for each. (pp 2203-2206) 5. Define what is meant by a multiple casualty incident (MCI) and distinguish between an open and closed incident. Answer: An MCI refers to any incident that has three or more patients; situations that place great demand on personnel, equipment, or resources such that a mutual aid response is required; or any incident that has the potential to become one of these two. Responses to MCIs will depend on the area of land covered by the incident, the location, and how spread out the patients are. An open incident has an undetermined number of patients at the time of the initial response. There may be a need for patient search and triage or treatment may need to be completed in multiple locations. Ongoing situations would also be considered open incidents, as the number of patients may not yet be known until the situation is resolved. Closed incidents should not be expected to produce more patients than are identified at the time of the response. Patients are triaged and treated as they are removed from the scene. (pp 2207-2208) 6. What is triage? What is the difference between primary and secondary triage? Answer: Triage is sorting patients based on the severity of their injuries. The idea of triage is to do the greatest good for the greatest number. Patients are visibly tagged with an assigned category. Primary triage is completed in the field, while secondary triage is completed as patients are brought to the treatment area. Once all patients have been through an initial triage, they may be re-triaged to determine if their condition has changed. Depending on available resources, re-triage should be performed as often as possible. (p 2209) 7. Identify the four triage categories and describe the typical description and injuries of patients assigned to each category. Answer: The red tag or immediate priority represents those patients with life-threatening conditions who need immediate treatment and transport. It includes conditions such as airway compromise, breathing difficulties, uncontrolled or severe bleeding, severe medical problems, decreased mental status, signs of shock, severe burns, and open chest or abdominal injuries. The yellow tag or delayed priority represents those patients who may be delayed for treatment or transport. It includes conditions such as burns without airway compromise, major or multiple fractures and joint injuries, and back injuries with or without spinal cord damage. The green tag or walking wounded are those patients who require minimal treatment and transport may be delayed until last. These patients may have conditions such as minor fractures or soft-tissue injuries. The black tag or expectant priority are those patients who are already dead or have little chance for survival. These patients present with obvious death, cardiac arrest, respiratory arrest, and non-survivable injuries such as open brain injuries. Regardless of their category, all triaged patients should have tags to clearly identify their category and aid tracking and documentation of their condition. (pp 2209-2210) 8. Describe the START triage system and how it standardizes patient triage in MCIs. Answer: START (Simple Triage and Rapid Treatment) allows for the ability to rapidly categorize patients at an MCI. The limited assessment includes patient’s ability to walk, respiratory status, hemodynamic status, and neurological status. The first step is identifying those who are the walking wounded by asking all victims who can to get up and move to another location. Those who are unable to walk are assessed next for respiratory status. If they are not breathing, manual opening of the airway should be performed. If the patient does not breathe after the airway is opened, they are triaged as black. If the patient does begin to breathe, they are triaged as red and moved for immediate treatment and transport. If the patient who is unable to walk is breathing as found, then triage is dependent on rate of breathing and categorized as red or assessed further for hemodynamic status. If a radial pulse is not present, they are triaged as red; if present, they are assessed for neurologic status by asking if they can follow certain commands. Those who cannot are triaged as red and those who can are triaged as yellow. (pp 2211-2212) 9. How does the JumpSTART triage system compensate for differences in the pediatric patient? Answer: The START triage system does not account for physiologic and developmental differences in the pediatric patient. JumpSTART is intended for pediatric patients appearing to be under the age of 8 or 100 pounds. Infants and children with special needs should be removed immediately to the treatment sector for immediate secondary triage. Children who can follow the command to get up and walk to another area are identified as walking wounded. There are also differences in the respiratory assessment compared to the START triage system. If the child is not breathing, the next step is to check for a pulse and if one is not found the child is triaged as black or expectant. Respirations are assessed if the child is breathing and determines whether the child is labeled as red or if hemodynamic status should be assessed. Absence of a distal pulse at this point triages as red; in the presence of a pulse, neurologic assessment is done using a modified AVPU. Those who are unresponsive or unable to localize pain are triaged as red; those who can withdraw or respond to pain or are alert are triaged as yellow. (p 2212) 10. What is the role of critical stress incident management (CISM) in dealing with the psychological impact of a major incident? Answer: Emergency workers are not immune to the psychological impact of an MCI. Some providers may have the training and experience to cope with them better than others, but large-scale events can impact paramedics permanently. Debriefing before, during, and after an incident should be a component of the agency’s preparedness plan prior to the incident. The inclusion of this type of support and intervention is dependent on the views of the agency director and medical director. CISM should be offered in the rehabilitation sector of the incident and considered for all responders. Responders should be encouraged to participate but not forced. There should also be access to resources after the event such as the Employee Assistance Program, mental health counselors, or peer counselors trained in CISM. Time frame should not be relevant as to when these resources are needed or accessed, as some effects are not seen right away and may be delayed in presenting. Impact on responders should be included in all post-incident evaluations. (p 2213) Unit Assessment 1. Discuss the introduction of NIMS and the principles for implementation in public safety. 2. What are the benefits of using the ICS for managing events? 3. What are the the primary roles and responsibilities in the ICS? 4. Outline and explain how EMS functions within the ICS. 5. Define what is meant by a multiple casualty incident (MCI) and distinguish between an open and closed incident. 6. What is triage? What is the difference between primary and secondary triage? 7. Identify the four triage categories and describe the typical description and injuries of patients assigned to each category. 8. Describe the START triage system and how it standardizes patient triage in MCIs. 9. How does the JumpSTART triage system compensate for differences in the pediatric patient? 10. What is the role of critical stress incident management (CISM) in dealing with the psychological impact of a major incident?