Chapter 40: Incident Management

Mass-Casualty Incident (MCI)

Any call that involves three or more patients, a situation that places great demand on equipment or personnel, that requires a mutual aid response.

Mutual Aid Response

Neighboring EMS systems working together when resources are insufficient.

National Incident Management System (NIMS)

• Implemented by the Department of Homeland Security

• A framework for federal, state, local governments, and private-sector and nongovernmental organizations to work together

• Guiding principles are flexibility, standardization, and unity of effort

• Three major components:

  1. Communications and information management

  2. Resource Management

  3. Command and Coordination

Incident Command System (ICS)

• Ensure responder and public safety, achieve management goals, and ensure efficient use of resources

• Avoid duplication of effort and freelancing—individual units and different organizations make independent and inefficient decisions

• Limit the span of control of individuals—5 subordinates to 1 supervisor

What are the organizational levels of an ICS?

• Sections

  • Finance/administration, logistics, planning, or operations

• Branches

  • Established when the span of control is a problem

  • In charge of activities directly related to the section

• Divisions and groups

  • Divisions are crews working in the same geographic area

  • Groups are crews working in the same functional area

Command | ICS Roles and Responsibilities

• The incident commander (IC) is in charge of the overall incident, developing plans to manage incidents

• IC command of duties varies by size

• Large MCIs require a unified command system—plans drawn up by multiple agencies that assume responsibility

• Single command system in which one individual is in charge—one agency has the most responsibility

• IC is on or near the scene

• Transfer of command to someone with more experience in an area

• Termination of command with demobilization procedures

Finance/Administration | ICS Roles and Responsibilities

• Responsible for documenting all expenditures at an incident for reimbursement

• Various functions:

  1. The time unit

     • Recording personnel time and equipment use

  2. The procurement unit

     • Vendor contracts

  3. The compensation and claims unit

     • Claims as a result of the incident and injury compensation

  4. The cost unit

     • Collecting, analyzing, and reporting costs

Logistics | ICS Roles and Responsibilities

• Responsible for communications equipment, facilities, food and water, fuel, lighting, and medical equipment and supplies

• Personnel trained to find food, shelter, fuel, and health care

Operations | ICS Roles and Responsibilities

• Responsible for managing tactical operations

• Supervise people at the scene, who will be divided into groups, divisions, and branches

Planning | ICS Roles and Responsibilities

• Solves problems as they arise from the incident

• The incident action plan provides clear, concise information about incident activities

Command Staff | ICS Roles and Responsibilities

• Safety officer

  • Monitors the scene for conditions or operations that may present a hazard

• Public Information Officer (PIO)

  • Provides the public and media with clear and understandable information

  • Cooperate with other PIOs in a joint information center (JIC)

• Liaison officer

  • Relays information to command, general staff, and other agencies

Mobilization and Deployment

• Check In at the Incident

  • Personnel tracking ensures that costs, wages, and reimbursements are calculated accurately

• Initial Incident Briefing

  • Obtain information on the incident and your specific functions and responsibilities

• Incident Record Keeping

  • Financial and documenting purposes

• Accountability

  • Keep supervisor advised of location, actions, command tasks, and tasks you are unable to complete

• Incident Demobilization

  • Determine which resources are needed or not needed

Preparedness | EMS Response Within the ICS

• Decisions are made and planning is done before an incident occurs

• Should have disaster plans and supplies that last for 72 hours

• Develop assistance programs

Scene Size-up | EMS Response Within the ICS

• Begins with dispatch

• What do I have?

  • Assess scenes for hazards, identify open or closed incidents, and estimate the number of casualties

• What resources do I need?

• What do I need to do?

  • Safety, incident stabilization, and preservation of property and the environment

Establishing Command | EMS Response Within the ICS

• Established by the most experienced public safety official

• Responders should be notified and resources should be requested

Communications | EMS Response Within the ICS

Designate channels strictly for command during a disaster.

Triage Supervisor | The Medical Branch of Incident Command

In charge of counting and prioritizing patients.

Treatment Supervisor | The Medical Branch of Incident Command

• Locates and sets up the treatment area with a tier for each priority of patient

• Assists with moving patients to the transportation area

Transportation Supervisor | The Medical Branch of Incident Command

• Coordinates the transportation and distribution of patients to hospitals to ensure that hospitals don’t get overwhelmed

• Documents and tracks the number of transport vehicles, patients, and destination

Staging Supervisor | The Medical Branch of Incident Command

• Assigned when an MCI requires a multivehicle or multiagency response

• Locates staging area, track unit arrivals, and release vehicles and supplies when ordered by command

Physicians on Scene | The Medical Branch of Incident Command

• Make difficult triage decisions, provide medical direction, and care

Rehabilitation Supervisor | The Medical Branch of Incident Command

• Establishes an area that provides protection for responders from the elements and the situation

• Located away from the scene

Extrication and Special Rescue | The Medical Branch of Incident Command

Extrication supervisors and rescue supervisors determine the type of equipment and resources required.

Morgue Supervisor | The Medical Branch of Incident Command

• Work with medical examiners, coroners, disaster mortuary assistance teams, and law enforcement

• Dead victims should be left where they are found

• The morgue should be out of view

Mass-Casualty Incidents

• How many seriously injured or ill patients can I care for effectively and transport in the ambulance? One? Two?

• What happens when I have three patients to manage?

• How long will it take for additional help to arrive?

• What happens if the number of patients exceeds the number of available ambulances?

  • Declare an MCI, request resources, and initiate ICS

• Do not leave a scene if there are other patients present

Triage

• Sort patients based on the severity of their injuries

• Primary triage quickly and accurately categorizes patients’ conditions and transport needs

  • Communicate the total number of patients and number in triage categories, recommendations for extrication, and resources

• Secondary triage is done as patients are brought to the treatment area

Triage Categories

• Immediate (red-tag)

  • Problem with ABCs, head trauma, or shock

• Delayed (yellow-tag)

  • Injuries to bones and joints

• Minimal (green-tag)

  • Soft-tissue injuries

• Expectant (black-tag)

  • Dead or severe injuries, such as cardiac arrest or open head injuries

• Intermediate (orange-tag)

Triage Tags

• Tracks and keeps an accurate record of patients

• Part of a patient’s medical record

• Digital photography is catalogued with the patient’s tag number

START Triage

• Stands for Simple Triage And Rapid Treatment

• Uses limited assessment of the patient’s ability to walk, respiratory status, hemodynamic status (pulse), and neurologic status

1. Calling out to patients and directing them to easily identifiable landmarks (away from your ambulance).

   • Green tag patients

2. Directed toward non-walking patients, assessing their respiratory status.

   • Black tag patients who don’t breathe after a simple maneuver

   • Red tag those who breathe (respiratory rate greater than 30 breaths/min or less than 10 breaths/min)

   • If the patient is breathing between 10–29 breaths/min, move on to the next assessment

3. Assess hemodynamic status.

   • Red tag if there is an absent radial pulse

   • If the radial pulse is present, move on to the next assessment

4. Assess the patient’s neurological status.

   • Red tag if the patient is unconscious or cannot follow simple commands

   • Yellow tag if the patient complies with one command

JumpSTART Triage for Pediatric Patients

• For use in children younger than 8 years old or weighing less than 100 pounds

• First begins with identifying the walking wounded, infants or children not able to walk, are taken to the treatment area

• If a pediatric patient is not breathing, position the airway and reassess breathing

  • Red tag if the patient is breathing

  • Black tag apneic patients with no pulse

  • Red tag if the apneic patient is breathing after five rescue breaths

• Red tag if the patient’s respiratory rate is less than 15 breaths/min or greater than 45 breaths/min

  • Move on to the next assessment if the range is 15–45 breaths/min

• Red tag if there is an absence of a distal pulse

  • Move on to next assessment if there is a distal pulse

• Red tag if a child who is unresponsive or unable to localize pain

  • Yellow tag child who can localize pain

Triage Special Considerations

• Red tag hysterical and disruptive patients regardless of injury

• Red tag responders who become sick or injured

• Hazmat and weapons of mass destruction

Destination Decisions

• Red tags and yellow tags should be transported by ground or air ambulance

  • Should be transported two at a time

  • Two or three at a time for yellow tags

• Use buses in extremely large situations for green tags

  • Have one EMT present, and have an ambulance follow

Disaster Management

• Elected officials declare disasters

• Respond when requested and see IC for assigned tasks

• Establishment of casualty collection areas

Disaster

A widespread event that disrupts functions and resources of a community and threatens lives and property.

Introduction to Hazardous Materials

• Step back and assess the situation before providing care

• The Hazardous Waste Operations and Emergency Response (HAZWOPER)

  • An understanding of what hazardous substances are and the risks associated with them

  • An understanding of the potential outcomes of an incident

  • The ability to recognize the presence of hazardous substances

  • The ability to identify the hazardous substances, if possible

  • An understanding of the role of the first responder awareness individual in the emergency response plan

  • The ability to determine the need for additional resources and to notify the communication center

Recognizing a Hazardous Material

• Requires detective work

• Stay uphill and upwind

• Question people at the incident

• Assess scene and interpret clues

Hazardous Material

Any material that poses an unreasonable risk of damage or injury to people, property, or the environment if it is not properly controlled.

Occupancy and Location | Recognizing a Hazardous Material

• So many different chemicals exist

• Location and type of building are good indicators

Senses | Recognizing a Hazardous Material

• Sight and sound are the safest

Containers | Recognizing a Hazardous Material

• Any vessel or receptacle that holds a material

• The type of container can be important or not

Container Volume | Containers

• Bulk Storage Containers

  • Fixed tanks, highway cargo tanks, rail tank cars, totes, and intermodal tanks

  • Surrounded by secondary containment to prevent spillage

• Intermodal tanks are shipping and storage vessels

Nonbulk Storage Vessels | Containers

• All types of containers other than bulk containers

• Drums

  • Store food-grade materials, corrosive substances, flammable liquids, and grease

  • The nature of chemicals determines construction

• Bags

  • Store solids and powders

  • Pesticide bag must be labeled with specific information

• Carboys

  • Store 1–15 gallons of corrosives and other types of chemicals

• Cylinders

  • Store liquids and gases

The Department of Transportation Marking System

• An identification system characterized by labels, placards, and markings

• Placards are diamond-shaped indicators that are placed on all 4 sides of a transport vehicle that carries hazardous materials

• Labels are smaller version of placard and are placed on boxes or smaller packages

Other Considerations | Recognizing a Hazardous Material

• A package or cargo material requires a certain amount of material before a placard is required

• Some chemicals are so hazardous, any amount of them requires a placard and a four-digit United Nations number

• The Emergency Response Guidebook (ERG)

• MSDS sheets

• Shipping papers whenever materials are transported to one place or another

• Includes names, address, material, and quantity

  • Bills of lading or freight bills for highway transportation

The Chemical Transportation Emergency Center (CHEMTREC)

• Provides information to first responders of all disciplines who are called to respond to chemical incidents

• If calling have name of chemical, caller, location, shipper, container type, railcar or vehicle markings, shipping carrier’s name, recipient, and local conditions

Identification | Recognizing a Hazardous Material

• Difficult because inconsistencies in labelling, dishonest transporters, and laws and regulations can be misleading

• Some substances are hazardous when mixed → Use shipping papers as a first clue

• Hazmat incidents indicated by visible cloud, leak, or spill, or an odor

• A large number of gases and fluids are odorless; don’t approach if people collapse

• Park upwind and uphill if you are the first to arrive

• Assess the situation and provide as much information as possible

• Do not reenter the scene or leave the scene unless you are cleared by the hazmat team

Establishing Control Zones | Hazmat Scene Operations

• Reduces the number of civilians and first responders who may be exposed

• Established based on chemical, environmental factors, and general layout

• If indoors, control access at doors

• If outdoors, control points around the hazard

• As the IC gets more information, control zones may grow or shrink—wind shifts are a factor

• The hot zone is the area immediately surrounding the release

• The warm zone

  • Personnel and equipment transition in and out

  • Location of the decontamination area, which must have containers for decontaminated clothing

• Cold zones are safe areas in which personnel don’t have to wear safe clothing

Role of the EMT | Hazmat Scene Operations

Report outside of hot and warm zones and provide triage, treatment, transport, or rehabilitation.

Classification of Hazardous Materials | Recognizing a Hazardous Material

• Toxicity Level

  • Measures the health risks a substance has

  • Level 0

    • Materials that cause no harm

  • Level 1

    • Materials that cause irritation

  • Level 2

    • Materials that could cause temporary damage or residual injury

  • Level 3

    • Materials that are extremely hazardous to health

  • Level 4

    • Materials so hazardous, minimal contact causes death

Personal Protective Equipment Level | Recognizing a Hazardous Material

• Level A

  • Most hazardous, requires fully encapsulated, chemical-resistant protective clothing and SCBA

• Level B

  • Requires non-encapsulated protective clothing

• Level C

  • Requires the use of nonpermeable clothing and eye protection. Face masks with that filter inhaled air out

• Level D

  • Requires a work uniform

• All levels require gloves

Caring for Patients at a Hazmat Incident | Recognizing a Hazardous Material

• Provide the simplest assessment and essential care

• No bandages or splints are applied until the decontaminated patient is in the treatment area

• Most deaths come from airway and breathing problems

  • Give oxygen at 12–15 L/min

• Antidotes or special treatments ordered by medical control

  • Medications, IV, or advanced care, paramedics/advanced personnel will be sent

Special Care

• Patients who require treatment if the duration of decontamination proves fatal

  • Rapid rinse after cutting a patient’s clothing

• Increase amount of protective gear when dealing with patients who aren’t properly decontaminated

• Prior to arrival:

  • Tape ambulance doors shut

  • Items not used should be placed in the outside compartments or in the front of the ambulance

  • Turn on the power vent ceiling fan and the air-conditioning unit fan when loading patients

  • Windows should be partially opened

  • Inform the hospital of a patient not fully decontaminated

  • Decontaminate the ambulance