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Chapter 47Chapter 47
Incident Management and Multiple-Casualty Incidents
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
EMS Operations
Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Incident Management
Establish and work within the incident management system.
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Multiple-Casualty Incidents
• Triage principles
• Resource management
• Triage − Performing
− Retriage
− Destination decisions
− Post-traumatic and cumulative stress
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IntroductionIntroduction
• Multiple-casualty incidents (MCIs) and disasters can be overwhelming.
• Response should use the principles of the incident command system (ICS).
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IntroductionIntroduction
• The National Incident Management System (NIMS) encourages organized response from all agencies.− Homeland Security Presidential Directive
requires students to complete certification and understand NIMS.
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The NIMSThe NIMS
• Provides consistent nationwide template for emergency response− Key principles:
• Flexibility
• Standardization
• Interoperability
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Major Components of NIMSMajor Components of NIMS
• Command and management
• Preparedness
• Resource management
• Communications and information management
• Supporting technologies
• Management and maintenance
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The Incident Command SystemThe Incident Command System
• Common language and “clear text” ensures better communication.
• Creates a modular organizational structure
• Controls duplication of effort and freelancing
• Limits span of control
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The Incident Command SystemThe Incident Command System
• Organizational divisions:− Sections
− Branches
− Divisions and groups
− Resources
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The Incident Command SystemThe Incident Command System
• Responders should find out:− Does ICS exists?
− Who is in charge?
− How is it activated?
− What will be your role?
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Incident Command System Roles and ResponsibilitiesIncident Command System Roles and Responsibilities
• Command− Incident
commander (IC)• Evaluates incident
• Creates plan of action
• Number of duties depends on size of incident
© FirePhoto/Alamy Images
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Incident Command System Roles and ResponsibilitiesIncident Command System Roles and Responsibilities
• Command (cont’d)− Unified command system
• Used when incident requires multiple organizations/jurisdictions
− Single command system• Used when one agency has the majority of
responsibility for incident management
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Incident Command System Roles and ResponsibilitiesIncident Command System Roles and Responsibilities
• Command (cont’d)− IC should be easy to identify.
− Transfer of command should be directed by standard operating procedures (SOPs).
− Termination of command and demobilization procedures should occur at the end of an incident.
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Incident Command System Roles and ResponsibilitiesIncident Command System Roles and Responsibilities
• Finance− Responsible for documenting all expenses that
should be reimbursed.
− Roles include:• Time unit
• Procurement unit
• Compensation/claims unit
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Incident Command System Roles and ResponsibilitiesIncident Command System Roles and Responsibilities
• Logistics− Responsibilities
include:• Facilities
• Food and water
• Equipment and supplies
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Incident Command System Roles and ResponsibilitiesIncident Command System Roles and Responsibilities
• Operations− Manage tactical
operations job.
− Oversee responders.
• Planning− Problem-solve as
issues arise.
− Predict next steps.
− Develop:• Demobilization
plan
• Incident action plan
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Incident Command System Roles and ResponsibilitiesIncident Command System Roles and Responsibilities
• Command staff− Safety officer
• Monitors for hazards
− Public information officer (PIO)• Presents information to the public and media
− Liaison officer (LNO)• Relays information between command, general
staff, and other agencies
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Communications and Information Management
Communications and Information Management
• All agencies should be able to communicate easily and quickly by radio. − Maintain professionalism.
− Communicate clearly and concisely.
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Mobilization and DeploymentMobilization and Deployment
• Check-in with finance section.
• Check-in with supervisor.
• Keep records.
• Keep your supervisor up to date.
• IC will decide on demobilization.
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PreparednessPreparedness
• Written disaster plans should be located in every EMS vehicle.
• EMS facilities are stocked with supplies.
• Mutual aid agreements are made with nearby organizations.
• Make sure you have immunizations.
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Scene Size-UpScene Size-Up
• When you arrive on the scene, ask yourself:− What do I have?
− What do I need to do?
− What do I need?
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Establish CommandEstablish Command
• Notify other responders and request necessary resources.
• Establish command early on.
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CommunicationsCommunications
• Use face-to-face communication when possible.− If you are communicating by radio do not use
codes or signals.
• Communication should be reliable, durable, field tested, and have backups.
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Medical Incident CommandMedical Incident Command
• Medical branch director oversees roles of medical team.
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Triage SupervisorTriage Supervisor
• Counts and prioritizes patients
• Ensures each patient receives an initial assessment
© David Crigger, Bristol Herald Courier/AP Photos
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Treatment SupervisorTreatment Supervisor
• Designates an area where patients are treated by their priority
• Sees that each patient has secondary triage
• Assists with moving patients
• Communicates the request for supplies
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Transportation SupervisorTransportation Supervisor
• Coordinates the transportation and distribution of patients
• Tracks and records: − Number of vehicles transporting
− Patients transported
− Destination of both
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Staging SupervisorStaging Supervisor
• Designates location for the staging area
• Plans for access and exit from the site
• Prevents traffic congestion
• Releases vehicles/supplies when needed
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Physicians on ScenePhysicians on Scene
• Assist with triage decisions
• Provide on-site medical direction and treatment
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Rehabilitation SupervisorRehabilitation Supervisor
• Creates a rehabilitation area during an incident that will last for a while
• Monitors personnel for stress signs
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Extrication and Special RescueExtrication and Special Rescue
• Supervisor coordinates the equipment and resources needed
• Typically work under the EMS branch © Courtesy Everett Col/age fotostock
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Morgue SupervisorMorgue Supervisor
• Works with medical examiners, coroners, disaster mortuary assistance, and law enforcement
• Coordinates body removal
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Multiple-Casualty IncidentsMultiple-Casualty Incidents
• MCI is defined as: − Having three or
more patients
− Stress on resources; requires mutual aid response
− An incident that can create one of the above
Courtesy Michael Rieger/FEMA
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Multiple-Casualty IncidentsMultiple-Casualty Incidents
• Open incident − Unknown amount
of casualties
− May need to search for patients
− Incident may be ongoing
• Closed incident − Number of
patients not expected to change
− Patients are triaged and treated as they are removed
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Multiple-Casualty IncidentsMultiple-Casualty Incidents
• The following questions will help you determine whether an incident is an MCI:− How many injured/ill patients can you care for?
− What happens when you have three patients?
− How long will it take for help to arrive?
− What do you do when you have eight critical patients and only three ambulances?
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Multiple-Casualty IncidentsMultiple-Casualty Incidents
• Never leave patients without other assistance.
• Declare an MCI if there are more patients than resources.
• Always follow local protocol.
© Nancy G Fire Photography, Nancy Greifenhagen/Alamy Images
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TriageTriage
• Sorting patients by seriousness of injury− Primary triage
takes place at the scene.
− Secondary triage takes place in the treatment areas.
Courtesy of Journalist 1st Class Mark D. Faram/U.S. Navy
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Triage CategoriesTriage Categories
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Triage TagsTriage Tags
• Should be:− Weatherproof
− Easy to read
− Color-coded
− Identify category
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Triage TagsTriage Tags
• Digital photos are sometimes used in identification of victims.
• Another alternative: Assign 20–25 tags at a time with a scorecard to mark patient category and priority.
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START TriageSTART Triage
• Simple Triage and Rapid Treatment (START) − Limited evaluation of:
• Ability to walk
• Respiratory status
• Hemodynamic status
• Neurologic status
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START TriageSTART Triage
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JumpSTART Triage for Pediatric Patients
JumpSTART Triage for Pediatric Patients
• Used for children under 8 years old or who appear to weigh less than 100 lbs
© L
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Triage Special ConsiderationsTriage Special Considerations
• Hysterical or disruptive patient
• Injured or sick responder
• Hazardous materials or weapons of mass destruction
• Multiple teams or areas of triage
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Destination DecisionsDestination Decisions
• Refer patients to trauma centers using:− Physiologic criteria
− Anatomic criteria
− Mechanism of injury
− Special considerations
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Destination DecisionsDestination Decisions
• Consider which hospital has the appropriate means to help a patient.
• Transport patients that are categorized as immediate by ambulance or air ambulance.− Walking wounded can be transported by bus if
needed.
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Destination DecisionsDestination Decisions
• Transport immediate patients two at a time.
• Transport delayed two or three at a time.
• Transport slightly injured last.
• Expectant patients are treated once all patients have been transported.
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Critical Incident Stress Management
Critical Incident Stress Management
• Emergency workers may suffer from psychological impact of MCI.
• Disaster plan may include a resource for debriefing or defusing of responders.
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Critical Incident Stress Management
Critical Incident Stress Management
• Critical incident stress management (CISM)− Should be available to all
− Participation not required
• Record psychological impact in post-incident evaluation.
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After-Action ReviewAfter-Action Review
• Include what worked and what didn’t work
• All observations should be written down.
• Never accuse someone of doing something wrong during the incident.
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SummarySummary
• Major incidents require the involvement and coordination of multiple jurisdictions, functional agencies, and emergency response disciplines.
• The National Incident Management System (NIMS) provides a consistent nationwide template to enable federal, state, and local governments to work together effectively and efficiently.
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SummarySummary
• The major NIMS components are command and management, preparedness, resource management, communications and information management, supporting technologies, and ongoing management and maintenance.
• The purpose of the incident command system (ICS) is to ensure safety, achieve incident management goals, and ensure the efficient use of resources.
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SummarySummary
• Using the ICS gives you a modular organizational structure that is built on the size and complexity of the incident.
• Preparedness involves the decisions and planning done before an incident occurs.
• Your agency should have written disaster plans.
• General ICS staff roles include command, finance, logistics, operation, and planning.
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SummarySummary
• At incidents that have a significant medical factor, the incident commander should appoint someone as the medical branch director.
• A multiple-casualty incident refers to any call that involves three or more patients, any situation that would require a mutual aid response, or any incident that has a potential to create one of the previously mentioned situations.
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SummarySummary
• The goal of triage is to do the greatest good for the greatest number.
• The four common triage categories are immediate (red), delayed (yellow), minimal (green), and expectant (black; likely to die or dead).
• It is vital to tag each patient during triage.
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SummarySummary
• START triage uses a limited assessment of the patient to triage patients.
• JumpSTART triage modifies the START triage system to take into account the differences of pediatric patients.
• Consider critical incident management before, during, or after an event.
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CreditsCredits
• Chapter opener: © David Crigger, Bristol Herald Courier/AP Photos
• Backgrounds: Orange—© Keith Brofsky/Photodisc/Getty Images; Red—© Margo Harrison/ShutterStock, Inc.; Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Blue—Courtesy of Rhonda Beck
• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.