Incident Command at a Mass Casualty Incident

Chris Goliver, M.D.Chief Resident

St. Vincent’s Mercy Medical Center

Incident Command System

Designed for all kinds of emergencies

Applicable from single jurisdiction to multiagency incidents

Applicable to both small day to day operations as well as very large and complex incidents

Design Requirements

Structure must be able to adapt to any type of emergency

Must be applicable to users of diverse backgrounds

Should be readily adaptable Must be able to expand Must be able to avoid CHAOS

CHAOS

C - Chief H - Has A - Arrived O - On S - Scene

ICS Terminology

Apparatus Command Command Post Communications Center Sector Staging Area

ICS Operations

Common Terminology - All communications should be in plain English (NO Codes)

Modular Organization Manageable Span of Control - In

general from 3 to 7 Unified Command Structure

Command Post

Location from which all operations are directed

Should only be one command post All appropriate authorities should

be at the command post

Staging Area

Established for temporary location of equipment and personnel

Status Conditions - Assigned, Available, and Out of Service

Major Incident

An event for which available resources are insufficient to manage the number of casualties

Consider in cases which require more than two ambulances, hazardous materials or specialized equipment

Preparing for a Major Incident

Phase 1 - The Preplan Phase 2 - Scene Management Phase 3 - Post Disaster Follow-up

FEMA Incident Command System

Federal law requires the use of ICS for hazardous materials incidents

Ideal to use the ICS as standard operating procedure on all incidents

ICS Organization

Built around five major components

Command Planning Operations Logistics Finance / Administration

Command Function

Command should belong to one person who can coordinate a variety of emergency activities

Command should be established immediately

The Incident Commander must be clearly identified

Types of Command

Singular Command - One individual is responsible for the entire operation

Unified Command - Specialized organizations are identified and personnel unify to compliment command

Example of Unified Command

Incidents that affect more than one jurisdiction

Incidents involving multiple agencies within a jurisdiction

ICS Organization

The Incident Commander will base decisions to expand the ICS Organization based on three major incident priorities:

Life Safety Incident Stability Property Conservation

Planning Section

Provides past, present, and future information about the incident and the status of resources

Operations Section

Directs and Coordinates all emergency scene operations

Ensures safety of all operational personnel

Operations Section Chief is in charge of the actual scene

Logistics Section

Supports the logistical needs of the incident

Primary function is to provide gear and support to the incident responders

Finance/Administration Section

Seldom used on small scale incidents

Accounts for costs and accounting of personnel

Establishing Command

Generally the first arriving unit starts the Incident Command System

Unification of EMS command with fire and police may become necessary

Scene Assessment

First unit on scene should make a quick and rapid assessment of the situation: Type of incident, Number of patients, Additional resources needed

Scene assessment must be continually updated

Obtaining Resources

Should have a written Standard Operating Procedure already in place for requesting additional resources

Use of staging to ensure timely response of resources

Task Force

Any combination of resources put together for a specific assignment

Strike Team

Set number of resources of the same kind and type

Examples: Ambulances, Engine companies

Extrication Sector

Responsible for managing entrapped patients at the scene

Patient care activities should only include assessment and treatment of life threatening injuries

Treatment Sector

As patients are delivered they are categorized according to their medical needs

Provides advanced care and stabilization until the patients are transported to a medical facility

Rehabilitation Sector

Usually set up in a location outside the operational area

Monitors personnel and ensures proper rest and hydration

Works with logistics to ensure proper hydration, nutrition and supplies

On-Scene Physicians

Medical Direction for EMS personnel

Use at treatment area to make secondary triage decisions

Emergency Surgery to facilitate extrication

Disposition of the Deceased

Assisting in the establishment of an appropriate and secure area for a morgue

Working with the medical examiner, law enforcement and other appropriate agencies to coordinate disposition

Transportation Sector

Communicates with the receiving hospitals, ambulances and aeromedical services

Must work closely with the treatment sector to determine appropriate destinations for the injured

Staging Sector

Required for large incidents to prevent vehicle congestion and delays

All emergency vehicles should report to staging for further direction

Support Sector

Coordinates the gathering and distribution of equipment and supplies for all other sectors

May be responsible for obtaining medical supplies, rescue equipment, etc.

Sector Identification

Radio communications use operation titles instead of personal or unit names

For example EMS sector to Command

Radio Communications

Preplanning includes identifying a radio frequency to be used in a major incident

All responding units should have multi-channel radios

Separate frequencies for EMS, Fire, Police, Etc.

Radio Communications

Sector Officers should have radios that allow direct communication with Command

Radio traffic MUST be in clear, concise and plain English

Avoid use of radio codes and signals

Principles of Triage

A method used to categorize patients for priorities of treatment

Assessment of patient severity is based on: Abnormal vital signs, Obvious anatomic injury, Concurrent disease factors that might affect prognosis

Primary vs. Secondary Triage

Triage is a CONTINUOUS process

Primary Triage

Used to rapidly categorize patient condition for treatment

Label patient with triage labels, tags or tape

Focus on speed to sort patients quickly

No care other than immediate lifesaving interventions

Secondary Triage

Used at Treatment area Patients are triaged and labeled

according to their present physiological status

START Triage

Simple Triage And Rapid Treatment. Uses a 60 second assessment

Focuses on the patient’s: Ability to Walk Respiratory Effort Pulses / Perfusion Neurological Status

30 - 2 - Can Do

Respiratory Rate >30 or <10 Capillary Refill < 2 seconds or

Positive Carotid with Negative Radial Pulses

Altered Mental Status or Inability to Follow Commands

START Triage

Assessment used to classify victims as:

Urgent Delayed Dead or Dying Critical

START Triage

Allows rescuers to quickly identify victims at greatest risk of early death

Advise other rescuers of the patient’s need for stabilization by tagging the patient with color coded disaster tags

START Triage

Repositioning the airway and controlling severe hemorrhage are the only initial treatment efforts in the primary triage

Triage Labeling

Many Variations of tags, tape and labels are available

Immediate - Red - Priority 1 Delayed - Yellow - Priority 2 Hold - Green - Priority 3 Deceased - Black - Priority 4

Purpose of Tagging

Identify the priority of the patient All tags and labels should be easy

to use, rapidly identify patient priority, allow for easy tracking, allow room for documentation and prevent patient from being re-triaged

Tracking System

A destination log that integrates the triage tagging system must be maintained by the transportation officer

Triage log must contain: Patient ID, Transporting unit, Patient priority, and Hospital destination

Transportation of Patients

Method of transportation determined by triage priority and situation

Air ambulances are usually reserved for critical patients

Buses should be considered for transporting large number of priority 3 patients

Critical Incident Stress Management

A potential hazard for rescue personnel

Should be part of the post disaster SOP

Monitor personnel for signs of stress

Develop pre-designated resources