medical incident command

8/14/2019 Medical Incident Command

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Chapter 50Chapter 50

Medical Incident CommandMedical Incident Command


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ObjectivesObjectives

Identify components of an incident commandIdentify components of an incident commandsystem (ICS)system (ICS)

Outline activities in preplanning sceneOutline activities in preplanning scene

management, and postdisaster follow-up of anmanagement, and postdisaster follow-up of anincidentincident

Identify FEMAs five ICS componentsIdentify FEMAs five ICS components

List command responsibilities during a majorList command responsibilities during a major

incident responseincident response


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ObjectivesObjectives Describe FEMA ICS section responsibilitiesDescribe FEMA ICS section responsibilities

Identify situations classified as major incidentsIdentify situations classified as major incidents

Describe steps needed to establish and operateDescribe steps needed to establish and operatethe ICSthe ICS

Given a major incident, describe sectors neededGiven a major incident, describe sectors needed

and responsibilities of eachand responsibilities of each


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ObjectivesObjectives

List problems related to the ICS andList problems related to the ICS and

to mass casualty situationsto mass casualty situations

Outline principles and technology ofOutline principles and technology of

triagetriage

Identify resources for managementIdentify resources for management

of critical incident stressof critical incident stress


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ScenarioScenario

Icy wind and sleet pound yourIcy wind and sleet pound your

ambulance as you arrive on theambulance as you arrive on the

scene of an overturned school bus inscene of an overturned school bus in

a small creek. Size-up reveals 18a small creek. Size-up reveals 18

young children and an elderly driver,young children and an elderly driver,

with several apparently severewith several apparently severe

injuries, difficult access to theinjuries, difficult access to thepatients, and diesel fuel leaking frompatients, and diesel fuel leaking from

the bus.the bus.


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Major IncidentMajor Incident

Event in which the available resourcesEvent in which the available resources

are insufficient to manage the numberare insufficient to manage the number

of casualties or the nature ofof casualties or the nature of

emergencyemergency May stress local, regional, state, andMay stress local, regional, state, and

even national and international resourceseven national and international resources

Examples of major incidentsExamples of major incidents


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Incident Command SystemIncident Command System

(ICS)(ICS)

Effective ICS allows for involvementEffective ICS allows for involvement

of:of: Single jurisdiction; single agencySingle jurisdiction; single agency

Single jurisdiction; multiagencySingle jurisdiction; multiagency

Multijurisdiction; multiagencyMultijurisdiction; multiagency


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Incident Command SystemIncident Command System

(ICS)(ICS)

Expands from nonmajor incident toExpands from nonmajor incident to

major incident in logical mannermajor incident in logical manner Using ICS as standard operatingUsing ICS as standard operating

procedure for small incidents permitsprocedure for small incidents permits

smooth transition in major incidentsmooth transition in major incident


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FEMA ICSFEMA ICS

Federal law requires ICS for hazmat incidentsFederal law requires ICS for hazmat incidents Many states use ICS for all types of incidentsMany states use ICS for all types of incidents

Incident management or command systemIncident management or command system

Developed by FEMADeveloped by FEMA

National standard for incident managementNational standard for incident management

Flexible systemFlexible system

Used by both public and private sectors in some routine andUsed by both public and private sectors in some routine and

most large-scale emergenciesmost large-scale emergencies


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ICS StructureICS Structure


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ICS OrganizationICS Organization

Five major componentsFive major components CommandCommand

PlanningPlanning

OperationsOperations

LogisticsLogistics

Finance/administrationFinance/administration


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The Command FunctionThe Command Function

One person coordinates variety of emergencyOne person coordinates variety of emergencyactivitiesactivities Cornerstone of ICS structureCornerstone of ICS structure

Initial command determined in preplanInitial command determined in preplan

Command established immediatelyCommand established immediately

Commander clearly identifiedCommander clearly identified

Commander responsibilitiesCommander responsibilities


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Types of CommandTypes of Command

Singular commandSingular command One individual responsible for operationOne individual responsible for operation

Unified commandUnified command Large events or as small incident evolvesLarge events or as small incident evolves

Specialized organizations identified andSpecialized organizations identified and

personnel unify to complement commandpersonnel unify to complement command EMS, fire, police, health department, Red CrossEMS, fire, police, health department, Red Cross


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Application of UnifiedApplication of Unified

CommandCommand


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ICS OrganizationICS Organization

Incident commander (IC) expands (orIncident commander (IC) expands (or

contracts) ICS organization based on:contracts) ICS organization based on: Life safetyLife safety

Incident stabilityIncident stability

Property conservationProperty conservation

If expansion is needed:If expansion is needed: Other command staff positions establishedOther command staff positions established


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Possible Command StaffPossible Command Staff

PositionsPositions


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Section ResponsibilitiesSection Responsibilities

Sections assigned by IC to sectionSections assigned by IC to section

chiefschiefs PlanningPlanning

OperationsOperations

LogisticsLogistics

Finance/administrationFinance/administration

Section chiefs report to ICSection chiefs report to IC


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Command SectionCommand SectionOrganizational PlanOrganizational Plan


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Section ChiefsSection Chiefs

Strong supervisors and managersStrong supervisors and managers

Primary rolePrimary role

Make things happenMake things happen Ensure rescuers working toward common goalEnsure rescuers working toward common goal

Number of sections varies by incidentNumber of sections varies by incident Determined by ICDetermined by IC


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Section ChiefsSection Chiefs

Not involved in physical tasksNot involved in physical tasks Accomplish command objectivesAccomplish command objectives Monitor work progressMonitor work progress

Redirect activities if neededRedirect activities if needed Coordinate activities with other sectionsCoordinate activities with other sections Request other resources as neededRequest other resources as needed

Monitor welfare of personnel in sectionMonitor welfare of personnel in section Provide command with frequent reportsProvide command with frequent reports Reallocate resources within sectionReallocate resources within section


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Planning SectionPlanning Section

Provides past, present, and futureProvides past, present, and future

information about incident and statusinformation about incident and status

of resourcesof resources Creates incident action plan (IAP)Creates incident action plan (IAP)

Operational periodsOperational periods


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Planning SectionPlanning Section


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Operations SectionOperations Section

Directs and coordinates emergency sceneDirects and coordinates emergency scene

operationsoperations

Ensures safety of operational personnelEnsures safety of operational personnel EMS operations often fall under this sectionEMS operations often fall under this section

Operations section chief is in charge of actualOperations section chief is in charge of actual

scene (ground zero)scene (ground zero)

ResponsibilitiesResponsibilities


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Operations SectionOperations Section


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Logistics SectionLogistics Section

Supports logistical needs of incidentSupports logistical needs of incident

Logistics appropriate to incidentLogistics appropriate to incidentsize/durationsize/duration

Provides gear and support toProvides gear and support torespondersresponders


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Logistics SectionLogistics Section


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Finance/AdministrationFinance/Administration

SectionSection Accounting and administration of incidentAccounting and administration of incident

Staff support functionStaff support function

Monitors costs, careful accountingMonitors costs, careful accounting

Seldom used on small incidentsSeldom used on small incidents

Essential as incident growsEssential as incident grows And on hazmat incidentsAnd on hazmat incidents

Not used in routine daily incidentsNot used in routine daily incidents


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Finance/AdministrationFinance/Administration

SectionSection


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Declaring a MajorDeclaring a Major

IncidentIncident More than two ambulances neededMore than two ambulances needed

Particularly in rural areasParticularly in rural areas

Situations involving hazardous orSituations involving hazardous or

radioactive materials or chemicalsradioactive materials or chemicals

Situations needing special resourcesSituations needing special resources Helicopters, rescue teams, multiple rescue orHelicopters, rescue teams, multiple rescue or

extrication unitsextrication units

When in doubt, declare a major incidentWhen in doubt, declare a major incident


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Preparing for a MajorPreparing for a Major

IncidentIncident Phase 1: The preplanPhase 1: The preplan

Phase 2: Scene managementPhase 2: Scene management

Phase 3: Post-disaster follow-upPhase 3: Post-disaster follow-up


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Major Medical IncidentsMajor Medical Incidents

Need to establish ICS at medicalNeed to establish ICS at medical

incident determined by:incident determined by: Number of casualtiesNumber of casualties

Nature of the eventNature of the event

Local/regional thresholdLocal/regional threshold


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Examples of Medical ICSExamples of Medical ICS


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Establishing CommandEstablishing Command

Group/sector functions or major functional areasGroup/sector functions or major functional areasimplemented by incident size and scopeimplemented by incident size and scope

Groups and sectors may include:Groups and sectors may include:

Support sectorSupport sector Staging sectorStaging sector

Helicopter LZs and vehicle apparatus arrivalsHelicopter LZs and vehicle apparatus arrivals

Treatment sectorTreatment sector

Unified EMS command with fire and police may beUnified EMS command with fire and police may be

neededneeded


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Scene AssessmentScene Assessment

First unit on sceneFirst unit on scene Rapid assessment of situationRapid assessment of situation

Full assessment as safety and time permitFull assessment as safety and time permit

Type of incident and potential durationType of incident and potential duration Entrapment or special rescue resources neededEntrapment or special rescue resources needed

Number of patients in each triage categoryNumber of patients in each triage category

Additional resources neededAdditional resources needed

Scene assessment continually updatedScene assessment continually updated


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CommunicationsCommunications

Command established by radio with dispatchCommand established by radio with dispatch EOC is where department heads, governmentEOC is where department heads, government

officers and officials, and volunteer agenciesofficers and officials, and volunteer agencies

gather to coordinate response to emergencygather to coordinate response to emergency

eventevent

Command and EOC share goalsCommand and EOC share goals

Different levels of responsibilityDifferent levels of responsibility

IC is responsible for on-scene activitiesIC is responsible for on-scene activities

EOC responsible for community-wide responseEOC responsible for community-wide response


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Obtaining ResourcesObtaining Resources

Request additional units as needed:Request additional units as needed: Dispatch should have written standardDispatch should have written standard

operating procedure (SOP) for requestingoperating procedure (SOP) for requesting

mutual aidmutual aid

May need to obtain food, shelter, clothingMay need to obtain food, shelter, clothing

IC responsible for deployment of resourcesIC responsible for deployment of resources Stay with vehicle until instructions receivedStay with vehicle until instructions received

Staging techniques used to deploy resourcesStaging techniques used to deploy resources


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Extrication SectorExtrication Sector

Manages entrapped patientsManages entrapped patients

Patient care activities in this sectorPatient care activities in this sector Only assessment and treatment of lifeOnly assessment and treatment of life

threatening situationsthreatening situations

Additional responsibilitiesAdditional responsibilities


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Treatment SectorTreatment Sector

Works with extrication sector in patient careWorks with extrication sector in patient care As patients delivered, categorized by medical needAs patients delivered, categorized by medical need

Care and stabilization until patients transported toCare and stabilization until patients transported to

medical facilitymedical facility Paramedics and hospital personnelParamedics and hospital personnel

With large numbers of patients:With large numbers of patients: Divided into immediate and delayed treatment zonesDivided into immediate and delayed treatment zones


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On-Scene Physicians atOn-Scene Physicians at

MCIsMCIs Medical directionMedical direction

On-scene medical directionOn-scene medical direction

Triage functionTriage function Increased ability to make difficult triage decisionsIncreased ability to make difficult triage decisions In treatment area for secondary triage decisionsIn treatment area for secondary triage decisions

Emergency surgery to facilitate extricationEmergency surgery to facilitate extrication

Treatment capabilitiesTreatment capabilities Invasive proceduresInvasive procedures

Assessment and direction of specific treatmentsAssessment and direction of specific treatments

i i i f hDi i i f h


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Disposition of theDisposition of the

DeceasedDeceased Depends on scale of incidentDepends on scale of incident

Personnel assigned to disposition of deceasedPersonnel assigned to disposition of deceased

DutiesDuties Work with medical examiner, coroner, lawWork with medical examiner, coroner, law

enforcement to coordinate dispositionenforcement to coordinate disposition

Assist in establishment of secure area for morgueAssist in establishment of secure area for morgue

if neededif needed Monitor personnel for signs of stressMonitor personnel for signs of stress


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Transportation SectorTransportation Sector

Communicates with hospitals, ambulances, andCommunicates with hospitals, ambulances, andaeromedical services for patient transportaeromedical services for patient transport

Works closely with treatment sector toWorks closely with treatment sector todetermine appropriate patient destinationsdetermine appropriate patient destinations

Arrival and departure of vehicles coordinatedArrival and departure of vehicles coordinatedwith staging sectorwith staging sector



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Staging SectorStaging Sector

Prevents vehicle congestion andPrevents vehicle congestion andresponse delaysresponse delays

All emergency vehicles should reportAll emergency vehicles should reportfor directionfor direction Other agencies supervised by stagingOther agencies supervised by staging

sector (disaster relief, news media)sector (disaster relief, news media)


h bili i ( h b)


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Rehabilitation (Rehab)Rehabilitation (Rehab)

SectorSector Standard operating procedures in many fireStandard operating procedures in many fire

and EMS agencies and major incidentand EMS agencies and major incident

response plansresponse plans

Set up outside operational areaSet up outside operational area

Monitors personnelMonitors personnel Ensures proper rest and hydrationEnsures proper rest and hydration

Works with logistics sectorWorks with logistics sector


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Support SectorSupport Sector

Coordinates equipment and suppliesCoordinates equipment and supplies

for all sectorsfor all sectors

May obtain medical supplies fromMay obtain medical supplies from

hospitals, rescue supplies, and otherhospitals, rescue supplies, and other

equipmentequipment



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Sector IdentificationSector Identification

All emergency responders must know ICSAll emergency responders must know ICSstructure and radio communicationstructure and radio communicationprocedureprocedure

Clothing and identification vary by systemClothing and identification vary by system Color-coded vests identify personnelColor-coded vests identify personnel Most communication face to faceMost communication face to face

ExceptionException Command and sector communicationsCommand and sector communications

Radio use is for command operationsRadio use is for command operations


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Sector IdentificationSector Identification

Radio communications use operationRadio communications use operation

titles:titles: "EMS sector to command" or "Fire sector"EMS sector to command" or "Fire sector

to rescue sector"to rescue sector" Ensures reaching appropriate individualEnsures reaching appropriate individual

by one radio designationby one radio designation


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Radio CommunicationsRadio Communications

Key function during major incidentKey function during major incident Preplanning includes identification ofPreplanning includes identification of

radio frequenciesradio frequencies

Responding units should have radiosResponding units should have radios

using common frequencyusing common frequency Separate frequencies for EMS, fire, andSeparate frequencies for EMS, fire, and

other support operationsother support operations


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Sector officers radios on channelSector officers radios on channel

that permits direct communicationsthat permits direct communications

with commandwith command Frequencies may be assigned inFrequencies may be assigned in

advanceadvance

Or by dispatching agency at incidentOr by dispatching agency at incident


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Clear, concise, and in plain EnglishClear, concise, and in plain English Helps set orderly toneHelps set orderly tone Avoid use of radio codes/signalsAvoid use of radio codes/signals

Prepare messages before transmittingPrepare messages before transmitting

Clearly identify unit number or sectorClearly identify unit number or sector

Minimize radio trafficMinimize radio traffic

Face-to-face communication preferredFace-to-face communication preferred

C P bl fCommon Problems of


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Common Problems ofCommon Problems of

MCIsMCIs

Failure to notify everyoneFailure to notify everyone

Lack of rapid patient stabilizationLack of rapid patient stabilization

Failure to collect patients in treatment areaFailure to collect patients in treatment area

Failure to triage properlyFailure to triage properly

Administering too much careAdministering too much care

Transporting patients prematurelyTransporting patients prematurely

C P bl fCommon Problems of


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Common Problems ofCommon Problems of

MCIsMCIs Using personnel improperlyUsing personnel improperly

Failure to distribute patients to hospitalsFailure to distribute patients to hospitals

appropriatelyappropriately

Lack of EMS command in fieldLack of EMS command in field

Lack of hospital communicationLack of hospital communication

Lack of preplanning and trainingLack of preplanning and training


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Principles of TriagePrinciples of Triage

TriageTriage Method to categorize patients for priorities ofMethod to categorize patients for priorities of

treatmenttreatment

Assessment of injury severity based on:Assessment of injury severity based on: Abnormal physiological signsAbnormal physiological signs

Anatomic injury (and mechanism of injury)Anatomic injury (and mechanism of injury)

Concurrent disease factorsConcurrent disease factors

Triage is aTriage is a continuouscontinuous process during a majorprocess during a major

incidentincident

Primar s SecondarPrimary vs Secondary


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Primary vs. SecondaryPrimary vs. Secondary

TriageTriage Primary triagePrimary triage

Categorizes patient condition for treatmentCategorizes patient condition for treatment

Documents patient location and transportDocuments patient location and transport

needsneeds Labels patient with triage labels, tags, or tapeLabels patient with triage labels, tags, or tape

Focuses on speed to sort patientsFocuses on speed to sort patients

No care rendered during primary triageNo care rendered during primary triage

Except lifesaving airway or hemorrhage controlExcept lifesaving airway or hemorrhage control

Primary vs SecondaryPrimary vs Secondary


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Primary vs. SecondaryPrimary vs. Secondary

TriageTriage Secondary triageSecondary triage

At treatment areaAt treatment area

Patients retriaged and labeledPatients retriaged and labeled

Not always necessaryNot always necessary Especially at small incidentsEspecially at small incidents


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START TriageSTART Triage

START (simple triage and rapidSTART (simple triage and rapid

treatment)treatment) 60-second assessment60-second assessment

Evaluate:Evaluate: Ability to walkAbility to walk

Respiratory effortRespiratory effort Pulses/perfusionPulses/perfusion

Neurological statusNeurological status


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Classify patients as:Classify patients as: UrgentUrgent

DelayedDelayed

Dead or dyingDead or dying

CriticalCritical


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Allows rescuers to:Allows rescuers to: Identify patients at risk of early deathIdentify patients at risk of early death

Advise others of patient's need forAdvise others of patient's need for

stabilization by tagging with disasterstabilization by tagging with disastertagstags


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START Triage SystemSTART Triage System

Insert

Fig 50-10

Insert

Fig 50-10


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Assess ability to walkAssess ability to walk

Evaluate breathing and rateEvaluate breathing and rate

Assess pulses/perfusionAssess pulses/perfusion

Assess mental statusAssess mental status


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Repositioning of airway andRepositioning of airway and

controlling severe hemorrhage arecontrolling severe hemorrhage are

only treatment efforts in primaryonly treatment efforts in primary

triage:triage: In a mass casualty event, theseIn a mass casualty event, these

measures should not delay triage ofmeasures should not delay triage of

other patientsother patients


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Triage Tagging/LabelingTriage Tagging/Labeling

Many tags, tape, and labels availableMany tags, tape, and labels available

International color coding and prioritiesInternational color coding and priorities

ImmediateImmediate RedRed Priority-1Priority-1 (P-1)(P-1) DelayedDelayed YellowYellow Priority-2Priority-2 (P-2)(P-2)

HoldHold GreenGreen Priority-3Priority-3 (P-3)(P-3)

DeceasedDeceased BlackBlack Priority-0Priority-0 (P-0)(P-0)

Kim McKenna:

Kim McKenna:


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METTAG CardMETTAG CardEd: need figure50-11Ed: need figure50-11


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Purpose of TaggingPurpose of Tagging

Identifies priorityIdentifies priority

Prevents retriage of patientPrevents retriage of patient

Tracking system during treatment/ transportTracking system during treatment/ transport

Tags and labels should:Tags and labels should: Be easy to useBe easy to use Rapidly identify patient priorityRapidly identify patient priority Allow for easy trackingAllow for easy tracking Allow room for some documentationAllow room for some documentation Prevent patients from retriaging themselvesPrevent patients from retriaging themselves

Tracking Systems forTracking Systems for


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Tracking Systems forTracking Systems for

PatientsPatients A destination log is maintained byA destination log is maintained by

the transportation section officerthe transportation section officer Should have name or triage label IDShould have name or triage label ID

numbernumberTracking log must contain:Tracking log must contain:

Patient identificationPatient identification

Transporting unitTransporting unit Patient priorityPatient priority

Hospital destinationHospital destination


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ICS Patient LogICS Patient Log

Transportation ofTransportation of


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Transportation ofTransportation of

PatientsPatients Method of transportation determinedMethod of transportation determined

by triage priority and situationby triage priority and situation

Ambulance a typical methodAmbulance a typical method

Buses considered for transporting aBuses considered for transporting alarge number of priority 3 patientslarge number of priority 3 patients

Air ambulances for critical patientsAir ambulances for critical patients

Critical Incident StressCritical Incident Stress


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Critical Incident StressCritical Incident Stress

ManagementManagement

Critical incident stressCritical incident stress Potential for rescuers at major eventsPotential for rescuers at major events

Critical incident stress debriefings partCritical incident stress debriefings part

of postdisaster SOPof postdisaster SOPTypes of servicesTypes of services

Other approaches to manage stressOther approaches to manage stress


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ConclusionConclusionA major incident is an event for which availableA major incident is an event for which available

resources are insufficient to manage the numberresources are insufficient to manage the number

of casualties or the nature of the emergency. Itof casualties or the nature of the emergency. It

may overwhelm local, regional, state, and evenmay overwhelm local, regional, state, and evennational and international capabilities.national and international capabilities.


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Questions?Questions?