Curriculum Update: Medical Incident Command

1. Curriculum Update:Medical Incident Command Condell Medical Center EMS System July 2006 Site code: #10-7200-E-1206 Revised by Sharon Hopkins, RN

2. Objectives • Upon successful completion of the module, the EMS provider should be able to: • list components of the medical incident command • discuss the responsibilities of the components of the medical incident command system • participate in a table top drill exercise • successfully complete the quiz with a score of 80% or better

3. A Major Incident Any event where available resources are insufficient to manage the number of casualties or the nature of the emergency

4. Components of Disaster Preparedness • Understand effects of man-made or natural disasters • Develop leadership skills during & after the emergency • Know and involve community links, resources, & backup strategies • Understand all components of the plan • Maintain core competencies by participating in disaster drill training

5. Preparation For A Major Incident • 3 phases in preparation • preplanning • working together and planning ahead • discuss common goals and specific duties • most successful with frequent meetings and practice sessions/exercises

6. Scene management • development of strategy to manage the incident • may need only local resources if small scaled incident or major and outside resources if large incident • takes coordinated effort for efficient and safe use of resources

7. Postdisaster follow-up • after action review • review of lessons learned • discussion of areas for improvement • evaluates stress related impact (anxiety and illness) among emergency workers

8. Disaster Management Things can get better or worse, but they rarely stay the same….. When planning, “simple” is usually the best process.

9. The Golden Hour The first hour after injury. Prehospital care delivered by EMS cannot be at the sacrifice of the golden hour any more than is necessary.  

10. Lessons Learned • Learn from history & other’s experiences/mistakes • Keep procedures simple • This is not the time to be introduced to new • Need to be familiar with equipment and how to respond to mass casualty incidents

11. Incidents will occur so plan for them Plan for the worst, hope for the best

12. Activation of a Mass Casualty Incident • The first responding unit functions as Command and must initiate the appropriate response plan (Mass Casualty or Multiple Victim) as well as start triage until relieved by personnel recruited to the scene • The way the first few minutes are handled during an emergency often predicts how the rest of the incident plays out

13. Multiple Victim Incident • Responding EMS personnel can control life threats with their usual resources • Adequate numbers of responders and ambulances can be at the site within 10-20 minutes • Surrounding hospitals can be accessed in timely manner and they can provide patient stabilization

14. Mass Casualty Plan • Number of patients and nature of injuries make normal level of stabilization & care unachievable • Number of EMS personnel and ambulances brought to the site within primary & secondary response times are not enough • Stabilization capabilities of hospital within 25 minutes are not adequate to handle all patients

15. Plan Activation • Mutual goal: to do the most good for the most people while trying to preserve life • Activate a plan as soon as possible • takes time to mobilize resources • alerts resources that they may be needed

16. Scene Assessment • Quick and rapid size-up/assessment • type of incident & potential duration • if entrapment or special rescue resources may be needed • number of patients potentially in each triage category - red, yellow, green, black • consider initial assignments to give incoming units • consider need for additional resources to manage the incident • Ongoing scene assessment - watch for changes

17. Incident Command System • A proven, flexible management tool the contributes to the strength and efficiency of an overall system • Organizes interagency functions & responsibilities • Required response plan to be used at all incidents per Department of Homeland Security, 2004 • Can be used for small incidents and major ones

18. Incident Management System Organization Incident commander Safety Officer Public Info Officer CISD Liaison Officer Finance/ Administration Logistics Operations Plans Intelligence EMS/Branch Triage Treatment Transportation

19. Role Identification • All section leaders need to be visibly identifiable • reflective, labeled vests • labeled hard hats • Need to be identifiable for those that are unfamiliar with the individual • easier to send responding personnel to “charge in Triage” than to send to “Bob in Triage”

20. Incident Command Roles • Command • established immediately • belongs to one person (initially to one person in the first responding unit) • should eventually be the one who can best manage the emergency scene the most effectively • needs ability to coordinate with variety of emergency activities • develop management strategy • request resources, provide assignments, delegate authority to subordinates

21. Incident Command Priorities • Life safety • always the first priority of responders and the public • Incident stability • needs to decide on strategies to minimize the effects on the area and maximize response effort using resources appropriately • Property conservation • minimizing damage to property while succeeding at the incident objectives

22. Section Responsibilities • Finance/administration section • seldom used section in small scale events • tracks costs and the way of reimbursement is handled • time accounting • procurement • payment of claims • estimation of costs

23. Section Responsibilities • Logistics section • provide gear and support to responders • airway, respiratory, hemorrhage control • burn management • patient packaging and immobilization • provides supplies, equipment, facilities, services, food, and communications support • resources for moving & transporting patients • people, ambulances, buses • medical unit cares for responders - offers rehab

24. Section Responsibilities • Operations section • directs and coordinates all emergency scene operations • ensures safety of all personnel • in charge of the tactical aspects • accomplishing tactical objectives • directing front-end activities • participating in planning • modifying action plans as needed • maintaining discipline • accounting for personnel • updating command

25. Section Responsibilities • Planning section • provide past, present, and future information about the incident and the status of resources • may need to create an incident action plan - written or verbal • defines response activities and use of resources • helpful when multiagency or multijurisdictional resources used and when the incident is complex

26. Section Responsibilities • Intelligence • gathers and shares incident related information and intelligence

27. Additional Responsibilities • Communications • usually the one area that is the most confusing, least effective, and most criticized • all transmissions need to be short and to the point • multiple victim plan - all radio traffic is conducted in the normal manner • mass casualty incident - one source designated from the scene to communicate with outside resources • scene personnel need to know who to communicate with and on what frequency

28. Technology Issues • Will equipment survive the environment? • radios may be knocked out • landlines and cell towers overwhelmed by callers/users and won’t function for rescue personnel • What is your department’s plan for communication with each other and responding assistance?

29. Additional Responsibilities • Staging officer • incident commander should provide instructions for the deployment of resources including staging area location and specific information if required (ie: direction of approach) • line vehicles up at scene to facilitate egress and prevent congestion • personnel should stay with their vehicles • keys should be left with the vehicle • stage away from the actual scene • maintain log of resources in staging

30. Additional Responsibilities • Rehabilitation Area • usually set up outside the operational area • personnel can get physical and psychological rest • provide medical care and treatment as needed • keep logs of those who are in rehab

31. EMS Branch of Operations • Triage • method of categorizing patients according to their priorities of treatment • an on-going process • based on • abnormal physiological signs • obvious anatomical injuries including mechanism of injury • concurrent disease factors that might affect prognosis • primary triage - at site to categorize patient conditions • secondary triage - used in treatment area to assign priorities of care

32. Triage • Recognized that it is very hard to do triage • We’re use to treating people, not moving them • Need to consider how to handle/manage uninjured survivors otherwise they will bog you down • Triage recommended to be done in pairs

33. Concept of Triage in Pairs • One person focused on the individual patient • performs clinical assessment & provides rapid treatment, gives moral support • 2nd person keeps eyes & ears open surveying environment • watches environment; talks to uninjured • prepares equipment • plans triage route • gathers info & communicates with others

34. START Triage • Another concept/process for performing triage • Purpose: to classify victim’s status: • delayed - walking wounded • urgent - serious • critical - immediate • dead/dying • Patient tagged with appropriate color-coded tag

35. Introduction of the START Triage System • When there aren’t enough personnel on the scene to treat all of the patients at the same time, sortingneeds to be done in order to prioritize which patients will be given treatment first • Use of the START system triage is one good method to use to do this sorting • START triage process uses more systematic approach than what is currently used locally

36. START Triage • Allows rescuers to quickly identify victims at greatest risk of early death and advise other rescuers of the patient's need for stabilization by tagging the patient with color coded disaster tags • As before, patients are continuously re-evaluated throughout the incident and are retagged as needed • Triage process the Region will be moving towards in the future

37. START Triage S simple T triage A and R rapid transportation T

38. START Triage • Field guide developed in Newport Beach, California at Hoag Memorial Hospital • Based on 60-second assessment • Focuses on • patient’s ability to walk • respiratory effort • pulses and perfusion • neurological status

39. Patient’s Ability To Walk • If the patient can walk and can understand basic commands, they are classified as “delayed category” - “walking wounded” • Can direct these patients to walk to a treatment or transportation site

40. Respiratory Effort • If breathing is absent, the patient is classified as “dead/dying” • Respiratory effort <10 or >30 = “critical” • Based on respiratory assessment and paramedic judgement, can classify patient as “urgent” or “delayed”

41. Pulses and Perfusion • Absent pulse, patient classified “dead/dying” • Carotid pulse present but no radial pulse the patient is classified as “critical” • If carotid and radial pulses are both present, assess mental status before deciding on triage category

42. Neurological Status • Assess by asking patient to do 2 simple tasks:  touch nose with index finger, stick out tongue  assess orientation by asking name, date and year • If both tasks can be performed, patient is classified as “delayed” • If patient fails either task, classify them as “critical”

43. Primary Triage • Used at site • Rapidly categorizes or sorts the patients • Each patient tagged • No care given except for immediate life-saving measures • ensure an open airway • control hemorrhage

44. Secondary Triage • Used in treatment area to retriage patient • Patient assigned priorities of care

45. Triage and Patient Categorization Criteria for triage classifications can be influenced and is determined by • size of the incident • number of injured patients • available manpower • Need to be familiar with your local SOP’s for patient triage

46. Disaster Tags I. METTAG System utilizes four-color tags • RED-- IMMEDIATE-- the most critically injured (Priority 1) (P-1) • Yellow--DELAYED-- less critically injured (Priority 2) (P-2) • Green-- HOLD -- non-life or limb-threatening (Priority 3) (P-3) • Black-- DECEASED-- dead or unexpected survival (Priority 0)

47. Disaster Tags • Many variations of tags, tape and labels available • Purpose of tagging • Identify the priority of the patient • Prevent re-triage of the same patient • Serve as a tracking system during treatment/transport

48. Disaster Tags • Tags/ labels should be • easy to use; easy to write on • not destroyed by the elements • rapidly identifies priority • allow for easy tracking • allow for some documentation • prevent patients from re-triaging themselves • Should be used routinely so their use becomes familiar

49. Mettag Samples

50. The METTAG System sample