Curriculum Update: Medical Incident Command

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Curriculum UpdateMedical Incident Command
Condell Medical Center EMS System July 2006 Site
code 10-7200-E-1206
Revised by Sharon Hopkins, RN
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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

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A Major Incident

• Any event where available resources are
  insufficient to manage the number of casualties
  or the nature of the emergency

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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

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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

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• 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

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• 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

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Disaster Management

• Things can get better or worse, but they rarely
  stay the same..
• When planning, simple is usually the best
  process.

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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.
• ? ?

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Lessons Learned

• Learn from history others 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

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

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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

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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

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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

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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

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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

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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

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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
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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

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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

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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

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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

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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

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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

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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

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Section Responsibilities

• Intelligence
• gathers and shares incident related information
  and intelligence

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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

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Technology Issues

• Will equipment survive the environment?
• radios may be knocked out
• landlines and cell towers overwhelmed by
  callers/users and wont function for rescue
  personnel
• What is your departments plan for communication
  with each other and responding assistance?

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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

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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

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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

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Triage

• Recognized that it is very hard to do triage
• Were 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

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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

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START Triage

• Another concept/process for performing triage
• Purpose to classify victims status
• delayed - walking wounded
• urgent - serious
• critical - immediate
• dead/dying
• Patient tagged with appropriate color-coded tag

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Introduction of the START Triage System

• When there arent enough personnel on the scene
  to treat all of the patients at the same time,
  sorting needs 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

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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

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START Triage

S
simple
T
triage
A
and
R
rapid
transportation
T

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START Triage

• Field guide developed in Newport Beach,
  California at Hoag Memorial Hospital
• Based on 60-second assessment
• Focuses on
• patients ability to walk
• respiratory effort
• pulses and perfusion
• neurological status

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Patients 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

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Respiratory Effort

• If breathing is absent, the patient is classified
  as dead/dying
• Respiratory effort lt10 or gt30 critical
• Based on respiratory assessment and paramedic
  judgement, can classify patient as urgent or
  delayed

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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

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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

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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

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Secondary Triage

• Used in treatment area to retriage patient
• Patient assigned priorities of care

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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 SOPs for patient triage

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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)

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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

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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

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Mettag Samples
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The METTAG System sample
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Putting START Triage Into Practice

• 60- second assessment that evaluates
• ability to walk on own
• ventilation rate
  lt 10 or gt30
• perfusion status
• mental status - 2 tasks
• Victims are classified as
• minor, delayed,
  immediate, dead/dying

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START Triage

• Based on evaluation of three parameters.
• Remember 30 - 2 - can do

R
30
espirations
2
P
erfusion
M
CAN DO
ental Status
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START Field Guide
Respirations
No
Yes
Position Airway - airway open?
gt 30/min
lt 30/min
Immediate
Assess perfusion
No
Yes
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START Field Guide (cont)
No
Yes
Assess Perfusion
Deceased
Immediate
Radial Pulse
None Present
Present
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START Field Guide (cont)
Radial Pulse Present
Radial Pulse Not Present
None Present
Control Bleeding
Assess Mental Status
Immediate
Mental Status
Cant follow commands
Follows commands
Immediate
Delayed
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EMS Branch of Operations

• Treatment officer
• establish areas to categorize patients
• red - immediate treatment for life threatening
  injuries
• yellow - serious injury
• green - delayed treatment transportation
  acceptable
• black - dead or imminently dying segregated from
  area
• visually identify color coded areas (ie flags,
  cones)
• area away from hazards and protected from
  elements
• easy access to transportation

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EMS Branch of Operations

• Transportation officer
• communicates with receiving hospital (multiple
  victim plan) or EMS Resource Hospital (mass
  casualty plan)
• establishes patient loading area
• establishes and operates helicopter landing zone
• coordinates patient distribution to receiving
  facilities
• advises command when last patient transported

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Transportation Issues

• Distribution of patients needs to be to the right
  place to maximize the number of survivors
• Ask what do injured people do?
• If you know what theyre expected to do, you can
  predict their reaction.
• People will do their own thing!

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Transportation Issues

• Bystanders
• wont wait for EMS to arrive
• will self evacuate and move away from the site
• foot, private car, police car
• will start self treatment
• closest hospital will be inundated with less
  serious patients, EMS arrival of more critically
  injured patients might cause delay in care
• more outlying hospitals rarely get used, they
  have had time to prepare, consider using them for
  transport

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Patient Tracking

• Transportation Officer must keep a log
• patients name or tag number
• transporting unit
• patient priority
• hospital destination
• Updated communication required to Incident
  Commander
• Needs close communication with Triage Officer and
  Staging

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Additional Resources

• Consider assignments of additional staff based on
  nature of the disaster
• media
• CISD
• To improve communications facilitate decision
  making, keep fire/EMS/police management together

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Cross Training

• Involve departments you might possibly need to
  work with
• Use unified command across all resources
• Be well identified visually
• vests
• hard hats
• arm bands

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Community Involvement

• Bring to the table for open discussion and
  smoother operations
• police
• fire/EMS
• schools
• transportation
• media
• city hall
• hospitals
• nursing homes

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Region X Policy Review

• System-wide crisis preparedness policy
• to enhance communication between hospitals, EMS
  providers, and community agencies regarding
  potential or actual area-wide crisis
• multiple patients with same symptoms
• weather related multiple patients
• special events (ie marathon/race, sports)
• gives early alert to potential activity

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System-Wide Crisis Policy

• Policy can be initiated by anyone
• Contact your supervisor
• Supervisor contacts Resource Hospital System
  Coordinator or designee
• Decision made to activate policy and EMS office
  to notify POD hospital (HPH for CMC system)
• IDPH may be contacted by POD
• Communications continue between involved parties
  until crisis over

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Potential Crisis To Affect Region

• Receiving a heads-up notification would be
  extremely helpful in planning for
• Avian bird flu
• Extremely hot or dangerously cold weather
• Multiple victims being transported from one
  sporting event (ie 3 day- 60 mile Avon Walk for
  Breast Health)

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Review - Avian Flu

• Contagious viral disease of animals that normally
  only affects birds and occasionally pigs
• Concern will be if/when the virus mutates to
  humans
• Need direct contact with infected poultry to
  become infected
• contaminated surfaces
• objects contaminated with bird feces

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Bird Flu Signs Symptoms

• Typical influenza-like symptoms
• fever
• cough
• sore throat
• muscle aches
• eye infections (conjunctivitis)
• acute respiratory distress
• viral pneumonia

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To Avoid Avian Flu

• Practice good hygiene during food preparation
  (personal surfaces)
• Properly and fully cook poultry including eggs
• Normal cooking temperature kills the virus
• Transmission more likely to be droplet (plops
  within 3 feet) than airborne (floats longer
  distances)

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Patient Treatment

• Treat with respiratory isolation any patient with
  severe, febrile respiratory illness similar to
  SARS
• standard precautions - good handwashing
• contact precautions - gloves and gowns
• airborne precautions - surgical masks on patients
  and staff
• continue precautions for 14 days after onset of
  symptoms
• Recommended annual flu vaccination

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Table Top Drills

• Enough drills should be run for every member at
  this session to be placed in a variety of roles
• Remember, the blue shirt will be the person who
  initially responds to the incident and needs to
  be making some early crucial decisions before
  more personnel show up
• Pick the location in your town where the
  following exercises would most likely occur

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Table Top Drill

• Work through problems on paper so they are not
  problems at the scene (or think of it as a
  rehearsal on how to handle the problem when it
  does present at the scene)
• The drills will be most effective if everyone
  involved can walk through and discuss all aspects
  including where equipment is stored and how the
  scene would be laid out

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Drill Scenario 1

• Your department has received a call of a bus
  versus train collision. Unknown number of
  casualties.
• During the table top drill discuss
• location to set up command, staging, treatment,
  transportation
• What other resources may be required for your
  town and the location you have picked?

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Drill Scenario 2

• You have received a call of a bleacher collapse
  at the local high school during an assembly
  multiple casualties reported
• During the table top drill discuss
• location to set up command, staging, treatment,
  transportation
• What other resources would be helpful in this
  setting?

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Drill Scenario 3

• You have received a call of an obnoxious odor in
  a local (nursing home, senior residents, day
  care).
• As you respond to investigate, you are informed
  of multiple complaints from multiple persons at
  the scene (headache, nausea, vomiting, eye and
  throat irritation)
• What needs to be considered to successfully run
  this disaster event?

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Drill 4

• You have received a call for an overturned semi.
  Upon arrival, there is actually an overturned
  tour bus of approximately 50 seniors.
• What unique aspects will seniors pose to the
  rescue providers?
• What if the weather (too hot, too cold, rainy,
  snowy) is a factor - how do you handle that and
  what provisions are made?

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Acknowledgement

• NIEMSCA contribution for the packet by
• Kishwaukee Community Hospital
• Seminar presentation by Colin Smart, Director TSG
  Associates
• Additions made by Sharon Hopkins, RN, BSN,
  Condell Medical Center EMS Educator
• Region X Policy and Procedures

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Medical Incident Command
Questions ??