hello and welcome to chapter 47 instant management and mass casualty incidents the paramedic has operational roles and responsibilities in establishing command under the incident command system in order to ensure patient public and personal safety upon completion of this chapter and the related course assignments you will be able to explain the purpose of the medical incident management in the ics and describe the major components of the national incident management systems otherwise known as nims you will also be able to describe how start and jump start triage methods are performed and discuss triage principles resource management and the need for re-triaging you will also be able to discuss the specific conditions that define a situation as a mass casualty incident including the role and purpose of critical instant stress management in an mci but let's start the chapter talking about incident types disasters and mass casualty incidents are the first two that we're going to talk about and a disaster is declared by local county state or federal government for purposes of providing additional resources and funds to those in need an mci is declared when the number of patients and the severity of the injuries suggest that available community resources will be overwhelmed mutual aid response is required in a multi-casualty incident that's any situation with more than one patient but that will not overwhelm available resources there is a set numerical cutoff at which a multi-casualty incident becomes a mass casualty incident so nims you're going to hear a lot about the national incident management system and this system designed to improve efficiency in the management of incidents regardless of the size and complexity nims courses may offer certifications that can be prerequisites co-requisites or any part of entry-level courses the instant command system so ics prepares responders to provide a coordinated effort during an incident as a paramedic you will typically be assigned to work within the ems or medical group under ics but you may also be asked to function in other areas let's talk a little bit about the national incident management system or nims and it was implemented in 2004 to provide a consistent nationwide template to promote effective and efficient emergency response it's used to prepare for prevent respond to and recover from domestic incidents regardless of its size and complexity flexibility and standardization and interoperability are the key principles of nims the organizational structure must be flexible and quick to adapt to use for any incident nims provides standardization and terminology resource classification personal training and certification interoperability allows agencies of different types or from different jurisdictions to communicate with each other through interoperability a common incident communication plan is developed and facilitates interoperable communications all resources must be able to work using a for similar framework so the major component of nims is command and management so incident management is standardized for all hazards across all levels of government so the command structure is based on an ics multi-agency coordination systems and public information systems preparedness this institutes procedures for all responders to include in their systems in preparation to respond to any incident at any time and resource management sets up systems that describe inventory track and dispatch resources before during and after the incident it creates standard procedures to recover equipment that has been used communications and information management this enables the necessary functions needed to provide interoperability in ongoing management and maintenance a nims integration center will be created to provide strategic direction and oversight of the nims so the incident management command system using common language and clear text ensures better communication among various agencies the ics creates a modular organizational structure and the goal is made is to make the best use of resources to manage the environment and treat the patients follow local standard operating procedures to establish the ics the ics is designed to control duplication of effort and freelancing freelancing is defined as individual units or agencies making independent decisions about the next steps the ics limits span of control it keeps the supervisor to work your ratios at one supervisor for three to seven workers a supervisor who is overseeing more than seven people must delegate tasks and supervision and so organizational divisions include sections branches divisions and groups and resources some areas have emergency operation centers operated by state city or federal government usually only activated in large emergencies with hundreds of patients and that will or could continue for days so responders in a mass casualty incident or disaster should use the instant command system and what you want to do is find out from your service if ics exists and who is in charge how's it activated and what is your role in the ics system so instant command system rules and responsibilities the general rules within the icms include command finance logistics operation and planning the command function includes public information officer and that's the pio safety officer and a liaison officer and then there's command so the incident commander evaluates the incident and creates a plan of action based on true strategic objectives and priorities the number of duties that the ics is responsible for depends on the size of the instance a small incident often mean that the ic will do it all instant of a medium or complexity uh often mean that the ics will delegate some functions but re retain others and then in a complex incident the ic may appoint team members to all command roles a unified command system is used when an incident requires multiple organizations or jurisdictions so plans are made in advance by the organization that takes on responsibility in the decision making the plan assigns the lead and support agencies for example hazmat team takes the lead during a chemical leak where the medical team would take the lead in a multi-vehicle car crash now a single command system is one in which one person's in charge so generally used with incidents in which one agency has the majority of responsibility for the incident ideally used for short term durations or limited incidents for small scale incidents that are not anticipated to increase in complexity ic may be located somewhere on the fringes of the scene that is clearly identified so know who the ic is where the command post is located and how to communicate with the ic for large scale instance or instance with several injured responders it may be responsible for the ic to be located a short distance from the scene it decreases distractions improves flow of vital information and helps ensure safety of those in command from secondary attacks okay transfer of commands so the ic command to one more experienced person in a critical area that could be transferred this transfers to be done in an orderly manner and ideally face to face your agency should have standard operating procedures or sops that direct the transfer of command at the conclusion of an incident there should be a termination of command and this includes demobilization procedures and it should be implemented as a situation de-escalates and operations so they manage the tactical operations job at a large scale incident and at a complex incident the operations chief oversees the responders working on the scene often have managerial experience within the fire department and then the finance of responsibility uh responsible for documenting all expenses at the incident that should be reimbursed so not always necessary for a small incident and tracks and reports personnel hours and cost materials and supplies at meetings the finance chief will help your organization receive reimbursements if you're eligible and the roles of the finance sections are time unit procedure unit and compensation unit and claims and then there's logistics so they're responsible for the calm equipment or communications equipment facilities food water fuel lighting medical equipment and supplies in large incidents many people may coordinate logistics but only one reports to the incident commander and then there's planning planning solves problems as they arise during the mci typically for units associated with the planning section so that's resources situation demobilization and documentation they use data from the current incident to analyze the previous plan and predict the next steps for the new plan they work closely with ops finance and logistics and they call upon technical experts to help with the planning process they set up a plan for demobilization and they develop the incident action plan and then you have command staff so command staff include the safety officer the public information officer and the liaison officer we'll talk a little bit about each of those so the safety officer they continually monitor the area for hazards to responders and patients possibly will interact with environmental health and hazmat teams and they have the authority to stop an emergency operation when a rescuer is endangered then you have the pio they present information with the public and media take posts away from incident to keep media safe from the emergency and keep distractions to a minimum they may work in conjunction with other organizations in a joint information center or jic and then there's the liaison officer and they relay information between command general staff and other agencies so let's talk about communications and information management next so communication should be integrated so that all agencies can communicate easily and quickly by radio this allows for accountability throughout the incident and instant communication you need to maintain professionalism on the radio communications communicate clearly concisely and using clear text and mobilization and deployment so once an incident is declared and additional resources and personnel are requested they are immobilized and deployed to a staging area the steps of a mobilization and deployment are they want to check with the ic upon arrival at a small scale incident or on with the resource on unit on a large scale incident they want to check in with the supervisor for the initial briefing about the incident and their job responsibilities this keeps they keep records as a way to document items that may need to be reimbursed and they keep their supervisor up to date on their location actions and completed and uncompleted tasks so that's accountability once the incident is controlled the ic will decide on demobilization of resources okay so the ems responds within the incident command system so the first thing that ems response will will do within the instant command system is preparedness preparedness is the decisions and basic plans that are made before the incident even occurs each ema ems agency generally has a written disaster plan and it's usually located at each ems station as well as on each ems vehicle you may have a checklist of supplies that need to be at your station which may include water batteries cots or other items for the personnel who will be staffing that station you should have your own disaster plan in place for your family in the event that you need to respond to a disaster make sure that you have all necessary immunizations and training is one of the most critical components of preparedness mock scenarios with multiple agencies working together should be practiced monthly after the preparedness you have the scene size up and dispatch will inform you if the mci scene is safe or unsafe do not hesitate to request more resources early on if the dispatch information suggests you need that when you arrive on scene ask yourself two basic questions what do i have and what will i need so check for hazards to warn other responders safety concerns such as hazmat fuel spills or electrical hazards and determine the resources you're going to need and then establish commands so establish command early on preferably by the first uni um arriving unit or the most experienced public safety official evaluate the scene then return to your post if working as the ic retain the mindset that you are there to service command do not become distracted with patient treatment and other tasks and then communications this is often the key problem at an mci or disaster to limit radio traffic use face-to-face communication when possible and if you are communicating by radio do not use codes or signals there are typically radio channels specified as emergency command channels the communication equipment you are using should be reliable durable field tested and have backups and you should also have a plan b for communication medical instant command is what we're going to talk about next and so medical incident command is also known as the medical branch of ics the medical branch director is appointed during incidents that call for large amounts of medical attention they oversee primary roles of the medical team triage treatment and transport they make sure the ems units are working with the ics they assign each medical unit with tasks prior to working at the scene and depending on the size of the incident ems may be its own command and work under the logistics section and then you have the triage unit leader they count and prioritize patients at the incident they ensure that the patient receives all initial assessment and treatment on patients must begin must not begin until every patient is triage the treatment unit leader so after the triage unit leader you have the treatment unit leader and they locate and set up the treatment area with a tier for each priority patient they see that each patient has secondary triage and that each gets enough care they assist with moving patients to the transport area and they communicate their request for sufficient quantities of supplies including bandages burn supplies respiratory supplies and patient packaging equipment after the triage treatment you have the transportation unit leader and they coordinate the transportation and distribution of the patients to appropriate hospitals and they track and record the number of vehicles transporting patients the patients transported and the destinations of both and then you have the staging area officer so they are assigned when a situation calls for multiple emergency vehicles or agencies they designate an efficient location for the staging area away from the incident they plan for assess and exit from the site they prevent traffic congested congestion among responding vehicles and they release vehicles and supplies when needed and then often in large instance you'll have physicians on scene they provide secondary triage decisions and on-site medical direction one treatment is required then you have the rehabilitation group group leader they treat uh create a rehab area for responders when they need to rest eat drink and get protection from the elements during the an incident that will last for a while so they monitor ems personnel for stress fatigue altered thinking and collapse then you have extrication and special resources and special rescue so an extrication task force leader or rescue task force leader may need to be appointed if there is a need for search and rescue or extrication of patients the supervisor coordinates the equipment and resources needed the supervisors will usually function as a specialty group under the operations group of the ics because extrication and rescue are medically complex then you have the morgue unit leader and in this instant where their victims have died a morgue supervisor is appointed the deceased should be left untouched until removal and storage plans are made and if the morgue area is created it should be out of sight so that there is no further psychological trauma to living patients and responders we talked about this earlier but i want to reiterate it an mci may overwhelm available resources and a mutual aid response is when neighboring ems systems respond to mass casualty incidents in each other's regions when there aren't enough local resources so let's give some examples of these they include bus or train crashes maybe an earthquake or a big residential building fire or loss of power to a hospital or nursing home and response to an mci will vary depending on location and how spread out the patients are and so this figure shows a diagram of an mci to identify an mci as an open incident or a closed incident so an open incident is an unknown amount of casualties when you are first answer a call a patient may need to be searched for or treatment of multiple locations so possibly an incident that's ongoing for example like a tornado or school shooting a close incident is the number of patients is not expected to change so patients are triaged and treated as they are removed and may turn into an open incident however when deciding what qualifies for an mci regions will use varying standards and protocols previous experience will help determine the status of an incident regular use of ics and participating in disaster planning drills tabletop mci exercises and other training will help prepare you for an instant having a solid understanding of the rules of mci and regular use of the m of ics and nims will help to keep the incident responders organized and efficient the following questions will help you determine whether an incident is a mass casualty incident how many injured or ill patients are on scene what resources are available how long will it take for additional help to arrive and where should these patients be transported never initiate transport of patients if there are unattended unintended patients present or who are sick or injured so consider relocating the patients to a smaller area to initiate treatment of the critical patients while continuing to observe those who are less injured if needed use your resources and delegate tasks to your partner or responders and other agencies such as police officers and always follow local protocol next we're going to talk about triage so triage is sorting patients by severity of their conditions and prioritizing them for care accordingly the goal is to do the greatest amount of good for the greatest number triage should be brief and it categorizes the patients are placed in should be basic triage primary triage is used to rapidly categorize patients patients will be identified with a triage tag in primary triage and after primary triage the triage leader will report to the medical branch director secondary triage is re-triage in the treatment group so the category of the patient could change suddenly and can be upgraded or downgraded due to patient condition avoid spending too much time assessing a single patient so we're going to talk about four common triage categories and they could be remembered using the mnemonic idme okay so idme is immediate which is red d is delayed m is minimal and e is expected immediate patients are force priority they need immediate care and transport these patients may have problems with abc's head trauma or shock delayed patients are second priority they will need care and transport but they can be delayed and minimal patients are third priority need little to no on-scene treatment and patients are known as walking wounded then you have the e and that's expectant patients and they are last priority they are either already dead or have little chance to survive these include cardiac arrest open head trauma or respiratory risk patients a new fifth triage category the orange tag category may be added and this represents an immediate category between critical red tagged and non-critical which is non-ambulatory yellow and there may be ambulatory patients who require prompt evaluation and treatment for medical comorbidities that are not acute trauma injuries associated with this event so let's talk about the tags it is important to label track and record patient's condition no matter what system you use so the triage tags should be weatherproof easy to read and color coded and clearly show triage categories this tag will be added to the patient's medical records and may be a tear off receipt it tracks the patient's location and identifies the patients if they are unresponsive digital photos are sometimes used in identification of victims so another method of tracking patients is a bar code scanner and triage tag that have barcodes whatever label system is used it's imperative for the transportation supervisor to be able to identify it okay so let's talk about the common most commonly used triage system in the united states and it is called start triage okay so it stands for simple triage and rapid transport and the staff at hagg memorial hospital in newport beach california created a simple form of triage named start triage that's what this is so it's used uh uses a limited evaluation of the patient so it uses the um i usually say rpm but they have written here the ability to walk respiratory status hemodynamic status and neurologic status so um let's talk a little bit more about this so the first step of the start triage system when you first get there you call out and you say hey can you hear me if you could hear me and if you could walk come stand up and walk so these injured patients are considered the walking wounded and they're categorized as minimal priority or third row priority patients okay the second step of start triage is to evaluate the non-ambulatory patients you want to check for respiratory status so that's the r if the patient is breathing or not open the airway using a simple manual maneuver okay if the patient begins to breathe they're crap they're categorized as a red but if they don't they're categorized as a black okay so if the patient i should say if the patient starts breathing quickly estimate their respiratory rate if it's faster than 30 breaths a minute they are categorized as a red if it's fewer than 30 breaths a minute you could continue down and check the radial pulse and what that's going to do is evaluate the hemodynamic status so this is the p in the rpm that i said so p check for the radial pulse if it's absent this suggests that the patient is hypotensive and you should categorize them as an immediate okay so that's a red if the radial pulse is present continue to move on then you're going to check the neurologic status and this is the m so rpm you could ask the patient to follow three commands show me three fingers if they don't understand the command and are unresponsive they're an immediate a patient who understands command is categorized as delay okay so start triages is how we categorize adults and jump start triage is how we categorize not only pediatric patients but people who appear to weigh less than 100 pounds or 45 kilograms so this system is used to assess children younger than eight or who appear to weigh less than 100 pounds first say same thing as star triages we're gonna identify the walking wounded and with jumpstart triage differs slightly only slightly so if a pediatric patient isn't breathing we're checking for a pulse if there's no pulse of course we're going to label them as expectant but if there is a pulse open the airway with a manual maneuver and give five rescue breaths so that's the big difference we're gonna give five rescue breaths if the patient still isn't breathing then we're gonna label them as expected okay major difference we're giving rescue breaths then we're gonna check with the rate of respirations so children fewer than 15 breasts or more than 45 breasts we're going to give as immediate okay um and then uh we're going to continue on the same as the start triage there's also a thing called salt triage and salt stands for short sort assess life-saving interventions and treatment and transport this triage system begins by prioritizing order in which the patients are assessed so patients will lay still and have obvious life-threatening injury or patients who are unable to walk but demonstrate purposeful movement or patients who are ambulatory and can follow commands to walk to a designated area and so salt method allows for immediate rapid interventions including bleeding control opening the airway needle decompression and auto injector antidotes so as you progress through your assessment you'll assess the airway mental status perfusion respiratory status and bleeding control the salt method is unique in that there are five patient categories so black tags are assigned gray tags are assigned and then there are three other that are similar to triage immediate delayed and minimal so when you talk about special triage considerations patients who are hysterical and disruptive to rescue efforts may need to be an immediate priority and transported out of the disaster site even if they are not seriously injured this type of behavior could create panic for other patients and rescuers do not hesitate to have the walking wounded assist you with simple tasks an injured or sick responder should be categorized as immediate and transported away from the scene so other responders do not lose their morale if hazardous materials or weapons of mass destruction are present the hazmat team must categorize patients as contaminated or uncontaminated before regular triage can begin some incidents will require multiple teams or areas of triage if patients are spread out so let's talk about destination decisions using the 2001 american college of surgeons committee on trauma field triage decision scheme refers patients to trauma centers using category including the physiologic criteria the anatomic criteria mechanism of injury the special considerations which is age and underlying health and this guideline helps pre-hospital responders identify individuals who will benefit from transportation to a trauma-specific center what you want to do is consider the hospital that has appropriate means to help the patient so some hospitals may become overwhelmed by a large number of patients some patients may require specialized care such as burn centers or pediatric centers and given hundreds of patients not all critical trauma patients will go straight to the trauma center patients may need to be transported to a hospital that is not ordinarily capable of accepting a trauma patient some patients may require specialty centers transport patients that are categorized as immediate or ambulance or air ambulance so you can start walking wounded by bus if needed in large situations and these patients should be taken to a hospital further away from the scene so as they don't overwhelm the closest hospitals at least one emt or paramedic must ride on the bus and an ambulance should follow transport immediate patients two at a time transport delayed two or three at a time and transport slightly injured last expected patients are treated once all the other patients have been transported dead victims are handled and transported according to the sop for the area so critical incident stress management an mci response is incredibly stressful there are a few things more emotionally wretching than discussing triage and management of an mci suicide rates have increased among ems workers and firefighters and police debriefing with others who respond to the event it may be beneficial once out reach out to colleagues struggling with emotional toll of the incident within your department it's a disaster plan there should be a resource for debriefing and diffusing the responders before during and after the mci depends on service director and medical directors views critical incident stress management or cism should be available to all responders participation is encouraged but not required all responders should have access to coping mechanisms and these services should always be available the physiological impact on responsible responders should be included in the post-incident evaluation and then there's an after action review so all agencies should participate in review after an incident ends for future future events include what worked and what didn't work and all observations should be written down for future review and never accuse someone of doing something wrong during the incident so all mcis are different and all reactions will be different okay so thank you for joining me for chapter 47 lecture on instant management and mass casualty incidents um if you enjoyed this lecture go ahead and subscribe to my channel i will be releasing all the other chapters thank you