okay gang so we're going to cover chapter 40 the incident management so the competencies we're going to talk about are triage principles resource management triage in performing triage re-triage destination decisions post-traumatic and cumulative stress talk about hazmat awareness as well so disasters and mass casualty incidents can be overwhelming obviously if but people kind of forget that any time there's more patience than you can handle that's truly a mass casualty incident that could be three or more patients it could be the lack of resources is why we're classifying this as a mass casualty incident again the incident command system you all should have taken the nims 100 200 700 800 that's where you're going to learn about the incident command system and again it's it's doing the greatest good for the greatest number of patients the nims it promotes coordination of emergency incidents at their national state in regional levels it really has been born out of other tragedies if you will uh implemented in 2004 it's the framework uh that enables everyone to work together if you think about 911 happening and during 9 11 all these agencies responded to help but nobody could talk to each other nobody knew who was in charge it was really very chaotic again one of the things that we talk about with nims is standardized terminology we're trying to learn to use common english when we speak in the radio instead of 10 codes or signals or whatever but we still haven't gotten there yet the the biggest hiccup in the whole making it a standardized language has always been our law enforcement brothers and sisters because they are so ingrained in the use of the 10 code that they really don't want to give it up resource classification personal training certifications those all come with names communication and information management resource management how to use the best resources to get the best for the bank command and management as well so with incident commands incident command system in other words sometimes we call it the incident management system it's to ensure a responder and public safety achieve the incident management goals and ensure the efficient use of resources during a mass casualty incident controls the duplication of effort and freelancing it's so that we don't waste resources limits to come span of control so basically one supervisor is in charge of three to no more than seven workers that way they're not overwhelmed organization levels they have sections branches divisions and groups we're trying to become standardized across the country so that any mass casualty incident we're all working on the same page so operations then there's a branch and there's a division or group underneath that planning has a as a section logistics and financing all have sec excuse me sections and beneath them branches and divisions or groups so the roles and responsibilities are command finance logistics operations planning and the command staff itself let's talk about command the incident commander that's the overall person in charge of an incident it's important to know who that person is how to communicate them and where the command post is located an incident commander may turn over command to someone with more experience in a critical area you as the emt may be the first incident commander at a scene and then when more uh experienced help arrives you can turn over that command to them finance people don't think about finances being some part of the instant command system it has to be for documenting all expenditures and we're thinking about reimbursement after the incident is done and we might get reimbursed from the federal government on this stuff so the local fire department doesn't blow their whole budget on one incident and we can get reimbursed from the government if if we properly document everything logistics getting equipment getting facilities getting water getting food getting porta potties fuel lighting medical supplies i mean the list is endless operations that's the big one right that's the complex incident that they're managing the tactical operations uh and again they supervise the people working at the scene and then planning uh again solving problems uh they're usually making plans for the the incident command they're developing these plans and these plans change as the incident changes and then obviously the command staff they're making sure everything runs smoothly they might have the public information officer who's speaking to the media we have a liaison officer who gets information and relays it to other commands or the staff or other agencies even in taking an online class even with your family communication is the weakest point and obviously it's going to be the weakest point in major incidents so it's recommended all communications be integrated in other words they should be able to communicate each with each other effortlessly we don't need a you know change to this channel then to that channel into that channel or you talk to that person and then they relay the information to that person communication is huge at major incidences check in with the uh the incident commander when you arrive you report to your supervisor for initial briefing and then uh record uh excuse me record keeping record keeping sorry allows for tracking of time spent on the incident for reimbursement so your your ambulance can be reimbursed by the federal government the state government whatever as long as you keep proper records accountability means keeping your supervisor advised of your location your actions and completed tasks they need to know where you are what you're doing or what you're not doing and then once the incident has been stabilized they'll determine which resources are needed and then they might begin to demobilize they they realize they don't need as many ambulances they have so our response within the incident command as ems professionals we start with preparedness again we're making decisions based on planning done before the incident begins involves decisions and planning about the most likely natural disasters in the area your ems service your fire department should be working on these plans continuously and you should have written plans that you regularly train on so that people know what to do in the event of a tornado in the event of a hurricane whatever so a scene size up what do i have what do i need what do i need to do those are really good questions what do i have what do i need what do i need to do so this your mass casualty incident might have something like this arrive a mobile emergency room staffed by emts paramedics nurses doctors and again the bigger cities have this kind of resource available to them with a command and establishing command connect command should not be established by the most senior official sorry let me say that again command should be established by the most senior official as long as they have training that's the biggest thing the biggest thing comes down to do they have the the knowledge necessary to be the person who is in command i kind of default back to my experiences and in some of these smaller rural departments the fire chief may not be the most well-trained person for the job heck it could be that the newest guy in the team that has the most training and the most knowledge but again the most senior is typically they do have the most training but sometimes they don't they need to know necessary resources and and how to request them and again we need to establish command early not later communications use face-to-face communications and that keeps us off the radio if you communicate on the radio don't use 10 codes everybody knows what 10-4 is but if i say what is 10-0 10-0 changes from state to state department department even within a state they change but everybody knows 10-4 so 10-4 is okay i guess but not anything other than that equipment should be reliable dependable and field tested and make sure that we have backups medical incident command is also known as the medical or ems branch of the incident command and the job of the ems is obviously the triage treatment and transport of our injured persons if you kind of look down the ems branch we do break it up though there is a triage part there is a treatment part and there is a transport part and again depending on the type of patient we have depends on how we staff those areas your triage supervisor they make sure that the patients receive initial assessment and we don't begin treatment until all patients are triaged the triage supervisor is making sure we have everybody accounted for and everybody is prioritized the treatment supervisor they set up a treatment area and they ensure that the secondary triage is performed and the adequate patient care is given and then they move those patients to the transportation area and then in the transportation supervisor takes over and they distribute the patients to the appropriate receiving hospitals they track the number of ambulances that the patients transported and where that patient goes i was part of an a a mass casualty incident way before nym started this was in the early 80s and we had a town wiped out by a tornado it was a small town but the entire town was wiped out did not triage we did not have names we could not communicate from one county to the other county on our radios um the first thing that we did when we got there with our ambulance was we loaded it up with they threw a person in the back of the ambulance and off we went and we took him to the closest hospital we quickly overloaded that closest hospital because we had no transportation supervisor to tell us what to do finally we kind of figured out on our own hey this hospital can't take any more patience we need to start going further away so this was all before nims and we learned a lot from this incident staging supervisor again they are there to make sure that when we have multi-vehicle multi-agencies respond that they're in charge of that area they have to have permission to enter the scene and drive only in designated areas the staging of supervisor ensures that and the staging area should be away from the scene so that there's no more confusion at the scene physicians this is kind of interesting to think about again they might make difficult triage decision decisions whether it's a black or a red person they provide secondary triage they could provide on-scene medical direction for the ems and the emts and they could actually do pride care in the treatment section and that's kind of a cool thing rehabilitation supervisor they have an area that provides protection from the elements in the situation rehabilitation or rehab as we call it that's where the responders get rest they get food they get drinks maybe it's cold then they get to and they've established an area where they can warm up again and they also monitor us for signs of stress extrication and special rescue we talked about that in the last chapter they have the special equipment and the resources and the training it's usually a function under the ems branch you have to think about this the morgue supervisor medical examiners the coroners there's a group out there called disaster mortuary assistant teams at the state and federal and regional levels law enforcement agencies to coordinate removal of bodies and body parts i was at a conference one time and the lecturer was talking about body parts at 9 11 and they at one point had to decide how small of a body part do we keep and how small do we not keep and i guess during their decisions and their their arguments and discussions they came up with the decision that they would not keep a body part any smaller than an eyeball they didn't it was there was too much or there was too many body parts smaller than an eyeball that they just did not keep crazy that they had to think about that and again the morgue should be out of view of the living patients and other responders that's just depressing mass casualties involve three or more patients it puts a good and great demand on the ems system because we may only have two emts and now we have three patients has a potential to produce mass casualties so we might have a fire at a school and we think okay we should be prepared for a mass casualty incident all systems are going to have different protocols uh when to declare mass casualty when to initiate that incident command system you and your team cannot treat and transport all injured patients at the same time it's just impossible we never leave the scene until with patience until there is excuse me we never leave the scene with patients if there are still other patients who are sick or wounded we can't that's abandonment if you don't have enough resources we can't we declare mass casualty incident we wait for additional resources and we initiate the incident command system with triage procedures triage means to really sort out or to classify patients based on the severity of their injuries it's really has to be really quick brief and basic primary triage is done in the field secondary is done when they're brought to the treatment area so i had a student tell me well triage is good no but as an emt i won't be doing the triage and i said well i beg to differ because as a paramedic my skills would be more useful somewhere else well as an emt you can obviously go through and triage people into the different categories so red and yellow those are probably the two that most people are going to struggle with do i make them a red do i make them a yellow green is easy black is easy it's the yellow red ones that most people have difficulties with so if you look at the red tag that's the person who should be treated obviously first and transported first severe medical problems signs of shock severe burns open chest wounds or abdominal wounds uncontrolled or severe bleeding airway problems abc problems yellow those can wait a little bit burns without airway compromise major or multiple broken bones back injuries they can wait there's no problem with abc there green tags they can walk and talk and chew gum black they're obviously dead or there's little chance of survival unfortunately in ems whoever's doing the triage may have to make that decision and live with that decision so this is a great system right here with the triage tags and the tape because it's very visible and people can see these color-coded tape the start triage is a simple triage and rapid treatment that's what start stands for the first step is call out patients and direct them to the easily identifiable landmark and those people that are walking guess what they're green if they're directed but they can't walk then we need to do a further assessment of them jumpstart is a start but it's specifically for pediatric patients younger than age are we're taking a guess that they weigh less than 100 pounds again we start with the green ones then after that we start talking to the patients who have respiratory assessments uh uh differences and then we have the to uh guess at their respirations their hemodynamics status their neurologic status so that's where we're going to go with the jump start system triage considerations patients who are hysterical and disrupt their rescue efforts might need to be handled as an immediate priority to get them out of that area a responder who becomes sick or injured should be handled as an immediate priority and again identifying patients as contaminated or decontaminated in hazmat situations is a huge triage consideration destination where we gonna go with these patients how they gonna get there you might have to have a city bus take all the walking wounded you might need helicopter or more additional ambulances and again patients should be transported two at a time until they're all transported from the site you have to be working with the transportation section to determine where you're going so you don't overload that one hospital patients that are in delay can be transported two or three at a time and then finally the slightly injured or the green ones people who are expected to uh who are still alive should be treated and transported excuse me who are still alive would receive treatment and transport last dead victims are handled and transported according to the standard operating procedures for that area disasters in a widespread event it disrupts the functions of your community it disrupts the resources of your community that tornado that i dealt with the the local fire department's fire trucks were in the fire station when the tornado hit and every fire truck was destroyed and covered in bricks so the resources of that community were disrupted if you will or disabled it threatens lives and properties so some of these disasters may not involve personal injuries but floods fires hurricanes they might have wide spread injuries your role when requested to report the incident command first assigned task your role so a casualty collection area may be established in a disaster with overwhelming number of casualties so you work with the incident command system and the incident commander as the same way with you would with any other operation area so our role is going to be patient care right so when you arrive at a possible hazmat we need to step back and let somebody else take care of that first you know rushing into unsafe scenes can be catastrophic the joke has always been how do you know you're at a hazmat situation count the number of dead cops i mean the the cops like to rush in i i'm i'm not knocking cops i'm one i was one my kids won but that was the joke number of dead cops then you can determine if it's a hazmat situation according to to the has whopper the first responders at the admit awareness level should have sufficient training or experience to demonstrate the understanding of what a hazmat situation is or hazmat substances are and their risks with them and then understanding the potential outcomes of an incident so you're training as a hazmat awareness uh ems professional you should have that understanding areas of training or experience are going to help you to recognize the presence of hazmat substances how to identify these substances if possible the role of the first responder and the need for additional resources so that's what really our role in the hazmat situation is we need to recognize that it's a hazardous material number one take a look at the whole scene identify visual indicators that it might be a hazmat situation like a a semi truck that is a tanker on the back a train car derailment and they have those placards on the side you could have the truck train crash you could have a boat crash you could have an airplane crash things that you don't think about are maybe an underground natural pipe the country is literally a network of underground natural gas pipes all over the country you don't even know it but your house might be very close to one of these these underground pipes you don't know you might have a deterioration of underground fuel tanks oil or gas buildup of methane uh in sewers and the sewer blows that happens in the bigger cities sometimes again a motor vehicle crash resulting in a ruptured gas tank that might just be the hazmat seen spilled gasoline so here's a couple examples burning container of flammable liquid and a crashed tanker truck we don't know what's in there until we can see what the placard says or if somebody tells us what's in there occupancy and location so there's a lot of different areas where chemicals are stored hospitals warehouses somebody's garage bowling alleys never thought of that one home improvement and garden centers your local lows are uh the home depot restaurants have hazardous material so this one is kind of kind of scary the senses can be safely used are those of sight and sound not smell okay if you smell it you might be too close and it might be too late so use all of your senses before you get in proximity of that chemical containers again a container is a vessel or receptacle that holds the material really looking at the different types and sizes of material could provide clues if you will about what's inside and there's two types of categories bulk and non-bulk containers volume we think about what's stored in there and again it's probably large quantities of a chemical they're usually surrounded by a secondary containment system to help in case you have an accidental release of that that chemical and large volume horizontal tanks are also common totes have the ability uh the capacity sorry ranging from 119 gallons to 700 gallons of this chemical could be flammable could be a corrosive it could be an oxidizer again these are some bad chemicals and it's and there's no secondary containment system if there's a problem so these are totes my experience with topes was being an industrial uh paramedic working for general motors and this is the what the paint um and the primers would come in for the vehicles big totes like this where they stored the totes if the alarm went off you had was it 20 or 30 seconds to get out of there before the door shut and they removed all the oxygen from that room so if you're in that room you're going to die intermodal tanks are both shipping and storage they hold between 5 000 and 6 000 gallons they could be pressurized or not this is what an intermodal tank would look like and sometimes you'll see those on semis sometimes you'll see them on trains it's crazy the next time you get stopped at a railroad and you have the north american field guide book for hazmat look up just one of those numbers one time as it goes by you and you'll you can see what kind of bad stuff is going through your community non-bulk storage vessels they hold commercial industrial chemicals the drums are easily recognizable it's like a barrel and again the nature of the chemical really dictates the construction of this drum non-bulk storage vessels also have bags are commonly used to store solids and powders they might be constructed of plastic paper or even plastic lined paper pesticide bags are labeled think about pesticides car boys transport and store corrosives and other types of chemicals glass plastic steel containers 5 to 15 gallons very small often placed in wood foam fiberglass or a steel box this is a car boy i never would have called it a car boy until taking emt class uninsulated compressed gas cylinders are used to source substance like nitrogen argon helium and oxygen even so how do we know what this this chemical is and without having i don't know how do i put this my goodness without knowing the what's inside there how do we know if it's safe or not so the department of transportation did this marking system and what they have of these labels are placards if you will on the outsides of buildings and cars and trucks and trains and they are going to tell you what that substance is this in this book in the emergency response guidebook it gives you an idea what the placard is and what's inside that container and there's so many that you cannot just memorize this but there are different categories they're diamond shaped they're on all four sides of the transportation vehicles and they might be even on boxes not necessarily the vehicle itself but on smaller individual boxes again if you look at this you kind of think oh lord what's in there well obviously the red one looks like it's something that is can be a source of fire the top right one looks like a corrosive so the d.o.t system does not require that all chemical shipments be marked oh lord in most cases the package or cam a cargo tank must contain a certain amount of hazardous material before that placard is required so some chemicals are so hazardous that shipping any amount requires the use of placards so think about it even though it's may not have enough in there to require a placard there's still some of that substance in there this is the book this is the bible this is what it should be in every ambulance and right next to this book should be a pair of binoculars because this is what's going to tell us what's in that hazardous material incident and the best way to look up those placards is by the use of your binoculars msds sheets those of you who work in factories in industry construction whatever you're probably familiar with an msds sheet is a material safety data sheet it's going to tell you what the chemical is what hazards it can have how to provide first aid if you have it if you're exposed to it or if you get it on your skin or in your eyes are ingested any anything that pertains to that chemical shipping papers now we have to think about shipping papers and these are going to be uh when materials are transported obviously from one place to another and they're going to tell you what it is how much it is and everything about what's being shipped chemtreck chemtreck is a company that is operated or by the american chemistry council this is a resource we can contact chemtreck as a first responder about any chemical incident and they're going to tell you everything pretty much what an msds sheet does but they're going to give you even more information so chem trek is a resource for us to use so even though you have all that you still may not be able to correctly identify that chemical you might see a cloud or smoke escaping from something a leaker spill from a tank we don't know an unusual strong noxious harsh odor oh man maybe by then it's too late for you so anything that suggests that it's a hazmat stop always park uphill upwind call the hazmat team they're the specialists that's not something that we are trained in ems that's that again it's another branch of the fire department or branch of the emergency management system whatever in your area but again the hazmat team has the ability to identify and safely make it safe for patients or get patients out of those zones again don't go anywhere near until the hazmat team comes in we can use a public address system i talked about using that the pa with the person trapped in the car with live wires on it we could do the same thing here we could tell them from a distance uh stay away from the scene or tell them where to go we establish these control zones we need to secure these areas so no one's going to get potentially contaminated by that chemical there's something called the hot zone the warm zone in the cold zone guess where we are yep we're in the cold zone and we want to stay in the cold zone the hot zone is where that hazmat team is and then the warm zone between the two is where we're gonna if we have patients in the hot zone we're gonna decontaminate them in the warm and get them out to the cold zone even the hazmat team members that go into the hot zone have to be decontaminated never thought about that but they have to be decontaminated when they come out of that hot zone the warm zone that's where we transition from that hot zone into the cold zone the decontamination process we're going to scrub them off we're going to wash them off we're going to use water maybe even some chemicals or strong soaps or whatever to get that hazardous material off their the equipment and off themselves the cold zone this is where i love to be this is where ems is this is where the command center is this is where everything is in a mass casualty incident except those hazmat team members they go into the hot zone your role as an emt is to provide triage treatment transport and rehabilitation for the rescuers you may not have any patients to transport you may not have any of that but you do have a role in that we do have a part in the rehabilitation of the rescuers there's a national standard nfpa 704 it's about how to classify hazardous materials according to their health hazard and toxicity levels their fire hazard chemical reactivity and any special hazards toxic levels they measure the health risk that might happen to someone who comes into contact with that chemical and obviously the higher the number the greater toxicity at level zero there's little or no hazardous you don't need any protection all the way up to four where minimal exposure causes death and you need a level a hazmat suit to be near that material that's the bad stuff the level a is the most hazardous you need to be fully encapsulated in protective clothing and underneath that you're going to wear a self-contained breathing apparatus or scba and everything is going to be there to protect you a level b again requires a breathing device of their own like an scba and eye protection but it's not encapsulated clothing level c you need a face mask that filters out your outside air level d coveralls all levels are going to have some form of glove so that we do not touch that material so there's a level a on your far left very few people will even go into those that's the hazmat team members level b uh that's again fire department or rescue personnel level c that could be us level d is us i mean that's when we think about protective equipment saw our patients it is it is um practical only to provide the simplest care in a hazmat zone in contamination area because of the dangers the kind time constraints and the bulky protective equipment so what we're saying is we're not going to do any uh like uses the traction splint we're not going to do anything that is time consuming because we want to get our patients out of these dangers out of this area there's the two things that we're going to assess with our patients number one any trauma such as vehicle fire collision whatever all that and then the injury and harm that have resulted from that toxic exposure so we have the trauma and then we have the exposure to think about most serious injuries deaths from hazmat result from airway breathing problems it's the stuff that we inhale so sometimes the hazmat team may find a patient who needs immediate treatment for decontamination that's been set up so now we have to deal not us but the hazmat team has to deal with that if you're going to be caring for patients in the in the hot zones or warm zones you need protective clothing that scba gloves goggles protective coat some type of respiratory protection if you're not using an scba and again a disposable fluid impervious gown so what is the purpose of the incident command system ensure responder and public safety achieve incident management goals ensuring the efficient use of resources or all of the above what have i said in the past about all of the above possible answers we really should consider those and it is it's all of those we have to meet those goals we have to be efficient in the use of our resources and we have to be safe upon arriving at a scene in which the incident command system has been activated you should be expected to be passed from sector to sector as needed in between assignments report directly to the incident commander in between assignments be assigned a specific responsibility for the duration of the incident be given general directions and allowed to function independently um what should you do upon arriving at a scene and the incident command system has been activated what do we do yep a we wanted we could be passed from sector to sector as needed in between assignments we're going to be given assignments all the time but we might have to go from triage to treatment to transport when ems responds to a disaster as part of their response within the incident command system ems should start with scene size up what is the next step for first responding units communicating with additional units establishing command caring for injuries stabilizing the incident so you respond to a disaster we start with scene size up what's the next step established command the sooner we establish incident command the better it's going to be for that scene which of the following statements best describes a mass casualty incident at least half the patients are dead a bus or plane crash we have more than two critical patients a patient count exhaust your resources okey-doke yep it's it taxes your resources or exhaust your resources it could be again three patients which of the following patients would have the highest treatment priority at the scene of a mass casualty 24 year old man who is unconscious has snoring respirations and severe burns he 32 year old woman who has pulses in abner with an abdominal evisceration 29 year old woman in full cardiac arrest 32 year old man with an open head injury exposed brain manner and no carotid pulse come on people i know you know this one yes it's got to be a i mean really b c and d those are good they're going to be triaged as black if they are well first off the b she has no pulse and not breathing next one is no pulse not breathing and the last guy has no pulse we're not going to be working them we're not going to be wasting time we're going to treat the people we can treat help the most how does a disaster differ from a mass casualty incident disasters may not involve personal injuries in a disaster ems may be unseen for days or weeks see only elected confession can declare a disaster or all of the above i know i always say look at d but let's think about this right it's still d yep you can call a mass casualty incident but you can't call a disaster that's got to be from somebody above our pay grade and at a true disaster you might be there for days or weeks hurricanes uh tornadoes uh uh fires i'm trying to think out loud what the heck i can think of uh tsunamis i don't know a large tanker truck is overturned on the highway when you arrive you see a clear liquid leaking from the rear of the tank the driver who appears to be unconscious is still in the vehicle and bleeding heavily from the face you should what notify law enforcement for traffic control fully assess the situation and request the appropriate assistance put on gloves gown mask and get to the driver and get them out go to the rear of the tanker and determine what type of fluid is leaking i hope you guys all get this one right because it is definitely be uh again we want to go in and help we have we feel the moral and ethical need to help that that driver but we have to make sure it's safe first which of the following situations most likely involve a hazardous material milk truck that overturn is leaking fluid tractor trailer rig that is emitting a visible cloud a moving van that collided head-on with a small car or a pickup truck from the gas company that struck a tree which one is most likely i know they all could be but what is most likely to involve a hazardous material yeah that visible cloud i mean yes we could have gasoline coming from a car but most likely is that cloud you actually see it again milk is not a hazardous material unless you're lactose intolerant nine when dealing with a hazardous material incident where should you set up your decontamination area inside the hazard zone inside the treatment zone between the hazard and treatment areas between the treatment treatment and transport area where should your decontamination area be we're not using the terms hot warm and cold now where should it be it's between the sea the hazardous zone and the treatment zone hazard zone is the hot zone the treatment zone is the cold zone which toxicity level would you assign a hazardous material spill that could cause a person temporary damage or residual injury unless prompt medical treatment is given level one two three or four this could cause a person temporary damage or residual injuries unless treatment is given one two three or four i think at this point you're all taking a guess right because i am too two is the correct answer one has fewer health hazards three is extreme health hazards and four is death so it's going to be a two all right gang we only have one more chapter to go hang in there