Incident Management

A mass-casualty incident (MCI) refers to any call that involves three or more patients, any situation that places such great demand on available equipment and would require a mutual aid response (agreement between neighboring EMS systems to respond when local resources are insufficient to handle the response). The National Incident Management System (NIMS) was developed to promote more efficient coordination between emergency responders. The Department of Homeland Security implemented NIMS in 2004 for flexibility and standardization. The major components that prompt multiple agencies to work together toward the same goal, while maintaining their autonomy, is the incident command system. Communication and information management is one of the principles. Effective communications, information management, and information sharing are critical aspects of domestic incident management. The NIMS communications and information management systems enable the essential functions needed to assess available information, provide interoperability, and ensure appropriate communication of decisions. Resource management is another principle. NIMS sets up mechanisms to describe, inventory, track, and dispatch resources before, during, and after an incident. Standard procedures to recover equipment used during the incident. Command and coordination is the last major principle. The NIMS standardizes incident management for all hazards and across all levels of government. It provides comprehensive frameworks and recommended organizational structures. The NIMS standard incident command structures are based on three key constructs: ICS, multiagency coordination systems, and public information system.

ICS is designed to avoid duplication of efforts and freelancing. One of the organizing principles of the ICS is to limit the span of control of any one individual. One supervisor for five subordinates. The organizational levels may include sections, branches, divisions, and groups. Sections are responsible for a major functional area such as finance/administration, logistics, planning, or operations. Branches are managed by the branch director and may be functional or geographic in nature. These tend to be established when span of control is a problem, for example at larger incidents, where more oversight may be needed. Branches are in charge of activity directly related to the section (fire, law enforcement, EMS, operations). Divisions and groups serve to align resources and crews working in the same geographic area. Groups usually refer to crews working in the same functional area, but possibly in different locations. Fire suppression group and EMS group are examples.

There are various roles of EMS response within the ICS. There is Command who establishes the strategic objectives and priorities, and develops a plan to manage the incident. There can also be a public information officer (PIO), safety officer, and liaison officer. Large MCIs, such as a hazmat incident, require a multiagency or multijurisdictional response and need to use a unified command system. In these cases, all plans are drawn up in advance. There may be the hazmat team that takes the lead in a chemical leak, and the medical team takes the lead in a multivehicle crash. They should cross train to ensure that a unified command system will function well and that communication among the responders is well established before a real incident occurs. A single command system is where one person is in charge, even if multiple agencies respond. It is important that you know who the IC is, how to communicate with the IC, and where the command post is located. When the incident draws to a close, there should be a termination of command and your agency should implement a demobilization procedure.

Another role within the ICS is the Finance/Administration officer. They are the section chief responsible for documenting all expenditures at an incident for reimbursement. Various functions include – the time unit, the procurement unit, the compensation and claims unit, and the cost unit. Time is the daily recording of personnel time and equipment use. The procurement unit deals with all matters concerning vendor contracts. The compensation and claims unit deals with claims as a result of the incident and injury compensation. Cost unit is responsible for collecting, analyzing, and reporting the costs related to an incident.

Some other roles are Logistics, Operations, and Planning within the ICS. Logistics is responsible for communications equipment, facilities, food and water, fuel, lighting, and medical equipment and supplies for patients and emergency responders. Trained to find supplies if needed. There is also operations which is responsible for managing the tactical operations usually handled by the IC on routine EMS calls. Will supervise the people working at the scene of the incident, who will be assigned to branches, divisions, and groups. Planning obtains data about the problem, analyzes the previous incident plan, and predicts what or who is needed to make the new plan work. They need to work closely with the operations, finance/administration, and especially logistics sections. They should document their decisions and what they learned from the incident. They are also involved in the development of an incident action plan, provide clear, concise information about incident activities, including objectives, tactics, and assignments. It should be written at the outset of the response and revised continually throughout the response.

The command staff include the safety officer monitors the scene for conditions or operations that may present a hazard to responders and patients. Working with environmental health and hazmat specialists. Have the authority to stop an emergency operation whenever a rescuer is in danger. A safety officer should remove hazards to EMS personnel and patients before the hazards cause injury. The public information officer (PIO) provides the public and media with clear and understandable information. Joint information center (JIC). In some circumstances, the PIO/JIC may be responsible for distributing a message to help a situation, prevent panic. A liaison officer relays information and concerns among command, general staff, and other agencies. If an agency is not represented in the command structure, questions and input should be given through the liaison officer.

Communications should be integrated and all agencies should be able to communicate quickly and effortlessly via radios. The stages of mobilization and deployment are check in at the incident, initial incident briefing, incident record keeping, accountability, and incident demobilization. You need to be prepared and have regular training for disasters that regularly happen. Disaster supplies for at least a 72 hour period of self sufficiency. When doing scene size-up start with dispatch and do not put yourself in harm’s way. Ask yourself what do I have and what resources do I need? What do I need to do. Is the incident an open one meaning it has not yet been contained. If that is the case there may be patients who are yet to be located and the situation may be ongoing, producing even more patients. A closed incident is one that is contained. Safety is paramount put yourself and your partner’s life above that of other bystanders because you have the skills while they typically do not. Make sure to establish a command. Communication is key while some regions have mobile self-contained communications centers, whereas others use local radio groups such as ham radio operators to assist with communications. Your plan should include a “plan B” in case of communications failure.

At incidents that have a significant medical factor, the IC will designate someone as the chief of the medical branch under the operations section. Triage, treatment, and transport of injured people. Triage supervisor is ultimately in charge of counting and prioritizing patients. During large incidents a number of triage personnel may be needed. Treatment Supervisor will locate and set up the treatment area with a tier for each priority of patient. Ensures that secondary triage of patients is completed and that adequate patient care is provided as resources allow. Also assists with moving patients to the transportation area. Transportation Supervisor coordinates the transportation and distribution of patients to appropriate receiving hospitals. Makes sure hospitals don’t get overwhelmed by a patient surge, coordinates with the IC to ensure that enough personnel and ambulances are in the staging area. Staging Supervisor is assigned when an MCI or disaster requires a multi vehicle responses. Vehicles receive direction from the staging supervisor to enter an MCI scene and should only drive in the directed area. Staging supervisor locates an area to stage equipment and responders, tracks units arrivals, and releases vehicles and supplies when ordered by command. Physicians on Scene is responsible for difficult triage decision. Rehabilitation supervisor establishes an area that provides protection for responders from the elements and the situations. The rehabilitation area should be located away from exhaust fumes and crowds. Responder’s needs for rest, fluids, food and protection from the elements are met. Extrication and Special Rescue determine the type of equipment and resources needed for the situation. Morgue Supervisor will work with area medical examiners, coroners, disaster mortuary assistance teams, and law enforcement agencies to coordinate removal of the bodies and even possibly body parts. Leave the dead victims in the location found until a removal and storage plan can be determined. Help in identification of the dead victims, determine if a morgue area is needed which should be out of view of the living patients.

Primary triage is the initial triage done in the field, allowing you to quickly and accurately categorize the patient’s condition and transport needs. During primary triage, patients are briefly assessed and then identified in some way, such as by attaching triage tags or colored triage tape. The main information needed on the tag is a unique number and a triage category. Triage supervisor should communicate the following information to the medical branch director: Total number of patients, Number of patients in each of the triage categories, Recommendations for extrication and movement of patients to the treatment area and Resources needed to complete triage and begin movement of patients. Secondary triage is done as patients are brought to the treatment area. Allows you to reassess all remaining patients and upgrade their triage category.

Triage Categories
Immediate(red), Airway and breathing compromises, uncontrolled or severe bleeding, severe medical problems, signs of shock, severe burns, open chest or abdominal injuries.
Delayed(yellow), Burns without airway compromise, major or multiple bone or joint injuries, back injuries with or without spinal cord damage.
Minor or minimal(green; hold) include Minor fractures, soft tissue injuries.
Expectant(black; likely to die or dead) Obvious death, major open brain trauma, respiratory arrest(if limited resources), cardiac arrest

Start is a system for triaging. First step is arrival at the scene by calling out to patients, “If you can hear my voice and are able to walk” go towards an easily identifiable landmark. -Green The second step in the START process is directed toward non-walking patients. Move to the first non-ambulatory patient and assess the respiratory status. If the patient is not breathing, open the airway by using a simple manual maneuver. A patient who still does not begin to breathe is triaged as expectant(black). If they do start breathing tag them as red, place in the recovery position and move on to the next patient. If the patient is breathing make a quick estimation of the respiratory rate. A patient who is breathing faster than 30 breaths/min or slower than 10 breaths/min is triaged as red. Assess the hemodynamic status of the patient by checking for bilateral radial pulse, an absent radial pulse implies the patient is likely hypotensive; tag them as red. The final assessment in the START triage is to assess the patient’s neurologic status. “Show me three fingers.” A patient who is unconscious or cannot follow simple commands is an immediate priority patient. A patient who complies with a simple command should be triaged in the delayed category (yellow).

JumpSTART is the system for pediatric patients. It begins by identifying the walking wounded. There are several differences within the respiratory status assessment compared with START. First if you find a pediatric patient that is not breathing, position the airway and reassess breathing. If they start breathing that is a red. If the child is apneic, check for pulse, if no pulse label black. If pulse is detected, provide 5 rescue breaths then reassess breathing. If the child remains apneic label as expectant(black). If the child resumes breathing, label as immediate(red). Primary reason is the most common cause of cardiac arrest in children is respiratory arrest. The next assessment in JumpSTART triage is also the hemodynamic status of the patient. Just like in START you are checking for a distal pulse. In the absence of a distal pulse move on to the next assessment. Final assessment is for neurologic status, because of the developmental differences in children their responses will vary. For JumpSTART, a modified AVPU score is used and a child who is unresponsive or responds to pain by posturing or with incomprehensible sounds or is unable to localize pain is tagged as an immediate priority. A child who responds to pain by localizing it or withdrawing from it or is alert is considered a delayed-priority patient(yellow).

There are a few special situations in triage, patients who are hysterical and disruptive to rescue efforts may need to be handled as an immediate priority and transported off the site, even if they are not seriously injured. Panic breeds panic. A responder who becomes sick or injured should be handled as an immediate priority as soon as possible to avoid negative morale. Hazmat and weapons of mass destruction incidents force the hazmat team to identify patients as contaminated or decontaminated before the regular triage process.

All patients triaged as immediate(red) or delayed(yellow) should be transported by ground or air ambulance to the most appropriate facility(trauma, burn, or pediatric). A bus may be used to transport minimal-priority patients, it is strongly suggested that they be transported to a hospital or clinic distant from the MCI or disaster site to avoid overwhelming the local area hospital resources. Immediate-priority patients should be transported two at a time until all are transported from the site. Then patients in the delayed category can be transported two or three at a time until all are at the hospital, finally the walking wounded are transported. Expectant patients who are still alive would receive treatment and transport at this time.

A disaster is a widespread event that disrupts functions and resources of a community and threatens lives and property. Many disasters do not necessarily result in personal injuries like droughts but floods, fires and hurricanes do. Only an elected official can declare a disaster. Unlike an MCI, which generally lasts no longer than a few hours, emergency responders will generally be on the scene of a disaster for days to weeks and sometime months. Your role in a disaster is to respond when requested and to report to the IC for assigned tasks. May mobilize medical and nursing teams with equipment and set up a casualty collection area at a facility near the disaster scene, such as a warehouse.

When at the scene of a hazmat incident, you must step back and perform a scene size-up. OSHA has published a set of guidelines known as the Hazardous Waste Operation and Emergency Response (HAZWOPER). First responders at the awareness level should have sufficient training or experience to demonstrate competency in the following areas. An understanding of what hazardous substances are and the risks associated with them. An understanding of the potential outcomes of an incident. The ability to recognize the presence of hazardous substances. The ability to identify the hazardous substances. An understanding of the role of the first responder awareness individual in the emergency response plan. The ability to determine the need for additional resources and notify the communication center. Stay upwind and uphill. Once you have a basic idea of what happened or determine that danger may be present you can begin to formulate a plan for addressing the incident. Occupancy and location are important factors to consider. A wide variety of chemicals are stored in warehouses, hospitals, laboratories, industrial complexes, residential garages, etc. So many different chemicals exist you could encounter almost anything during any type of emergency situation. Location and type of building are two good indicators of the possible presence of hazardous material. Use your senses, you can generally safely use sight and sound. Some clues are vapor clouds or the sounds of an alarm from a toxic gas sensor. Leading with your nose is not a good tactic.

A container is any vessel or receptacle that holds a material. There is no correlation between the color of the drum and the possible contents. One way to distinguish containers is to divide them into two categories based on their capacity: bulk and non-bulk storage containers. Bulk storage containers include fixed tanks, highway cargo tanks, rail tank cars, totes and intermodal tanks. Common sizes for bulk containers include totes, which commonly hold 275 and 330 gallons (1041 and 1249 L). Intermodal tanks are both shipping and storage vessels and hold between 4000 and 6000 gallons (15142 and 22712 L). Often these bulk storage containers are surrounded by a secondary containment system to help control an accidental release. A 5000 gallon (18927 L) vertical storage tank for example may form a catch basin. Non-bulk storage vessels can hold a few ounces to 119 gallons (450 L) of product and include vessels such as drums, bags, compressed gas cylinders, cryogenic containers and more. The nature of the chemical determines the construction of the storage drums. Steel utility drums hold flammable liquids, cleaning fluids, oil and other noncorrosive chemicals. Polyethylene drums are used for corrosives such as acids, bases, oxidizers and other materials that cannot be stored in steel. Cardboard drums hold solid material such as soap flakes, sodium hydroxide pellets, and food-grade materials. Bags are used to store solids and powders such as cement powder, sand, pesticides, soda ash and slaked lime. Pesticide bags must be labeled with specific information. Carboys carry corrosives and other types of chemicals and are transported and stored in containers from 1 to 15 gallons (4 to 57 L) of product. Nitric acid, sulfuric acid and other strong acids are transported and stored in thick glass carboys protected by a wooden or polystyrene crate to shield from damage during shipping. Cylinders hold liquids and gases; uninsulated compressed gas cylinders are used to store substances such as nitrogen, argon, helium and oxygen.

The Department of Transportation Marking System
Class 1 Explosives
Class 2 Gases
Class 3 Flammable liquid
Class 4 Flammable solid, spontaneously combustible and dangerous when wet
Class 5 Oxidizer, Organic
Class 6 Poison
Class 7 Radioactive
Class 8 Corrosive
Class 9 miscellaneous Hazardous Material

Cargo tank must contain about 1000 pounds before a placard is required. Helpful information is found in The Emergency Response Guidebook and Material Safety Data Sheet (MSDS). These provide basic information about the chemical makeup of a substance, potential hazards it presents and appropriate first aid in the event of exposure. Shipping papers are required whenever hazardous materials are transported from one place to another. They include the names and addresses of the shipper and the receiver, identify the material being shipped and specify quantity and weight. Bills of lading or freight bills. CHEMTREC (Chemical Transportation Emergency Center) offers a phone conferencing service to connect you with thousands of shippers, subject matter experts and chemical manufacturers.

Some substances are not hazardous until mixed with another substance. Always maintain a high index of suspicion. In the event of a leak or spill a hazmat incident is often indicated by the presence of the following. A visible cloud or strange-looking smoke resulting from the escaping substance. A leak or spill from a tank or container with or without hazmat placards. An unusual, strong, noxious, harsh odor in the area, some gases are odorless. The safety of you and your team, the other responders and the public must be your most important concern. Do not reenter the scene and do not leave the area until you have been cleared by the hazmat team, or you may contribute to the situation by spreading hazardous materials.

Establishing a control zone helps reduce the number of civilians and responders who may be exposed to the released substance. Make sure no one will accidentally enter a scene. Hot zone – hazardous materials, warm zone – decontamination corridor, cold zone where the incident commander and command post are; factor in the wind. A patient’s skin and clothing may contain hazardous material, decontamination area, water that is used must be captured.

Toxicity levels
Level 0 little if any health risk
Level 1 causes irritation on contact but only mild residual injury
Level 2 temporary damage or residual injury unless prompt medical treatment is provided. Both levels 1 and 2 are considered slightly hazardous but require use of self-contained breathing apparatus (SCBA) if you are going to come in contact
Level 3 includes materials that are extremely hazardous to health. Contact with these materials requires full protective gear so that none of your skin surface is exposed
Level 4 is materials that are so hazardous that minimal contact will cause death. You need specialized gear that is designed for protection against that particular hazard

There are four recognized protection levels, A, B, C and D.
Level A, the most hazardous, requires fully encapsulated, chemical-resistant protective clothing that provides full protection as well as SCBA and special sealed equipment
Level B requires nonencapsulated protective clothing or clothing that is designed to protect against a particular hazard
Level C requires the use of nonpermeable clothing and eye protection. In addition, face masks that filter all inhaled outside air must be used
Level D requires a work uniform, such as coveralls, that affords minimal protection

All levels of protection require the use of gloves. Two pairs of rubber gloves are needed for protection in case one pair must be removed because of heavy contamination.

Because of dangers, time constraints and bulky protective gear that team members wear it is practical only to provide the simplest assessment and essential care in the hazard zone and the decontamination area. In addition, to avoid entrapment and spread of contaminants no bandages or splints are applied – except pressure dressings that are needed to control bleeding – until the clean decontaminated patient has been moved to the treatment area. Must address the following two issues and any trauma that has resulted from other mechanisms, such as vehicle crash, fire, or explosion. Injury and harm that have resulted from exposure to the hazardous substance. If the patient appears to be in distress, give oxygen at 12 to 15 L with a nonrebreathing mask. Special treatment includes medications, intravenous fluids or other advanced care. Before the decontamination area has been completely set up, the hazmat team will find one or two patients who need immediate treatment and transport without delay if they are to survive. It may be necessary to simply cut away all of the patient’s clothing and do a rapid rinse to remove the majority of the contamination matter before transport. Try to take steps to make decontamination of the ambulance easier, like taping the cabinet doors shut and removing any equipment that will not be used en route from the patient compartment and placing it in the front of the ambulance or in an outside compartment. Turn on the vent. Inform the hospital that you are transporting a critically injured patient who has not been fully decontaminated at the scene.