Medical Incident Command
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Chapter 50 Medical Incident Command
Objectives
Identify components of an incident command system (ICS)
Outline activities in preplanning scene management, and postdisaster follow-up of an incident
Identify FEMA’s five ICS components
List command responsibilities during a major incident response
Objectives
Describe FEMA ICS section responsibilities
Identify situations classified as major incidents
Describe steps needed to establish and operate the ICS
Given a major incident, describe sectors needed and responsibilities of each
Objectives
List problems related to the ICS and to mass casualty situations
Outline principles and technology of triage
Identify resources for management of critical incident stress
Scenario Icy wind and sleet pound your ambulance as you arrive on the scene of an overturned school bus in a small creek. Size-up reveals 18 young children and an elderly driver, with several apparently severe injuries, difficult access to the patients, and diesel fuel leaking from the bus.
Discussion
What are your priorities on this call?
What resources will you request?
Describe your primary role until additional help arrives
List sectors that will need to be established on this scene
How will you decide which patients to transport first?
Major Incident
Event in which the available resources are insufficient to manage the number of casualties or the nature of emergency
May stress local, regional, state, and even national and international resources
Examples of major incidents
Incident Command System (ICS)
Effective ICS allows for involvement of: Single jurisdiction; single agency Single jurisdiction; multiagency Multijurisdiction; multiagency
Incident Command System (ICS)
Expands from nonmajor incident to major incident in logical manner
Using ICS as standard operating procedure for small incidents permits smooth transition in major incident
ICS Terminology
Apparatus
Medical direction
Command
Mutual aid
Command post
Sector
Communications center
Staging area
FEMA ICS
Federal law requires ICS for hazmat incidents
Many states use ICS for all types of incidents
Incident management or command system Developed by FEMA National standard for incident management Flexible system Used by both public and private sectors in some routine and most large-scale emergencies
ICS Structure
ICS Organization
Five major components Command Planning Operations Logistics Finance/administration
The Command Function
One person coordinates variety of emergency activities
Cornerstone of ICS structure
Initial command determined in preplan
Command established immediately
Commander clearly identified
Commander responsibilities
Types of Command
Singular command
One individual responsible for operation
Unified command Large events or as small incident evolves Specialized organizations identified and personnel unify to complement command
EMS, fire, police, health department, Red Cross
Application of Unified Command
ICS Organization
Incident commander (IC) expands (or contracts) ICS organization based on: Life safety Incident stability Property conservation
If expansion is needed:
Other command staff positions established
Possible Command Staff Positions
Section Responsibilities
Sections assigned by IC to section chiefs Planning Operations Logistics Finance/administration
Section chiefs report to IC
Command Section Organizational Plan
Section Chiefs
Strong supervisors and managers
Primary role “Make things happen” Ensure rescuers working toward common goal
Number of sections varies by incident
Determined by IC
Section Chiefs
Not involved in physical tasks Accomplish command objectives Monitor work progress Redirect activities if needed Coordinate activities with other sections Request other resources as needed Monitor welfare of personnel in section Provide command with frequent reports Reallocate resources within section
Planning Section
Provides past, present, and future information about incident and status of resources Creates incident action plan (IAP) Operational periods
Planning Section
Operations Section
Directs and coordinates emergency scene operations
Ensures safety of operational personnel
EMS operations often fall under this section
Operations section chief is in charge of actual scene (“ground zero”)
Responsibilities
Operations Section
Logistics Section
Supports logistical needs of incident
Logistics appropriate to incident size/duration
Provides gear and support to responders
Logistics Section
Finance/Administration Section
Accounting and administration of incident
Staff support function
Monitors costs, careful accounting
Seldom used on small incidents
Essential as incident grows
And on hazmat incidents
Not used in routine daily incidents
Finance/Administration Section
Declaring a Major Incident
More than two ambulances needed
Particularly in rural areas
Situations involving hazardous or radioactive materials or chemicals
Situations needing special resources
Helicopters, rescue teams, multiple rescue or extrication units
When in doubt, declare a major incident
Preparing for a Major Incident
Phase 1: The preplan
Phase 2: Scene management
Phase 3: Post-disaster follow-up
Major Medical Incidents
Need to establish ICS at medical incident determined by: Number of casualties Nature of the event
Local/regional threshold
Examples of Medical ICS
Establishing Command
Group/sector functions or major functional areas implemented by incident size and scope
Groups and sectors may include:
Support sector Staging sector
Helicopter LZs and vehicle apparatus arrivals
Treatment sector
Unified EMS command with fire and police may be needed
Scene Assessment
First unit on scene
Rapid assessment of situation
Full assessment as safety and time permit Type of incident and potential duration Entrapment or special rescue resources needed Number of patients in each triage category Additional resources needed
Scene assessment continually updated
Communications
Command established by radio with dispatch EOC is where department heads, government officers and officials, and volunteer agencies gather to coordinate response to emergency event Command and EOC share goals Different levels of responsibility IC is responsible for on-scene activities EOC responsible for community-wide response
Obtaining Resources
Request additional units as needed: Dispatch should have written standard operating procedure (SOP) for requesting mutual aid May need to obtain food, shelter, clothing IC responsible for deployment of resources
Stay with vehicle until instructions received
Staging techniques used to deploy resources
Extrication Sector
Manages entrapped patients
Patient care activities in this sector
Only assessment and treatment of life threatening situations
Additional responsibilities
Treatment Sector
Works with extrication sector in patient care
Care and stabilization until patients transported to medical facility
As patients delivered, categorized by medical need
Paramedics and hospital personnel
With large numbers of patients:
Divided into immediate and delayed treatment zones
On-Scene Physicians at MCIs
Medical direction
Triage function
On-scene medical direction
Increased ability to make difficult triage decisions In treatment area for secondary triage decisions Emergency surgery to facilitate extrication
Treatment capabilities
Invasive procedures Assessment and direction of specific treatments
Disposition of the Deceased
Depends on scale of incident
Personnel assigned to disposition of deceased
Duties Work with medical examiner, coroner, law enforcement to coordinate disposition Assist in establishment of secure area for morgue if needed Monitor personnel for signs of stress
Transportation Sector
Communicates with hospitals, ambulances, and aeromedical services for patient transport
Works closely with treatment sector to determine appropriate patient destinations
Arrival and departure of vehicles coordinated with staging sector
Responsibilities
Staging Sector
Prevents vehicle congestion and response delays
All emergency vehicles should report for direction
Other agencies supervised by staging sector (disaster relief, news media)
Responsibilities
Rehabilitation (Rehab) Sector
Standard operating procedures in many fire and EMS agencies and major incident response plans
Set up outside operational area
Monitors personnel
Ensures proper rest and hydration
Works with logistics sector
Support Sector
Coordinates equipment and supplies for all sectors
May obtain medical supplies from hospitals, rescue supplies, and other equipment
Responsibilities
Sector Identification
All emergency responders must know ICS structure and radio communication procedure
Clothing and identification vary by system Color-coded vests identify personnel Most communication face to face
Exception
Command and sector communications
Radio use is for command operations
Sector Identification
Radio communications use operation titles: "EMS sector to command" or "Fire sector to rescue sector" Ensures reaching appropriate individual by one radio designation
Radio Communications
Key function during major incident
Preplanning includes identification of radio frequencies
Responding units should have radios using common frequency
Separate frequencies for EMS, fire, and other support operations
Radio Communications
Sector officers’ radios on channel that permits direct communications with command Frequencies may be assigned in advance Or by dispatching agency at incident
Radio Communications
Clear, concise, and in plain English
Helps set orderly tone Avoid use of radio codes/signals
Prepare messages before transmitting
Clearly identify unit number or sector
Minimize radio traffic
Face-to-face communication preferred
Common Problems of MCIs
Failure to notify everyone
Lack of rapid patient stabilization
Failure to collect patients in treatment area
Failure to triage properly
Administering too much care
Transporting patients prematurely
Common Problems of MCIs
Using personnel improperly
Failure to distribute patients to hospitals appropriately
Lack of EMS command in field
Lack of hospital communication
Lack of preplanning and training
Principles of Triage
Triage
Assessment of injury severity based on:
Method to categorize patients for priorities of treatment
Abnormal physiological signs Anatomic injury (and mechanism of injury) Concurrent disease factors
Triage is a continuous process during a major incident
Primary vs. Secondary Triage
Primary triage Categorizes patient condition for treatment Documents patient location and transport needs Labels patient with triage labels, tags, or tape Focuses on speed to sort patients No care rendered during primary triage
Except lifesaving airway or hemorrhage control
Primary vs. Secondary Triage
Secondary triage At treatment area Patients retriaged and labeled Not always necessary
Especially at small incidents
START Triage
START (simple triage and rapid treatment)
60-second assessment
Evaluate: Ability to walk Respiratory effort Pulses/perfusion Neurological status
START Triage
Classify patients as: Urgent Delayed Dead or dying Critical
START Triage
Allows rescuers to: Identify patients at risk of early death Advise others of patient's need for stabilization by tagging with disaster tags
START Triage System Insert Insert Fig Fig50-10 50-10
START Triage
Assess ability to walk
Evaluate breathing and rate
Assess pulses/perfusion
Assess mental status
START Triage
Repositioning of airway and controlling severe hemorrhage are only treatment efforts in primary triage:
In a mass casualty event, these measures should not delay triage of other patients
Triage Tagging/Labeling
Many tags, tape, and labels available
International color coding and priorities Immediate Red Priority-1 (P-1) Delayed Yellow Priority-2 (P-2) Hold Green Priority-3 (P-3) Deceased Black Priority-0 (P-0)
Kim KimMcKenna: McKenna: Ed: Ed:need needfigure50-11 figure50-11
METTAG Card
Purpose of Tagging
Identifies priority
Prevents retriage of patient
Tracking system during treatment/ transport
Tags and labels should:
Be easy to use Rapidly identify patient priority Allow for easy tracking Allow room for some documentation Prevent patients from retriaging themselves
Tracking Systems for Patients
A destination log is maintained by the transportation section officer Should have name or triage label ID number Tracking log must contain:
Patient identification Transporting unit Patient priority Hospital destination
ICS Patient Log
Transportation of Patients
Method of transportation determined by triage priority and situation
Ambulance a typical method
Buses considered for transporting a large number of priority 3 patients
Air ambulances for critical patients
Critical Incident Stress Management
Critical incident stress Potential for rescuers at major events Critical incident stress debriefings part of postdisaster SOP Types of services Other approaches to manage stress
Conclusion A major incident is an event for which available resources are insufficient to manage the number of casualties or the nature of the emergency. It may overwhelm local, regional, state, and even national and international capabilities.
Questions?
Objectives
Identify components of an incident command system (ICS)
Outline activities in preplanning scene management, and postdisaster follow-up of an incident
Identify FEMA’s five ICS components
List command responsibilities during a major incident response
Objectives
Describe FEMA ICS section responsibilities
Identify situations classified as major incidents
Describe steps needed to establish and operate the ICS
Given a major incident, describe sectors needed and responsibilities of each
Objectives
List problems related to the ICS and to mass casualty situations
Outline principles and technology of triage
Identify resources for management of critical incident stress
Scenario Icy wind and sleet pound your ambulance as you arrive on the scene of an overturned school bus in a small creek. Size-up reveals 18 young children and an elderly driver, with several apparently severe injuries, difficult access to the patients, and diesel fuel leaking from the bus.
Discussion
What are your priorities on this call?
What resources will you request?
Describe your primary role until additional help arrives
List sectors that will need to be established on this scene
How will you decide which patients to transport first?
Major Incident
Event in which the available resources are insufficient to manage the number of casualties or the nature of emergency
May stress local, regional, state, and even national and international resources
Examples of major incidents
Incident Command System (ICS)
Effective ICS allows for involvement of: Single jurisdiction; single agency Single jurisdiction; multiagency Multijurisdiction; multiagency
Incident Command System (ICS)
Expands from nonmajor incident to major incident in logical manner
Using ICS as standard operating procedure for small incidents permits smooth transition in major incident
ICS Terminology
Apparatus
Medical direction
Command
Mutual aid
Command post
Sector
Communications center
Staging area
FEMA ICS
Federal law requires ICS for hazmat incidents
Many states use ICS for all types of incidents
Incident management or command system Developed by FEMA National standard for incident management Flexible system Used by both public and private sectors in some routine and most large-scale emergencies
ICS Structure
ICS Organization
Five major components Command Planning Operations Logistics Finance/administration
The Command Function
One person coordinates variety of emergency activities
Cornerstone of ICS structure
Initial command determined in preplan
Command established immediately
Commander clearly identified
Commander responsibilities
Types of Command
Singular command
One individual responsible for operation
Unified command Large events or as small incident evolves Specialized organizations identified and personnel unify to complement command
EMS, fire, police, health department, Red Cross
Application of Unified Command
ICS Organization
Incident commander (IC) expands (or contracts) ICS organization based on: Life safety Incident stability Property conservation
If expansion is needed:
Other command staff positions established
Possible Command Staff Positions
Section Responsibilities
Sections assigned by IC to section chiefs Planning Operations Logistics Finance/administration
Section chiefs report to IC
Command Section Organizational Plan
Section Chiefs
Strong supervisors and managers
Primary role “Make things happen” Ensure rescuers working toward common goal
Number of sections varies by incident
Determined by IC
Section Chiefs
Not involved in physical tasks Accomplish command objectives Monitor work progress Redirect activities if needed Coordinate activities with other sections Request other resources as needed Monitor welfare of personnel in section Provide command with frequent reports Reallocate resources within section
Planning Section
Provides past, present, and future information about incident and status of resources Creates incident action plan (IAP) Operational periods
Planning Section
Operations Section
Directs and coordinates emergency scene operations
Ensures safety of operational personnel
EMS operations often fall under this section
Operations section chief is in charge of actual scene (“ground zero”)
Responsibilities
Operations Section
Logistics Section
Supports logistical needs of incident
Logistics appropriate to incident size/duration
Provides gear and support to responders
Logistics Section
Finance/Administration Section
Accounting and administration of incident
Staff support function
Monitors costs, careful accounting
Seldom used on small incidents
Essential as incident grows
And on hazmat incidents
Not used in routine daily incidents
Finance/Administration Section
Declaring a Major Incident
More than two ambulances needed
Particularly in rural areas
Situations involving hazardous or radioactive materials or chemicals
Situations needing special resources
Helicopters, rescue teams, multiple rescue or extrication units
When in doubt, declare a major incident
Preparing for a Major Incident
Phase 1: The preplan
Phase 2: Scene management
Phase 3: Post-disaster follow-up
Major Medical Incidents
Need to establish ICS at medical incident determined by: Number of casualties Nature of the event
Local/regional threshold
Examples of Medical ICS
Establishing Command
Group/sector functions or major functional areas implemented by incident size and scope
Groups and sectors may include:
Support sector Staging sector
Helicopter LZs and vehicle apparatus arrivals
Treatment sector
Unified EMS command with fire and police may be needed
Scene Assessment
First unit on scene
Rapid assessment of situation
Full assessment as safety and time permit Type of incident and potential duration Entrapment or special rescue resources needed Number of patients in each triage category Additional resources needed
Scene assessment continually updated
Communications
Command established by radio with dispatch EOC is where department heads, government officers and officials, and volunteer agencies gather to coordinate response to emergency event Command and EOC share goals Different levels of responsibility IC is responsible for on-scene activities EOC responsible for community-wide response
Obtaining Resources
Request additional units as needed: Dispatch should have written standard operating procedure (SOP) for requesting mutual aid May need to obtain food, shelter, clothing IC responsible for deployment of resources
Stay with vehicle until instructions received
Staging techniques used to deploy resources
Extrication Sector
Manages entrapped patients
Patient care activities in this sector
Only assessment and treatment of life threatening situations
Additional responsibilities
Treatment Sector
Works with extrication sector in patient care
Care and stabilization until patients transported to medical facility
As patients delivered, categorized by medical need
Paramedics and hospital personnel
With large numbers of patients:
Divided into immediate and delayed treatment zones
On-Scene Physicians at MCIs
Medical direction
Triage function
On-scene medical direction
Increased ability to make difficult triage decisions In treatment area for secondary triage decisions Emergency surgery to facilitate extrication
Treatment capabilities
Invasive procedures Assessment and direction of specific treatments
Disposition of the Deceased
Depends on scale of incident
Personnel assigned to disposition of deceased
Duties Work with medical examiner, coroner, law enforcement to coordinate disposition Assist in establishment of secure area for morgue if needed Monitor personnel for signs of stress
Transportation Sector
Communicates with hospitals, ambulances, and aeromedical services for patient transport
Works closely with treatment sector to determine appropriate patient destinations
Arrival and departure of vehicles coordinated with staging sector
Responsibilities
Staging Sector
Prevents vehicle congestion and response delays
All emergency vehicles should report for direction
Other agencies supervised by staging sector (disaster relief, news media)
Responsibilities
Rehabilitation (Rehab) Sector
Standard operating procedures in many fire and EMS agencies and major incident response plans
Set up outside operational area
Monitors personnel
Ensures proper rest and hydration
Works with logistics sector
Support Sector
Coordinates equipment and supplies for all sectors
May obtain medical supplies from hospitals, rescue supplies, and other equipment
Responsibilities
Sector Identification
All emergency responders must know ICS structure and radio communication procedure
Clothing and identification vary by system Color-coded vests identify personnel Most communication face to face
Exception
Command and sector communications
Radio use is for command operations
Sector Identification
Radio communications use operation titles: "EMS sector to command" or "Fire sector to rescue sector" Ensures reaching appropriate individual by one radio designation
Radio Communications
Key function during major incident
Preplanning includes identification of radio frequencies
Responding units should have radios using common frequency
Separate frequencies for EMS, fire, and other support operations
Radio Communications
Sector officers’ radios on channel that permits direct communications with command Frequencies may be assigned in advance Or by dispatching agency at incident
Radio Communications
Clear, concise, and in plain English
Helps set orderly tone Avoid use of radio codes/signals
Prepare messages before transmitting
Clearly identify unit number or sector
Minimize radio traffic
Face-to-face communication preferred
Common Problems of MCIs
Failure to notify everyone
Lack of rapid patient stabilization
Failure to collect patients in treatment area
Failure to triage properly
Administering too much care
Transporting patients prematurely
Common Problems of MCIs
Using personnel improperly
Failure to distribute patients to hospitals appropriately
Lack of EMS command in field
Lack of hospital communication
Lack of preplanning and training
Principles of Triage
Triage
Assessment of injury severity based on:
Method to categorize patients for priorities of treatment
Abnormal physiological signs Anatomic injury (and mechanism of injury) Concurrent disease factors
Triage is a continuous process during a major incident
Primary vs. Secondary Triage
Primary triage Categorizes patient condition for treatment Documents patient location and transport needs Labels patient with triage labels, tags, or tape Focuses on speed to sort patients No care rendered during primary triage
Except lifesaving airway or hemorrhage control
Primary vs. Secondary Triage
Secondary triage At treatment area Patients retriaged and labeled Not always necessary
Especially at small incidents
START Triage
START (simple triage and rapid treatment)
60-second assessment
Evaluate: Ability to walk Respiratory effort Pulses/perfusion Neurological status
START Triage
Classify patients as: Urgent Delayed Dead or dying Critical
START Triage
Allows rescuers to: Identify patients at risk of early death Advise others of patient's need for stabilization by tagging with disaster tags
START Triage System Insert Insert Fig Fig50-10 50-10
START Triage
Assess ability to walk
Evaluate breathing and rate
Assess pulses/perfusion
Assess mental status
START Triage
Repositioning of airway and controlling severe hemorrhage are only treatment efforts in primary triage:
In a mass casualty event, these measures should not delay triage of other patients
Triage Tagging/Labeling
Many tags, tape, and labels available
International color coding and priorities Immediate Red Priority-1 (P-1) Delayed Yellow Priority-2 (P-2) Hold Green Priority-3 (P-3) Deceased Black Priority-0 (P-0)
Kim KimMcKenna: McKenna: Ed: Ed:need needfigure50-11 figure50-11
METTAG Card
Purpose of Tagging
Identifies priority
Prevents retriage of patient
Tracking system during treatment/ transport
Tags and labels should:
Be easy to use Rapidly identify patient priority Allow for easy tracking Allow room for some documentation Prevent patients from retriaging themselves
Tracking Systems for Patients
A destination log is maintained by the transportation section officer Should have name or triage label ID number Tracking log must contain:
Patient identification Transporting unit Patient priority Hospital destination
ICS Patient Log
Transportation of Patients
Method of transportation determined by triage priority and situation
Ambulance a typical method
Buses considered for transporting a large number of priority 3 patients
Air ambulances for critical patients
Critical Incident Stress Management
Critical incident stress Potential for rescuers at major events Critical incident stress debriefings part of postdisaster SOP Types of services Other approaches to manage stress
Conclusion A major incident is an event for which available resources are insufficient to manage the number of casualties or the nature of the emergency. It may overwhelm local, regional, state, and even national and international capabilities.
Questions?
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