Triage and Mass Casualty Incidents Essential EMS Training Program - Module 1, Lesson 12

Essential EMS Training Program This class has been developed by Medical Teams International in Cooperation with the Ministry of Health of Several Countries to assist in the Development of Emergency Medical Services Block 2, Lesson 12 2016 Version Essential EMS Training Program

Medical Incident Command Can you manage this scene? Is there a plan? . Photo: First World Trade Tower Bombing New York City

Triage and Mass Casualty Incidents In Cambodia, Responsibility of Under-Secretary H.E. Dr. Prak Piseth Rainsey Disaster Management is located in Office of Preventative Medicine in MOH Utilized whenever there is a declared Disaster or a outbreak of disease affecting large number of people (Ebola, Influenza, WMD)

Multiple Causality Incident Any incident that generates a large number of patients Makes traditional EMS response ineffective Also called a “mass-casualty incident”

QUESTION? At least 16 people died and 23 more were injured on Thursday when a bus careened down an embankment near the Thai border as its transmission and brakes failed, according to police. Can you handle this by yourself? When there are more victims at the scene of an emergency, the First Responder must prioritize the injured victims. By prioritizing or triage, the First Responder is working to provide treatment to help save the most victims. The victims should not be moved unless the area near the victim is unsafe. It is important not to stay and treat the patient, until the patient is moved to the designated treatment area. The only two exceptions are to open the airway, and to control bleeding. Photo: Phnom Penh Post

Multiple Casualty Incidents possible in Myanmar Cyclones and high wind storms Fires Demonstrations Bus or Mass Transportation accidents Earthquake

Topics in the Class Origin of the Incident Command System When to Use Incident Command System Command at a Mass-Casualty Incident Divisions of Command Command System Support The START System

Origin of Incident Command System Developed by the US Forest Service to better combat forest fires Developed and refined over many years (20) Forest fires require many departments to respond (Who is in charge) Forest fires are often very large involving thousands of hectares Forest fires often last weeks (Who pays for it)

Incident Command History Developed by Forest Service (1970-1980’s) Used effectively for World Trade Center Bombing and Murrah Office Bombing. (1992) Adopted by US Federal Government for any multi-Jurisdictional response (1 Mar 2004) Used by almost every agency in US for every day responses Used internationally ( Fukishma in Japan)

When do we use a Mass Casualty System? Anytime we have more victims than we have resources to handle them Most agencies practice everyday on every call Anytime we have more than one agency on the scene Anytime we are responding to a declared disaster

Singular vs Unified Command Singular command One person coordinates the incident. Most useful in smaller, single-jurisdictional incidents. Unified command Managers from different jurisdictions share command. Fire, EMS, law enforcement Local Government Officials International Workers

Priorities for every Incident 1. Scene Safety !!!! All rescuers go home safely 2. Patient safety. Get them to a hospital. 3. Stabilization of the incident 4. Conservation of property

Incident Structure Every Incident has five basic Components in it. In a small incident one person can manage all five components In a large incident each component may need to be handled by a different person In very large Incidents, Each of the basic components can be subdivided into smaller divisions (or Jobs)

Five Divisions of any Incident C—Command F—Finance/ administration L—Logistics O—Operations P—Planning Can use the acronym C-FLOP to help remember the divisions

Five Divisions – Two for any Incident Command - Someone has to be in charge Operations – You have to treat and move patients to hospital Other three apply to every incident but will only be separate in large events

Division 1 - Command Every incident has an incident commander or person in charge. Usually this will be the first qualified person to arrive Establishes a command post Will stay in command until they formally notify every one on the scene who is the new command

Division 2 Finance Administration A small incident will not need this as a separate function. A large incident will need someone to purchase everything extra that is needed to mitigate the incident A very large incident may need a team to handle all of the extra financial burdens

Division 3 Logistics In a small incident the commander knows where to get services such as extra supplies or special equipment. Usually needed supplies on Ambulance A larger incident may need to assign someone to find and procure needed equipment A very large incident will need a team of people to find equipment and supplies

Division 4 - Operations These are the people that are actually providing care for the patients or scene. In a small incident this will be the Incident commander In a large incident this will be assigned to many people from many organizations.

Division 5 - Planning In a small incident this may be as simple as: “I plan for this patient to go first, then that one”. In an incident that lasts many days then someone (or a team) must decide what resources are to be deployed and where. (These are written plans)

Implementing ICS First arriving unit establishes command Unit will establish a command center Will direct units as they respond If many patients are involved, He will establish a staging area and a treatment area. He will ask for all of the necessary items that are needed immediately.

Isolated MCI Most MCI events are Isolated and will be handled by the Ambulances and Responders in the province These events will be Major Accidents, Plane crash, mass gatherings injuries The local Incident commander can manage as outlined in the following slides.

Major vs Isolated MCI A major MCI may affect a large part of Cambodia or Myanmar and last for several days The Incident will be assigned to positions as outlined in the disaster plan The incident will be mitigated or managed similar to this outline

Managing an ICS If there are many patients the Incident commander will estimate how many patients are involved as ask for additional help. The commander will assign personnel to establish four treatment areas to triage patients. Green, Yellow, Red, Black. The commander will assign a treatment “officer” in each area as well as a transport “Officer” to move patient out to Hospitals.

Triage Means “Sort" or to Divide into groups (French) We must divide the injured patients into groups to provide the best care. In a MCI we will divide patients into four groups We have another Triage or Sorting of patients at the hospital. These are similar but a little different

Treatment Areas Green These are the “Walking Wounded” or minor injuries Red These are the most severe injuries and will be transported first Yellow These are Severely injured but are stable and can wait until the “Red” tagged patients are off the scene Black Deceased patients, No care needed

. Using vests at a mass-casualty incident makes it easier to identify personnel. The incident commander directs the response and coordinates resources. Mark Officers with Wide Tape with position or Use another Method such as Bandanas

Basic elements of the incident management system.

Examples of branches that may operate in a major incident.

Patient Triage System In a small incident the Incident commander can rapidly triage which patient goes first until the few patients are on the way to a hospital. In a very large Incident he will utilize the international START / SALT system

Operation of the START system, the most widely used triage system.

The principals of the START system Simple Triage and Rapid Transport or START Can easily find more info about START on Internet Based on Ability to walk Respiratory effort Pulses/ perfusions Neurological status

SALT Triage

First step in START Ask everyone in hearing of your voice to get up and walk to a treatment area. (Green) Patients that do not get up and move are then assessed Only medical intervention is an attempt to open the airway Patients that are not breathing are classified as Dead (Tagged Black)

Second Step - Rapid Triage The START system is based on three observations: RPM--Respiration, Perfusion and Mental Status. Each patient must be evaluated quickly, in a systematic manner, starting with Respiration (breathing). The second step of the RPM series of triage tests is circulation of the patient. The best field method for checking circulation is to check the radial pulse.

Third Step in START The third step is the evaluation of the Patient’s mental status. Only done for patients who have adequate breathing and adequate circulation. Test the patient's mental status by asking them to: "Open your eyes." "Close your eyes." "Squeeze my hand." Patients who can follow these simple commands and have adequate breathing and adequate circulation are tagged yellow. A patient who is unresponsive or cannot follow this type of simple command is tagged Red. (These patients are "unresponsive" to verbal stimuli.)

Immediate Care Patients (Red) Patients who are breathing and have any of the following conditions are classified as immediate ( tagged Red) -respiratory rate greater than 30 per minute. -unresponsive (unable to follow commands) All other Patients are tagged Yellow

Transportation off of the scene All patients must be rapidly moved off the scene The “transport officer” will work with the Treatment area Officers to transport the patients. Red first, then yellow, green, black The transport Officer will divide the patients among all available hospitals so that no hospital receives too many

IMPORTANT POINT

THE START system

Treatment / Incident Vests In a large incident a series of Vests can be used to identify the Assignments Key personnel are assigned Vests Roles can be changed by changing vests Vests can be made and stored on Ambulance to be available when needed

Important Note!!! .

Title - 36 This is a very short overview of Triage and Medical Incident Command The only way learn how to manage an incident is to practice, practice, practice. Plan an exercise at least once or twice a year with local responders Look up more information on the internet and join the planning group in your area if there is one.

Practice Four Patients – Tell what Category 1) Pt with broken arm, Normal pulse & respiration 2) patient with traumatic amputation of lower leg 3) Patient not Breathing (after Opening Airway) 4) patient with large lac to arm, normal pulse, afraid Note: Instructor will have to quickly paint visual Image of all Pts Answers Green, Red, Black, Green

More Practice Patient with Forearm FX Patient with Bilateral wrist FX rapid pulse, rapid respirations Patient with GSW to Head, Normal breathing respirations, Unconscious Patient with no pulse, resp, after opening Answers are Green, Red, Black (Possibly Yellow if not many patients), Black

Even More Practice Patient with large laceration but scared and not willing to get up and walk. Normal pulse, Patient with GSW to Stomach, Rapid pulse, shallow Respirations Patient with 3rd Degree burns over 100% BSA Patient with obvious paralysis normal pulse, resp. Note: make up as many situations as necessary for students to understand concepts Answers: Green, Red, Black as no one will survive 100% burns but Yellow as they will be the last off before black , Yellow

Title - 36 Detail - 24