Marin County Multiple Patient Management Plan Training Module January 2018 Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

This training presentation is intended for use by EMS, hospital and law enforcement personnel in Marin County, California. It may not be used without expressed permission from the Marin County EMS Agency. Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Introduction This plan is used in Marin County to manage Multi-Casualty Incidents (MCIs) The 2018 Multiple Patient Management Plan (MPMP) replaces the previous plan published July 1, 2013 The MPMP integrates key concepts and guidance from: FIRESCOPE Field Operations Guide 420-1 (aka “FOG” Manual) California Public Health and Medical Emergency Operations Manual (aka “EOM”) California Patient Movement Plan (draft) Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Important Changes from 2013 plan Adds “Immediate Trauma Patient” category to triage Recommends colored triage tape for field triage Changes term Coordinating Hospital to “Patient Distribution Center” Increases number of patients transported for Level I, Level II & Level III MCI activations Attachments added/revised: ICS 201 Command Worksheet (revised) Quick reference flow charts for Hospitals and Dispatch Centers Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

References This Plan meets the standards of the following by reference or incorporation and may be used for guidance when required: National Incident Management System (NIMS) Standardized Emergency Management System (SEMS) Incident Command System (ICS) Simple Triage and Rapid Treatment (START) and JumpSTART FIRESCOPE FOG 420-1 California Master Mutual Aid Agreement California Government Code California Emergency Services Act Marin County Fire Service Mutual Aid Plan California Public Health and Medical Emergency Operations Manual California Patient Movement Plan (TBD) County of Marin Emergency Operations Plan County of Marin Medical and Health Annex County of Marin ACS Plan County of Marin FTS Guide (TBD) Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

MCI Alert & Activation The IC may initiate either an ALERT or an ACTIVATION ALERT: Notifies all EMS system participants of a potential multi- casualty event ACTIVATION: Notifies all EMS system participants of a multi- casualty event in progress “Alert” or “Activation” should be cancelled when no longer needed Marin County Communications may initiate an Alert and is responsible for sending the alert/activation/cancellation to EMS system participants Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

MCI Activation Levels in MPMP Local MCI Level I Activation Level II Activation Level III Activation Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Local MCI (6-15 patients*) Example: Multiple vehicle collision involving 15 patients requiring transportation. Operational Focus is on incident management including the use of resources necessary to mitigate the problem (scene safety, security, specialty response, on-scene triage, patient transportation, etc.) Managed with local jurisdiction (i.e., ALS zone) resources EMS system modifications may be implemented. (e.g. cancelling diversions, using private ambulances for 9-1-1 calls, amending dispatch criteria, etc.) * Guideline only – actual number of patients may vary Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Level I Activation (16-50 patients*) Example: Aircraft collision, skilled nursing facility evacuation, large motor vehicle collision, involving 20-30 patients. Operational and Strategic Focus shifts from individual incident management to maintaining the County’s EMS system and a possible transition from focused patient care to population based care In-county mutual aid from other ALS zones will be requested EMS system modifications to be implemented * Guideline only – actual number of patients may vary Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Level II Activation (51-200 patients*) Example: Large aircraft collision, hospital facility evacuation, isolated natural incident, involving 80 patients. Operational and Strategic Focus is on scene management, resources necessary to mitigate the incident and maintain the County’s EMS System. This includes a transition from focused patient care to population based care. The use of out-of-county mutual aid resources is anticipated Modifications to the daily 9-1-1 system are made to support the incident and stability of the system * Guideline only – actual number of patients may vary Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Level III Activation (> 200 patients*) Example: Significant natural disaster or other incidents involving more than 200 patients. Operational and Strategic focus is on scene management, resources necessary to mitigate the incident and maintain the County’s EMS System. This includes a transition from focused patient care to population based care. The use of out-of-county mutual aid resources from regional, state and federal partners is anticipated Activation of Operational Area Patient Distribution Center is likely Includes significant modifications to support the incident and maintain 9-1-1 response * Guideline only – actual number of patients may vary Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Patient Distribution MPMP allows for immediate transport of patients to local hospitals prior to a communications link being established with the Patient Distribution Center For a Local MCI, Marin hospitals will accept: 1 Immediate, 1 Delayed, 2 Minor For a Level 1 or higher, Marin hospitals will accept: 2 Immediate, 2 Delayed, 4 Minor Trauma patients who meet Immediate criteria should be labeled “Immediate Trauma Patient” Transport units will not provide patient report or consults while enroute to receiving hospital Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

MPMP Forms MPMP includes several forms that may be used by on-scene personnel: ICS 201 - Command Worksheet Patient Routing Worksheet for Local MCI & Level I Patient Routing Worksheet for Levels II & III ICS 214 - Unit Log ICS 206 - Incident Medical Plan Transportation Group Supervisor Worksheet ICS 255 - Patient Status Sheet (for Marin) Position Checklists Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Incident Command First-arriving unit will establish Incident Command Then: Upgrade MCI Alert to Activation or cancel Assign ICS roles as needed Identify incident command post and staging area(s) Request tactical radio frequencies as needed, including “HOSP” talk group Order additional resources Incident Command Post Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

“Broad Street MCI” Eastern Street Broad Street MCI Scene Incident Staging Ambulance Minor Immediate Delayed Morgue To Hospital Eastern Street Broad Street MCI Scene Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Medical Communications MCI Organization Incident Commander Operations Section Medical Group Triage Unit Single Resources Morgue Treatment Unit Immediate Delayed Minor Transportation Unit Medical Communications Coordinator Ground Ambulance Air Ambulance Fire Group Extrication Unit Staging Patient Distribution Center (Adapted from: FIRESCOPE Field Operations Guide 420-1) Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Radial pulse present or capillary refill <2 sec. S.T.A.R.T. Triage DECEASED Radial pulse present or capillary refill <2 sec. Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Triage tape Identify MINOR patients using GREEN tape if able to walk and follow commands For each remaining patient assess: Respirations (> 30/min.) Perfusion (capillary refill > 2 sec.) Mental Status (does not obey commands) Identify IMMEDIATE patients using RED tape if any of above met Identify DECEASED patients using BLACK tape if not breathing after repositioning airway Identify DELAYED patients using YELLOW tape if respirations < 30, perfusion <2 seconds, and obeys commands Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Triage Tag Patients should receive a triage tag once relocated to the treatment area Marin EMS providers use a triage tag similar to the one shown Remove “contaminated” strip if not applicable Remove all colored triage strips below the one selected Attach tag to arm, leg or neck Front Back Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

MCI Trailers (heavy) – 50 patients Marin County maintains three trailers stocked with equipment and supplies for an MCI Each can used to treat about 50 patients Trailers may be ordered by the IC MCI Trailer Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

MCI Trailers (light) – 25 patients Eight low-profile trailers are strategically located throughout Marin Each can be used to treat about 25 patients. MCI Trailer Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Air Operations Ordering air ambulances is at the discretion of the IC Air ambulance transportation will be directed by the Air Ambulance Coordinator Air ambulances will generally be used to transport immediate patients to hospitals outside Marin County Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

9-1-1 Communications Center Dispatch Center Marin County Sheriff’s Communications Center will: Notify hospitals, providers, law enforcement, and EMS Agency of a multi-casualty incident; may initiate alerts Assign radio frequencies as needed for the incident Dispatch additional incident resources as requested by the IC 9-1-1 Communications Center Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Patient Distribution Center The Patient Distribution Center will: Initiate an MCI using ReddiNet® Coordinate patient distribution with on-scene MedComm (Medical Communications Coordinator) Receive patients from scene Use ReddiNet® to track all patients from an incident As Level III Trauma Center, Marin General Hospital is the designated Patient Distribution Center for MCIs (Kaiser San Rafael serves as backup) Marin General Hospital Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

EMS Agency Marin County EMS Agency: Will be notified of all MCI alerts or activations May send an Agency Rep to the incident scene or Comm Center if requested May activate Operational Area Patient Distribution Center if large numbers of patients must be transported outside Marin Order other medical/health resources if needed. Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

OA Patient Distribution Center Large numbers of patients to be transported out of Marin may require activation of an OAPDC OAPDC works with nearby OAs, Region II and State to distribute patients to medical facilities outside Marin Directed by the MHOAC (Medical Health Operational Area Coordinator) and staffed by EMS Agency Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Reno Championship Air Races Crash September 16, 2011 Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

The Venue Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Minutes Before Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Milliseconds Before Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

The Impact Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

The Scene A highly-modified P-51 “Mustang” flown by veteran pilot, James “Jimmy” Leeward, suddenly dives directly into a VIP grandstand packed with spectators Initial response includes four ALS ambulances The pilot and 6 spectators are dead on arrival Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

The Aftermath 54 patients are triaged and transported in 62 minutes: 25 Immediate 18 Delayed 11 Minor 7 Deceased 4 patients later die in the hospital Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Now assume this incident has just occurred at Gnoss Field in Novato, and you are on duty… Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Questions What would the initial dispatch of resources likely include? When would you request an MCI activation? What is the ICS organization needed for this incident. How would you handle all the walking wounded? What level MCI would this incident fall under according to the MPMP? Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

More Questions How many ambulances will you need for this incident? Who orders them? How many air ambulances? Which ICS role handles patient distribution with the Patient Distribution Center? How many patients can be sent to Marin’s three acute hospitals right away? How will patients be tracked from the scene to the hospital? Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”

Copyright © 2018 All rights reserved by Marin County EMS Agency For a copy of the Multiple Patient Management Plan or this training presentation please go to: www.MarinEMS.org Copyright © 2018 All rights reserved by Marin County EMS Agency Marin County Emergency Medical Services “Excellent Care – Every Patient, Every Time”