37: Special Operations

Cognitive Objectives (1 of 4) 7-3.1 Explain the EMT-B’s role during a call involving hazardous materials. 7-3.2 Describe what the EMT-B should do if there is reason to believe that there is a hazard at the scene. 7-3.3 Describe the actions that an EMT-B should take to ensure bystander safety.

Cognitive Objectives (2 of 4) 7-3.4 State the role the EMT-B should perform until appropriately trained personnel arrive at the scene of a hazardous materials situation. 7-3.5 Break down the steps to approaching a hazardous situation. 7-3.6 Discuss the various environmental hazards that affect EMS.

Cognitive Objectives (3 of 4) 7-3.7 Describe the criteria for a multiple-casualty situation. 7-3.8 Evaluate the role of the EMT-B in the multiple-casualty situation. 7-3.9 Summarize the components of basic triage. 7-3.10 Define the role of the EMT-B in a disaster operation.

Cognitive Objectives (4 of 4) 7-3.11 Describe basic concepts of incident management. 7-3.12 Explain the methods for preventing contamination to self, equipment, and facilities. 7-3.13 Review the local mass-casualty incident plan.

Psychomotor Objectives 7-3.16 Given a scenario of a mass-casualty incident, perform triage. Additional Affective Objective* 1. Discuss the psychological impact of wanting to act but recognizing that a scene is not safe to enter. *This is a noncurriculum objective.

Incident Command System ICS is used to help control, direct, and coordinate resources. It ensures clear lines of responsibility and authority. Incident commander has overall responsibility for the scene. Safety officer is designated to circulate among responders.

Structure of an Incident Command System

Information Officer All information to the public and news media originates at the command post.

Safety Officer Circulates through incident scene to ensure safety of responders and victims. Orders by the safety officer have full authority of the incident commander.

Sector Commanders Coordinate activities of specialty groups EMS Rescue Fire

Sectors of Typical IC Structure Operations Planning Logistics Finance

Incident Command Command structure must be established early and expanded as needed. Incident command may vary in different communities. An EMT-B must not deviate from the directions and orders given by command.

Key Components of the ICS at a Mass-Casualty Incident (1 of 2) Command center Staging area Extrication area Decontamination area

Key Components of the ICS at a Mass-Casualty Incident (2 of 2) Triage area Treatment area Supply area Transportation area Rehabilitation area

National Incident Management System (1 of 2) Nationwide template to enable federal, state, and local governments and private-sector and non-governmental organizations to work together in an emergency

National Incident Management System (2 of 2) Applicable to all jurisdictions Utilized by a variety of disciplines Improves coordination and cooperation Built on existing incident management systems

Mass-Casualty Incidents Incidents involving three or more patients Places high demand on available resources May require mutual aid response Courtesy of Journalist 1st Class Mark D. Faram/U. S. Navy

Triage (1 of 2) Triage is the sorting of two or more patients based on the severity of their conditions. Patients are ranked in the order of the severity of their conditions. Treatment priority is determined by rank.

Triage (2 of 2) Triage is an essential component of operations at a mass-casualty incident.

Triage Categories

Triage Priorities Patients should be color coded early. Patients tagged red should be assessed in the treatment area. Patients in dangerous areas should be removed to a non-hazardous environment prior to triage.

Triage Procedures Rotate hospital destinations. Trauma center should receive the most critical patients. Utilize a transport officer to evenly distribute patients. Courtesy of Journalist 1st Class Mark D. Faram/U. S. Navy

Disaster Management The role of the EMT-B is to respond when requested and report to incident command. A casualty collection area may be set up and staffed by nursing and medical staff with equipment. You may have to bring patients to this area.

Introduction to Hazardous Materials Any substance that is toxic, poisonous, radioactive, flammable, or explosive and can cause injury or death with exposure Responders must have special training before becoming involved with hazardous materials.

Hazardous Materials Situations A train or truck with a leaking substance A leak, fire, or other emergency at an industrial plant, refinery, or other storage facility A gas pipe leak or rupture Deterioration of underground fuel tanks Buildup of methane in sewers Car crash involving a ruptured gas tank

Recognition of Hazardous Materials (1 of 2) Warning signs Placards Labels

Recognition of Hazardous Materials (2 of 2) Visible cloud or odd-looking smoke coming from an escaping substance A leak or spill from a tank, container, truck, or railroad car An unusually strong, noxious, acrid odor

HazMat Placards The four-digit number that appears on the warning placard identifies the specific hazardous material.

First Arrival Stop at safe distance. Call for a HazMat team. Stay out of danger zone. Gather information. Do not reenter the scene. Do not leave until cleared by HazMat.

Identifying Hazardous Materials Safety perimeters Uphill and upwind Efforts to ensure safety and survival of the masses.

Approach a hazardous incident cautiously from upwind. HazMat Scene Safety Approach a hazardous incident cautiously from upwind.

HazMat Scene Operations HazMat will determine the specific hazardous material involved. Only those trained in HazMat and wearing protective gear should enter the zone. As an EMT-B, your job is to remain in the designated treatment area. HazMat will bring patients to you.

Decontamination Area Designated area where contaminates are removed Anyone who leaves the hazard zone must pass through this area. Wait for the patients to be brought to you.

Classification of Hazardous Materials—Toxicity Levels Health Hazard Protection Needed Little or no hazard None 1 Slightly hazardous SCBA (level C suit) only 2 3 Extremely hazardous Full protection; with no exposed skin (level A or B suit) 4 Minimal exposure causes death Special HazMat gear (level A suit)

Caring for Patients at a HazMat Incident Only essential treatment will take place in the hazard zone and decontamination area. Injuries should be treated as any other patient. Treatment for exposure will be mainly supportive. Initiate transport.

Special Care Some patients may need to be treated without full decontamination. Protect yourself with proper gear. Ensure the receiving hospital is aware patient has not been fully decontaminated. Ambulance will need to be decontaminated after transport.

Resources Emergency Response Guidebook Chemical Transportation Emergency Center (CHEMTREC) 1-800-424-9300

Personal Protective Equipment Levels Level A—Fully encapsulated, chemical-resistant protective clothing Level B—Nonencapsulated protective clothing with respiratory protection Level C —Nonpermeable clothing, eye protection, filtering face mask Level D —Work uniform; minimal protection

Four Levels of Protection Level A Level B Level C Level D

Review Which of the following statements BEST describes a mass-casualty incident? A. At least half of the patients are dead B. Either a bus or an airplane has crashed C. You have more than two critical patients D. The patient count exhausts your resources

Review Answer: D Rationale: A mass-casualty situation is one that places such a great demand on available equipment or personnel that the system is stretched to its limits or beyond. While bus accidents and plane crashes are classic examples of mass-casualty incidents, they are not the only situations that can exhaust your resources.

Review Which of the following statements BEST describes a mass-casualty incident? At least half of the patients are dead Rationale: Mass-casualty incidents are not based upon the number of fatalities. B. Either a bus or an airplane has crashed Rationale: This is a good example of a potential mass-casualty incident; however, there may be very few patients. C. You have more than two critical patients Rationale: This situation places a burden upon the first EMS providers, but it may not stress available resources. D. The patient count exhausts your resources Rationale: Correct answer

Review 2. Which of the following patients would have the HIGHEST treatment priority at the scene of a mass-casualty incident? A. 24-year-old man, who is unconscious, has snoring respirations, and severe burns. B. 32-year-old woman, who is pulseless and apneic with an abdominal evisceration. C. 29-year-old woman, who is in full cardiac arrest with massive open chest trauma. D. 32-year-old man with an open head injury, exposed brain mater, and no carotid pulse.

Review Answer: A Rationale: Three of the four patients (B, C, and D) are dead. Triage efforts are aimed at providing the greatest amount of good for the greatest number of people. Attempting to resuscitate a patient in traumatic cardiac arrest is futile in almost all cases.

Review (1 of 2) 2. Which of the following patients would have the HIGHEST treatment priority at the scene of a mass-casualty incident? 24-year-old man, who is unconscious, has snoring respirations, and severe burns. Rationale: Correct answer B. 32-year-old woman, who is pulseless and apneic with an abdominal evisceration. Rationale: In a mass-casualty situation, this is a traumatic arrest. The woman has minimal possibilities of survival with no vital signs upon arrival.

Review (2 of 2) 2. Which of the following patients would have the HIGHEST treatment priority at the scene of a mass-casualty incident? C. 29-year-old woman, who is in full cardiac arrest with massive open chest trauma. Rationale: Efforts must be directed toward the patients with the greatest possibility of survival. D. 32-year-old man with an open head injury, exposed brain mater, and no carotid pulse. Rationale: This patient presents with the lowest possibility of surviving.

Review 3. Patient #1 is a conscious male with a large scalp laceration and moderate venous bleeding. Patient #2 is a semiconscious infant with shallow breathing and bradycardia. Patient #3 is an unconscious older man with open head trauma, exposed brain matter and agonal breathing. Patient #4 is a middle-aged woman with bilateral open femur fractures and cool, clammy skin. Which patient should you treat FIRST? A. Patient #1 B. Patient #2 C. Patient #3 D. Patient #4

Review Answer: B Rationale: Patients #2 and #4 are both critical patients; however, patients with airway and/or breathing problems have the highest priority. The infant in this scenario has an altered level of consciousness, shallow breathing, and bradycardia—ominous signs that indicate impending cardiac arrest. Patient #1 should be tagged as delayed; his injury is not life-threatening. Patient #3 has the lowest priority; his injury is fatal.

Review (1 of 2) 3. Patient #1 is a conscious male with a large scalp laceration and moderate venous bleeding. Patient #2 is a semiconscious infant with shallow breathing and bradycardia. Patient #3 is an unconscious older man with open head trauma, exposed brain matter and agonal breathing. Patient #4 is a middle-aged woman with bilateral open femur fractures and cool, clammy skin. Which patient should you treat FIRST? Patient #1 Rationale: Patient #1 will be the third patient treated in this scenario. B. Patient #2 Rationale: Correct answer

Review (2 of 2) 3. Patient #1 is a conscious male with a large scalp laceration and moderate venous bleeding. Patient #2 is a semiconscious infant with shallow breathing and bradycardia. Patient #3 is an unconscious older man with open head trauma, exposed brain matter and agonal breathing. Patient #4 is a middle-aged woman with bilateral open femur fractures and cool, clammy skin. Which patient should you treat FIRST? C. Patient #3 Rationale: Patient #3 is the lowest priority since his injuries are considered fatal. D. Patient #4 Rationale: Patient #4 is a high priority, but patients with breathing or airway complications are a higher concern.

Review 4. A large tanker truck has overturned on a highway. When you arrive, you see a clear liquid leaking from the rear of the tanker. The driver, who appears to be unconscious, is still in the vehicle and is bleeding heavily from the face. You should: A. immediately notify law enforcement for traffic control. B. fully assess the situation and request the appropriate assistance. C. put on gloves, a gown, and a mask and quickly remove the driver. D. go to the rear of the tanker and determine what type of fluid is leaking.

Review Answer: B Rationale: Upon arriving at the scene of a possible hazardous materials incident, you must first step back and assess the situation. This can be very stressful—especially if you see a patient. However, rushing into such a situation puts your own life in jeopardy. Once you have properly assessed the scene, you should request the appropriate assistance, such as the fire department or hazardous materials team.

Review (1 of 2) 4. A large tanker truck has overturned on a highway. When you arrive, you see a clear liquid leaking from the rear of the tanker. The driver, who appears to be unconscious, is still in the vehicle and is bleeding heavily from the face. You should: immediately notify law enforcement for traffic control. Rationale: Law enforcement is part of the assistance needed at the scene; however, rescue, fire, and hazmat providers must also be notified. B. fully assess the situation and request the appropriate assistance. Rationale: Correct answer

Review (2 of 2) 4. A large tanker truck has overturned on a highway. When you arrive, you see a clear liquid leaking from the rear of the tanker. The driver, who appears to be unconscious, is still in the vehicle and is bleeding heavily from the face. You should: C. put on gloves, a gown, and a mask and quickly remove the driver. Rationale: This is a potentially hazardous environment. Access should not be attempted until the scene has been deemed safe. D. go to the rear of the tanker and determine what type of fluid is leaking. Rationale: Unless you are trained as a hazardous materials technician and part of the entry team, do not enter the hazard zone.

Review 5. During a natural disaster, a command post is set up and an incident commander is in charge. He/she is also joined in a unified command with three other commanders. Which of the following is NOT a commander in a unified command structure? A. Fire operations B. EMS operations C. Law enforcement D. Red Cross disaster chief

Review Answer: D Rationale: In a large-scale MCI, in which a unified command structure has been established, the incident commander will also be joined in command with a fire commander, EMS commander and a law enforcement commander.

Review 5. During a natural disaster, a command post is set up and an incident commander is in charge. He/she is also joined in a unified command with three other commanders. Which of the following is NOT a commander in a unified command structure? Fire operations Rationale: This is part of the unified command structure. B. EMS operations C. Law enforcement D. Red Cross disaster chief Rationale: Correct answer

Review 6. What type of hazardous materials are transported with white warning placards? A. Corrosive B. Explosive C. Poisonous D. Flammable

Review Answer: C Rationale: Placards that are predominantly white in color signify the presence of poisons. Black placards indicate a corrosive chemical, orange placards indicate an explosive chemical, and red placards indicate a flammable or combustible chemical.

Review 6. What type of hazardous materials are transported with white warning placards? Corrosive Rationale: The corrosives placard is black. B. Explosive Rationale: The explosives placard is orange. C. Poisonous Rationale: Correct answer D. Flammable Rationale: The flammable materials placard is red.

Review 7. 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? A. Level 1 B. Level 2 C. Level 3 D. Level 4

Review Answer: B Rationale: Level 2 toxicity includes materials that could cause temporary damage or residual injury unless prompt medical treatment is provided. Level 1 toxicity includes materials that would cause little, if any, health hazard. Level 3 toxicity includes materials that are extremely hazardous to health and requires full protective gear. Level 4 toxicity includes materials that are so hazardous that even minimal contact will cause death.

Review 7. 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 1 Rationale: Level 1 materials cause little health hazards. B. Level 2 Rationale: Correct answer C. Level 3 Rationale: Level 3 materials are extremely hazardous. D. Level 4 Rationale: Level 4 materials cause death, even with minimal contact.

Review 8. When dealing with a hazardous materials incident, where should you set up your decontamination area? A. Inside the hazard zone B. Inside the treatment area C. Between the hazard zone and treatment area D. Between the treatment and transportation zone

Review Answer: C Rationale: The decontamination area should be set up between the hazard zone and the treatment area. This way, patients cannot bring any hazardous materials into the treatment area and contaminate any one else.

Review 8. When dealing with a hazardous materials incident, where should you set up your decontamination area? Inside the hazard zone Rationale: It needs to be on the edge of the hazard zone — not inside it. B. Inside the treatment area Rationale: You do not want contaminated patients in the treatment area. C. Between the hazard zone and treatment area Rationale: Correct answer D. Between the treatment and transportation zone Rationale: Patients need to be decontaminated prior to entering the treatment and transport area.

Review 9. Upon arriving at a scene in which the incident command system has been activated, you should expect to: A. be passed from sector to sector, as needed, in between assignments. B. report directly to the incident commander in between assignments. C. be assigned a specific responsibility for the duration of the incident. D. be given general directions and allowed to function independently.

Review Answer: A Rationale: The incident commander establishes sectors of responsibility and sector officers. When functioning at an incident in which the incident command system has been activated, you should report to the appropriate sector officer, carry out your assignment, and report back to the sector officer. In many cases, you will be asked to report to a different sector.

Review (1 of 2) 9. Upon arriving at a scene in which the incident command system has been activated, you should expect to: be passed from sector to sector, as needed, in between assignments. Rationale: Correct answer B. report directly to the incident commander in between assignments. Rationale: Only sector or unit officers report to the incident commander.

Review (2 of 2) 9. Upon arriving at a scene in which the incident command system has been activated, you should expect to: C. be assigned a specific responsibility for the duration of the incident. Rationale: Responsibilities may change as sector officers see the need for change. D. be given general directions and allowed to function independently. Rationale: The purpose behind the incident command system is to prevent personnel from functioning independently.

Review 10. Which of the following situations MOST likely involves a hazardous material? A. Milk truck that overturned and is leaking fluid B. Tractor trailer rig that is emitting a visible cloud C. Moving van that collided head-on with a small car D. Pickup truck from the gas company that struck a tree

Review Answer: B Rationale: A crash does not need to occur for a spill or leak to happen. A vehicle that is emitting a visible cloud should make you suspicious that a hazardous material is involved—especially if the vehicle is a tractor trailer rig. In such cases, you should stay uphill and upwind and notify the fire department or hazardous materials team.

Review 10. Which of the following situations MOST likely involves a hazardous material? Milk truck that overturned and is leaking fluid Rationale: This is a possibility, but not the most likely possibility. B. Tractor trailer rig that is emitting a visible cloud Rationale: Correct answer C. Moving van that collided head-on with a small car D. Pickup truck from the gas company that struck a tree