1. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MASS CASUALTY INCIDENTS

2. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI RESPONSE Potential Danger Major and catastrophic incidents are a potential in any community. With the great variety of natural and man- made disasters that face us everyday, something major can happen almost anywhere. Major and catastrophic incidents are a potential in any community. With the great variety of natural and man- made disasters that face us everyday, something major can happen almost anywhere. Whether it is a natural disaster or terrorist incident there can be significant impact on the community Whether it is a natural disaster or terrorist incident there can be significant impact on the community

3. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI RESPONSE Familiarization with Target Hazards Site that have great potential for significant loss of life or monetary loss: Site that have great potential for significant loss of life or monetary loss: Public assembly facilities Public assembly facilities Hospitals Hospitals Nursing homes Nursing homes Theaters Theaters Industrial sites using hazardous materials Industrial sites using hazardous materials Railroads Railroads Highways Highways Schools Schools Malls Malls

4. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Prepare Train in ICS / UICS Train in ICS / UICS Understand your responsibilities Understand your responsibilities Understand the vocabulary Understand the vocabulary Train in mock disasters Train in mock disasters

5. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Primary concern must be to save as many lived as possible and protect responders Response Response First unit establishes command and sizes-up the scene First unit establishes command and sizes-up the scene The IC determines need for additional resources The IC determines need for additional resources Triage Triage Treatment Treatment Transport Transport

6. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Establish Command Senior member of first arriving unit becomes IC Senior member of first arriving unit becomes IC Will remain in charge until relieved by a higher authority Will remain in charge until relieved by a higher authority Unified Command should be considered early in the event. Unified Command should be considered early in the event.

7. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Scene Organization Ensure an effective response Ensure an effective response Secure the area (limit access) Secure the area (limit access) Determine scene safety (is decon required) Determine scene safety (is decon required) Assign personnel Assign personnel Establish staging and T-3 areas Establish staging and T-3 areas Establish communications Establish communications Determine ingress and egress (flow of traffic) Determine ingress and egress (flow of traffic) Maintain records Maintain records

8. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Potential for Terrorism The IC must be cognizant of the possibility the MCI was deliberate The IC must be cognizant of the possibility the MCI was deliberate Preserve evidence Preserve evidence Watch for secondary devices Watch for secondary devices PIO releases only necessary information PIO releases only necessary information

9. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Decontamination PPE may be needed if the scene includes: PPE may be needed if the scene includes: Nuclear Nuclear Biological Biological Chemical Chemical Determined by HazMat Team Determined by HazMat Team Victims must be deconed prior to T-3 Victims must be deconed prior to T-3

10. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response T-3 Triage Triage Treatment Treatment Transport Transport

11. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Triage The concept of triage is simply a method of quickly identifying victims who have immediately life-threatening injuries The concept of triage is simply a method of quickly identifying victims who have immediately life-threatening injuries AND who have the best chance of surviving so that when additional rescuers arrive on scene, they are directed first to those patients. AND who have the best chance of surviving so that when additional rescuers arrive on scene, they are directed first to those patients.

12. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness START (Simple Triage and Rapid Treatment) Developed by Hoag Hospital and the Newport Beach Fire Department (Newport Beach, CA) Developed by Hoag Hospital and the Newport Beach Fire Department (Newport Beach, CA)Hoag Hospital and the Newport Beach Fire DepartmentHoag Hospital and the Newport Beach Fire Department Relies on making a rapid assessment (taking less than a minute) of every patient Relies on making a rapid assessment (taking less than a minute) of every patient Determining which of four categories patients should be in Determining which of four categories patients should be in Visibly identifying the categories for rescuers who will treat the patients Visibly identifying the categories for rescuers who will treat the patients

13. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Triage Victims are divided in the following categories: Victims are divided in the following categories: Immediate (RED) Immediate (RED) Life-threatening Life-threatening Delayed (YELLOW) Delayed (YELLOW) Serious but not life-threatening Serious but not life-threatening Minor (GREEN) Minor (GREEN) Walking wounded Walking wounded Deceased (BLACK) Deceased (BLACK) Includes non-salvageable Includes non-salvageable

14. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response START Triage Simple Triage and Rapid Treatment Simple Triage and Rapid Treatment Designed to assess a large number of victims objectively, efficiently and rapidly Designed to assess a large number of victims objectively, efficiently and rapidly Can be used by personnel with limited training Can be used by personnel with limited training 30 – 60 seconds per victim 30 – 60 seconds per victim

15. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Evaluating Patients START, ambulatory patients are automatically triaged for delayed care START, ambulatory patients are automatically triaged for delayed care 30-2 can do 30-2 can do Non-ambulatory evaluated: Non-ambulatory evaluated: Respiration Respiration Perfusion Perfusion Mental status Mental status R.P.M R.P.M

16. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness

17. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Visibly identifying the categories for rescuers who will treat the victims… The Triage Tag or Colored Strip The Triage Tag or Colored Strip Color Coded Color Coded Person doing initial START triage does NOT fill out the tag, only tears off the color strip Person doing initial START triage does NOT fill out the tag, only tears off the color strip Should write time and initial the tag Should write time and initial the tag

18. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Medical Treatment During Triage Only life-threatening problems are corrected Only life-threatening problems are corrected Opening the airway Opening the airway Attempt to control exsanguation Attempt to control exsanguation Resuscitation is not attempted Resuscitation is not attempted

19. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Triage Categories Triage Categories START START RED – Immediate RED – Immediate RPM outside of desired values RPM outside of desired values YELLOW – Delayed YELLOW – Delayed RPM within desired values RPM within desired values Significant injuries Significant injuries GREEN – Minor GREEN – Minor Ambulatory, able to move with instruction from EMS Ambulatory, able to move with instruction from EMS

20. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Target Values Respiration Respiration Between 10 & 30 per minute Between 10 & 30 per minute Capillary refill Capillary refill Less than 2 seconds or radial pulse present Less than 2 seconds or radial pulse present Victim can do what you ask Victim can do what you ask

21. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Assess Respiration If between 10-30 go to perfusion If between 10-30 go to perfusion If 30 tag red and move to next patient If 30 tag red and move to next patient If not breathing, open airway and remove obstructions if visible If not breathing, open airway and remove obstructions if visible If victims starts breathing, follow #1 or #2 above If victims starts breathing, follow #1 or #2 above If patient is still not breathing, prioritize BLACK If patient is still not breathing, prioritize BLACK

22. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness R=Respiration First check for breathing (estimate rate) First check for breathing (estimate rate) Yes Rate < 30>30Red Tag Check Perfusion

23. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Breathing Continued… Not Breathing Reposition/Open Airway Still Not BreathingBreathing Resumes Black Tag-DeadRed Tag-Immediate

24. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Assess Perfusion If radial pulse is present or capillary refill is less than 2 seconds go to MENTAL STATUS assessment If radial pulse is present or capillary refill is less than 2 seconds go to MENTAL STATUS assessment If no radial pulse or capillary refill greater than 2 seconds, prioritize RED If no radial pulse or capillary refill greater than 2 seconds, prioritize RED

25. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness P = Perfusion Check a radial pulse Check a radial pulse Yes Check Capillary Refill Not Present Red Tag & Move to Next patient Note: May have the victim or a less injured victim put pressure on any bleeding and elevate feet < 2 Seconds> 2 Seconds Move to Mental Status

26. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Assess Mental Status Assess the victim’s ability to follow simple commands Assess the victim’s ability to follow simple commands Alert to person, place and time Alert to person, place and time If victim does not follow command, is unconscious or disoriented, prioritize RED If victim does not follow command, is unconscious or disoriented, prioritize RED If victim follow commands and is oriented, prioritize GREEN or YELLOW If victim follow commands and is oriented, prioritize GREEN or YELLOW

27. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness M = Mental Status Check Mental Status Check Mental Status Follows Simple Commands YesNo Yellow Tag-Delayed & Move to next victim Red Tag-Immediate & Move to next victim

28. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness

29. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Black – deceased Red – immediate Yellow – delayed Green – minor This tag shows the patient's category as "Immediate."

30. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness < 2 Sec. Respirations No Position Airway No RespirationsRespirations DeceasedImmediate Yes < 30/m> 30/m Perfusion Radial Pulse Absent OR Control Bleeding If Nec. Immediate Radial Pulse Present Capillary Refill> 2 Sec. Mental Status Follows Simple Instr. Delayed Cant Follow Simple Instr. Immediate

31. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Treatment Patients are re-evaluated using more in-depth assessment Patients are re-evaluated using more in-depth assessment Secondary triage Secondary triage Separate treatment areas; Red, Yellow, Green Separate treatment areas; Red, Yellow, Green Definitive/stabilizing emergency care Definitive/stabilizing emergency care ABC’s ABC’s Wound care Wound care

32. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Transport Transported by triage determination Transported by triage determination Red go first Red go first Green patients made be transported by alternative means (Bus) Green patients made be transported by alternative means (Bus) Accompanied by medical personnel Accompanied by medical personnel Transportation Officer designates facility Transportation Officer designates facility

33. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response CISM Pre-incident education Pre-incident education Information on symptoms of stress and methods to deal with stress Information on symptoms of stress and methods to deal with stress Defusing Defusing Brief group sessions to vent thoughts and feeling Brief group sessions to vent thoughts and feeling Immediately following incident Immediately following incident Debriefing Debriefing Longer more structured group sessions Longer more structured group sessions Typically 24 – 72 hours following incident Typically 24 – 72 hours following incident

34. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Long-Term Operations EMS among last to leave EMS among last to leave Stand by during search Stand by during search Maintain rehab care Maintain rehab care

35. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness MCI Response Reports and Records IC must assemble all reports and records IC must assemble all reports and records Resources requested and received and where assigned Resources requested and received and where assigned Incoming and outgoing ambulances (times) Incoming and outgoing ambulances (times) Triage log Triage log Staging log Staging log Patient destination log Patient destination log

36. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness REGIONAL MEDICAL COORDINATION CENTER (MCC) MCC Responsibilities MCC Responsibilities Provide initial and update alerts via appropriate communication resources Provide initial and update alerts via appropriate communication resources Provide frequent updates to on-scene EMS ICS Directors/Supervisors/Leaders regarding hospital casualty care capacity Provide frequent updates to on-scene EMS ICS Directors/Supervisors/Leaders regarding hospital casualty care capacity May assist with relay casualty transport information to receiving facilities May assist with relay casualty transport information to receiving facilities May assist with relay urgent and routine communications to appropriate entities May assist with relay urgent and routine communications to appropriate entities May assist in coordination and distribution of resources May assist in coordination and distribution of resources Other appropriate tasks as necessary for an effective regional medical response Other appropriate tasks as necessary for an effective regional medical response

37. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness SCENE MANAGEMENT EMS personnel should accomplish the following actions upon arrival. EMS personnel should accomplish the following actions upon arrival. Survey the scene Survey the scene If Incident Command has not been established the senior EMS personnel shall assume the role of IC. The IC shall assume to role of all other elements of the ICS until she/he as assigned other personnel to their roles. If Incident Command has not been established the senior EMS personnel shall assume the role of IC. The IC shall assume to role of all other elements of the ICS until she/he as assigned other personnel to their roles. Advise dispatch who has assumed command and who has EMS Branch Director/Group Supervisor and their exact location. Advise dispatch who has assumed command and who has EMS Branch Director/Group Supervisor and their exact location.

38. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness SCENE MANAGEMENT EMS personnel should accomplish the following actions upon arrival. (cont.) EMS personnel should accomplish the following actions upon arrival. (cont.) Organize the scene and ensure an effective response including: Organize the scene and ensure an effective response including: Securing the area and limiting access to nonessential personnel Securing the area and limiting access to nonessential personnel Determining whether the incident scene is safe to enter and whether decontamination is required Determining whether the incident scene is safe to enter and whether decontamination is required Assigning personnel to the necessary tasks and roles Assigning personnel to the necessary tasks and roles Establishing staging, triage, treatment, and transportation areas Establishing staging, triage, treatment, and transportation areas Establishing communication between areas Establishing communication between areas Establishing traffic pattern that provided for the smooth flow of patients and vehicles Establishing traffic pattern that provided for the smooth flow of patients and vehicles Ensure that appropriate record-keeping takes place Ensure that appropriate record-keeping takes place

39. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness SCENE MANAGEMENT EMS personnel should accomplish the following actions upon arrival. (cont.) EMS personnel should accomplish the following actions upon arrival. (cont.) Call for additional resources Call for additional resources EMS personnel EMS personnel Any specialized equipment Any specialized equipment MEDDRUN MEDDRUN CHEMPACK CHEMPACK Regional Medical Coordination Center (MCC) Regional Medical Coordination Center (MCC) Other available resources Other available resources Inform the “Coordinating Resource” of nature and scope of incident Inform the “Coordinating Resource” of nature and scope of incident

40. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness INCIDENT/UNIFIED COMMAND Fire EMS Law Enforcement Operations Law Enforcement Branch Fire Branch Public Works Branch EMS Branch Triage Group Triage Units Litter Bearer Teams Medical Examiner Personnel Treatment Group Treatment Teams Red Team Immediate Yellow Team Delayed Green Team Minor Transport Group Medical Communications Coordinator Air Ambulance Coordinator Ground Ambulance Coordinator Medical Safety Assistant Staging PlanningLogistics Finance Administration