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

2. 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

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

4. 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)

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

6. 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

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

8. 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

9. 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)

10. Incident Command History
Developed by Forest Service ( ’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)

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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)

22. 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.

23. 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.

24. 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

25. 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.

26. 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

27. 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

28. .
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

29. Basic elements of the incident management system.

30. Examples of branches that may operate in a major incident.

31. 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

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

33. 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

34. SALT Triage

35. 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)

36. 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.

37. 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.)

38. 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

39. 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

40. IMPORTANT POINT

41. THE START system

42. 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

43. Important Note!!! .

44. 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.

45. 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

46. 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

47. 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

48. Title - 36
Detail - 24