1. PDLS © : EMS Response to Disaster Prehospital Considerations Jorge D. Yarzebski, NREMTP

2. Objectives To review EMS considerations in disaster situations and the unique needs of children To review EMS considerations in disaster situations and the unique needs of children What to expect from prehospital providers What to expect from prehospital providers Review the Incident Command System (ICS) and Field Triage as it applies to prehospital providers Review the Incident Command System (ICS) and Field Triage as it applies to prehospital providers

3. Objectives Recognize and formally declare a MCI Recognize and formally declare a MCI Communication Communication - Interagency - Hospitals

4. Emergency Medical Services Network of multiple services and agencies ‘coordinated’ to provide aid and medical care from 1º response to definitive care based on training Network of multiple services and agencies ‘coordinated’ to provide aid and medical care from 1º response to definitive care based on training - First Responder - Basic - Intermediate - Paramedic - RN’s/MD’s

5. Coordination Incident Command System Incident Command System - Management system created to address concerns of interagency compatibility and interaction - Direct - Control - Coordinate

6. ICS (Incident Command System) Senior on scene: command Senior on scene: command - assess need for further resources and direct incoming resources to where they are needed - This starts with first to arrive - Triage: initial fast assessment of every patient, sort for evacuation and first in line for care when additional resources arrive Responsibilites delegated through ICS Responsibilites delegated through ICS

7. ICS Scene control Scene control - limit access for civilians - media cameras - maintain in/out routes for vehicles which do need entry Communications Communications - notify hospitals of rough numbers, kinds of injuries

8. When YOU are the first to arrive… Declaring the Multiple Casualty Incident Declaring the Multiple Casualty Incident - Recognize the major incident - Available resources are insufficient to manage the number and nature of injuries and environment Possibilities Possibilities - More than two ambulances required (dependent on resources)

9. When YOU are the first to arrive… - HAZMAT - Special resources: Fire, Police, rescue with specialized extrication equipment, SAR, Medivac Dispatch Dispatch - En route request for assistance, confirm upon arriving on scene or cancel request* *follow SOP for particular department *follow SOP for particular department

10. EMS ICS Coordinates EMS activities – Activates MCI response plan Coordinates EMS activities – Activates MCI response plan Supervises Supervises - TRIAGE, TAGGING, TREATMENT, TRANSPORTATION Assigns personnel Assigns personnel Guides difficult medical decisions Guides difficult medical decisions

11. Need Help?

12. First to Arrive Initial units assumes command Initial units assumes command - Senior/most experience takes control - Requests additional support - Updates safety/mechanism/conditions Support Support

13. Support

14. Triage “to sort” or place in order “to sort” or place in order Guides decisions about allocating scarce resources and limited time Guides decisions about allocating scarce resources and limited time “greatest good for greatest number” “greatest good for greatest number” Protocol helps make decisions Protocol helps make decisions ICS separates triage from treatment immediately: see everybody once briefly for focus ICS separates triage from treatment immediately: see everybody once briefly for focus

15. START Most commonly used triage system across country Most commonly used triage system across country Initial eval –not final Initial eval –not final Time limited (plan 1 min/patient) Time limited (plan 1 min/patient) Categorize and move on Categorize and move on

16. START “If you can hear me and are able, walk over here” GREEN triage done – still need individual evaluation, but can await more staff, allows initial rescuers to focus on more severely injured people. “If you can hear me and are able, walk over here” GREEN triage done – still need individual evaluation, but can await more staff, allows initial rescuers to focus on more severely injured people. Avg 80% of victims will be green, self extricate (may self transport – eases burden on field but hard on hospitals) Avg 80% of victims will be green, self extricate (may self transport – eases burden on field but hard on hospitals) *Not applicable for under 8 years old* *Not applicable for under 8 years old*

17. Kids in triage Don’t follow commands Don’t follow commands May actually hide from rescuers in full gear (spaceman look) May actually hide from rescuers in full gear (spaceman look) May be extricated by GREEN parents/ adults with delay in triage and treatment May be extricated by GREEN parents/ adults with delay in triage and treatment Need distraction and dedicated supervisor able to run after wandering toddlers Need distraction and dedicated supervisor able to run after wandering toddlers

18. JumpSTART (under 8) Kids more airway dependent – rescue breaths attempted if pulse present (unlike adults) Resp 15-40 instead of <30 Kids more airway dependent – rescue breaths attempted if pulse present (unlike adults) Resp 15-40 instead of <30 Vascular system clamps down sooner, so cap refill less reliable Vascular system clamps down sooner, so cap refill less reliable - Use peripheral pulse instead Mental status AV/PU instead of follow/not Mental status AV/PU instead of follow/not

19. JumpSTART “If you can hear me and you are able, walk over here for help.” “If you can hear me and you are able, walk over here for help.” GREENs are done. Screen GREEN adults for RED/YELLOW kids carried out. GREENs are done. Screen GREEN adults for RED/YELLOW kids carried out. Assess non-ambulatory patients as you find them using RPM. Assess non-ambulatory patients as you find them using RPM.

20. ICS Treatment: patients may outnumber transport, leading to time in field where treatment can be started. Treatment: patients may outnumber transport, leading to time in field where treatment can be started. Sort patients by category (greens, yellow, red, black) and treat within areas. If greens self triaged, they need evaluation. Sort patients by category (greens, yellow, red, black) and treat within areas. If greens self triaged, they need evaluation.

21. Treatment Limited initial treatment – don’t delay evacuation if vehicle available Limited initial treatment – don’t delay evacuation if vehicle available Oxygen, dressings, splints Oxygen, dressings, splints Airway management? Remember, no intubations during triage, and no codes during mass casualty event, unless sufficient personnel and equipment that no other care is delayed Airway management? Remember, no intubations during triage, and no codes during mass casualty event, unless sufficient personnel and equipment that no other care is delayed

22. Treatment Kids will be mixed in – do you have enough supplies in kid size (oxygen, IVs, splints)? Kids will be mixed in – do you have enough supplies in kid size (oxygen, IVs, splints)? Does your locality stock a “disaster truck”? Does your locality stock a “disaster truck”? Does it have kid size equipment and kid sized doses of Hazmat antidotes? Does it have kid size equipment and kid sized doses of Hazmat antidotes? Do you have Broselow tapes to guide dosing? Do you have Broselow tapes to guide dosing?

23. Treatment - airway Non breathing child (with pulse): rescue breaths, then if no response, BLACK Non breathing child (with pulse): rescue breaths, then if no response, BLACK Non breathing child without pulse: BLACK Non breathing child without pulse: BLACK Oxygen: how administered? Do you have octopus adaptors to set more than one NRBM off each nozzle? REDs first. Oxygen: how administered? Do you have octopus adaptors to set more than one NRBM off each nozzle? REDs first.

24. Treatment IV fluids? Depends on numbers: does everyone need an IV? Are there enough IV kits to give everyone an IV? Use triage to guide => treat REDs first, then YELLOWs. Do GREENs need IV? IV fluids? Depends on numbers: does everyone need an IV? Are there enough IV kits to give everyone an IV? Use triage to guide => treat REDs first, then YELLOWs. Do GREENs need IV? BLACK/expectant: pain control (if drugs available) NO IV fluids, NO oxygen BLACK/expectant: pain control (if drugs available) NO IV fluids, NO oxygen

25. Treatment: Dressings – rinse gross dirt with sterile fluids or tap water if available, sterile cover to prevent further contamination Dressings – rinse gross dirt with sterile fluids or tap water if available, sterile cover to prevent further contamination Pressure dressing for active bleeding Pressure dressing for active bleeding - Recruit neighbor to help hold pressure during triage while awaiting transport/evacuation - ARE KIDS CAPABLE OF THIS? - IS IT APPROPRIATE PSYCHOLOGICALLY? Splint – extremity injuries Splint – extremity injuries

26. Treatment Medications: pain control, specific antidotes with Hazmat event/team Medications: pain control, specific antidotes with Hazmat event/team Monitoring: repeat assessment after triage, re-categorize if necessary (to worse, never better – even if they respond to treatment, they have the same underlying injury) Monitoring: repeat assessment after triage, re-categorize if necessary (to worse, never better – even if they respond to treatment, they have the same underlying injury)

27. ICS Transport: decides which patients leave scene first and where they’re going Transport: decides which patients leave scene first and where they’re going - Remember that helpful bystanders and self transporters will fill nearest hospital first - Includes decisions about longer transport times for specialty care ( e.g. out of town for burn unit straight from scene rather than to hospital for transfer) - PEDIATRIC SPECIALTY CENTERS

28. Communication Telephones Telephones Cellular Phones Cellular Phones Pager System Pager System Radios Radios Whistles Whistles Loudspeakers/Megaphones Loudspeakers/Megaphones

29. Your Pedi First in Bag Is your ambulance equipped to handle a Pediatric MCI? Is your ambulance equipped to handle a Pediatric MCI? What is essential to your first in bag? What is essential to your first in bag? - Airway supplies - Dressings - Tags Do we include Broselow tapes to guide dosing? Do we include Broselow tapes to guide dosing?

30. Ambulance / Disaster Preparedness Top to bottom Top to bottom BLS / ALS specific BLS / ALS specific Pre-determined scope of practice rules Pre-determined scope of practice rules Policy formulation Policy formulation Incident specific arrangements Incident specific arrangements Sectioning shell - age specific Sectioning shell - age specific

31. Supplies: Oral pharyngeal airways Oral pharyngeal airways Bag Valve Mask’s Bag Valve Mask’s O2 / delivery devices O2 / delivery devices Pulse oximeter Pulse oximeter P.O. ear probes P.O. ear probes CO2 monitors CO2 monitors Trauma scissors Trauma scissors Stethoscopes Stethoscopes Blood pressure cuffs Blood pressure cuffs Cervical collars Cervical collars Portable suction Portable suction Padded board splints Padded board splints Obstetrics kit Obstetrics kit Blankets Blankets Sheets Sheets

32. Supplies Car seats Car seats Toys Toys Airway rolls Airway rolls O2 multiplexer O2 multiplexer Naso-gastric tubes Naso-gastric tubes Chest tubes Chest tubes Nebulizers Nebulizers I.V. solutions I.V. solutions Needles Needles Sharps containers Sharps containers Glucometer Glucometer I.O. needles I.O. needles Broselow Tape Broselow Tape Adhesive tape Adhesive tape Medications Medications Clean water / cups Clean water / cups

33. Supplies Formula Formula Purifier / preservative Purifier / preservative hand lights with batteries hand lights with batteries Light sticks Light sticks Candles / waterproof matches Candles / waterproof matches Rain tarps/ poles Rain tarps/ poles Ground clothes Ground clothes Paper / waterproof pens Paper / waterproof pens Disaster Tags Disaster Tags Disposable bags Disposable bags Chlorine bleach Chlorine bleach Soap / towels Soap / towels Hand tools Hand tools

34. Supplies Radio CB/am/fm Radio CB/am/fm Whistle Whistle Meals Ready to Eat Meals Ready to Eat Bandage Bandage Triangular bandage Triangular bandage Kling Kling Aluminum foil Aluminum foil Vaseline gauze Vaseline gauze Trauma dressings Trauma dressings Gauze Gauze Hydrogen peroxide Hydrogen peroxide Alcohol Alcohol Cold / hot packs Cold / hot packs Gloves Gloves Instaglucose Instaglucose Sterile water / saline Sterile water / saline

35. Supplies Backboards/ straps Backboards/ straps Optional / Monitors defibrillators Optional / Monitors defibrillators AED / SAED AED / SAED Other regional specific adjuncts Other regional specific adjuncts

36. Supplies Expanded practice Expanded practice Special needs Special needs

37. Thank you