Managing Multiple Casualty Incidents

The Hospital/Pre-hospital Interface

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Definitions:
MCI Multiple Casualty Incident
Any incident where the
number/severity of patients exceeds
the capacity of local resources.
Local Healthcare Team All elements
of a response: Dispatch, Fire/EMS,
Law Enforcement, Hospitals, Public
Health (HSPD-8)
START Simple Triage And Rapid
Transport
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Learning Objectives
Effectively identify & communicate
critical pieces of information.
(dispatch, scene, hospital) using
good radio etiquette.
Establish & implement the Incident
Command System in a MCI situation.
Describe key roles, responsibilities
and functions necessary to manage
an MCI
Use START triage system to
categorize patients during an MCI.
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If you get a report that

the scene has 5 yellow
patients and 3 red
patients, do you know
what that means?

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S.T.A.R.T. Triage System

S.T.A.R.T. (Simple Triage And Rapid Transport)
Example of a triage method that quickly classifies victims
and prioritizes treatment

MINOR
DELAYED
IMMEDIATE
MORGUE
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Little or no care needed,

Delay care, injuries not life-threatening
Immediate care for life-threatening situation
No care, mortal injuries, cannot be saved
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Types of Multiple Casualty

Incidents
Trauma
Acute Medical
Biological

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How Responses are

Organized
Disaster plans are prepared
Responders become familiar with the plan

Plans include the use of:

Communication Plan
Incident Command System (ICS/HICS)
Provides leadership and structure
Identifies Roles and Responsibilities

Triage
Used to manage limited resources
Prioritize patient care based on
survivability
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Module One:
Communications

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Question
What problem is most
commonly identified after
exercises or real events in
the Post Incident Review
or After Action Report?

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Implementing the
Communications Plan (Group
Discussion)

Do you have a communications plan?

What are your Dispatch Procedures
responder notification?
How is the Hospital Notified?
How does On-Scene Command
Communicate with the Hospital?
How do you Communicate with other
hospitals?
How/when do you communicate with the
public?
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WHAT TO COMMUNICATE FIRST

Initial contact scene/situation sizeup
Safety

Assume/Announce Command
Request Resources
Identify location, access and
positioning
Assign/Allocate Resources
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Size-Up, Assume Command

Dispatch: Local Ambulance: On

scene of a multiple vehicle crash
with approximately 20 casualties.
Local Ambulance will be I-90
Command on the east bound
Gold Creek Off ramp.

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Keys to Clear Radio

Communication
Key microphone 2 seconds before speaking
on a repeater based radio system
Say who you want to talk to first then say
who you are.
Use clear text (plain language NO TEN
CODES)
Speak slowly and clearly (practice this)

Repeat back communications to

acknowledge receipt of message.
Assume messages not acknowledged were not
heard and repeat initial message
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Keys to Clear Interpersonal

Communications
Develop/refine and practice your
communications plan
Organize your thoughts to present
the information clearly and concisely
(SBAR)
Have a back-up plan (runners, written
notes)
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I am 10-23 at a
10-50. 10-52
times two and a
10-51.

Dispatch: HP 1: I am on
scene at a car crash with
casualties. I need 2
ambulances and a wrecker.
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Dont use 10-Codes!

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Hospital: Medic 1: Enroute to your

facility with a TBI. 2 min LOC and
GMS with GCS of 9.
Hospital: Local Ambulance:
Transporting Pt. #3 triaged as
red/immediate, due to head
injury with respiratory rate of
40, radial pulse present, and
responds to pain only.
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Avoid Acronyms
and Abbreviations!

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SBAR
(focused communication)
Situation: En route with 52 year old
male triaged as Red
Background: Motor vehicle crash
ejected
Assessment: Head and chest injuries
Recommendations: Activate Trauma
Team
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Public Information
If pub info isnt addressed early/
aggressively it will impact the incident
and incident communications
this is one of the reasons phones go down
and your hospital becomes overwhelmed
with people seeking information

Assign people to answer phones, craft

messages for media, meet with
families, track patients.
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Request Resources
Call for help
You can always cancel them if not needed
Be specific about what units and capabilities
you want
Order enough resources

Tell them where to report & how to access

the scene
If coming in a vehicle, where should it be
positioned?
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Assign/Allocate/Reassign
Resources
Individuals or resources should be
assigned:
Someone to report to (a boss).
A task TO ACCOMPLISH
Where to go.
What to do when done with THE task.

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Group Activity
Photo/description of MCI Incident
Divide into groups (Prehospital/Hospital)
Play act initial establishment of
command for each area and
communication between groups

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An Organized Response
Requires planning
Coordinates resources and
personnel

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Report to Staging Area

Sign in when you arrive;
Sign out when you leave
Bring ID, credentials
Find your designated
supervisor
Follow directions

Medical volunteers at
If asked to leave or
staging area
provide care else where
do so

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Accountability: Task

Tell them what needs to be done

Ensure assignment is understood
Give them the tools they need
Tell them what to do when done

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Use SMART Objectives

Specific
Measurable
Action Oriented
Realistic
Timeframe

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Break

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On-Scene
Incident Command Structure
Incident Commander

Safety Officer

Medical Branch
Director
Triage Group
Supervisor
Transport Group
Supervisor.
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Technical Rescue

Treatment Group
Supervisor

Dive Team

Extrication Team
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Emergency Dept
Hospital Incident Command
Incident Commander
Cindy
Triage
Unit Leader
Paula

Treatment
Unit Leader
Dr. Jones

Transfer
Unit Leader
Bob

Communications
Unit Leader
Bob

Immediate
Red Team
Delayed
Yellow Team
Minor
Green Team
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WHAT ARE YOUR Local

Resources?

Ground Ambulances
Air Ambulances
Fire/Rescue Vehicles
ED beds
Hospital beds
Operating Rooms
Blood Supply
Imaging/Lab
Capacity
Ventilators
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EMTs
Flight Crews
Firefighters
Technical Rescue
MDs, RNs, CNAs
Surgeons, OR Crews
Blood Bank Staff
Imaging/Lab Staff
Resp Therapists
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Group Activity
What resources are
available to my
community during an
MCI?
Where are they?

How do we contact them?

How long will they take to arrive?
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Why is it important to
give the incident a
name?

Because you could have multiple

incidents going on simultaneously.
Helps avoid confusion.
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Assessment and Care of Multiple

Patients
On-Scene
Rescue/Extrication
Triage
Treatment
Transport

Hospital
Decon
Triage/Re-Triage
Treatment
Admission/Discharg
e/Transfer

*see slide

* see slide

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On-Scene Triage Group Supervisor

Responsibilities/Tasks:
Ensure safety
See each patient rapidly, categorize and
label patients using a standard triage
system
Communicate triage decisions with
Medical Branch Director, and coordinate
with treatment and extrication groups.
Track Patients:
Remove patients to the treatment area
Red Patients move first!
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Hospital Treatment Unit Leader

Responsibilities
Provide definitive care: identify and fix the problem
Provide lifesaving basic life support before
advanced life support..
Match patient needs with provider skills.
Use available resources, making decisions about
resource allocation at each step.
Use tools to document and aid organization
Transport/Transfer/Admit them to the place where
these needs can be met.

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Rescue Group(s)
Rescue and triage are happening
simultaneously
Rescue Groups focus on:
Extrication
Technical Rescue (high/low angle)
Dive Teams
HazMat, Decon
Patient Movement (out of hazard zone to
patient collection area/treatment)
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Staying Organized
Organizational
Tools
Plans
Protocols
Forms
Job Action Sheets

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Triage Systems

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START
Triage
A process in
which
victims are
sorted into
groups;
priorities of
care are
established
and
resources are
allocated.
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S.T.A.R.T. Triage System

S.T.A.R.T. (Simple Triage And Rapid Transport)
Example of a triage method that quickly classifies victims
and prioritizes treatment

MINOR
DELAYED
IMMEDIATE
MORGUE
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Little or no care needed,

Delay care, injuries not life-threatening
Immediate care for life-threatening situation
No care, mortal injuries, cannot be saved
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START uses R P M
Respirations (<10 OR >30)
Pulse (no radial pulse)
Mental status (unable to follow
simple commands)

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Triage Flow Chart

Flow Chart Decisions:
1. Separate walking
wounded from
others
2. Use RPM life
functions to tag
remaining patients:
a. Respirations
b. Circulation
c. Mental Status
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First Step: Breathing

Cannot breathe on own after airway opened [BLACK tag]

Breathing rapidly >30 breaths per minute [RED tag]
Breathing regularly (go to next step in flow chart PERFUSION)
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Second Step: Blood Flow

If detectable
radial pulse, go
to step 3: Mental
Status
If no detectable
radial pulse check capillary
refill
Refill more than 2
seconds control
bleeding - [RED tag]
Capillary refill less
than 2 seconds - go
to step 4: Mental
Status
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Third Step: Mental Status

Cannot follow simple command - [RED tag]

Can follow simple command - [YELLOW tag]
End of algorithm all victims should be tagged now.
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PATIENTS ARE RED IF THEY HAVE EVEN

ONE FINDING OF:
RR <10 OR > 30
No Radial Pulse
Cannot follow simple commands

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Activity:
Triage Practice Case #1
A woman runs up to you, supporting her
left arm, and says, I think its broken.
Respiratory rate is 24/minute
Radial pulse rate is 120/minute

How would you label her?

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Activity:
Triage Practice Case #2
You approach a man who is lying on the
ground
He is taking 36 breaths per minute
You cannot find a radial pulse
He moans when you use a painful pinch
How would you label him?

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Activity:
Triage Practice Case #3
A woman is sitting slumped over, not
breathing
You open her airway still not breathing
There is no radial pulse
Her carotid pulse is 30 beats/minute

She does not respond to noise, touch, or

painful stimuli

How would you label her?

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Triage Organizes Priorities

Normal Circumstances
Use all available manpower and supplies
Resource use focuses on saving one life

Mass Casualty Situation

Number of injured exceeds ability to treat in
normal manner
Resource use focuses on saving as many
lives as possible
Minor injuries wait for care
Severe injuries receive immediate care
Mortal injuries do not receive care
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What Makes Triage Difficult

More patients than resources
Victims who are Beyond Rescue
Black tag (morgue) category
To NOT treat such patients will oppose all your
training and instincts

Example:
Patient has no pulse and is not
breathing
Routine situation compared to a mass casualty
situation
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Now that you understand START;

Does the triage system you use daily
in the ED work for MCIs?
If not, you need to decide whether
during an MCI you will:
Stay with START system initiated prehospital or Adapt your current system to include a
category for the patients who are
expected to die given maximum
treatment with the available resources
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 What Triage system

does your ED use
everyday?
MCI Triage Options:
Stay with the START
system initiated prehospital or Adapt your current
system to include a
category for the
patients who are
expected to die even
if they are given
maximum treatment
with the available
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Tools for S.T.A.R.T

Left side
used for
notes on
injuries and
vital signs
Right side
contains
decision flow
chart
(algorithm)
Note the four
color-coded
categories at
the bottom

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Tools for S.T.A.R.T.

Triage kit MAY include:
Tape to create triage areas
Patient triage tags
Clipboards & Tracking tools
ID Vests

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Review

Communication
Organization
Resource Management
Roles and Responsibilities
Prioritization (triage)
Accountability (Personnel, Patients,
Tasks)

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For More Information

HICS:
http://www.emsa.ca.gov/hics/hics.asp

NIMS:
http://www.dhs.gov/interweb/assetlibrary/NIMS-90-web
.pdf

FEMA (Certificate in basicICS):

http://training.fema.gov/EMIWeb/IS/is195.asp

OSHA:
http://www.osha.gov/SLTC/etools/ics/org.html
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More Information on
Triage
MINOR
DELAYED
IMMEDIATE
MORGUE

For additional practice:

http://www.citmt.org/start/exercise.htm
For more information on tags:
http://www.mettag.com
To find out to fill out a tag:
http://www.digisys.net/oes/triagetag.ht
m

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Basic HICS/ICS Organizational

Structure
Incident
Commander
Public Information
Officer

Command Staff

Safety Officer

Liaison Officer

General
Staff

Operations
Section Chief
Branch
Director

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Planning
Section Chief

Logistics
Section Chief

Finance
Section Chief

Division/Group
Supervisor
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Hospital ICS Chart

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References
Brady, Paramedic Emergency Care, Bledsoe, Porter, Shade
NIMS ICS Field Guide, 1 st Edition Infomed
Disaster Medicine, 2002 Lippincott Williams & Wilkins, Hogan and Burnstein
Emergency Medical Services at a Mass Casualty Incident, Joseph Cahill,
Domestic Preparedness Journal V. III, Issue 7, July 2007
Creating Order from Chaos: Part II: Tactical Planning for Mass Casualty and
Disaster Response a Definitive Care Facilities, Baker, Michael S., Article
Military Medicine, Mar 2007
In a Moments Notice: Surge Capacity for Terrorist Bombings, Challenges
and Proposed Solutions, CDC, April 2007
International Nursing Coalition for Mass Casualty Education, Educational
Competencies for Registered Nurses Responding to Mass Casualty
Incidents, August 2003
Mass Casualty Incident Program, Initial Triage Training, AEMS, courtesy of
Pheonix FD.
Virginia Mass Casualty Incident Management, Secondary Triage
Improving health system preparedness for terrorism and mass casualty
events, Recommendations for action, July 2007, AMA/APHA Consensus
report
Mass Medical Care with Scarce Resources, A Community Planning Guide,
Health Systems Research Inc., Feb. 2007
Nancy Carolines, Emergency Care in the Streets, Sixth Edition
National Incident Management System, Principles and Practice, Walsh,
Christen, Miller, Callsen and Maniscalco

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