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MASS CASUALTY

MANAGEMENT
SYSTEM

ROMEO ALMAZAN BITUIN, MD, MHA


Health Emergency Management Staff Coordinator
Dr. Jose Fabella Memorial Hospital
Department of Health
1
OUTLINE OF PRESENTATION

I. Overview of Mass Casualty


II. Establishing Mass Casualty
Management System
III. Field Management
IV. Management of Victims
V.Transfer Organization

2
QUESTION 1

Define Mass Casualty


QUESTION 2

What is a Mass Casualty Management


System
Overview of Mass Casualty

GLOBAL TREND

1.
2.
Kobe Earthquake, Japan 1995
Sarin attack in Tokyo, 1995
                  

3. New York 911 Tragedy, 2001


4. Iraq Crisis, 2003
5. Terrorism – WMD
6. Asian Tsunami
7. Leyte Landslide, 2006

5
Overview of Mass Casualty

WORLD Since 1900 %

Top 5 hazards by mass accidents 32.8


frequency of wind storm 19.6
occurrence flood 18.0
earthquake 7.5
drought 6.0
83.9
ASIA

Top 5 hazards by mass accidents 37.2


frequency of wind storm 19.7
occurrence flood 18.4
earthquake 8.0
epidemic 4.0
87.4
CRED Disaster Data 6
Overview of Mass Casualty

Mass Casualty Incident

 Produces several patients


 As few as six or as many as several hundred
 Affects local hospitals
 Patients are greater than resources of the
initial responders

7
Overview of Mass Casualty

Preparation for Mass Casualty

 Pre-planning and training are critical


 Establish guidelines and procedures
 Early implementation of Incident Command
 First five minutes will determine next five
hours

8
Overview of Mass Casualty

Response Categories for Mass Casualties


 Mass Casualties can occur in a variety of
ways
 Effect on emergency response and
community impact
 Include transportation, violent crimes and
building collapse

9
Overview of Mass Casualty

Response Categories of Mass Casualties


 Hazardous materials incidents
 Civil disturbances
 Natural disasters
 Major fires
 Terrorist attacks

10
Overview of Mass Casualty

Problems in Mass Casualty Incidents

Most common being:


 Who is in command of the incident

 Location of the Command Post

 Lack of communication between agencies

leading to conflicting priorities and orders

11
Overview of Mass Casualty

Problems in Mass Casualty Incidents


 Perimeter establishment delayed or not done
at all
 Large crowds of people
 Media involvement
 Political involvement
 Inadequate resources

12
Establishing Mass
Casualty Management
System

13
Establishing a Mass Casualty Management System

Mass Casualty Incident

Any event resulting in a number of victims


large enough to disrupt the normal course of
emergency and health care services

14
Establishing a Mass Casualty Management System

Casualty Management

• Management of victim of a mass casualty


event
• Objective is to minimize loss of life and
disabilities

15
Establishing a Mass Casualty Management System

Mass Casualty Management System

The group of Units, Organizations, Sectors which work


jointly during a mass casualty event

Based on:
- Pre-established procedures
- Maximization of use of existing resources
- Multi-sectoral preparation and response
- Strong pre-planned and tested coordination
16
Establishing a Mass Casualty Management System

Different Approaches to MCI

1. “Scoop and Run”


2. Classical Approach
3. Mass Casualty Management System

17
Establishing a Mass Casualty Management System

Scoop and Run


• Most common
• Does not require specific technical
ability from rescuers
• Justified for small numbers occurring near a
hospital
• May just transfer problem to the hospital

18
Establishing a Mass Casualty Management System

Classical Approach

• First responders are trained (basic triage


and field care)
• Disregard the receiving hospitals from the
field
• Quickly result to chaos

19
Establishing a Mass Casualty Management System

Mass Casualty Management Approach

• Most sophisticated approach includes pre-


established procedures for:
a. resource mobilization
b. field management
c. hospital reception

20
Establishing a Mass Casualty Management System

Mass Casualty Management Approach


• Training of various level of responders
• Incorporates links between field and health
care facilities
• Command Post
• Multi-sectoral Response
• Dependent on the availability of large
amounts of human & material resources
21
Establishing a Mass Casualty Management System

Problems in Developing MCM


• Limited human resources
• limited material resources
– facility
– transport
– communication
• Poor communication
– topography
– isolation
• Political 22
Establishing a Mass Casualty Management System

Activities at various levels of responses:


alerting process
‘E’/Disaster
Site/Scene initial assessment
command / control / coordinate
manage information
search/rescue
field care-- mostly health activities
transport/traffic control
facility reception at ER / A&ED
hospital mass casualty mgt. & command
system 23
Establishing a Mass Casualty Management System

Field Management
Definition:
Encompass procedures used to organize the disaster area in order to
facilitate the management of victims
Components

Alerting Process Search and Rescue

Pre-identification of Field Care


Field Areas

Safety/ Security Evacuation

Command Post (EMC) Emergency


Management Center 24
Establishing a Mass Casualty Management System

RESCUE CHAIN---SECTORAL
Impact Zone
Command Post

*SEARCH*
Triage
Traffic Control ER
*RESCUE* Stabilization
Evacuation
Regulation of Evacuation or
*First Aid*
CP / A&ED
AMP

Pre-Hospital Organization Hospital Organization


25
Establishing a Mass Casualty Management System

Field Organization
Alerting Process

Definition: Sequence of activities implemented to


achieve the efficient mobilization of
adequate resources
Aim:
- Confirm the initial warning
- Evaluate the extent of the problems
- Ensure that appropriate resources are informed
and mobilized 26
Establishing a Mass Casualty Management System

Field Organization

Alerting Process
Dispatch Center:
 Core of the Alerting Process
(Operation/Communication Center)
 Functions:
• receives all warning messages (radio/phone)
• mobilize a small assessment team (Flying
Team) from police, fire or ambulance services

27
Establishing a Mass Casualty Management System

Initial Assessment
 Precise location of the event
 Time & type of the event
 Estimated number of casualties
 Added potential risk
 Exposed population
 Resources needed

28
Establishing a Mass Casualty Management System

Pre-Identification of Field Areas

 Impact Zone
 Command Post
 Collecting Area in unstable location
 Advance Medical Post Area (3-T Principle)
 Evacuation Area
 VIP & Press Area (Information Officer)
 Access Roads (geographical presentations if
available)
 Check point for resources (Staging Area)
29
Establishing a Mass Casualty Management System

Safety
• Best practice technique to protect victims, responders
& exposed population: immediate/potential risk
• Measures:
Direct action:
- risk reduction - fire fighting
- contain hazardous material
- evacuation of exposed population
Preventive actions: establish field areas
- primary- impact zone
- secondary- rescue/ICP/AMP
- tertiary-“buffer zone”; tri-media 30
Establishing a Mass Casualty Management System

Safety

• Personnel: fire services; specialized units hazardous


materials & explosives (bio-nuclear
and radioactive materials) experts, etc.,
airport manager, chemical plant expert

31
Establishing a Mass Casualty Management System

Security Measures
• Non-interference of external elements:
- crowd/traffic control

• Contribute to safety:
– protect workers from external influence; additional
stress
– free flow: victims/resources
– protect general public from risk exposure
• ensured by police officers / special units (security:
airport/building/hospital/establishments, etc..)
32
Establishing a Mass Casualty Management System

Command Post ( CP / or ICP)


Multi-sectoral control unit to:
 Coordinate sectors involved in field/scene management
 Linked w/ back-up system: provide information &
mobilization resources
 Supervise victim management
REQUISITE: radio communication network: main criterion
to be effective
Purpose: coordination / communication hub of people who
don’t work routinely (pre-hospital setting)
Location: external boundary of restricted area (impact zone)
close to AMP/ Evacuation Area/ accessible/easily identified
* should accommodate: com./visuals/maps/boards

33
Establishing a Mass Casualty Management System

Personnel
 High ranking officer (government police, fire, health,
defense)
- plant manager/ airport manager/ chief security, etc…
- fire officer / police officer skilled in ICS / MCM
 Identified by name/position, coordinator / commander
 May depend on what type of incident
 Must be familiar with each other’s roles during previous
meetings/ drills/ simulation exercises (policy)
 This core group cooperate with volunteer organizations

34
Establishing a Mass Casualty Management System

METHOD
 The communication / coordination hub of the pre-
hospital organization. By constant re-assessment,
CP will identify needs to increase / decrease
resources:
- organize timely rotation of rescue workers exposed
to stressful/exhausting conditions in close
coordination w/ back-up system
- ensure adequate supply of equipment / manpower
- ensure welfare / comfort of rescue workers
- provide info to back-up system, other officials, and
tri-media thru an Information Officer
- release as soon as situation allows “E” staff and re-
establish normal operations
- determine termination of field operations
35
Establishing a Mass Casualty Management System

MANAGEMENT OF VICTIMS
 Search & Rescue
- locate victims
- remove victims from unsafe locations – collecting area
- assess victim’s status (on-site triage)
- provide first aid , if necessary (no CPR on-site in MC Event)
- transfer victims to AMP thru entry triage (medical triage)
- under supervision of the CP/ IC/ or Commander/Coordinator
- may in special situation, require medical personnel (trained)
- to stabilize/resuscitate/amputate (trapped) victim before
extrication.

36
Establishing a Mass Casualty Management System

Management of Victims

• Field Care
- Pre-established capabilities / inventory: pre-
planning
- Integrated community plan: practiced w/ policy
support
- The “Golden Hour” Principle

37
Establishing a Mass Casualty Management System

Recent progress in pre-hospital


emergency / disaster medicine

Establish AMP with specially skilled /trained ----


“disaster field medical teams”
- good triage / stabilization capacity
- specifically trained / up-skilled medical teams
- good (radio) communications between the field
scene & medical facility

“ Don’t transfer chaos in the scene,

to the hospital……” 38
Establishing a Mass Casualty Management System

TRIAGE

Basis: urgency (victim’s status)


survival (chance or likelihood)
care resource availability and capability
Objectives:
Quick identification for immediate stabilization
for life-saving (measures) and surgery
Levels:
On-site–----- ‘where they lie’
Medical ----- at Advance Medical Post
Evacuation --- transport
39
Establishing a Mass Casualty Management System

On-site T: Acute
Non-acute Red: transferred as soon as
possible to tertiary facilities
in an equipped ambulance
Medical T: Red with medical escort
Yellow Yellow: after evacuation of Red,
Green without life-threatening
Black problem
Green: ‘walking wounded’-to
AS/OPD
Evacuation T - transport:
Black: to morgue Forensic Services
Red
Public Health & Psycho-Social
Yellow
Green interventions to relatives/kin
Black 40
Establishing a Mass Casualty Management System

First Aid

Personnel:
• volunteers, fire, police staff, special units, EMT’s, and
medical personnel
Location:
• on-site, before moving victim
• at collecting point/ area in an unstable environment.
• “Green Area” of “AMP”
• ambulance in transit to facility
Action:
• primarily to transfer with consideration of the ABC’s
order of priority
41
Establishing a Mass Casualty Management System

Advance Medical Post (AMP)

Purpose:
 reduce loss of life & limb - save as many as possible in
the context of existing & available resources/ situation
 victim’s status; chance of survival; resources
Location:
 50-100 meters from Impact Zone (walking distance )
 direct access to: Evacuation Road. / Command Post
 Clear Radio-Com Zone… and SAFE (Upwind)
 tent / bldg / open / mobile field hospital..??

42
Establishing a Mass Casualty Management System

Advance Medical Post (AMP)

Role:
 Provide “entry” medical triage
 Effective stabilization for victims of a MCI/Situation
• intubation, tracheostomy, chest drainage,
• shock mgt , analgesia , fracture immobilization
• fasciotomy, control external bleed & dressing
 Convert red to yellow category as maybe possible
 Organize patient transfer to designated care facility/ties
 AMP 3-T principle: Tag – Treat – Transfer….
Personnel:
 ER (A&ED), physicians/ nurses (trained & skilled)
 support: Anesthetists / Surgeons / EMT’s / Nurses / Aiders,
etc. 43
Establishing a Mass Casualty Management System

AMP
NON-ACUTE

TRIAGE Black Green


NON-ACUTE
C
evacuation
P
ACUTE

Red Yellow
ACUTE

C P– Collecting Point
44
Establishing a Mass Casualty Management System
COLLECTION AREA
(in unstable condition)

TRIAGE AREA
(color tagging of victims)
COMMAND POST
TREATMENT AREA
(management and stabilization)

1st
3rd 2nd

PRIORITY III PRIORITY II PRIORITY I

T R A N S P O R T A R E A

45
Establishing a Mass Casualty Management System

Field Management Plan: Diagram

Working
T C
Area
r o
Triage a n
Evacuation
f t
AMP
f r
i o
c l
Impact Zone
Command Post

Strictly Restricted

Restricted
Traffic
46
Access Route
Establishing a Mass Casualty Management System

Transfer Organization
 Procedures used to ensure that victims of a MC
situation is safely, quickly, and efficiently transferred by
appropriate vehicles to the appropriate and prepared
facility
 Preparation for Evacuation:
1. Single Reception Facility

2. Multiple Reception Facilities


* type of vehicle required
* type of escort required
* destination
47
Establishing a Mass Casualty Management System

Transfer Organization

 Preparation for Transport


Evacuation Officer reporting to ATM:
 assess patient’s status: vital signs, ventilation / hemostasis
 check security of equipment / & accessories
 ensuring efficiency of immobilization measures
 ensure triage tags: secure/& clearly visible
 Evacuation Procedures: Regulation
Principles
- not to overwhelm care facility
- avoid spontaneous evacuation of unstable patients.

48
Establishing a Mass Casualty Management System

Transfer Organization
 Evacuation Procedures: Regulation
Rules:
- victim is in most possible stable condition
- victim is adequately equipped for transfer
- receiving facility correctly informed and ready
- the best possible vehicle and escort– available
Victim Flow
- “Noria” Principle, Spanish word from Arabic--… ”wheel”
WW I Battle of Chemin de Dames, Verdun, France
* conveyor belt’ flow from first aid to the most
sophisticated care level..

49
Establishing a Mass Casualty Management System

Victim Flow : “Conveyor Belt” Management Diagram

Triage Treatment
3-T
Triage Evacuation
Tag
Treat

and

Transfer

Impact Collecting
AMP TRANSFER
Zone Point

HOSPITAL

50

Victims Flow Transport Resource Flow


Establishing a Mass Casualty Management System

Victim Flow
- Ambulance Traffic Control

Radio Links:
*Transport Officer at AMP
*Hospital Admission / ER Department
*Command Post
*Ambulance Headquarters

Responsibility of Ambulance Driver


*takes order from the Transport Officer

51
Establishing a Mass Casualty Management System

Victim Flow
Road Control:
Police Officers ----- crowd and traffic control

 Evacuation of Non-Acute Victims


- use available mass transport
- as much as possible, to primary care centre

52
Establishing a Mass Casualty Management System

Field Organization Checklist


 Situation Assessment
 Report to Central Level
 Work Areas Pre-identification
 Safety
 Primary Area: Impact Zone
 Secondary Area Units: CP/AMP/EVAC/TRANSFER
 Radio Communications
 Crowd & Traffic Control
 Search and Rescue
 Triage & Stabilization
 Controlled Evacuation

53
Fallacy

“IT CAN’T HAPPEN


TO US”

54
Incident Command System
Performance Objectives
 Discuss the advantages of using the
Incident Command System
 Discuss the two types of command
 Discuss the Incident Command
Process
 Discuss Incident Priorities

57
Performance Objectives
 Discuss the components of the
Incident Command System
 Discuss the Incident Command
System organization
 Discuss the use of the Incident
Command checklist

58
Question 1

HOW WILL YOU DIFFERENTIATE A SINGLE


COMMAND FROM A UNIFIED COMMAND ?
Question 2

WHAT IS THE ROLE OF THE INCIDENT


COMMANDER ?
Question 3

WHEN DO YOU TRANSFER COMMAND ?


Incident Command System
 Developed in the 1970’s during the
California wildfires
 Business management practices of planning,
directing, organizing, coordinating,
delegating, communicating and evaluating

62
Incident Command System
 Framework necessary to manage
resources, personnel and equipment
 Designed to be flexible and can be used in
large or small incidents
 Creates a safe environment for all involved

63
Benefits of Incident Command
 Common terminology
 Position titles and Chain of
Command for decision making
 Responder accountability

64
Basic Command Types

There are two types of


command:
 Single Command

 Unified Command

65
Single Command
 Based on first arriving emergency
units.
 Initial Incident Commander begins
assessment of incident
 Rescue, Triage, Treatment,
Transport

66
Basic Command Structure
Single Command

IN C ID E N T
COMMANDER

RESCUE/ TR IA G E TR E A TM E N T TR A N S P O R T
E X TR IC A TIO N

67
Unified Command
 Incidents that involve jurisdictions or
agencies involved in the decision
making and planning process
 Ensures plan is communicated and
supported by all resources assembled

68
INCIDENT CO M M AND SY ST EM
INC ID E NT
COM M AND

S A F E T Y O F F IC ER L IA ISO N OF F ICE R

PU BL IC IN F OR M A T ION
OF F ICE R

OP ER A T ION S OF F ICE R PL A NN ING OF F IC E R L OG IS T ICS OF FIC ER AD M INIS TRATIVE O F F ICE R


F IE L D M ED IC AL C O M M A ND ER

STAG IN G O F F IC E R M ED IC AL G R O UP TRAN S P O RT G RO U P R E SO U RC E S S ER VIC E S U PP O RT TIM E


S UP E RVIS O R S UP ER VIS O R

S ITU ATIO N PR O CU R E M EN T
TRE ATM E N T TE AM TR IAG E TEAM G R O U N D AMB ULANC E CO M MU N ICATIO N S SU PP LY
LE AD E R LE AD ER
D O CU M E N TATIO N C O M PE NS ATIO N
AIR AM BU LAN CE M E D IC AL F AC ILITIE S
TR E ATM EN T ME MB ER S TRIAG E ME M B ER S
IMM ED IATE DE M O BILIZATIO N CO S T
FOOD G RO U N D S U P PO R T
TR E ATM EN T ME MB ER S MO R G U E MAN AG ER
D ELAYE D

TR E ATM EN T ME MB ER S
M IN O R

69
Overview of Incident Command
Process
Process is based on:
 Size up

 Setting Incident Priorities

 Predicting incident course and harm

 Strategic goals and tactical objectives

70
Size Up
 Rapid mental evaluation of factors
influencing an incident
 Must continue throughout incident
with ongoing evaluation
 Incident situation, incident cause
and incident status

71
Incident Situation
May be one or combination of:
 Biological

 Nuclear

 Fire

 Chemical

 Explosion or natural event

 Natural disaster with MCI

72
Incident Cause

 Incident Cause is important


because additional or specialized
resources may be needed
 The Incident Commander must
determine if the incident was
accidental or intentional

73
Incident Status

Is the incident:
 In a somewhat controlled state

or
 Does it remain uncontrolled

74
Setting Incident Priorities
 After size up of the incident a
course of action is determined
 High priority is life safety for the
public and responders
 Incident stabilization
 Protection of critical systems

75
Estimating Potential Incident Course
and Harm

 Responder is making a prediction


on what will likely occur during the
incident
 Based on available information
 Responder’s experience

76
Strategic Goals

 Broad general statements of desired


outcome of the incident
 Example:

mass casualty overturned school bus


- extrication, triage, treatment,
transport

77
Incident Command System

Organization

 Comprised of two major categories


which assist in organizing functions
into an effective design:
- Command Staff
- General Staff

78
Command Staff

Consists of the :
 Incident Commander

 Safety Officer

 Liaison Officer

 Public Information Officer

79
Incident Commander
IN C ID E N T
COMMANDER

80
Incident Commander
 First person on the scene with
communications capability
 Remains in command until
transferred or incident is
terminated
 Complete authority and
responsibility

81
Incident Commander

 Must assume and announce


command, rapidly evaluate
incident, identify resources on
hand, request additional
resources and establish
incident action plan

82
Incident Commander

 Fill command staff and


functional areas
 Must approve all information
releases to the media

83
Transfer of Command

 Based on the initial responders


experience and comfort level
 Higher ranking officer does not
need to assume command
 Transfer procedures should be
predetermined
84
Transfer Of Command

 Detailed briefing is required


 Face to Face is best method
 Include: current status, strategies
and tactics employed, progress,
safety, accountability and
resources assigned or needed

85
General Staff

Consists of:
 Operations (includes

staging)
 Planning

 Logistics

 Administrative/Finance

86
Operations Section

IN C ID E N T
COMMANDER

O P E R A TIO N S

87
Operations Section

 Operations officer functions under


direction of the Incident Commander
 Deploys tactics to control and
resolve the incident
 Responsible for execution of the
incident action plan

88
Operations Section
 Makes recommendations for changes
to plan based on incident status
 Oversees and is in direct contact
with the staging manager
 Task supervisors report to
Operations not Incident Command

89
Planning Section

IN C ID E N T
COMMANDER

O P E R A TIO N S P L A N N IN G

90
Planning Section
 Responsible for collection,
evaluation, distribution and use of
information about the incident
 Forecast and develop plans to
contain and resolve incident
 Communicates with logistics
section

91
Logistics Section

IN C ID E N T
COMMAND

O P E R A TIO N S P L A N N IN G L O G IS TIC S

92
Logistics Section
 Responsible for providing facilities,
services and materials in support of
incident
 Includes equipment, personnel and
associated materials and tools
 Support branch and Services branch

93
Administrative / Finance Section

IN C ID E N T
COMMANDER

O P E R A TIO N S P L A N N IN G L O G IS TIC S A D M IN IS TR A TIV E


F IN A N C E

94
Administrative/Finance Section
 Generally not located at incident
site
 Responsible for financial,
administrative and cost analysis
 Divided into four units: time,
procurement, compensation/claims
and cost
95
Summary
 Incident Command created to deal
with any incident in an organized
manner
 Manages resources, personnel and
equipment to mitigate the incident
 Builds from first responder

96
Summary

 Expandable to manage hundreds


 Implementation is critical for safe
and effective operation
 Allows for multi-agency operations
and response based on incident
type

97
Thank you
98
CRITICAL INCIDENT
MANAGEMENT

99
Performance Objectives

 Discuss critical incident stages


 Discuss decision making in a
critical incident

100
Critical Incident Management
Characteristics
 Demands a coordinated response
to prevent incident from getting
worse
 This includes unresolved element
of danger such as additional bomb,
a threat to citizens and responders
or an unusual incident

101
Critical Incident Management
Characteristics
 Often random in nature and
disrupt normal life
 Terrorist organizations use
opportunity as a tool for civil
disturbance
 A mass casualty is a critical
incident
102
Mass Casualty Incident
Overview
 Produces several patients
 As few as six or as many as
several hundred
 Affects local hospitals
 Patients are greater than resources
of the initial responders

103
Preparation For Mass Casualty

 Pre-planning and training are


critical
 Establish guidelines and procedures
 Early implementation of Incident
Command
 First five minutes will determine
next five hours

104
Functional Systems Approach
 Three levels of function: strategic,
tactical and task (operation)
 Management is strategic
 Team leaders are tactical
 Resources not involved in
supervision are task

105
Critical Incident Stages

They consist of:


 Initial Response

 Incident Control using the Six Step

Response
 Recovery Stage

106
Initial Response Stage

 Ability to establish command and


control
 Faced with confusion and panic
 Crucial to develop a team and
place a plan in action

107
Initial Response Objectives

 Protecting citizens and rescue of


victims
 Limit incident growth
 Protect arriving responders
 Identify ingress and egress routes

108
Initial Response Objectives
As soon as possible:
 Gain control of the scene

 Restore order

 Prevent target opportunities

109
Incident Control Using The
Six-Step Response
The Six-Step response is based on
the Incident Command System. It
includes: Assume Command,
Situation Assessment, Identify and
Set Perimeters, establish
Command Post, assign Safety
Officer and establish Staging Area
and assign a Staging Officer
110
# 1 – Assume Command

 Must advise incoming responders


of incident location
 Secure tactical frequency
 Request supervisory support

111
# 2 – Situation Assessment
 Size up of the incident that
includes the type of threat,
approximate number of injured,
size of threatened area and
possibility of secondary event.

112
# 2 – Situation Assessment

In simple terms the assessment


should describe:
 What do you have

 What are you doing

 What do you need

113
# 3 - Identify and Set Perimeters

 Divide the incident into


manageable divisions
(geographical areas)
 Allows command to provide
resources where they are needed

114
# 3 - Identify and Set Perimeters

 Critical incidents have three


standard perimeters. All
perimeters are divisions
 Expand perimeters based on
weather
 Perimeters are the hot zone, inner
perimeter and outer perimeter
115
The Hot Zone

 Area in which the incident has


occurred
 May be a street corner or spread
over a large area
 Secured by placing responders in
positions of controlling ingress and
egress

116
Inner Perimeter

 Protects responders in hot zone


 Uniformed personnel only
 Used as decontamination area,
treatment area and evacuation
area for walking wounded

117
Outer Perimeter

 Provides last line of defense from


internal incident acceleration
 Provides first line of defense from
external acceleration
 Secure area for command post,
resources and control of the media

118
Perimeter Placement Illustration

119
# 4 – Establish Command Post

 Typically begins at first responders


vehicle
 Incident dynamics will require
Incident Commander to shift to a
fixed command post
 Must be away from hot zone

120
# 4 – Establish Command Post
 The command post will ensure
support for field personnel, create a
controlled environment and improve
communications

121
# 5 - Establish Safety Officer

 Should be filled as soon as


possible
 Officer selected on operational
experience and ability to recognize
acceptable and unacceptable risk
 Operations can be stopped or
modified

122
# 6 - Establish Staging Area

 Effective tool in correct and safe


deployment of resources
 Staging Supervisor must track,
rotate and relieve resources as
appropriate
 Area established within inner or
outer perimeter. Avoid congestion

123
Inter Agency Planning

 Failure to include all agencies


during planning process may
compromise responders
 Identify and establish liaisons with
all agencies and coordinate tactical
operations

124
Secondary Incidents

 May be more destructive and


damaging than initial incident
 World Trade Center crashes were
primary incident with collapse of
the towers as secondary incidents
claiming more lives

125
Recovery Stage

 Begun when aggressive threats of


incident are neutralized
 Incident is not over when last
patient is transported
 Recovery must be managed
aggressively

126
Recovery Stage

 Planning Section of incident


command is responsible for initial
recovery
 Typically the longest and most
poorly managed part of the
incident
 May require months to years
127
Goals in the Recovery Stage

 Most important goal is document


collection
 Information can assist in Post
Incident Analysis, cost recovery
and tracking responder injuries or
deaths

128
Goals in the Recovery Stage

 Provide critical incident stress


management for responders
 Collect and properly dispose of
used medical supplies and
biohazard waste from the incident

129
Post Incident Analysis
Critical for operational review.
Benefits include:
 Operational performance

 Organizational needs

 Procedure modification

 Additional training

130
Summary

 Critical Incident Management can


place a heavy burden on
responders
 Requires a coordinated response
from all agencies involved
 Mass casualty incident is a critical
incident, terrorist related or not

131
Summary

 Identifying critical stages will give


the responder a better chance of
dealing with the incident
 Six – Step response is a tool for
incident management
 Humanitarian Assistance

132
133
9-11-01
TRIAGE

135
QUESTION 1

What is the meaning of Triage ?


What is the basis of triage ?
QUESTION 2

Do you always use Triaging ?


Give conditions.
QUESTION 3

In the MCMS, how many times do you triage


and where ?
Description
This lesson provides participants with
methods of prioritizing care delivery in
mass casualty situations. The decision-
making process is explored with the goal
being the maximum positive effect for the
greatest number of patients.

2
Objectives

 Describe the basic concepts of sorting and


allocating treatment to patients in a triage
situation
 Demonstrate the decision-making process
in determining priority of care

3
What is Triage ?
 French word meaning to “Sort”
 Utilized to identify treatment priorities
 Process by which a decision is made on which victim
receives treatment and which does not
 Four basic priorities of patient treatment and transport

141
Priorities
Highest Priority
• Patients that require immediate care and transportation
• Patients receive treatment at the scene for life
threatening injuries
• First to be sent to available medical facilities

142
Priorities

Intermediate Priority

 Patient treatment and transport


can be delayed

143
Priorities

Delayed or Low Priority


 Referred to as “walking wounded”

 Injuries require medical care at

some point
 Treatment and transport can be

delayed
 Monitor patients and reassess

144
Priorities
Lowest Priority
 Patients have either died or are near death

 If still alive they have suffered severe or

serious injuries with little chance of survival


 When resources are limited, patients must be

ignored

145
Initial Triage Officer

 Must size up situation


 Ensure safe approach and scene survey
 Activate additional resources
 Number of victims
 Size of the incident
 Better off requesting more equipment and
personnel than not enough

146
Simple Triage and Rapid Transport System

This system focuses on three areas :


1. Respirations
2. Pulse Rate and Quality
3. Mental Status

147
Simple Triage and Rapid Transport System

System requires first responders to have


tags, ribbons or tape in four colors

• Priority One (Highest Priority )



Red – Immediate care : Life
threatening injuries

148
Simple Triage and Rapid Transport System

• Priority Two (Intermediate Priority)


 Yellow – Urgent care: delay treatment and
transport up to one hour
 Priority Three (Delayed or Low Priority)
 Green – Walking wounded: delay treatment
and transport up to three hours

149
Simple Triage and Rapid Transport System

 Priority Four (Lowest Priority)


 Black – No care required: patient is dead or
near death
 Hardest priority to deal with emotionally

 Necessary for others to survive

150
Simple Triage and Rapid Transport System

 First Step is to make an announcement


for all people able to get up and walk to
specific area
 Allows responder to focus on injured
 People who successfully move should be
tagged “Green”
 Tell people to look out for each other
and notify responders of any significant
changes
151
Simple Triage and Rapid Transport System

 Second step is to conduct an orderly survey


of remaining victims
 Decide how to move through area
 Perform quick assessment on each person
and label or tag
 No more than 10 seconds per patient

152
Simple Triage and Rapid Transport System

 Correct life threatening : airway or breathing


problem and profuse bleeding
 The objective is to: locate, identify and tag
priority one patients who require immediate
care and transportation

153
Patient Assessment
Respiration
Assess breathing rate
• Greater than 30 per minute, patient is
priority one and tagged red
• Less than 30 per minute, move on to
assessing pulse and mental status

154
Patient Assessment
 Not Breathing
• Quickly make sure mouth is clear
• Open airway with head tilt method
• During mass casualty incident, cervical spine
immobilization may not be able to be done

155
Patient Assessment

 Open patients airway and position so it


remains open
 If patient does not start to breath with
simple airway maneuvers, tag priority four -
black

156
Patient Assessment
 Pulse Rate and Quality
• Check radial pulse
• No more than 5 second check
• Pulse is weak or irregular - Red Tag Priority One

157
Patient Assessment
 Pulse Rate And Quality
• If pulse is strong, move on to assess mental
status
• If there is NO pulse, black tag priority four

158
Patient Assessment
 Mental Status
• Breathing and pulse should have already been
checked
• Have patient respond to simple commands such as
“open your eyes” or “squeeze my hand”

159
Patient Assessment
 Mental Status
• If patient can perform this function, is breathing
and has a pulse, yellow tag priority two
• If patient is unresponsive and cannot follow simple
commands, red tag priority one

160
all walking wounded START TRIAGE

MINOR
RESPIRATION

YES NO
Position Airway

over under
YES NO
30/min 30/min
IMMEDIATE DECEASED
IMMEDIATE

PERFUSION
Respirations 30/min
Radial Pulse Present
Radial Pulse Absent Perfusion 2 secs
Capillary Refill Mental Status can do
Over Under
2 2
Secs Secs

Control MENTAL STATUS


Bleeding

IMMEDIATE
Can’t Follow Can Follow
Simple Commands Simple Commands

IMMEDIATE DELAYED
THANK YOU

162

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