1 Mass Casualty Management System

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
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
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
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
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
Response Categories of Mass Casualties

 Hazardous materials incidents
 Civil disturbances
 Natural disasters
 Major fires
 Terrorist attacks
10
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
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
Any event resulting in a number of victims

large enough to disrupt the normal course of
emergency and health care services
14
Casualty Management
• Management of victim of a mass casualty

event
• Objective is to minimize loss of life and
disabilities
15
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
Different Approaches to MCI
1. “Scoop and Run”

2. Classical Approach
3. Mass Casualty Management System
17
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
Classical Approach
• First responders are trained (basic triage

and field care)
• Disregard the receiving hospitals from the
field
• Quickly result to chaos
19
Mass Casualty Management Approach
• Most sophisticated approach includes pre-

established procedures for:
a. resource mobilization
b. field management
c. hospital reception
20
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
Problems in Developing MCM

• Limited human resources
• limited material resources
– facility
– transport
– communication
• Poor communication
– topography
– isolation
• Political 22
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
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
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
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
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
Initial Assessment
 Precise location of the event
 Time & type of the event
 Estimated number of casualties
 Added potential risk
 Exposed population
 Resources needed
28
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
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
Safety
• Personnel: fire services; specialized units hazardous

materials & explosives (bio-nuclear
and radioactive materials) experts, etc.,
airport manager, chemical plant expert
31
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
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
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
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
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
Management of Victims
• Field Care
- Pre-established capabilities / inventory: pre-
planning
- Integrated community plan: practiced w/ policy
support
- The “Golden Hour” Principle
37
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
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
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
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
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
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
AMP
NON-ACUTE
TRIAGE Black Green

NON-ACUTE
C
evacuation
P
ACUTE
Red Yellow
ACUTE
C P– Collecting Point
44
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
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
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
 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
 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
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

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
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
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
 Discuss the two types of command
 Discuss the Incident Command
Process
 Discuss Incident Priorities
57
 Discuss the components of the
 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 ?

 Developed in the 1970’s during the
California wildfires
 Business management practices of planning,
directing, organizing, coordinating,
delegating, communicating and evaluating
62
 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
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
 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
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
System requires first responders to have

tags, ribbons or tape in four colors
• Priority One (Highest Priority )


Red – Immediate care : Life
threatening injuries
148
• 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
 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
 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
 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
 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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MASS CASUALTY

ROMEO ALMAZAN BITUIN, MD, MHA

I. Overview of Mass Casualty

Define Mass Casualty

What is a Mass Casualty Management

3. New York 911 Tragedy, 2001

WORLD Since 1900 %

Top 5 hazards by mass accidents 32.8

Top 5 hazards by mass accidents 37.2

Mass Casualty Incident

 Produces several patients

Preparation for Mass Casualty

 Pre-planning and training are critical

Response Categories for Mass Casualties

Response Categories of Mass Casualties

Problems in Mass Casualty Incidents

Most common being:

 Location of the Command Post

 Lack of communication between agencies

leading to conflicting priorities and orders

Problems in Mass Casualty Incidents

Mass Casualty Incident

Any event resulting in a number of victims

• Management of victim of a mass casualty

Mass Casualty Management System

The group of Units, Organizations, Sectors which work

Different Approaches to MCI

1. “Scoop and Run”

Scoop and Run

• First responders are trained (basic triage

Mass Casualty Management Approach

• Most sophisticated approach includes pre-

Mass Casualty Management Approach

Problems in Developing MCM

Activities at various levels of responses:

Alerting Process Search and Rescue

Pre-identification of Field Care

Safety/ Security Evacuation

Command Post (EMC) Emergency

Pre-Hospital Organization Hospital Organization

Definition: Sequence of activities implemented to

Pre-Identification of Field Areas

• Personnel: fire services; specialized units hazardous

Command Post ( CP / or ICP)

Recent progress in pre-hospital

Establish AMP with specially skilled /trained ----

“ Don’t transfer chaos in the scene,

Basis: urgency (victim’s status)

Advance Medical Post (AMP)

Advance Medical Post (AMP)

TRIAGE Black Green

PRIORITY III PRIORITY II PRIORITY I

Field Management Plan: Diagram

2. Multiple Reception Facilities

 Preparation for Transport

Victim Flow : “Conveyor Belt” Management Diagram

Victims Flow Transport Resource Flow

Responsibility of Ambulance Driver

 Evacuation of Non-Acute Victims

Field Organization Checklist

“IT CAN’T HAPPEN

HOW WILL YOU DIFFERENTIATE A SINGLE

WHAT IS THE ROLE OF THE INCIDENT