ERIE COUNTY MASS CASUALTY INCIDENT PLAN

JULY 2018

Table of Contents

Preface 1 Acknowledgement 2

Introduction 3Purpose 3

Situation and Assumptions 4-5MCI Overview 6-7Concept of Operations 8

Incident Management Types 9Mass Casualty Levels 10Incident Management 11-12Direction, Control, and Coordination 13Communication 13-14Notification 14Implementation 15Documentation 16Demobilization 16

Other Things to Consider 17Life Safety 17Responder Health and Safety 17-18Incident Scene Security 18-19Staging 19Rehabilitation Area 19-20Family Assistance Center 21Survivors 21Deceased Persons 22

Organizational Positions and Responsibilities 22First Arriving Unit (Officer) 22First Arriving Unit (Driver) 22Incident Commander 22Safety Officer 23Public Information Officer 23Liaison Officer 23Operations Section Chief 23Staging Officer 23

EMS Team Leader 24Treatment Team Leader 24Triage Team Leader 24

Organizational Positions and Responsibilities (continued) 24Transportation Team Leader 24Morgue Team Leader 24

Triage Unit 25-2730-2-Can Do 27-28Triage Tag Instructions 29-31Treatment of Casualties 32Transportation 33-34MCI with Hazardous Materials 35Hazard Control Zones 36Hazardous Materials Key Points/Decontamination 37-39

Rehab Unit 40Responsibilities 40Establishing the Rehabilitation Sector 40-42Rehab Sector Operational Guidelines 43Medical Evaluation in the Rehab Sector 44

Support Services 45Chief Elected Officials 45Coroner's Office 45Emergency Management Coordinator 45EMS 45Fire Services 45Law Enforcement 46Hazardous Materials Team 46Regional EMS Council 46Public Works 46American Red Cross 46Department of Human Services 46Division of Federal, State, and Local Responsibilities 47

MCI Quality Improvement Process 48MCI Quality Improvement Sheet 49Terms and Definitions 50-54ICS Forms 55-56

PREFACE

The Erie County Department of Public Safety Advisory Board (ECDOPS) recognized the need for a standard approach to incidents involving multiple patients that require coordination between more than one pre-hospital agency and more than one hospital. The EMS sub-committee was tasked with oversight on development of a Mass Casualty plan.

ECDOPS goal is to ensure that the victims of mass casualty incidents are transported as quickly as possible to hospitals that are prepared to provide definitive care. To achieve this goal a standard approach was developed;

· First it was agreed upon that a standard incident management system was to be used by all responding agencies.

· Second, a pre-plan for anticipated resources was needed· Third, standard terminology and was needed for all responders· Fourth, the plan needed to be flexible to allow for modifications in extenuating circumstances· Fifth, the plan needed to be easily available to all responders

The EMS sub-committee has moved to achieve these goals by designing a 3-volume plan. Each volume builds upon the first, utilizing common terminology and coloring. The expectation is for all responders to be intimately familiar with this plan, and to utilize its parts to avoid common mistakes at the scene of a mass casualty.

This plan was developed with input from various sources with direct design/oversight by the following:

Bill Hagerty, Executive Director - Emergycare - EMS Sub-Committee Chair

Jerry Smith, Paramedic - Millcreek Paramedic Service - EMS Subcommittee Vice Chair

Steph Fox, EMT - Stancliff Hose Company - EMS Subcommittee Secretary

William McClincy, Director - EMMCO West, Inc.

Caleb Dixon, Deputy Emergency Manager- Millcreek Township OEM

Cindi Dahlkemper, BSN - Brookside VFD

Todd Steele, Director of Operations - Emergycare

Jim Pyle, Chief - Mckean Hose Company

Lou DePalma, EMT-Cranesville VFD

Dale Robinson- Erie County Dept. of Public Safety

Joe Cree, Operations Manager- West County Paramedic Association

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Acknowledgement

The Erie County Mass Casualty Incident Plan is designed to comply with all applicable state and county laws and regulations and provides the policies and procedures to be followed in dealing with a mass casualty incident resulting from natural or man-made disasters.

Acknowledgement of this plan is indicated by the following signatures:

Organization Signatory Date

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Introduction

Incidents resulting in a large number of casualties pose a variety of problems for the emergency services system and the community as a whole. A method should exist for directing the response to the incident by emergency services personnel, government agencies, and by the private sector. Adequate personnel and supplies should be available to carry out fire suppression, rescue activities, patient care and transportation functions. However, these resources should be obtained in a manner that minimizes reduction of emergency services to the surrounding area.

Resources available at the scene for patient treatment and transport should be allocated according to a system of priorities based upon need. Resource allocation is necessary due to the limitations on time and availability of trained personnel, equipment, and supplies that exist during multiple casualty situations. Since patients cannot all be treated immediately, patient care operations should be organized to provide optimum care as quickly as possible, according to need.

The Erie County Mass Casualty Incident (MCI) Plan has been developed as an operations guide for the management of field medical operations. This plan is based on the Incident Command System (ICS) and the components may be expanded and contracted as necessary. The plan may be initiated any time that the resources available at the incident are insufficient to meet the needs of the operation or structured organization is required.

These operating guidelines have been developed for use as a framework by fire departments, EMS agencies, dispatch centers, hospitals, non-government organizations and other governmental agencies that may assist or support a mass casualty incident.

This plan is not meant to replace traditional training in Incident Command, Mass Casualty, Hazardous Materials or any other applicable disciplines. Rather it is designed to establish a framework to which responders should base their agency response and on-scene operations. This plan has been divided into 3 volumes to better prepare responders for a mass casualty event. Some information is contained in all three volumes.

Volume I — Mass Casualty Incident Preparations Volume II — Mass Casualty Incident Operations Volume III — Mass Casualty Incident Field Guide

Purpose

This plan is intended to be activated and utilized for actual/potential mass casualty incidents. It should be implemented whenever a situation occurs that requires resources beyond the normal day to day operations and mutual aid and overwhelms the resources of an EMS Agency. This MCI plan provides for uniform guideline for handling mass casualty incidents within the structure of the Incident Command System (ICS). It is also meant to serve as an informational guide for future planning, training, exercises and equipment procurement.

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Situation and Assumptions

Situation

1. Northwestern Pennsylvania is susceptible to a number of natural and man-made disasters. According to the recent Hazard and Vulnerability Analysis (HVA), the disasters with the highest probability of occurrence and those that could cause the most significant impact include: Tornados Winter Storms Flooding Transportation Accident (airplane, railroad, interstate) Fire/Explosion Energy Emergency Hazardous Materials Incidents Criminal Activity

2. A WMD (Weapons of Mass Destruction) event, a natural or man-made disaster or a disease outbreak are three incidents which may trigger the MCI Plan and may overwhelm existing medical resources.

a) An act of terrorism produces a crime scene and results in mass casualties. This act may or may not have a WMD component.

b) An epidemic, or covert WMD event, may delay the onset of symptoms or have characteristics that mimic day-to-day illnesses. Discovery will require medical professionals to detect similar patterns of symptoms.

c) A natural (or man-made) occurring or threatened disaster may cause the immediate activation of the MCI Plan.

Assumptions

1. An MCI can occur at any time, day or night.

2. The incident is limited in scope of area, number of casualties and time required for control.

3. EMS services, nationwide, are on the verge of a crisis; lack of, or low reimbursement by insurance carriers, lack of personnel, high employee turn-over and ever increasing regulations and expectations impact the day-to-day operations more and more. A significant event will tax the system very quickly.

4. Mainly due to a fragmented communications infrastructure, information relating to Situational Awareness will be lacking. As consolidation of dispatch centers occur, Situational Awareness should improve.

5. The area hospitals will be notified via the MedCom system and Knowledge Center that MCI has occurred.

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6. Local hospitals will each assign a Liaison to the County MACC or communicate and coordinate via the Knowledge Center – Healthcare Information Management system.

7. All EMS agencies will use the DMS All Risk Triage Tag (DMS-05764)

8. All EMS providers will use the S.T.A.R.T (Simple Triage and Rapid Treatment) triage system.

9. There should be enough equipment and supplies within each county to meet the needs of an MCI. The challenge will be in identifying the equipment and supplies needed at the scene, communicating that information to the EOC, and having the logistical support network to quickly fulfill the needs in a timely manner.

10. Upon determination that resource requests exceed/may exceed locally available resources, the local jurisdictional EOC will make request to the County MACC. If needed the county will request assistance from the NW PA ERG or other Regional “Task Forces” through the PA Intra-State Mutual Aid Agreement (PIMAS). These resources may take 24-to 48 hours to arrive. Resources may also be requested from PEMA, but may not be available for a minimum of 72 hours.

11. Certain groups, such as non-English speaking people, elderly, mobility impaired, children, and those in the lower socioeconomic means, may be impacted greater than people outside of these groups.

12. Alternate transportation may be needed to transport those with minor injuries.

13. Relatives/friends will seek information regarding the status of their relatives/friend including whether they were injured and what hospital they are at, often arriving at the scene seeking this information.

14. The event may require a Joint Information Center (JIC) to be established to ensure accuracy of information.

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MCI Overview

Early organization of an MCI incident management structure is crucial to obtain the desired outcome. This early organization is dependent upon the actions of first arriving units, which may include career and volunteer EMS, fire and law enforcement agencies. It is critical that a Unified Command be established as quickly as possible. As units arrive on the scene, personnel from these varied groups assume or are assigned positions with specific responsibilities and tasks, based on the best use of available personnel resources.

However, although each person’s tasks are specific these individuals do not operated in a void but must interact with other team members to accomplish the joint goals of rapid triage, treatment, and transportation. For this reason, it is important to understand the overall progression of an MCI and the contributions of each team member.

The following outline summarizes the actions that occur during an MCI. This outline is of necessity, vague. It is intended to be used as framework against which the more detailed tasks of each team member can be compared.

1. Pre-Arrivala. MCI occursb. Dispatch is notified of the incidentc. Dispatch sends appropriate personnel/equipment, advising of potential MCId. Responding units notify dispatch en-route of possible hazards, alternate response routes, etc.

2. Arrivala. First arriving unit confirms/denies actual MCIb. First arriving unit establishes command, notifies dispatch of size up, including approximate

number/category of patients, wind direction, incident location and requests additional resources as needed.

c. Dispatch activates MCI plan after receiving “ground truth” report of MCI d. First available personnel begin triage using START systeme. Additional units arrivef. MCI positions are established per ICS standardsg. Dispatch is advised of the exact number of victims and their categories.

3. General Tasksa. Additional assistance is requested as neededb. Staging area, manpower pool, and equipment pool are establishedc. Media area is establishedd. Scene is securede. Decontamination area is establishedf. Treatment area is establishedg. Transportation area is established. Clear routes of ingress and egress ambulances with help from law

enforcement and/or fire police4. Patient Flow

a. Patients are properly tagged prior to movementb. Patients are prioritized to undergo decontamination procedures if needed by the Hazmat team.

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c. Patients are directed to appropriate treatment area.i. MINOR (green tag)

ii. DELAYED (yellow tag)iii. IMMEDIATE (red tag)iv. MORGUE (black tag)

d. Personnel treat patients and document injuries/treatmente. Patients are moved to the load zonef. Transportation Group Supervisor receives hospital capabilities report from PSAPg. Transportation Group Supervisor directs patient(s) transport, making sure all patients are

transported to the assigned area hospital(s)5. De-escalation

a. Transportation of the deceased is the responsibility of the County Coroner. EMS agencies may be requested to assist with this process

b. Paperwork is completed and forwarded to the Incident Commanderc. Mass Fatality Plan is activated if neededd. Demobilization process is completed

6. Quality Improvementa. An after action review/critique should typically be held within 5 days after occurrenceb. County EMA in conjunction with the Authority Having Jurisdiction (AHJ) may coordinate the

process or may delegate the process to the Regional EMS Councilc. Agencies requesting a QI review should contact the AHJ. Should a participating hospital desire a

review they should contact the County EMAd. The QI process may be informal or formal depending on the nature of the reviewe. All participating agencies are invited to send a representative, the coordinator may elect to request

specific personnel be in attendance.

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Concept of Operations

1. It is recognized in the Commonwealth of Pennsylvania that the lowest level of government shall have incident authority. Each municipality should appoint an overall incident commander for their area. It is also recognized that the local municipality may depend on other local, state or federal assistance during a mass casualty event. In these situations a unified command approach between all agencies should be used.

2. Care should be taken to limit disturbance of the scene to those activities critical to the removal of living victims for transport to medical facilities. Once viable patients are removed, no action should be taken on remains or personal effects until the Coroner's arrival.

3. Depending on the nature of the incident, the initial IC will likely be a law enforcement, EMS or fire official. Command should transition to Unified Command upon the arrival of other agencies as appropriate to the situation. The Coroner may assume command of the incident once all lifesaving activities have been accomplished, survivors removed, and on-site hazards stabilized. More likely, command will be maintained by the initial IC or transferred to a more appropriate agency or jurisdiction; and the coroner's functions on scene will be accomplished through designation as a Branch or Group.

4. Based on the scope of the situation, a local emergency may be declared. This would enact the Local Emergency Operation Plans, and other emergency measures into effect, thus enhancing the response and recovery effort. A request for state and federal resources shall go through the local municipal EOC. If the needed resources cannot be found locally the county will seek to fill through regional task forces.

5. Depending on the scope of the incident and the length of time necessary to complete emergency response and recovery operations, a rest/recovery area for response personnel should be established. This area should be separate from the staging area and incident scene when possible.

6. In a disaster situation, identification of deceased is a critical issue; accordingly, remains must be treated with respect and dignity. Upon notification of the number of fatalities involved, the County Coroner's Office will determine if it will be necessary to initiate procedures to establish a temporary facility or activate the mass fatality plan.

7. Although all first responders are mandated to comply with NIMS and implement ICS, the transformation from ICS into a Unified Command will always remain challenging. EMS Commanders should take a leadership role in helping to transition from ICS into a Unified Command where they would become the "Medical Branch Director".

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Incident Management Types

Incidents may be typed in order to make decisions about resource requirements. Incident types are based on the following five levels of complexity. These levels help to establish the type of incident

management/su000rt team is needed. (Source: U.S. Fire Administration)

TYPE 5

••••

•

The incident can be handled with one or two single resources with up to 6 personnel.Command and General Staff positions (other and the IC) are not activated.No written Incident Action Plan (IAP) is required.The incident is contained within the first operational period and often within an hour to a few hours after resources arrive on scene.Examples include a vehicle fire, an injured person, or a police traffic stop.

• Command staff and general staff functions are activated only if needed. • Several resources are required to mitigate the incident. • The incident is usually limited to one operational period in the control phase. • The agency administrator may have briefings, and ensure the complexity analysis and

delegations of authority are updated.TYPE 4 • No written IAP is required but a documented operational briefing will be completed for all

incoming resources. • The role of the agency administrator includes operational plans including objectives and priorities. • Examples include a Level 1 or 2 MCI, small structural collapse, small search operations • When capabilities exceed initial attack, the appropriate ICS positions should be added to match

the complexity of the incident. • Some or all of the Command and General Staff positions may be activated, as well as Division/Group Supervisor and/or Unit Leader level positions. • A Type 3 Incident Management Team (I MT) or incident command organization manages initial

TYPE 3 action incidents with a significant number of resources, an extended attack incident until containment/control is achieved, or an expanding incident until transition to a Type 1 or 2 team.

• The incident may extend into multiple operational periods. • A written IAP may be required for each operational period. • Examples include a Level 3 MCI, airliner crash, large building collapse • This type of incident extends beyond the capabilities for local control and is expected to go into multiple

operational periods. A Type 2 incident may require the response of resources out of area, including regional and/or national resources, to effectively manage the operations, command, and general staffing.

• Most or all of the Command and General Staff positions are filled. • A written IAP is required for each operational period.

TYPE 2 • Many of the functional units are needed and staffed. • Operations personnel normally do not exceed 200 per operational period and total incident

personnel do not exceed 500 (guidelines only). • The agency administrator is responsible for the incident complexity analysis, agency

administrator briefings, and the written delegation of authority. • Examples include a Level 4 or 5 MCI, large community evacuation • This type of incident is the most complex, requiring national resources to safely and

effectively manage and operate. • All Command and General Staff positions are activated. • Operations personnel often exceed 500 per operational period and total personnel will

usually exceed 1,000. • Branches need to be established.

TYPE 1 • The agency administrator will have briefings, and ensure that they complexity analysis and delegation of authority are updated.

• Use of resource advisors at the incident base is recommended. • There is a high impact on the local jurisdiction, requiring additional staff for office administrative and support

functions. • Examples include large pandemic, large brush fire (100,000's of acres), major hurricane

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Mass Casualty LevelsTypically there should be 1 ambulance for every 2 patients needing transported.The table below is a general guide for resources that may be needed for different levels of MCI’s.

*LEVELS ARE FOR DISPATCH ONLY. FIELD PROVIDERS SHOULD REPORT ACTUAL VICTIM COUNT

Level 1 (Up to 10 patients)

Relatively Minor incident involving 3-10 surviving person. Local resources stressed for a short period of time

Level 2 (11-20 Patients)

Mass Casualty Incident involving 11-20 surviving persons. County resources stressed for an extended time.

Level 3 (21-50 Patients)

Catastrophic Casualty Incident involving 21-50 surviving persons. Regional Resources stressed for an extended period of time.

Respond To Scene 2 BLS Transportable Units2 ALS Transportable Units2 Medical Units (Fly Car)

4 BLS Transportable Units3 ALS Transportable Units2 Medic Units (Fly Car)

6 BLS Transportable Units4 ALS Transportable Units2 Medic Units (Fly Car)EMMCO West EMS Strike Team

Place on Standby

Air Medical1 BLS Transportable1 ALS Transportable

Air Medical2 BLS Transportable Units1 ALS Transportable UnitMass Transit Vehicle

2 Air medical3 BLS Transportable Units1 ALS Transportable UnitMass Transit Vehicle

Transfer Assignment

Upon Request 1 BLS Squad to 1 central station of affected area.

1 BLS Squad to 2 central stations and affected area.

**PLEASE NOTE: Fire Department response shall be dictated by local dispatch protocol

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Incident Management1. Incident Command System (ICS)

a) ICS shall be used as the basis for the command structure used at any mass casualty incident. This is in keeping with the Federal requirements of the NIMS (National Incident Management System). ICS is a management tool that provides a flexible structure for response to emergency situations. It allows local, state, federal, and private entities to be integrated under a single command structure.

b) The ICS 5 functional areas include:a. Command - overall incident managementb. Operations - manages tactical plan to accomplish incident objectivesc. Planning - gathers intelligence, formulates incident action pland. Logistics - provides service and support functione. Finance/Administration - monitors all aspects of the incident for cost effectiveness

c) These functions apply to incidents of all sizes and types, including planned events and emergencies that occur without warning.

2. Unified Command System (UC or UCS)a) When a mass casualty incident extends to multiple geographic jurisdictions or involves shared management

responsibilities with more than one agency in a single jurisdiction, a Unified Command is the most effective incident management structure. UC ensures the integration and consolidation of action plans, as well as maximizes the use of resources.

b) The UC group would include individuals designated by the authority having jurisdiction (AHJ) or by various key departments within a jurisdiction (emergency medical services, fire, police etc.). This group is responsible for developing overall objectives, strategies, a single Incident Action Plan, and joint priorities for the incident.

c) Criteria for the selection of a Unified Commander are based on factors such as:a. Greatest jurisdictional involvementb. Greatest number of resources involvedc. Statutory Authorityd. Individual Qualifications i.e., knowledge of ICS

d) The UC team assembles at a central location in order to develop their objectives and monitor the incident. The designated area should afford some privacy from distractions yet it must have communications availability.

e) The UC structure also plays an important role in managing the "span of control". It assists leadership in managing large-scale incident. This "span of control" is vital to the success of a large-scale incident.

· A manageable span of control should be kept at between 5 to 7 individuals.

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A sample of a command structure that would be employed under the UCS is shown below:

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Unified CommandEMS Police Fire

Operations

Firefighting Branch

Staging Branch

Medical Branch

Transportation Group

Treatment Group

Triage Group

Law Enforement

Public Works Branch

Planning Logistics Admin/Finance

PIO Liaison

Safety

A. Direction, Control, Coordination and Support

1. The first emergency responder on scene will take command of the incident until relieved by an appropriate authority (emergency medical services, fire, police, etc.).

2. The Incident Commander will establish an Incident Command Post (ICP) as soon as possible and ensure that the location of the ICP is disseminated to all responders. Other ICS positions and sections will be staffed as needed to maintain a manageable span of control.

3. Transition to a Unified Command System should occur early in the incident

4. Ensure that all responders are following the unity of command.

5. The Coroner will supervise/authorize the removal of those victims obviously deceased. Emergency responders will not remove personal articles from the victims or from elsewhere at the scene (even for "safe keeping") until authorized by the Coroner.

6. The EOC will be used to exercise coordination and support, to gather information and to coordinate activities of the responders during an MCI.

a. The County EMA, or their elected officials, will make the determination to activate the EOC.

B. Communication1. Interoperable communications are necessary to maintain incident information flows in appropriate timeframes

among First Responders, Law Enforcement personnel, Hospitals and Health Care Providers, Emergency Managers, Coroners, and State/Federal agencies at an MCI.

2. To ensure the widest possible interoperability communications the County PSAP will assume primary communications for all mass casualty incidents. Outlying communication centers should monitor the operational frequency to provide resources if requested, and to act as a backup in the event the County PSAP loses communication capabilities.

3. If agencies from multiple communications centers are dispatched to an MCI the County PSAP will assume the role as the primary communications center for that event. The outlying communication centers will continue their normal operations while monitoring the MCI operations frequency.

4. For extended incidents the Logistics Sections Chief or Communications Unit Leader (COML) should work to integrate Communication Technicians (COMT) and possible deployment of a Communications on Wheels (COW) unit.

5. All communication shall be made in plain language.

6. As part of the process of setting up a Command Post, the Incident Commander is also responsible for establishing, maintaining and enforcing effective uncluttered communications.

7. Communication needs should be addressed by the Logistics Section Chief.

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8. A Communications Unit Leader may be appointed to control communications. Since a representative of each agency group (EMS, Police, Fire, etc.) responding will be at the Command Post, any interagency communication (in the absence of a common frequency or talk group) will have to be relayed through Command or the Communications Unit Leader.

9. Forms of Communicationa) Face-to-Face: This is the best communications form because the participants can combine a variety of

interpersonal methods as they speak.b) Radio: Radio communications provide a remote capability when face-to-face communications are not

possible. This form of communication, however, can also lead to messages being misunderstood or not heard at all. It is critical that radio communications are short, concise and made only when necessary as not to tie up the radio frequency and block emergency traffic.

c) Knowledge Center: This internet based program is used for situational awareness, patient tracking and ICS forms. The program is monitored statewide by numerous agencies.

d) Computers / Fax: This form of communication gives the Incident Commander the ultimate information access and instant technical assistance

e) Mobile Telephones (Cellular): Provide for a direct link with fixed facilities or other mobile telephones. In times of a disaster cellular telephone systems may become overloaded and hard to utilize.

f) Standard Operating Procedures: Effective SOP's can reduce the need for verbal communications during critical moments of the operation.

10. Communications ResourcesRefer to the NWPA Regional Interoperability Communications Plan

C. Notification1. Notification of an actual mass casualty incident (MCI) will come from a "ground truth" report from a recognized responder.a) An MCI exists when the:

· Number of patients and the nature of their injuries make the normal level of stabilization and care unachievable; and/or

· The resources that can be brought to the field within primary and secondary response times is insufficient to clear the scene in 20 minutes; and/or

· Stabilization capabilities of hospitals that can be reached within 25 minutes are insufficient to handle all the patients

b) Mass casualty incidents may be categorized according to the approximate number of patients involved. The PSAP will be notified the number of patients involved. Appropriate resources will be dispatched.

2. Upon receiving the notification, the dispatch personnel will immediately contact the County PSAP (if received at outlaying call center), who will then make proper notifications.

3. Both the local and county EOC may be activated. The Emergency Management staff will report to the EOC and begin making notifications to appropriate agencies, groups and organizations (Penndot, PAFBC, DEP, PEMA, CDC...). Once the EOC is staffed the County PSAP will notify the IC/UC of its availability to respond to requests for assistance or resources.

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D. ImplementationThe following indicates the usual actions appropriate in a Mass Casualty Response:

1. The first arriving unit estimates the number of casualties including the location and type of incident. If an obvious MCI exists, the first arriving unit immediately advises their dispatcher.

a. If this notification is not made by the first arriving unit, it should be made by the first arriving supervisor or person designated to do so by local procedure.

b. It is critical that the dispatcher be clearly told that "THIS IS A MASS CASUALTY INCIDENT” this way, all components of the plan can be immediately activated.

2. After the first arriving EMS unit on scene develops a gross estimate of the number of victims and types of problems, the unit begins triage.

3. Incident Command is established and the Incident Commander designates a command post as soon as possible.

4. An EMS/Medical Branch Director or Group Leader assigns the following: a. TRIAGE UNIT LEADER b. TREATMENT UNIT LEADER c. TRANSPORT UNIT LEADER d. PATIENT TREATMENT AREA UNIT LEADER e. STAGING MANAGER

5. Law enforcement coordinates with the Incident Commander to establish and maintain the inner and outer parameter, handle traffic flow (ingress and egress), and sustain scene security. Law enforcement will also be made aware of the staging area and routing to staging

6. Under the direction of the Triage Team Leader, arriving crews begin tagging patients at the location found. Appropriate triage tags will be used and attached to the patient's left wrist or left ankle. DO NOT attach the tag to the victim's clothing.

7. Walking wounded (GREEN) are directed to a Casualty Collection Point (CCP).

8. Next arriving crews place victims on back-boards and move patients into treatment area in tag color priority (RED first, then (YELLOW).

9. Arriving EMS units report to Staging Manager. Equipment is off loaded for use in the patient treatment area. Personnel are assigned as needed.

10. Treatment Group Supervisor supervises all activity in the patient treatment area and requests additional resources as necessary through the EMS Group Leader.

11. The Transportation Group Supervisor, in cooperation with Treatment Group Supervisor, assigns transport priorities to patients.

12. Transporting EMS units will not make direct contact with receiving hospitals unless there is a dramatic degradation in a patient's condition that calls for hospital intervention.

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Documentation

Documentation is important to the successful outcome of any incident, an MCI is no different. Many people will be concerned with the proper documentation to track not only the progress of the incident, but for inclusion in subsequent investigations.

1. ICS forms - utilizing standard ICS forms are the preferred method to ensure proper documentation. The ICS structure allows for modification of the standard forms to ensure they contain the information that is needed for specific situations/agencies. Examples of the recommended forms are included in Volume II — Mass Casualty Operations as well as Volume III — Mass Casualty Field Guide.

2. Patient Care Record Keeping - Disaster Management Systems, Inc. waterproof triage tags with bar coding will be used for patient triage and documenting assessment findings and patient care. The triage tag will become part of the patient’s hospital medical record.

3. Transport Record Keeping – the Transportation Group Supervisor will document the number and type of patients (i.e., morgue, immediate, delayed, and minor) sent to each area hospital on a transportation log for each receiving facility. He or she will also consult with the hospitals to determine the capacity and capability of receiving facilities in order to avoid patient overload at any one hospital.

Demobilization1. Early in the incident, a Demobilization Plan needs to be developed to ensure resources are returned to the owning

organizations (or vendor) when they are no longer needed. The plan can be for the entire incident or a separate plan can be developed for each operational/functional area (e.g., site operations, Search and Recovery, Mortuary Services, Family Assistance Center).

2. All incident workers should attend a Critical Incident Stress Debriefing (CISD) after the incident is over.a) In addition to the end-of-shift briefings, CISD sessions should be scheduled after the incident or after a

specific function of the incident has been completed.b) Incident workers should be given a list of symptoms of Post-Traumatic Stress Disorder and contact numbers for

support services in their local area.c) Request for a Critical Incident Stress Management (CISM) team should be made using your agency

policy, or by contacting the County PSAP.

3. Agencies should ensure that their Employee Assistance Program is aware of the incident.

4. The Incident Commander should schedule a review or critique of the mass casualty incident.

5. Develop and maintain a list of the documentation requirements of all the involved agencies. The list should be used to ensure that everyone receives documentation needed for their files and reports.

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Other things to considerOperations at any large scale incident are very fluid, which makes it difficult to remember some of the tasks that we perform on a daily basis. This section is a brief reminder of some of those tasks.

Life Safety1. The safety of emergency response personnel should take precedence, especially in incidents where

hazardous materials or biohazards are involved.

2. Regardless of cause, an MCI scene should always be treated as a crime scene. The site should be maintained intact and minimally disturbed during the removal of survivors. Exceptions may be made in the case of natural disasters.

a) Stabilization and emergency medical treatment of victims is very important. Rapid and effective treatment is crucial in situations where other life safety hazards exist.

b) No property, body parts, or other items should be removed unless they are critical to the recovery of a survivor. In that case, they may be transported to the hospital with the victim. Such items need to be documented and tracked so that arrangements can made for their return to the incident scene or other designated location.

3. Once all survivors have been removed, the incident scene will be secured and access restricted to facilitate further investigation and removal of the remains.

Responder Health & SafetyCritical Incident Stress Debriefings should be made available to all personnel working the incident, including dispatchers and other off-site workers. The location of the debriefing should be adequate in size and free from distractions and interruptions. This debriefing will be neutral in nature, not an accusation critique. The intent of the debriefing is to provide stress education, reassurance, and a mechanism for ventilation of feelings.

a) Stress is a natural reaction to a mass casualty incident.

b) CISM is an organized, simple and accepted method of assisting emergency personnel to appropriately manage the psychological trauma of emergency work.

c) A Critical Incident Stress Debriefing is a group process with seven phases designed to mitigate the impact of a critical incident on personnel and to accelerate their normal recovery process.

1. Potential BIOHAZARD situation: Every direct contact with body fluids has a transmissible infection potential. There is a high probability that workers at an incident involving mass casualties and/or fatalities will come in to contact with bodily fluids. The IC must take appropriate precautions for infectious disease control.

a) Based on the scope of the incident, the IC may direct a HazMat type response

b) The IC, in coordination with health and medical officials, should establish and enforce an appropriate level of protection for response and recovery personnel.

i. All personnel involved in response and recovery operations should wear approved safety equipment and protective clothing.

ii. All other personnel should remain outside the inner perimeter until the IC declares it safe to enter.

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c) Just as in a HazMat incident, hot and cold zones along with suit-up and decontamination areas should be established.

d) Decontamination of all patients, response personnel, and equipment needs to be considered.

e) A means to dispose of the large quantities of biohazard materials generated must be identified and established.

f) Protective immunization and infectious disease screening should be considered for all personnel that may come in direct contact with remains.

Incident Scene SecurityScene security is crucial to maintain site integrity, keep onlookers from taking souvenirs, maintain chain of custody and protect the public and response personnel.

1. Perimeter- The scene requires a clearly marked perimeter. An established perimeter will help control the overwhelming numbers of volunteers that may converge on the scene, maintain the dignity and privacy of victims, and keep citizens from viewing potentially graphic scenes.

a) When possible, determine and protect the full extent of the incident site. This will include all wreckage, debris, victims, survivors and fatalities.

b) Secure the site by roping off the area when possible and assign sufficient personnel to enforce the perimeter.

c) Establishing two perimeters is usually beneficial:i. An outer perimeter restricts unauthorized persons from approaching the incident scene and on-scene emergency operations. ii. An inner perimeter separates the on-scene emergency response and support functions from the incident scene. This helps limit access to the incident scene to properly outfitted personnel with specific tasks to perform.

d) Public works personnel may be needed to place barricades and establish detour routes as part of the outer perimeter and to re-route traffic.

3. Entry Control Point – An entry Control Point and a positive identification control system should be established at the scene. Account for all personnel entering and leaving the area.

a) The IC may authorize the use of federal, state and jurisdictional identification cards for granting access to the staging areas and Incident Command locations.

b) Security personnel should restrict access inside the inner perimeter to those who are issued specific identification (e.g., specially designed badges, armbands or distinctive insignia/clothing).

c) Proper Identification procedures will also help ensure that emergency personnel work only their scheduled shift times (i.e., keeps workers from over-extending themselves).

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4. During long term operations, especially on “high visibility incidents”, access control procedures should be changed daily to foil attempts by unauthorized individuals to gain entry (e.g., change colors of workers badges/armbands, etc.).

5. Wearing a uniform or being an emergency responder should not be the sole authorization for an individual to enter the scene. Agency issued picture ID’s should be required.

6. Maintain security until all of the appropriate authorities have released control of the scene.

STAGING1. Staging areas should be within easy access of the scene but should not interfere with incident

operations. Incident Command will designate a staging area.

2. Anyone reporting/responding to the incident should report first to the staging area.

3. The first unit at the staging area will assume the role of Staging Manager until such time as he/she is released by Command.

4. The staging, logging and typing of all incoming personnel, fire/rescue apparatus, ambulances and other resources is the responsibility of the Staging Manager.

5. Staging Manager must maintain communications with the medical branch to supply necessary ambulances, as well as with Command to advise on available resources and send requested resources to the scene.

Equipment and personnel sent from the staging area to the scene should be noted in the staging area log, including the time of dispatch (24-hour clock).

6. The Staging Manager is also in charge of actually managing the staging area, ensuring orderly parking, maintaining clear access to the incident site, and maintaining an accurate log of currently available equipment, apparatus and manpower. In a large-scale incident, Staging may need to request one or more aides from Command to assist with these functions.

Rehabilitation Area1. A Rehabilitation Area needs to be established for response and recovery personnel so they can rest and relax

during breaks.

a) When possible, the area should be close enough to the incident scene that personnel can walk to it but remain out of view of incident operations.

b) The area should be secured with entry controls to allow personnel to rest/relax without interruption by media or unauthorized personnel.

c) Factors affecting the work/rest schedule include, but are not limited to, temperature, weather, terrain, and condition of remains.

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2. The Rehabilitation Area should offer:

a) A place for personnel to clean up during breaks and, if possible, showers for use at the end of their shifts.

b) Food and beverages suitable for the conditions.

c) Chairs and cots.

d) Crisis counselors.

e) Distractions (TV, radio, books, magazines).

f) First aid/medical support.

3. All workers should be made to comply with the established work/rest schedule to minimize the chances of burnout or critical stress.

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Family Assistance Center (FAC)1. Word of a possible MCI will spread quickly and families and friends of possible victims are likely to proceed to

the scene. A designated location for families to gather should be established as a Family Assistance Center in an area that is away from the scene.

2. Security and access control needs to be established at the FAC to limit entry to authorized personnel and family members only.

a. Personnel at traffic control points and perimeter security need to know where to direct family members trying to get to the scene.

3. The needs of family members must be considered. These include:a. Need for Information: care must be taken to ensure that they are kept up to date of the situation with

information on their loved one(s) provided as soon as it is available.

b. Grief Counseling Needs: family members should have access to separate areas where they can grieve in private and have access to clergy or counselors.

c. Physical Needs: families may remain away from their homes for an extended period of time; therefore the

FAC should address their basic needs of:· Food· Shelter· Transportation· Communications (telephones, e-mail, and internet access)· Child care· Medical area

4. The American Red Cross has been designated by the Federal Government to assist in times of aviation emergencies. In mass casualty incidents resulting from other causes, local government must be prepared to activate and staff the FAC.

Survivors1. Consideration should be given to establishing a temporary site near the incident scene where survivors can be

isolated from response operations, the media, etc. The site can be something as simple as a bus parked near the incident scene that could be used until a FAC can be established.

2. Survivors of an incident that do not require transportation to the hospital may be reluctant to leave the incident scene, especially if they believe that a friend or family member is one of the fatalities.

3. Counselors/clergy should be assigned to work with the survivors to help alleviate their fears and to assure them that the remains of their family member(s) or friend(s) will be handled with dignity.

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Deceased Persons1. For investigation purposes, deceased persons will be tagged, covered with a sheet or blanket, and not

moved unless necessary.

2. Command will coordinate with the County coroner in arranging for temporary morgue facilities, refrigerated trailers and/or transportation.

Organizational Positions and ResponsibilitiesIn determining staffing of each position, the IC must take into account both the qualifications of the available personnel and the demands of the particular incident. Positions should be staffed based on the best use of available resources. Any position not assigned by the IC becomes the responsibility of the IC.

Position specific check sheets are located in Volume II — Mass Casualty Incident Operations.

First Arriving Unit (Officer)¨ Performs size-up and determines if safe to enter.¨ Gives a brief radio report.¨ Declares MCI, if needed.¨ Estimates number, and severity of patients.¨ Maintains role of Incident Commander until properly relieved.¨ Additional resources will be dispatched according to level of MCI.

First Arriving Unit (Driver)¨ Isolates walking wounded, if possible.¨ Triages remaining patients, using the START system.¨ Establishes a funnel point.¨ Maintains role of Triage Team Leader until relieved.

Incident CommanderConsistent with the Incident Command System, the IC is responsible for overall incident management, including:

¨ Ensuring clear authority and knowledge of agency policy.¨ Ensuring incident safety.¨ Establishing an Incident Command Post.¨ Obtaining a briefing from the prior IC and/or assessing the situation.¨ Establishing immediate priorities.¨ Determining incident objectives and strategy (ies) to be followed.¨ Establishing the level of organization needed, and continuously monitoring the operation and

effectiveness of that organization.¨ Managing planning meetings as required.¨ Approving and implementing the Incident Action Plan.¨ Coordinating the activities of the Command and General staff.¨ Approving requests for additional resources or for the release of resources.¨ Approving the use of participants, volunteers, and auxiliary personnel.¨ Authorizing the release of information to the news media.¨ Ordering demobilization of the incident when appropriate.¨ Ensuring incident after-action reports are complete.

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Safety Officer¨ Reports directly to the Incident Commander.¨ Must have incident specific training/knowledge.¨ Identifies and causes correction of occupational safety and health hazards.¨ Ensures safety messages and briefings are made.¨ Exercises emergency authority to stop and prevent unsafe acts.¨ Review the IAP for safety implications.¨ Assign assistants qualified to evaluate special hazards.¨ Initiate preliminary investigations of accidents within the incident area.¨ Review and approve the Medical Plan.

Public Information Officer (PIO)¨ Responsible for formulating and disseminating factual and timely information about the incident to the news

media and other appropriate agencies.o Prepares public information releases (upon IC's approval).o Establishes a single phone number that should be released to the public for information.o Other personnel should not give statements to the media unless authorized by the PIO.

¨ Determines, according to direction from the IC, any limits on information release.¨ Arranges for tours and other interviews or briefings that may be required.¨ Maintains current information, summaries, and/or displays on the incident.

Liaison Officer¨ Responsible for interacting (by providing a point of contact) with the other agencies and

organizations involved in a disaster.¨ Maintains a list of assisting and cooperating agencies and agency representatives.¨ Assists in setting up and coordinating interagency contacts.¨ Monitors incident operations to identify current or potential inter-

organizational problems.¨ Provides agency-specific demobilization information and requirements.

Operations Section Chief¨ Responsible for managing all tactical operations at an incident.¨ Must have incident specific training/knowledge.¨ Performs duties as directed by the Incident Commander.¨ Ensures safety of tactical operations.¨ Develops operations portion of the IAP.¨ Requests additional resources to support tactical operations.¨ Establishes staging area.

Staging Officer¨ Keeps a current inventory of all resources for his/her staging area.¨ Arranges a staging area where personnel and resources that are not immediately needed

can be positioned to await an assignment.¨ Maintains communications with the Transport Team Leader to supply necessary ambulances, as well

as, to advise on available resources, and send requested resources to the scene.

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EMS Team Leader¨Responsible for developing a Medical Group necessary to manage multiple casualty patients.¨Coordinates triage, treatment, transportation, staging, and morgue operations.¨Ensures adequate resources are requested/assigned within Medical Group.¨Accounts for the personnel assigned to the Medical Group.¨Maintains records and forwards them to the IC.

Treatment Team Leader¨Responsible for supervising treatment and prioritizing patients for transport.¨Establishes treatment area(s) and/or patient loading area(s).¨Ensures adequate resources to treat patients.¨Coordinates patient loading with Transportations Officer.¨Maintains documentation of activities within treatment area.¨Identifies and directs specific treatment unit leaders as necessary.

Triage Team Leader¨Responsible for directing and coordinating triage activities.¨Assigns early arriving EMTs to initiate field triage.¨Ensures that all patients are tagged.¨Directs movement of patients to treatment/transport area.¨Ensures adequate resources necessary to conduct triage activities.

Transportation Team Leader¨Responsible for coordinating the loading and transporting of all patients from the incident site.¨Ensures adequate resources for transportation of all patients.¨Directs the movement of transport units between staging and loading areas.¨Documents patient destination, departure time, and transporting agency.

Morgue Team Leader¨Responsible for coordinating the management of the deceased.¨Coordinates morgue duties with local police and County Coroner.¨Assures security of the personal effects and bodies of the deceased.¨Coordinates disposition of patients who die in the treatment area.¨Maintains documentation of morgue activities.

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Triage Unit

Triage is the process of sorting two or more patients and is accomplished by evaluating the severity of each injury or medical problem. This process is used to determine who will receive care first, using available resources. Triage is performed using the Simple Triage and Rapid Treatment System (START). Once a patient is evaluated, he or she is assigned an emergency triage level: MINOR, DELAYED, IMMEDIATE and MORGUE.

1. Simple Triage and Rapid Treatment System (S.T.A.R.T)

a. The START system was designed in 1983 and updated in 1994. It is developed to allow first responders to triage multiple victims in less than one minute, based on three primary observations: Respiration, Perfusion and Mental Status (RPM). This system can be applied by fire/rescue squads, industrial or school safety personnel and other medical professionals.

b. With START, the steps are always the same no matter what injuries the victim may have. Using this process, a rescuer can quickly and efficiently triage large numbers of disaster victims. Triage assessments are clearly identified to subsequent rescue personnel. As these additional rescuers arrive they can quickly begin a more comprehensive triage, treatment and re-evaluation beginning with victims tagged IMMEDIATE.

c. The START System is not designed to replace approved protocols, or establish a standard of care but rather as a way to quickly identify those victims that are in most need of immediate medical care.

2. Pediatric Triage (JumpStart)

a. JumpSTART was developed in 1995 specifically for the triage of children and to parallel the structure of the START system, the adult MCI triage tool most commonly used in the United States and adopted in many countries around the world.

b. JumpSTART’s objectives are:i. to optimize the primary triage of injured children in the MCI setting

ii. to enhance the effectiveness of resource allocation for all MCI victimsiii. to reduce the emotional burden on triage personnel who may have to make rapid life or death

decisions about injured children in chaotic circumstances.

JumpSTART provides an objective framework that helps to ensure that injured children are triaged by responders using their heads instead of the hearts, thus reducing over-triage that might siphon resources from other patients who need them more and result in physical and emotional trauma to children from unnecessary painful procedures and separation from loved ones. Under-triage is addressed by recognizing the key differences between adult and pediatric physiology and using appropriate pediatric physiologic parameters at decision points.

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3. Triage Tagging

Patients are tagged for easy recognition by other rescuers arriving on the scene. Tagging should be done using one of the DMS TRIAGE TAGS, however other means are acceptable if approved triage tags are not accessible.

a) The Four Triage Priorities

Priority Triage Level Description

1IMMEDIATE

Life-threatening

Victims with a red IMMEDIATE triage tag require immediate medical attention because they have life-threatening injuries. These patients can't breathe well, lack a radial pulse, cannot follow simple commands and/or are in shock. Emergency workers know that patients with a red tag must receive immediate care.

2DELAYED

Delay up to 1 hr.

If a victim has a radial pulse, does not have fatal or life-threatening injuries, is able to follow simple commands, but cannot sit or stand because of injuries, she is given a yellow-colored DELAYED triage tag. This tag tells emergency workers that a victim does not need treatment within the next hour, but treatment should not be delayed for more than 6 hours.

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MINORDelay up to 3 hrs.

Victims who are able to walk and only have minor injuries are placed at a MINOR triage level. MINOR triage tags are typically green and let emergency workers know victims with these tags should be treated only when patients of a higher priority are evacuated. Patients with these tags may be asked to assist emergency workers until more help arrives. According to the Agency for Healthcare Research and Quality, it can take anywhere from 3 hours to 3 days before patients with MINOR tags receive medical care.

4 MORGUE

Those who have fatal wounds, or have died because of a MCI, are given MORGUE triage tags. If an emergency worker sees a victim is not breathing, he or she will attempt to open the airway. If breathing does not resume that victim is tagged as deceased. Victims tagged MORGUE should be rechecked after all IMMEDIATE victims are treated.

b) The First Step in START: Get up and Walk! The first step in START is to tell all the people who can get up and walk to move to a specific area. If patients can

get up and walk, they are probably not at risk of immediate death. In order to make the situation more manageable, those victims who can walk are asked to move away from the

immediate rescue scene to a specific designated safe area. These patients are now triaged as MINOR. If a patient complains of pain on attempting to walk or move, do not force him or her to move. The patients who are left in place are the ones on whom you must now concentrate.

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The Second Step in START: Begin Where You Stand!Begin the second step of START by moving from where you stand. Move in an orderly and systematic manner through the remaining victims, stopping at each person for a quick assessment and tagging. The stop at each patient should never take more than one minute.

ü REMEMBER: Your job is to find and tag the IMMEDIATE patients —those who require immediate attention. Examine each patient, correct life-threatening airway and breathing problems, tag the patient with a red tag and MOVE ON!

c) How to Evaluate Patients Using RPMThe START system is based on three observations: RPM—Respiration, Perfusion and Mental Status. Each patient must be evaluated quickly, in a systematic manner, starting with Respiration (breathing).

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BREATHING: IT ALL STARTS HERE

a. If the patient is breathing, you then need to determine the breathing rate. Patients with breathing rates greater than 30 per minute are tagged IMMEDIATE. These patients are showing one of the primary signs of shock and need immediate care.

b. If the patient is breathing and the breathing rate is less than 30 per minute, move on to the circulation and mental status observations in order to complete your 30-second survey.

c. If the patient is not breathing, quickly clear the mouth of foreign matter. Use a head-tilt maneuver to open the airway. In this type of mass casualty situation, you may have to ignore the usual cervical spine guidelines when you are opening airways during the triage process.

d. SPECIAL NOTE: The treatment of cervical spine injuries in mass casualty situations is different from anything that you've been taught before.

e. Open the airway, position the patient to maintain the airway and - if the patient breathes -- tag the patient IMMEDIATE. Patients who need help maintaining an open airway are IMMEDIATE.

f. If you are in doubt as to the patient's ability to breathe, tag the patient as IMMEDIATE. If the patient is not breathing and does not start to breathe with simple airway maneuvers, the patient should be tagged DECEASED.

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CIRCULATION: IS OXYGEN GETTING AROUND?

a. The second step of the RPM series of triage tests is circulation of the patient. The best field method for checking circulation (to see if the heart is able to circulate blood adequately) is to check the radial pulse or capillary refill.

b. The radial pulse is located on the palm side of the wrist, between the midline and the radius bone (forearm bone on the thumb side).

c. To check the radial pulse, place your index and middle fingers on the bump in the wrist at the base of the thumb. Then slide it into the notch on the palm side of the wrist. You must keep your fingers there for five to ten seconds, to check for a pulse. If the radial pulse is absent or irregular the patient is tagged IMMEDIATE. If the radial pulse is present, move to the final observation of the RPM series: mental status.

d. Alternately you can assess capillary refill by pressing the victim's fingernail and observing how long it takes color to return.

MENTAL STATUS: OPEN YOUR EYES

a. The last part of the RPM series of triage tests is the mental status of the patient. This observation is done on patients who have adequate breathing and adequate circulation.

b. Test the patient's mental status by having the patient follow a simple command:"Open your eyes." "Close your eyes." "Squeeze my hand." Patients who can follow these simple commands and have adequate breathing and adequate circulation are tagged DELAYED. A patient who is unresponsive or cannot follow this type of simple command is tagged IMMEDIATE. (These patients are "unresponsive" to verbal stimuli.)

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Triage Tag Instructions

Each type of Triage Tag is constructed of 100% synthetic paper. This makes the tag completely waterproof. The tag

readily accepts ball point pen when wet and has been tested in all decontamination solutions.

1. Follow the START SystemPatients should be triaged utilizing the START triage system.

The 3 simple parameters (RPM) to remember:a. Respirations (> or < 30 per minute)b. Perfusion (Capillary Refill > or < 2 seconds)c. Mental Status (Follow simple commands)

The R.P.M. pneumonic is located on the back of the TRIAGE TAG for easier sorting of patients.

2. Check if a Contamination Hazard Exists?If YES:Stage in a safe area. Notify HazMat team and HazMat will assume triage and decontamination responsibilities.

If NO:The CONTAMINATED tear-off strip may be removed and standard triage procedures may be initiated.

The CONTAMINATED STRIP running along the bottom of the triage tag has three functions.

To prevent the tag from being used until patient contamination has been considered.To identify victims who have been exposed to a hazardous material.To aid rescuers with identifying clothing (evidence) belonging to victims.

3. PERFORATED TAGSAt the bottom of the TRIAGE TAG are colored tear-off tabs that correspond to the patients triage category.

During triage, the initial rescuer will tear off the bottom colors until the bottom one matches the victim classification. Retain the removed colors, the tabs will be gathered to assist in determining overall patient count, transport priority, and resource allocation.

The initial rescuer does not fill out the triage tag, however it is recommended that they write the time and their initials on it.

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4. TRIAGE TAGInjury Classification

i. The anatomical (front/rear) figure is used to illustrate areas of injury, any chief complaints, and mechanisms of injury.

ii. The section for checking off major injury categories is also to be used to indicate type of injury.iii. The Radiological, Biological, and Chemical symbols are used to identify the type of Nerve Agent(s)

the patient may have been exposed to.

VitalsThe boxes are used to record the patient's blood pressure, pulse, and respiration.

Drugs This section is available to record the drug type and drug dose that was given (Diazepam, Morphine, IV solutions etc.), as well as, what time the drug was administered.

S.L.U.D.G.E.M.The section labeled SLUDGEM is to be used to chart signs/symptoms of Nerve Agent exposure. This will help alert first responders to the possibility of Nuclear, Biological or Chemical agents.

The section under SLUDGEM is used to record the use of any auto injectors.

The Primary and Secondary Decontamination Check Circles

The circles are used after victims have undergone decontamination procedures. The solution used during decontamination also needs to be recorded on the tag. It should be noted that no patient should be allowed to leave the exclusion zone without undergoing decontamination procedures.

5. REMAINDER OF TAG At this point, the rest of the tag is placed over the victims head and becomes identification for the victim and a claim ticket for personal property after the incident.

6. PATIENT TRACKINGTransportation Receipt The first tear-off tag from the top is used for recording patient destination. The tag may be removed just prior to the patient leaving the scene. Both the destination along with how and when the patient was transported (ambulance number, helicopter, bus, etc.) shall be recorded on the tag.

Ambulance ReceiptThe tear-off tag along the left side of the tag will be removed at the loading zone and given to the transporting ambulance in order keep a record of the number of patients transported and their destinations.

7. THE PERSONAL PROPERTY RECEIPT TAG The tear-off tag located along the left side of the Triage Tag is used for identifying valuables removed from victims (jewelry, wallets, watches, cash etc.). These items should be collected and placed in a smaller 1-gallon clear plastic bag. The back of the Property tag may be used to record property of unusual value. The Property tag is then placed with the valuables and sealed.

At this point both the clothing bag and the property bag are placed into a second large plastic bag and sealed using duct tape or other air tight measures.

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Treatment of Casualties

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The primary objective is to evaluate and get treatment for patients in an orderly and expedient manner. There are times when rapid transport is not a feasible option due to the complexity or location of the incident. Onsite treatment areas may have to be established using designated areas (tarps and canopies), existing structures (Alternate Care Site) or Casualty Collection Points (temporary shelters).

a) All patients not immediately transported are to be sent from the triage area to this area.

b) A treatment area may be divided up by triage category (RED, YELLOW, GREEN, and MORGUE) for easier treatment and then transport of patients.

c) The Medical Branch Director will decide if a treatment area is needed, if so, a Treatment Group Supervisor will be designated. The primary responsibilities of the Treatment Group Supervisor will consist of, but not be limited to, the following activities:

· Determine the number of injuries and/or illness associated with the incident.

· If a hazardous materials incident or WMD incident exists determine the medical consequences that such an incident may have on patients and rescuers. Communicate this information to the Medical Branch Director.

· If technical decon is necessary, including mass decon of large numbers of casualties under the advice of a medical command physician. Coordinate the implementation of this activity with the EMS Officer and other appropriate personnel to include HazMat and Fire Officers.

· Set forth and enforce treatment priorities in the Treatment Sector. Avoid unnecessary delays in patient care and/or transport for interventions of unproven value in their effect on morbidity/mortality.

· Ensure that patients with serious traumatic injuries are removed from the Treatment Sector and transported to hospitals as rapidly as possible. (Certain patients with unstable medical conditions may benefit from stabilization on-scene prior to transport.)

· Ensure that Treatment Sector personnel are kept informed of the status of the incident and the priorities for on-scene emergency medical care.

· Ensure that re-triage of patients in the “immediate” and “delayed” sectors occurs upon patient arrival and every 15 minutes thereafter. Re-Triage of patients in the “minor” sector should occur every 30 minutes.

· Ensure appropriate utilization of Air Medical EMS transport resources.

· Discuss utilization of alternative transport resources for patients in the "minor" sector with the Transportation Team Leader.

Assist Treatment Sector personnel with prioritization of their patients for transport. Coordinate this activity with the Transportation Team Leader.

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Transportation

Transportation occurs after treatment except in cases of life threatening conditions which are amenable to field treatment as resources and personnel allow.

1. Transportation Area: This needs to be established at the scene as close as possible to the incident site to allow for the efficient loading of victims into vehicles for transport to the designated area hospital.

2. The area must allow a vehicle to proceed directly from staging to the scene, be loaded, and then depart promptly for its destination.

a) The area should have good road access and allow for safe loading. b) The area should be established within the outer perimeter and out of view of the media, family members,

and the public.

3. Care should be taken to assure that loading of victims is done professionally.

4. Medical Units: First-arriving medical units should typically be held at the scene for medical supplies and resources, but may be utilized for transportation when needed.

5. Personnel from medical units designated for transportation shall remain with their respective units at the Staging Area until requested.

6. Several patients should be transported in each vehicle in order to maximize resources available. EMS units should not be allowed to leave the incident with only 1 patient. Ex: 1 red + 1 yellow, 1 yellow + 1 yellow, 1 yellow + 2 green (Do not transport 2 reds in a single unit)

7. Air Transportation: Air transportation should be utilized when needed. If multiple air assets are requested an Air Branch Director should be designated. Agencies requested should be informed as to the designated landing zone.

8. Landing zones need to be established with the designated personnel to ensure safety and staffing to facilitate expeditious patient transferring. The landing zone should be located as to not interfere with on-going incident scene operations.

9. Buses: Buses may be used to transfer multiple patients to area receiving hospitals as appropriate. These patients should have minor injuries and be accompanied by a medically qualified individual capable of maintaining medical treatment and evaluation as needed.

10. Transportation Group Supervisor: The Medical Branch Director should designate someone to serve as the Transportation Group Supervisor to coordinate the transportation of patients to appropriate medical receiving facilities. The primary responsibilities of the Transportation Group Supervisor are discussed further in Volume II – Mass Casualty Operations.

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Transport area example

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Egress

Equipment staging

MCI with Hazardous Materials

Hazardous materials (Hazmat) incidents involving chemicals occur every day, exposing may people to injury or contamination. During a hazardous materials incident, responders must protect themselves from injury and contamination by wearing personal protective equipment (PPE).

Remember: A hazardous materials sign indicates a potential problem, but not all hazardous material problems will be displayed. Be sure to find the proper response to the problem before beginning patient treatment. 1) The single most important step when handling any hazardous materials incident is to identify the substance(s)

involved. Federal law requires that hazardous materials signs be displayed on all vehicles that contain large quantities of hazardous materials.

a) Manufacturers and transporters should display the appropriate sign, along with a 4 digit identification number for better identification of the hazardous substance. These numbers are used by professional agencies to identify the substance and to obtain emergency information.

2) If there is any suspicion of a hazardous materials spill, responders should stay away. Unless a responder(s) has received training in handling hazardous materials and can take the necessary precautions to protect him/her, he/she should keep far away from the contaminated area or “hot zone”. The HazMat team is responsible for dealing with incidents involving hazardous spills.

a) The U.S. Department of Transportation published the Emergency Response Guidebook, which lists the most common hazardous materials, their 4 digit identification numbers, and proper emergency actions to control the scene. It also describes the emergency care of ill or injured patients.

3) Once the appropriate protection of the responders has been accomplished, triage and treatment in the hot zone should be limited to rudimentary airway management (opening) and then evacuation to a lesser level of exposure should occur.

a) Antidote administration should be considered and given early (Markl, DuoDote, Cyanokit…) if available. b) All other medical treatment should be deferred until gross decontamination is performed.

4) Secondary triage can be considered and occur after decontamination has been conducted.

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Hazard Control Zones

1. Establishing Hazard Control Zonesa) The Incident Commander, with guidance from the Safety Officer, will immediately designate the three major

zones around the affected area. These zones serve to reduce the contamination of people and equipment by controlling and directing tactical operations. People should move through access control points only. The zones are as follows:

· Hot Zone (Exclusion Zone) - This is the area of greatest danger. Access into this area may be permitted only while wearing PPE. All other standard safety and operating procedures will be adhered to for Hot Zone operations. The Hot Zone shall extend far enough to prevent adverse effects from hazardous materials. Only those responders necessary to control the incident or rescue others may enter this area. The area must be clearly defined.

· Warm Zone (Contamination Reduction Zone) - The Warm Zone is an area of limited access and where decontamination occurs. The purpose of this zone is to reduce the spread of contamination and control access to and from the Hot Zone. It also serves as a buffer zone and is initially a non-contaminated area. Entry and exit from the Hot Zone will always be accomplished through the Decontamination Corridor and it will be controlled and secured. PPE is required in this area. The size of this zone will be determined by the nature of the incident and the size of the decon operations to be conducted within. The incident commander and staff will make this decision based on information and monitoring. The area must be clearly defined.

· Cold Zone (Support Zone) - The Cold Zone is the area bordering the outer perimeter of the Warm Zone and is a clean area for support operations. It shall be upwind and uphill from the Hot and Warm Zones and as far away from the Hot Zone as necessary for safe operations. The command post and resource sectors will be located in this area, in most instances. During larger incidents, such as a MCI, additional resources may be located in a staging area located outside the Cold Zone.

b) The zones will be defined based on results of sampling, monitoring, and incident size-up. If monitoring instruments are not immediately available, the Incident Command Staff will use physical data and chemical information to determine the safest zone. The criteria for establishing zone boundaries include:

ü Visual survey and scene size-up.

ü Location and types of other hazardous substances and area hazards.

ü Research data on physical and chemical properties of hazardous materials.

ü The ability to safely access the contaminated area.

ü Area necessary for the control zones to be effective.

ü Current weather conditions.

ü Number of responders available to properly control these zones.

ü Number of victims and potential exposures to all responders and the public.

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Hazardous Materials Key Points Decontamination

Decontamination is the physical or chemical process of removing, reducing, or preventing the spread of contaminates from people, equipment, structures, the environment or anything that may be contaminated.

Importance of DecontaminationThe three most important reasons for decontaminating are:

· Remove the agent from the patient's skin and clothing, thereby reducing further possible agent exposure and further effects among victims.

· Protect emergency responders and medical personnel from secondary contamination.· Provide patients with psychological comfort at, or near, the incident site, so as to prevent them from spreading

contamination over greater areas.

Types of Decontamination· Dry Decontamination: This involves the use brushes to gently remove contaminants off

patients, towels or absorbent pads to wipe down patients, or clothing removal.· Mass (Gross) Decontamination: Mass decontamination process is performed on ambulatory patients or response

personnel who have had direct exposure to hazardous solids, liquids, mist, smoke and certain gases, and who may be displaying related symptoms. This process involves the use of copious amounts of water typically utilizing fire nozzles and is generally required when large numbers of people need decontaminated.

· Technical (Fine) Decontamination: This decontamination process is performed on contaminated patients and personnel involved in a hazardous materials incident. This involves establishing a decon corridor to systematically remove contaminants from patients' clothing and body, as well as, response personnel. Ambulatory patients are deconned separately from non-ambulatory patients.

Methods of Decontamination

The decontamination process involves reducing or removing agents with the use of specific physical means or by chemical neutralization. However, selecting the appropriate decon method is primarily influenced by situational circumstances.

PHYSICAL: this involves physically removing contaminate from the contaminated patient or object by means of:

· Flushing (use of water or water/soap)· Scraping· Absorbent powder

CHEMICAL: this involves removing or reducing the threat from a specific contaminant by rendering it less harmful through a chemical change that requires the use of:

· Soap · Bleach · Special solutions

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FACTORS THAT DETERMINE HIGHEST PRIORITY FOR AMBULATORY VICTIM DECONTAMINATION

Casualties closest to the point of release Casualties reporting exposure to vapor or aerosol Casualties with evidence of liquid contaminate on clothing or skin Casualties with serious medical symptoms (shortness of breath, chest tightness, etc.) Casualties with conventional injuries

Decontamination Procedures

Removing clothes and showering with water is the most expedient and practical method for mass casualty decontamination. Showering is recommended whenever liquid transfer from clothing to skin is suspected. Disrobing should occur prior to showering for chemical agents. However, the decision to disrobe should be made by the Incident Commander based upon the situation. Wetting down casualties as they start to disrobe would speed up the process and is recommended for decontamination biological and radiological casualties.

Many victims are reluctant to complete the decon process if required to disrobe in the presence of others. Consideration should be given to victim privacy when setting up decon stations.

Ambulatory Decontamination · Patient should enter the initial decon station of the tent. · Patient should remove all clothing, valuables and removable items. These items must be placed in a plastic

bag along with the “CONTAMINATED” tag from the triage tag and sealed. · Patient should shower with liquid soap and warm water in a top to bottom manner. · Patient should thoroughly rinse with warm water. · Patient should dry with clean towel and then dispose of the towel. · Patient should don dry clothing. · Patient should be guided to the cold zone observation and screening area.

UNDRESS(put clothes/valuablesin clear plastic bag)

SHOWER/RINSE DRY DRESS

Non-Ambulatory Decontamination · Bring patient into decon station on a backboard or stretcher. · Cut away or remove patient’s clothing and place it in a plastic bag along with the contaminated tag from

the triage tag, and seal. · Starting with the front, spray, scrub or wipe one quarter of the patient at a time. · Roll the patient to their side, then spray, scrub or wipe the back from the highest to lowest point. · Thoroughly rinse the patient. · Dry the patient with a clean towel. · Place the patient on a clean board or stretcher. · Cover patient with a clean blanket. · Place a triage tag/wristband on the patient. · Transport the patient to the cold zone observation or treatment area.

UNDRESS and/or CUT CLOTHES

SHOWER/RINSE DRY COVER

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(put clothes/valuablesin clear plastic bag)

In the course of decontaminating patients, first responders may inadvertently become contaminated. High-pressure, low volume decontamination showers should be used primarily for wet decontamination of responders in Level A suits after a hazardous materials incident. This gross decon forcibly removes the contaminant from the personal protective equipment (PPE) worn by emergency responders while conserving water. Often a secondary wash, possible a tertiary wash, and rinse station are used as well.

GROSS RINSE SCRUB/RINSE FINAL PPE REMOVAL SCRUB/RINSE

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Rehab Unit

To ensure that the physical and mental condition of personnel operating at an incident are maintained a rehab unit should be established. Personnel are the most important resource at an incident and we need to work to avoid deterioration to a point that would affect their health and safety or that of other personnel, or that would jeopardize the safety or integrity of the incident

This guideline applies to ALL Emergency Services Personnel who are operating at the scene of any emergency. REHAB should occur when: significant physical activity is being undertaken and/or exposure to unusual weather conditions occur and/or prolonged duration of the event and/or the Incident Commander requests that a REHAB Sector be established.

SECTION 1 - RESPONSIBILITIES

Incident Commander:The Incident Commander will evaluate the incident, considering physical, mental and environmental circumstances, and make provision for rest and rehabilitation of ALL personnel operating at the incident.

These provisions will include: Medical monitoring, evaluation and necessary treatment and transport to an appropriate medical facility. Food fluid replenishment Mental rest and recovery Relief from environmental and abnormal weather

EMS/Medical Branch Director:The EMS/Medical Branch Director and any assistants will continuously evaluate the need for and effectiveness of the REHAB sector to ensure that its purpose is being maintained. They will request additional resources as required to maintain the necessary Rehabilitation of personnel on the incident.

Unit Leaders:The individual unit leaders will continually monitor their personnel to ensure that their physical and mental health is maintained through utilization of the REHAB sector and rotation of personnel.

Individual Personnel:*Climate: During extended periods of operation or highly physical working conditions, all personnel involved in the incident should be encouraged to continuously maintain their hydration through drinking of water, activity beverages (such as Gatorade) or non-caffeinated hot drinks (during cold weather operations).

*Fatigue: Throughout the operation of the incident, personnel will monitor their own, as well as other individuals, level of fatigue and report to any Incident, REHAB, or EMS Officer when they feel that the level of physical or mental fatigue or exposure to the environment could affect the health and/or safety of themselves, other personnel involved or the incident itself.

SECTION 2 - ESTABLISHING THE REHABILITATION SECTOR

The Incident Commander and/or EMS Officer will establish a Rehabilitation Sector whenever conditions indicate that rest and rehabilitation are necessary to ensure adequate personal and scene safety. In the event that a REHAB Sector is established, it will be manned at the minimum by one EMT or Paramedic. An EMT or Paramedic will be placed in charge of the REHAB Sector and will be identified as the REHAB Officer in coordination with the Incident Command Structure.

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When should REHAB occur?ü All structure fires ü Large, multi-agency response incidents including MCI, WMD, brush fires and Hazardous Materials incidents. ü Extended Rescue Operationsü Temperatures >90 degrees and <32 degreesü Training operations >2 hours in lengthü At the discretion of the Incident Commander

The REHAB Officer will: ü Wear a vest with the identification of REHAB Officer visible on both the front and back. ü Have an operational portable radio or other communications device that is capable of direct communication with

the Command Post, EMS/Medical Branch and Triage/Treatment Team leaders.ü Have available to him/her and utilize a checklist and clipboard to assist in the timely establishment of the

REHAB Sector with all necessary equipment and supplies. ü The REHAB officer will report directly to the EMS/Medical Branch Director. In the event that an EMS/Medical

Branch is not established, the REHAB Officer will report to the Incident Commander.

Locating the REHAB Sector: Up wind from the incident site in an area that is free from exhaust fumes from emergency or other vehicles.

Depending upon environmental conditions, either in a cool, shaded area OR a warm dry area. This might entail the use of a nearby building, if available.

In an area with minimal noise disturbance from emergency operations, equipment or crowds.

Near the air cylinder refills station or the manpower staging area, if possible. Such a location would ensure that all emergency workers are seen by the Rehab Officer.

Out of site of the incident if possible. Emergency workers will have a difficult time being rehabilitated if they are watching the incident going on. They want to get back in the “game” too quickly.

In an area that has access for incoming units, should the transport of an individual in the Rehab Sector become necessary.

In an area that will provide shelter from inclement weather.*HOT WEATHER-Cool, shaded area. *COLD WEATHER-Warm, dry and wind-free area.

Site Designation of the REHAB Sector An ample sized area sheltered from the environment, where a REHAB Sector can be established utilizing tarps, salvage covers, canopies, fans, heaters, lighting, etc.

Optimally, the REHAB Sector should be established next to the SCBA area to allow for appropriate rehabilitation after removing SCBA.

The USFA suggests the “two air bottle rule” or 45 minutes of work time to be considered maximum workload prior to mandatory REHAB. After the appropriate work time, the responder should spend no less than 10 minutes and may exceed one hour, depending on the physical appearance and condition of the responder, in the REHAB Sector. After REHAB is complete the responder will be sent to the Staging Area. This will be completed only after being medically cleared by the REHAB Officer.

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A nearby garage, carport, driveway, building, or other stable and easily accessible structures are sufficient facilities for REHAB area establishment. The front lawn of an adjacent house could be utilized for REHAB at the scene of a house fire, but may not be appropriate for an incident of larger magnitude.

Ambulances, Fire Apparatus (such as the back of a rescue truck), or other emergency vehicle at the scene or called for, can be utilized for REHAB purposes.

In a high-rise situation, REHAB should be established on the floor below the staging floor, only after cleared for safety and operations by the Incident Commander.

Specialty REHAB vehicles may be utilized when available.

REHAB ResourcesThe REHAB supplies secured should include, at a minimum, the following:

ü Fluids- Water, activity beverage and ice. NO caffeinated beverages should be utilized.

ü Food- Short Term: Granola bars (less than 3 hours activity)

Long Term: Make arrangements for soup, broth, stew and sandwiches. Obtain food through support agencies such as the American Red cross, local fire department auxiliary groups, or local civic/food service agencies. Preplanning may be an appropriate tactical consideration in order to expedite the delivery of these services.

ü Medical- Blood Pressure Kits (Multiple Cuffs and Sizes)Oxygen Supplies and Delivery Devices (Multi-port, Non-Rebreather)Extra Oxygen Cylinders (Rehab Units)ThermometersHot/Cold PacksTriage TagsStair/Folding Chairs, Folding litterALS and BLS Medical Kits – This should include IV fluids (warm/room temperature) and cardiac monitor.

ü Other - Portable Radio (s)Supplies Cooling Vests

Misting FansDrinking CupsClipboards, log sheets and REHAB flow chart for documentationTowels (soak in cold water for cooling or use to dry off cold/wet areas)Heaters (for cold weather warming)Dry clothing (scrubs, sweats, socks, etc.)Quartz lights (for lighting and heating)BlanketsSpray bottles (for warm weather cool downs)Traffic cones, marker flags and/or emergency scene tape to establish sectorAwnings/Tents/Tarps/Shelters

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Section 3- REHAB SECTOR OPERATIONAL GUIDELINES

Climate and environmental conditions at the emergency scene shall not be the sole justification for establishing a Rehabilitation Area.

Any activity or incident that is large in size, long in duration, and/or labor intensive will rapidly deplete the energy and strength of personnel and therefore merits consideration for rehabilitation.

Climate and environmental conditions that indicate the need to establish and maintain a Rehabilitation Area are: HEAT STRESS INDEX >90 DEGREES F.WIND CHILL INDEX <30 DEGREES F.

HydrationA critical factor in the prevention of heat exhaustion, heat strokes, or heat related injuries is the maintenance of water and electrolytes. Water must be replaced during training exercises and at emergency scenes.

During heat and physical stress situations, REHAB staff will attempt to have personnel who are actively working at the scene consume AT LEAST ONE (1) QUART OF WATER PER HOUR.

If an activity beverage is used, the re-hydration solution should be a 50/50 mixture of water and the commercially prepared beverage. It should be administered at about 40 degrees F.

Re-hydration is also important during cold weather operations where heat stress may occur during firefighting, rescue operations, or other strenuous activity- especially when protective equipment is being worn.

Alcohol and caffeine beverages should be avoided BEFORE and DURING heat stress because both interfere with the body’s water conservation mechanisms. Carbonated beverages should also be avoided.

NourishmentFood should be provided at the scene of an extended incident where units are engaged FOR MORE THAN THREE (3) HOURS.

Soup, broth and stew are recommended because of quicker digestion by the body.

Foods such as apples, oranges, and bananas provide supplemental forms of energy replacement. Fatty and salty foods should be avoided.

Mandatory Rest PeriodsTwo air bottles or 45 minutes of strenuous work is the recommended level prior to mandatory rehabilitation.

Rest periods should be no less than 10 minutes and may extend to greater than one hour, depending on responder’s physical condition.

Personnel should not be moved from a hot environment to an air conditioned environment because the body’s cooling system could shut down in response to the shock of the external cooling. An air conditioned environment is acceptable after an appropriate cool-down period in ambient temperatures.

Twelve hours is the maximum amount of time that ANY emergency personnel, INCLUDING INCIDENT COMMAND, should be continuously involved at an emergency scene, no matter how many rest/rotations sequences are provided. Personnel should be rotated through heavy, moderated and light work between each REHAB period.

RecoveryAfter being fully rehabilitated and medically evaluated in the REHAB Sector, the emergency responder will be released to the Equipment/Personnel Staging area.

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SECTION 4-MEDICAL EVALUATION IN THE REHAB SECTOR

EMS Responsibilities Personnel reporting to the REHAB Sector will receive a complete evaluation (ASSESSMENT) and treatment (IF NEEDED), for environmental emergencies, as well as for minor injuries.

Heart Rate should be checked as soon as the responder arrives at REHAB. If the heart rate is greater than 110 bpm, a tympanic temperature is necessary. If the temperature exceeds 100.6 degrees F, the responder should not be medically cleared to return to service and/or wear protective gear.

If the heart rate is greater than 110 bpm and the temperature is less than 100.6, an extended rehab time is necessary.

If the heart rate is less than 100 bpm, normal rehab should be instituted.

Continue with the assessment of the responder including blood pressure and respirations every 5-10 minutes. Blood pressure will tend to drop with increased fluid loss, as the heart rate increases to compensate for the loss. With increased fluid intake, if heart rate does not decrease and blood pressure return to normal, EKG monitoring and IV therapy may be mandatory. This should be initiated on a “per patient/per assessment basis”.

If, after continued rehabilitation, no changes occur in patient status, immediate ALS transportation to the hospital is necessary. If resistance is met by the responder, the REHAB Officer should seek the advice of a medical command physician and the responder’s chief officer.

Vital SignsVital sign will be taken on every individual that enters the REHAB Sector with the heart rate being the determining factor for level of rehabilitation.

Documentation Crews entering the REHAB Sector will be required to fill out the “Check-In/Check-Out” form at the entrance to the REHAB Sector. Personnel will enter the REHAB SECTOR as a crew. The form will include the following information:

· Unit/Team Number· Number of Persons· Time In· Time Out

Crews will not leave the REHAB Sector until being released by the REHAB Officer.

All medical evaluations shall be documented on the Rehabilitation and Monitor Check Sheet. Additionally, all individuals that receive treatment beyond the standard medical evaluation shall have a Pennsylvania Patient care Report generated for them. This includes all patients receiving transport to the hospital, as well as any invasive ALS treatments performed.

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Support Services

Chief Elected Officials Declare an emergency and/or disaster.

Coroner’s Office Lead agency for the collection, storage, and disposition of all human remains and their personal effects. Make appropriate notifications and report to incident scene to provide advice and assistance to the IC while

survivors are rescued. Analyze resource needs and request assistance as required. Establish and supervise Tag & Flag Teams Identify, set up and coordinate activities at the Incident Morgue to include:

(a) Victim tracking(b) Fingerprinting(c) Physical examinations(d) Withdrawal of blood and body fluids(e) Forensic examinations(f) Victim identification(g) Preparation for final disposition and release of remains.

Determine identity and cause of death, complete reports, and work with the State ME for issuance of death certificates.

Arrange for release or disposition of personal effects.

Emergency Management Coordinator (EMC) Activate and staff EOC. Manage the EOC and support field operations. Hold periodic briefings when necessary for the EOC staff to exchange information. Ensures communication and message flow. Ensures documentation of all emergency information. Recommend declaration of emergency and request additional resources from state and/or federal agencies. Ensures coordination with municipal EOC’s regarding emergency service needs, incident command, reporting,

damage assessment, resource management, assistance to special needs and disaster assistance. Provided public information if the PIO is not available. Coordinate with mutually supporting counties.

EMS Respond to the scene and assume incident command if survivors are present and/or if the scene requires medical

interventions. Lead agency for survivor triage and treatment. Identify and set up the Transport Area and designate a Transport Group Supervisor.

Fire Services Respond to the scene and assume incident command if the scene requires fire suppression/prevention, rescue or

hazardous materials response activities. Make appropriate notifications for assistance. Stabilize the incident scene. Assist with triage and treatment survivors. Assist with protection of the incident site. Assist with search and recovery as resources and the situation permit.

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Law Enforcement Provide perimeter control and scene security. Provide security for the Family Assistance Center and temporary morgue facilities as needed. Assume incident command once all lifesaving and fire suppression activities have been completed (as

appropriate). Assist in reconstruction and investigation of the scene.

NOTE: If an event is possible a criminal/terrorist act, law enforcement is the lead agency and will fill the IC/US position.

Hazardous Materials Team Lead agency for operations to prevent/mitigate the exposure to hazardous materials Assist with triage and treatment of survivors Setup decon areas Provided technical assistance to the IC/UC

Regional EMS Council Liaison for Department of Health, Bureau of EMS Maintains and deploys MCI trailer, Medical Surge Equipment Cache, Mobile Medical Support System Responsible for Alternate Care Sites Assists Federal, State and Local agencies, upon request, in the provision of onsite mitigation, technical

assistance, and situational assessment, coordination of functions or post-incident evaluations, in the event of a potential or actual disaster, mass casualty situation or other substantial threat to public health.

Public Works Provides equipment, personnel, and other resources for heavy rescue operations, and/or traffic control as needed. Provides debris removal and disposal for locally maintained roads and bridges and repair damage as necessary.

American Red Cross (ARC) Family assistance center Controlled location where family members can go to wait and hear about their family member. Provides a location for family that is away from the disaster or casualty event, prevents family members from

impairing emergency responders ability to complete their job. Provides a location for mental health and health services to family members, if needed, while they wait to hear

any news. Controls media access to family members and controls the information family members hear about the situation. Works with hospitals and families to help gather information that will help identify potential victims. Respite centers for first responders are always housed in separate locations so that they can have the privacy

they need.

Department of Human Services Coordinate the delivery of mental health services to survivors, families of victims, and emergency services

workers, as required. a) Mental health services for survivors, families of victims, and Family Assistance Center staff should be a

component of a Family Assistance Group activated under the Operations Section. b) Mental health services for responders and support personnel will be the responsibility of the Medical

Unit under the Logistics Section with assistance from the Safety Officer. Facilitate outreach teams to enter the impacted community to provide proactive counseling services, such as the

DCORT (Disaster Crisis Outreach and Referral Team). Coordinate with the Red Cross, if involved, to meet the emergency human service needs of the survivors and

families of the victims. Facilitate critical incident stress debriefings.

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Division of Federal, State and Local Responsibilities

Federal: Federal assets may be dispatched to the region once the Governor has requested assistance and/or the President has declared an emergency. Assets to support a mass casualty event may include SNS stockpile, preposition equipment program pods, assistance from Northcom, or the activation of the NDMS (National Disaster Medical System).

State: Coordination for resource requests may come from either Emergency Management or through the Department of Health depending on the nature of the event and how it evolves.

Local: In an emergency that overwhelms hospital capacity, hospitals coordinate information through the Unified Medical Command to the respective county EOC. Hospitals collect disaster related information and pass it through either ESF 8 (if activated) or through public health. Erie County Department of Health is the ESF 8 lead agency in Erie County.

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MCI Quality Improvement Process

A. IntroductionThe last phase of the MCI Plan is a review of the incident. The review will be a Quality Improvement survey of the MCI response operational effectiveness. The review will explore the circumstances of the incident and will typically be conducted in a formal critique setting, attended by MCI participants and hosted by either the Incident Commander's agency or the EMS agency.

B. Definition A scheduled meeting called to review the actions, accomplishments and difficulties encountered by the MCI participants.

C. CISMA critical incident stress management (CISM) debriefing should be hosted by the jurisdictional agency and/or EMA agency prior to any incident review/critique.

D. Critique ResponsibilityA formal critique of the incident may be called for by the following:

· Incident Commander or participant· Regional EMS Council· EMS agency · Participating hospital(s)

E. Critique Coordination Typically, an incident critique will be scheduled within five days of the occurrence of the MCI. The County EMA Coordinator may choose to schedule and host the critique or may delegate the critique coordination process to the Regional EMS Council. Should a participating hospital want to review the incident, the appropriate hospital representative should contact the EMA which will coordinate and/or host the critique.

F. Critique Format The critique of a MCI should utilize the MCI Review Sheet, found on the next page. This critique will be informal in nature, with discussion centered on the following MCI components:

· Initial report· Initial response· Scene management· Medical management · Miscellaneous· MCI Plan applicability and practicality

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MCI Quality Improvement Sheet

Initial Report· How was incident reported?· What was reported? Any conflicting information?· Who was notified? Who was not notified?

Initial Response· What was sent in the “first wave” dispatch? Why?· Did first arriving responder do a size-up/report on conditions? · Were additional resources requested by first in units? What?· Were there conflicting requests for resources? Why and how?· Were mutual aid resources needed? Which?· Were ambulance back-fill effected? Which?

Scene Management· Was incident declared and command established? Who was the IC?· Were hazards identified and controlled?· Was Unified Command ever established? Command post established? Was UC post communicated to all

participants?· Which ICS positions were activated? Vests used?· Were passerby’s and/or volunteers utilized? How?· Ambulance staging established? Landing Zone established? · Who is credentialing volunteers?

Medical Management· Which medical ICS positions, if any, were utilized? Which were combined?· How did Incident Commander and EMS/Medical Group supervisor communicate?· How were various positions identified? Vests used?· Were patients triaged prior to ambulance arrival? START tags used?· Treatment areas designated and prepared?· How did primary triage compare to secondary triage/treatment?· What information was or was not given to base hospital?· START categories and patient count? What channel/means used? Any conflicting information?· How were patients sorted among hospitals? Who determined destination?

Miscellaneous· Lessons learned?· What went well?· What would you do differently?· What problems were unique to the situation?· What problems are likely to be encountered again?· Any problems require MCI Plan modifications?· CISM team utilized?

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Terms and Definitions

Advanced Life Support (ALS) The advanced pre-hospital and inter-hospital emergency care of serious illness or injury by appropriately trained health professionals and Advance-EMT, Paramedics, PHRN.

AmbulanceA vehicle specifically designed, constructed or modified and equipped, used or intended to be used, and maintained or operated for the purpose of providing emergency medical care to patients and the transportation of patients if used for that purpose. The term includes ALS or BLS vehicles that may or may not transport patients.

Basic Life Support (BLS)The basic pre-hospital and inter-hospital emergency medical care and management of illness or injury performed by specially trained, certified or licensed personnel.

ChiefThe ICS title for individuals responsible for command of functional sections: Operations, Planning, Logistics, and Finance/Administration.

CommandThe radio designation for the IC. Refers to the person, functions, and the location of the IC.

Command StaffThe Command Staff consists of the Information Officer, Safety Officer, and Liaison Officer. They report directly to the Incident Commander. They may have an assistant or assistants, as needed.

Communications UnitAn organizational unit in the Logistics Section responsible for providing communication services at an incident. It may also be a facility (e.g., a trailer or mobile van) used to provide the major part of an incident Communications Center.

DecontaminationThe process of making any individual, object or area safe for unprotected personnel; the process of rendering any chemical or biological agents harmless; or the process of removing chemical or radiation agents.

Dispatch CenterA facility from which resources are ordered, mobilized, and assigned to an incident.

DivisionUsed to divide an incident into geographical areas of operation and identified by alphabetic characters for horizontal applications and often by floor numbers when used in buildings. (Formally known as “sectors”)

Emergency Management Coordinator (EMC) The individual within each political subdivision that has coordination responsibility for jurisdictional emergency management.

Emergency Operations Center (EOC)A pre-designated facility established by an agency or jurisdiction to coordinate the overall agency or jurisdictional response and support to an emergency.

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Emergency Operations PlanThe plan that each jurisdiction has and maintains for responding to appropriate hazards.

Finance/Administration SectionResponsible for all incident costs and financial considerations.

Funnel PointA point between the incident site and treatment areas designated by the Triage Team Leader and identified by a white flag, through which every casualty should pass to access the treatment areas. The purpose of the point is to number and tag patients.

General StaffThe group of incident management personnel reporting to the Incident Commander. They may each have a deputy as needed. The General Staff consists of:

ü Operations Section Chiefü Planning Section Chiefü Logistics Section Chiefü Finance/Administration Section Chief

Ground Truth ReportAn actual field confirmation of a report by a known/trusted source.

Hazard and Vulnerability Analysis (HVA)A compilation of natural, human-caused and technological hazards and their predictability, frequency, duration, intensity and risk to population and property.

Hazardous MaterialAny material which is explosive, flammable, poisonous, corrosive, reactive, or radioactive or any combination and requires special care in handling because of the hazards it poses to public health, safety, and/or the environment.

Hazardous Materials Incident (HazMat)Uncontrolled, unlicensed release of hazardous materials during storage or use from a fixed facility or during transport outside a fixed facility that may impact the public health, safety and/or environment.

Impact AreaThe immediate area of an incident scene where the patients received their injuries and they were initially found.

Incident Action Plan (IAP)An oral or written plan containing general objectives reflecting the overall strategy for managing an incident. It may include the identification of operation resources and assignments. It may also include attachments that provide direction and important information for management of the incident during one or more operations periods. (Ex: ICS forms 202,203,204)

Incident Commander (IC)The individual responsible for all incident activities, including the development of strategies and tactics and the ordering and the release of resources. The IC has overall authority and responsibility for conduction incident operations and is responsible for the management of all incident operations at the incident site.

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Incident Command Post (ICP) The standard position for the IC, usually stationary, inside a command vehicle or in a specified area as designated by the IC. It is identified by a green flashing light or an orange flag.

Incident Command System (ICS) A standardized on-scene emergency management construct specifically designed to provide for the adoption of an integrated organizational structure that reflects the complexity and demands of single or multiple incidents, without being hindered by jurisdictional boundaries. ICS is the combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure, designed to aid in the management of resources during incidents.

Incident Communications CenterThe location of the Communication Unit and the message center.

Incident ObjectivesStatements of guidance and direction necessary for the selection of appropriate strategy (ies), and the tactical direction of resources. Incident objectives are based on realistic expectations of what can be accomplished when all allocated resources have been effectively deployed. Incident objectives must be achievable and measureable yet flexible enough to allow for strategic and tactical alternatives.

Incident TypesIncidents are categorized by five types based on complexity. Type 5 incidents are the least complex and Type 1 the most complex.

Information OfficerA member of the Command Staff responsible for interfacing with the public and media or with other agencies requiring information directly from the incident. There is only one Information Officer per incident. The Information Officer may have assistants.

Joint Information Center (JIC) A JIC is a central location that facilitates operation of the Joint Information System. The JIC is a location where personnel with public information responsibilities perform critical emergency information functions, crisis communications and public affairs functions. JICs may be established at various levels of government or at incident sites, or can be components of Multiagency Coordination Systems.

Liaison OfficerA member of the Command Staff responsible for coordinating with representatives from cooperating and assisting agencies.

Logistics Section The section responsible for providing facilities, services, and materials for then incidents.

Mass Casualty Incident (MCI)An emergency incident involving the injury and/or death of a number of patients beyond what the jurisdiction is routinely capable of handling. Also called a Multi-Casualty Incident or Multiple Patient Incident.

MorgueAn area on or near the incident site that is designated for the temporary placement of deceased victims.

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Mutual Aid AgreementWritten agreement between agencies and/or jurisdictions in which they agree to assist one another upon request by furnishing personnel and equipment.

National Disaster Medical System (NDMS)NDMS is a section under the U.S. Department of Homeland Security, Federal Emergency Management Agency that has the responsibility of managing and coordinating the Federal medical response to major emergencies and Federally declared disasters including: natural, technological, major transportation accidents, and acts of terrorism (includes events involving WMDs)

National Incident Management System (NIMS) A system described in HSPD-5 that provides a consistent nationwide approach for Federal, State, local, and tribal governments; the private sector; and nongovernmental organizations to work effectively and efficiently together to prepare for, respond to, and recover from domestic incidents regardless of cause, size, or complexity.

National Response Framework (NRF) Guides how the nation conducts all-hazards response. The framework documents the key response principles, roles, and structures that organize national response. It describes how communities, States, the Federal government, and private sector and nongovernmental partners apply these principles for a coordinated and effective national response.

Operations SectionThe section responsible for all tactical operations at the incident. Includes branches, divisions and/or groups, task forces, strike teams, single resources, and staging areas.

Planning SectionResponsible for the collection, evaluation, and dissemination of tactical information related to the incident and for the preparation and documentation of Incident Action Plans. The section also maintains information on the current and forecasted situation and on the status of resources assigned to the incident.

Planning MeetingA meeting held as needed throughout the duration of an incident, to select specific strategies and tactics for incident control operations and for service and support planning. On larger incidents, this meeting is a major element in the development of the Incident Action Plan.

Procurement UnitFunctional unit within the Finance/Administration Section responsible for financial matters involving vendor contracts.

Public Information Officer (PIO)A member of the Command Staff who is responsible for interfacing with the public and media or with other agencies with incident-related information requirements.

Rehabilitation AreaAn area outside the fire ground perimeter where crews are assigned for rest, nourishment, comfort and medical evacuation.

Rehabilitation ServicesServices provided at a disaster for the rest, nourishment and hydration, etc. of ALL emergency workers.

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ResourcesAll personnel, equipment, and supplies potentially available for assignment to an incident and that are tracked.

Safety OfficerA member of the Command Staff responsible for monitoring and assessing safety hazards or unsafe situations, and for developing measures for ensuring personnel safety. The Safety Officer may have assistants.

S.T.A.R.T. (Simple Triage and Rapid Treatment) A system that allows rapid triage of a large number of patients using the assessment of respirations, pulse, and mental status (RPM) to determine the triage category. This triage method allows rapid, prioritized medical treatment and transportation of the most seriously injured patients.

Staging AreaStaging areas are locations set up at an incident where resources can be place while awaiting a tactical assignment. Staging areas are managed by the Operations section.

TriageMedical screening of patients to determine their relative priority for treatment.

Triage AreaAn area of the Patient Collection Station specifically designated for IMMEDIATE, DELAYED, MINOR and MORGUE patients.

Triage TagA tag used by triage personnel to identify and document the patient’s medical condition.

TreatmentMedical management of a patient.

Treatment AreaA designated area for the stabilization of patients.

TransportMovement of patients; typically referring from the scene to a health care facility.

Transportation AreaA designated area where patients are moved following treatment as they await transport to a medical facility.

Unified CommandIn ICS, Unified Command is a unified team effort which allows all agencies with responsibility for the incident, either geographical or functional, to manage an incident by establishing a common set of incident objectives and strategies. This is accomplished without losing or abdicating agency authority, responsibility, or accountability.

Unity of CommandThe concept by which each person within an organization reports to one and only one designated person. The purpose of Unity of Command is to ensure unity of effort under one.

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ICS FormsThe ICS uses a series of standard forms and supporting documents that convey directions for the accomplishment of the objectives and distributing information. Provided below is a list of the forms that are used in order to effectively manage a mass casualty incident.

ICS Form Title DescriptionIncident Briefing ICS Form 201

Provides the Incident Command/Unified Command and General Staffs with basic information regarding the incident situation and the resources allocated to the incident. This form also serves as a permanent record of the initial response to the incident.

Incident Objectives ICS Form 202

Describes the basic strategy and objectives for use during each operational period.

Organization Assignment List ICS Form 203

Provides information on the response organization and personnel staffing.

Field Assignment ICS Form 204

Used to inform personnel of assignments. After Incident Command/Unified Command approve the objectives, staff members receive the assignment information contained in this form.

Incident Communications Plan ICS Form 205

Provides, in one location, information on the assignments for all communications equipment for each operational period. The plan is a summary of information. Information from the Incident Communications Plan on frequency assignments can be placed on the appropriate Assignment form (ICS Form 204).

Medical Plan ICS Form 206

Provides information on incident medical aid stations, transportation services, hospitals, and medical emergency procedures.

Incident Status Summary ICS Form 209

Summarizes incident information for staff members and external parties, and provides information to the PIO for preparation of media releases.

Check-In List ICS Form 211

Used to check in personnel and equipment arriving at or departing from the incident. Check-in/out consists of reporting specific information that is recorded on the form.

General Message ICS Form 213

Used by: ▪Incident dispatchers to record incoming messages that cannot be orally transmitted to the intended recipients.▪EOC and other incident personnel to transmit messages via radio or telephone to the addressee.▪Incident personnel to send any message or notification that requires hard-copy delivery to other incident personnel.

Unit Log ICS Form 214

Provides a record of unit activities. Unit Logs can provide a basic reference from which to extract information for inclusion in any after-action report

Operational Planning Worksheet ICS Form 215

Documents decisions made concerning resource needs for the next operational period. The Planning Section uses this Worksheet to complete Assignment Lists, and the Logistics Section uses it for ordering resources for the incident. This form may be used as a source document for updating resource information on other ICS forms such as the ICS 209.

Incident Action Plan Safety Analysis ICS Form 215a

Communicates to the Operations and Planning Section Chiefs safety and health issues identified by the Safety Officer.

Air Operations Summary ICS Form 220

Provides information on air operations including the number, type, location, and specific assignments of helicopters and fixed-wing aircraft.

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General Plan ICS Form 226

Addresses long-term objectives approved by Incident Command/Unified Command. These objectives are often expressed as milestones (i.e., timeframes for the completion of all and/or portions of incident response operations). A General Plan should identify the major tasks to be carried out through the end of emergency response operations, the duration of the tasks, and the major equipment and personnel resources needed to accomplish the tasks within the specified duration.

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