Saturday, December 16, 1995 21:55:10 Puget Sound EMSForum Item From: Sylvia Feder,dBug WasEMS@AOL.COM,Internet Subject: MCI information To: Puget Sound EMSForum Cc: tom gudmestad,Medic One OnLine Hi all, Found this on the Internet. Maybe we should create a conference for MCI stuff....what do people think?? syl ******** EMS Pulse December 1995 Part 2 ******************************* KEEPING YOUR EDGE: UP TO YOUR NECK IN ALLIGATORS: Command and Control of Multiple Casualty Incidents by Steven Kuhr, CEM, EMT-P --- Abstract: --- This article will explore the basic management of multiple casualty incidents (MCI). The clinical issues of MCI management, such as hands-on triage and patient care, and advanced incident management (for large-scale or protracted incidents) is not within the scope of this article and the author invites others to contribute as such to EMS Pulse. MCIs are often complex events which require aggressive and assertive command and control in order to execute the most efficient victim-care under chaotic conditions. The use of an Incident Command System (ICS) is the management tool of choice. ICS employs a rapidly developed on-scene organization designed to meet the needs of an incident through a commander and subordinate functional managers who directly oversee the specific actions to meet specific objectives. In the case of MCI management, the objectives are as follows: command and leadership; safety of operations; staging and mobilization of resources; triage and categorization of victims; collection and treatment of victims; and transportation of victims to medical facilities. --- Learning Objectives: --- Upon completion of this article, the reader will be able to: 1. Define a multiple casualty incident; 2. Detail the history and theory of MCI Incident Command; 3. Detail the role and responsibility of the EMS Incident Commander; and, 4. Detail the role and responsibility of sectors and sector officers Multiple casualty incidents (MCI) can be among the most stressful respon ses you will ever encounter as an EMS provider. Recent events which have caught the nation's attention corroborate this. Among the more prominent recent MCIs are the Oklahoma City Bombing, the Arizona Amtrak derailment, and the Illinois collision between a School Bus and a commuter train. Can any of these happen in your area? The answer is probably yes; an MCI of almost any type can occur in your area at any time. With proper training, planning and exercising, you can come away from an MCI with a sense of accomplishment. Moreover, you will approach an MCI with confidence instead of the sense of dread which often overcomes many EMS responders when the bell rings. This article will serve as an entry-level orientation of MCI operational procedures. For some it will be a review and for others it may be the first encounter with MCI operations. While many varying definitions of an MCI exist, for our purposes, I chos e to use the definition developed by New York City EMS. An MCI is defined as - Any incident which produced six or more victims - An Incident which requires more than two ambulances - An incident which has unusual or peculiar circumstances (e.g.: hazardous materials emergency, hostage situation, bomb scare, etc.) **Incident Command Background** Management of an MCI is really no different than the management of other types of major emergencies. The management model which has been accepted as the national standard-of-care for major emergency response is the Incident Command System which takes a management-by-objectives approach. ICS was developed in 1970 in California in response to a series of catastrophic wildland fires which destroyed hundreds of acres across many different jurisdictions. Many diverse agencies from many jurisdictions responded and acted in an non-cohesive manner, creating a situation where coordination was clearly needed. The foundation of ICS is the systematic and rapid development of an organization to accomplish defined objectives, hence the term "management-by-objectives." In the case of an EMS response to a major event, the objectives are geared toward effective and organized patient-care, whereas in the fire service the objectives are vectored toward fire suppression and rescue. And while a cross-over of responsibilities may exist where firefighters also provide patient-care and vice versa, ICS allows for this by assigning personnel to specific tasks based on their training and daily responsibilities. In the mid-1970's another management system was developed by the Phoenix Fire Department. This system, Fire Command, is similar to ICS in design and also allows for a management-by-objectives approach. The similarities of each command system was very apparent. A national project has come about in the past few years to combine the finest attributes of each system in an effort to define a new national standard entitled the Incident Management System. Whether you call it ICS or IMS, the bottom-line is that you will employ an organized, efficient response to MCIs. **MCI Command Background** In 1983, a management task force was commissioned by the Chief of NYC*EM S to identify weaknesses in MCI management and to develop an operational plan with the goal of effective and efficient patient care through organization. In their research, the team found that ICS and Fire Command, as well as an MCI management model developed by the California Fire Chiefs Association, had application to New York's needs. The EMS Incident Command Model was born and has been in effect now for 12 years. NYC*EMS has enjoyed success in the area of MCI management with all experience, training, and exercising coming to bear on February 26, 1993 when a terrorist's bomb exploded in the basement of the World Trade Center killing six and injuring 1,042. **Early-Arriving Ambulances and Squads** Medical Incident Command begins with the arrival of the first EMS unit. First-in units have a tremendous responsibility; therefore, all EMS providers should be competent in their role within MCI incident command and should be well versed in the role of early arriving units. First-in units must conduct a size-up. This serves to verify that an MC I emergency exists (aircraft crash, fire, bus accident, etc.); a unit's initial size-up is no different that the old "10 second survey". Verify that you are safe; identify what has happened and how many victims have been produced or can be produced; what resources are needed to resolve the incident; the location of your command post; and, the best and safest access route into the staging area. The senior EMT or paramedic then assumes control until relieved by supervising personnel. If possible and if safe to do so, contact with commanders of other emergency service agencies (fire and police) should be made in order to effect a coordinated effort among all personnel. The first-in unit also develops a preliminary plan of action, which is consistent with that of other emergency groups. This may be as simple as identifying triage and treatment areas in the incipient stages of an operation. Secondary and other later arriving units must follow the direction of th e senior member of the first-in unit in that this individual has the authority to direct operations. It must also be understood that in smaller EMS systems, the senior member on the first-in unit may serve as the medical incident commander in that he/she may be the senior-most member of the organization on-scene. The onus to assume command of MCI medical operations is usually with the Crew Chief in volunteer EMS systems. **EMS Field Supervisors** In EMS systems where supervision is conducted by field supervisors who a re independent of ambulance and squad crews, the first arriving EMS supervisor assumes command of the EMS operation and retains command until relieved by a superior officer. A stationary and easily identifiable EMS command post must be established. Setting up a command post adjacent to the command post of other groups operating is desired to effect easy cross-agency communication and coordination. If this is not possible, assigning a liaison officer to accomplish the objective of interagency coordination will prove to be quite beneficial. The EMS Commander should wear a vest or some such outer garment which clearly identifies the individual as the EMS Commander. **Role of the EMS Command** The EMS Commander becomes the "chief executive" of the medical operation and is responsible and accountable for the success (or failure) of the operation. The EMS Commander develops a strategy and implements tactical operations to meet the medical needs of an incident. This includes assessing and modifying (if necessary) the preliminary action plan which was developed by first arriving units. As additional supervisory personnel arrive, EMS Command delegates authority to them to manage medical/tactical objectives, primarily, staging, triage, treatment, and transport. These functions are carried out in modular management units called sectors. The individual supervising the respective function then becomes the sector officer who reports directly to EMS Command. **Command and Control** EMS Commanders must be well versed in the art of Incident Command. This can only be accomplished through training and experience. Just as we will have gone through training at our respective prehospital care levels (EMT-D, EMT-CC, EMT-P, etc.), personnel responsible for command of MCIs must also seek out training in ICS, especially that which has an emphasis on MCI management. Experience can only be gained by actual or exercised MCI responses. Taking advantage of participating in every available disaster exercise can also help hone those incident command skills. Command presence is a critical attitude which must be felt and conveyed by the EMS commander. Command is nothing short of logical and competent leadership; command presence includes attributes such as being calm, confident and authoritative. This is crucial so that when you're at your command post and you feel like you're up to your neck in alligators, you can pull together all your training and experience and apply it effectively to successfully manage the MCI. **Triage** In the best of worlds, EMS providers would be able to provide care to MC I victims which is as close as possible to conventional, everyday prehospital care. This, however, is often not possible. The essence of triage is to do the most good for the most victims based on the limited amount of medical responders usually available. It is crucial that triage be conducted to sort the victims requiring the most attention from those who do not, or who are deceased. This is not a simple task and may have a strong emotional impact on EMTs and paramedics. A Critical Incident Stress Debriefing mechanism , to address the emotional needs of the triage team, should be available as part of your organization's basic operational plans and procedures. A triage officer, appointed by EMS Command, is responsible for operation al oversight of the triage sector. The triage officer should not clinically assess victims, rather, the triage officer supervises the effort. Effective triage management includes categorization of victims using color-coded triage tags. The triage officer also facilitates the movement of victims to the treatment area in a prioritized and timely manner (based on the victim's classification) and in coordination with the treatment officer. The triage officer also monitors the safety of the triage team. **Casualty Collection and Treatment Management** Once victims are triaged, they are moved to a treatment sector. If all victims are triaged and no further victims are expected, the victims may remain in place with the triage sector now serving as the treatment sector. As in triage, an officer is assigned as the sector officer to oversee medical operations. Clinical oversight is also required here to ensure that the most appropriate and highest quality care is provided to the victims. Clinical oversight can be accomplished by an EMS physician or a senior paramedic who reports to the treatment officer. Care should be provided to victims in a descending order-of-triage. Victims tagged as the highest priority (immediate -- red tags) are treated before the victims tagged delayed (yellow tags). All victims however should be constantly re-triaged to ensure the appropriate application of medical care at the appropriate time. The treatment sector can subdivided into patient care groups based on the triage color scheme; red tag victims can be placed in a red tag area and so on. This not only adds a sense of organization and coordination but also enhances efficacy of medical care by allowing EMTs and paramedics to vector their efforts accordingly. Treatment officers coordinate their activities with the triage and transport officers. **Transport Management** As victims enter the transport sector from the treatment sector, victims are once again re-assessed for proper triage categorization and then transported accordingly. Transport may be accomplished by land ambulances or air ambulances. The movement of patients by both means come under the purview of the transport officer. The transport officer is also responsible for the distribution of victims to hospitals and specialty centers. Therefore, the transport officer must maintain a dynamic list of hospital availability. This can be accomplished by either direct communication with the hospitals or through a dispatch center which gathers the information and communicates it to the transport officer. The latter is the efficient and logical choice. Patient tracking is another function of the transport sector. The trans port officer should assign a tracking aide to gather victim pedigrees which include the victim's name, gender, age, injury, and disposition. Victim tracking ensures efficient documentation and victim accountability. This is important for many reasons including family notifications and investigations (such as a National Transportation Safety Board investigation after an aircraft emergency). **Safety** Last but certainly not least, is the safety sector. MCIs usually occur at the worst possible times in the worst possible places. Safety hazards are often quite prevalent but a dilemma exists when victims need to be cared for in adverse, unsafe conditions. Enter the safety officer. The safety officer, an immediate member of the EMS Commander's command staff, is responsible for the safety of operating personnel. The safety officer monitors conditions while EMTs and paramedics are providing patient care. The safety officer is also authorized to execute emergency command authority to cease an unsafe act or avert unsafe conditions. Therefore, it is imperative that the orders of the safety officer be complied with immediately without hesitation. Anecdotally, I know of a story where a safety officer gave an order to evacuate a specific area at the scene of a plane crash. A paramedic and physician decided, on their own, to disregard the order in favor not abandoning their patient. A flash fire occurred and both suffered severe burn injuries. This story drives home the point of safety officer compliance. **Conclusions** While there may be a lot to digest, this is really only the basics of MC I command and control. The management scheme detailed here, however, will provide you with the foundation necessary to succeed at small to moderate patient producing events. Advanced planning, training and preparation is needed to ensure that responders are aware of their roles and that other agencies understand their role in their support to your operation. Conversely, how do you support their operation? Start small. Write a basic MCI plan and practice it. Build on it from there and you will soon see the benefits of your effort. The goal is organized, effective and efficient patient care. Keep that in mind and you'll do well the next time someone yells, "send me as many ambulances as you can"! .............................................................................. ...................... About the Author: Steven Kuhr, CEM, EMT-P, is a deputy chief of the New York City Emergency Medical Service (NYC*EMS) Queens Borough Command. He has served in many capacities at NYC*EMS. As a captain he commanded the Special Operations Division, an MCI Command and Control and Hazardous Materials response unit. He held emergency management responsibilities serving as liaison to other agencies as well as the Mayor's Emergency Control Board and has represented NYC*EMS on many national, regional and local working groups. He has participated in countless MCI responses in a leadership capacity. He is a nationally Certified Emergency Manager. He is also a contributing editor of RESCUE Magazine, a JEMS Publication, and is a member of the Editorial Advisory Board and Contributing Editor of Fire Engineering magazine. He lectures and writes on disaster and related topics. He may be reached by e-mail at skuhr@panix.com. **Author's Note: On the Internet, an electronic mail list (listserv) regarding MCI management (MCI-Talk) is available at the below address. This growing list boasts over 150 experts on MCI command. We invite all EMS, fire, law enforcement and emergency management personnel to participate in the discussions. So join in and subscribe as follows: To subscribe send e-mail to: listserv@mediccom.norden1.com no subject is needed In the body of the text write subscribe mci-talk Postings then go to MCI-Talk@mediccom.norden1.com **Disclaimer: The procedures detailed here are proven as successful and serve as an overview of national standards in MCI management. It should not, however, substitute your local protocols for MCI management. ****************************** CREDITS Editor: William Storm, EMT-D Advisory: Jeffrey T. Reilly, EMT-P, Chief, HVAC Medical Advisor: Dr. Victor Cohen, M.D., FACEP; Director, E.D., St. Agnes Hospital, White Plains, NY Web Page Designer/Coordinator: Scott Savett, NREMT EMS Pulse can be contacted by phone, mail, fax, or e-mail.: HVAC, Box #5 2 Pleasant Ridge Road Harrison, NY 10528 Phone: (914) 921-0100 Fax: (914) 921-0102 Internet: Editor: wasems@aol.com HVAC: hvacems@aol.com World Wide Web URL: ------------------------------------------------ Copyright 1995 Harrison Volunteer Ambulance Corps, All Rights Reserved. ------------------------------------------------ End Part 2 ----Internet Header Follows---- Path: dbug.org!nwfocus1.wa.com!nwnews.wa.com!uunet!in1.uu.net!newsfeed.internetmci.com!howland.reston.ans.net!paladin.american.edu!auvm!AOL.COM!WasEMS Comments: Gated by NETNEWS@AUVM.AMERICAN.EDU Newsgroups: misc.emerg-services Message-ID: <951213122307_71861245@mail02.mail.aol.com> Date: Wed, 13 Dec 1995 12:23:08 -0500 Sender: Emergency Services Discussion List From: WasEMS@AOL.COM Subject: EMS Pulse 12-95 pt 2 Lines: 355