EMS Mass Casualty Incident (MCI) Protocol

• This Standard Operating Procedure pertains to EMS Mass Casualty Incidents.
• The purpose is to establish procedures for triage, extrication, treatment, and transportation of victims in multiple casualty incidents.
• The document was reviewed annually.
• The document was effective as of April 4, 2012.

Definitions:

• Mass Casualty Incident (MCI): An incident with ten or more victims.
• Multiple Casualty Incident: An incident with fewer than ten victims, or any incident where the number of casualties overwhelm available resources.
• Triage: Sorting patients and injuries to determine treatment and transportation priorities.
• Triage, Treatment and Transport Site (T-3): Area to centralize patients for triage, treatment and transport.
• Casualty Collection Point (CCP): Serves as a buffer between the incident site and the T-3 site, established if the number of patients requires organized inflow.

General Information:

• Incident Command will be established and follow ICS procedures.
• Fire Department personnel manage Extrication and Triage Groups.
• A T-3 Site will be established close to the incident and managed by MedStar personnel.
• Fire Department personnel assigned to the T-3 site will coordinate with the T-3 Group Supervisor (MedStar Employee) for patient management.
• The Fire Department Triage Group Supervisor establishes a Casualty Collection Point (CCP) immediately outside the T-3 if conditions warrant.
• A Medical Branch may be established if required.
• Medical personnel and equipment are requested in the same manner as additional fire companies.
• A media information area should be established away from the incident scene and T-3 to ensure patient confidentiality.
• Triage is a continuous process, and is initiated by the first arriving company.
• Triage is closely monitored and continued through extrication, treatment, and transport, and it's implemented on all multi-victim incidents
• Five rolls of surveyor's tape (1 red, 1 yellow, 1 green, 1 blue, 1 black) will be carried on all apparatus.
• Branch Directors, Group Supervisors, and Unit Leaders will wear vests to indicate authority and responsibility in a crowd.
• Incident Command organizational charts, a triage flowchart, and an MCI worksheet are attached in this SOP.
• The MCI worksheet F.D. 304 is carried in EMS clipboards and used by Branch Directors, Group Supervisors, and Unit Leaders at all Mass Casualty Incidents.
• This directive is implemented anytime an MCI is declared or a one-alarm or greater assignment is committed to an EMS incident.
• The Fort Worth Fire Department MCI Trailer is automatically dispatched on all declared MCI incidents, or any time a one-alarm assignment or greater is committed to an EMS incident.

Incident Command:

• Rapidly evaluate the situation (size-up).
• Develop an on-scene management strategy.
• Assign necessary Fire Department companies as needed.
• Provide continuous command and progress reports to Alarm and the EOC.
• Delegate authority to subordinates using Sections, Branches and/or Groups as per the National Incident Management System.
• Review and evaluate the effectiveness of operations at the site and revise as needed.
• Phase down the incident response as appropriate.

Triage Group:

• Triage Group operations are managed by Fire Department personnel.
• The Incident Commander designates a fire officer to work with the MedStar Triage Medic at the T-3 site to triage patients placed within the T-3 Site.
• Fire Department personnel assist the MedStar Triage Medic at the T-3 by tagging patients and guarding the entrance to the T-3 Site.
• The Fire Department Triage Group Supervisor is responsible for initiating a Casualty Collection Point (CCP) if needed.
• If established, the CCP is located adjacent to, but outside of, the T-3 Site entrance.
• If a CCP is established, the Fire Department Triage Group Supervisor is responsible for selecting the order of patients moved from the CCP to the T-3 Site.

Triage Using the S.T.A.R.T. Method:

• The START method of triage of patients means Simple Triage And Rapid Transport.
• When using S.T.A.R.T., only two interventions are allowed for patient care: opening the airway (two attempts only), and controlling life-threatening hemorrhaging (apply one pressure dressing only).
• The process based on patient assessment and medical criteria enables responders to appropriately and rapidly prioritize patients.
• The appropriate length and color tape is attached to the patient in such a manner as to be readily visible at all times.
• Patient's condition changes, remove the initial color tape and replace it with the color tape that indicates the patient's new condition.

Triage Color Coding:

• Black (Priority 0): Deceased, do not remove bodies until authorized. Do not start CPR until all patients are tagged and resources are available.
• Red (Priority 1): Critical/immediate patients requiring ALS.
• Yellow (Priority 2): Non-Critical/Delayed patients whose transportation can be delayed.
• Green (Priority 3): Minor or no injuries (Walking Wounded); transportation by ambulance is unnecessary.
• Blue (Priority 4): Expectant, alive but seriously injured (non-salvageable) those who should not consume limited available resources.
• The triage process will begin with a patient assessment and should be limited to 30 seconds per patient.
• A public address announcement will be made directing people who are uninjured to move to a designated safe area away from the CCP and T-3 Sites. These victims will be triaged after the other victims have been assessed and treated.

START determines priority based on:

• Airway: If not open after two attempts, tag BLACK. This is intervention (1).
• Breathing: If respirations are greater than 30 per minute, tag RED.
• Circulation: Check capillary refill. Delayed (greater than 2 seconds), tag RED; also, if radial pulse is absent, tag RED. Rescuers may apply a pressure bandage to life-threatening hemorrhaging. This is intervention (2).
• Mental Status: If unable to follow commands, tag RED; will be tagged YELLOW (delayed) or GREEN (minor injuries, ambulance transport unnecessary) if passes assessment.
• Victims are moved to the T-3 or CCP (if established) in accordance with tagged priorities.

Extrication Group:

• The Incident Commander designates a Fire Department emergency responder to direct Extrication Group operations.
• Request personnel and equipment resources for rescue and rapid field triage and supervise their utilization
• Personnel assure that patients found throughout the incident are triaged, and, if necessary, moved to the T-3, or CCP (if established).
• Deceased persons are not moved, with the exception to rescue injured victims until movement is coordinated with the Medical Examiner. There location will be marked with a flag or some other device.
• The Incident Commander is kept advised of the progress of the operation, including moving to the Treatment Sector when all victims have been moved.
• Extrication group will coordinate with other Groups and Divisions.

Triage, Treatment and Transportation Group (T-3):

• Managed by the EMS Group Supervisor (First-in MedStar 80/81).
• All Triage within the T-3 will be managed by the MedStar Triage Medic.
• The Triage Medic is responsible for the triage all patients before they are placed inside of the T-3.
• Each patient is tagged for tracking with a Triage Tag.
• Ensure that the entrance to the T-3 is guarded by not allowing patients into the T-3 until they have been tagged.
• All patient treatment will be provided in the Treatment Area of the T-3 Site.
• Treatment Group operations are directed by MedStar personnel.
• The Incident Commander assigns a fire officer to assist the MedStar Treatment Medic with communication and management of the Treatment Area.
• The Fire Department officer assigned to the T-3 reports the location of the T-3 Site to the Incident Commander. The fire officer can also request personnel and equipment resources, supervise their utilization and keep the Incident Commander apprised of the operation's progress. Coordinate with other Groups and Divisions as necessary.
• Medical Transportation operations are directed by MedStar personnel.
• All patient transportation from the site will occur from the T-3 Site.
• The Incident Commander designates a fire officer to assist the MedStar Transportation Medic with communications, management of patient transportation, and to keep the Incident Commander apprised of progress.
• The assigned Fire Department officer Assists in coordinating information to Incident Command. Requests additional transport resources (buses, helicopters, help plan) through the Incident Commander, report the location of Ambulance Staging and loading areas to both, request, through Incident Command, the designation of a helicopter landing area if necessary, Coordinate with other Groups or Divisions, and notify Incident Commander when the last victim has been transported.

Incident Command Structure:

• This may be expanded by adding any or all of the following:
• Medical Branch Director:May be designated by the Incident Commander, is located adjacent to the Command Post, coordinates operations of the Medical Supply, Extrication, Triage and the T-3 Site and keep the Incident Commander apprised of the situation.
• Medical Supply Group:The Incident Commander may designate a Medical Supply Group Supervisor and establishes it nearby the T-3. This group should also determine the supply needs of other divisions and coordinate additional supplies as needed.
• Staging Group/Division:The Incident Commander designates a Staging Group Supervisor responsible for coordinating with Police Department to block access required for the staging operations, ensure appropriate parking of vehicles in the staging area. They also need to maintain the log of companies as well as inventories of equipment & medical supplies. This group will review the minimum resources needed with the Incident Commander and maintain a visible position with emergency lights on.
• Transportation Officer: A Transportation Group Supervisor may be established for incidents involving multiple T-3 areas. The Transportation Group Supervisor shall be a MedStar representative, be located adjacent to the Command Post, designate and direct the activities of transportation aides assigned to the Treatment areas, maintain the transportation log of patients and receiving facilities and keep Incident Command appraised of the situation.