Incident Command: Managing Multi-Casualty Incidents

• A fireground Incident Commander (IC) must be skilled in managing multi-casualty incidents (MCIs), as any response could escalate into one.
• Mass shootings, like the Route 91 Music Festival Shooting in Las Vegas, NV, exemplify the rise in MCIs, which have been around for decades.
• MCIs now require more sophisticated protocols at both national and local levels for astute officers to save the most lives.
• Man-made disasters, such as active shooter events or terrorist attacks, increase the likelihood of large-scale MCIs, demanding unified command and effective public information management.
• Swift triage, treatment, and transport are critical
• ICs must command MCIs as proficiently as any fire, applying learned incident command principles and performing ongoing mental size-ups using FPODP (Facts, Probabilities, Own Situation, Decisions, Plan).
• ICs must bridge tactical gaps, maintain incident power curves, set clear objectives, decentralize command using ICS, and possess knowledge of local MCI protocols, nomenclature, and resource levels.
• Utilizing START (Simple Triage and Rapid Treatment) is essential for rapid patient categorization
• An MCI on a freeway involved multiple vehicles and required extrication, leading to the ordering of additional resources and the use of START for patient organization
• Managing patient care alone in MCIs is challenging.
• MCI are often associated with concurrently managing at least one significant hazard.
• Responders are often dispatched to violent crime scenes which requires staging until law enforcement secures the scene, prioritizing caution and firefighter safety.
• Fire dispatch centers use lateral communication with law enforcement dispatch to coordinate entry clearance for fire and EMS.
• Lack of coordination between law enforcement and fire/EMS during active-threat incidents can result in chaos due to communication breakdowns, conflicting objectives, and strained resources.

Century Theater Shooting - Aurora, Colorado, July 20, 2012

• A shooter opened fire, shooting 70 people in just over two minutes, resulting in 12 fatalities.
• The initial dispatch inadequately conveyed the scope, dispatching only a single engine, battalion chief, and ambulance.
• Upon arrival, the battalion chief encountered over 1,400 people fleeing the theater complex, many covered in blood.
• The battalion chief faced the challenge of establishing scene control and determining resource needs, starting behind the power curve due to poor situational awareness.

The Challenges of the Theater Shooting

• There was a failure to establish direct communication between police and fire incident commanders
• Geographical distance exacerbated the communication breakdown between police and fire commanders.
• The police department did not know how to directly communicate with the fire department.
• Dispatchers received sequential 9-1-1 calls, which were needed to be answered, leading to unacknowledged rescue and EMS requests.
• There were lost requests, duplicate requests, and miscommunication due to information passing through multiple dispatchers.
• Police and fire personnel do not participate in regular communications interoperability drills.
• Radio interoperability issues involved police channels being unavailable on the Fire Department ‘Suppression' Fleet channels, and accessing interoperable talk groups required switching from primary channels, risking missed transmissions.

How to Manage Chaos

• Public safety agencies must adhere to three rules when responding to emergencies:
  • Task saturation: Prioritizing the task at hand, such as wound treatment or providing cover, within a limited area.
  • Tactical approach: Company officers focus on guiding their teams, which may limit awareness of other tactical activities.
  • Strategic focus: Understanding incident commanders must set a strategic mode and goal, and assign tactical assignments.

Emergency Complexity

• Simple emergencies: These are routine, employing step-by-step processes for control.
• Complicated emergencies: These require thought and are more complex, like manhunts or cardiac arrests with arrhythmias.
• Complex emergencies: Require a high level of coordination, communication and trust
• Active shooter situations are an example of a complex emergency, presenting unique challenges that require constant adaptation.

Basic Incident Types

• Law Enforcement Only
• Fire/EMS Only
• Combined law enforcement, fire, and EMS event
• Combined events require coordination, communication, and trust.

Commander Responsibilities

• Establish a strategic unified command.
• Identify tactical divisions and groups.
• Assign task-specific actions for effective extrication, triage, treatment, and transport.
• The modern MCI response evolved from military practices and necessity.
• "Slow is smooth; smooth is fast" is a useful approach for managing MCIs.
• Paramedics represented advanced life support capabilities, providing triage similar to battlefield medics in order to save the most people with limited resources.
• All significant MCIs have shortages of resources initially.
• Quick patient triage to allocate resources effectively is crucial for saving lives.
• Patients are sorted into immediate, delayed, and minor categories.
• Time is critical, and the "golden hour" must be maximized.
• Triage, treatment, and transport are the three primary objectives
• Incident command system must stay ahead regarding resource requests, communication, apparatus, and equipment movement.
• The incident could potentially be larger: a high-rise fire, collapse.
• Additional responders like law enforcement, media, site managers etc.
• Unified command, mutual aid, and rescue task forces bridge the gap between fire and law enforcement.
• Rescue task forces are embedded with law enforcement to remove patients to a casualty collection point.
• Casualty collection points are locations for treatment and transport.

Twin Parks Apartments Incident - FDNY

• The FDNY responded to a fire on January 9, 2022, at 333 East 181 Street (Twin Parks North West).
• First-arriving units reported unconscious victims on the third floor, with the fire escalating to a second alarm.
• The fire was recognized as extraordinary, and the FDNY responded with a third alarm.
• The FDNY saved nearly 100 occupants at the Twin Parks North West building.
• The fire began in Apartment 3N, a duplex on the second and third floors of the 19-story building.
• The fire started from an electric space heater on the second floor and spread to Apartment 3J and the public hallway due to open doors.
• Smoke reached the 19th floor due to open doors to the fire apartment and stairwells, leaving limited time for rescues.
• FDNY members removed over 30 victims from cardiac arrest.
• Smoke inhalation killed seventeen people.

Analyzing the Incident

• Incident priorities, command and control, and leaders' intent must be interrelated and clearly communicated.
• Resource management must be tracked, and additional resources need to be called for early due to the number of victims.
• Time to task completion must be drilled upon and have times tracked.
• Street management plan for ambulance access and egress.
• Communications must be clear, calm, and precise.
• Radio frequencies - Consider additional radio frequencies for use as command
• Surge capacity - Have a written plan and know the number of patients that can be brought to a hospital
• Reflex time must be understood to know timing of ambulances arriving
• Maintaining a manageable span of control - Strive to stay within 3-7.
• Being current enables the modern fire commander to proactively implement strateiges

The "SAW-CSS-RECEO-VSS" System

• Is commonly used, and easily applied to MCIs.

MCI Size-Up Includes

• FPODP or FIRST algorithm
• MCI type: Trauma from a MVA/shooting, Hazmat, Medical from sick building
• Type of patients: Triage using the START system as one of three categories

Tactical Arrival

• Arrival report will be dictated by the SOG(s)

Apparatus Placement

• Consider apparatus placement early as you don't get a 2nd chance.
• First arriving engine to see 3 sides of the incident
• Be cautious of a hot zone that could damage apparatus
• The travel plan has to identify before more units arrive
• Consider Staging and Helispots

Water Supply

• Probably won't be a factor, but consider water supply for decontamination during hazardous incidents
• Need to take action to take advantage of hydrants as soon as possible

Command

• One incident commander at a time and they must be the first to assume command on scene
• Call additional alrms early to confirm stagin location
• Establish the Incident Command System
• Have communications - maybe a seperate tactical channel for medical group
  • The IC will make the location known and communicate with law enforcement early to engage unified command

MCI Strategies May Be

• Offensive
• Defensive
• Combination

Safety is a Primary Concern

• Security
• Secondary devices
• Exposure of hazardous materials

Rescue Has Objectives

• Triage

• Treatment

• Transportation

• Assigning a group supervisor

• Consider RTFs to work for a rescue group supervisor Task MCC with determining where patients will be transported

For MCIs

• Exposures are other areas with victims
• Consider a exposure downwind of hazmat releases from moving vehicles
• Know that walking the wounded can potentially cause large-scale MCIs.
• Has the threat been neutralized?

General

• Take a poll to make sure everyone is accounted for

• Family will want to know, so call all

• Ventilation For an MCI, ventilation refers to extreme weather exposure to victims while they are being

• Treated and awaiting transportation

• Always have a backup plan,

• Make sure you are in the right area

• Support: Consider the following for support

  • Law enforcement
  • Investigator -Public information officer
  • Safety officer
  • Red cross -Utility companies ReHab AirLight unit or hazmat team

• ICS and communications -ICS varies on complexity Medical operation may require a separate channel if over 50 patients

Specific positions

• List of postions include medical group of supervisor
• Unit leader: will notify hospitals of any traumas or transfers of patients
• Like all tactical supervisors, Medical Group Supervisors bridge
• Mgs links strategic and tactical, will likely objective treatment or triage The MBD will manage
• Medical Branch director will manage larger operations, medical devisions are established and will manage larger operations