Multi-Casualty Incidents PDF

Multi-Casualty Incidents  Fig. 15-0. View from shooter's window at Mandalay Bay. *Source.* Photo courtesy of Clark County Sheriff (NV) Introduction The fireground IC must be proficient at MCI command because any response could become an MCI, and unfortunately, mass shooti...

Multi-Casualty Incidents  Fig. 15-0. View from shooter's window at Mandalay Bay. *Source.* Photo courtesy of Clark County Sheriff (NV) Introduction The fireground IC must be proficient at MCI command because any response could become an MCI, and unfortunately, mass shootings are on the rise, such as the Route 91 Music Festival Shooting in Las Vegas, NV (fig. 15-0). Multi-casualty incidents have been around for decades. Structure fires, motor vehicle accidents (MVA), hazardous materials incidents, industrial acci­ dents, and other incidents have grown into MCIs since firefighters have been responding to fires (fig. 15-1). The difference now is two-fold. First, MCI protocols at the national and local levels have become more sophisticated, requiring the astute officer to understand how to apply them to save the most savable lives. Second, manmade disasters (active shooter, terrorist acts, etc.) have created a greater potential of a large MCI that will involve unified command and other challenges, including public information management and transition to a Type 3 incident or above. The unified command component is presented in much greater detail in chapter 16. *Time is the most criticalfactor in an MCI.* Patients must be rapidly triaged, treated, and trans­ ported to definitive care. The IC must be proficient in commanding an MCI just as effectively as any fire. Like any incident, the components and principles of incident command that you have learned in this book will apply to the MCI. Perform an ongoing mental size-up with FPODP, bridge the tactical gap, stay ahead of the incident power curve, give clear objectives, decentral­ ize command with incident command system (ICS), and so on. In addition, you must possess a working knowledge of your local MCI protocols, nomenclature, and resource levels. Units responded to an MVA on the freeway. Upon arrival, the first-due engine reported mul­ tiple vehicles involved, including the need for extrication. I ordered an additional engine, truck, and several transporting medic units. Some occupants had no complaints, some had signifi­ cant injuries and were entrapped. Crews utilized simple triage and rapid treatment (START) to quickly organize the patients. Upon arrival and assumption of command, the incident was organized into a rescue group and a medical group. The rescue group objective was extrication of all entrapped victims. The medical group objectives included triage, treatment, and transport of all patients. Unified com­ mand was established with the highway patrol. Since the patient count was only eight, the MGS was able to contact the trauma center and coordinate the transportation destinations of all the patients. The incident was mitigated relatively quickly. Evolution of MCI Response  Previous and current generations of responders are often dispatched to a violent crime and required to stage until law enforcement declares the scene secure. This erring on the side of caution and firefighter safety is commonplace. Fire dispatch centers communicate laterally with law enforcement dispatch centers to notify fire and EMS when they are cleared to enter the scene. This can cause myriad problems. One example is the lag time between cops on scene getting information to staged fire and EMS crews, creating a significant delay in treatment of patients. Another example is that conditions often change and the scene that is declared secure dete­ riorates by the time fire and EMS arrive. This occurred on a shooting one night when we were staged awaiting the all clear from law. We were notified by dispatch that the scene was now all clear per law and went in. Once inside the scene, multiple gang members had guns drawn and threatened to shoot our crew if we didn't move fast enough to save their fallen colleague. A major problem in the past was the abject lack of coordination between law and fire/EMS during active-threat incidents, such as an active shooter. Lack of communication, unified com­ mand, use of ICS, and competing objectives would create chaos. Cops and fire would set up different command posts that did not talk to each other or identify priorities, strategy, or joint tactical objectives. Resource requests would be conflicting or redundant, straining the entire system. CASE STUDIES IN COMMAND Century Theater Shooting CAPTAIN (RET) RYAN FIELDS-SPACK, AURORA (CO) FIRE DEPARTMENT On July 20, 2012, a shooter entered the Century Movie Theater in Aurora, Colorado, and opened fire (fig. 15-2). In just over two minutes, he shot 70 people---with 12 suc­ cumbing to their injuries. As with many incidents, the initial dispatch did not convey the scope of the situation and came in as a "person shot." Thus, a single complement of engine, battalion chief and ambulance were dispatched. Upon arrival, the battalion chief noted over 1400 people streaming out of the theater complex, many of them covered in blood. Starting from this point, the battalion chief had the challenge of both setting up the scene and working to decipher what had happened---and how many resources were needed. In short, he was behind the power curve from the beginning due to diminished initial situational awareness. The Challenges Three specific challenges confronted responders during the Aurora theater shooting. After the incident, the Aurora city council contracted with the company Tri-Data Divi­ sion, System Planning Corp, to conduct a formal after-action report. The lessons learned can similarly be applied to many of today's active shooter incidents. For Aurora spe­ cifically, Tri-Data identified three core communication challenges:^1^ Challenge 1 *Police andfire commanders did not establish a unified command.* As responders approached the scene at the theater on July 20, 2012, they faced multi­ ple choke points, a fire alarm activated in the background, and over 1400 patrons streaming into the parking lot. Per Tri-Data, "There was a failure to establish direct communications links between the police and fire incident commanders and, to a lesser extent, with responding mutual aid units." This was due in large part to the geo­ graphical distance between the police and fire commander on the scene. Challenge 2 *The police department was unable or did not know how to communicate directly with the* *fire department.* Dispatchers, in addition to tracking and assigning resources, were also receiving sequential 9-1-1 calls that needed to be answered. As a result, "multiple requests for rescue and EMS from police in the field were acknowledged by the police dispatcher but not received or not acknowledged by the fire department incident commander, and needed resources were not assigned." Further, "\... requests \[were\] being made directly to the police dispatcher by multiple field units, which made it difficult to identify dupli­ cate requests and keep track of EMS assignments. Any time information must pass through multiple hands it is possible there will be miscommunication, duplicate requests, and lost requests." Challenge 3 *Police and fire department personnel did not participate in regular communications* *interoperability drills.* While the sheer volume of injured on the scene exacerbated the communication diffi­ culties, the following radio interoperability challenges were noted: "Police channels were not available on the Fire Department 'Suppression' Fleet channels. Accessing interoperable talk groups required switching away from primary police or fire chan­ nels, making it highly possible that critical transmissions would be missed." How Can *Calm the Chaos* Help? Implementing the strategies and tactics taught in this text can vastly improve upon the preparedness of the next commander at an incident like this. Chief Kastros has articu­ lated that public safety agencies, whether law enforcement, fire, or EMS, are bound by three general rules as they respond to emergencies and apply to everyday calls for ser­ vice, as well as those once-in-a-career active shooter events. The rules include: Every first responder executes an emergency response from one of three points of view: Task saturation: A paramedic treating a wound or an officer providing cover Tactical approach: Company officers are guiding the tactical activities of their Strategic focus: Incident commanders are charged to identify a strategic mode Those points of view take place on emergencies with varying levels of complexity. They can be simple, complicated, or complex. Simple emergencies: First responders face simple emergencies daily, and they Complicated emergencies: A manhunt for a dangerous person or a cardiac arrest Complex emergencies: An active shooter is a complex emergency---one with a There are three basic types of incidents first responders face every day: Law Enforcement Only. Fire/EMS Only. Combined law enforcement, fire, and EMS event---where all agencies are called in their respective task-oriented, tactical, and strategic activities at the same time. These combined complex events require a level of coordination, communi­ cation, and trust that is increasingly difficult to achieve. By implementing the strategies in this textbook, you will be better prepared to manage the scene of the next complex active shooter incident. You will calmly and confidently: Establish a strategic unified command. Identify tactical divisions and groups. Assign task-specific actions to effectively extricate, triage, treat, and transport the patients to lifesaving care. The responders to the Aurora Theater shooting performed incredibly well during a once-in-a-career event. Today, with the lessons we learned and the guidance offered in this text, we can be exceptional and bring calm to chaos on the next one. The modern response to MCIs has evolved out of the military and from necessity. The adage, "Slow is smooth; smooth is fast" made popular from the movie *The Shooter* is a great way to approach an MCI. As paramedics and advanced life support came of age in the early 1970s and America was coming out of Vietnam, it was the perfect merging of these two historic moments. Paramedics were a rare commodity in the days of Johnny and Roy on the hit show *Emergency!* Qualified paramedics on scene, like medics in battle, represented a limited echelon of skills and equipment that provide advanced life support capabilities. The need to perform triage in the street on larger incidents mimicked the need in the field of battle so the most good could be done for the most people, with limited resources. Any significant MCI will have a shortage of resources, initially. The ability to quickly triage patients and call vast amounts of resources that can be expeditiously assigned and organized is vital to saving lives. Sorting the patients into immediate, delayed, and minor categories will give those who need the advanced care the highest priority. *It's all about time, and the golden hour cannot be paused.* *We must act with the utmost efficiency.* The three primary objectives in an MCI are triage, treatment, and transport of patients. Everything the incident commander does must support these three critical tactical objectives. Surrounding this nucleus of effort must lie an incident command system that remains ahead of the curve regarding resource requests, communications, apparatus, and equipment move­ ment in and out of the scene and maximizes limited resources initially. This is all within a potentially larger incident like a high-rise fire, collapse, explosion, major vehicle accident, or active shooter. Each of these incidents will also tap resources and cause chaos around the inci­ dent with additional responders like law enforcement, media, site managers, school principals, and potentially countless other stakeholders. Advancements in strategies like unified command and mutual aid, along with tactical advancement like rescue task forces, have bridged the gap between fire and law. A rescue task force (RTF) is comprised of fire/EMS personnel embedded with law enforcement to comprise a team with the objective to enter the space immediately adjacent to the threat, and remove patients to casualty collection points. A casualty collection point (CCP) is a location where vic­ tims are brought from the hot zone/defensive space, to the warm/cold zones/offensive space to be treated and transported. This allows EMS to follow up and provide medical treatment and transportation much sooner. I was at the FDNY Fire Academy on Randall's Island on the morning of January 9,2022. I was the *Chief of Training* for the FDNY's 1,700 employees and was in my fourth-floor office catching up from a busy week. On this Sunday, I also had the command chief duty, which meant that I was responsible for citywide duty as the command chief and would respond to large-scale or unusual incidents during my 24-hour tour. The fire academy is a relatively short ride to the Bronx. The report of the fire was received for 333 East 181 Street (Twin Parks North West). While responding, the first-to- arrive units were receiving reports from the Bronx dispatchers of unconscious victims on the third floor. The working structural fire was soon confirmed and upgraded to a second alarm. With the information I was receiving, I was quick to recognize this escalating fire as something out of the ordinary and began responding on transmission of the second alarm and arrived shortly after the transmission of the third alarm. Upon my arrival I would assume command. However, I would largely assist and support the command structure already in place and functioning well. While commanding this fire, we had a ring-side view from the front of the structure to the incredible and lifesaving work of our members. The FDNY responded to what would become one of the worst fires in New York City's history. Yet, at the same time, the fire would result in a historic number of rescues and lives saved, testing the training, dedication, professionalism, and resolve of FDNY mem­ bers. Tragically, 17 lives were lost at this horrific fire. We are all profoundly impacted when we are unable to save one victim, no less an unimaginable and heartbreaking 17. While mourning the loss of so many lives, we must also acknowledge the FDNY mem­ bers from fire and EMS who put forth a heroic effort to rescue and save nearly 100 occu­ pants from the Twin Parks North West building. FDNY members play to win, saving lives at all costs. This FDNY "play to win" mindset on every run of every tour, every day, was evident on this day, at this fire. It is the winning mindset of the FDNY and our members' dedication to training that prepares and positions them to perform under even the most demanding conditions, such as those confronted at the Twin Parks North West fire. The fire began in Apartment 3N, a duplex apartment on the second and third floors of the 19-story residential apartment building located at 333 East 181st Street. The entrance to 3N was on the third floor, and a stairway inside the apartment descended to the second floor ("duplex down"). The fire, which was caused by an electric space heater, began in a bedroom on the lower level---the second floor. The fire area at the Twin Parks operation was extensive, consisting of both levels of Apartment 3N (the apartment of origin), Apartment 3J (across the hall from 3N) and the third-floor public hallway. With the doors open to both 3N and 3J, both apartments and the public hall­ way quickly became part of the fire area. Given the science of fire dynamics (including flow path and the stack effect), it is clear that high pressure within Apartment 3N moved fire, heat, and smoke toward lower-pressure areas on the third floor and verti­ cal stairwell shafts. However, an integral part of the story was a chain of open doors that allowed smoke to permeate the building. The open door to the fire apartment, open stairwell doors on numerous floors and open doors to apartments on several floors above the fire floor allowed deadly, toxic smoke to quickly spread to apartments throughout the structure. Video evidence shows that as the fire department was arriving, smoke had already reached the 19th (top) floor. This left precious little time for rescues, requiring a fifth alarm assignment and herculean FDNY effort to save lives in imminent peril. In total, there were more than 60 fire victims, and FDNY members removed more than 30 victims from the structure in cardiac arrest. Seventeen people succumbed to their injuries, including eight children. A majority of the victims who died were at least ten floors above the fire---nine of the fatalities were found in stairwells on the upper floors, far from the fire. All of the deceased died from smoke inhalation (fig. 15-3). Both fire and EMS members performed many courageous actions inside and outside the fire building. While this incident took place in a 19-story structure, many of the lessons that can be taken from this fire are applicable for many other incidents that have the potential to produce a large number of victims. This can include anything from an overturned school bus to a carbon monoxide (CO) emergency during a crowded religious service to a fire in a nursing home or hospital. Simply stated, you don't need to have tall struc­ tures to respond to large-scale incidents. My goal is that I can transfer several key takeaways to provide insight so you can better prepare, develop, and employ similar strategies and tactics before the next time you respond to large scale incident---wherever that may take place. It is about transferring my experience to you (fig. 15-4). There are so many important lessons to reinforce from the Twin Parks Fire. Below I present 10 for your consideration. I chose these specific 10 to highlight for use in this book, as these are items that can easily be overlooked and not often discussed.  1\. **Incident priorities, command and control, and leaders' intent---**These items 2. **Resource management---**Tracking and calling for needed resources early 3. **Time to task completion---**If you do not know how long it takes to stretch and 4. **Street management plan---**Access and egress for ambulances is most often not 5. **Communications---**Clear, calm, and concise. Be mindful to not communicate 6. **Radio frequencies---**Consider additional radio frequencies for use as command 7. **Surge capacity---**Have a written plan and know the number of patients you can bring to a hospital without overwhelming the emergency room. Can your emer­ gency room properly care for several people in cardiac arrest? 8. **Reflex time---**Understand how long it will take to have adequate resources on scene. Consider the time needed for 5,10, 30, or more ambulances to arrive. 9\. **Maintaining a manageable span of control---**We all know when it comes to the ideal span of control that three to seven (with five being ideal) is the goal. Strive to stay within this goal and consider sectors (divisions/groups), both horizontal and vertical, to stay compliant with span of control. 10\. **Stay current---**Modern incidents require commanders that have an in-depth knowledge of today's structures and what is burning. Understanding fire dynamics enables today's incident commander to proactively and appropriately implement strategies, tactics, and tools that demonstrate mastery of the modern fire environment. Training and education are a never-ending process---keep learning.  The SAW-CSS-RECEO-VSS system has been used nationwide for years and is easily applied to MCIs. You will notice that *italicized words correspond with key points on the tactical worksheet* that follows. Size-Up *Remember, size-up is a mental, ongoing process.* Start with your *FPODP or FIRST* algorithm. * MCI type* refers to the nature of the MCI, or what caused it. Three types exist. First is a trauma MCI, like a MVA or a shooting. Second is a Hazmat MCI, like a leak or exposure to a hazardous material. Third is a medical MCI, like a sick building or several people with food poisoning. If this is an explosion or suspected intentional act, consider second­ ary devices. * Type* of patients refers to how many patients and what level triage they are currently. Based upon the START system, patients will be triaged in one of three categories: imme­ diate, delayed, and minor, Your *initial size-up* will conclude with an arrival report to incoming units; however, remember that size-up is continuous. As you talk to the RP, bystanders, occupants, employees, and attempt a lap, you will garner more critical information. The *IOCAN* system is designed to give a quick arrival report. Your arrival report is likely dictated by your SOGs. Consider any local MCI protocols when giving your arrival report. Apparatus Placement Apparatus placement should be considered early, as you typically do not get a second chance. Plan ahead based upon your type of apparatus, mission, SOGs, and order of arrival. A first-arriving engine will likely attempt to see *three sides* of the scene, allowing the officer to have a tactical advantage before stepping off the rig. An MCI could involve fire or explosions, so be cautious and consider the long-term impact of your staging area. The *hot zone* is any area that will cause damage to apparatus, including but not limited to collapse, thermal insult, excessive smoke, hazardous materials, power lines, and so on. Ensure that apparatus is staged out of the hot zone, including potential changes in conditions. The *travel plan* is critical to identify early before more units arrive on scene. The more patients, the more apparatus and ambulances will be coming through the scene. Depending upon the size and scope of the incident, some ambulances may make more than one round trip to and from the hospital. A one-way travel route for ambulances to pick up patients from treatment areas is ideal and reduces congestion and potential for backing accidents. Consider a *staging* area in addition to the travel plan and a *helispot* for air ambulances to land and take off. Water Supply Water supply will likely not be a factor unless you have a working fire with MCI or need water for decontamination during a hazardous materials incident. Water supply must be considered as soon as possible to take advantage of any hydrants while responding into the scene. * Who* is securing the water supply? *Where* is the water supply? Is it reachable by one engine, or is this an extensive lay? Will water tenders be required? PVTzat is the supply? A dry or wet forward lay by the first-due engine from the hydrant to the fire? A wet forward lay by the second-due engine? A driveway/split lay? A reverse lay by the second engine from the first, out to the hydrant? A tank transfer? A water shuttle from a distant hydrant, or drafting operation? Once a patent water supply is established, it should be announced on the tactical channel. Command Command must be established and announced. *There can only be one IC at a time, and the IC* *must be on scene to assume command.* While your SOGs will determine specific parameters, some fundamental best practices exist. When the first-arriving officer is a chief or staff officer with no tactical capability, assuming command is the most likely option. Developing an LAP and calling additional resources will typically be the best decision. That said, during an MCI, you may begin START triage. * Name* the incident and identify the *ICP.* You may find yourself working with *law* enforcement early and enter into *unified com­* *mand. See chapter 16for more on unified command.* Call *additional resources alarms* early and confirm the staging location. Set up your *ICS* early. A medical group is adequate for most incidents; however, a medical branch would be more appropriate for larger incidents. Do you have adequate channels for *communications?* Consider a separate tactical chan­ nel for the medical group/branch. Strategy Obviously, an MCI is going to have a lifesaving priority. That said, you may have to determine if the strategy is offensive, defensive, or combination based upon any potential threat from an active shooter or hazardous material, for example. This may require a combination strategy as victims are brought from the defensive space to the offensive space. Safety The three primary safety concerns with MCIs are scene *security* from threats, *secondary devices* from terrorist acts, and *hazardous material* exposure. That said, an MCI will be the result of another event, such as a structure fire, vehicle accident, building collapse, active threat, and so on. Each of these has separate and distinct safety concerns in addition to the three primary listed above. Keep those in mind and set up your divisions/groups and safety officer accordingly. Rescue The three primary tactical objectives for an MCI are triage, treatment, and transport. Each will require supervision of some level. For most MCIs, a medical group supervisor will suffice and manage all three objectives. If the incident is large enough where a medical branch is established, the more supervi­ sion will be required. A triage unit leader may be required just to supervise the triage of vast number of patients. A treatment unit leader will potentially have an immediate, delayed, and minor treat­ ment area for the patients with manager supervising each area. A patient transportation unit leader/group supervisor may be required for transporta­ tion of patients via ground and air ambulances. Consider RTFs working under a rescue group supervisor. Ona larger incident, a medical communications coordinator (MCC) would be tasked with contacting the trauma center to determine where patients are to be transported. Exposures For an MCI, exposures could be other areas where victims may be *located away* from the inci­ dent. This could be due to stray bullets, or contaminated victims moving offsite. Consider *downwind* exposures due to hazardous materials releases and plumes. Confinement As with the shooting at Mandalay Bay in Las Vegas, victims may be spread over a large area and they may be mobile. Walking wounded are a common phenomenon with large-scale MCIs. If you have hazardous materials contamination, it is critical that the walking wounded not spread the hazardous materials to hospitals. Extinguishment Is whatever caused the MCI neutralized? It may be an *active threat,* or a *hazardous material* *leak.* Ensure that no additional injuries are sustained. Overhaul Ensure you have *all* victims, and all responders are accounted for. This includes knowing *who* was transported and *where* they were transported. Family will want to know. Ventilation For an MCI, ventilation refers to extreme *weather* exposure to victims while they are being treated and awaiting transport. Consider *shelter* like large tents or buses. Salvage Talk to the owner/occupant/AP or manager to transfer care of the scene to the appropriate party. Support Here, we consider what is needed to support the IAP. Several agency-specific resources are cer­ tainly available. As a minimum, consider the following: * Law enforcement (LE)* * Investigator* * Public information officer (PIO)* * Safety officer (SO)* * Red Cross* * Utility companies (gas, electricity, and water)* * Rehab* * Air/light unit* * Hazmat team* * Buses* * Air ambulance* ICS and Communications for Multi-Casualty Incidents Like any incident, the use of ICS on an MCI will vary based upon the size and complexity of the event (see figs. 15-5,15-6, and 15-7). You may only require a medical group supervisor if you have a MVA with 5-10 patients; however, you may require multiple branches if you have haz­ ardous materials and/or significant fire and rescue challenges with dozens of patients. A separate tactical channel should be considered for medical operations. If the incident warrants and you have branches established with over 50 patients, for example, multiple tac­ tical channels may be required for triage, treatment, and transportation so one channel does not become overwhelmed. Specific positions may be utilized to break down the division of labor to a more manageable span of control. Each position can be added as needed and as the incident escalates. Below is a list of positions to consider for MCI operations of a larger scale. You will likely not use all positions on the day-to-day MCI responses. However, the ability to scale quickly and stay ahead of the incident power curve is vital in the once-in-a-career incident. You will undoubtedly have local protocols, policy, and SOGs. Below are definitions and positions to consider as the MCI expands. Consider this a toolbox from which to choose to command and coordinate an MCI. Medical Group Supervisor Like any tactical supervisor, a MGS bridges the gap between the units working at the task level and the IC at the strategic level. The MGS will likely have the objectives of triage, treatment, and transport of patients and medical communications with the trauma center that is respon­ sible for coordinating patient transportation destinations. In a smaller, simpler MCI, this may be all that is required to manage the medical functions of the incident. If an incident was Fig. 15-5. A simple MCI organizational chart Fig. 15-6. Example of a moderate-sized MCI organizational chart Fig. 15-7. Example of a complex MCI organizational chart. Each medical division will have triage and treatment units. geographically spread out over a large area, multiple medical *division* supervisors may be required to function as a tactical supervisors to break down the incident to a manageable span of control. For example, Medical Division North, Medical Division South, and so on. Medical Branch Director The medical branch director (MBD) is a step above a MGS and would be utilized to manage larger MCI operations where multiple medical divisions are established as described previously. Transportation Unit Leader/Group Supervisor The Transportation tactical supervisor may be a *unit leader* or a *group supervisor,* depending upon the scope of the incident. The transportation *unit leader* would be utilized on small- to medium-sized incidents and report to the MGS. On a larger MCI when a medical branch is established, a transportation *group supervisor* would be utilized and report to the medical branch director. *There should be one transportation unit leader/group supervisor per incident to* *prevent duplicate ordering of ground and air ambulances that could over-tax the system. In either* *case, they coordinate with the medical branch/group/divisions.* Triage Unit Leader The triage unit leader will have single resources reporting to them with the objective of triag­ ing all patients into immediate, delayed, minor, or deceased categories. The triage unit leader would coordinate laterally with the treatment unit leader and vertically with the medical group/ division supervisor. Treatment Unit Leader A treatment unit leader has the primary tactical objective of supervising and supporting the three treatment areas: immediate, delayed, and minor. Each of these areas would have an area manager in charge of the respective area. The treatment unit leader would coordinate later­ ally with the triage unit leader and vertically with the medical group/division supervisor. Medical Communications Coordinator The MCC is responsible for coordinating patient transportation destinations. The MCC com­ municates and coordinates between the trauma center that assign patients to various hospi­ tals, the treatment unit leader, and the patient transportation unit leader/group supervisor. Additional Positions Other positions that may be utilized on extremely large incidents where resources are avail­ able include: Immediate, Delayed, and Minor Treatment Area Managers Ground Ambulance Coordinator Air Ambulance Coordinator Patient Loading Coordinator Medical Supply Coordinator Transportation Recorder Morgue Manager Helispot Manager Staging Area Manager Medical Unit for First Responders WISDOM FROM THE MASTERS Management of the Intentional Mass Casualty Incident---A New Concept CHIEF ERIC SAYLORS, EL CERRITO (CA) FIRE DEPARTMENT The following section is a framework for effectively managing an intentional mass casualty incident (IMCI). The framework starts with a big-picture view of the events, followed by a small-picture view of operations. The big-picture view outlines the dif­ ferences between an IMCI and an (unintentional) MCI, identifies the principle of the problem, creates a common operating picture, and orders the incident priorities into strategic and tactical objectives. The small-picture view describes the current prac­ tices supported by research at a tactical level when encountering a massive killing perpetrated by an intelligent actor. Big Picture---MCI versus Fast-Moving IMCI This section divides mass casualty incidents into two types of events: MCIs and IMCIs. IMCIs and MCIs consist of patients involved in a shared event resulting from an accident. Think of vehicle collisions, mass transit derailments, or hazmat exposures. IMCIs con­ sist of victims resulting from an intentional event instigated by an *intelligent actor (IA).* The incidents are deliberate and, therefore, may have secondary events in the future. Think of a school shooting, the Boston Marathon bombing, or a vehicle driving into a crowd. The presence of an *intelligent actor* is the distinguishing factor between an MCI and an IMCI. Intelligent actors create an unknowable threat to responders that resists timely incident stabilization. In other words, responders must take action in a threat zone before the scene is safe or cleared. Operating in a threat zone requires a different mindset than a traditional MCI. The following outlines this mindset by describing the principle of the problem, the common operating picture, and incident priorities. Principle of the Problem Time is everything. Victims of IMCIs are typically bleeding to death at a rapid rate. Most walking wounded flee the scene once the killing starts, leaving behind the criti­ cally injured. Evidence suggests roughly half of the victims bleed to death without intervention in the first ten minutes. Surgery is the only thing capable of saving most victims; therefore, the time from injury to surgery is critical. Any action that delays the victim getting to surgery costs lives. IMCIs are fast-moving MCIs that require imme­ diate action and transport, skipping many activities prescribed in traditional MCIs, such as triage, patient counts, and triage tags. The goal is to control massive hemor­ rhages on scene and transport every victim to surgery within 45 mins. Common Operating Picture Most EMS doctrine addresses patients with specific complaints requiring prescribed care. Patients tend to have multiple caregivers per patient in a stable environment, as opposed to victims, who are people in a threat environment that require immediate removal. Think of victims as those encountered in a burning house, drowning, or trapped in confined spaces. The priority for victims is to remove them from the threat zone. People found in burning homes are not triaged before removal, nor are downing victims assessed in the water. Fast-moving IMCIs produce victims. Victims must be removed from the threat zone before transitioning to patients and receiving tradi­ tional care. Threat zones can be secured or cleared. A *secured* threat zone has an element of force protection that can return effective fire but is not under fire. In other words, you have an LE officer with a gun to protect you. Areas with a stable law enforcement presence are secured. A *cleared* threat zone is an area that received a systematic search by law enforcement, eliminating any credible threat. Clearing areas takes enormous time and should happen after all victims and fire/EMS staff are removed. In an analogous way, the fire service can think of clearing as an overhaul after a fire; it happens once the threat is contained and the victims are gone. The goal of responders during an IMCI is to only operate in secured areas before the terrain is clear. Finally, there are no *safe* areas when encountering an intelligent actor. Zones of Operation---Direct Threat, Indirect Threat, and Evac Zone Events with hostile intelligent actors construct zones of operation called direct threat, indirect threat, and evac zone. Each has operational priorities and limitations. The direct threat (DT) zone typically refers to the line of fire or path of explosion. Without adequate training, equipment, and force protection, fire or EMS personnel should not operate in the DT zone. The indirect threat (ID) zone is outside of the line of fire or path of explosion. The ID zone is contiguous with the DT zone, where fire and EMS personnel control massive hemorrhage and extricate victims. Finally, the evac zone is the location victims are moved for transport. An evac zone is not a casualty collection point (CCP) but a loading site for victims from manual to vehicle transport. CCPs are used in rare occurrences when the manual movement of victims is impossible due to an engagement with a hostile force or bottleneck in the terrain. Managing a CCP is a specialized skill beyond most first responders' training and equipment and should only be utilized as a last resort. Incident Priorities, Strategic Objectives, and Tactical Objectives The progression of incident priorities on a fast-moving IMCI is life, scene security, and recovery. Meeting incident priority of life preservation requires law enforcement to stop the killing by neutralizing the threat, followed by fire and EMS services stopping the dying by providing bleeding control and movement of victims to definitive care. Law enforcement forms contact teams and moves toward the stimulus, constantly engaging the LA(s) until they are neutralized. Once the threat is neutralized, fire and EMS crews operate in the ID zone to control massive hemorrhage, extricate the victims to the evac zone, sort victims based on injury, and transport the victims to definitive care. Meeting the incident priority of scene security includes the removal of fire personnel and victims from initial threat zones to prevent additional injuries, device triggering, or evidence destruction. Finally, a large number of transported victims can move the location of an IMCI to an MCI at the hospitals. Additional resources should be assigned to hospitals to assist with patient care if needed. Meeting the incident priority of recovery includes providing victim notification/uni- fication centers at the initial scene and hospitals. In addition, the responders need immediate mental health assessment and treatment before going home. Finally, resources and plans for long-term mental health needs for the responders, victims, vic­ tims' families, witnesses, and community must be addressed. The proceeding incident priorities and objectives are listed in the ad hoc IAP that follows: Incident Action Plan Framework Based on *NFPA 3000,^2^* Tactical Emergency Casualty Care (TECC), and the Hartford Consensus^3^ **Incident Priorities** Life ♦ Scene security --- Recovery **Strategic Objectives** Law---Neutralize threat (stop the killing) Law---Clear building Fire---Provide bleeding control and movement of victims to definitive care (stop the dying) ♦ Remove all unnecessary fire personnel from scene ♦ Assist hospitals with impact --- Provide for immediate recovery **Tactical/Operational Objectives** T---Threat suppression (law) H---Hemorrhage control RE---Rapid extrication A---Assess victims T---Transport victims ♦ Full personal accountability report (PAR) of units assigned to incident ♦ Dispatch engine/trucks to hospitals to assist with treatment/triage --- Notify city office of emergency management --- Set up victim notification and unification centers at scene, at hospitals, and --- Use PIO for social media and media messaging to victims' families Small Picture Empirical evidence suggests the decades-old rescue task force (RTF) is objectively inef­ fective. The diamond formation of the RTF is logistically heavy and slow, relying on a maneuver known as diplomatic protection run backward. In the tactic, firefighters are surrounded and escorted as diplomats into the threat area instead of out of it. In addi­ tion, the RFT typically attempts to triage victims in the threat zone while struggling to move them to the evac zone. As a result of struggles with an RTF, a team out of Sac­ ramento, California, consisting of medical doctors, researchers, combat psychologists, fire/EMS personnel, and military special forces operators developed an alternative tactic known as a rescue strike team (RST). Over two hundred repetitions of RST in multiple environments yielded times 74% faster than an RFT tactic. The study mea­ sured the time of fire/EMS entering the threat zone to when all victims and rescuers arrived in the evac zone. The following describes the basics of the RST. The RST assumes that law enforcement should devote all officers to suppressing the threat by killing the IA, locking them down, or driving them from the scene. Once the threat is suppressed, there is no need for a diamond formation with a one-to-one ratio of fire/EMS personnel to law officers. Instead, the fire/EMS personnel are escorted to the victims by one LE officer through a secured corridor. The LE escort is part of the initial contact team and knows the best path to the victims. The RST operates under a rescue unit leader (RUL), who is typically the first captain on the scene. The RUL makes contact with the LE escort and confirms the threat is suppressed. The RUL then leads the on-scene fire/EMS crews with the LE escort to the victims. The RUL is the eyes and ears of the IC, the level of accountability for all rescuers in the threat zone, and direct contact with LE. The RUL should always stay within arm's reach of the LE escort to provide constant communication with LE. The link-up of the RUL and LE escort links communications between fire and law early on in the incident before the establishment of unified command, regardless of radio differences. An RST can consist of 4 to 20 rescuers. Evidence suggests 20 rescuers with a small wound kit and a moving device such as a drag sled or Fox Trot litter can control hemorrhaging and move 50 victims 200 feet in about twelve minutes within a secure corridor. Members of the RST team focus only on controlling massive hemorrhages and moving victims. Victims are treated and moved on a first-come, first-serve order. Triage is discouraged in the threat zone, as it is unreliable and timely. Victims are either dead and marked with a purple glow stick or removed. In addition, victim counts are discouraged and replaced with round number estimates. For example, a victim estimate is roughly 10,20, 30,60, and so on. Exact victim counts in the threat zone are timely and unreliable, as the counter cannot know the number of dead and alive. As the last live victim is removed from the threat zone, the RUL announces to the IC that the final victim and rescuer are coming out and moves to the evac one with the LE escort. As victims arrive in the evac zone, they are sorted into three categories based on wound location: abdominal, chest, or extremity, a process known as the ACE acronym. Wound treatability drives the logic of the ACE acronym. Both abdominal and chest wounds are in non-compressible areas, requiring surgery ASAP, whereas tourniquets can con­ trol bleeding from extremities on scene. Therefore, given a choice, victims should leave the scene in the order of the ACE acronym; abdominal first, then chest, and finally extremities. The RST is a simple and effective tactic based on an ink blot maneuver, as opposed to the diplomatic protection of the RTF. In an inkblot maneuver, force protection secures an area so that logical units have freedom of movement in a secured area. RST is not the only effective tactic in an IMCI, but it is the next evolution. As of this writing, it is yet unknown. The purpose of this is an introduction and awareness to the RST concept. Summary Fire department incident commanders must be proficient at managing a multi-causality inci­ dent, as nearly any response has the potential to become one. Management of patient triage, treatment, and transport alone is a challenge, and when this operation is occurring simulta­ neously with the mitigation of at least one hazard, it will test even the most experienced IC and organizations. The pace of the media coverage of significant events requires proactive planning for information management, as does the degree of coordination with patient prior­ itization and facility destinations. As the MCI is often an incident within an incident that requires management, these added external communication demands become an incident outside the incident that require management and should not be overlooked. Time is the most critical factor in a multi-casualty incident, as patients must be rapidly tri­ aged, treated, and transported to definitive care. As it has been repeated throughout this text, being aggressive is proactively seeking opportunities to address the time that you can control. Staying ahead of the incident power curve for the MCI starts ahead of the incident with an IC who has a working knowledge of EMS protocols, nomenclature, resource levels and destina­ tion capabilities. With the increased potential for hostile events to become an MCI, proactive planning and practice for managing through unified command (chapter 16) is a must. As it has been shared through the "wisdom from the master's" contributions, from apartment fires to active shootings, the next major MCI could be your next response. Maintain the "what if" mindset and be prepared. Chapter Review Review Questions 1. Describe START. 2. What are the pros and cons of models which require law enforcement securing or clear­ ing a scene for fire department or EMS response? 3. What are the three primary objectives in a multi-causality incident? 4. Describe a casualty collection point. 5. What are the responsibilities of a transportation unit leader? 6. Explain some of the expanded communication demands of a multi-casualty incident. FESHE Strategy and Tactics (C0279) Related Content The content contained in chapter 15 provides detailed information specific to multi-causality incidents. While the FESHE CO279 course does not specifically reference multi-causality inci­ dents, they involve the same processes and principles of structural firefighting requiring size-up, determination of incident priorities, selection of appropriate strategy, and coordination of tac­ tics and resources. The chapter format supports the CO279 course outline by detailing infor­ mation on multi-causality incident operations, communications, and coordination of these events, and ICS/NIMS roles and responsibilities to support and manage them. NFPA1021 Job Performance Requirements The information in this chapter can be utilized to support training and educational programs associated with the Emergency Services Delivery Fire Officer I JPR 4.6,4.6.1, 4.6.2, Fire Offi­ cer II JPR 5.6,5.6.1, and Fire Officer III 6.6 and 6.6.1. For larger-scale incidents and pre-planning, the content in this chapter also supports training and education for Fire Officer III 6.6.3 "Develop a plan for the organization given an unmet need for resources that exceed what is available in the organization." Endnotes 1\. "Aurora Century 16 Theater Shooting: After Action Report for the City of Aurora," Tri-Data Division, System Planning Corp., April 2014, Opinion\_Docs/14CV31595%20After%20Action%20Review%20Report%20Redacted.pdf. 2\. National Fire Protection Association *(NFPA) 3000: Standardfor an Active Shooter/Hostile* *Event Response (ASHER) Program* (NFPA, 2024), 3/0/0/3000. 3 Lenworth Jacobs et al. and the Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events, "Improving Survival from Active Shooter Events: The Hartford Consensus," Journal of Trauma and Acute Care Surgery 74, no. 6 (June 2013): 1399-1400, survival\_from\_active\_shooter\_events [ ] The.3.aspx.