Southern Nevada Fire Operations Multi-Casualty Incident (MCI) Procedures PDF

Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 1 of 17 PURPOSE This procedure establishes a standard structure and guideline for the operation of Fire Department...

Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 1 of 17 PURPOSE This procedure establishes a standard structure and guideline for the operation of Fire Department units at multi/mass-casualty incidents. The system may be applied to any multi/mass-casualty incident regardless of the number of patients or incident size. This procedure shall be integrated into the overall incident management system and may include major transportation incidents, explosions or fire with multiple injuries, hazardous materials incidents with exposure victims, structural collapse incidents and hostile events with multiple patients. PROCEDURE The policy is to integrate the multi-casualty procedures within the framework of the incident management system. It is the responsibility of the first-arriving company officer to implement these procedures on any multi-casualty incident. This procedure follows the National Incident Management System (NIMS, Dec. 2008). This also follows the Clark County Multi-Jurisdictional Mass Casualty Plan. Definitions A. MCI: A Multi-Casualty Incident (MCI) is an incident in which the number of patients combined with the complexity of the event warrants the declaration of a Level 1, 2, 3, 4, or 5 MCI. o Level 5 MCI: A level 5 MCI may produce from 5 to 10 patients. These incidents are typically handled by the department having jurisdiction and do not require extended use of multi-agency resources. The Emergency Operations Center (EOC) can be utilized, but is usually not required during a Level 5 MCI. Type 5 NIMS incident. o Level 4 MCI: A Level 4 MCI produces 10 to 25 patients. Regional and multijurisdictional medical mutual aid is necessary for further diagnosis and treatment. The EOC may be required to assist with the management of a Level 4 MCI. Type 4 NIMS incident. o Level 3 MCI: A Level 3 MCI produces a large amount of casualties - from 25 to 50 patients. A Level 3 MCI exceeds the capabilities and resources routinely available in a single jurisdiction. These incidents will require a concerted multi-agency effort including the activation and management assistance of the EOC. Type 4 to Type 3 NIMS incident. Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 2 of 17 o Level 2 MCI: A Level 2 MCI is a major emergency that may produce 50 to 100 patients. A Level 2 MCI requires resources from multiple jurisdictions and will quickly overwhelm the treatment capabilities of local hospitals. These incidents will require a concerted multi-agency effort including the activation and management assistance of local EOC and the hospital’s Medical Surge Area Command (MSAC). Type 3 NIMS incident. o Level 1 MCI: A Level 1 MCI is a major emergency that may produce more than 100 patients. A Level 1 MCI requires resources from multiple jurisdictions and will quickly overwhelm the treatment capabilities of local hospitals. These incidents will require a concerted multi-agency effort including the activation and management assistance of local EOC and the hospital’s Medical Surge Area Command (MSAC). Type 3 NIMS incident. B. Extreme MCI: An Extreme MCI is an event in which the number of patients exceeds 300 or greater. The Mass Casualty Incident Advanced Plan (MCI-A) is included in The Clark County Multi-Jurisdictional Mass Casualty Plan. It provides guidance and procedures for the response to any incident involving 300 or greater casualties hereinto referred to as an Extreme Mass Casualty. It was designed specifically to deal with local disasters including Weapons of Mass Destruction Chemical, Biological, Radiological, Nuclear and high- yield Explosives or CBRNE. C. Hostile MCI: A Multi-Casualty Incident caused by a deliberate action of an offender to cause harm to others. D. Medical Alarms: A group of engines, truck companies, rescues, and support staff. 1. First Alarm Medical FAO (Task Force): A First Alarm Medical Task Force consists of Three (3) Engines; One (1) Truck; Two (2) Rescues; One (1) BC; One (1) EMS Coordinator/Supervisor and request Two (2) private ambulances. 2. First Alarm Medical Henderson (Task Force): Four (4) Engines; One (1) Truck; Three (3) Rescues; Two (2) BC’s; and Operations Support Officer (OSO). 3. Additional Medical Alarms: Repeat initial Medical Alarm assignment minus the EMS Coordinator/Supervisor or OSO Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 3 of 17 E. Ambulance Strike Team: A group of five (5) ambulances of the same type with common communications and a leader. 1. FD Ambulance Strike Team: Five (5) Fire Department Rescues and One (1) Team Leader. 2. Private Ambulance Strike Team: Five (5) Private Ambulances and One (1) Team Leader. Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: MULTI-CASUALTY INCIDENT (MCI) PROCEDURES 03/02/2015 n/a SOP# SNFO-11 Page 4 of 17 Appendix 1 – MCI Command Responsibilities The Incident Commander (IC) is responsible for the strategic level of the command structure and should: 1. 2. 3. 4. 5. 6. 7. Establish overall incident objectives Set priorities Develop an action plan, communicate the plan. Obtain and assign resources. Planning—based on evaluating interventions and predicting outcomes Communicate specific objective to tactical level units Initiate a Unified Command with other agencies, when appropriate. The first-arriving company officer at the scene of a multi-patient or mass casualty incident shall establish Command. The initial Incident Commander (IC) shall remain in Command until Command is transferred or the incident is stabilized and Command is terminated. The IC is responsible for building a command structure that matches the organizational needs of the incident to achieve the tactical objectives. The general tactical objectives, listed in order of priority, are: 1. 2. 3. 4. Provide for the safety, accountability and welfare of rescue personnel and victims. Remove endangered occupants and treat the injured. Stabilize the incident and provide for life safety. Ensure the functions of triage, extrication, treatment and transportation are established as needed and performed appropriately. 5. Conserve property. In addition, the EMS TACTICAL objectives to be completed during any multi-patient/mass casualty incident include: 1. Completion of a “Triage Report” 2. Declaration of “All IMMEDIATES Transported” 3. Declaration of Level 1-5 will be made by the on scene Battalion Chief to dispatch and relayed to the FAO (Fire Alarm Office). Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 5 of 17 Assignments Rescue/Extrication  Assigned Early – The IC normally establishes the Rescue/Extrication Group position early in the incident. It is often assigned to the first resource in the area. Additional positions would follow as additional resources arrive on scene. This is where the most resources are needed early. Extrication and initial patient care is manpower intensive. The IC should support this group with adequate resources and equipment. As the incident evolves and resources are no longer needed the Rescue/Extrication Group Supervisor can release personnel to help in other areas.  Hazard Zone – Often the Rescue/Extrication Group is operating in the hazard zone with potential risks to personnel and patients. Appropriate PPE should be worn and action should be taken to provide safeguards.  Prioritize Patients – Personnel operating within the extrication area generally do primary care on the patients and then coordinate the transport of patients to the triage area. Where possible, critical patients should be extricated, triaged and delivered to the treatment area ahead of more stable patients. To do this there must be some interface with the medical group.  Responsibilities – The Rescue/Extrication Group Supervisor is responsible for managing the rescue of entrapped victims. This requires: 1. Determination of resources needed to extricate patients    Rescue tools Backboards Personnel 2. Communicate resource requirements to IC 3. 4. 5. 6. 7. 8. Provide tactical direction and supervision to assigned crews Ensure safety of members operating in the area Ensure efficiency of Rescue/Extrication operations Coordinate patient transportation to triage area Coordinate with Treatment Unit for patient care during rescue operation Provide IC with progress reports Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 6 of 17 Medical Group Responsibilities – The Medical Group Supervisor controls the activities within the Medical Group in order to assure the best possible emergency medical care to patients during a multi-casualty incident. The Medical Group Supervisor reports to the IC and supervises the Triage Unit Leader, and Treatment Unit Leader. The additional responsibilities of this position are: 1. Establishes medical group with assigned personnel; requests additional personnel and resources sufficient to handle the magnitude of the incident. 2. Designates Triage Unit Leader and Treatment Unit Leader and designates locations for triage and treatment. 3. Isolates morgue and minor treatment areas apart from immediate and delayed treatment areas. 4. Determines the amount of medical supplies and resources needed (medical caches, backboards, O2, medications, IV’s, splints, bandages, etc.) 5. Establishes communication and coordination with Transportation Group Supervisor. 6. Ensures proper security, traffic control, and access through medical group area.  Triage Unit – The Triage Unit Leader is responsible for the triage and tagging of all patients at major incidents. Personnel assigned to triage must have the basic medical skills to make appropriate triage decisions. Triage and tagging may take place in either the extrication area or at the entry to the treatment area. In either case, close coordination must be maintained with the treatment unit and Extrication Group. The Triage Unit Leader reports to the Medical Group Supervisor. Additional responsibilities of the Triage Unit Leader are: 1. Ensure that all patients are assessed and sorted in accordance with appropriate triage protocol. START Triage, RPM, 30-2-Can do. 2. Determine resources required to conduct triage.  Communications  Personnel  Equipment and supplies Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 3. 4. 5. 6. 7. 8.  MULTI-CASUALTY INCIDENT (MCI) PROCEDURES 03/02/2015 n/a SOP# SNFO-11 Page 7 of 17 Communicate resource requirement to Medical Group Supervisor Develop triage organization Ensure safety and security of all members operating in the triage area Ensure efficiency of triage operation Provide progress reports to Medical Group Supervisor Coordinate patient movement from triage to treatment Treatment Unit – The Treatment Unit Leader will establish an area where patients can be collected and treated. The Treatment Unit Leader is responsible for the overall management of patient care delivery in the treatment area. It is in the treatment area that extensive treatment and advanced life support care are conducted. Additional responsibilities include: 1. Identify and establish a suitable area  Upwind and uphill  Sufficient space  Unimpeded access and egress 2. Identify and request additional needed resources  Communications  Personnel  Equipment and supplies 3. Coordinate with Triage Unit Leader the movement of patients from triage area 4. Ensure patients received in treatment area are: 5. 6. 7. 8. 9.  Separated by triage category  Reassessed and re-triaged as appropriate  Receive prompt treatment in accordance to ALS/BLS guidelines Establish communication and coordination with Transportation Group Supervisor Assign, supervise and coordinate personnel within area Ensure efficiency of treatment operations Direct movement of patients to ambulance loading area Provide progress reports to Medical Group Supervisor Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: MULTI-CASUALTY INCIDENT (MCI) PROCEDURES 03/02/2015 n/a SOP# SNFO-11 Page 8 of 17  If the incident scene is very large, it may be necessary to establish more than one treatment area in different locations. Branch operations may be required to coordinate these efforts. Geographic designations (i.e., “East Treatment”, “West Treatment”) should be utilized (“Transportation Branch, Multiple Site Coordination”).  When transportation is immediately available, transportation of the patient becomes a priority over extended on-site treatment. Note: As with any other ICS organization, unassigned responsibilities of any group or division remain with the supervisor. If the Medical Group Supervisor does not assign a Triage and Treatment Unit leader, they are still responsible for triage and treatment. On smaller MCI incidents the Medical Group Supervisor will not need to create these units. They will only require additional manpower to assist with triage, treatment and the movement of patients to transportation vehicles. Remember; only make the ICS structure as big as it needs to be. On larger incidents with a large number of casualties these positions will not only be helpful, but necessary. Transportation Group Responsibilities – The Transportation Group Supervisor is responsible for overall management of patient movement from the scene to the receiving hospitals. Special attention must be given to the needs of the patient and whether transportation to a specialty hospital is required (trauma, burns, pediatric, etc.). In addition, the ability of the receiving hospital to handle additional patients must be a part of the decision making process. Additional responsibilities include: 1. Identify and request additional resources    Request ground and air ambulances as needed (Consider requesting a Supervisor when utilizing private ambulance) Communications Personnel 2. Designate ambulance staging area 3. Coordinate transportation of patients with Treatment Unit Leader 4. Coordinate air ambulance transportation. Landing Zone (Helispot) requirements: Minimum safe distance from incident personnel 500 ft. Must have a minimum of 100 ft. in all directions of any and all obstructions. Maximum slope angle of 10 degrees. Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: MULTI-CASUALTY INCIDENT (MCI) PROCEDURES 03/02/2015 n/a SOP# SNFO-11 Page 9 of 17 Hard surface or packed/wet down dirt, a wet down of the area will minimize brownout (zero visibility) conditions from loose dirt and rotor wash. No loose debris. No overhead obstructions (power lines, antennas, and buildings). 5. Maintain Patient tracking records When all IMMEDIATE patients have been transported from the scene, Transportation should notify Command. A declaration by Command to Dispatch of “All IMMEDIATES Transported” is an EMS tactical benchmark. Morgue Depending on the size of the incident, a separate morgue area may need to be established for deceased patients from the Triage and Treatment areas.     Area should be separate from Triage and Treatment areas Area should be protected from public and media Area should be protected and monitored Consider use of Police for this assignment Safety Command should assign Safety Officer as soon as the basic Division / Groups / Units have been established. Staging  As the incident escalates, a Staging Area Manager may be required. To avoid scene congestion, a Level II staging area may be identified for any First Alarm Medical incident.  Additional Resources should be requested using standard assignments and alarms as much as possible (e.g., 2-1 Medical, 1st Alarm Medical, 2nd Alarm Medical, etc.) This will facilitate an incremental approach to the incident, similar to firefighting operations, and provide predictable resources. Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: MULTI-CASUALTY INCIDENT (MCI) PROCEDURES 03/02/2015 n/a SOP# SNFO-11 Page 10 of 17 Medical Supply Medical Supply Group/Unit is responsible for the procurement, delivery and stockpiling of medical supplies needed at the scene. This Group/Unit should be established on large incidents (25 or more patients). Capabilities The Medical Supply Group/Unit will provide the following to other Group/Units as needed:      Provide EMS supplies (triage tags, IVs, backboards, trauma supplies, gloves, goggles, masks, etc.). Provide biohazard supplies (biohazard trash containers, biohazard plastic bags, sharps containers, etc.) Provide oxygen refill. Set up an oxygen manifold. Obtain needed offsite supplies *Note: Depending on how far you expand the Incident Command System, each of these assignments may be designated either Unit, Group or Branch. Incident command structure for a Level 5 Response (10 or fewer patients) Incident Command Rescue Extrication Medical Possible LZ (Helispot)/Group On smaller incidents the Incident Commander will typically only need to establish 2-3 Groups: Rescue Extrication, Medical and possibly LZ (Helispot). The IC must insure that each group has adequate resources to operate effectively. In this situation Medical Group will be responsible for Triage and Treatment without formally breaking them down into units. If the Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 11 of 17 incident has 4 or 5 critical patients, the IC may opt to establish a Transportation Group to handle the larger amount of rescues and organize patient destination. Incident command structure for a Level 4 Response (10 to 25 patients) Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: MULTI-CASUALTY INCIDENT (MCI) PROCEDURES 03/02/2015 n/a Page 12 of 17 SOP# SNFO-11 Incident Command Structure for a large incident: Greater than 25 patients COMMAND SA – Dep/IC LOGISTICS SECTION PLANNING SECTION SAFETY STAGING POLICE PIO ADMINISTRATION SECTION FIRE BRANCH OCCUPANT SERVICES OPERATIONS SECTION HAZ MAT BRANCH TECHNICAL RESCUE BRANCH TRANSPORTATION BRANCH MEDICAL BRANCH TRIAGE TREATMENT EXTRICATION MORGUE MEDICAL SUPPLY HOSPITAL COMMUNICATION COORDINATOR AMBULANCE STAGING MANGER IMMEDIATE AIR OPERATIONS DELAYED MINOR LZ (Helispot) An Example of a fully expanded ICS system for an MCI. The IC can expand or collapse the system as needed. Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 13 of 17 Appendix 2 – Extreme MCI Command Responsibilities Assignments/Responsibilities Initial Arriving Company        Recognize the magnitude of the event – stop short Establish Command (BIR) Request additional resources and designate level II staging location and radio channel Identify a holding area for ambulatory victims Initiate “Sifting” of ambulatory victims to holding area o The “sifting” procedure is considered a self-triage system. The fact that these patients have been ambulatory for several minutes post event, can follow directions, and can walk the short distance to the holding area, supports the assumption that they are less contaminated/injured than those remaining in the Hot and Warm Zones and quite likely are not contaminated/injured at all. Isolate hazard area If applicable to the incident, utilize HazMat IQ evaluation system Rescue Extrication Group      Ensure scene safety of hazard area If hazardous materials are suspected this group will work under the supervision of the Hazmat Team Ensure proper PPE Rescue and remove viable non-ambulatory victims from the hazard area Ensure proper decontamination if required Initial decontamination will consist of some form of gross mass decontamination. These procedures aim at removing the worst surface contamination from large numbers of victims. Mass decontamination can be either wet or dry. o Wet Mass Decon - This is a gross decon process that uses large volumes of lowpressure water to reduce the level of contamination. This operation includes removing victims clothing and flushing them with water from handheld lines and master streams from a fire apparatus. Wet decon will require: water, areas for both male and female, privacy to undress/dress, and a holding area for clothes and personal belongings. Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 14 of 17 o Dry Mass Decon – This system is designed for non-critical patients to clean themselves. Dry decon kits should be requested from command. These kits include:      A large trash bag for victims to undress inside (cut a hole for their head). A smaller bag for their clothes Sani-wipes to clean off any residue. Armband and matching tag for clothes bag Deliver patients to the triage area of the Medical Group Holding Area Group   Manage and organize the patients in the holding area Ensure that all patients are assessed and sorted in accordance with appropriate triage protocol. START Triage, RPM, 30-2-Can do.  Re-triage patients every 30 minutes or sooner by patient condition    Coordinate with 2nd Opinion Group for questionable patients Determine the need for wet or dry decon and complete (if needed) Coordinate the movement of patients to the casualty collection point (if required) 2nd Opinion Group    Responsible to manage questionable patients (those showing increasing signs of illness/injury) who have exited the warm zone Ensure proper PPE to handle contaminated patients Move questionable patients to proper area (decon, triage, treatment) Medical Group     Responsible for the triage and initial treatment of patients requiring transportation to area hospitals Only the critically ill/injured (immediates) will be transported to the hospitals Delayed and Minor patients will be transported to the casualty collection point or treated on scene Ensure a smooth flow of patients through the triage and treatment areas to the transportation group Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: 03/02/2015 n/a MULTI-CASUALTY INCIDENT (MCI) PROCEDURES SOP# SNFO-11 Page 15 of 17 Transportation Group     Responsible for the movement of critically ill/injured patients to the area hospitals Contact hospitals to obtain a bed count Establish ambulance staging area with easy access/exit Maintain accountability of patients and destinations Casualty Collection Points – Five designated locations configured to hold large numbers of sick or injured patients. Each casualty collection point will be augmented by an ambulance strike team.      Thomas & Mack Center Cashman Field Las Vegas Convention Center Las Vegas International Speedway Sam Boyd Stadium Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: MULTI-CASUALTY INCIDENT (MCI) PROCEDURES 03/02/2015 n/a Page 16 of 17 SOP# SNFO-11 Initial On Scene Organizational Chart Incident Command Holding Area Group Rescue/Ext. Group Medical Group Triage Unit Transportation Group 2nd Opinion Group Treatment Unit Hot Zone - Deceased Warm Zone non-ambulatory Cold Zone Sifting Initial Arriving Company Establish Command BIR Holding Area Request Resources Begin “Sifting” ambulatory to Holding Area. Southern Nevada Fire Operations STANDARD OPERATING PROCEDURES EMERGENCY OPERATIONS Effective date: Supersedes: MULTI-CASUALTY INCIDENT (MCI) PROCEDURES 03/02/2015 n/a SOP# SNFO-11 Page 17 of 17 Hot Zone - Deceased Warm Zone non-ambulatory Rescue/Ext Decon CP Cold Zone To Hospital Hazmat Medical Triage Holding Area TX Transport Loading 2nd opinion To Casualty Collection Point Ambulance Staging