LAFD Multi-Casualty Incident Operation Manual PDF

BOOK 70 MULTI-CASUALTY INCIDENT OPERATION MANUAL MULTI-CASUALTY INCIDENT COMMAND SYSTEM Introduction The establishment of this Incident Command System (ICS) organizational structure is designed to provide an organized Department response to multi-casualty medical emergency incidents. There exists...

BOOK 70 MULTI-CASUALTY INCIDENT OPERATION MANUAL MULTI-CASUALTY INCIDENT COMMAND SYSTEM Introduction The establishment of this Incident Command System (ICS) organizational structure is designed to provide an organized Department response to multi-casualty medical emergency incidents. There exists the constant threat of earthquake, brush fire, high rise fire, airplane crash, hazardous chemical incident, flood, and in short, the unusually high potential for both man-made and natural disasters, all of which could result in emergency medical incidents far beyond capabilities of the initial resources dispatched. This document is intended to establish the systematic deployment of resources in order to provide the appropriate emergency medical service in the event of significant emergency medical incidents. This document establishes an emergency medical organization within the ICS. This organization is specifically designed to incorporate all levels of emergency resources. The majority of emergency medical incidents are normally handled by initial responding units with subsequent request for additional assistance depending upon the number of victims involved and the severity of their injuries. Large multi-casualty incidents will overwhelm the initial responding resources. The Incident Commander must have delineated and expandable operational procedures to assure that proper emergency prehospital care and the prevention of further injury to victims, the public, and public safety personnel will be provided. These predetermined emergency medical operational procedures must provide for the effective treatment/transportation of multi casualties through the principles of "triage" management. The medical organization structure is designed to utilize all aspects of emergency resources, including on-scene physician medical direction. CHART: LAFD Incident Command System Medical Branch CHART: LAFD Incident Command System Medical Group(Expanded Overview CHART: LAFD Incident Command System Medical Branch(Expanded Overview) Incident Commander's Initial Responsibilities The medical portion of an incident may be handled by the Incident Commander and/or Medical Group Supervisor through additional emergency and hospital personnel and equipment depending upon the number of victims, severity of injuries, and magnitude of the incident. The Incident Commander shall assure the following: The Incident Command System is sufficiently implemented to meet the needs of the Multi Casualty Incident (MCI). Sufficient ambulances and/or appropriate transport vehicles have been requested. The Hospital Emergency Administrative Radio (HEAR) system has been activated through the Medical Alert Center (MAC). Sufficient Department personnel have been requested. Medical Branch: Definition and Function Definition: The Medical Branch structure is designed to provide the Incident Commander with an organizational system for handling any number of patients or an unusual geographic separation of a multi-casualty incident. One or more additional Medical Group(s) may be established under the Medical Branch Director if geographical or incident conditions warrant. The degree of implementation will depend upon the complexity of the incident. Function: The Medical Branch structure is designed to provide the Incident Commander with an organizational system for handling any number of patients or an unusual geographic separation of a multi-casualty incident. One or more additional Medical Group(s) may be established under the Medical Branch Director if geographical or incident conditions warrant. The degree of implementation will depend upon the complexity of the incident. The Medical Branch is not the standard Medical res organization used within the LAFD. The Medical Branch is reserved for incidents with a medical component that includes an unusually large number of victims, where patients are spread over a large area, or access to patients is separated by a great distance. The following examples are of incident types where the Medical Branch may be implemented: Metro Rail Incident: separation of access and egress by as much as 800 feet. Airplane Crashes: some victims treated and transported from the runway; others from a remote area. Medical Group: Definition and Function Definition: Department resources assembled at an incident that do not necessarily function within a single geographical area. Medical Groups are the basic level established at an LAFD incident when the number of resources exceed the span of control of the Incident Commander or Operations Chief. Function: The Medical Group is the standard organization used by the LAFD at medical incidents. As with all portions of the res, only those elements that require activation are implemented. Medical Branch Director Definition: Qualified Medical Branch Director Supervised By: Incident Commander or Operations Section Chief Subordinates: Group Supervisors Function: The Medical Branch Director is responsible for the implementation of the Incident Action Plan within the Branch. 1. Check in and obtain briefing from the Incident Commander/Operations Section Chief. 2. Review Group assignments for effectiveness of current operation and modify as needed. 3. Provide input to the Incident Commander/Operations Section Chief for the Incident Action Plan. 4. Supervise Branch activities. 5. Report to the Incident Commander/Operations Section Chief on Branch activities. 6. Maintain appropriate records. Medical Group Supervisor Definition: Qualified Group Supervisor Supervised By: Incident Commander, Operations Section Chief (or Branch Director) Subordinates: Triage Unit Leader, Treatment Unit Leader, Medical Supply Coordinator, Transportation Unit Leader Function: Establish command and control of the activities within a Medical Group, in order to assure the best possible emergency medical care to patients during a multi-casualty incident. Duties: 1. Check in and obtain briefing from Incident Commander, Operations Section, or Multi Casualty Branch Director. 2. Participate in Multi-Casualty Operations Section/Branch planning activities. 3. Establish Medical Group with assigned personnel. Determine amount and types of additional resources and supplies needed to handle the magnitude of the incident (medical caches, ambulances, helicopter, and other methods of patient transportation). Note: Coordinate air ambulance requests with Incident Commander/Operations or Medical Branch. 4. Designate Unit Leaders and treatment area locations as appropriate. 5. Isolate Morgue and Minor Treatment Area from Immediate and Delayed Treatment Areas. 6. Request law enforcement/coroner involvement as needed. 7. Establish communi.cations and coordination with the Transportation Unit Leader (or Group Supervisor if Medical Branch is activated) 8. Ensure activation of Hospital Emergency Administrative Radio (HEAR) system through the Medical Alert Center (MAC). 9. Direct and/or supervise on-scene personnel from agencies such as Coroner's Office, Red Cross, law enforcement, ambulance companies, county health agencies, and hospital personnel. 10. Ensure proper security, traffic control, and access for the Medical Group area. 11. Direct medically trained personnel to the appropriate Unit Leader. 12. Maintain records of activities. OPERATIONAL CONSIDERATIONS 1. Group command location should be in a safe area remote from triage/treatment areas with law enforcement perimeter control. 2. Ambulance traffic pattern and patient loading areas. 3. Treatment areas (consider isolating from each other): a. Immediate b. Delayed c. Minor 4. Morgue (consider security and remoteness). Triage Unit Leader Definition: Qualified Unit Leader Supervised By: Medical Group Supervisor Subordinates: Triage Personnel, Transporters/Litter Bearers, and Morgue Manager Function: Assume responsibility for providing triage management and movement of patients from the triage area. When triage has been completed, the Unit Leader may be reassigned as needed. Duties: 1. Check in and obtain briefing from Medical Group Supervisor. 2. Develop organization sufficient to handle assignment. 3. Inform Medical Group Supervisor of the total estimated number of patients, their triage classifications, and resource needs. 4. Implement triage process, and manage all triage activities at the incident scene. 5. Assume functions of Treatment Unit Leader until position is activated. 6. Direct the triage and movement of injured from the triage area. Note: the movement of patients by Triage Transporters to the treatment location shall be coordinated with the Treatment Unit Leader when implemented, i.e., do not move patients to the treatment area(s) until the treatment area(s) are prepared to accept patients. 7. Provide direction and guidance to personnel working on scene. 8. Establish a safe triage area. 9. Give periodic status reports to Medical Group Supervisor. 10. Maintain security and control of the triage area. 11. Establish Morgue. 12. Maintain record of activities. OPERATIONAL CONSIDERATIONS 1. Assess resource needs: a. Command, Communications b. Personnel c. Equipment and Supplies d. Relief Units 2. Inform Medical Group Supervisor of minimum needs. 3. Consult with triage personnel. 4. Give job assignments: a. Safety b. Records  c. First-Aiders d. Transporters: 30-minute Rotation Relief 5. Establish Morgue location. Note: Do not allow deceased patients to be moved from their original locations unless absolutely necessary. If possible, take pictures or mark location of deceased. This information is essential to the Coroner (see Appendix E). 6. SAFETY SHALL BE OF PARAMOUNT CONSIDERATION Triage Personnel Definition: Medically Qualified Personnel Supervised By: Triage Unit Leader Function: To triage patients on scene and assign them to appropriate treatment areas. Duties: 1. Check in and obtain briefing from Triage Unit Leader. 2. Report to designated on-scene triage location. 3. Triage and tag injured patients. Classify patients while noting injuries and vital signs if taken. 4. Direct movement of patients to proper treatment areas. 5. Provide appropriate medical treatment (ABC's) to patients prior to movement as incident conditions dictate. Morgue Manager Definition: Qualified Personnel as Assigned Supervised By: Triage Unit Leader Subordinates: Personnel as Required Function: Assume responsibility for Morgue area activities until relieved of that responsibility by the police department or Office of the Coroner. Duties: 1. Check in and obtain briefing from Triage Unit Leader. 2. Assess resource/supply needs and order as needed. 3. Manage all Morgue area activities. 4. Keep area off limits to all but authorized personnel. 5. Coordinate with law enforcement and assist the Coroner's Office as necessary 6. Keep identity of deceased persons confidential 7. Establish on-incident Morgue location if necessary 8. Advise Triage Unit Leader of location. 9. Maintain records, including deceased identity (if available), where the deceased was found, etc. MORGUE MANAGER OPERATIONAL CONSIDERATIONS 1. Assess resource needs: a. Communications b. Equipment and Supplies c. Personnel d. Relief Personnel e. Law Enforcement 2. Give job assignments: a. Security b. Records c. Placement Control 3. Morgue location: a. Remote from triage area. b. Not readily available to other patients. c. Accessible to vehicles (ambulance, law enforcement and the Coroner's Office) 4. The handling and identification of contaminated bodies shall be coordinated with the Medical Branch Director/Group Supervisor. CONFORM TO COUNTY CORONER'S POLICY: Mortality Management Guidelines - Appendix E Treatment Unit Leader Definition: Qualified Unit Leader Supervised By: Medical Group Supervisor Subordinates: Treatment Dispatch Manager Immediate Treatment Manager Delayed Treatment Manager  Minor Treatment Manager Function: Assume responsibility for treatment, coordination of patient treatment, and preparation for transport, in the treatment areas. Direct movement of patients to loading location(s) Duties: 1. Check in and obtain briefing from Medical Group Supervisor. 2. Develop organization sufficient to handle assignment. 3. Plan layout. 4. Direct and supervise Immediate, Delayed, and Minor Treatment Areas, assures Treatment Dispatch Manager documents patients' destinations. 5. Advise Triage Unit Leader of readiness to accept patients. 6. Request sufficient medical caches and supplies as necessary. 7. Establish communications and coordination with Transportation Unit Leader (or Medical Group Supervisor if Medical Branch is activated). 8. Communicate patient transportation needs to the Transportation Unit Leader/Group Supervisor. THE MOST CRITICAL PATIENTS SHOULD BE TRANSPORTED FIRST. See Appendix B. 9. Ensure continual triage of patients throughout treatment areas. 10. Directs the prioritizing and movement of patients from the treatment areas to the ambulance loading area(s). 11. Manage all activities within Treatment Unit. 12. Keep areas off limits to all personnel except those needed. Acquire law enforcement assistance, when available. 13. Assign hospital emergency response teams to treatment areas through their team leader. 14. Give periodic status reports to Medical Group Supervisor. 15. Maintain record of activities. OPERATIONAL CONSIDERATIONS 1. Assess resource needs: a. Command, Communications b. Equipment and Supplies c. Medical Teams d. Relief Personnel e. Hospital Emergency Response Teams(HERT) 2. Give job assignments: a. Treatment Managers b. Treatment Area Dispatcher c. Records d. Security 3. Standing orders. 4. Use volunteers during major disasters only, and assign them to Minor Treatment. Coordinate their use through Incident Commander. 5. Consider having each ambulance transport a delayed patient with each immediate patient. Must be coordinated with Transportation. Treatment Dispatch Manager Definition: Qualified Person Supervised By: Treatment Unit Leader Subordinates: As Needed Function: Responsible for coordinating with Transportation Unit/Group or Medical Group Supervisor, the transportation of patients out of the treatment area. Implementation: The institution of the Treatment Dispatch Manager's position is generally reserved for large-scale incidents. There is only one Treatment Dispatch Manager per Medical Group. Duties: 1. Check in and obtain briefing from Treatment Unit Leader. 2. Organize treatment dispatch function. Request Recorders and other resources as necessary. 3. Establish communications with the Treatment Unit Leader, Immediate, Delayed, and Minor Treatment Managers. 4. Establish communications with Transportation Unit or Medical Group as directed by the Treatment Unit Leader. 5. Verify that patients are prioritized for transportation. 6. As directed advise the Transportation Unit/Group or Medical Group Supervisor of the number of patients, triage classification, and when patients are prepared for transport. 7. Select mode of transportation for patients leaving treatment areas under direction of the Treatment Unit Leader (helicopter, ambulances, or buses). 8. Coordinate ambulance loading with the Immediate, Delayed, and Minor Treatment Managers and ambulance personnel under the direction of the Treatment Unit Leader. 9. Maintain appropriate records including transport request and patients transported. Provide this information to the Transportation Recorder at the conclusion of the incident. OPERATIONAL CONSIDERATIONS 1. Assess resource needs: a. Communications b. Equipment and Supplies c. Recorders and Other Personnel 2. Cause the most critical patients who are ready for transport to be transported first. 3. Give job assignments. 4. Consider having each ambulance transport a delayed patient with each immediate patient. Must be coordinated with Transportation. Immediate Treatment Manager Definition: Qualified Manager Supervised By: Treatment Unit Leader Subordinates: Medical Teams Function: Responsible for treatment and retriage of patients assigned to Immediate Treatment Area. Duties: 1. Check in and obtain briefing from the Medical Group Supervisor (or if activated, the Treatment Unit Leader) and brief subordinates. 2. Request or establish Medical Teams as necessary. 3. Assign treatment personnel to patients received in the Immediate Treatment Area. 4. Ensure treatment of patients triaged to the Immediate Treatment Area. 5. Assure that patients are prioritized for transportation. 6. Coordinate transportation of patients with Treatment Unit Leader/Treatment Dispatch Manager. THE MOST CRITICAL PATIENTS SHOULD BE TRANSPORTED FIRST. 7. Notify Treatment Unit Leader/Treatment Dispatch Manager of patient readiness and priority for transportation. 8. Assure that appropriate patient information is recorded. Delayed Treatment Manager Definition: Qualified Manager Supervised By: Treatment Unit Leader Subordinates: Medical Teams Function: Responsible for treatment and retriage of patients assigned to Delayed Treatment Area. Duties: 1. Check in and obtain briefing from the Medical Group Supervisor (or if activated, the Treatment Unit Leader) and brief subordinates. 2. Request or establish Medical Teams as necessary. 3. Assign treatment personnel to patients received in the Delayed Treatment Area. 4. Ensure treatment of patients triaged to the Delayed Treatment Area. 5. Assure that patients are prioritized for transportation. 6. Coordinate transportation of patients with Treatment Unit Leader/Treatment Dispatch Manager. THE MOST CRITICAL PATIENTS SHOULD BE TRANSPORTED FIRST. 7. Notify Treatment Unit Leader/Treatment Dispatch Manager of patient readiness and priority for transportation. 8. Assure that appropriate patient information is recorded. Minor Treatment Manager Definition: Qualified Manager Supervised By: Treatment Unit Leader Subordinates: Treatment Teams Function: Responsible for treatment and retriage of patients assigned to Minor Treatment Area. Duties: 1. Check in and obtain briefing from the Medical Group Supervisor (or if activated, the Treatment Unit Leader) and brief subordinates. 2. Request or establish Medical Teams as necessary. 3. Assign treatment personnel to patients received in the Minor Treatment Area. 4. Ensure treatment of patients triaged to the Minor Treatment Area. 5. Assure that patients are prioritized for transportation. 6. Coordinate transportation of patients with Treatment Unit Leader/Treatment Dispatch Manager. THE MOST CRITICAL PATIENTS SHOULD BE TRANSPORTED FIRST. 7. Notify Treatment Unit Leader/Treatment Dispatch Manager of patient readiness and priority for transportation. 8. Assure that appropriate patient information is recorded. 9. Coordinate volunteer personnel/organizations (Red Cross) through agency representatives and Treatment Unit Leader. Treatment Managers: Duties and Considerations Duties: 1. Manage all activities within treatment area. 2. Develop organization sufficient to handle assignment. 3. Plan layout; isolate Minor Treatment Area from Immediate and Delayed where possible. 4. Keep areas off limits to uninvolved personnel. Acquire law enforcement assistance when available. OPERATIONAL CONSIDERATIONS 1. Assess resource needs: a. Command, Communications b. Equipment and Supplies c. Medical Teams d. Relief Personnel e. Hospital Emergency Response Teams (HERT) f. Buses for minor triaged patients. 2. Give job assignments: a. Patient Care b. Transporters: Ambulance Loading c. Records d. Security 3. Standing orders. 4. Consider the span of control when working with extremely large numbers of patients and Treatment Teams. Treatment Team Coordinators may need to be established to manage large numbers of Treatment Teams, along with their needed supplies, and the necessary ongoing triage to determine a priority for which patients should be transported first. Treatment Teams Definition: Qualified Personnel with Supervision Composition: Paramedic EMT-1 Volunteer Personnel NOTES: Medical team type refers to qualification of personnel only. It does not refer to means of transportation, equipment, or ability to transport patients. Volunteers are generally not used by the Department to augment staffing at incidents. However, during major catastrophic emergencies, such as a major earthquake, the Incident Commander may assign community response teams/volunteers to nonhazardous operations, for example, providing care in Minor Treatment Areas. Supervised By: Assigned Manager/Unit Leader Duties: 1. Receive briefing. 2. Perform triage and treatment as assigned. 3. Record patient information on triage tags. 4. Report changes in patient status to appropriate assigned Manager or Unit Leader. Transportation Unit Leader [Group Supervisor] Definition: Qualified Manager Supervised By: Medical Group Supervisor (or Medical Branch Director if Activated) Subordinates: Medical Communications Coordinator, Transportation Recorder, Ambulance Staging Manager Function: Coordination of patient transportation and maintenance of records relating to patient identification, patient classification (Immediate, Delayed, or Minor), transporting unit's identification and destination. Duties: 1. Check in and obtain briefing from Medical Group Supervisor or Medical Branch Director (if activated). 2. Develop organization sufficient to handle assignments. 3. Ensure communications are established with the Medical Alert Center (MAC) or base hospital if MAC cannot be communicated with. Note: Patient destination will be determined by Department personnel based upon hospital information provided by the Medical Alert Center (MAC). 4. Maintain record of all hospitals being utilized and their handling capabilities for proper dispatching. 5. Designate an ambulance staging area. 6. Coordinate with Ambulance Staging Manager and Treatment Unit Leader. 7. Ensure the direction of ambulances regarding hospital destinations of patients and provision of ambulance identification and hospital destination to the Treatment Unit/Medical Group(s). 8. Assure that patient information and destination are recorded. 9. As required, request additional ambulances through channels to the Incident Commander. 10. Notify Ambulance Staging Manager of ambulance requests. 11. Coordinate requests for air ambulance transportation through channels with the Medical Group Supervisor, the Medical Branch Director, and Operations when activated. 12. When directed, establish air ambulance helispot with the Medical Group Supervisor, or if activated, the Medical Branch Director. 13. Maintain record of activities. OPERATIONAL CONSIDERATIONS 1. Command location for patient transportation function (geographically located adjacent to the Medical Communication Coordinator). 2. Develop an ambulance traffic pattern to avoid confusion. 3. Security. 4. At a large incident, consider additional staff to facilitate medical communications. 5. For efficient use of transport resources, consider having each ambulance transport a delayed patient with each immediate patient. Medical Communications Coordinator Definition: Qualified Coordinator Supervised By: Transportation Unit Leader/Group Supervisor Subordinates: Personnel as Required Function: Maintain communications with the Medical Alert Center (MAC) to assure proper patient transportation and destination. Coordinate information through Transportation Unit Leader/Group Supervisor and Transportation Recorder. At a large incident, this position may require a separation of communications: One person managing incident medical communications; and One person managing hospital communications. Duties: 1. Check in and obtain briefing from Transportation Unit Leader/Group Supervisor. 2. Establish and maintain communications with the Medical Alert Center (MAC) and communicate patient disposition through that system. 3. Obtain standing orders through the MAC and advise Treatment Unit Leader through channels. 4. Determine and maintain current status of hospital/medical facility availability and capability. 5. Obtain the designation of additional base station(s) to be used for specialized, individual case medical instructions, if necessary (pursuant to treatment area demands). 6. Receive basic patient information/ classification, i.e., Immediate, Delayed, or Minor from Transportation Unit Leader/Group Supervisor. 7. Communicate hospital availability to Transportation Unit Leader/Group Supervisor who will update the Treatment Unit Leader(s)/Medical Group Supervisors of hospital destination for ambulances. 8. Coordinate patient off-incident destination with the MAC. 9. Select patient destination for patients leaving the treatment area. 10. Maintain close liaison and information coordination with the Transportation Unit Leader/Group Supervisor and Transportation Recorder. 11. Maintain appropriate records. OPERATIONAL CONSIDERATIONS 1. Location adjacent to Transportation Unit Leader/Group Supervisor. 2. Maintain close coordination of efforts and liaison with the Treatment Unit Leader. 3. Anticipate potential patient numbers and consider requesting the response of one or more Hospital Emergency Response Teams (HERT) with the concurrence of the Medical Branch Director/Group Supervisor and approval of the Incident Commander. Transportation Recorder Definition: Qualified Personnel as Assigned Supervised By: Transportation Unit Leader (Group Supervisor) Subordinates: As Needed Function: Maintain records of patients, triage classification, mode of transportation, hospital status, and destination. Duties: 1. Check in and obtain briefing from Transportation Unit Leader. 2. Record transportation requests. 3. Record the ambulance agency and ambulance identification number of units transporting patients. 4. Assure that appropriate patient tracking information is recorded. 5. When directed, coordinate the recording of information on patients transported with the Treatment Dispatch Manager (when position is activated). Ambulance Staging Manager Definition: Personnel as Assigned Supervised By: Transportation Unit Leader/Group Supervisor Subordinates: Personnel as Required Function: Manage the Ambulance Staging Area and dispatch ambulances as requested. Duties: 1. Check in, obtain briefing from, and coordinate communications and activities with the Transportation Unit Leader/Group Supervisor. 2. Develop organization sufficient to handle assignment. 3. Establish appropriate staging area for ambulances. 4. Establish routes of travel for ambulances for incident operations. 5. Plan layout of staging area (consider immediate and future needs). 6. Assure the necessary equipment is available in ambulances for patient needs during transportation. 7. Establish immediate contact with ambulance agencies at the scene: 8. Request additional transportation resources as appropriate through the Transportation Unit Leader/Group Supervisor. 9. Provide an inventory of medical supplies available at Ambulance Staging Area for use at the scene. 10. Assume the responsibility of the Medical Supply Unit Leader until the position is activated. 11. Maintain records as required. OPERATIONAL CONSIDERATIONS 1. Establish safe ambulance staging location(s). 2. Assess Staging resource needs:  a. Command, Communications b. Equipment and Supplies c. Apparatus d. Personnel e. Relief Personnel f. Law Enforcement 3. Identify a numbering system for private ambulances. Medical Supply Unit Leader Definition: Qualified Personnel as Assigned Supervised By: Medical Group Supervisor Subordinates: Personnel as Required Function: Acquire and maintain control of appropriate medical equipment and supplies from units assigned to the Medical Group. Duties: 1. Check in and obtain briefing from Medical Group Supervisor. 2. Acquire, distribute, and maintain status of medical equipment and supplies within the Medical Group. 3. Request additional medical supplies through Medical Group Supervisor (medical caches). 4. Distribute medical supplies to treatment and triage units. 5. Maintain appropriate records. Medical Branch/Group Glossary DELAYED TREATMENT: Second priority in patient treatment. These people require aid, but injuries are less severe. HOSPITAL EMERGENCY ADMINISTRATIVE RADIO (HEAR): A communications system between medical facilities and on incident Department personnel, which provides available hospital patient receiving capability and/or medical control. HOSPITAL TEAMS/HOSPITAL EMERGENCY RESPONSE TEAMS (HERT): Hospital teams that respond to the incident upon request. IMMEDIATE TREATMENT: A patient who requires rapid assessment and medical intervention for survival. MEDICAL ALERT CENTER (MAC): Located at Los Angeles County USC Medical Center, MAC coordinates 11 blanket-standing orders" and patient destinations for multi-casualty incidents occurring within Los Angeles County. MEDICAL GROUP ORGANIZATIONAL STRUCTURE: This is designed to provide the Incident Commander with a basic expandable system for handling patients in a multi-casualty incident. MEDICAL SUPPLY CACHE: A cache consists of standardized medical supplies and equipment stored in a predetermined location for dispatch to incidents. MINOR TREATMENT: These patients' injuries require simple rudimentary first-aid. MORGUE (Temporary on Incident): An area designated for temporary placement of the dead. The Morgue is the responsibility of the Coroner's Office when a Coroner's representative on scene. MULTI-CASUALTY INCIDENT: The combination of numbers of injured persons and type of injuries exceeding the capabilities of an initial EMS response. QUALIFIED: A person meeting the certification and/or requirements established by the agency that has jurisdiction over the incident. STANDING ORDERS: Policies and procedures approved by the local EMS Agency for use by an EMT- II or EMT-P in situations where direct voice contact with a base hospital cannot be established or maintained. START: Acronym for Simple Triage and Rapid Treatment. This is the initial system that has been adopted for use by the California Fire Chiefs' Association. TREATMENT TEAM: Combinations of medically trained personnel who are responsible for on-scene patient treatment. TRIAGE: The screening and classification of sick, wounded, or injured persons to determine priority needs in order to ensure the efficient use of personnel, equipment, and facilities (see Appendix "D"). TRIAGE TAG: A tag used by triage personnel to identify and document the patient's medical condition (see Appendix "F"). Appendix A- ICS Modular Development Program APPENDIX A MULTI-CASUALTY INCIDENT COMMAND SYSTEM MODULAR DEVELOPMENT PROGRAM MODULAR ORGANIZATION The Incident Command System (ICS) organizational structure develops in a modular fashion based upon the kind and size of an incident. The organization's staff builds from the top down with responsibility and performance placed initially with the Incident Commander. As the need exists, separate sections can be developed, each with several units which may be established. The specific organizational structure established for any given incident will be based upon the management needs of the incident. If one individual can simultaneously manage all major functional areas, no further organization is required. Positions that are not assigned/filled are functionally performed at the next higher level. If one or more of the areas require independent management, an individual is named to be responsible for that area. For ease of reference and understanding, personnel assigned to manage at each level of the organization will carry a distinctive organizational title: Incident Command: Incident Commander Command Staff: Officer Section: Section Chief Branch: Branch Director (Optional Level) Group: Group Supervisor Unit: Unit Leader Appendix B PATIENT MOVEMENT AND COMMUNICATIONS APPENDIX B PATIENT MOVEMENT AND COMMUNICATIONS 1. Patients are triaged at the incident location when i.t is safe to do so. 2. Patients are not moved to the treatment areas(s) until the treatment area(s) are prepared to accept them. This is confirmed by communication between triage and treatment units. 3. The Treatment Unit Leader(s) have the responsibility to communicate patient readiness for transport. a. Treatment Teams shall notify their Treatment Area Manager of readiness and priority of their patient transport needs. b. The Treatment.Unit Leader(s) shall prioritize patient transportation be.tween the Treatment areas in their unit and notify the transportation Unit Leader/Group Supervisor of their transportation needs. c. Incident complexity, size, and volume of communications may require the implementation of a Treatment Dispatch Manager and necessary recorders. The Treatment Dispatch Manager communicates, coordinates, and documents the movement of patients from the treatment area to the patient loading area, and into ambulances for transport to the identified hospital. d. The Treatment Unit Leader or Treatment Dispatch Manager provide all patient transportation needs to the Transportation Group Supervisor and records all transportation of patients from their group. e. All air ambulance transports shall be coordinated through the Transportation Unit/Group, Medical Group, and Operations when they are activated. APPENDIX C MCI Quick Reference Guide MULTI-CASUALTY INCIDENT QUICK REFERENCE STARTER GUIDE First On-Scene Size up. Develop incident action plan. Request resources. Provide protection from fire or other further injury to patients. Recon area to ensure all patients are identified. Establish a medical group command post. Secure operational area. Ensure HEAR system activation through the MAC. Incident Location / Triage Area Triage at incident site if safe to do so.  Communicate to Incident Commander the total number of patients and their triage classification (give an early estimate with large numbers of patients). Use START system. Triage Unit Leader performs function of Treatment Unit Leader until that position is activated. Provide transporters/litter bearers to transport patients to treatment areas. Transport patients to treatment areas when Treatment Unit communicates preparedness to receive them. Leave dead bodies in place unless absolutely necessary to move them (they interfere with rescue operations). Establish Morgue as necessary. APPENDIX D Recommended Triage Principles APPENDIX D RECOMMENDED TRIAGE PRINCIPLES THE START PROGRAM FOR TRIAGE There are several principles that must be learned to effectively triage and deliver disaster style medicine. The objective of triage is to accomplish the greatest medical good for the greatest number of patients. A primary goal of triage is to select the patients in greatest need of urgent care. It is recognized that triage in a mass casualty situation offers little time or resources for doing CPR, taking blood pressures, or even counting pulse rates. However, minimal intervention to stabilize the airway or to control hemorrhage is done at the same time as the initial triage. The Simple Triage and Rapid Treatment (START) plan allows the first responders to triage patients in 60 seconds or less, depending on three simple observations. These physical assessments are: ventilation, perfusion, and mental status. The START plan does not attempt to make diagnoses. A START Field Guide is located on page 48. Triage personnel must tag ALL patients. IT IS A TIME CONSUMING AND OFTEN FATAL MISTAKE TO TRIAGE IN THE FIELD WITHOUT TAGGING A PATIENT. Patients are tagged so that rescuers arriving later can immediately turn their attention to the patients most in need. A triage tag has been adopted by the California Fire Chiefs' Association (see Appendix "F"). Triage personnel must rate or place the injured into one-of-four categories: 1. Deceased (Nonsalvageable) 2. Immediate 3. Delayed 4. Minor Deceased: No ventilation present even after attempting to reposition the airway. Immediate: Ventilations present only after repositionin'g the airway: or, respirations over 30 per minute; or, capillary refill takes over 2 seconds; or, patient fails to follow simple commands. Delayed: Any patient who does not fit the Immediate category nor the Minor category. Minor: These patients are separated from the general group at the start of triage by ordering "anyone who can walk" followed by an area assignment where the patients should proceed. APPENDIX E Mortality Management Guidelines APPENDIX E MORTALITY MANAGEMENT GUIDELINES DRAFT WORKING GUIDELINES RECOMMENDED BY AD HOC CORONER'S COMMITTEE DURING DISASTER OPERATIONS In the event of a major disaster, it may be some time before bodies can be collected and cared for by the Office of the Chief Medical Examiner-Coroner. Therefore, the following guidelines have been prepared to aid local agencies in handling the dead until the Coroner or an authorized representative can relieve those agencies of that responsibility. Handling the Dead When it becomes necessary to remove bodies from disaster sites due to rescue work or the health and safety of others, a set of specific procedures should be followed: 1. Do not remove any personal effects from the body. The personal effects must remain with the body at all times. 2. Attach a tag or label to the body with the following information: a. The date and time found. b. The exact location where found, including floor and room number, or other specific location as appropriate. c. The name and work telephone number of person making identity or filling out tag. d. If the body is contaminated with hazardous, biological, or other materials, so state. 3. If available, place the body in a disaster pouch or in plastic sheeting and securely tie to prevent unwrapping. Attach a second tag to the sheeting or pouch. 4. If personal effects are found and thought to belong to a body, place them in a separate container and tag. Do not assume that any adjacent loose effects belong to a body. 5. Move the properly tagged body with their personal effects to one locale, e.g., garage or  other cool building. Note: Do not use a vehicle or storage area with floors that can become permeated with body fluids or other liquids. 6. Bodies must be secured or safeguarded at all times until the arrival of the Coroner or an authorized representative. APPENDIX F Multi-Casualty Forms APPENDIX F MULTI-CASUALTY FORMS TRIAGE TAG: Explains how the treatment personnel will fill out triage tags. MULTI-PATIENT INCIDENT WORK SHEET: This form is used to record available patient information that will be communicated by the Medical Communications Coordinator to the base hospital or the Medical Alert Center (MAC). Column 1: Identifies patient information. Column 2: Identifies patient's injuries. Column 3: Lists patient's vital signs. Column 4: Identifies the rescue ambulance that will transport the patient. Column 5: Identifies any special care facility that the patient may require. Column 6: Identifies the hospital destination and estimated time of arrival of the patient. HOSPITAL RESOURCE AVAILABILITY: Space is provided for the hospital name, the number of beds [available (A) and used (U)], critical, and noncritical. MULTI-CASUALTY RECORDER WORK SHEET: The top portion of the form is self-explanatory. Column 1: The ambulance company name. Column 2: The ambulance identification number. Column 3: The patient triage tag number. Column 4: The patient's priority: Immediate (I) Delayed (D) Minor (M) Column 5: The hospital destination where the patient is being sent. Column 6: Recording the time the ambulance is dispatched off scene. This form is for use by Treatment Dispatch and/or Recorder(s) Retain this form when completed. AMBULANCE STAGING RESOURCE STATUS : The Ambulance Staging Resource Status checklist is a form for keeping resource status. Space is provided for the agency name and unit identification number, as well as their time in and time out of staging. MEDICAL GROUP WORK SHEET : An abbreviated patient flow chart is included with space for names of persons filling the positions. At the bottom is a checklist for other things to be considered, a location for hospital team identification, and a location to list names of cooperating agencies. MEDICAL BRANCH WORK SHEET : An abbreviated patient flow chart is included with space for names of persons filling the positions. At the bottom is a checklist for other things to be considered: space for hospital team identification, and names of cooperating agencies. TRIAGE TAG TRIAGE TAG - Part I Part the triage is used for documentation by triage personnel if time is available. Left and right corners are yellow and are perforated along the lines shown. One corner can be retained by the Treatment Unit Leader, the other can be retained by the Transportation Supervisor, The hospital destination can be marked on the tabs. The graphic area is to record initial injuries and other appropriate data. If bandage and dressing are applied to the injury, the description can be circled and an arrow drawn to identify the injured site. Vital Signs: the area to record initial vital signs, time and orientation. Perforated along the line shown. Black with white lettering "DECEASED. It Red with black lettering "IMMEDIATE." Yellow with black lettering "DELAYED." Green with black lettering "Minor. It Leave all parts attached if MINOR care, or tear off bottom parts to indicate triage priority. If the triage priority of the patient changes, remove the entire bottom portion, leaving the injury information, and add a second tag identifying the new triage priority and the reason for the change TRIAGE TAG - Part II Part II of the tag can be used by the treatment teams for documentation as time allows. MEDICAL COMPLAINTS/HISTORY: An additional area for injuries, complaints, or medical history. Drugs or solutions administered to the patient. NOTES: An additional area treatment instructions. Personal information possible. MULTI-CASUALTY HOSPITAL RESOURCE AVAILABILITY MULTI-CASUALTY RECORDER WORK SHEET MULTI-CASUALTY AMBULANCE STAGING RESOURCE STATUS MEDICAL GROUP WORK SHEET MEDICAL BRANCH WORK SHEET