MCI 2023.pdf

Mass Casualty Incidents (MCI) PARA 1500 Patient Care Theory What is an MCI?  Defined: A Mass Casualty Incident (MCI) is any event in which the number of patients exceeds the resources available to the initial responders. Sometimes referred to as a Multi-Casualty Incident depending on local termi...

Mass Casualty Incidents (MCI) PARA 1500 Patient Care Theory What is an MCI?  Defined: A Mass Casualty Incident (MCI) is any event in which the number of patients exceeds the resources available to the initial responders. Sometimes referred to as a Multi-Casualty Incident depending on local terminology.  Some examples: Small and large scale motor vehicle collisions.  Floods.  Tornadoes.  Earthquakes.  Terrorist attacks.  Aircraft or train accidents.  COVID-19  Active shooter or stabbing attacks. Would you consider a single vehicle collision an MCI?  Why MCI management is important MCI’s can be overwhelming and chaotic. You arrive to an uncontrolled scene with multiple patients and bystanders who are constantly moving around, people are calling you over to assess their loved ones or patients they have found. You may be the first agency on scene, traffic control, extrication and command of all incoming resources may become your responsibility. You must adequately manage the scene, triage patients, coordinate with allied agencies, communicate with Paramedic dispatch, assess the need for air ambulance, and guide all incoming resources to the appropriate staging locations and eventually to the patients. All these responsibility may fall onto you and your partner initially.  Learning about these kinds of events and using a systematic approach to scene management will help you treat patients most efficiently and preserve the greatest number of lives.  Ottawa General Code Orange 3 Level Scale of MCIs Level 1 Volume of patients overwhelms the initial responding ambulance, but the system has enough resources. 3 Level Scale of MCI’s Level 2 Volume of patients overwhelms the initial responding ambulance, but the system doesn’t have enough resources to handle it, thereby creating transport delays Level 2 MCI Highway 401 in Kingston, October 27th, 2018. Six people involved, one fatality. 3 Level Scale of MCI’s Level 3 Multiple patients, initial responding service is completely unable to cope with the demand, severe backup to transport, additional resources must be found and utilized. Level 3 MCI Seoul Halloween Stampede October 29th, 2022. At this time 155 killed. Major Incident  A major incident is an event for which available resources are insufficient to manage the number of casualties or the nature of the emergency   Major incidents may stress and overwhelm local, regional, Provincial, and even national and international resources Examples of major incidents- floods, earthquakes, train/aircraft crashes, large fires, explosions, chemical spills, stadium collapse 2004 Indian Ocean earthquake  An undersea earthquake that occurred at December 26, 2004 with an epicenter off the west coast of Sumatra, Indonesia. The earthquake triggered a series of devastating tsunamis along the coasts of most landmasses bordering the Indian Ocean, killing large numbers of people and inundating coastal communities across South and Southeast Asia, including parts of Indonesia, Sri Lanka, India, and Thailand.  Recent analysis compiled by the United Nations lists a total of 229,866 people lost, including 186,983 dead and 42,883 missing. catastrophe is one of the deadliest disasters in modern history. Open vs Closed MCI’s  Open Incident (uncontained): Has a number of casualties not yet located when you answer the initial call. Rescuers may have to search in multiple locations for the patients, or further casualties could occur in an on-going event (terrorist attacks or natural disasters).  Closed Incident (contained): A situation that is not expected to produce more patients, and the patients have all been located an accounted for (MVC’s, house fires).  An MCI can start as an open incident, and then become an closed incident. A closed incident can become an open incident as well. Saskatchewan Mass stabbings, September 4th 2022. Occurred in 13 different locations and resulted in 12 deaths and 18 injured. Emergency Management Ontario (EMO) Emergency Management Ontario (EMO) coordinates a system of mutually supportive partnerships that mages emergencies.  EMO coordinates emergency management program in the province and ensure the implementation in all municipalities and provincial ministries. In emergencies where the local capacity is overwhelmed, the municipality can declare an emergency (under Ontario’s Emergency Management and Civil Protection Act) to receive more support and resources.  If the emergency requires support beyond the capacity of the municipalities and the province, a formal request can be made to the federal government for assistance.  Source: ontario.ca/page/emergency-management-ontario Preparedness      The decisions and basic planning that has been implemented before an MCI or disaster occurs. Preplanned response or mutual aid agreements. Internal resources to remain self-sufficient for the first 72hrs. These plans cover all the anticipated/potentials. Some agreements may be omitted due to location or population e.g Hurricane preparations in Ontario. Training and drills is the cornerstone to ensuring preparedness and to identify deficiencies. Incident Management System (IMS)  The Incident Management System (IMS) is a standardized approach to emergency management encompassing personnel, facilities, equipment, procedures, and communications operating within a common organizational structure. IMS is predicated on the understanding that in any and every incident, there are certain management functions that must be carried out regardless of the number of persons who are available or involved in the emergency response. IMS may also be used for managing planned events, such as a concert or parade. An incident is an occurrence or event that requires an emergency response to protect life, property or the environment. Source: https://training.emergencymanagementontario.ca/coursematerial/IMS100_EN_PDFUA.pdf Incident Management System (IMS)  IMS is highly flexible and adaptable because it provides a standardized approach to the management of personnel, equipment and other resources, procedures, and communications within a common organizational structure. IMS can be quickly expanded or contracted according to changing circumstances and needs. It is predicated on the understanding that in any and every incident there are certain management functions - command, operations, planning, logistics and finance/administration - that must be carried out, regardless of the scale or complexity of the incident. Source: https://training.emergencymanagementontario.ca/coursematerial/IMS100_EN_PDFUA.pdf IMS vs ICS    The terms of often used interchangeably, however there are nuanced differences. ICS is primarily a command and control system delineating job responsibilities and organizational structure for the purpose of managing day-to-day operations for all types of emergency incidents. IMS incorporates ICS and provides a more comprehensive system for multiple jurisdictions to work together. Your text book and this lecture will primarily cover ICS. Incident Command System (ICS) The Incident Command System (ICS) is a standardized on-site management system designed to enable effective, efficient incident management by integrating a combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure.  The ICS is used to manage an incident or a non-emergency event and can be used equally well for both small and large situations.  ICS was first implemented in Canada on a large scale by the Province of British Columbia in the mid 1990s.  Source: https://www.icscanada.ca/en/home.html Incident Command System (ICS)  An effective ICS provides for:    Single jurisdiction and single agency involvement (Single Command System). Single jurisdiction and multiagency involvement (Single or Unified Command System). Multijurisdiction or multiagency involvement (Unified Command System). ICS Roles and Responsibilities  General Staff: Finance  Logistics  Operations  Planning  Command (Incident Commander, Public Information Officer, Liaison Officer, Safety Officer).  ICS Roles and Responsibilities Finance Sector: Responsible for documenting all expenditures at an incident for tracking and reimbursement. Not always used at smaller MCI’s.  Logistics Sector: Responsible for communications and medical equipment, facilities, food, water, fuel. Usually deals with the staging, supply, and support.  ICS Roles and Responsibilities Operations Sector: At larger incidents, the operations sector takes over the control of managing the tactical operations from the Incident Commander.  Planning Sector: Solves problems during the MCI, anticipates further complications, and creates a plan to overcome the barrier.  ICS Roles and Responsibilities  Incident Commander (IC): The person in charge of the overall incident.          Responsibilities of the Incident Commander include: Establish communications Ensuring the safety of all responders Assessing and reassessing the situation Determining objectives, strategies, tactics and priorities appropriate to the level of response Approving an Incident Action Plan Coordinating all activities to manage an incident Authorizing the release of information to the public Authorizing demobilization ICS Roles and Responsibilities    Public Information Officer: Responsible for providing the public and the media with clear information and status updates. Liaison Officer: Relays information and concerns among command, the general staff, and other agencies. Safety Officer: Monitor the scene for conditions that may present a hazard to responders and patients. The safety officer has the authority to stop all actions on a scene. ICS Terminology Span of Control: The number of resources a leader can effectively manage during an incident. 3-7, ideally 5.  Freelancing: When individual units or organizations take independent and often ineffective actions.  Incident Command System (ICS)  Must be able to expand from dealing with a non-major incident to a major incident in a logical manner  Using an ICS as standard operating procedure for small incidents permits a smooth transition when a major incident occurs ICS Organization  Incident Commander will base decision to expand (or contract) the ICS organization on three major incident priorities:     Life safety Incident stability Property conservation When expansion is required, Incident Commander will establish other command staff positions Incident Command System Incident Command EMS Command Law Enforcement Command Staging Fire/Rescue Command Support Air Ops Triage Treatment Transport EMS Branch Within The ICS Communications  Command established over the radio with CACC or Emergency Operations Center (EOC)     An EOC is where department heads, government officers and officials, and volunteer agencies gather to coordinate their response to an emergency event Command and the EOC share the same goals but function at different levels of responsibility Incident Commander is responsible for on-scene activities EOC is responsible for the entire community-wide response to the event Emergency Operations Center Emergency Operations Center Radio Communications   Communications are a key function during a major incident  Preplanning includes identification of radio frequencies to be used in major incident responses and ways they will be used.  Ensuring alternated forms of communications are available if radio/cell networks are damaged. All responding units should work off their designated channel  Separate frequencies for EMS, fire, and other support operations Radio Communications  Radio traffic must be clear, concise and in plain English       Calm communication helps set an orderly tone Avoid use of radio codes or jargon. Messages should be considered and prepared before transmitting The speaker should clearly identify the unit number or sector All radio traffic should be minimized Face-to-face communication is preferred and encouraged to limit radio traffic Ok so you arrive on scene to find Scene Assessment for EMS First unit on the scene should make a quick and rapid assessment of the situation (“windshield assessment”) Precise and complete assessment should be done as soon as safety and time permit        Type of incident and potential duration Entrapment or special rescue resources needed Number of patients in each triage category Additional resources needed Scene assessment must be continually updated Scene Reporting The Methane mnemonic device can be used to organize your reporting. Arriving first on scene        Perform initial scene assessment and communicate with dispatch. Determine which scene hazards are present, a rough number of patients, and which additional resources will be required. Highest level of care or most experienced Paramedic becomes the triage officer. Second Paramedic becomes Incident Commander until relieved by a higher authority (usually a supervisor). Establishes on radio: Unit 4123 establishing scene command. Directs all further resources until relieved. First crew in, last crew out. MCI Kits and Identification Vests  High visibility vests are used to identify key personnel and eliminate confusion when multiple agencies are involved.  MCI kits include all necessary materials needed to establish command and to begin the process of triage. Mass Casualty Incidents  Procedures    Most knowledgeable or experienced provider arriving on scene first typically becomes triage officer. Additional help should be requested Perform initial assessment on all patients first   Perform START or JumpSTART triage. Assign available personnel & equipment to priority one patients Mass Casualty Incidents  Procedures:  Patient transport decisions are based on a variety of factors: Prioritization  Destination facilities  Transportation resources   Triage officer remains at scene to assign & coordinate personnel, supplies & vehicles ICS Organization  Built around seven major components 1. Extrication sector 2. Triage sector 3. Treatment sector 4. Transportation sector 5. Staging sector 6. Supply sector 7. Mobile Command sector Entrance MCI 1. Extrication Sector     Responsible for managing entrapped patients at the scene. The extrication and rescue officers determine the type of equipment and resources needed. Victims may need to be extricated prior to being triaged and treated. Minimal treatment performed at this point. Security Zone Exit Entrance Extrication Sector MCI 2. Triage Sector TRIAGE – from the French “trier”, meaning “to count or sort” Triage is a continuous process during a major incident in which patients are assessed and categorized into different levels of care depending on their injury and the immediacy of care required  Security Zone Exit Entrance Command Extrication Sector MCI Triage Principles of Triage  Assessment of patient injury severity is based on: Abnormal physiological signs  Obvious anatomic injury (including mechanism of injury)  Concurrent disease factors that might affect the patient's prognosis  Primary vs. Secondary Triage  Primary triage      Used to rapidly categorize patient condition for treatment Document location of patient and transport needs Label patient with triage labels, tags, or tape Focus on speed to sort patients quickly No care (other than immediate lifesaving airway or hemorrhage management) is rendered during primary triage ( This is much easier said than done!). Primary vs. Secondary Triage  Secondary triage Used at treatment area.  Patients are retriaged.  Not always necessary especially at small incidents.  Better categorizes patients based on treatment capabilities.  Purpose of Tagging     Identify the priority of the patient Prevent re-triage of the same patient Serve as a tracking system during treatment/ transport All tags and labels should:      Be easy to use Rapidly identify patient priority Allow for easy tracking Allow room for some documentation Prevent patients from “re-triaging” themselves Triage Tag Figure 49-12 Triage Levels (START triage) Simple Triage And Rapid Treatment  Red (IMMEDIATE)   Yellow (DELAYED)   Potentially life threatening Green (MINOR)   Critical patients Minor injuries (ambulatory) Blue or Black (EXPECTANT)  Dead or critically injured RED (Immediate) First priority.  Patients who need immediate prehospital care and transport. Treat these patients first, and transport as soon as possible. Usually require management of ABC’s.  Typical Injuries:         Airway and breathing difficulties Uncontrolled or severe bleeding Severe medical problems Decreased mental status Signs of hypoperfusion Severe burns Open chest of abdominal injuries Yellow    (Delayed) Second priority. Patients whose treatment and transport can be temporarily delayed. Typical Injuries:    Burns without airway problems Major or multiple bone or joint injuries Back injuries with or without spinal cord damage GREEN (Minor)     Third priority. “Walking Wounded” Patients who require minimal or no treatment and transportation can be delayed until last. Typical Injuries:   Minor fractures Minor soft tissue injuries (contusions, abrasions, laceration). BLUE or BLACK (Expectant)    Fourth priority. Patients who are already dead or have little changes for survival. Treat salvageable patients before treating these patients. Typical Injuries:     Obvious death Obvious nonsurvivable injury, such as major open brain trauma. Respiratory arrest (resource dependent) Cardiac arrest START Adult Triage algorithm JumpSTART Pediatric Triage    JumpSTART accounts for the physiologic and developmental differences between pediatric and adult patients. Infants, children, and those with special needs who cannot ambulate should be taken to the treatment sector for secondary triage as soon as possible. Respirations are delivered as respiratory arrest is the most common cause of cardiac arrest in pediatrics. JumpSTART Pediatric Triage    Due to developmental differences, assessment of neurologic status is also modified. A modified AVPU score is used. An unresponsive child or one who responds to pain by posturing, with incomprehensible sounds, or is unable to localize pain is considered a red tag. JumpSTART Pediatric Triage *Applies to children less than 8 years or 45kg*. Special Triage Situations       These patient may be treated and transported sooner or later than their clinical situation and triage category indicates. Hysterical or disruptive patients. Injured rescuers. Contaminated patients (CBRN). Trapped or inaccessible patients. Multiple triage sites due to distance or obstacles. 3. Treatment Sector  Works closely with the extrication sector in patient care delivery   Provides advanced care and stabilization until the patients are transported to a medical facility   As patients are delivered, they are categorized according to their medical needs Most paramedics and hospital personnel are assigned to this area With large numbers of patients, the area is usually further divided into immediate and delayed treatment zones Security Zone Exit Entrance Command Treatment Extrication Sector MCI Triage Emergency treatment units 4. Transportation Sector Communicates with the receiving hospitals, ambulances, and aeromedical services for patient transport  Must work closely with the treatment sector to determine appropriate destinations for injured patients  The arrival and departure of transfer vehicles must be coordinated with the staging sector  Security Zone Exit Transport Command Treatment Extrication Sector MCI Triage Entrance Transportation of Patients     Method of transportation determined by triage priority and situation Ambulance(s) are the typical method of transportation Buses should be considered for transporting large numbers of patients categorized as Green Air ambulances are usually reserved for transport of critical patients or those who require specialty care. Tracking Systems for Patients  A destination log that integrates the triage tagging system must be maintained by the transportation section officer   The log should contain the patient’s name or triage label ID number A tracking log must contain the following information:     Patient identification Transporting unit Patient priority Hospital destination 5. Staging Sector Required for large incidents to prevent vehicle congestion and response delays  All emergency vehicles (fire, police, EMS) should report for direction   Other agencies should also be supervised by the staging sector (e.g., disaster-relief services and news media) Security Zone Exit Transport Command Treatment Extrication Sector MCI Triage Staging Entrance 6. Support / Supply Sector Coordinates gathering and distribution of equipment and supplies for all other sectors  May be responsible for obtaining medical supplies from area hospitals, rescue supplies, and other equipment needed at the incident  Security Zone Exit Transport Staging Command Treatment Safety Zone MCI Triage Supply Entrance 7. Mobile Command  On scene central command center to control the radio communications and ground communications during the incident. Rehabilitation Sector     Part of standard operating procedures in many fire and EMS agencies and major incident response plans Usually set up in a location outside the operational area Monitors personnel and ensures proper rest and hydration Works with logistics sector to ensure proper hydration and personnel monitoring supplies On-Scene Physicians at MCIs  Medical direction   Triage function     On-scene medical direction of paramedics Increased ability to make difficult triage decisions Use at treatment area to make secondary triage decisions Emergency surgery to facilitate extrication Treatment capabilities   On-scene ability to perform specialized invasive procedures More accurate assessment and direction of specific treatments Removal of the Deceased   Depending on the scale of the incident, personnel may be assigned to disposition of the deceased Duties may include:    Working with the medical examiner, coroner, law enforcement, and other appropriate agencies to coordinate removal Assisting in the establishment of an appropriate and secure area for a morgue, if needed Monitoring personnel for signs of stress Security Zone Exit Transport Staging Entrance Mobile Command Treatment Supply Extrication Sector MCI Triage Morgue Extrication Sector Supply Sector Triage Sector Transport Sector Staging Sector Agencies that may be involved in an MCI            Red Cross The military Search and rescue Hazmat Hydro workers Mechanics or technicians Tactical units Air resources Hospitals Nursing staff Construction or road workers Small Scale MCI  Time of day   Level 1 in daytime can turn into Level 2 at night Calls common to Small Scale MCI MVA’s  Building fires  HazMat exposures  Small Scale MCI  Common errors made in Small Scale MCI Failure to identify & contain patients rapidly  Failure to establish strong scene control  Creates ‘control vacuum’  Allows for ‘free lancing’   Mission conflict   The inevitable conflict that occurs between agencies on scene First in, last out Small Scale MCI  First in responsibilities  Scene assessment Overall impression of the magnitude of the event  Potential number of victims  Medical needs   Communication  Relay of information to communication center Triage  Choreography or ‘set up’  Small Scale MCI  Choreography or ‘set up’  Hazard identification  Largest hazard for paramedics - traffic Best ingress  Best egress  Other specifics of scene  Problems Unique to MVA’s     Patient containment in vehicles Rescue vehicle gridlock Most critical patients occasionally come last - destination consideration Specialty equipment required Problems Unique to Structure Fires     Multiple evacuation points Smoke inhalation doesn’t present immediately Trauma often secondary to falls from patients fleeing or jumping from floors Firefighters often become patients QUESTIONS ?????