Vous êtes sur la page 1sur 62

Managing Multiple Casualty Incidents

The Hospital/Pre-hospital Interface

n_Da

Definitions:
MCI Multiple Casualty Incident
Any incident where the
number/severity of patients exceeds
the capacity of local resources.
Local Healthcare Team All elements
of a response: Dispatch, Fire/EMS,
Law Enforcement, Hospitals, Public
Health (HSPD-8)
START Simple Triage And Rapid
Transport
n_Da

Learning Objectives
Effectively identify & communicate
critical pieces of information.
(dispatch, scene, hospital) using
good radio etiquette.
Establish & implement the Incident
Command System in a MCI situation.
Describe key roles, responsibilities
and functions necessary to manage
an MCI
Use START triage system to
categorize patients during an MCI.
n_Da

If you get a report that


the scene has 5 yellow
patients and 3 red
patients, do you know
what that means?

n_Da

S.T.A.R.T. Triage System


S.T.A.R.T. (Simple Triage And Rapid Transport)
Example of a triage method that quickly classifies victims
and prioritizes treatment

MINOR
DELAYED
IMMEDIATE
MORGUE
n_Da

Little or no care needed,


Delay care, injuries not life-threatening
Immediate care for life-threatening situation
No care, mortal injuries, cannot be saved
5

Types of Multiple Casualty


Incidents
Trauma
Acute Medical
Biological

n_Da

How Responses are


Organized
Disaster plans are prepared
Responders become familiar with the plan

Plans include the use of:


Communication Plan
Incident Command System (ICS/HICS)
Provides leadership and structure
Identifies Roles and Responsibilities

Triage
Used to manage limited resources
Prioritize patient care based on
survivability
n_Da

Module One:
Communications

n_Da

Question
What problem is most
commonly identified after
exercises or real events in
the Post Incident Review
or After Action Report?

n_Da

Implementing the
Communications Plan (Group
Discussion)

Do you have a communications plan?


What are your Dispatch Procedures
responder notification?
How is the Hospital Notified?
How does On-Scene Command
Communicate with the Hospital?
How do you Communicate with other
hospitals?
How/when do you communicate with the
public?
n_Da

10

WHAT TO COMMUNICATE FIRST


Initial contact scene/situation sizeup
Safety

Assume/Announce Command
Request Resources
Identify location, access and
positioning
Assign/Allocate Resources
n_Da

11

Size-Up, Assume Command

Dispatch: Local Ambulance: On


scene of a multiple vehicle crash
with approximately 20 casualties.
Local Ambulance will be I-90
Command on the east bound
Gold Creek Off ramp.

n_Da

12

Keys to Clear Radio


Communication
Key microphone 2 seconds before speaking
on a repeater based radio system
Say who you want to talk to first then say
who you are.
Use clear text (plain language NO TEN
CODES)
Speak slowly and clearly (practice this)

Repeat back communications to


acknowledge receipt of message.
Assume messages not acknowledged were not
heard and repeat initial message
n_Da

13

Keys to Clear Interpersonal


Communications
Develop/refine and practice your
communications plan
Organize your thoughts to present
the information clearly and concisely
(SBAR)
Have a back-up plan (runners, written
notes)
n_Da

14

I am 10-23 at a
10-50. 10-52
times two and a
10-51.

Dispatch: HP 1: I am on
scene at a car crash with
casualties. I need 2
ambulances and a wrecker.
n_Da

15

Dont use 10-Codes!

n_Da

16

Hospital: Medic 1: Enroute to your


facility with a TBI. 2 min LOC and
GMS with GCS of 9.
Hospital: Local Ambulance:
Transporting Pt. #3 triaged as
red/immediate, due to head
injury with respiratory rate of
40, radial pulse present, and
responds to pain only.
n_Da

17

Avoid Acronyms
and Abbreviations!

n_Da

18

SBAR
(focused communication)
Situation: En route with 52 year old
male triaged as Red
Background: Motor vehicle crash
ejected
Assessment: Head and chest injuries
Recommendations: Activate Trauma
Team
n_Da

19

Public Information
If pub info isnt addressed early/
aggressively it will impact the incident
and incident communications
this is one of the reasons phones go down
and your hospital becomes overwhelmed
with people seeking information

Assign people to answer phones, craft


messages for media, meet with
families, track patients.
n_Da

20

Request Resources
Call for help
You can always cancel them if not needed
Be specific about what units and capabilities
you want
Order enough resources

Tell them where to report & how to access


the scene
If coming in a vehicle, where should it be
positioned?
n_Da

21

Assign/Allocate/Reassign
Resources
Individuals or resources should be
assigned:
Someone to report to (a boss).
A task TO ACCOMPLISH
Where to go.
What to do when done with THE task.

n_Da

22

Group Activity
Photo/description of MCI Incident
Divide into groups (Prehospital/Hospital)
Play act initial establishment of
command for each area and
communication between groups

n_Da

23

An Organized Response
Requires planning
Coordinates resources and
personnel

n_Da

24

Report to Staging Area


Sign in when you arrive;
Sign out when you leave
Bring ID, credentials
Find your designated
supervisor
Follow directions

Medical volunteers at
If asked to leave or
staging area
provide care else where
do so

n_Da

25

Accountability: Task

Tell them what needs to be done


Ensure assignment is understood
Give them the tools they need
Tell them what to do when done

n_Da

26

Use SMART Objectives

Specific
Measurable
Action Oriented
Realistic
Timeframe

n_Da

27

Break

n_Da

28

On-Scene
Incident Command Structure
Incident Commander

Safety Officer

Medical Branch
Director
Triage Group
Supervisor
Transport Group
Supervisor.
n_Da

Technical Rescue

Treatment Group
Supervisor

Dive Team

Extrication Team
29

Emergency Dept
Hospital Incident Command
Incident Commander
Cindy
Triage
Unit Leader
Paula

Treatment
Unit Leader
Dr. Jones

Transfer
Unit Leader
Bob

Communications
Unit Leader
Bob

Immediate
Red Team
Delayed
Yellow Team
Minor
Green Team
n_Da

30

WHAT ARE YOUR Local


Resources?

Ground Ambulances
Air Ambulances
Fire/Rescue Vehicles
ED beds
Hospital beds
Operating Rooms
Blood Supply
Imaging/Lab
Capacity
Ventilators
n_Da

EMTs
Flight Crews
Firefighters
Technical Rescue
MDs, RNs, CNAs
Surgeons, OR Crews
Blood Bank Staff
Imaging/Lab Staff
Resp Therapists
31

Group Activity
What resources are
available to my
community during an
MCI?
Where are they?

How do we contact them?


How long will they take to arrive?
n_Da

32

Why is it important to
give the incident a
name?

Because you could have multiple


incidents going on simultaneously.
Helps avoid confusion.
n_Da

33

Assessment and Care of Multiple


Patients
On-Scene
Rescue/Extrication
Triage
Treatment
Transport

Hospital
Decon
Triage/Re-Triage
Treatment
Admission/Discharg
e/Transfer

*see slide

* see slide

n_Da

34

On-Scene Triage Group Supervisor


Responsibilities/Tasks:
Ensure safety
See each patient rapidly, categorize and
label patients using a standard triage
system
Communicate triage decisions with
Medical Branch Director, and coordinate
with treatment and extrication groups.
Track Patients:
Remove patients to the treatment area
Red Patients move first!
n_Da

35

Hospital Treatment Unit Leader


Responsibilities
Provide definitive care: identify and fix the problem
Provide lifesaving basic life support before
advanced life support..
Match patient needs with provider skills.
Use available resources, making decisions about
resource allocation at each step.
Use tools to document and aid organization
Transport/Transfer/Admit them to the place where
these needs can be met.

n_Da

36

Rescue Group(s)
Rescue and triage are happening
simultaneously
Rescue Groups focus on:
Extrication
Technical Rescue (high/low angle)
Dive Teams
HazMat, Decon
Patient Movement (out of hazard zone to
patient collection area/treatment)
n_Da

37

Staying Organized
Organizational
Tools
Plans
Protocols
Forms
Job Action Sheets

n_Da

38

Triage Systems

n_Da

39

START
Triage
A process in
which
victims are
sorted into
groups;
priorities of
care are
established
and
resources are
allocated.
n_Da

40

S.T.A.R.T. Triage System


S.T.A.R.T. (Simple Triage And Rapid Transport)
Example of a triage method that quickly classifies victims
and prioritizes treatment

MINOR
DELAYED
IMMEDIATE
MORGUE
n_Da

Little or no care needed,


Delay care, injuries not life-threatening
Immediate care for life-threatening situation
No care, mortal injuries, cannot be saved
41

START uses R P M
Respirations (<10 OR >30)
Pulse (no radial pulse)
Mental status (unable to follow
simple commands)

n_Da

42

Triage Flow Chart


Flow Chart Decisions:
1. Separate walking
wounded from
others
2. Use RPM life
functions to tag
remaining patients:
a. Respirations
b. Circulation
c. Mental Status
n_Da

43

First Step: Breathing

Cannot breathe on own after airway opened [BLACK tag]


Breathing rapidly >30 breaths per minute [RED tag]
Breathing regularly (go to next step in flow chart PERFUSION)
n_Da

44

Second Step: Blood Flow


If detectable
radial pulse, go
to step 3: Mental
Status
If no detectable
radial pulse check capillary
refill
Refill more than 2
seconds control
bleeding - [RED tag]
Capillary refill less
than 2 seconds - go
to step 4: Mental
Status
n_Da

45

Third Step: Mental Status

Cannot follow simple command - [RED tag]


Can follow simple command - [YELLOW tag]
End of algorithm all victims should be tagged now.
n_Da

46

PATIENTS ARE RED IF THEY HAVE EVEN


ONE FINDING OF:
RR <10 OR > 30
No Radial Pulse
Cannot follow simple commands

n_Da

47

Activity:
Triage Practice Case #1
A woman runs up to you, supporting her
left arm, and says, I think its broken.
Respiratory rate is 24/minute
Radial pulse rate is 120/minute

How would you label her?

n_Da

48

Activity:
Triage Practice Case #2
You approach a man who is lying on the
ground
He is taking 36 breaths per minute
You cannot find a radial pulse
He moans when you use a painful pinch
How would you label him?

n_Da

49

Activity:
Triage Practice Case #3
A woman is sitting slumped over, not
breathing
You open her airway still not breathing
There is no radial pulse
Her carotid pulse is 30 beats/minute

She does not respond to noise, touch, or


painful stimuli

How would you label her?


n_Da

50

Triage Organizes Priorities


Normal Circumstances
Use all available manpower and supplies
Resource use focuses on saving one life

Mass Casualty Situation


Number of injured exceeds ability to treat in
normal manner
Resource use focuses on saving as many
lives as possible
Minor injuries wait for care
Severe injuries receive immediate care
Mortal injuries do not receive care
n_Da

51

What Makes Triage Difficult


More patients than resources
Victims who are Beyond Rescue
Black tag (morgue) category
To NOT treat such patients will oppose all your
training and instincts

Example:
Patient has no pulse and is not
breathing
Routine situation compared to a mass casualty
situation
n_Da

52

Now that you understand START;


Does the triage system you use daily
in the ED work for MCIs?
If not, you need to decide whether
during an MCI you will:
Stay with START system initiated prehospital or Adapt your current system to include a
category for the patients who are
expected to die given maximum
treatment with the available resources
n_Da

53

What Triage system


does your ED use
everyday?
MCI Triage Options:
Stay with the START
system initiated prehospital or Adapt your current
system to include a
category for the
patients who are
expected to die even
if they are given
maximum treatment
with the available
n_Da
resources

54

Tools for S.T.A.R.T

Left side
used for
notes on
injuries and
vital signs
Right side
contains
decision flow
chart
(algorithm)
Note the four
color-coded
categories at
the bottom

n_Da

55

Tools for S.T.A.R.T.


Triage kit MAY include:
Tape to create triage areas
Patient triage tags
Clipboards & Tracking tools
ID Vests

n_Da

56

Review

Communication
Organization
Resource Management
Roles and Responsibilities
Prioritization (triage)
Accountability (Personnel, Patients,
Tasks)

n_Da

57

For More Information


HICS:
http://www.emsa.ca.gov/hics/hics.asp

NIMS:
http://www.dhs.gov/interweb/assetlibrary/NIMS-90-web
.pdf

FEMA (Certificate in basicICS):


http://training.fema.gov/EMIWeb/IS/is195.asp

OSHA:
http://www.osha.gov/SLTC/etools/ics/org.html
n_Da

58

More Information on
Triage
MINOR
DELAYED
IMMEDIATE
MORGUE

For additional practice:


http://www.citmt.org/start/exercise.htm
For more information on tags:
http://www.mettag.com
To find out to fill out a tag:
http://www.digisys.net/oes/triagetag.ht
m

n_Da

59

Basic HICS/ICS Organizational


Structure
Incident
Commander
Public Information
Officer

Command Staff

Safety Officer

Liaison Officer

General
Staff

Operations
Section Chief
Branch
Director

n_Da

Planning
Section Chief

Logistics
Section Chief

Finance
Section Chief

Division/Group
Supervisor
60

Hospital ICS Chart

n_Da

61

References
Brady, Paramedic Emergency Care, Bledsoe, Porter, Shade
NIMS ICS Field Guide, 1 st Edition Infomed
Disaster Medicine, 2002 Lippincott Williams & Wilkins, Hogan and Burnstein
Emergency Medical Services at a Mass Casualty Incident, Joseph Cahill,
Domestic Preparedness Journal V. III, Issue 7, July 2007
Creating Order from Chaos: Part II: Tactical Planning for Mass Casualty and
Disaster Response a Definitive Care Facilities, Baker, Michael S., Article
Military Medicine, Mar 2007
In a Moments Notice: Surge Capacity for Terrorist Bombings, Challenges
and Proposed Solutions, CDC, April 2007
International Nursing Coalition for Mass Casualty Education, Educational
Competencies for Registered Nurses Responding to Mass Casualty
Incidents, August 2003
Mass Casualty Incident Program, Initial Triage Training, AEMS, courtesy of
Pheonix FD.
Virginia Mass Casualty Incident Management, Secondary Triage
Improving health system preparedness for terrorism and mass casualty
events, Recommendations for action, July 2007, AMA/APHA Consensus
report
Mass Medical Care with Scarce Resources, A Community Planning Guide,
Health Systems Research Inc., Feb. 2007
Nancy Carolines, Emergency Care in the Streets, Sixth Edition
National Incident Management System, Principles and Practice, Walsh,
Christen, Miller, Callsen and Maniscalco

n_Da

62