Curriculum Update:
Medical Incident Command
Condell Medical Center
EMS System
July 2006
Site code:
#10-7200-E-1206
Revised by Sharon Hopkins, RN
Objectives
• Upon successful completion of the module,
the EMS provider should be able to:
– list components of the medical incident
command
– discuss the responsibilities of the components
of the medical incident command system
– participate in a table top drill exercise
– successfully complete the quiz with a score of
80% or better
A Major Incident
Any event where available resources are
insufficient to manage the number of
casualties or the nature of the emergency
Components of Disaster
Preparedness
• Understand effects of man-made or natural
disasters
• Develop leadership skills during & after the
emergency
• Know and involve community links,
resources, & backup strategies
• Understand all components of the plan
• Maintain core competencies by
participating in disaster drill training
Preparation For A Major Incident
• 3 phases in preparation
 preplanning
• working together and planning ahead
• discuss common goals and specific
duties
• most successful with frequent meetings
and practice sessions/exercises
 Scene management
• development of strategy to manage the
incident
• may need only local resources if small
scaled incident or major and outside
resources if large incident
• takes coordinated effort for efficient and
safe use of resources
 Postdisaster follow-up
• after action review
• review of lessons learned
• discussion of areas for improvement
• evaluates stress related impact (anxiety
and illness) among emergency workers
Disaster Management
Things can get better or worse, but they
rarely stay the same…..
When planning, “simple” is usually the
best process.
The Golden Hour
The first hour after injury.
Prehospital care delivered by EMS cannot be
at the sacrifice of the golden hour any
more than is necessary.


Lessons Learned
• Learn from history & other’s
experiences/mistakes
• Keep procedures simple
• This is not the time to be introduced to new
• Need to be familiar with equipment and
how to respond to mass casualty incidents
Incidents will occur so plan
for them
Plan for the worst, hope for
the best
Activation of a Mass Casualty
Incident
• The first responding unit functions as
Command and must initiate the appropriate
response plan (Mass Casualty or Multiple
Victim) as well as start triage until relieved
by personnel recruited to the scene
• The way the first few minutes are handled
during an emergency often predicts how the
rest of the incident plays out
Multiple Victim Incident
• Responding EMS personnel can control
life threats with their usual resources
• Adequate numbers of responders and
ambulances can be at the site within 10-20
minutes
• Surrounding hospitals can be accessed in
timely manner and they can provide patient
stabilization
Mass Casualty Plan
• Number of patients and nature of injuries
make normal level of stabilization & care
unachievable
• Number of EMS personnel and ambulances
brought to the site within primary &
secondary response times are not enough
• Stabilization capabilities of hospital within
25 minutes are not adequate to handle all
patients
Plan Activation
• Mutual goal: to do the most good for the
most people while trying to preserve life
• Activate a plan as soon as possible
– takes time to mobilize resources
– alerts resources that they may be needed
Scene Assessment
• Quick and rapid size-up/assessment
– type of incident & potential duration
– if entrapment or special rescue resources may be
needed
– number of patients potentially in each triage
category - red, yellow, green, black
– consider initial assignments to give incoming units
– consider need for additional resources to manage
the incident
• Ongoing scene assessment - watch for changes
Incident Command System
• A proven, flexible management tool the
contributes to the strength and efficiency of
an overall system
• Organizes interagency functions &
responsibilities
• Required response plan to be used at all
incidents per Department of Homeland
Security, 2004
• Can be used for small incidents and major
ones
Incident Management System
Organization
Incident commander
Safety Officer
Public Info Officer
CISD
Finance/
Logistics
Administration
Liaison Officer
Operations
Plans
Intelligence
EMS/Branch
Triage
Treatment
Transportation
Role Identification
• All section leaders need to be visibly
identifiable
– reflective, labeled vests
– labeled hard hats
• Need to be identifiable for those that are
unfamiliar with the individual
– easier to send responding personnel to
“charge in Triage” than to send to “Bob
in Triage”
Incident Command Roles
• Command
– established immediately
– belongs to one person (initially to one person in the
first responding unit)
– should eventually be the one who can best manage
the emergency scene the most effectively
– needs ability to coordinate with variety of
emergency activities
– develop management strategy
– request resources, provide assignments, delegate
authority to subordinates
Incident Command Priorities
• Life safety
– always the first priority of responders and the
public
• Incident stability
– needs to decide on strategies to minimize the
effects on the area and maximize response
effort using resources appropriately
• Property conservation
– minimizing damage to property while
succeeding at the incident objectives
Section Responsibilities
• Finance/administration section
– seldom used section in small scale events
– tracks costs and the way of reimbursement is
handled
• time accounting
• procurement
• payment of claims
• estimation of costs
Section Responsibilities
• Logistics section
– provide gear and support to responders
• airway, respiratory, hemorrhage control
• burn management
• patient packaging and immobilization
– provides supplies, equipment, facilities,
services, food, and communications support
– resources for moving & transporting patients
• people, ambulances, buses
– medical unit cares for responders - offers rehab
Section Responsibilities
• Operations section
– directs and coordinates all emergency scene
operations
– ensures safety of all personnel
– in charge of the tactical aspects
•
•
•
•
•
•
•
accomplishing tactical objectives
directing front-end activities
participating in planning
modifying action plans as needed
maintaining discipline
accounting for personnel
updating command
Section Responsibilities
• Planning section
– provide past, present, and future information
about the incident and the status of resources
– may need to create an incident action plan written or verbal
• defines response activities and use of resources
• helpful when multiagency or multijurisdictional
resources used and when the incident is complex
Section Responsibilities
• Intelligence
– gathers and shares incident related
information and intelligence
Additional Responsibilities
• Communications
– usually the one area that is the most confusing,
least effective, and most criticized
– all transmissions need to be short and to the point
– multiple victim plan - all radio traffic is conducted
in the normal manner
– mass casualty incident - one source designated
from the scene to communicate with outside
resources
• scene personnel need to know who to communicate
with and on what frequency
Technology Issues
• Will equipment survive the environment?
– radios may be knocked out
– landlines and cell towers overwhelmed
by callers/users and won’t function for
rescue personnel
• What is your department’s plan for
communication with each other and
responding assistance?
Additional Responsibilities
• Staging officer
– incident commander should provide instructions
for the deployment of resources including staging
area location and specific information if required
(ie: direction of approach)
– line vehicles up at scene to facilitate egress and
prevent congestion
– personnel should stay with their vehicles
– keys should be left with the vehicle
– stage away from the actual scene
– maintain log of resources in staging
Additional Responsibilities
• Rehabilitation Area
– usually set up outside the operational area
– personnel can get physical and psychological
rest
– provide medical care and treatment as needed
– keep logs of those who are in rehab
EMS Branch of Operations
• Triage
– method of categorizing patients according to their
priorities of treatment
– an on-going process
– based on
• abnormal physiological signs
• obvious anatomical injuries including mechanism of injury
• concurrent disease factors that might affect prognosis
– primary triage - at site to categorize patient conditions
– secondary triage - used in treatment area to assign
priorities of care
Triage
• Recognized that it is very hard to do triage
• We’re use to treating people, not moving them
• Need to consider how to handle/manage
uninjured survivors otherwise they will bog
you down
• Triage recommended to be done in pairs
Concept of Triage in Pairs
• One person focused on the individual patient
– performs clinical assessment & provides rapid
treatment, gives moral support
• 2nd person keeps eyes & ears open
surveying environment
– watches environment; talks to uninjured
– prepares equipment
– plans triage route
– gathers info & communicates with others
START Triage
• Another concept/process for performing triage
• Purpose: to classify victim’s status:
delayed - walking wounded
urgent - serious
critical - immediate
dead/dying
• Patient tagged with appropriate color-coded
tag
Introduction of the
START Triage System
• When there aren’t enough personnel on the
scene to treat all of the patients at the same
time, sorting needs to be done in order to
prioritize which patients will be given
treatment first
• Use of the START system triage is one good
method to use to do this sorting
• START triage process uses more systematic
approach than what is currently used
locally
START Triage
• Allows rescuers to quickly identify victims
at greatest risk of early death and advise
other rescuers of the patient's need for
stabilization by tagging the patient with
color coded disaster tags
• As before, patients are continuously reevaluated throughout the incident and are
retagged as needed
• Triage process the Region will be moving
towards in the future
START Triage
simple
triage
and
rapid
transportation
START Triage
• Field guide developed in Newport Beach,
California at Hoag Memorial Hospital
• Based on 60-second assessment
• Focuses on
– patient’s ability to walk
– respiratory effort
– pulses and perfusion
– neurological status
Patient’s Ability To Walk
• If the patient can walk and can understand
basic commands, they are classified as
“delayed category” - “walking wounded”
• Can direct these patients to walk to a
treatment or transportation site
Respiratory Effort
• If breathing is absent, the patient is
classified as “dead/dying”
• Respiratory effort <10 or >30 = “critical”
• Based on respiratory assessment and
paramedic judgement, can classify patient
as “urgent” or “delayed”
Pulses and Perfusion
• Absent pulse, patient classified “dead/dying”
• Carotid pulse present but no radial pulse the
patient is classified as “critical”
• If carotid and radial pulses are both present,
assess mental status before deciding on triage
category
Neurological Status
• Assess by asking patient to do 2 simple tasks:
 touch nose with index finger, stick out tongue
 assess orientation by asking name, date and year
• If both tasks can be performed, patient is
classified as “delayed”
• If patient fails either task, classify them as
“critical”
Primary Triage
• Used at site
• Rapidly categorizes or sorts
the patients
• Each patient tagged
• No care given except for
immediate life-saving
measures
– ensure an open airway
– control hemorrhage
Secondary Triage
• Used in treatment area to retriage patient
• Patient assigned priorities of care
Triage and Patient
Categorization
Criteria for triage classifications can be
influenced and is determined by
– size of the incident
– number of injured
patients
– available manpower
• Need to be familiar with
your local SOP’s for patient triage
Disaster Tags
I. METTAG System utilizes four-color tags
• RED-- IMMEDIATE-- the most critically
injured (Priority 1) (P-1)
• Yellow--DELAYED-- less critically injured
(Priority 2) (P-2)
• Green-- HOLD -- non-life or limb-threatening
(Priority 3) (P-3)
• Black-- DECEASED-- dead or unexpected
survival (Priority 0)
Disaster Tags
• Many variations of tags, tape and labels
available
• Purpose of tagging
– Identify the priority of the patient
– Prevent re-triage of the same patient
– Serve as a tracking system during
treatment/transport
Disaster Tags
• Tags/ labels should be
– easy to use; easy to write on
– not destroyed by the elements
– rapidly identifies priority
– allow for easy tracking
– allow for some documentation
– prevent patients from re-triaging themselves
• Should be used routinely so their use
becomes familiar
Mettag Samples
The
METTAG
System
sample
Putting START Triage Into
Practice
60- second assessment that evaluates:
– ability to walk on own
– ventilation rate
< 10 or >30
– perfusion status
– mental status - 2 tasks
Victims are classified as
– minor, delayed,
immediate, dead/dying
START Triage
Based on evaluation of three parameters.
Remember “30 - 2 - can do”:
espirations
erfusion
ental Status
START Field Guide
Respirations
No
Yes
Position Airway airway open?
No
Yes
> 30/min
< 30/min
Immediate Assess perfusion
START Field Guide (cont)
No
Deceased
Yes
Assess
Perfusion
Immediate
Radial Pulse
None Present
Present
START Field Guide (cont)
Radial Pulse
Present
Radial
Pulse
None Present
Not Present
Control Bleeding
Assess Mental
Status
Immediate
Mental Status
Can’t follow commands
Immediate
Follows commands
Delayed
EMS Branch of Operations
• Treatment officer
– establish areas to categorize patients
•
•
•
•
red - immediate treatment for life threatening injuries
yellow - serious injury
green - delayed treatment & transportation acceptable
black - dead or imminently dying; segregated from area
– visually identify color coded areas (ie: flags, cones)
– area away from hazards and protected from
elements
– easy access to transportation
EMS Branch of Operations
• Transportation officer
– communicates with receiving hospital (multiple
victim plan) or EMS Resource Hospital (mass
casualty plan)
– establishes patient loading area
– establishes and operates helicopter landing zone
– coordinates patient distribution to receiving
facilities
– advises command when last patient transported
Transportation Issues
• Distribution of patients needs to be to the
right place to maximize the number of
survivors
• Ask “what do injured people do?”
• If you know what they’re expected to do,
you can predict their reaction.
• People will do their own thing!
Transportation Issues
• Bystanders
– won’t wait for EMS to arrive
– will self evacuate and move away from the site
• foot, private car, police car
– will start self treatment
– closest hospital will be inundated with less serious
patients, EMS arrival of more critically injured
patients might cause delay in care
– more outlying hospitals rarely get used, they have
had time to prepare, consider using them for
transport
Patient Tracking
• Transportation Officer must keep a log
– patient’s name or tag number
– transporting unit
– patient priority
– hospital destination
• Updated communication required to
Incident Commander
• Needs close communication with Triage
Officer and Staging
Additional Resources
• Consider assignments of additional
staff based on nature of the disaster:
– media
– CISD
• To improve communications &
facilitate decision making, keep
fire/EMS/police management together
Cross Training
• Involve departments you might possibly
need to work with
• Use unified command across all resources
• Be well identified visually
– vests
– hard hats
– arm bands
Community Involvement
• Bring to the table for open discussion and
smoother operations:
police
fire/EMS
schools
transportation
media
city hall
hospitals
nursing homes
Region X Policy Review
• System-wide crisis preparedness policy
– to enhance communication between
hospitals, EMS providers, and community
agencies regarding potential or actual areawide crisis
• multiple patients with same symptoms
• weather related multiple patients
• special events (ie: marathon/race, sports)
– gives early alert to potential activity
System-Wide Crisis Policy
• Policy can be initiated by anyone
• Contact your supervisor
• Supervisor contacts Resource Hospital System
Coordinator or designee
• Decision made to activate policy and EMS office
to notify POD hospital (HPH for CMC system)
• IDPH may be contacted by POD
• Communications continue between involved
parties until crisis over
Potential Crisis’ To Affect Region
Receiving a heads-up notification would be
extremely helpful in planning for:
• Avian bird flu
• Extremely hot or dangerously cold weather
• Multiple victims being transported from one
sporting event (ie: 3 day- 60 mile Avon
Walk for Breast Health)
Review - Avian Flu
• Contagious viral disease of animals that
normally only affects birds and occasionally
pigs
• Concern will be if/when the virus mutates to
humans
• Need direct contact with infected poultry to
become infected
– contaminated surfaces
– objects contaminated with bird feces
Bird Flu Signs & Symptoms
• Typical influenza-like symptoms
–
–
–
–
–
–
–
fever
cough
sore throat
muscle aches
eye infections (conjunctivitis)
acute respiratory distress
viral pneumonia
To Avoid Avian Flu
• Practice good hygiene during food
preparation (personal & surfaces)
• Properly and fully cook poultry including
eggs
• Normal cooking temperature kills the virus
• Transmission more likely to be droplet
(“plops” within 3 feet) than airborne
(“floats” longer distances)
Patient Treatment
• Treat with respiratory isolation any patient
with severe, febrile respiratory illness similar
to SARS
– standard precautions - good handwashing
– contact precautions - gloves and gowns
– airborne precautions - surgical masks on patients
and staff
– continue precautions for 14 days after onset of
symptoms
• Recommended annual “flu” vaccination
Table Top Drills
• Enough drills should be run for every
member at this session to be placed in a
variety of roles
• Remember, the “blue shirt” will be the
person who initially responds to the incident
and needs to be making some early crucial
decisions before more personnel show up
• Pick the location in your town where the
following exercises would most likely occur
Table Top Drill
• Work through problems on paper so they
are not problems at the scene (or think of it
as a rehearsal on how to handle the problem
when it does present at the scene)
• The drills will be most effective if everyone
involved can walk through and discuss all
aspects including where equipment is stored
and how the scene would be laid out
Drill Scenario #1
• Your department has received a call of a bus
versus train collision. Unknown number of
casualties.
• During the table top drill discuss:
– location to set up command, staging,
treatment, transportation
– What other resources may be required for
your town and the location you have
picked?
Drill Scenario #2
• You have received a call of a bleacher
collapse at the local high school during an
assembly; multiple casualties reported
• During the table top drill discuss:
– location to set up command, staging,
treatment, transportation
– What other resources would be helpful in
this setting?
Drill Scenario #3
• You have received a call of an obnoxious
odor in a local (nursing home, senior
residents, day care).
• As you respond to investigate, you are
informed of multiple complaints from
multiple persons at the scene (headache,
nausea, vomiting, eye and throat irritation)
• What needs to be considered to successfully
run this disaster event?
Drill #4
• You have received a call for an overturned
semi. Upon arrival, there is actually an
overturned tour bus of approximately 50
seniors.
• What unique aspects will seniors pose to the
rescue providers?
• What if the weather (too hot, too cold, rainy,
snowy) is a factor - how do you handle that
and what provisions are made?
Acknowledgement
• NIEMSCA contribution for the packet by:
– Kishwaukee Community Hospital
• Seminar presentation by Colin Smart,
Director TSG Associates
• Additions made by Sharon Hopkins, RN,
BSN, Condell Medical Center EMS
Educator
• Region X Policy and Procedures
Medical Incident Command