MASS CASUALTY
MANAGEMENT
SYSTEM
ROMEO ALMAZAN BITUIN, MD, MHA
Health Emergency Management Staff Coordinator
Dr. Jose Fabella Memorial Hospital
Department of Health
1
OUTLINE OF PRESENTATION
I.
II.
Overview of Mass Casualty
Establishing Mass Casualty
Management System
III. Field Management
IV. Management of Victims
V. Transfer Organization
2
QUESTION 1
Define Mass Casualty
QUESTION 2
What is a Mass Casualty Management
System
Overview of Mass Casualty
GLOBAL TREND
1.
2.
3.
4.
5.
Kobe Earthquake, Japan 1995
Sarin attack in Tokyo, 1995
New York 911 Tragedy, 2001
Iraq Crisis, 2003
Terrorism – WMD
6. Asian Tsunami
7. Leyte Landslide, 2006
5
Overview of Mass Casualty
WORLD
Since 1900
%
Top 5 hazards by
frequency of
occurrence
mass accidents
wind storm
flood
earthquake
drought
32.8
19.6
18.0
7.5
6.0
83.9
mass accidents
wind storm
flood
earthquake
epidemic
37.2
19.7
18.4
8.0
4.0
87.4
ASIA
Top 5 hazards by
frequency of
occurrence
CRED Disaster Data
6
Overview of Mass Casualty
Mass Casualty Incident

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
Produces several patients
As few as six or as many as several hundred
Affects local hospitals
Patients are greater than resources of the
initial responders
7
Overview of Mass Casualty
Preparation for Mass Casualty

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Pre-planning and training are critical
Establish guidelines and procedures
Early implementation of Incident Command
First five minutes will determine next five
hours
8
Overview of Mass Casualty
Response Categories for Mass Casualties
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Mass Casualties can occur in a variety of
ways
Effect on emergency response and
community impact
Include transportation, violent crimes and
building collapse
9
Overview of Mass Casualty
Response Categories of Mass Casualties
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Hazardous materials incidents
Civil disturbances
Natural disasters
Major fires
Terrorist attacks
10
Overview of Mass Casualty
Problems in Mass Casualty Incidents
Most common being:
 Who is in command of the incident
 Location of the Command Post
 Lack of communication between agencies
leading to conflicting priorities and orders
11
Overview of Mass Casualty
Problems in Mass Casualty Incidents

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Perimeter establishment delayed or not done
at all
Large crowds of people
Media involvement
Political involvement
Inadequate resources
12
Establishing Mass
Casualty Management
System
13
Establishing a Mass Casualty Management System
Mass Casualty Incident
Any event resulting in a number of victims
large enough to disrupt the normal course of
emergency and health care services
14
Establishing a Mass Casualty Management System
Casualty Management
• Management of victim of a mass casualty
event
• Objective is to minimize loss of life and
disabilities
15
Establishing a Mass Casualty Management System
Mass Casualty Management System
The group of Units, Organizations, Sectors which work
jointly during a mass casualty event
Based on:
- Pre-established procedures
- Maximization of use of existing resources
- Multi-sectoral preparation and response
- Strong pre-planned and tested coordination
16
Establishing a Mass Casualty Management System
Different Approaches to MCI
1. “Scoop and Run”
2. Classical Approach
3. Mass Casualty Management System
17
Establishing a Mass Casualty Management System
Scoop and Run
• Most common
• Does not require specific technical
ability from rescuers
• Justified for small numbers occurring near a
hospital
• May just transfer problem to the hospital
18
Establishing a Mass Casualty Management System
Classical Approach
• First responders are trained (basic triage and
field care)
• Disregard the receiving hospitals from the
field
• Quickly result to chaos
19
Establishing a Mass Casualty Management System
Mass Casualty Management Approach
• Most sophisticated approach includes preestablished procedures for:
a. resource mobilization
b. field management
c. hospital reception
20
Establishing a Mass Casualty Management System
Mass Casualty Management Approach
• Training of various level of responders
• Incorporates links between field and health
care facilities
• Command Post
• Multi-sectoral Response
• Dependent on the availability of large
amounts of human & material resources
21
Establishing a Mass Casualty Management System
Problems in Developing MCM
• Limited human resources
• limited material resources
– facility
– transport
– communication
• Poor communication
– topography
– isolation
• Political
22
Establishing a Mass Casualty Management System
Activities at various levels of responses:
alerting process
‘E’/Disaster
Site/Scene
initial assessment
command / control / coordinate
manage information
search/rescue
field care-- mostly health activities
transport/traffic control
facility reception at ER / A&ED
hospital mass casualty mgt. & command
system
23
Establishing a Mass Casualty Management System
Field Management
Definition:
Encompass procedures used to organize the disaster area in order to
facilitate the management of victims
Components
Alerting Process
Search and Rescue
Pre-identification of
Field Areas
Field Care
Safety/ Security
Evacuation
Command Post
(EMC) Emergency
Management Center
24
Establishing a Mass Casualty Management System
RESCUE CHAIN---SECTORAL
Impact Zone
Command Post
*SEARCH*
*RESCUE*
*First Aid*
Triage
Stabilization
Evacuation
CP / AMP
Pre-Hospital Organization
Traffic Control
ER
Regulation of Evacuation
or
A&ED
Hospital Organization
25
Establishing a Mass Casualty Management System
Field Organization
Alerting Process
Definition: Sequence of activities implemented to
achieve the efficient mobilization of
adequate resources
Aim:
- Confirm the initial warning
- Evaluate the extent of the problems
- Ensure that appropriate resources are informed
and mobilized
26
Establishing a Mass Casualty Management System
Field Organization
Alerting Process
Dispatch Center:
 Core of the Alerting Process
(Operation/Communication Center)

Functions:
• receives all warning messages (radio/phone)
• mobilize a small assessment team (Flying
Team) from police, fire or ambulance services
27
Establishing a Mass Casualty Management System
Initial Assessment
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Precise location of the event
Time & type of the event
Estimated number of casualties
Added potential risk
Exposed population
Resources needed
28
Establishing a Mass Casualty Management System
Pre-Identification of Field Areas
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Impact Zone
Command Post
Collecting Area in unstable location
Advance Medical Post Area (3-T Principle)
Evacuation Area
VIP & Press Area (Information Officer)
Access Roads (geographical presentations if
available)
Check point for resources (Staging Area)
29
Establishing a Mass Casualty Management System
Safety
• Best practice technique to protect victims, responders
& exposed population: immediate/potential risk
• Measures:
Direct action:
- risk reduction - fire fighting
- contain hazardous material
- evacuation of exposed population
Preventive actions: establish field areas
- primary- impact zone
- secondary- rescue/ICP/AMP
- tertiary-“buffer zone”; tri-media
30
Establishing a Mass Casualty Management System
Safety
• Personnel: fire services; specialized units hazardous
materials & explosives (bio-nuclear and
radioactive materials) experts, etc.,
airport manager, chemical plant expert
31
Establishing a Mass Casualty Management System
Security Measures
• Non-interference of external elements:
- crowd/traffic control
• Contribute to safety:
– protect workers from external influence; additional
stress
– free flow: victims/resources
– protect general public from risk exposure
• ensured by police officers / special units (security:
airport/building/hospital/establishments, etc..)
32
Establishing a Mass Casualty Management System
Command Post ( CP / or ICP)
Multi-sectoral control unit to:


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Coordinate sectors involved in field/scene management
Linked w/ back-up system: provide information &
mobilization resources
Supervise victim management
REQUISITE: radio communication network: main criterion
to be effective
Purpose: coordination / communication hub of people who
don’t work routinely (pre-hospital setting)
Location: external boundary of restricted area (impact zone)
close to AMP/ Evacuation Area/ accessible/easily identified
* should accommodate: com./visuals/maps/boards
33
Establishing a Mass Casualty Management System
Personnel

High ranking officer (government police, fire, health,
defense)
- plant manager/ airport manager/ chief security, etc…
- fire officer / police officer skilled in ICS / MCM


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Identified by name/position, coordinator / commander
May depend on what type of incident
Must be familiar with each other’s roles during previous
meetings/ drills/ simulation exercises (policy)
This core group cooperate with volunteer organizations
34
Establishing a Mass Casualty Management System
METHOD

The communication / coordination hub of the prehospital organization. By constant re-assessment,
CP will identify needs to increase / decrease
resources:
- organize timely rotation of rescue workers exposed to
-
stressful/exhausting conditions in
close coordination
w/ back-up system
ensure adequate supply of equipment / manpower
ensure welfare / comfort of rescue workers
provide info to back-up system, other officials, and
tri-media thru an Information Officer
release as soon as situation allows “E” staff and reestablish normal operations
determine termination of field operations
35
Establishing a Mass Casualty Management System
MANAGEMENT OF VICTIMS

Search & Rescue
- locate victims
-
remove victims from unsafe locations – collecting area
assess victim’s status (on-site triage)
provide first aid , if necessary (no CPR on-site in MC Event)
transfer victims to AMP thru entry triage (medical triage)
under supervision of the CP/ IC/ or Commander/Coordinator
may in special situation, require medical personnel (trained)
to stabilize/resuscitate/amputate (trapped) victim before
extrication.
36
Establishing a Mass Casualty Management System
Management of Victims
• Field Care
- Pre-established capabilities / inventory: pre-planning
- Integrated community plan: practiced w/ policy
support
- The “Golden Hour” Principle
37
Establishing a Mass Casualty Management System
Recent progress in pre-hospital
emergency / disaster medicine
Establish AMP with specially skilled /trained ---“disaster field medical teams”
- good triage / stabilization capacity
- specifically trained / up-skilled medical teams
- good (radio) communications between the field
scene & medical facility
“ Don’t transfer chaos in the scene,
to the hospital……”
38
Establishing a Mass Casualty Management System
TRIAGE
Basis: urgency (victim’s status)
survival (chance or likelihood)
care resource availability and capability
Objectives:
Quick identification for immediate stabilization
for life-saving (measures) and surgery
Levels:
On-site–----- ‘where they lie’
Medical ----- at Advance Medical Post
Evacuation --- transport
39
Establishing a Mass Casualty Management System
On-site T:
Medical T:
Acute
Non-acute
Red:
Red
Yellow
Green
Black
Yellow: after evacuation of Red,
without life-threatening
problem
Evacuation T - transport:
Red
Yellow
Green
Black
transferred as soon as
possible to tertiary facilities
in an equipped ambulance
with medical escort
Green: ‘walking wounded’-to
AS/OPD
Black: to morgue Forensic Services
Public Health & Psycho-Social
interventions to relatives/kin
40
Establishing a Mass Casualty Management System
First Aid
Personnel:
• volunteers, fire, police staff, special units, EMT’s, and
medical personnel
Location:
•
•
•
•
on-site, before moving victim
at collecting point/ area in an unstable environment.
“Green Area” of “AMP”
ambulance in transit to facility
Action:
• primarily to transfer with consideration of the ABC’s
order of priority
41
Establishing a Mass Casualty Management System
Advance Medical Post (AMP)
Purpose:


reduce loss of life & limb - save as many as possible in
the context of existing & available resources/ situation
victim’s status; chance of survival; resources
Location:
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50-100 meters from Impact Zone (walking distance )
direct access to: Evacuation Road. / Command Post
Clear Radio-Com Zone… and SAFE (Upwind)
tent / bldg / open / mobile field hospital..??
42
Establishing a Mass Casualty Management System
Advance Medical Post (AMP)
Role:


Provide “entry” medical triage
Effective stabilization for victims of a MCI/Situation
• intubation, tracheostomy, chest drainage,
• shock mgt , analgesia , fracture immobilization
• fasciotomy, control external bleed & dressing

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Convert red to yellow category as maybe possible
Organize patient transfer to designated care facility/ties
AMP 3-T principle: Tag – Treat – Transfer….
Personnel:
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ER (A&ED), physicians/ nurses (trained & skilled)
support: Anesthetists / Surgeons / EMT’s / Nurses / Aiders,
etc.
43
Establishing a Mass Casualty Management System
AMP
NON-ACUTE
TRIAGE
Black
Green
NON-ACUTE
C
P
evacuation
ACUTE
Red
Yellow
ACUTE
C P– Collecting Point
44
Establishing a Mass Casualty Management System
COLLECTION AREA
(in unstable condition)
TRIAGE AREA
(color tagging of victims)
COMMAND POST
TREATMENT
AREA
(management and stabilization)
1st
3rd
PRIORITY III
2nd
PRIORITY II
T R A N S P O R T
PRIORITY I
A R E A
45
Establishing a Mass Casualty Management System
Field Management Plan: Diagram
Working
Area
Triage
Evacuation
AMP
Impact Zone
T
r
a
f
f
i
c
C
o
n
t
r
o
l
Command Post
Strictly Restricted
Restricted
Access Route
Traffic
46
Establishing a Mass Casualty Management System
Transfer Organization


Procedures used to ensure that victims of a MC
situation is safely, quickly, and efficiently transferred by
appropriate vehicles to the appropriate and prepared
facility
Preparation for Evacuation:
1. Single Reception Facility
2. Multiple Reception Facilities
* type of vehicle required
* type of escort required
* destination
47
Establishing a Mass Casualty Management System
Transfer Organization

Preparation for Transport
Evacuation Officer reporting to ATM:

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assess patient’s status: vital signs, ventilation / hemostasis
check security of equipment / & accessories
ensuring efficiency of immobilization measures
ensure triage tags: secure/& clearly visible
Evacuation Procedures: Regulation
Principles
-
not to overwhelm care facility
- avoid spontaneous evacuation of unstable patients.
48
Establishing a Mass Casualty Management System
Transfer Organization

Evacuation Procedures: Regulation
Rules:
-
victim is in most possible stable condition
victim is adequately equipped for transfer
receiving facility correctly informed and ready
the best possible vehicle and escort– available
Victim Flow
- “Noria” Principle, Spanish word from Arabic--… ”wheel”
WW I Battle of Chemin de Dames, Verdun, France
* conveyor belt’ flow from first aid to the most
sophisticated care level..
49
Establishing a Mass Casualty Management System
Victim Flow : “Conveyor Belt” Management Diagram
Triage
3-T
Triage
Tag
Treatment
Evacuation
Treat
and
Transfer
Impact
Zone
Collecting
Point
AMP
TRANSFER
HOSPITAL
50
Victims Flow
Transport Resource Flow
Establishing a Mass Casualty Management System
Victim Flow
- Ambulance Traffic Control
Radio Links:
*Transport Officer at AMP
*Hospital Admission / ER Department
*Command Post
*Ambulance Headquarters
Responsibility of Ambulance Driver
*takes order from the Transport Officer
51
Establishing a Mass Casualty Management System
Victim Flow
Road Control:
Police Officers ----- crowd and traffic control

Evacuation of Non-Acute Victims
- use available mass transport
- as much as possible, to primary care centre
52
Establishing a Mass Casualty Management System
Field Organization Checklist

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Situation Assessment
Report to Central Level
Work Areas Pre-identification
Safety
Primary Area: Impact Zone
Secondary Area Units: CP/AMP/EVAC/TRANSFER
Radio Communications
Crowd & Traffic Control
Search and Rescue
Triage & Stabilization
Controlled Evacuation
53
Fallacy
“IT CAN’T HAPPEN
TO US”
54
Incident Command System
Performance Objectives

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Discuss the advantages of using the
Incident Command System
Discuss the two types of command
Discuss the Incident Command
Process
Discuss Incident Priorities
57
Performance Objectives

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Discuss the components of the
Incident Command System
Discuss the Incident Command
System organization
Discuss the use of the Incident
Command checklist
58
Question 1
HOW WILL YOU DIFFERENTIATE A SINGLE
COMMAND FROM A UNIFIED COMMAND ?
Question 2
WHAT IS THE ROLE OF THE INCIDENT
COMMANDER ?
Question 3
WHEN DO YOU TRANSFER COMMAND ?
Incident Command System


Developed in the 1970’s during the
California wildfires
Business management practices of
planning, directing, organizing,
coordinating, delegating,
communicating and evaluating
62
Incident Command System



Framework necessary to manage
resources, personnel and equipment
Designed to be flexible and can be
used in large or small incidents
Creates a safe environment for all
involved
63
Benefits of Incident Command



Common terminology
Position titles and Chain of
Command for decision making
Responder accountability
64
Basic Command Types
There are two types of
command:
 Single Command
 Unified Command
65
Single Command



Based on first arriving emergency
units.
Initial Incident Commander begins
assessment of incident
Rescue, Triage, Treatment,
Transport
66
Basic Command Structure
Single Command
INCIDENT
COMMANDER
RESCUE/
EXTRICATION
TRIAGE
TREATMENT
TRANSPORT
67
Unified Command


Incidents that involve jurisdictions or
agencies involved in the decision
making and planning process
Ensures plan is communicated and
supported by all resources assembled
68
INCIDENT COMMAND SYSTEM
INCIDENT
COMMAND
SAFETY OFFICER
LIAISON OFFICER
PUBLIC INFORMATION
OFFICER
OPERATIONS OFFICER
FIELD MEDICAL COMMANDER
STAGING OFFICER
MEDICAL GROUP
SUPERVISOR
PLANNING OFFICER
TRANSPORT GROUP
SUPERVISOR
RESOURCES
ADMINISTRATIVE OFFICER
LOGISTICS OFFICER
SERVICE
SUPPORT
SITUATION
TREATMENT TEAM
LEADER
TRIAGE TEAM
LEADER
GROUND AMBULANCE
PROCUREMENT
COMMUNICATIONS
SUPPLY
MEDICAL
FACILITIES
FOOD
GROUND SUPPORT
DOCUMENTATION
AIR AMBULANCE
TREATMENT MEMBERS
IMMEDIATE
TREATMENT MEMBERS
DELAYED
TIME
COMPENSATION
TRIAGE MEMBERS
DEMOBILIZATION
COST
MORGUE MANAGER
TREATMENT MEMBERS
MINOR
69
Overview of Incident Command
Process
Process is based on:
 Size up
 Setting Incident Priorities
 Predicting incident course and harm
 Strategic goals and tactical
objectives
70
Size Up



Rapid mental evaluation of factors
influencing an incident
Must continue throughout incident
with ongoing evaluation
Incident situation, incident cause
and incident status
71
Incident Situation
May be one or combination of:
 Biological
 Nuclear
 Fire
 Chemical
 Explosion or natural event
 Natural disaster with MCI
72
Incident Cause


Incident Cause is important
because additional or specialized
resources may be needed
The Incident Commander must
determine if the incident was
accidental or intentional
73
Incident Status
Is the incident:
 In a somewhat controlled state
or
 Does it remain uncontrolled
74
Setting Incident Priorities




After size up of the incident a
course of action is determined
High priority is life safety for the
public and responders
Incident stabilization
Protection of critical systems
75
Estimating Potential Incident Course
and Harm



Responder is making a prediction
on what will likely occur during the
incident
Based on available information
Responder’s experience
76
Strategic Goals
Broad general statements of desired
outcome of the incident
 Example:
mass casualty overturned school bus
- extrication, triage, treatment,
transport

77
Incident Command System
Organization

Comprised of two major categories
which assist in organizing functions
into an effective design:
- Command Staff
- General Staff
78
Command Staff
Consists of the :
 Incident Commander
 Safety Officer
 Liaison Officer
 Public Information Officer
79
Incident Commander
INCIDENT
COMMANDER
80
Incident Commander



First person on the scene with
communications capability
Remains in command until
transferred or incident is
terminated
Complete authority and
responsibility
81
Incident Commander

Must assume and announce
command, rapidly evaluate
incident, identify resources on
hand, request additional
resources and establish
incident action plan
82
Incident Commander


Fill command staff and
functional areas
Must approve all information
releases to the media
83
Transfer of Command



Based on the initial responders
experience and comfort level
Higher ranking officer does not
need to assume command
Transfer procedures should be
predetermined
84
Transfer Of Command



Detailed briefing is required
Face to Face is best method
Include: current status,
strategies and tactics employed,
progress, safety, accountability
and resources assigned or
needed
85
General Staff
Consists of:
 Operations (includes
staging)
 Planning
 Logistics
 Administrative/Finance
86
Operations Section
INCIDENT
COMMANDER
OPERATIONS
87
Operations Section



Operations officer functions under
direction of the Incident Commander
Deploys tactics to control and
resolve the incident
Responsible for execution of the
incident action plan
88
Operations Section



Makes recommendations for changes
to plan based on incident status
Oversees and is in direct contact
with the staging manager
Task supervisors report to
Operations not Incident Command
89
Planning Section
INCIDENT
COMMANDER
OPERATIONS
PLANNING
90
Planning Section



Responsible for collection,
evaluation, distribution and use of
information about the incident
Forecast and develop plans to
contain and resolve incident
Communicates with logistics
section
91
Logistics Section
INCIDENT
COMMAND
OPERATIONS
PLANNING
LOGISTICS
92
Logistics Section



Responsible for providing facilities,
services and materials in support of
incident
Includes equipment, personnel and
associated materials and tools
Support branch and Services branch
93
Administrative / Finance Section
INCIDENT
COMMANDER
OPERATIONS
PLANNING
LOGISTICS
ADMINISTRATIVE
FINANCE
94
Administrative/Finance Section



Generally not located at incident
site
Responsible for financial,
administrative and cost analysis
Divided into four units: time,
procurement, compensation/claims
and cost
95
Summary



Incident Command created to deal
with any incident in an organized
manner
Manages resources, personnel and
equipment to mitigate the incident
Builds from first responder
96
Summary



Expandable to manage hundreds
Implementation is critical for safe
and effective operation
Allows for multi-agency operations
and response based on incident
type
97
Thank you
98
CRITICAL INCIDENT
MANAGEMENT
99
Performance Objectives


Discuss critical incident stages
Discuss decision making in a
critical incident
100
Critical Incident Management
Characteristics


Demands a coordinated response
to prevent incident from getting
worse
This includes unresolved element
of danger such as additional bomb,
a threat to citizens and responders
or an unusual incident
101
Critical Incident Management
Characteristics



Often random in nature and
disrupt normal life
Terrorist organizations use
opportunity as a tool for civil
disturbance
A mass casualty is a critical
incident
102
Mass Casualty Incident
Overview




Produces several patients
As few as six or as many as
several hundred
Affects local hospitals
Patients are greater than resources
of the initial responders
103
Preparation For Mass Casualty




Pre-planning and training are
critical
Establish guidelines and
procedures
Early implementation of Incident
Command
First five minutes will determine
next five hours
104
Functional Systems Approach




Three levels of function: strategic,
tactical and task (operation)
Management is strategic
Team leaders are tactical
Resources not involved in
supervision are task
105
Critical Incident Stages
They consist of:
 Initial Response
 Incident Control using the Six Step
Response
 Recovery Stage
106
Initial Response Stage



Ability to establish command and
control
Faced with confusion and panic
Crucial to develop a team and
place a plan in action
107
Initial Response Objectives




Protecting citizens and rescue of
victims
Limit incident growth
Protect arriving responders
Identify ingress and egress routes
108
Initial Response Objectives
As soon as possible:
 Gain control of the scene
 Restore order
 Prevent target opportunities
109
Incident Control Using The
Six-Step Response
The Six-Step response is based on
the Incident Command System. It
includes:
Assume
Command,
Situation Assessment, Identify and
Set
Perimeters,
establish
Command Post, assign Safety
Officer and establish Staging Area
and assign a Staging Officer
110
# 1 – Assume Command



Must advise incoming responders
of incident location
Secure tactical frequency
Request supervisory support
111
# 2 – Situation Assessment

Size up of the incident that
includes the type of threat,
approximate number of injured,
size of threatened area and
possibility of secondary event.
112
# 2 – Situation Assessment
In simple terms the assessment
should describe:
 What do you have
 What are you doing
 What do you need
113
# 3 - Identify and Set Perimeters


Divide the incident into
manageable divisions
(geographical areas)
Allows command to provide
resources where they are needed
114
# 3 - Identify and Set Perimeters



Critical incidents have three
standard perimeters. All
perimeters are divisions
Expand perimeters based on
weather
Perimeters are the hot zone, inner
perimeter and outer perimeter
115
The Hot Zone



Area in which the incident has
occurred
May be a street corner or spread
over a large area
Secured by placing responders in
positions of controlling ingress and
egress
116
Inner Perimeter



Protects responders in hot zone
Uniformed personnel only
Used as decontamination area,
treatment area and evacuation
area for walking wounded
117
Outer Perimeter



Provides last line of defense from
internal incident acceleration
Provides first line of defense from
external acceleration
Secure area for command post,
resources and control of the media
118
Perimeter Placement Illustration
119
# 4 – Establish Command Post



Typically begins at first responders
vehicle
Incident dynamics will require
Incident Commander to shift to a
fixed command post
Must be away from hot zone
120
# 4 – Establish Command Post

The command post will ensure
support for field personnel, create a
controlled environment and improve
communications
121
# 5 - Establish Safety Officer



Should be filled as soon as possible
Officer selected on operational
experience and ability to recognize
acceptable and unacceptable risk
Operations can be stopped or
modified
122
# 6 - Establish Staging Area



Effective tool in correct and safe
deployment of resources
Staging Supervisor must track,
rotate and relieve resources as
appropriate
Area established within inner or
outer perimeter. Avoid congestion
123
Inter Agency Planning


Failure to include all agencies
during planning process may
compromise responders
Identify and establish liaisons with
all agencies and coordinate tactical
operations
124
Secondary Incidents


May be more destructive and
damaging than initial incident
World Trade Center crashes were
primary incident with collapse of
the towers as secondary incidents
claiming more lives
125
Recovery Stage



Begun when aggressive threats of
incident are neutralized
Incident is not over when last
patient is transported
Recovery must be managed
aggressively
126
Recovery Stage



Planning Section of incident
command is responsible for initial
recovery
Typically the longest and most
poorly managed part of the
incident
May require months to years
127
Goals in the Recovery Stage


Most important goal is document
collection
Information can assist in Post
Incident Analysis, cost recovery
and tracking responder injuries or
deaths
128
Goals in the Recovery Stage


Provide critical incident stress
management for responders
Collect and properly dispose of
used medical supplies and
biohazard waste from the incident
129
Post Incident Analysis
Critical for operational review.
Benefits include:
 Operational performance
 Organizational needs
 Procedure modification
 Additional training
130
Summary



Critical Incident Management can
place a heavy burden on
responders
Requires a coordinated response
from all agencies involved
Mass casualty incident is a critical
incident, terrorist related or not
131
Summary



Identifying critical stages will give
the responder a better chance of
dealing with the incident
Six – Step response is a tool for
incident management
Humanitarian Assistance
132
9-11-01
133
TRIAGE
135
QUESTION 1
What is the meaning of Triage ?
What is the basis of triage ?
QUESTION 2
Do you always use Triaging ?
Give conditions.
QUESTION 3
In the MCMS, how many times do you triage
and where ?
Description
This lesson provides participants with
methods of prioritizing care delivery in
mass casualty situations. The decisionmaking process is explored with the goal
being the maximum positive effect for the
greatest number of patients.
2
Objectives


Describe the basic concepts of sorting and
allocating treatment to patients in a triage
situation
Demonstrate the decision-making process in
determining priority of care
3
What is Triage ?




French word meaning to “Sort”
Utilized to identify treatment priorities
Process by which a decision is made on
which victim receives treatment and which
does not
Four basic priorities of patient treatment
and transport
141
Priorities
Highest Priority
• Patients that require immediate care and
transportation
• Patients receive treatment at the scene for life
threatening injuries
• First to be sent to available medical facilities
142
Priorities
Intermediate Priority
 Patient treatment and transport
can be delayed
143
Priorities
Delayed or Low Priority
 Referred to as “walking wounded”
 Injuries require medical care at some
point
 Treatment and transport can be
delayed
 Monitor patients and reassess
144
Priorities
Lowest Priority
 Patients have either died or are near
death
 If still alive they have suffered severe or
serious injuries with little chance of
survival
 When resources are limited, patients
must be ignored
145
Initial Triage Officer



Must size up situation
Ensure safe approach and scene survey
Activate additional resources
 Number of victims
 Size of the incident
 Better off requesting more equipment and
personnel than not enough
146
Simple Triage and Rapid Transport System
This system focuses on three areas :
1. Respirations
2. Pulse Rate and Quality
3. Mental Status
147
Simple Triage and Rapid Transport System
System requires first responders to have
tags, ribbons or tape in four colors
• Priority One (Highest Priority )

Red – Immediate care : Life
threatening injuries
148
Simple Triage and Rapid Transport System
• Priority Two (Intermediate Priority)
 Yellow – Urgent care: delay treatment and
transport up to one hour
 Priority Three (Delayed or Low Priority)
 Green – Walking wounded: delay treatment
and transport up to three hours
149
Simple Triage and Rapid Transport System
 Priority Four (Lowest Priority)
Black – No care required: patient is dead or
near death
 Hardest priority to deal with emotionally
 Necessary for others to survive

150
Simple Triage and Rapid Transport System




First Step is to make an announcement
for all people able to get up and walk to
specific area
Allows responder to focus on injured
People who successfully move should be
tagged “Green”
Tell people to look out for each other
and notify responders of any significant
changes
151
Simple Triage and Rapid Transport System




Second step is to conduct an orderly survey
of remaining victims
Decide how to move through area
Perform quick assessment on each person
and label or tag
No more than 10 seconds per patient
152
Simple Triage and Rapid Transport System


Correct life threatening : airway or breathing
problem and profuse bleeding
The objective is to: locate, identify and tag
priority one patients who require immediate
care and transportation
153
Patient Assessment
Respiration
Assess breathing rate
• Greater than 30 per minute, patient is
priority one and tagged red
• Less than 30 per minute, move on to
assessing pulse and mental status
154
Patient Assessment

Not Breathing
• Quickly make sure mouth is clear
• Open airway with head tilt method
• During mass casualty incident, cervical
spine immobilization may not be able to
be done
155
Patient Assessment


Open patients airway and position so it
remains open
If patient does not start to breath with
simple airway maneuvers, tag priority four black
156
Patient Assessment

Pulse Rate and Quality
• Check radial pulse
• No more than 5 second check
• Pulse is weak or irregular - Red Tag
Priority One
157
Patient Assessment

Pulse Rate And Quality
• If pulse is strong, move on to assess
mental status
• If there is NO pulse, black tag priority
four
158
Patient Assessment

Mental Status
• Breathing and pulse should have already
been checked
• Have patient respond to simple
commands such as “open your eyes” or
“squeeze my hand”
159
Patient Assessment

Mental Status
• If patient can perform this function, is
breathing and has a pulse, yellow tag
priority two
• If patient is unresponsive and cannot
follow simple commands, red tag priority
one
160
START TRIAGE
all walking wounded
MINOR
RESPIRATION
YES
NO
Position Airway
over
30/min
under
30/min
YES
IMMEDIATE
NO
DECEASED
IMMEDIATE
PERFUSION
Radial Pulse Present
Radial Pulse Absent
Capillary Refill
Over
2
Secs
Control
Bleeding
IMMEDIATE
Under
2
Secs
MENTAL STATUS
Can’t Follow
Can Follow
Simple Commands
Simple Commands
IMMEDIATE
DELAYED
Respirations
30/min
Perfusion
2 secs
Mental Status
can do
THANK YOU
162