Wake County Department of Public Safety

Transcription

1 Wake County Department of Public Safety Multiple Patient Incident Management Plan Prepared for: Wake County Department of Public Safety Wake County, North Carolina March 2006

2 Table of Contents TABLE OF CONTENTS GLOSSARY...IV 1.0 INTRODUCTION RESPONSE CATEGORIES MULTIPLE PATIENT INCIDENT PLAN: LEVELS I AND II MULTIPLE PATIENT INCIDENT PLAN: LEVELS III THROUGH V SPECIAL SITUATIONS: HAZARDOUS MATERIALS, CONFINED SPACE/STRUCTURAL COLLAPSE, WATER RESCUE AND VEHICLE EXTRICATION CHEMICAL, BIOLOGICAL, RADIOLOGICAL, NUCLEAR AND EXPLOSIVE INCIDENTS THE USE OF NON-CREDENTIALED AND NON-EMS HEALTHCARE PERSONNEL CRITICAL INCIDENT STRESS MANAGEMENT ON-SITE REST AND REHABILITATION MASS GATHERING MANAGEMENT EXERCISING THE MULTIPLE PATIENT INCIDENT PLAN SPECIAL CONSIDERATIONS FOR INCIDENT MANAGEMENT RECOMMENDATIONS TO ENHANCE RESPONSE CAPABILITIES JOB AIDS ROLE SPECIFIC LOG FORMS i

3 Glossary TABLE OF FIGURES FIGURE 1 MPI DISPATCH RESPONSE BY LEVEL... 5 FIGURE 2 MPI NOTIFICATION RESPONSE BY LEVEL... 6 FIGURE 3 DISPATCH 1 TALKGROUP... 9 FIGURE 4 OPS/TAC TALKGROUP... 9 FIGURE 5 MEDICAL NET TALKGROUP FIGURE 6 ICS DURING A LEVEL 1 MPI FIGURE 7 ICS DURING A HIGHER LEVEL MPI FIGURE 8 MANAGING SINGLE INCIDENTS IN WHICH DIVISIONS ARE REQUIRED FIGURE 9 AREA CONCEPT FOR DISTRIBUTED INCIDENTS INCLUDING CBRN RELEASES FIGURE 10 PATIENT FLOW DURING AND MPI FIGURE 11 MASS GATHERING PREDICTIVE PATIENT MODEL FIGURE 12 JOB AID FIRST UNIT ON-THE-SCENE FIGURE 13 JOB AID MEDICAL BRANCH DIRECTOR FIGURE 14 TRIAGE GROUP SUPERVISOR FIGURE 15 JOB AID TREATMENT GROUP SUPERVISOR FIGURE 16 JOB AID TRANSPORTATION GROUP SUPERVISOR FIGURE 17 JOB AID MEDICAL STAGING AREA MANAGER FIGURE 18 JOB AID PATIENT DESTINATION COORDINATOR FIGURE 19 JOB AID - ASSISTANT SAFETY OFFICER FIGURE 20 JOB AID REHABILITATION UNIT LEADER FIGURE 21 MEDICAL BRANCH DIRECTOR ON-SCENE ASSIGNMENT LOG FIGURE 22 MEDICAL BRANCH DIRECTOR INCIDENT MANAGEMENT LOG FIGURE 23 TRIAGE GROUP SUPERVISOR MULTIPLE PATIENT INCIDENT SCENE LOG FIGURE 24 TREATMENT GROUP SUPERVISOR PATIENT LOG FIGURE 25 TREATMENT GROUP SUPERVISOR AREA MANAGER LOG FIGURE 26 TRANSPORTATION GROUP SUPERVISOR PATIENT DISPOSITION LOG FIGURE 27 MEDICAL STAGING AREA MANAGER RESOURCE LOG FORM iii

4 Glossary GLOSSARY ALS Black Tag BLS BVM CAPRAC SMAT-II Care-Giver CBRNE CISD Cold Zone COMMAND Designated Wake County Hospital Representative DISPATCH 1 Division EMS FIRE General Staff Green Tag HAZMAT Hot Zone IC ICS IMS LAW Advanced Life Support Deceased - No Transport - move only if needed to reach live patients Basic Life Support Bag Valve Mask Capital Regional Advisory Committee State Medical Assistance Team Level II Medical staff providing patient treatment Chemical, Biological, Radiological, Nuclear, Explosive Critical Incident Stress Debriefing Designation of area not contaminated by hazardous material Radio identification of Incident Commander The individual who will serve as liaison between the MPI incident and Wake County Hospitals Dispatch Talkgroup Organizational unit that can be used to establish geographical separate activities at either the Incident Commander level or the Operations level Emergency Medical Services Radio designation of Fire Department Staff to the Incident Commander includes: Section Chiefs, Safety and Public Information Officers Patients can wait 3 or more hours before transport Hazardous Material Designation of area of most significant contamination by hazardous material Incident Commander Incident Command System Incident Management System Radio designation of Law Enforcement iv

5 Level A PPE Level B PPE Level C PPE MC TalkGroup MEDICAL MEDICAL NET MPI NIMS OPS/TAC TalkGroup OUTBOUND PFD Level A Personal Protective Equipment Level B Personal Protective Equipment Level C Personal Protective Equipment Medical Command TalkGroup Radio designation of Medical Branch Director Designation of the MC TalkGroup Multiple Patient Incident National Incident Management System Operations/Tactical TalkGroup Radio designation of Patient Destination Coordinator Personal Flotation Device Glossary Red Tag Immediate - Patients with immediate life threat - must have rapid transport to survive REHAB RESCOM SAFETY SCBA SHP SOP STAGING TREATMENT TRIAGE USAR-3 Warm Zone Yellow Tag Radio designation of Rehabilitation Unit Leader Wake County 911 Call Center Radio designation of Assistant Safety Officer Self-Contained Breathing Apparatus Radio designation of State Highway Patrol Standard Operating Procedures Radio designation of Medical Staging Area Manager Radio designation of Treatment Group Supervisor Radio designation of Triage Group Supervisor Mass Care Trailer Designation of area outside the hot zone where no or acceptable levels of contamination exist Delayed - Patients can wait 1-3 hours for transport v

6 Response Categories 1.0 Introduction This document is intended to serve as a guide for Wake County emergency personnel responding to any incident that involves multiple victims. It employs the standard organizational structure of the Incident Command System (ICS), in accordance with the National Incident Management System (NIMS). The ICS defines the operating characteristics, interactive management components, and structure of incident management throughout the life cycle of an incident of any scale. This Multiple Patient Incident (MPI) response plan will be used to direct the efficient and effective triage, treatment and transportation of multiple victims from the scene of all types of incidents including fires, motor vehicle crashes, HAZMAT incidents, chemical, biological, radiological, nuclear, or explosives (CBRNE) incidents, natural disasters, or any incident involving multiple patients. The plan was written to comply with the National Incident Management System. The intent of NIMS is to form similarly structured, cohesive emergency response systems across the country that can easily interface with state and federal resources by virtue of their common command structure. The leader of the response effort, the Incident Commander (IC), is responsible for the coordination of multi-agency responses, the dissemination of public information, communication and information management, and the management of system resources. In order for these systems and responses to function appropriately, it is necessary to engage in planning, training, and exercises well in advance of an incident. While this MPI plan provides specific directives for emergency personnel, it cannot anticipate the difficulties emergency workers will face during actual deployments. It is thus imperative for response agencies to engage in cooperative exercises in which difficult situations are simulated in order to test and improve existing plans. These exercises also serve to enhance interagency team building that will ultimately lead to more effective responses. Section 2.0 of this plan provides general guidance to classify Multiple Patient Incidents. Accompanying this guidance are recommended response actions in terms of resource deployments, including dispatch and notification standards. The organization and management of these response resources in the field is addressed in Sections 3.0 and 4.0 of this plan. 1 of 83

7 Response Categories 2.0 Response Categories All incidents will be managed using the incident management system. The Incident Commander will come from the public safety agency that holds jurisdiction over the primary hazard present on scene. Other county and non-county agencies engaged in a unified response will function under the direction of the Incident Commander. Multiple patient incidents will be classified according to the number of victims on the scene. This classification permits the use of predetermined dispatch Levels that will signal a minimum number of units to respond to the scene of an incident. MULTIPLE PATIENT INCIDENT RESPONSE PROCEDURES Level I MPI: Involves more than two (2) patients and up to five (5) patients total. Dispatch Response: Dispatch one (1) MPI task force composed of 1 qualified EMS Officer 3 Ambulances (Advanced Life Support) 2 Fire Companies (engine or ladder; at least 4 personnel each) 2 Law Enforcement officers from appropriate jurisdiction (including SHP for highway incidents) Level II MPI: Involves from six to ten (6-10) patients total. Dispatch Response: 2 MPI Task Forces (defined above) Fire Department Chief Officer Notification Actions: EMS Command Staff group including Incident Information Officer and Medical Director(s) Emergency Management Duty Officer Public Safety Command Staff group Wake County Public Information Officer 2 of 83

8 Level III MPI: Involves between eleven and twenty (11 20) patients total. Response Categories Dispatch Response: 3 MPI Task Forces (defined above) Fire Department Chief Officer Two passenger buses (for transport of patients triaged as Green and provider rehabilitation) Wake County Major Medical Operations Support Vehicle One qualified EMS Officer to RESCOM to assist with resource allocation and mutual aid Additional task forces to be dispatched per Incident Commander request after completion of triage Notification Actions: EMS Command Staff group including Incident Information Officer and Medical Director(s) Emergency Management Duty Officer Public Safety Command Staff group Wake County Public Information Officer Designated Wake County Hospital Representative Wake County Major Incident Management Team (when commissioned) Level IV MPI: Involves twenty-one (21) to forty (40) patients Dispatch Response: 3 MPI Task Forces (defined above) Fire Department Chief Officer Three passenger buses (for transport of patients triaged as Green and provider rehabilitation) Wake County Major Medical Operations Support Vehicle One qualified EMS Officer to RESCOM to assist with resource allocation and mutual aid Raleigh Fire Department USAR-3 (Mass Care Trailer) Wake County Major Incident Management Team (when commissioned) Additional task forces to be dispatched per Incident Commander request after completion of triage Notification Actions: EMS Command Staff group including Incident Information Officer and Medical Director(s) Emergency Management Duty Officer 3 of 83

9 Response Categories Public Safety Command Staff group Wake County Public Information Officer Designated Wake County Hospital Representative Surrounding County 911 Centers reference potential for regional Mutual Aid requests Notify WakeMed CAPRAC SMAT-II Team Level V MPI: Involves greater than forty (40) patients Dispatch Response: 4 MPI Task Forces (defined above) Fire Department Chief Officer Five passenger buses (for transport of patients triaged as Green and provider rehabilitation) Wake County Major Medical Operations Support Vehicle One qualified EMS Officer to RESCOM to assist with resource allocation and mutual aid Raleigh Fire Department USAR-3 (Mass Care Trailer) Wake County Major Incident Management Team (when commissioned) WakeMed CAPRAC SMAT-II Team Additional task forces to be dispatched per Incident Commander request after completion of triage Notification Actions: EMS Command Staff group including Incident Information Officer and Medical Director(s) Emergency Management Duty Officer Public Safety Command Staff group Wake County Public Information Officer Designated Wake County Hospital Representative Surrounding County 911 Centers reference potential for regional Mutual Aid requests For incidents that require resources in excess of those delivered in response to Level V, it is appropriate to request additional dispatches of one or more of the predefined dispatch Levels. A summary of Multiple Patient Incident Dispatch and Notification actions discussed above is presented in Figure 1 and Figure 2 that follow. 4 of 83

10 Response Categories MULTIPLE PATIENT INCIDENT RESPONSE PROCEDURES Level I Level II Level III Level IV Level V Dispatch Number of Responders upon Dispatch EMS Officer(s) Ambulances - ALS Fire Companies Law Enforcement Officers Fire Department Chief Passenger Buses Wake Co. Major Medical Operations Support Vehicle EMS Officer to RESCOM Fire Department USAR-3 (Mass Care Trailer) Wake County Major Incident Management Team (when commissioned) WakeMed CAPRAC SMAT-II Team Additional Task Forces after completion of triage As required As required As required FIGURE 1 MPI DISPATCH RESPONSE BY LEVEL 5 of 83

11 Response Categories MULTIPLE PATIENT INCIDENT RESPONSE PROCEDURES Level I Level II Level III Level IV Level V Notifications EMS Command Staff Group and Medical Director Yes Yes Yes Yes EMS Duty Officer Yes Yes Yes Yes Public Safety Command Yes Yes Yes Yes Staff Group Wake County Public Yes Yes Yes Yes Information Officer Designated Wake County Hospital Representative Yes Yes Yes Wake County Major Incident Management Team Yes Surrounding County 911 Centers Yes Yes WakeMed CAPRAC SMAT- II Team Yes FIGURE 2 MPI NOTIFICATION RESPONSE BY LEVEL 6 of 83

12 Multiple Patient Incident Plan: Levels I and II 3.0 Multiple Patient Incident Plan: Levels I and II For scenes identified as multiple patient incidents, the Multiple Patient Incident (MPI) Plan shall be used to provide command and control. This Plan shall be used for all types of incidents involving multiple patients including fires, motor-vehicle accidents, HAZMAT incidents, etc. The organizational chart shown in Figure 6 represents the basic incident command structure to be employed in MPI situations. This particular chart depicts a situation in which EMS has central authority and fills the position of Incident Commander. This top position should be initially filled by the first unit on scene and then handed off to the first arriving qualified EMS officer. If there are other hazards present (e.g. HAZMAT) or as the incident transitions to a non-ems dominated scenario, the Medical Branch Director should transfer the role of Incident Commander to the most appropriate on-scene agency. Communication between organizational elements responding to the MPI is governed by established radio protocols and designations. These are shown as net-diagrams in Figures 3-5. PRINCIPLES OF MPI MANAGEMENT The first arriving unit assumes the role of Incident Commander and/or Medical Branch Director. The second person on the first unit shall assume the role of Triage Group Supervisor, provided that the staging concerns have been addressed, to triage non-ambulatory patients where they are found and to direct ambulatory patients to a safe area for rapid triage. Additional detail is available from the Triage Group Supervisor job aid. If the role of Incident Commander has already been filled by another agency, then the first unit shall assume the roles of Medical Branch Director and Triage Group Supervisor. The first arriving EMS personnel will provide greater good to the victims by not personally initiating patient care, but rather organizing the scene and response for the large number of ambulances, personnel and resources that will soon follow. 7 of 83

13 Multiple Patient Incident Plan: Levels I and II The most qualified individuals available, regardless of rank or seniority, should fill command and operational positions. While the first unit on scene is by default the Incident Commander/Medical Branch Director, it is vital that these individuals relinquish their positions when more qualified emergency personnel arrive on scene. Selection of the Incident Commander in a multi-agency incident should be predicated on the primary hazard of the incident. The agency providing the Incident Commander may change during an incident as the primary hazard changes. Quickly and clearly communicate the response Level and resource requirements to treat patients concurrently, not consecutively. As soon as practical/available, use two radios for each ICS position o COMMAND AND GENERAL STAFF OFFICERS one radio on assigned DISPATCH 1 TalkGroup (Figure 3); a second on OPS/TAC TalkGroup (Figure 4) o MEDICAL BRANCH DIRECTOR one radio on assigned OPS/TAC TalkGroup; another radio on the MC TalkGroup designated as the MEDICAL NET TalkGroup (Figure 5). o DIVISION/GROUP SUPERVISORS one radio on the assigned MEDICAL NET TalkGroup; another on the MC TalkGroup assigned to your specific DIVISION or GROUP. o NOTE During MPI Levels I and II, not all positions in Figures 3, 4 and 5 will be manned. Appoint an assistant if necessary to help with documentation and communications. Order resources EARLY. It is better to order too many initially and cancel en route than to continually request additional resources in small increments. DO NOT JUMP THE CHAIN OF COMMAND. Communicate one level up or down to maintain a manageable span of control at all levels. Make the system work for you! 8 of 83

14 Multiple Patient Incident Plan: Levels I and II -- See Figure 4 FIGURE 3 DISPATCH 1 TALKGROUP -- See Figure 5 FIGURE 4 OPS/TAC TALKGROUP 9 of 83

15 Multiple Patient Incident Plan: Levels I and II -- See Figure 4 FIGURE 5 MEDICAL NET TALKGROUP 10 of 83

16 Multiple Patient Incident Plan: Levels I and II ICS During a Level 1 MPI Fire Branch Director Incident Commander/ Medical Branch Director (Dual Function) Law Enforcement Branch Director Triage Group Supervisor M PI ICS As event escalates, transition to higher level MPI ICS structure as necessary. FIGURE 6 ICS DURING A LEVEL 1 MPI ESCALATION OF MPI LEVELS If at any time the scene meets the criteria for escalating the MPI Level, notify dispatch and incident command immediately. This escalation may be the result of newly discovered victims, the presence of CBRNE, or other complicating factors. The following actions should be taken in such an event: Communicate the new Level of response required (MPI II-V) to all agencies on scene and broadcast a new alert to RESCOM and the Medical Resource Hospital (where applicable). 11 of 83

17 Multiple Patient Incident Plan: Levels I and II Request the dispatch of additional task forces and resources required by the higher MPI Level. Complete all notification actions required by the higher MPI Level. Assign the appropriate Incident Management System positions to qualified emergency personnel as they arrive. Transfer the Patient Disposition Log to the Transportation Group Supervisor (when established). MPI ROLES AND RESPONSIBILITIES The following pages describe the roles and responsibilities of key on-scene personnel. The success of a response effort will greatly depend on the ability of these key personnel to organize and direct an orderly response. The most qualified individuals, regardless of rank or seniority, should fill these positions. Job Aids summarizing responsibilities for each role are presented in Section 14. These Job Aids may be used by emergency personnel during an incident to ensure that all critical tasks have been accomplished. Role specific Log Forms for recording critical information about patients, transport and the incident are presented in Section 15. FIRST ARRIVING UNIT ON THE SCENE It is critical that the first arriving unit assumes the role of incident manager instead of care-giver. Until the incident manager role is transitioned, this unit will be called COMMAND. The first arriving EMS personnel will provide greater good to the victims by not personally initiating patient care, but rather organizing the scene and response for the large number of ambulances, personnel and resources that will soon follow. Responsibilities/Actions of the first unit on scene include: Survey the scene for indications of CBRNE. If you believe there has been a release, take appropriate measures as described in the job aid. See following section Special Considerations for the First Unit on the Scene of a CBRNE Incident. If no other agency has done so, assume the role of Incident Commander and Medical Branch Director, and don the Incident Commander vest. If non-ems personnel have already filled the role of Incident Commander, then assume the role of Medical Branch Director and don the Command vest for that position. 12 of 83

18 Multiple Patient Incident Plan: Levels I and II Direct your partner to assume the role of Triage Group Supervisor, provided that the staging concerns have been addressed, to triage non-ambulatory patients where they are found and to direct ambulatory patients to a safe area for rapid triage. Additional detail is available from the Triage Group Supervisor Job Aid. Perform and report to RESCOM, on the assigned TalkGroup for the incident, a quick scene size up to include: o Brief description of the incident o Exact location of the incident o Advise of any hazardous conditions present o Indicate incident Level o Number of patients o Number of seriously injured o Recommended routes to and from the scene o Assessment of any special equipment or resources needed on scene such as heavy rescue, HAZMAT, helicopters, etc Report to or establish the Command Post from which to coordinate incident response. If EMS is the first arriving agency on scene, establish the Incident Command Post and take the following actions: o Select a visible location upwind and away from any hazards. o Communicate the location of this Command Post to RESCOM and remain there. RESCOM shall communicate the location of the Command Post to other agencies responding to the incident. o Request a OPS/TAC TalkGroup from RESCOM. Transfer the role of Medical Branch Director only after the arrival of a more qualified EMS officer and after a face-to-face report has been given. NOTE: The establishment of Staging is critical to ensuring to the efficient operation of a multiple patient incident. If no other responders are on-scene, the incident commander must address Staging at the onset. Staging does not have to be performed by EMS personnel. 13 of 83

19 Multiple Patient Incident Plan: Levels I and II SPECIAL CONSIDERATIONS FOR THE FIRST UNIT ON SCENE OF A CBRNE INCIDENT Objectives 1. Protect yourself from harm. 2. Document the scene and communicate with RESCOM. 3. Protect inbound units from entering hot zone. Actions 1. Move upwind or laterally out of the plume of the contaminant. 2. Advise RESCOM of possible CBRNE incident and indicate more information to follow soon. 3. Observe the defining casualty pattern or unusual features that tell you this is a CBRNE incident. a. Does the casualty field follow the wind? b. What symptoms do the patients exhibit? c. Are there any unusual substances in the air or covering nearby surfaces? d. Are there dead animals or insects at the scene? e. Does this appear to be terrorist/criminal in nature? Report this information to RESCOM and request instructions from HAZMAT Officer. 14 of 83

20 Multiple Patient Incident Plan: Levels I and II MEDICAL BRANCH DIRECTOR The position of Medical Branch Director represents Wake County EMS within the incident management system. This position will be called MEDICAL for all communications. The Medical Branch Director is responsible for all patient care activities to include the triage, treatment and transportation of all victims related to the incident. Responsibilities of the Medical Branch Director include: Don the appropriate vest, report to and remain in the Command Post. Interface with the Operations Section Chief (when established) or Incident Commander to obtain necessary manpower and logistical support. Coordinate all on-scene EMS activity. Request enough units to treat patients concurrently, not consecutively. Order sufficient quantity of units EARLY. It is better to order more than is needed and cancel en route than constantly ordering in small increments. If the incident involves HAZMAT/CBRNE, 21 or more patients, or will last a long time, request early activation of the Major Incident Management Team. Appoint the Triage Group Supervisor if not already accomplished. Identify a staging location for incoming EMS units. Identify a secure route of travel for ambulances to access and depart the scene. This item is critical to successful management of an incident. EMS resources must be able to reach the scene without delay. Request the support of law enforcement to assist with this as needed. This task is delegated to Staging once established. Contact the Designated Wake County Hospital Representative and provide the following information: o Brief description of the scene. o Approximate number of patients. o Rough estimation of total Red, Yellow, and Green classifications. o Approximate time that the first ambulance will depart from the scene. 15 of 83

21 Multiple Patient Incident Plan: Levels I and II o Request the number of patients, by category (Red/Yellow/Green), each hospital is prepared to receive. Provide accountability for EMS personnel working on the incident scene. Maintain the Patient Log worksheet found in Log Forms (Section 15). Oversee the triage, treatment and transport of victims. Where appropriate to maintain span-of-control, assign additional ICS MPI positions as qualified personnel become available to fill additional roles shown on Figure 5: o Treatment Group Supervisor o Transportation Group Supervisor o Medical Staging Area Manager o Patient Destination Coordinator o Assistants If the Transportation Group has not been implemented, assign patients to an ambulance and a destination. Record this on the Patient Disposition Log in Log Forms (Section 15). Using the forms in Log Forms (Section 15), maintain a record of who holds command positions, what resources are mobilized, and what TalkGroup is in use. Ensure notification to the Designated Wake County Hospital Representative (or all hospitals) when last patient has left the scene. Escalation to higher Level MPI If at any time the scene meets the criteria for escalating the Level of the Multiple Patient Incident, take the following action: o Communicate the new response Level (MPI II-V) to the Incident Commander and the Designated Wake County Hospital Representative. If you are Incident Commander, take the following additional actions: o Request the dispatch of additional task forces and resources required by the higher MPI Level. o Complete all notification actions required by the higher MPI Level. o Request dispatch of any additional resources required: o Fire Department Chief, 16 of 83

22 Multiple Patient Incident Plan: Levels I and II o Passenger Buses, o Major Medical Operations Support Vehicles, o EMS Officer to RESCOM, o Fire Department Mass Care Trailer, o CAPRAC SMAT-II Team. o Assign MPI positions to qualified emergency personnel as they arrive. o Transfer Patient Log worksheet to the Treatment Group Supervisor (when established). Transfer the Patient Disposition Log to the Transportation Group Supervisor (when established). o Transfer role of Incident Commander or Medical Branch Director to another qualified individual. TRIAGE GROUP SUPERVISOR The Triage Group Supervisor reports to the Medical Branch Director and is responsible for supervising and conducting the systematic sorting and prioritization of all patients. This position will be called TRIAGE for all communications. The triage function should be done in a safe area (cold zone after decontamination, safe distance from hazardous areas such as fire, building collapse, gunman, etc.). Initially, triage patients yourself. Delegate this task to assistants as they arrive and begin to supervise this function. Responsibilities of the Triage Group Supervisor include: Perform a rapid primary triage by sorting and prioritizing through the use of the START triage method for adults and JUMPSTART triage method for pediatric patients. Sort patients by category and report this number to the Medical Branch Director. o Red: Immediate life threat (must have rapid transport to survive) o Yellow: Delayed (Injuries can wait 1-3 hours before transport) o Green: Ambulatory (Injuries can wait 3+ hours before transport) o Black: Deceased (No Transport move only if needed to reach live patients 17 of 83

23 Multiple Patient Incident Plan: Levels I and II If scene is spread over a wide area or triage within the incident site would endanger patients and emergency personnel, consider establishing a Triage Area where patients may be relocated to perform triage. In complex incidents, assign triage team leaders to each class of patient as sufficient personnel become available. Direct ambulatory patients away from the hazard and to a safe triage area. Ensure the in-place triage of non-ambulatory patients If the incident involves multiple asymptomatic patients (HAZMAT exposure), confer with Medical Branch Director to set up secure evaluation area. Do NOT let these patients leave the scene without further evaluation and decontamination if necessary Coordinate the distribution of triage supplies to responders Coordinate movement of patients from the triage area to arriving EMS units and make a note of their departure on the form found in the Log Forms (Section 15). When Transportation is established, they will assume responsibility for documentation of patient destination. Request additional personnel from the Medical Branch Director, as necessary, to move patients. Ensure that the scene has been checked for all victims that may have been missed. Use first responders and law enforcement to assist with this task. Remember, in some instances, patients may not just be on the ground, but also entrapped in debris or suspended in the trees above. Look up as well as under and not just around. If at any time the scene meets the criteria for escalating the Multiple Patient Incident Level, notify the Medical Branch Director and Incident Commander. Account for the safety of all personnel working in the triage group. Report triage completed to the Medical Branch Director when all patients have been triaged and moved to the treatment sector or transported from the scene. Use the accompanying triage tracking form found in Log Forms (Section 15) to maintain a record of patients. 18 of 83

24 Multiple Patient Incident Plan: Levels III through V 4.0 Multiple Patient Incident Plan: Levels III through V The operational structure is shown in Figure 7 on the following page. This structure is based on recommended NIMS plans and establishes layers of authority and responsibility. Directly under the Incident Commander are the Section Chiefs. The Branch Directors report to the Section Chiefs with the Division or Group Supervisors reporting to the Branch Directors, or to Operations. *Note In higher levels of MPI, it is likely all the positions depicted in the radio nets in Figures 3, 4 and 5 will be manned. EMS responders should avoid filling general staff functions (logistics, finance, planning, public information) in order to provide the highest number of medical caregivers onscene available for life-saving interventions. To fill the highest-level command positions, the County should maintain a multi-agency team known as the Major Incident Management Team. This Team will be composed of personnel representing the spectrum of County services and will be trained to work together in general command staff roles. This Team should be notified at Level III and activated for Level IV or V MPI, for any incident involving terrorist/criminal releases of CBRNE, and for any incident in which the Incident Commander deems additional support necessary. For incidents that require resources in excess of those delivered in response to Level V, it is appropriate to request additional dispatches of one or more of the predefined dispatch Levels. 19 of 83

25 Multiple Patient Incident Plan: Levels III through V ICS During a Higher Level MPI Incident Commander Safety Officer Public information Officer Major Incident Management Team Planning Section Chief Operations Section Chief Logistics Section Chief Finance Section Chief Staging Officer Fire Branch Director Medical Branch Director Law Branch Director Assistant Safety Officer Treatment Group Supervisor Triage Group Supervisor Transportation Group Supervisor Rehabilitation Unit Leader Red Team Unit Leader Red Team Unit Leader Medical Staging Area Manager Yellow Team Unit Leader Yellow Team Unit Leader Patient Destination Coordinator Green Team Unit Leader Green Team Unit Leader Loading Zone Coordinator FIGURE 7 ICS DURING A HIGHER LEVEL MPI Command and General Staff are shown in double line boxes. Branch Directors and Medical Staff are shown in single line boxes. 20 of 83

26 Multiple Patient Incident Plan: Levels III through V Managing Single Events in Which Divisions are Required Incident Commander Safety Officer Public Information Officer Major Incident Management Team Planning Section Chief Operations Section Chief Logistics Section Chief Finance Section Chief Staging Officer Division A Operations Supervisor Division B Operations Supervisor Fire Group A Supervisor Medical Group A Supervisor Law Group A Supervisor Law Group B Supervisor Medical Group B Supervisor Fire Group B Supervisor FIGURE 8 MANAGING SINGLE INCIDENTS IN WHICH DIVISIONS ARE REQUIRED In many situations, MPI s will cover large areas. A relevant example would be a train wreck in which triage, treatment, and transport are performed on either side of the wreckage. To accommodate these situations, operational divisions should be established, headed by the same incident commander and serviced by the same general command staff. Figure 8 above depicts an appropriate command structure in such incidents. In these situations, it is necessary to delineate geographic operational divisions in all communications. Each division shall be assigned a separate operational channel to facilitate intra-divisional communications. When communicating outside the division, all communications should include some language to describe the originating and destination division or group. As an example, a call from one Division Supervisor to another should sound like, Division A to Division B or Division A to Operations. Using this clear divisional language, it will be possible to maintain clarity for all parties listening on the OPS channels. 21 of 83

27 Multiple Patient Incident Plan: Levels III through V Area Command Concept for Distributed Events Including CBRN Releases Area Command Incident Commander A Incident Commander B Incident Commander C FIGURE 9 AREA CONCEPT FOR DISTRIBUTED INCIDENTS INCLUDING CBRN RELEASES In incidents that are geographically distributed such as biological, chemical, or radiological agent releases it may be necessary to establish an Area Command and subordinate Incident Commanders delineated by the divisional terminology. While each Incident Commander would be responsible for operations at his/her scene, the Area Commander would provide coordination of logistical and communications support to all operating Incident Commanders. Figure 9 above reflects this arrangement. As an example, inclement weather causes concurrent bus accidents at several sites within the County. In such a situation it will be advantageous to have an incident commander at each accident site to maintain a manageable span of control. To facilitate operations, each incident commander should receive a divisional designation and separate OPS channel to provide clarity in communications. PATIENT FLOW DURING AN MPI Patient Flow During an MPI, Figure 10 on the following page, is a schematic illustration of the operational flow of patients at the MPI scene as they are triaged, treated, moved from treatment to the loading zone, and then transported to the receiving hospitals. This process requires tight coordination between the Transportation Group and all other functions. The operation of these functions is described in more detail in the following discussion of Group Supervisor Task Descriptions. 22 of 83

28 MPI Scene Multiple Patient Incident Plan: Levels III through V Triage Corridor A Hospitals Triage Corridor B Treatment Area A 3rd & Main Red Yellow Green Patient Destination Coordinator (If Staffed) Treatment Area B 5th & Walnut Red Yellow Green Transportation Group Supervisor A Transportation Group Supervisor B Medical Staging Area Loading Zone A Loading Zone B Hospitals FIGURE 10 PATIENT FLOW DURING AND MPI 23 of 83

29 Multiple Patient Incident Plan: Levels III through V GROUP SUPERVISOR TASK DESCRIPTIONS This section details additional roles and responsibilities that may be used by emergency personnel during an actual response to ensure that all critical tasks have been accomplished. There are various worksheets in Log Forms (Section 15) of this document pertaining to each role discussed. TREATMENT GROUP SUPERVISOR The Treatment Group Supervisor reports to the Medical Branch Director and is responsible for overseeing all patient care interventions that are conducted on scene in order to stabilize life-threatening and serious injuries prior to the patient(s) being transported. This position will be called TREATMENT for all communications. The focus should be on good basic life support care until/unless advanced life support resources are available. Responsibilities of the Treatment Group Supervisor include: Establish Treatment Areas that are segregated according to priority classification (Red/Yellow/Green/Black). Use available markers and identifiers (tarps, signs, flags, barrier tape, etc ) that clearly indicate the location of each Treatment Area. Coordinate the location of the Treatment Area with the Triage Group Supervisor. When selecting a location, think BIG! The Treatment Area should be large enough to handle all the victims as well as equipment and personnel necessary to treat them. Ensure that the Treatment Area is located a safe distance from the hazardous incident site. The Treatment Area should be proximal to the triage area, readily accessible with clearly identified entrance and exit points and located away from vehicle exhaust or heavy equipment that is operating in the area. Have a backup location for the primary Treatment Area identified in the event that it is no longer safe to operate there. If the scene is broken up (i.e. train or commercial aircraft wreckage) or victims are congregating in widespread multiple areas (high rise structure fire with victims exiting on all sides of the building), consider the need for multiple Treatment Areas. If there are large numbers of casualties to be treated, consider assigning a Treatment Unit leader to each of the Treatment Areas (Red/Yellow/Green). This provides for a more effective span of control, smoother operation, and accurate/timely communication of 24 of 83

30 Multiple Patient Incident Plan: Levels III through V needs. Treatment Unit leaders should identify themselves according to the respective Triage color that they are assigned (i.e. Red Unit Leader/Yellow Unit Leader/Green Unit Leader). When establishing the individual Treatment Areas, it is recommended that the Black Tag Area (Morgue) be as far away from the Green Treatment Area as possible. This facilitates movement of patients who expire while in the Red Treatment prior to transport from the scene, and minimizes the psychological effects on patients in the Green Treatment Area who would otherwise view the dead. Determine appropriate location for an off-site Treatment Area for all Green tag patients Request law enforcement to secure the Black Tag Area (Morgue) Maintain contact with Triage Group Supervisor for updated estimates of total patients being triaged. Ensure that an appropriate stock of medical equipment and supplies is available in the Treatment Area. Consider the use of a nearby public facility or city transit bus to hold all ambulatory patients for evaluation and identification. Ensure that at least one ALS unit is available to provide medical support at each site or facility utilized. Coordinate patient movement from Treatment Area to the Patient Loading Zone with the Transportation Group Supervisor. Account for the safety of all personnel working in the Treatment Area. 25 of 83

31 Multiple Patient Incident Plan: Levels III through V TRANSPORTATION GROUP SUPERVISOR The Transportation Group Supervisor reports to the Medical Branch Director and is responsible for the flow of all patients from the incident scene to hospital facilities by both ambulance and helicopter. The Transportation Group Supervisor also serves as the sole communications link between the scene and destination facilities (transporting units do not engage in radio communications with the hospitals during an MPI unless there is significant change in patient status). This position will be called TRANSPORTATION for all communications. The Transportation Group Supervisor is also responsible for maintaining an accurate and up-to-date record of hospital capabilities by priority and the master log of patients transported from the scene. A blank Patient Disposition Log is included in Log Forms (Section 15) of this document. Responsibilities of the Transportation Group Supervisor include: Patients shall depart the scene only at the direction of the Transportation Group Supervisor! There are no exceptions to this rule! Establish the Patient Loading Zone in conjunction with the Treatment Group Supervisor. This area should: o Preferably be large enough to accommodate multiple ambulances. o Be clearly marked and have easy access in and out without bottlenecks or the need for 3-point turns. o Be located near the Treatment Area. Identify a location to place the alternate transportation resources (buses, etc.) and ensure that Green tag patients are directed there. Communicate the location of the Patient Loading Zone to the Medical Staging Area Manager. Contact the Designated Wake County Hospital Representative to determine the total number of patients, by priority that each hospital can receive. It is important to update the hospital capability information frequently during an incident, as these numbers will change quickly when transport of patients from the scene is initiated. If established, the Patient Destination Coordinator may be assigned this task. Assign patients to transporting ambulances and destinations to emergency medical crews. Make sure crews know the directions to their destination hospital. 26 of 83

32 Multiple Patient Incident Plan: Levels III through V Request additional transport units from the Staging Officer to be sent from Staging to the Patient Loading Zone. Be specific regarding what level of ambulance is being requested (ALS vs. BLS). Coordinate order of patient departure with the Treatment Group Supervisor. Notify the Medical Branch Director when the last patient has been transported from the scene. Account for the safety of all personnel working in the Patient Loading Zone. Designate assistants early on in the incident! While the above listing reflects the responsibilities of the Transportation Group Supervisor, it is not practical to assume that one individual can manage the rapid flow of written, radio and face-to-face communication that will be necessary. Based on scene size and complexity and resource availability, the following Transportation Assistant function is recommended: Patient Destination Coordinator: Serves as the communications point between the scene and destination facilities. Maintains the accurate count of patients, by priority, which each facility is prepared to receive. Maintains the Patient Disposition Log in Log Forms (Section 15). Upon the EMS unit or helicopter departing the scene, the Patient Destination Coordinator will advise a receiving hospital of: o EMS unit # or helicopter ID transporting to their facility o Number of patients on board o Priority of the patients on board o Any special needs of the patients (i.e., burn, OB, pediatric, etc.) 27 of 83

33 Multiple Patient Incident Plan: Levels III through V PATIENT DESTINATION COORDINATOR The Patient Destination Coordinator reports to the Transportation Group Supervisor. The Patient Destination Coordinator is responsible for assigning patients to a transport unit, and transport units to destination hospitals. This position will be called OUTBOUND for all communications. To relieve the Transportation Group Supervisor of record keeping work, this person should take over maintenance of the Patient Disposition Log included in Log Forms (Section 15). The Patient Destination Coordinator is also responsible for interfacing with the Designated Wake County Hospital Representative to determine the number of patients, by category (Red/Yellow/Green) that each hospital is prepared to receive. The Patient Destination Coordinator should ensure that all Green tag patients are loaded onto available multiple patient transportation vehicles and that required medical personnel staff those vehicles during transit to a casualty collection point or hospital. MEDICAL STAGING AREA MANAGER The Medical Branch Director may designate a Medical Staging Area Manager to manage the volume of resources being committed to the incident in order to reduce congestion and confusion at the scene. This position will be called STAGING for all communications. The Medical Staging Area Manager should work quickly to establish a large staging area (parking lot, field, tarmac, etc.) that is near the scene, but not directly on top of it. The Staging Area should be large enough to handle multiple ambulances. It should also be easy to find and have clearly identifiable access points. The Staging Area may be an impromptu site or may be selected from one of the eight predesignated Wake County Staging Areas. This is particularly important for mutual aid response from outside Wake County. Responsibilities of the Medical Staging Area Manager include: Maintain a visible presence in the Staging Area. Inform the Transportation Group Supervisor of the Staging Area location. Ensure that ALL patient transportation resources check in upon their arrival in the Staging Area. Ensure that ALL patient transportation resources in the Staging Area are operating on the appropriate TalkGroup. Implement the passport system to manage personnel and equipment accountability. 28 of 83

34 Multiple Patient Incident Plan: Levels III through V Provide the crews in Staging with simple, easy-to-follow directions from the Staging Area to the Patient Loading Zone. Maintain a log of medical resources as they arrive and depart using the form in Log Forms (Section 15). Remind crews that there should be no radio contact with hospital facilities when transporting from the incident scene unless there is significant change in patient status. Keep the Transportation Group Supervisor updated with the number of units remaining in the Staging Area. Dispatch transport resources to the Patient Loading Zone at the request of the Transportation Group Supervisor. Inform the Medical Branch Director when the number of ambulances in the Staging Area is below the minimum level requested. If personnel are directed to leave their ambulances in the Staging Area and report to the scene for manpower, ensure that door and ignition keys are left with the vehicle. Account for the safety of all personnel working in the Staging Area. ASSISTANT SAFETY OFFICER The Assistant Safety Officer reports to the Medical Branch Director and is tasked with observing and identifying hazards that could endanger the safety of patients and emergency personnel. This position will be called SAFETY for all communications. The Assistant Safety Officer is also responsible for determining the work/rest interval at the scene of an incident. Responsibilities of the Assistant Safety Officer include: Perform a scene assessment to determine what, if any, threats to safety are present. Determine the necessary work/rest interval and report this to the Medical Branch Director for notification. Oversee workers, ensuring they report to rehabilitation at the necessary intervals. Document the working time and conditions of personnel who are directly participating in the extrication, decontamination, or treatment of patients. Document the conditions under which any EMS worker is injured for afteraction evaluation. 29 of 83

35 Multiple Patient Incident Plan: Levels III through V REHABILITATION UNIT LEADER The Rehabilitation Unit Leader reports to the Assistant Safety Officer (when established) or to the Medical Branch Director. He receives his support through the logistics chain. This position will be called REHAB for all communications. Regardless of its reporting structure, REHAB remains a function of the EMS agency. The Rehabilitation Unit Leader is tasked with establishing a Rehabilitation Area in which emergency personnel can receive medical evaluations, rehydration, and food. The Rehabilitation Unit Leader is also responsible for keeping a record of personnel s time in the Rehabilitation Area. Responsibilities of the Rehabilitation Unit Leader include: Establish the Rehabilitation Area and make its location known in cooperation with the Assistant Safety Officer. Obtain supplies including food and water. If operating outside in winter, provide blankets or heating equipment. If operating in summer, provide location with air conditioning. Track the time in, time out, and status of emergency personnel in the Rehabilitation Area. Oversee the medical evaluation of personnel and prevent unfit individuals from returning to work according to the Wake County EMS Incident Rehabilitation Protocol. 30 of 83

36 Multiple Patient Incident Plan: Levels III through V MAJOR INCIDENT MANAGEMENT TEAM During large incidents, specialized knowledge and leadership will be required. To accommodate these needs, individuals trained in specific high level management disciplines should staff several Major Incident Management Teams. These individuals may come from any emergency response agency or any branch of government. What is more important is that their skill set and training meet the needs that incident related positions require. To complement skills and training, the teams should regularly simulate responses to enhance communication and teamwork. The Major Incident Management Team should be notified at Level III and activated for a Level IV or V MPI. The Team should also be activated at the discretion of the Incident Commander when it appears that an incident will last a long time or require specialized logistical support. While the standard activation will mobilize all team members to an incident site, an Incident Commander may request only a subset of the team to support a specialized function. 31 of 83

37 Special Situations 5.0 Special Situations: Hazardous Materials, Confined Space/Structural Collapse, Water Rescue and Vehicle Extrication Special situations may arise in which it is unsafe for EMS personnel without special training and equipment to perform medical interventions. In such cases, cooperation with rescue personnel will be necessary. While the ultimate goal of any such cooperation is the medical care of victims, it may be necessary to delay treatment until the appropriately trained personnel have implemented measures representing a reasonable level of caution. During these special situations, a medically aware safety officer should supervise operations. Hazardous Materials/CBRNE Incidents The health threat posed by exposure to hazardous materials warrants extreme caution on the part of all responders. Appropriately trained, properly attired EMS personnel may enter a suspected hot zone only as part of a coordinated hazardous materials response. EMS personnel without specialized training and equipment may not enter a suspected hot zone. It is the role of HAZMAT to control the hot zone and establish a decontamination facility. Specially trained HAZMAT EMS personnel should be developed to perform life saving measures, triage and extraction in the hot zone, while other personnel perform gross and technical decontamination. Warm zone medics will be standing by during decontamination to provide life saving intervention in the event that a patient s condition deteriorates. Once the patient is stabilized, decontamination may resume and the patient will then be passed to the cold zone where EMS will resume treatment and transport of the patient. Technical decontamination may be completed at the scene, at another location, or at the receiving hospital. Refer to Section 6.0 for additional information regarding Triage and Decontamination at CBRNE incidents. Confined Space/Structural Collapse/ and Trench Rescues At no time shall personnel enter a confined space, collapsed structure, or earthen trench without the appropriate authority and supervision of qualified rescue personnel. Appropriately trained, properly attired personnel may enter these environments to begin patient assessment or emergency care only as part of a coordinated rescue response. The agency responsible for rescue will coordinate with EMS personnel to facilitate patient care, but retain the ultimate responsibility for extracting victims from confined 32 of 83

38 Special Situations spaces, collapsed structures, or trenches. Patients in these situations will frequently require advanced life support care in the environment in which they are entrapped, and specialized EMS personnel should be maintained to meet those needs. Water Rescue Water rescue is the responsibility of trained and qualified special teams. Properly trained EMS personnel may accompany rescue personnel to perform assessments and life saving measures. Water rescue personnel have the ultimate responsibility for extracting victims from water hazards. All personnel operating around water will wear appropriate personal flotation devices (PFDs) at all times. Upon extraction, EMS assumes responsibility for medical interventions and transportation. Vehicle Extrication Qualified rescue personnel will perform extrication. It is the role of EMS to monitor the status of a patient undergoing extrication and to provide required medical attention. Appropriately trained, properly attired EMS personnel will enter these environments when it is safe to begin patient assessment or emergency care. 33 of 83

39 Chemical, Biological, Radiological, Nuclear and Explosive Incidents 6.0 Chemical, Biological, Radiological, Nuclear and Explosive Incidents Chemical, biological, radiological, nuclear, and explosive (CBRNE) incidents pose one of the greatest risks to first responders. While the detonation of a conventional explosive device or a nuclear weapon will present unmistakable damage patterns, chemical, biological, and radiological incidents will present more subtle indicators. These incidents are typically so difficult to identify that it is not apparent to emergency personnel until the first responders have been exposed to contamination. It is thus imperative that emergency personnel be trained to recognize the signs of a hazardous materials release. IDENTIFYING A CBRNE INCIDENT Some clues may be present that could be indicators that a CBRNE incident has taken place. Unusual numbers of dying animals are present. For example, all the birds that are usually present at outside trash bins are dead. Lack of insect life. If normal insect activity (ground, air, and/or water) is missing, then check the ground, water surface, or shoreline for dead insects. Numerous individuals are experiencing unexplained water-like blisters, wheals (like bee stings), and/or rashes. Numerous individuals are exhibiting serious health problems ranging from nausea to disorientation, difficulty breathing, convulsions, and death. Multiple incapacitated patients with no obvious injury. There is a definite pattern of casualties (i.e., the casualties are aligned with the wind direction outdoors). Casualties are distributed in a pattern that may be associated with possible agent dissemination methods (i.e., a fewer number of ill people working indoors versus outdoors, or outdoors versus indoors). Unusual liquid droplets are present. Numerous surfaces exhibit oily droplets/film; numerous water surfaces have an oily film. 34 of 83

40 Chemical, Biological, Radiological, Nuclear and Explosive Incidents TRIAGE AND DECONTAMINATION FOR CBRNE INCIDENTS For safety reasons, the HAZMAT team will direct operations in the hot zone as well as the decontamination process. EMS shall have a special strike team capable of performing ALS medical operations in the contaminated area. These individuals will receive proper HAZMAT and CBRNE training and will serve only these specific roles at the scene of a HAZMAT/CBRNE incident. The team will be activated by any Level MPI when a chemical, biological, or radiological agent is suspected to be present. The team will include medics capable of operating in the hot zone utilizing full Level A Personal Protective Equipment (PPE). Level A PPE includes a self-contained breathing apparatus (SCBA) with a full-face mask and a chemically impermeable suit. These medics shall perform triage of victims in the hot zone, ensuring that victims are extracted in the appropriate order as described below. In addition, the hot zone medics will perform life saving procedures to aid non-ambulatory patients while ambulatory patients are rapidly decontaminated. The team will also include warm zone medics. These personnel shall monitor patients during decontamination. They will re-triage patients according to changing status and will provide life saving intervention when necessary. Decontaminated patients will be handed off to medics in the cold zone for transportation and treatment. While only a limited number of medics will function in the hot zone, there should be an emergency extraction team composed of fire, HAZMAT, or EMS personnel ready to extract emergency workers from inside the hot zone at any time. At NO TIME are EMS personnel to unnecessarily jeopardize their safety while performing medical interventions in support of a rescue in progress. No EMS personnel will enter a contaminated area without appropriate PPE. The PPE appropriate to the situation will be determined by existing standard operating procedures (SOP S) or by personnel trained to a HAZMAT technician or specialist PPE level with additional training in CBRNE incidents. 35 of 83

41 Chemical, Biological, Radiological, Nuclear and Explosive Incidents DECONTAMINATION TRIAGE Decontamination triage priority is opposite that of standard medical triage. This is because the high lethality of CBRNE agents means those individuals who exhibit strong symptoms on scene have been heavily exposed and are likely to expire, regardless of treatment. For these special situations, priority will be placed on (1) gross decontamination of ambulatory patients, followed by (2) decontaminating conscious, non-ambulatory patients, after which (3) unconscious, non-ambulatory patients should be decontaminated. (4) Deceased victims, or those expected to expire shortly, are the lowest priority. PERFORM PATIENT DECONTAMINATION At the scene of an incident in which hazardous materials are present, the fire department provides direction with regard to decontamination. Appropriately trained, properly attired EMS personnel may enter a suspected hot zone only as part of a coordinated HAZMAT response. The following items are general guidance that should be followed at the scene of a hazardous materials incident. Gross decontamination equipment is to be functional before any personnel make entry to perform a rescue and/or reconnaissance. At a minimum, gross decontamination will be performed on all patients expected or known to be at risk for contamination. Decontamination will be performed in two stages. They are: Gross decontamination, which includes the removal of the patient from a high-risk area, followed by clothing removal, except underwear. Then a head-to-toe rinse utilizing copious amounts of water. Technical decontamination, which includes head-to-toe washing in a systematic fashion to ensure no additional agent remains on the patient. The airway will be cleaned first, then open wounds, and then the rest of the body in a systematic head-to-toe fashion. Decontaminated wounds are to be covered with an occlusive dressing. 36 of 83

42 Chemical, Biological, Radiological, Nuclear and Explosive Incidents Decontamination Considerations: Modesty of those being decontaminated should be considered, but should not delay the decontamination process. Multiple decontamination corridors to segregate male and female patients shall be established as soon as equipment and personnel are available. The decontamination corridor shall be set up in such a fashion that runoff does not affect the cold zone. Containment of this runoff should be considered but shall not delay the initiation of decontamination. As soon as possible, efforts should be made to prevent the runoff from leaving the scene. Scrubbing will be done using the appropriate brushes and cleaning solution and in a manner that does not lead to abrading or irritation of the skin. Rinsing will be done using tepid water temperatures (when available) and in a manner that minimizes splash, skin irritation, or injury. Patient transportation will not be delayed to accomplish technical decontamination at the scene. 37 of 83

43 Chemical, Biological, Radiological, Nuclear and Explosive Incidents EMERGENCY DECONTAMINATION PROCEDURE FOR RESPONSE PERSONNEL When operating in a hazardous environment, it is advisable to reserve a special decontamination corridor exclusively for the emergency decontamination of personnel operating in the hot zone. The set up of this corridor is the responsibility of the HAZMAT team. This decontamination corridor will be set up in accordance with standard HAZMAT procedures and will include the following: 1. Gross decontamination station 2. Rinse station 3. Soap solution application and scrubbing station 4. Secondary rinse station 5. Secondary soap solution application and scrubbing station 6. Final rinse station Procedures 1. Announce MAYDAY, MAYDAY officer/firefighter/medic down and indicate location on radio. If personnel are in the hot zone, the emergency extraction team will be activated and deployed, if needed, and bring the downed responder to the emergency decontamination corridor. 2. If there is no emergency decontamination corridor available, then the medical decontamination corridor will be temporarily closed. 3. Attempt to ascertain the nature of the problem (e.g., suit breach, heat illness, etc.). 4. Lay the patient down on a backboard, if available. 5. Perform a quick head-to-toe rinse/wash/rinse of the PPE. 6. Rapidly remove suit, cutting it, if necessary, and in a manner that minimizes contamination spread. 7. Assure patient airway is open. 8. If heat stress is observed, initiate cool-down of patient with water, if indicated. 9. Inform Treatment Group Supervisor of situation and findings and advise Transportation Group Supervisor to prepare an ALS transport. 10. Initiate appropriate preliminary medical care (e.g., O 2, BVM support, etc.) and antidote administration, if indicated, as soon as possible. 11. Transport patient to Treatment Area. 38 of 83

44 Chemical, Biological, Radiological, Nuclear and Explosive Incidents Pass patient over to treatment personnel without stepping into cold zone. CBRNE Task List for Use During MPI Responses When the Triage Group Supervisor determines that there are multiple patients exposed to hazardous materials or environments, the following actions shall be taken. 1. In coordination with law enforcement, the fire department, and the EMS CBRNE strike team, the Incident Commander will establish a demarcation between the hot zone and cold zone. Do not allow persons in the hot zone to immediately leave the scene without evaluation! 2. HAZMAT personnel with special training in CBRNE should work quickly to identify any hazardous substances present. 3. Ambulatory patients will be directed to a secure area near the perimeter of the hot zone where they will await decontamination. As soon as the decontamination corridor has been established, the walking wounded will be decontaminated. These individuals should then be isolated in a Treatment Area, secured by law enforcement if necessary, for medical observation by EMS personnel familiar with the symptoms and treatments for toxic exposures. 4. Asymptomatic persons believed exposed to hazardous materials should also receive full decontamination and be placed in the isolated medical observation area. 5. Decontamination efforts will be coordinated between the HAZMAT Commander and the receiving hospitals to ensure victims are managed in an appropriate manner 6. After the ambulatory patients have been decontaminated, the EMS CBRNE strike team in conjunction with HAZMAT personnel shall enter the hot zone to perform decontamination triage on non-ambulatory patients. 7. The Treatment Group Supervisor will contact the Designated Wake County Hospital Representative with information on the type and level of exposure. The Designated Wake County Hospital Representative shall relay this information to Poison Control or consult with internal clinical experts. Information to be determined includes: 39 of 83

45 Chemical, Biological, Radiological, Nuclear and Explosive Incidents o Symptoms to be expected o Approximate time to onset of symptoms o Recommended treatments 8. If patients begin to exhibit symptoms of exposure, they should be removed from the Treatment Area and placed in a special Treatment Area designated solely for victims of the toxic exposure. 9. After the time to onset of symptoms has passed, asymptomatic patients may be released. Patients who are minors should be released only to their parent or guardian. 40 of 83

46 The Use of Non-Credentialed and Non-EMS Healthcare Personnel 7.0 The Use of Non-Credentialed and Non-EMS Healthcare Personnel In multiple patient incidents exceeding a certain size, the number of patients will inevitably overwhelm emergency responders. In such situations, non-credentialed health care providers may be called upon to perform certain tasks. While these individuals may be qualified in their respective state or district, this does not automatically license them to perform medical procedures on behalf of Wake County EMS. As such, it is necessary to carefully consider the role of non-credentialed healthcare personnel in the context of a multiple patient incident. In particular, the legal and logistical concern of allowing non-agency personnel to perform medical procedures on behalf of Wake County EMS presents a significant risk to the County and incident victims. To minimize these risks, non-credentialed personnel are recommended to do the following tasks: Monitoring patient vital signs Aiding in the lifting or carrying of patients Distributing supplies Administrative tasks Credentialing Non-EMS Affiliated HealthCare Workers In many situations, it would be advantageous to use Wake County s population of nurses, doctors, and other healthcare workers to care for victims of multiple patient incidents. In order to permit them to legally perform advanced life saving procedures, it is necessary to establish a credentialing system. The Wake County EMS agency has conceptualized such a system and its creation and operation is best described by the following: 1. Develop a target audience for the program 2. Complete procedure for implementation 3. Establish review board 4. Create website for information 5. Create application for program (load to website) 6. Review returned applications 7. Offer orientation session 8. Issue photo identification cards 9. Maintain a database of credentialed individuals 41 of 83

47 The Use of Non-Credentialed and Non-EMS Healthcare Personnel 10. Conduct a once a year meeting to measure response, disseminate information, and update records. Development of Program In the event of a mass care scenario, it will be necessary for the EMS community, in partnership with other healthcare agencies, to establish and manage freestanding medical casualty collection points. These facilities will require the use of trained medical personnel greater than those resources available from the EMS system. For that purpose, this project will establish a pre-credentialed pool of healthcare workers, with varying levels of skill, to assist. This will expedite the admission of workers into secure areas to assist. The same pool of medical personnel could also be enlisted to assist in special needstype shelters for Human Services. Solicitation of Volunteers The building of the pool of personnel will start with the hospital-based community. This will include staff nurses, respiratory therapists, nurse aides, and other trained professionals. The secondary approach will focus on other clinical providers that have experience in more acute care scenarios (ortho, cardiac, pediatrics, etc.). The final approach will be for any interested healthcare person in the community. Distribution of Applications A website will be established for personnel seeking additional information on this program. It will detail as many areas of the program as possible and will include a downloadable application to the program. As applications are received, a panel chaired by the Medical Director will review them. When sufficient numbers are accepted, the initial orientation program will be scheduled. Orientation Program To include at a minimum: Mass care and special needs shelter operations Incident command overview Activation particulars Expectations of the EMS System Identification cards 42 of 83

48 The Use of Non-Credentialed and Non-EMS Healthcare Personnel Maintenance of Database Participants will be given a project contact with Wake County EMS should they at any time no longer be able to participate. To exit the project, they will simply need to make this notification and return their identification card. 43 of 83

49 Critical Incident Stress management 8.0 Critical Incident Stress Management Threatening situations, hostage situations, serious injuries, deaths, and other tragedies can produce high levels of psychological stress. Personnel that respond to emergencies encounter highly stressful events almost daily. In some situations, an event is so emotionally overwhelming that emergency responders may experience significant stress reactions. These unusually strong emotional reactions may have the potential to interfere with the emergency responder s ability to function either at the scene or later. Signs and Symptoms of Stress Reactions: Physical Chills, fatigue, nausea, fainting, twitches, vomiting, dizziness, weakness, shock symptoms, difficulty breathing, elevated blood pressure, rapid heart rate, etc. Cognitive Confusion, nightmares, uncertainty, abstract thinking, poor attention/decisions, poor concentration/memory, increased or decreased awareness of surroundings, etc. Emotional Fear, guilt, grief, panic, denial, anxiety, etc. Behavioral Withdrawal, antisocial acts, inability to rest, intensified pacing, increased alcohol consumption, etc. Spiritual Anger at God, questioning of basic beliefs, withdrawal from place of worship, sense of isolation from God, etc. Critical Incident Stress Debriefing Critical Incident Stress Debriefing (CISD) is designed to prevent or mitigate the development of post-traumatic stress syndrome among emergency service professionals. Critical incident stress management represents an integrated system of interventions, which are designed to prevent and/or mitigate the adverse psychological reactions that often accompany emergency services, public safety, and disaster response functions. Intervention is especially directed towards the mitigation of posttraumatic stress reactions. After action CISD interventions are the responsibility of the Wake County Department of Human Services. The contact information for this resource will be made available to first responders after the event has concluded. Participation in any debriefing is voluntary. 44 of 83

50 On-Site Rest and Rehabilitation 9.0 On-Site Rest and Rehabilitation During the course of an extended incident, it will be necessary for personnel to take breaks to re-hydrate, rest, and receive cursory medical evaluations. Incident Commanders should work to ensure that no team member is permitted to continue emergency operations beyond safe levels of physical or mental endurance. The Assistant Safety Officer will be responsible for enforcing this policy of periodic rest breaks. The work/rest interval will be set by the Assistant Safety Officer and must be strictly observed by all responding agencies. To accomodate this policy, an on site Rehabilitation Area should be established when the incident is expected to last for an extended period. The Incident Commander or the Medical Branch Director will determine the need for a Rehabilitation Area. The Rehabilitation Unit Leader will be responsible for monitoring activities in this area in addition to maintaining a log of each emergency worker s rest breaks and medical condition. The intent of this rehabilitation is to lessen the risk of injury that may result from extended field operations under adverse conditions. The Rehabilitation Area will be used to evaluate and assist personnel who could be suffering from the effects of sustained physical or mental exertion during emergency operations. The Rehabilitation Unit Leader will provide a specific area where personnel will assemble to receive: A physical assessment Revitalization - rest, hydration and food Medical evaluation and treatment of injuries Continual monitoring of physical condition Transportation for those requiring treatment at medical facilities If possible, this area should be indoors or inside a large climate controlled vehicle to allow personnel to rest near room temperature. A specially equipped rehabilitation vehicle is recommended. 45 of 83

51 Mass Gathering Management 10.0 MASS GATHERING MANAGEMENT Preplanning Within Wake County, there are a large number of mass gathering events each year. A non-inclusive list of events and estimated attendance is included in the table below. Wake County Mass Gatherings Non Inclusive list and estimated attendance Indoor Events Attendees Occurrence Number Carolina Hurricanes Hockey 14,000 Per Game 36 Games NC State Basketball - Mens 23,000 Per Game 6 Games NC State Basketball - Women's 1,000 Per Game 4 Games Circus 10,000 Per Day 4 Days Dorton Arena 3,000 Per Day 4 Days CIAA Basketball Classic 15,000 Per Day 7 Days WWE Wrestling Events 23,000 Per Day 4 Days Arena Cross 10,000 Per Day 3 Days Monster Truck Jam 12,000 Per Day 2 Days Outdoor Events Attendees Occurrence Number Parades Christmas Parade 150,000 Per Day 1 Day Thanksgiving Parade 35,000 Per Day 1 Day Veteran's Day Parade 20,000 Per Day 1 Day Sporting Events Attendees Occurrence Number NC State Football 54,000 Per Game 10 Games Tarheel Regatta 10,000 Per Day 7 Days Senior Games 15,000 Per Day 14 Days Bicycle Races Road Races St. Augustines Football 2,000 Per Day 4 Days Concerts Attendees Occurrence Number Cary Amphitheater 13,000 Per Day 7 Days Concerts Alltel Pavillion 20,000 Per Day 30 Days Gatherings Attendees Occurrence Number NC State Fair 75,000 Per Day 10 Days NC 4th of July Celebration 100,000 Per Day 1 Day New Years Celebration 150,000 Per Day 1 Day Political Rallies 5,000 Per Day 3 Days 46 of 83

52 Mass Gathering Management The City of Raleigh and a few other municipalities require permits for mass gatherings. However, events held in unincorporated areas do not require permits or any other advance permission. Wake County in general, and Wake County EMS, is not part of the municipal permitting process. Thus, unless the organizers of an event specifically request an EMS presence at their event, the first notification of the EMS system often will be the first call to the 911 centers from that event. Three recommendations to address this scenario include: Inclusion of the Wake County Department of Public Safety in the permitting process for mass gatherings should be made a high priority Where no permit is required for a mass gathering, consideration should be given to establishing one Establishing a medical intelligence function, with a portion of that resource dedicated to learning of and communicating with the promoters of community events When contacted by event promoters, Wake County EMS agencies are often in the mode of responding to requests for a standby ambulance. Promoters may have little knowledge of the actual medical needs an event is likely to generate. The EMS system should take a more proactive approach to EMS planning for large events, communicating to event promoters about the likely needs and resources recommended for a particular type of event. A community s lead EMS agency has responsibilities that extend beyond daily ambulance response. Wake County, although well equipped to handle the normal dayto-day EMS needs of the community, is significantly under-equipped and under-staffed for the management of mass gatherings. Mass gatherings do not occur in the typical urban (roadway and buildings) environment of EMS operations. Events may be indoors in large arenas or stadiums, or outdoors, as in street festivals, walks, marathons, bike races, road races, etc. To properly manage large, outdoor events, an EMS agency must have specialized equipment and specially trained personnel in sufficient numbers to be able to physically access and medically manage patients in all manner of environments. These needs are specifically addressed in the sections that follow. 47 of 83

53 Mass Gathering Management When possible, Wake County EMS shall be informed in advance of mass gathering events. Information shall include the number of attendees, the location, and any demographic intelligence available. Staffing Levels Despite extensive research on the topic, emergency professionals have been unable to produce exact guidance as to the resources required to medically manage a mass gathering event. Rather, the National Association of EMS Physicians produced a document entitled Mass Gathering Medical Care: The Medical Director s Checklist. The document indicates that each mass gathering situation is a unique combination of factors that must be weighed in assigning medical resources. EMS managers must consider a variety of factors including: Crowd composition, size, and mood Weather Size of venue Type of event Event duration Alcohol consumption VIPs in attendance Specific threats and general security concerns Transport time to nearest hospital Each factor will influence the number of patients in a different way depending on a vast array of seasonal, geographic, and demographic variables. The best indicator of the staffing needs for a future event is historical data. By comparing a future event to similar past events, EMS managers can gain an appreciation of the likely volume of patients. To supplement EMS managers understanding of an event, they should coordinate with the local law enforcement intelligence group to determine specific threats and likely crowd composition. While no exact guidance is available covering all types of events, the American College of Emergency Physicians EMS Committee recommends two paramedics and one EMT-B ambulance driver for every 10,000 people in attendance. For every 50,000 attendees there should also be one physician on site. For long duration events, it is recommended to have multiple shifts so that crews can have adequate time to rest between patient contacts. 48 of 83

54 Mass Gathering Management The above guidance is the generally accepted standard practice. New information based on statistical research is also available. Using historical data from a variety of sources, Arbon, Bridgewater, and Smith* (2001) developed a model for predicting the likely number of patients expected at an event. Their model anticipates volume based on weather, crowd size, and venue type. It has been reproduced in simplified form in Figure 11. *The original reference may be found at the Journal of Prehospital and Disaster Medicine s Web Site. The address is The article is taken from Volume 16, Number 3. Equipment and Facilities The equipment and facilities required by a mass gathering will vary depending on the number of attendees and the location and type of event. As a minimum, one fully stocked EMS unit capable of advanced life support should be present for every 10,000 people. When possible, a treatment center should be established for events in which greater than 5,000 people will be present. If the event is inside a facility such as a stadium, the treatment center should be located in a specially outfitted room of the building. If the event occurs outdoors and there are no facilities available, the treatment center can be established inside the high capacity patient transport vehicle. As an additional measure, when there are more than 50,000 attendees, a specially equipped EMS command vehicle should be mobilized to provide communications and equipment in the event of a large-scale emergency. As a further measure, when events are held outdoors, EMS should use a small all terrain vehicle, such as a Gator, to transport patients and equipment. Distributed Mass Gatherings In addition to the above, the greater Raleigh area hosts many mass gatherings that are distributed in some way throughout the community. These events pose unique challenges, in that streets are closed and crowds often impede ambulance access. Specially trained and equipped EMS personnel are best able to access patients in these environments and to provide prompt and efficient care and evacuation. The paragraphs below detail some recommended strategies for dealing with such incidents. 49 of 83

55 Mass Gathering Management Bicycle Medics Like their law enforcement counterparts, teams of paramedics aboard bicycles have proven to be very effective in delivering medical care in and around distributed mass gatherings such as parades, marathons, and street festivals. These teams can be established and maintained at relatively low cost (the major expense being the time to initially train the medics to an acceptable standard of proficiency). Motorcycle Medics In many locations in the United States and the world, individual or paired motorcycle paramedics provide quick access to patients during parades, Fourth-of-July celebrations, motorcycle rides, etc. Again, the major cost of establishing such a capability is the time to initially train the medics to an acceptable standard of proficiency. All-terrain patient transport vehicles Quite a few mass gatherings entail rural or semi-rural environments. In these events, not only is it a challenge to access the patient, but also then the patient must be evacuated from a remote or un-paved area to an area that can be accessed by an ambulance. All-terrain patient transport vehicles are readily available from commercial sources for use by EMS agencies serving events of this type. Kubota has recently introduced a four-wheel drive diesel powered chassis that is small and agile, can be adapted for use as an ambulance/transport unit, and is street legal for operation. They are easily transportable in enclosed trailers to event scenes. 50 of 83

56 Mass Gathering Management Segway People Mover devices A new solution to the problem of moving dismounted medics around distributed mass gatherings is the Segway People Mover now in service with Boston and several other EMS agencies. Multiple-patient transport vehicles At a certain level, using individual ambulances to transport one or two patients away from the scene of a large emergency is a very inefficient use of resources. Multipatient transport vehicles, ranging from four to 16 patient capacity, can be very helpful in moving injured patients who require sub-critical levels of care, keeping larger number of paramedics available to provide at-scene care. Predictive Patient Model The chart on the following page provides statistically derived guidance for staffing mass gatherings. The chart is intended to serve only as a guide, and will not accurately predict patient contacts when the temperature and humidity are very low. When using this tool, you should always use your own judgment in determining its utility. To use the model, follow the instructions for each variable to fill in column A. After filling in column A, multiply each value in column A by its corresponding value in column B and write this result in column C. Total the numbers in column C and subtract 78 to obtain the total number of expected patients per day. You should assume that one in every ten patients must be transported. 51 of 83

57 Mass Gathering Management Mass Gathering Predictive Patient Model Variable Instructions A B C Is population seated or mobile? Is the event fenced or walled? Is it indoor? Is it outdoor? Is it a sporting event? What is the relative humidity? (%) Number of expected attendees? Number of attendees multiplied by humidity? Day or night or both? If the attendees are seated, place a 1 in column A. Otherwise place a zero in column A. Place a 1 in column A if the event is fenced or walled and zero in column A if it is not. Place a 1 in column A if the event is indoors and a zero if outdoors. Place a 1 in column A if the event is outdoors and a zero if it is indoors. Events that are both indoor and outdoor receive a 1 for both indoor and outdoor variables. Place a 1 in column A for a sporting event and zero for nonsporting events. Write the relative humidity expected in column A. For example, 50% relative humidity is written as 50. Write the number of expected attendees in column A. If the exact number is unknown, overestimate. Multiply the number of attendees by the relative humidity and write this value in column A. (For example 50% humidity and 100 attendees results in a value of 5000.) Place a 1 in column A if the event occurs during day and night and a zero if it is only a day or only a night event. Total Number of Expected Patient Contacts FIGURE 11 MASS GATHERING PREDICTIVE PATIENT MODEL 52 of 83

58 Exercising the Multiple Patient Incident Plan 11.0 Exercising the Multiple Patient Incident Plan No plan, however carefully conceived, can be effectively implemented without extensive training and simulation. In order to effectively implement and exercise this plan, the following actions are recommended: Design and staff the Major Incident Management Team. These individuals should come from the core personnel of the County s critical response agencies. Train these individuals in Intermediate and Advanced ICS, the various command and general staff positions, and on ICS for EMS and get buy in of its operational principles. Train all EMS and mutual aid agencies on the basics of the Incident management system and NIMS organization, using the MPI plan as an example of such organization. All EMS supervisory personnel (EMS District Chiefs, contract agency officers, and above) should complete I-100, I-700, and ICS FOR EMS. Develop a scenario appropriate to Wake County. A simple scenario would be a bus accident. The situation could include complicating factors such as a toxic release at the accident site. Perform a tabletop exercise in which the command personnel from relevant agencies participate, including the Major Incident Management Team. Modify the MPI plan based on the results of the tabletop exercise. Using the same or another appropriate scenario, perform a full field exercise in which mutual aid partners and hospitals are able to participate. This will allow the communications, command and control, and logistics of an actual incident to be explored in a safe environment. Using the results of the exercise, the plan should once again be updated to reflect lessons learned. 53 of 83

59 Special Considerations for Incident Management 12.0 Special Considerations for Incident Management AEROMEDICAL OPERATIONS The Wake County EMS system utilizes aeromedical resources under the control of the Systems Standards Policy #1, found within the Wake County ALS Protocols and Policies. The integration of these resources requires additional manpower and coordination by scene managers. In recognition of this, aeromedical agencies should only be used when their presence will enhance patient care and provide a service that cannot be met by other on-scene resources. When using aeromedical resources, establish helicopter-landing zone in conjunction with Fire Department personnel on the scene. When aeromedical resources are requested, the Transportation Group Supervisor should designate a Landing Zone Coordinator. This person does not have to be from Wake EMS. The roles of the Landing Zone Coordinator includes: Assists with the transfer of patients to flight teams after being assigned a destination and helicopter by the Transportation Group Supervisor. Ensures safety of helicopter landing zone. NOTE: Unless otherwise directed by the Medical Branch Director or Transportation Group Supervisor, helicopter flight teams are to wait with their aircraft until patients are delivered to them for evacuation from the scene. 54 of 83

60 Recommendations to Enhance Response Capabilities 13.0 RECOMMENDATIONS TO ENHANCE RESPONSE CAPABILITIES 1. Adopt Incident Command as the standard procedure for all MPI incidents. a. Achieve interagency agreements on how ICS will be done on incidents of different sizes and types. o Emphasize the importance of staffing the Command and General Staff and Operations levels of the ICS organization. o Emphasize importance of utilizing the most qualified individuals available to fill command and operational positions rather than highest-ranking personnel. o The Incident Commander in a multi-agency incident should be predicated on the primary hazard of the incident. o Recognize that command should change as the primary hazard changes. o Avoid Unified Command situations where same individual is required to fill two positions Incident Commander & Medical Branch Director. b. Achieve interagency agreements to adopt same level of ICS training for staff. Schedule joint training among agencies. c. Train and do table top and field exercises together. 2. Adopt the use of Major Incident Management Teams to staff the Command and General Staff levels of ICS for Level IV and V MPI incidents. a. Select and train several teams drawn from public agencies. Multidiscipline Multi-agency. [Not limited to Public Safety] b. Establish a call system so at least one team is always available for prompt mobilization. c. Team members will be trained to fill a specific position within the ICS structure. d. Teams will train together regularly - bimonthly. e. All teams will jointly train together annually. f. Assign emergency response capable vehicles to Senior Command Staff for rapid deployment throughout the County. 3. Adopt an Incident Level ID system for quickly identifying the size of an incident and whether or not there is a HAZMAT or CBRNE component. 4. Adopt the use of Task Forces and Strike Teams for response to various Levels and types of incidents. 55 of 83

61 Recommendations to Enhance Response Capabilities a. Achieve interagency agreements on the composition of Task Forces and Strike Teams. b. Incorporate the results into the Computer Aided Dispatch system. 5. Adopt the use of preset Staging Areas within the County to support/facilitate rapid deployment and staging of resources for MPI incidents. 6. Develop and train special EMS HAZMAT Strike Teams to provide medical support/intervention in the Hot Zone in support of Fire HAZMAT teams. a. Maintain training and equipment for all EMS providers to function in Level C PPE to provide medical interventional care in the warm zone. b. Train all personnel to the awareness levels of NFPA 1670 rescue discipline. 7. Designate an appropriate hospital to serve as Designated Wake County Hospital Representative to coordinate information flow to and from hospitals during MPI incidents. 8. Develop as a readily deployable resource small transportation vehicles similar to Gators for use by EMS personnel staffing Mass Gathering events. 9. Develop as a readily deployable resource a bike medic team for utilization throughout mass gathering events. 10. Develop as a readily deployable resource one or more high capacity patient transport vehicles (i.e. buses) capable of transporting multiple stretcher/litter patients from an MPI. 11. Obtain one or more Rehabilitation vehicles [buses] with capacity for supporting multiple responders. This could be shared with Fire. Include: o Climate controlled environment for several responders o Medical Staff o Monitoring equipment 12. Obtain vehicle suitable for use as EMS command vehicle. This could be combined with the Rehabilitation vehicle. 13. Obtain and stock several MPI trailers capable of delivering a basic compliment of EMS supplies required for support to an MPI incident quickly throughout the County. 14. Predetermine, through coordination with Wake County Emergency Management, casualty collection points throughout the County that can be used as care facilities for multiple Green tag patients. 56 of 83

62 Recommendations to Enhance Response Capabilities 15. Integrate the communications center personnel to training on the MPI plan. 16. Secure additional radio capabilities for hospital emergency rooms to facilitate communication during MPI incidents. A separate amplifier to bring signal into emergency room so that EMS staff can communicate using their handheld radios. (Currently hospital base radios must remain on their primary patient information TalkGroup and are of little value in other communications) Portable radio for communication between Emergency Room staff and MPI team. 17. Achieve interagency agreement between fire departments and EMS agencies on the requirement for medical staff to be utilized to provide medical attention to any victim undergoing extrication. 18. Obtain interagency agreement to allow personnel duty assignments across agency lines during MPI as may be required to effectively and efficiently staff Branches, Groups, and resources teams. 19. Achieve interagency agreement on training all staff to conduct all radio communication using site/location specific designations since there may be more than one location for Staging, Triage, etc. 20. Achieve interagency agreement to include EMS in the planning and intelligence sharing process for Mass Gatherings or demonstrations so that appropriate resources can be scheduled and assigned. 21. Adopt a policy for the use of Non-EMS affiliated healthcare personnel in mass care settings. 22. Establish a program for the Credentialing of Non-EMS Affiliated Healthcare Workers in the community. 23. Establish formal mutual aid agreements similar to the Triangle EMS Mutual Aid Agreement to better resource type EMS assets from the region. This would include: Negotiate committed responses from Mutual Aid partners. Survey resource levels of mutual aid partners to include: o Personnel o Training o Staffing policies o PPE o Equipment 57 of 83

63 Recommendations to Enhance Response Capabilities o HAZMAT capabilities 24. Establish a system wide plan for stocking, management, and deployment of inventories of supplies required to support MPI incidents. Coordinate this effort with other agencies to insure that efforts are complimentary and not duplicative. 25. Keep vests for all MPI/ICS command positions in each EMS unit so that arriving EMS units can easily identify on-scene command personnel. 58 of 83

64 Job Aids 14.0 JOB AIDS The following pages detail specific Job Aid cards to clearly identify the roles and responsibilities of the various ICS positions needed in the management of a Multiple Patient Incident. These cards should be duplicated and placed within all EMS system response vehicles after the appropriate in-service. Job Aids: 1. First Unit On-Scene 2. Medical Branch Director 3. Triage Group Supervisor 4. Treatment Group Supervisor 5. Transportation Group Supervisor i. Medical Staging Area Manager ii. Patient Destination Coordinator 6. Assistant Safety Officer i. Rehabilitation Unit Leader 59 of 83

65 Job Aids FIRST UNIT ON-THE-SCENE JOB AID RADIO CALL SIGN: COMMAND It is critical that the first arriving unit assume the role of "incident manager" and not "caregiver". REQUIRED TASKS: Survey the scene for indications of Chemical, Bioterrorism, Radiation, or Nuclear involvement and take appropriate measures (on rear of this card) If no other agency has done so, assume the role of INCIDENT COMMAND. Announce on the assigned talkgroup that you are COMMAND. Don the COMMAND vest. If you are assuming COMMAND, complete the following: Select a location UPWIND and UPHILL from any hazards Communicate the location of COMMAND on the assigned talkgroup AND REMAIN THERE Request additional talkgroups for tactical operations, as necessary Transfer MEDICAL BRANCH DIRECTOR responsibilities to the next arriving qualified EMS officer after a face-to-face briefing If COMMAND has already been established, assume the role of MEDICAL BRANCH DIRECTOR. Don the MEDICAL vest. Address the STAGING of incoming units to your scene. This must be established early by the INCIDENT COMMANDER. This role does not have to be filled by an EMS person Assign your partner to assume TRIAGE GROUP SUPERVISOR. Have them don the TRIAGE vest and read the TRIAGE GROUP SUPERVISOR Job Aid. Have them begin assessing non-ambulatory patients where they are found and to direct ambulatory patients to a safe area of the scene for rapid triage. Perform a size-up of the scene and report this to RESCOM on the assigned talkgroup. This should include: BRIEF description of the incident Exact location of the incident Advise of any hazardous conditions present Indicate the MPI Category and Level (I thru V) Total Number of Patients Number of Seriously Injured Patients Recommended routes into and away from the scene Assessment of any SPECIAL resources needed at the scene (such as rescue unit, Hazmat) MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM FIGURE 12 JOB AID FIRST UNIT ON-THE-SCENE 60 of 83

66 Job Aids FIRST UNIT ON-THE-SCENE JOB AID RADIO CALL SIGN: COMMAND Special Considerations for the First Unit On-the-Scene of a CBRNE Incident OBJECTIVES: Protect yourself from harm. Document the scene and communicate with RESCOM. Prevent inbound units from entering hot zone. ACTIONS: Move upwind or laterally out of the plume of the contaminant. Advise RESCOM of possible CBRNE event and indicate more information to follow soon. Observe the defining casualty pattern or unusual features that tell you this is a CBRNE event: Does the casualty field follow the wind? What symptoms do the patients exhibit? Are there any unusual substances in the air or covering nearby surfaces? Are there any dead animals or insects at the scene? Does this appear to be terrorist/criminal in nature? Report this information to RESCOM and request instructions from HAZMAT officer. MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM 61 of 83

67 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM MEDICAL BRANCH DIRECTOR RADIO CALL SIGN: MEDICAL Responsible for ALL patient care activities to include triage, treatment, and transportation of all victims at the incident REQUIRED TASKS: Don the appropriate vest, report to and remain in the COMMAND POST Interface with the OPERATIONS SECTION CHIEF (when established) or COMMAND to obtain necessary manpower and logistical support Coordinate all on-scene EMS activity Request enough units to treat patients CONCURRENTLY, not consecutively. Order sufficient quantity of resources EARLY. It is better to have more than is needed and cancel enroute than to continue ordering in small increments If the incident involves CBRNE, has greater than 21 patients, or will require an extended operation, request the activation of the MAJOR INCIDENT MANAGEMENT TEAM Appoint the TRIAGE GROUP SUPERVISOR, if not already done so Identify a staging location for incoming EMS units Identify a secure route of travel for EMS units to access and depart the scene. This is a crucial element of the successful management of the scene. Request LAW ENFORCEMENT assistance in securing this route. Delegate to STAGING once established Establish contact with the DESIGNATED WAKE COUNTY HOSPITAL REPRESENTATIVE or assign a PATIENT DESTINATION COORDINATOR to complete. Provide them the following information: BRIEF description of the scene Approximate number of patients Rough estimate of total RED, YELLOW, and GREEN patients Approximate time first ambulance will depart the scene Request number of patients, by triaged category, each hospital is prepared to receive MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM MORE INFO ON REAR FIGURE 13 JOB AID MEDICAL BRANCH DIRECTOR 62 of 83

68 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM MEDICAL BRANCH DIRECTOR TASKS CONTINUED: Provide accountability for EMS personnel working on the Incident Scene Oversee the triage, treatment, and transportation of victims. Where appropriate assign the following ICS MPI positions: TREATMENT GROUP SUPERVISOR TRANSPORTATION GROUP SUPERVISOR MEDICAL STAGING AREA MANAGER PATIENT DESTINATION COORDINATOR ANY NECESSARY ASSISTANTS TO THE ABOVE POSITIONS If the TRANSPORTATION GROUP has not been implemented, assign patients to an ambulance and a destination. Record this on the PATIENT DISPOSITION LOG form Using the ON-SCENE ASSIGNMENT LOG form, maintain a record of who holds command positions, what resources are mobilized, and what talkgroups are in use If at any time the scene meets the criteria for escalating the level of the Multiple Patient Incident, take the following actions: Communicate the new response level (II thru V) to the Incident Commander and the Designated Wake County Hospital Representative Request the necessary MPI Task Forces Request dispatch of any additional resources required: Fire Department Chief Passenger Buses Major Medical Operations Support Vehicles EMS Officer to RESCOM Fire Department Mass Care Trailer CAPRAC SMAT-II Team Assign MPI positions to qualified personnel as they arrive Transfer the Patient Disposition Log to the Transportation Group Supervisor Ensure notification to the DESIGNATED WAKE COUNTY HOSPITAL REPRESENTATIVE when the last patient has left the scene Collect the various LOGS maintained by ICS MPI positions for the incident MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM 63 of 83

69 Job Aids TRIAGE GROUP SUPERVISOR RADIO CALL SIGN : MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM TRIAGE Responsible for supervising and conducting a systematic sorting and prioritization of all patients REQUIRED TASKS : Don the appropriate vest and acquire the necessary materials for TRIAGE Perform a rapid primary triage by sorting all ambulatory patients to a safe area Perform a rapid triage of all non -ambulatory patients using the START triage method for adults and JUMPSTART for pediatric patients Sort patients by category and report this number to the MEDICAL BRANCH DIRECTOR RED: Immediate Life Threat YELLOW: Delayed (1-3 hours before transport) GREEN: Ambulatory (or 3+ hours before transport) BLACK: Deceased (transport not required) If scene is spread over a wide area or triage at the incident site would endanger patients and emergency personnel, consider establishing a TRIAGE AREA where patients can be relocated If a complex incident, assign a TRIAGE TEAM LEADER to each category of patient as personnel become available If the incident involves multiple asymptomatic patients (such as a Hazmat exposure), consult with MEDICAL BRANCH DIRECTOR to set up secure evaluation area. DO NOT LET THESE PATIENTS LEAVE THE SCENE WITHOUT EVALUATION AND NECESSARY DECONTAMINATION Coordinate the distribution of triage supplies to responders Coordinate the movement of patients from Triage to arriving EMS units using the PATIENT DISPOSITION LOG form. This task will be assumed if a TRANSPORTATION GROUP SUPERVISOR is appointed. MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM MORE INFO ON REAR FIGURE 14 TRIAGE GROUP SUPERVISOR 64 of 83

70 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM TRIAGE GROUP SUPERVISOR TASKS CONTINUED: Request additional personnel from the MEDICAL BRANCH DIRECTOR, as necessary, to move patients Ensure that the scene has been checked for all victims that may have initially been unaccounted for. Use other responders on scene to assist. Search entrapped debris and overhead structures such as trees. Be thorough. If at any time the scene meets the criteria for escalating the level of the Multiple Patient Incident, notify the MEDICAL BRANCH DIRECTOR and the INCIDENT COMMANDER Account for the safety of all personnel working in the Triage Group Report "Triage Completed" to the MEDICAL BRANCH DIRECTOR when all patients have been triaged and moved to the Treatment Area (or transported from the scene) Complete the MPI SCENE LOG to document all patients seen by the Triage Group and submit to the MEDICAL BRANCH DIRECTOR post "Triage Completed" MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM 65 of 83

71 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM TREATMENT GROUP SUPERVISOR RADIO CALL SIGN: TREATMENT Responsible for overseeing all patient care interventions that are conducted on the scene in order to stabilize life-threatening and serious injuries prior to patient transportation REQUIRED TASKS: Don the appropriate vest and acquire the necessary materials for TREATMENT Establish a Centralized Treatment Area (THINK BIG): Consider impact from weather, safety, hazardous materials, etc. Determine need for secondary Treatment Area Divide the Treatment Area into 4 DISTINCT AND WELL MARKED AREAS Designate a clearly marked entrance and exit point for the Treatment Area Consider the need for Multiple Treatment Areas, particularly on large scenes or scenes where victims are congregating in multiple areas - including an Off-Site Casualty Collection Point for Green Tag patients If the incident warrants, designate TREATMENT UNIT LEADER for each patient classification Make an initial request for equipment, supplies, and personnel needed for the Treatment Area to the MEDICAL BRANCH DIRECTOR. Until the arrival of the Major Medical Operations Support Vehicle, use resources from EMS units not employed in patient transport Maintain contact with the TRIAGE GROUP SUPERVISOR for updated estimates of total patients being triaged Direct personnel to perform a Secondary Triage and to provide ONLY LIFE SAVING interventions. Do not focus too heavily on one patient in order to provide adequate observation of all patients Advise the TRANSPORATION GROUP SUPERVISOR of the number of victims requiring immediate transporation MORE INFO ON REAR MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM FIGURE 15 JOB AID TREATMENT GROUP SUPERVISOR 66 of 83

72 MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM TREATMENT GROUP SUPERVISOR TASKS CONTINUED: Coordinate with the TRANSPORATION GROUP SUPERVISOR the movement of victims to the Transporation Loading Zone Job Aids Identify a location where the Deceased may be stored away from the Treatment Area. Request Law Enforcement to secure this area Utilize the TREATMENT AREA PATIENT LOG form to document patient information Use the AREA MANAGER LOG form to track Treatment Team Leader assignments and patient census information Submit all completed Log forms to the MEDICAL BRANCH DIRECTOR upon termination of the Treatment Group MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM 67 of 83

73 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM TRANSPORTATION GROUP SUPERVISOR RADIO CALL SIGN: TRANSPORTATION Responsible for the flow of all patients from the incident scene to hospital facilities - no patient leaves the scene until directed to do so REQUIRED TASKS: Don the appropriate vest and acquire the necessary materials for TRANSPORTATION Establish a Patient Loading Zone in coordination with the TREATMENT GROUP SUPERVISOR considering: It is large enough to accommodate multiple ambulances? Provide easy in and out without bottlenecks or 3-point turns located near the Treatment Area Identify a location to place the alternate high capacity transportation resources (buses, vans, etc.) and ensure Green Tag patients are directed there Communicate the location of the Patient Loading Zone to the MEDICAL STAGING AREA MANAGER If necessary, designate a PATIENT DESTINATION COORDINATOR Contact the DESIGNATED WAKE COUNTY HOSPITAL REPRESENTATIVE to determine the total number of patients by category that each hospital can receive. Request continual updates as the incident evolves. Delegate to PATIENT DESTINATION COORDINATOR, if designated Designate a LANDING ZONE COORDINATOR if the use of aeromedical resources is indicated and approved by the MEDICAL BRANCH DIRECTOR Coordinate order of patient departure with the TREATMENT GROUP SUPERVISOR documenting same on the PATIENT DISPOSITION LOG form MORE INFO ON REAR MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM FIGURE 16 JOB AID TRANSPORTATION GROUP SUPERVISOR 68 of 83

74 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM TRANSPORTATION GROUP SUPERVISOR TASKS CONTINUED: Assign patients to ambulances and destinations to the crews. Ensure that the receiving facilities are notified when an ambulance departs the scene. Request additional transport units from the MEDICAL STAGING AREA MANAGER as needed The receiving hospitals should be advised of the following: EMS Unit (or other transport vehicle) ID that is enroute Number of patients on-board Priority of the patients on-board Special needs of the patients (i.e. burn, OB, pediatric) When the unit departed the scene This will be delegated to the PATIENT TRANSPORTATION COORDINATOR if assigned Notify the DESIGNATED WAKE COUNTY HOSPITAL REPRESENTATIVE and MEDICAL BRANCH DIRECTOR when the last patient has been transported from the scene Submit all completed Log forms to the MEDICAL BRANCH DIRECTOR upon termination of the Transportation Group MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM 69 of 83

75 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM MEDICAL STAGING AREA MANAGER RADIO CALL SIGN: STAGING Responsible for coordinating the arrival and departure of and maintain accountability for all medical units REQUIRED TASKS: Don the appropriate vest Interface thru the chain of command with the OPERATIONS SECTION CHIEF (when established) or COMMAND to establish the Staging Area Use preselected area or improvise when convenient Think BIG Consider safety and hazardous conditions Proximal to incident site that is easy to locate, access, and capable of handling a large number of ambulances and other vehicles Inform the TRANSPORTATION GROUP SUPERVISOR of the Staging Area location Maintain a visible presence in the Staging Area Ensure that ALL medical resources check in with you Ensure that ALL medical resources are on the appropriate operational TalkGroup Track the arrival of medical units and segregate ALS transport units from BLS transport units. Use the RESOURCE LOG form to document all arrivals and departures of personnel and units Provide crews in staging simple routing instructions to access the Transportation Loading Zone Update the TRANSPORTATION GROUP SUPERVISOR periodically with the number of units remaining in the Staging Area MORE INFO ON REAR MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM FIGURE 17 JOB AID MEDICAL STAGING AREA MANAGER 70 of 83

76 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM MEDICAL STAGING AREA MANAGER TASKS CONTINUED: Send ambulances and/or personnel from the Staging Area when advised by the TRANSPORTATION GROUP SUPERVISOR Track the departure of medical units ensuring they are familiar with the route to their destination hospital. Remind them to maintain RADIO SILENCE during transports unless there is a significant change in patient status. Ensure that any personnel leaving the Staging Area without their vehicles have left the door/ignition keys with the vehicle Submit all completed Log forms to the MEDICAL BRANCH DIRECTOR upon termination of the Staging Area MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM 71 of 83

77 MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM PATIENT DESTINATION COORDINATOR RADIO CALL SIGN: OUTBOUND Responsible for assigning patients to transport and transport to hospitals Job Aids REQUIRED TASKS: Don the appropriate vest and acquire the necessary materials for OUTBOUND Establish a Patient Loading Zone in coordination with the TREATMENT GROUP SUPERVISOR considering: It is large enough to accommodate multiple ambulances? Provide easy in and out without bottlenecks or 3-point turns Located near the Treatment Area Identify a location to place the alternate high capacity transportation resources (buses, vans, etc.) and ensure Green Tag patients are directed there Communicate the location of the Patient Loading Zone to the MEDICAL STAGING AREA MANAGER Contact the DESIGNATED WAKE COUNTY HOSPITAL REPRESENTATIVE to determine the total number of patients by category that each hospital can receive. Request continual updates as the incident evolves. Designate a LANDING ZONE COORDINATOR if the use of aeromedical resources is indicated and approved by the MEDICAL BRANCH DIRECTOR Coordinate order of patient departure with the TREATMENT GROUP SUPERVISOR documenting same on the PATIENT DISPOSITION LOG form MORE INFO ON REAR MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM FIGURE 18 JOB AID PATIENT DESTINATION COORDINATOR 72 of 83

78 Job Aids MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM PATIENT DESTINATION COORDINATOR TASKS CONTINUED: Assign patients to ambulances and destinations to the crews. Ensure that the receiving facilities are notified when an ambulance departs the scene. Request additional transport units from the MEDICAL STAGING AREA MANAGER as needed The receiving hospitals should be advised of the following: EMS Unit (or other transport vehicle) ID that is enroute Number of patients on-board Priority of the patients on-board Special needs of the patients (i.e. burn, OB, pediatric) When the unit departed the scene Notify the DESIGNATED WAKE COUNTY HOSPITAL REPRESENTATIVE and MEDICAL BRANCH DIRECTOR when the last patient has been transported from the scene Submit all completed Log forms to the MEDICAL BRANCH DIRECTOR upon termination of the Transportation Group MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM 73 of 83

79 RADIO CALL SIGN: MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM SAFETY Observe and identify hazards that could endanger the safety of patients and emergency personnel REQUIRED TASKS: ASSISTANT SAFETY OFFICER Don the appropriate vest Job Aids Interface with the MEDICAL BRANCH SUPERVISOR (when established) or COMMAND to establish scope of operation for which you will be responsible Perform a scene assessment to determine what, if any, threats to safety are present Determine the necessary work/rest interval and report this to the Medical Branch Director Oversee responders, ensuring they report to rehabilitation at the necessary intervals Document the working time and conditions of personnel who are directly participating in the extrication, decontamination, or treatment of patients Document the conditions under which any EMS worker is injured for after-action evaluation STOP ALL OPERATIONS AT ANY TIME A DANGEROUS SITUATION IS RECOGNIZED MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM FIGURE 19 JOB AID - ASSISTANT SAFETY OFFICER 74 of 83

80 REHABILITATION UNIT LEADER RADIO CALL SIGN: MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM REHAB Provide an environment in which responders may recover from work activities and oversee their fitness to return to duty REQUIRED TASKS: Don the appropriate vest Job Aids Interface with the ASSISTANT SAFETY OFFICER (when established) or the MEDICAL BRANCH DIRECTOR to secure from Logistics the supplies and equipment required to establish the Rehabilitation Area and determine its location. Obtain supplies including water and food. If outside, provide necessary adjuncts based upon presented weather conditions (heaters, blankets, air conditioning, etc.) For each responder seen in the Rehabilitation Area, document their Time In, Time Out, and Physical Status Oversee the medical evaluation of personnel and prevent unfit individuals from returning to work Submit all completed Log forms to the MEDICAL BRANCH DIRECTOR upon termination of the Rehabilitation Unit MULTIPLE PATIENT INCIDENT JOB AID - WAKE COUNTY EMS SYSTEM FIGURE 20 JOB AID REHABILITATION UNIT LEADER 75 of 83

81 Log Forms 15.0 ROLE SPECIFIC LOG FORMS The following pages provide examples of the various Logs and Forms required to document activities within the Incident Command System during a Multiple Patient Incident. Medical Branch Director On Scene Assignment Log Incident Management Log Triage Group Supervisor Multiple Patient Incident Scene Log Treatment Group Supervisor Patient Log Area Manager Log Transportation Group Supervisor Patient Disposition Log Medical Staging Area Manager Resource Log Form 76 of 83

82 Log Forms MEDICAL BRANCH DIRECTOR ON-SCENE ASSIGNMENT LOG Assign Roles Done? Medical Resources: Requested? HAZMAT? Triage Supervisor Treatment Supervisor Transportation Supv. Destination Coord. Medical Staging Landing Zone Ambulances (specify #) Police (secure area) Busses Vans Medical Examiner Red Cross Specialty teams / equip. Mass Decon Safety Rescue Assignment Record: Command Triage Treatment Transportation Destination Coordinator FIGURE 21 MEDICAL BRANCH DIRECTOR ON-SCENE ASSIGNMENT LOG 77 of 83

83 MEDICAL BRANCH DIRECTOR INCIDENT MANAGEMENT LOG Log Forms 1. Contact RESCOM and Obtain MPI Operations Channel: Responding Units Declare MPI: Unit Assignment Incident Type: Incident Location: # Patients: # Ambulances Needed: Command Post Location: Staging Location: Suggested Routes: Hazards: Danger Zone: 2. Assign Group Supervisors Group Unit Name Triage Safety Transport Staging TREATMENT 3. Coordinate all EMS Activity with Incident Command EMS Activity Unit OPS Ch. Resource Requests (Ambulances, Personnel, Buses, Medical, Supplies, Medical Examiner, Red Cross, etc.) Landing Zone Extrication Rescue Teams HAZMAT Team Incident Commander FIGURE 22 MEDICAL BRANCH DIRECTOR INCIDENT MANAGEMENT LOG 78 of 83

84 TRIAGE GROUP SUPERVISOR MULTIPLE PATIENT INCIDENT SCENE LOG Log Forms FIGURE 23 TRIAGE GROUP SUPERVISOR MULTIPLE PATIENT INCIDENT SCENE LOG 79 of 83