CHATHAM COUNTY EMERGENCY OPERATIONS PLAN

Transcription

1 CHATHAM COUNTY EMERGENCY OPERATIONS PLAN INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN SEPTEMBER 2014

2 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN THIS PAGE INTENTIONALLY BLANK SEPTEMBER 2014

3 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN New Document September 2014 RECORD OF CHANGES i SEPTEMBER 2014

4 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN THIS PAGE INTENTIONALLY BLANK ii SEPTEMBER 2014

5 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN ACRONYMS CEMA DRP EOC EMS EOP ESF HAZMAT IC ICS MCI MFI NIMS PIO Chatham Emergency Management Agency Disaster Readiness Plan Emergency Operations Center Emergency Medical Service(s) Emergency Operations Plan Emergency Support Function Hazardous Materials Incident Commander Incident Command System Mass Casualty Incident Mass Fatality Incident National Incident Management System Public Information Officer iii SEPTEMBER 2014

6 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN DEFINITIONS Assessment: The evaluation and interpretation of measurements and other information to provide a basis for decision-making. Assignments: Tasks given to resources to perform within a given operational period based on operational objectives defined in the Incident Action Plan. Branch Director: The organizational level having functional or geographical responsibility for major aspects of incident operations. Command: The act of directing, ordering, or controlling by virtue of explicit statutory, regulatory or delegated authority. Command Staff: In an incident management organization, the Command Staff consists of the Incident Command and the special staff positions of Public Information Officer, Safety Officer, Liaison Officer, and other positions as required, who report directly to the Incident Commander. They may have an assistant or assistants, as needed. Engine Company: A fire apparatus consisting of a minimum of three firefighters, one of which is assumed to the qualified as a company level officer. Additional manpower is encouraged. In a mass casualty incident event, the engine company can expect to be used both as manpower and to perform patient care to their level of training. Incident Command Post: The field location at which the primary tactical-level, onscene incident command functions are performed. Incident Command Post may be collocated with the incident base or other incident facilities and is normally identified by a green rotating or flashing light. iv SEPTEMBER 2014

7 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN TABLE OF CONTENTS Record of Changes... i Acronyms and Definitions... iii Table of Contents... v I. Introduction... 1 II. Purpose... 1 III. Scope... 1 IV. Authorities... 2 V. Situation and Assumptions... 3 VI. Implementation... 4 VII. Concept of Operations... 5 A. Goals and Objectives... 5 B. MCI Levels MCI Level MCI Level MCI Level MCI Level C. Communications Pre-hospital Hospital... 7 D. On-Scene and Pre-Hospital Job Descriptions First Arriving Unit Incident Command Medical Branch Director Safety Officer Public Information Officer Transportation Unit Leader Staging Area Manager Triage Unit Leader Treatment Unit Leader Treatment Area Manager Medical Supply Coordinator Transport Recorder Transportation Loader Medical Communication Coordinator Morgue Coordinator Transportation Flow Coordinator... 9 E. Critical Task... 9 F. Triage Methods v SEPTEMBER 2014

8 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN G. Treatment Area H. Tracking, Tagging, and Identification I. Transportation Area J. Logistics and Resources K. Training and Exercise VIII. Responsibilities A. CEMA B. Fire/EMS Services C. Police Services D. Memorial Hospital E. Candler / St. Joseph s Hospitals F. Coroner G. American Red Cross H. Salvation Army I. Chatham Area Transit J. Savannah Chatham County Public School System K. Savannah Chatham Metro Police Dept. Animal Control IX. Annex Management and Maintenance L. Executive Agent M. Types of Changes N. Coordination and Approval O. Notice of Change P. Distribution APPENDICIES Appendix 1 Scene Set-Up Appendix 2 Job Aids Appendix 3 On-Scene Forms Appendix 4 Critical Incident Stress Debriefing Appendix 5 Directions to Hospital Appendix 6 Incident Response Pocket Guide CHARTS Chart H.1 Critical Tasks... 9 Chart H.2 JumpSTART Pediatric MCI Triage Chart H.3 START Adult Triage Chart H.4 CISD Four Group Tools vi SEPTEMBER 2014

9 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN I. INTRODUCTION A. Mass casualty incidents are incidents resulting from man-made or natural causes resulting in injuries or illnesses that exceed or overwhelm the Emergency Medical Service (EMS) and hospital capabilities of a municipality, jurisdiction, or region. A mass casualty incident is likely to impose a sustained demand for health and medical services. B. The EMS responding agency will coordinate mass casualty incident response to minimize loss of life and human suffering. C. A major hurricane, thunderstorm, hazardous materials release, military and civil mass transit incidents, or acts of terrorism are examples of emergencies where a mass casualty incident might occur. II. PURPOSE A. The ultimate purpose in a This Mass Casualty Incident (MCI) response is treat, transport and track patients in a timely, safe, and respectful manner while reasonably accommodating religious, cultural and societal expectations. B. MCI Management Plan is intended to address techniques in field operations and must be employed when the number of patients exceeds immediately available resources. C. In addition, it serves as the basis for routine operations. The key elements for successfully managing any incident are command, control and coordination. D. This plan standardizes operations during mass casualty incidents. It is intended to be an all hazards plan to meet the needs of any MCI regardless of the incident s cause. If necessary, these procedures can be modified based on the number of patients, the cause or severity of injuries and special circumstances involved in the incident. III. SCOPE A. In an effort to make this document compliant with the National Incident Management System (NIMS), MCI Levels have been integrated to allow for scalability. B. MCI will use a Unified Command Structure, bringing together Incident Commanders (IC) of all major organizations involved in the incident in 1 SEPTEMBER 2014

10 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN order to coordinate and effective while at the same time carrying out their own jurisdictional responsibilities. IV. AUTHORITIES A. The Chatham County Coroner has the legal authority to determine the cause and manner of death, and in coordination with Public Health s Vital Records department will manage death certification for fatalities. The Coroner and Law Enforcement (LE) share legal authority in victim identification. It is the duty of the coroner to inquire into and determine the circumstances of death for suspicious or unusual deaths. (O.C.G.A ) Suspicious or unusual deaths are when any person dies in any county in this state: 1. As a result of violence; 2. By suicide or casualty; 3. Suddenly with in apparent good health; 4. When unattended by a physician; or 5. In any suspicious or unusual manner. B. This Mass Casualty Annex derives its authority from legal responsibility as detailed in the Death Investigation Act of Georgia. C. This Annex is consistent with 1. The U.S. Department of Homeland Security s National Response Framework, which states the primary management of an incident should occur at the lowest possible geographic, organizational, and jurisdictional level. 2. Official Code of Georgia Death Investigation Act, Title The Georgia Emergency Operations Plan 4. The Chatham County Local Emergency Operations Plan 5. The National Incident Management System 6. The Emergency Management Assistance Compact 7. Homeland Security Presidential Directive 5 8. O.C.G.A SEPTEMBER 2014

11 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN D. Confidentiality of Medical/Dental Records. Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law ) covers the requirement to maintain confidentiality of missing person/victim records in MF response. Medical and dental providers of suspected victims are relieved of confidentiality restraints by the HIPAA Exemption for Coroners (CFR ). E. The Code of Chatham County, 21 December 2012, Chapter 4, Administration, Article III, Emergency Management. F. Georgia Emergency Management Act of 1981 as Amended (OCGA 38-3) G. Emergency Operations Plan (EOP), 29 March 2012 H. Disaster Readiness Plan (DRP), 20 September 2013 V. SITUATIONS AND ASSUMPTIONS A. An MCI will be challenging and require support and leadership from each level of government. B. Emergency service personnel are responsible for managing MCIs; however, there are many other agencies/organizations involved in a mass casualty response. C. This MCI Annex will be activated in concert with a Mass Fatality Incident (MFI) Plan to ensure care for survivors, and normally be activated in concert with jurisdictional and Public Health Emergency Operation Centers (EOCs). Coordination of EMS or other healthcare assets will be handled by the local EOC Emergency Support Function (ESF)-08 section with support from County and State support. D. A diverse pool of public and private resources at regional, state and federal levels may be necessary to effectively manage and/or support MCI decedent operations. E. NIMS and the Incident Command System (ICS) will be used in each MCI response. F. Unless caused by a natural disaster, i.e., tornado, the incident site will be treated like a crime scene until authorities having jurisdiction over the incident have determined otherwise. G. Incident site operations will be performed according to professional protocols to ensure accurate identification of human remains and, 3 SEPTEMBER 2014

12 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN depending on the nature of the event (e.g., commercial airline accident and criminal or terrorist act), to preserve the scene and collect evidence. H. Contaminated victims may require decontamination on scene prior to transportation. Local assistance or mutual aid from the fire department, hazardous materials (Hazmat) unit, Disaster Mortuary Operational Response Team (DMORT), military, or other non-coroner discipline may be needed. I. Family members, the general public, government officials, and the media have high expectations concerning the identification of victims and morgue services. J. Support is essential to managing the short- and long-term emotional impact of responders. K. If the incident is suspected to be an infectious disease outbreak, the Georgia Department of Public Health and its public health partners will coordinate with and provide guidance on the communicable disease investigation. VI. IMPLEMENTATION A. As the governing body of Chatham County, the Chatham County Board of Commissioners is vested with the power to protect the lives, health, welfare and property of citizens in the event of an emergency situation requiring the safeguard of the public interest, pursuant to Georgia Constitution Article. 9, 2, 3, GA. Constitution Article. 9, 2, 1 and the laws of the State of Georgia. B. The Chatham County Board of Commissioners has adopted the Chatham County Emergency Management Ordinance for the protection of the public during emergencies and shall only be implemented upon a declaration of emergency and the signing of a declaration stating they are in effect. 1. These Ordinances may be executed when in the judgment of the Chairman of the Chatham County Board of Commissioners, with appropriate advice from CEMA and other agencies, emergency conditions exist which require the declaration to be issued. 4 SEPTEMBER 2014

13 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN 2. An emergency is defined as an extraordinary condition exists in which the threat or actual occurrence of a disaster or event, including an energy emergency, as defined in the Georgia Emergency Management Act and any amendments thereto, which may result in the large scale loss of life, injury, property damage or destruction, or in the major disruption of routine community affairs or business and government operations, and is of sufficient severity and magnitude to warrant extraordinary assistance by CEMA and other Chatham County departments and other agencies to supplement the efforts of available public and private resources. VII. CONCEPT OF OPERATIONS A. Goals and Objectives There are three primary goals of MCI Management 1. Do the greatest good for the greatest number. The primary concern is to serve as many lives as possible with the resources available, while protecting the first responders and bystanders. 2. Manage Limited Resources. In a resource limited environment heroic resuscitative efforts are not appropriate. In normal day-today circumstances four or more providers may work on a single patient. During a MCI the provider to patient ratio is reversed. Scarce resources management recognizes not enough providers, equipment, vehicles, or time to provide the normal level of prehospital care. Providers must focus their efforts on salvaging as many patients as possible while waiting for the arrival of additional resources. 3. Do Not Relocate the Incident. Do not relocate the incident by transporting all of the patients to one hospital. Providers must use triage to determine patient prioritization for treatment and transport. The first arriving EMS units may never transport a single patient; it is better to establish command and conduct scene size-up, then conduct triage, establish the treatment area and wait for more units to arrive and provide patient transportation. Many victims are likely to leave the scene and seek shelter and/or treatment at the closest emergency department or hospital. This is likely to occur before first responders are able to complete the triage process and establish control of the scene. The unexpected patient influx may overwhelm the closest emergency department. This is of particular concern when an incident occurs in close proximity to an emergency department or hospital. It is essential that communications be established with the Regional coordinating hospital/trauma center s 5 SEPTEMBER 2014

14 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN Emergency Department closest to the incident scene as quickly as possible. The participating emergency department will send an Emergency Room doctor and Hospital Representative. First Responders need to verify the bed availability at that emergency department prior to the initial transport of patients. Effective scene to hospital communications, combined with triage will ensure that patients will be distributed to the appropriate receiving hospital, in the correct order and quantity. B. MCI Levels - MCI response will initially be determined by the number of patients. The first arriving Medical unit will, as part of the initial size up, estimate what EMS resources will be needed based on the categories below. Additional supervisory resources may be needed to establish the Incident Management System and should be called for as per local procedures. The decision to declare an MCI Level is left to the IC 1. MCI Level 1 (3-10 Immediate/Red victims) Note: Larger agencies may be capable of handling incidents less than 10 patients without necessitating implementation of the MCI Plan.. a. 5 Ambulances b. 2 Engine Companies or a minimum of six first responders c. 1 EMS Supervisor / Paramedic / Operational Chief 2. MCI Level 2 (11-20 Immediate/Red victims) a. 10 ambulances b. 5 Engine Companies or fifteen first responder personnel c. 2 EMS Supervisors / Paramedics / Operational Chiefs d. 1 MCI Trailer 3. MCI Level 3 ( Immediate/Red victims) a. 15 Ambulances b. 10 Engine Companies or thirty first responder personnel c. 3 EMS Supervisors / Paramedics / Operational Chiefs d. 1-2 MCI Trailers 6 SEPTEMBER 2014

15 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN 4. MCI Level 4 ( Immediate/Red victims) a. 20 Ambulances b. 10 Engine Companies or thirty first responder personnel c. 5 EMS Supervisors / Paramedics / Operational Chiefs d. 2 MCI Trailers e. 2 Busses f. 1 Command / Communications Trailer / Vehicle C. Communications: Establish communications with the Regional coordinating hospital/trauma center s Emergency Department. The initial Coordinating Emergency Department cannot unilaterally hand off that role to another facility unless EMS on scene confirms that they have a good communication between the scene and the secondary Coordinating Emergency Department. 1. Pre-Hospital a. In the event of a multiple casualty incident in the region where more than one EMS agency is responding, Plain English will be used. b. Units will identify themselves using the Agency s name as a prefix, i.e. Southside M-12 or Effingham Unit 3. c. In a large scale incident, vehicles may be called from outside the normal response area. Southeast Georgia Area Regional Radio Network or National Interoperability Field Operations Guide channels, 800 MHz, will be designated, if needed. 2. Hospital a. Once an incident has been activated, and a disaster declared, the appropriate disaster code will be initiated in accordance with hospital protocol. b. Should the telephones not be operable, in part or in full, the Emergency Management Plan for communication failure shall be initiated under the direction of the command center. c. Hospitals should track patient flow and availability via GHA SEPTEMBER 2014

16 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN D. On-Scene/Pre-Hospital Organization Jobs will be filled on an as needed basis. The jobs needed will be incident specific. See Appendix 2 for detailed Job Aids 1. First Arriving Unit First unit on scene gives visual size-up, assumes and announces command, and confirms incident location. Performs a Safety Assessment, sizes up the scene, Sends Information, Sets up the scene for management of the casualties and begins triaging patients. 2. IC Responsible for the overall management and coordination of personnel and resources responding to the incident. 3. Medical Branch Director To ensure supervision and coordination is provided for extrication triage, treatment, and transportation of every patient. 4. Safety Officer To monitor and assess hazardous and unsafe situations and develop measures for ensuring personnel safety. 5. Public Information Officer (PIO) Disseminate factual and timely reports to the news media concerning the nature and extent of the incident, emergency medical care, and treatment of victims. 6. Transportation Unit Leader Track and distribute patients to medical facilities by assigning the mode of transportation and destination for each patient. 7. Staging Area Manager Maintain separate stockpiles of manpower, reserve equipment and expended equipment at a staging area away from the incident. 8. Triage Unit Leader Assess and sort casualties to appropriately establish priorities for treatment and transportation. 9. Treatment Unit Leader Provide patient counts, triage, and treatment to patients awaiting transportation. 10. Treatment Area Manager Provide patient counts, triage and treatment to patients awaiting transportation. 11. Medical Supply Coordinator Acquire, distribute and maintain the status of medical equipment and supplies. 12. Transport Recorder Assist in ensuring proper documentation of victim/patient and unit movements. 8 SEPTEMBER 2014

17 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN 13. Transportation Loader Ensure patients are safely loaded into the assigned ground ambulance, air ambulance, or other vehicle, and verify vehicle destination and travel directions. 14. Medical Communication Coordinator Maintain and Coordinate medical communications at the incident scene between Transport Group Supervisor/Unit Leader and the designated Coordinating Emergency Department. 15. Morgue Coordinator Establish and maintain a temporary morgue area for deceased persons who die enroute to or in the Treatment Area. 16. Transportation Flow Coordinator Establish flow and traffic patterns E. Critical Tasks The primary concern is to save as many lives as possible with the resources available, while at the same time protecting the first r e s p o n d e r s a n d b y s t a n ders. To accomplish this, the first responding unit should use the following chart Chart H.1: Critical Tasks 9 SEPTEMBER 2014

18 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN a. First Arriving Unit Action: The first arriving unit on the scene of an MCI must restrain themselves from rushing into the scene. If the incident involved hazardous materials all units should remain uphill and upwind of the incident. The successful initial management of an MCI is based upon the first arriving unit establishing incident command and to properly assess hazards and report key information to their dispatch center. b. Establish Command: The senior crewmember of the first arriving unit or senior officer must establish incident command and report that they established command to their dispatcher. This individual will remain in command until properly relieved. It is the responsibility of the Incident Commander to perform the initial scene size-up and report their findings to the dispatcher. c. Scene Safety Assessment: Begin by assessing the scene for safety and looking for existing hazards, (e.g. electrical hazards, flammable liquids, hazardous materials, other life threatening situations and the potential for secondary explosive devices or other security threats.) The first arriving unit should also make an effort to control the scene by designating a danger zone and a safe zone if the incident involves hazardous materials. Consult the Emergency Response Guide for initial isolation distances. Consider the weather, topography and wind when establishing the danger and safe zones. HAZMAT / Weapons of Mass Destruction (WMD) Requires the use of local / regional HAZMAT Team. d. Scene Size-Up: The Incident Commander must then size-up the scene. Assess the incident location, size and complexity. Confirm the physical location of the incident and determine the size of the area affected. Determine the complexity of the incident. Survey the incident scene for the potential type of and/or cause of the incident. Estimate the number of injured, dead and uninjured. Estimate the severity level of the injuries and determine the level of the MCI. Evaluate the scene for access and egress issues and determine safe routes. e. Send Information: This initial report from the incident scene to the dispatcher is essential to the proper management of the incident. The initial report and scene size-up is also critical to the safety of first responders, victims, and the 10 SEPTEMBER 2014

19 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN F. Triage Methods: community alike. Contact dispatch with your scene size-up information. Request additional resources and notify the closest emergency department/hospital f. Set-Up the Scene for Casualty Care. See Appendix 1 for detailed guidance for Scene Set-Up. g. Hospital Notification: The Hospital that is geographically closes to the scene must be notified immediately that a MCI has been declared and provided with the initial report. It is vital the First Arriving Unit tell the dispatcher to contact the CLOSEST emergency department as well as the regional coordinating hospital, or contact the CLOSEST emergency department as well as the regional coordinating hospital directly, and inform the facility that a MCI is in progress. General information to include in notification is as follows: 1) The nature or apparent cause of the event. 2) Estimated number of injured. 3) Whether or not the victims may be contaminated. 4) When they can expect to receive first patients. 5) If there is a potential security threat to the emergency department or hospital. 1. Simple Triage and Rapid Treatment (START) a. The method of initial field triage to be utilized is the START method for adult patients. There are some incidents where START Triage may not be the most appropriate tool to sort patients. Pediatric patients, ages 8 and under, will be better served by using JumpSTART. b. Patients who have been exposed to various HAZMAT or WMD may need to be triaged using guidelines are specific to the agent to which they have been exposed. Patients who have been exposed, or who believe they have been exposed to chemical, biological or radiological weapons have much different triage needs than trauma patients. START Triage is currently the preferred tool for sorting trauma patients. 11 SEPTEMBER 2014

20 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN 1) The following Flow Charts are examples of START Triage for Children and Adults. Chart H.2 : JumpSTART Pediatric MCI Triage 12 SEPTEMBER 2014

21 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN Chart H.3: START Adult Triage 13 SEPTEMBER 2014

22 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN 2. Model Uniform Core Criteria (MUCC): Currently, compliance with MUCC is not mandatory. G. Treatment Area: a. There is a need for MUCC for mass casualty triage, because disasters frequently cross jurisdictional lines and involve responders from multiple agencies who may be using different triage tools. MUCC criteria reflect the current available science, but acknowledges there are significant research gaps. When no science was available, decisions were formed by expert consensus derived from current available triage systems. The intent is to ensure providers at a mass casualty incident utilize triage methodologies and incorporate these core principles in an effort to promote interoperability and standardization. Mass casualty triage systems currently in use can be modified using these criteria to ensure interoperability. b. The criteria include: 1) General considerations 2) Global sorting 3) Lifesaving interventions 4) Assignment of triage categories c. The criteria only apply to providers who are organizing multiple victims in a discrete geographic location(s) regardless of the size of the incident. They are classified by whether they were derived through available direct scientific evidence, indirect scientific evidence, expert consensus, and/or are used in multiple existing triage systems. 1. Patient Flow Refer to Appendix 1 for Scene Set-Up to see a visual of how patient flow will work. a. Incident / Danger / Hot Area Primary Triage b. Decontamination (If needed). c. Secondary Triage d. Treatment 14 SEPTEMBER 2014

23 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN e. Transportation 1) Ambulance Loading Area 2) Air Evacuation Area f. Destination Hospital 2. Patients are moved into the Treatment Area to receive emergency medical care on the basis of the triage priority. The Treatment Area is usually divided into separate areas for the care of Red Tagged/Immediate, Yellow Tagged/Delayed and Green Tagged/Minimal patients. Personnel, equipment and supplies are also allocated to patients based on their triage priority. 3. Designate a separate, secure and isolated area for the Incident Morgue. The Incident Morgue is for the placement of victims who die in the Treatment Area. An EMS provider must be assigned to this area to confirm death and track patients transported to and from this area. This area should be secured by Law Enforcement Officers, not EMS providers. 4. Enough space should be provided on all four sides of the each patient to allow providers space to treat, kneel and move safely between patients. There should be three feet of open space on all four sides of each patient. Be aware that the treatment area required will easily exceed the size of the tarps. Responders must expand and/or relocate the treatment area during an incident to accommodate increasing space requirements. 5. Secondary Triage Decisions: Most secondary triage decisions in a MCI are based on clinical experience and judgment. Review the following. a. IMMEDIATE (RED TAGGED) 1) Life threatening injuries/illnesses. 2) Risk of asphyxiation or shock is present or imminent. 3) High probability of survival if treated and transported immediately. 4) Can be stabilized without requiring constant care or elaborate treatment. 15 SEPTEMBER 2014

24 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN b. DELAYED (YELLOW TAGGED) 1) Potentially life threatening injuries/illnesses. 2) Severely debilitating injuries/illnesses. 3) Can withstand a slight delay in treatment and transportation. c. MINOR (GREEN TAGGED) 1) Non-life threatening injuries. 2) Patients who require a minimum of care with minimal risk of deterioration. d. DECEASED (BLACK TAGGED) 1) Die in route to or in the treatment area. 2) Unresponsive with no circulation; cardiac arrest. H. Tracking, Tagging and Identification 1. Accounting for all victims of an MCI is equally as important as accounting for first responders. Victim and patient accountability begins with the initial triage process when the EMS personnel conducting triage report their triage information to the Triage Officer. After all of the reports have been received the Triage Officer will have an initial count of the number of injured, ill and deceased victims. This information is then used to determine what additional resources may be required to successfully manage the incident. 2. This same information is then used to confirm that all living victims have been moved from the incident site to the Treatment Area to receive emergency medical care. 3. A TRIAGE TAG with a Bar Code will be attached to each patient as they enter the treatment area. The unique patient identification number located on each tag will be used to identify and track each patient through the treatment and transportation process, to their arrival at the receiving medical facility. The tag will remain on the patient at all times, however the tags are perforated and a small portion will removed by transportation for tracking. The bar code tracking system needs to be verified, coordinated and available to 16 SEPTEMBER 2014

25 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN all resources, and how to procure those resources during a MCI event. 4. After all living patients have been transported from the scene, the Transportation Unit Leader should contact the Coordinating Emergency Department and complete a final accounting for each patient transported from the scene. The purpose for this is to make certain that every ambulance, transportation vehicle, and patient arrived safely at an emergency department/hospital and no patient remains at the incident scene. I. Transportation Area: 1. Establish the Transportation Area in a location between the Treatment Area and the patient pick-up point. The pick-up point is where the ambulances, or other designated transportation resources, will drive up to and park, while waiting for the patients to be loaded into the ambulances or other vehicles. 2. Ideally all vehicles should follow a one-way traffic pattern into the Transportation Area. Every effort should be made to avoid having ambulances and other vehicles backing up to reduce the risk of having personnel, patients or equipment run over during the patient loading process. 3. Transportation Flow a. Staging Area 1) Non-transport assignment a) Triage b) Treatment c) Assistant 2) Transport b. Patient Loading Area c. Destination Hospital J. Logistics and Resources 1. Chatham County Emergency Management in coordination with local emergency support functions, Georgia Emergency 17 SEPTEMBER 2014

26 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN Management, and private partnerships will identify resources that are needed to respond to, recover from, and mitigate incidents that are both man-made and natural in occurrence. List of potential resources for available use or need will be complied based on past incidents, past full scale exercises, and current best practices risk analysis. 2. Replace with identify resources, shortages and needs based on hazard impact, response, and recovery needs are identified and a source for such items will be identified. Additionally, the request for such resource(s) will follow the ESF and EOP Structure. It will than fall upon the logistics section in the EOC, if activated, for the incident to identify a resource source for procurement. 3. Private agencies play a critical role in providing resource need in support of an emergency incident. These relationships between the public and private sector are established before an incident occurs or a resource is needed. As a resource need is identified during the mitigation phase of planning and such resources are not obtainable through public means, private sources are than identified that are able to provide such resources. MOU s and contracts that identify the availability and cost of resources during critical times are than procured. K. Training and Exercise: supporting partners and agencies should cross train personnel as needed to support the plan. Education of the plan will be conducted and coordinated with the primary agency and CEMA. Scheduling of the training will be included in Support Annex E Training and Exercise. VIII. RESPONSIBILITIES A. Chatham Emergency Management Agency is the overall coordinator for Chatham County in disasters and emergency management. CEMA is responsible for the following activities when the MCI Plan requires activation. 1. Maintain communication with IC. 2. Coordinate local resources as needed / requested. 3. Coordinate resources through outside agencies as required. 4. Coordinate overall strategic disaster response during a major emergency or disaster. 18 SEPTEMBER 2014

27 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN 5. Secure additional resources through state and federal agencies as needed. 6. Coordinate with and supports requests from field agencies during a major emergency or disaster. 7. Assume strategic long-term planning for a mass casualty incident. 8. Coordinate dissemination of critical public information and instructions, including public health advisories, evacuation instructions, and shelter information. 9. Notify area hospitals immediately upon identification of a mass casualty incident. 10. Coordinate with local hospitals to determine the need to request outside resources immediately upon awareness of an incident and may overload area hospitals. 11. Ensure activation of communication links between emergency responders and area hospitals. 12. Direct coordination of patient needs, transportation, and hospital capabilities between field units and area hospitals. B. Fire/EMS Services 1. Provides triage, aid and treatment. 2. Provides transportation of injured and deceased. 3. Maintains ore re-establishes capacity to respond to other simultaneous incidents. 4. Conducts on-site decontamination of survivors. C. Police Services 1. Establishes required security at the incident site and establishes a perimeter as necessary. 2. Conducts investigative and law enforcement activities associated with a mass casualty incident. 3. Provides traffic control at incident site and ensures access for emergency vehicle ingress and egress. 4. Assists fire department with rescue operations as able. 19 SEPTEMBER 2014

28 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN 5. Assists coroner in the identification of the deceased. 6. Assists in providing death notifications to next of kin. 7. Provides required security at medical facilities, including temporary medical facilities and triage centers. 8. Coordinates with the EOC behavioral health unit to provide chaplains to deliver comfort and solace for emergency workers and disaster victims as able. D. Memorial Hospital 1. Establishes an internal MCI unit. 2. Provides medical care. 3. Stabilizes and prepares patients who need advanced critical care for transport to regional hospitals. 4. Provides support for decontamination. 5. Establishes point-of-contact for incident and public information. 6. Locks down facility as needed to focus on response. 7. Provides updates to the EOC regarding hospital capabilities and capacity. 8. Restocks consumable medical supplies to field units upon EOC request as able. 9. Assists in obtaining post-incident stress management services. 10. Ensures updates in GHA Maintains a record of patients transported to its facility by EMS. 12. Supply a medical liaison to the EOC. E. Candler / St. Joseph s Hospitals 1. Establishes an internal MCI unit. 2. Provides medical care. 3. Stabilizes and prepares patients who need advanced critical care for transport to regional hospitals. 20 SEPTEMBER 2014

29 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN 4. Provides support for decontamination. 5. Establishes point-of-contact for incident and public information. 6. Locks down facility as needed to focus on response. 7. Provides updates to the EOC regarding hospital capabilities and capacity. 8. Restocks consumable medical supplies to field units upon EOC request as able. 9. Assists in obtaining post-incident stress management services. 10. Ensures updates in GHA Maintains a record of patients transported to its facility by EMS. 12. Supply a medical liaison to the EOC. F. Coroner 1. Take charge of death scene. 2. Perform Coroner functions. 3. Assist in identification of alternate transportation routes. 4. Oversee management of human remains. 5. Release deceased when no longer needed for investigation. 6. Supplement dispatch staff as needed to handled added communication workload. 7. Perform search and rescue as needed. 8. Establish procedures for releasing names of deceased. 9. Notify next-of-kin. 10. Secure and return personal property and possessions of decedents to next-of-kin. 11. Make determination to activate Mass Fatality Incident Response. 21 SEPTEMBER 2014

30 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN G. American Red Cross 1. Provide trained personnel or volunteers to assist families and to aid in helping identify the dead. 2. Assist displaced residents. 3. Establish temporary or mass shelter. 4. Support local response by providing food, first aid, blood and blood products as necessitated by the event. 5. Provide food for emergency medical workers, volunteers and patients if requested. 6. Assist in re-unification efforts. 7. Assist law enforcement in notification of next-of-kin. 8. Assist in hospitals, infirmaries, and morgues as available. H. Salvation Army 1. Provide food for emergency responders at a mass casualty site as needed. 2. Coordinate with the EOC behavioral health unit to provide comfort and solace for emergency workers and disaster victims as able. I. Chatham Area Transit: Assist victim transport as requested by the incident commander or the EOC. J. Savannah Chatham County Public School System 1. Contact parents if/when school children are involved. 2. Provides buses for transportation as requested. K. Savannah Chatham Metro Police Department Animal Control/Human Society 1. Assist in arranging temporary care for pets whose owners have been injured or killed. 2. Assist in re-unification of people and their pets. 22 SEPTEMBER 2014

31 EOP / INCIDENT ANNEX H MASS CASUALTY INCIDENT PLAN IX. ANNEX MANAGEMENT AND MAINTENANCE A. Executive Agent: CEMA is the executive agent for Annex management and maintenance. The Annexes will be updated periodically as required to incorporate new directives and changes based on lessons learned from exercises and actual events. This section establishes procedures for interim changes and full updates of the Annexes. B. Types of Changes: Changes include additions of new or supplementary material and deletions. No proposed change should contradict or override authorities or other plans contained in statute, order, or regulation. C. Coordination and Approval: Any department or agency with assigned responsibilities within the EOC Annexes may propose a change to the plan. CEMA is responsible for coordinating proposed modifications to the Annexes with primary and support agencies and other stakeholders, as required. CEMA will coordinate review and approval for proposed modifications as required. D. Notice of Change: After coordination has been accomplished, including receipt of the necessary signed approval supporting the final change language, CEMA will issue an official Notice of Change. The notice will specify the date, number, subject, purpose, background, and action required, and provide the change language on one or more numbered and dated insert pages and will replace the modified pages in the EOP. Once published, the modifications will be considered part of the EOP for operational purposes pending a formal revision and re-issuance of the entire document. Interim changes can be further modified or updated using the above process. E. Distribution: CEMA will distribute the Notice of Change to participating agencies. Notice of Change to other organizations will be provided upon request. Re-issuance of the individual annexes or the entire EOP Plan will take place as required. Working toward continuous improvement, CEMA is responsible for an annual review and update of the EOP plan to include related annexes, and a complete revision every four years (or more frequently if the County Commission or CEMA deems necessary). The review and update will consider lessons learned and best practices identified during exercises and responses to actual events, and incorporate new information technologies. CEMA will distribute revised EOP Annex documents for the purpose of interagency review and concurrence. 23 SEPTEMBER 2014

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33 EOP / INCIDENT ANNEX H / APPENDIX 1 SCENE SET-UP APPENDIX 1 SCENE SET-UP 25 SEPTEMBER 2014

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35 EOP / INCIDENT ANNEX H / APPENDIX 1 SCENE SET-UP APPENDIX 1 SCENE SET-UP Uncontaminated Scene: Care should be taken to set-up the scene to ensure safe and efficient operations. It is important for responders to establish an orderly flow of patients from the incident scene through the treatment area and onto the transport area. The layout of the scene should create a funnel effect, where patients are moved from the widest portion of the funnel, the incident location, and then enter the treatment area through a controlled entry point. From the treatment area they will progress through the transportation area and onto an ambulance or other vehicle. The following uncontaminated patient flow diagram provides an example one way to organize the scene. Ultimately the way a scene is organized will depend on scene security & location, terrain, weather, the number of patients, and other factors. 27 SEPTEMBER 2014

36 EOP / INCIDENT ANNEX H / APPENDIX 1 SCENE SET-UP Contaminated Scene Set-Up The management of contaminated patients requires a notably different scene layout. An orderly flow of patients from the incident scene in the hot zone, through the warm zone, and then through the cold zone, then and on to the transport area must be established to prevent contamination of the cold zone. The following contaminated patient flow diagram provides a sample diagram of one way to organize the scene. The hazardous material involved, weather, wind, terrain, the number of patients, and other factors must be considered during a HAZMAT related MCI. 28 SEPTEMBER 2014

37 EOP / INCIDENT ANNEX H / APPENDIX 1 SCENE SET-UP Designation of Hot, Warm, and Cold Zones Upon arrival the HAZMAT Team will assess the incident scene and designate a Hot Zone, Warm Zone and a Cold Zone. Hot Zone. The hot zone is the area that immediately surrounds a hazardous materials incident. The hot zone normally extends out in a 360 degree radius around the incident scene. The hot zone is also referred to as the exclusion zone, or restricted zone, in other documents. Patients may receive antidotes and other lifesaving treatments in the hot zone. Entry into this area is normally restricted to HAZMAT team members. Warm Zone. The warm zone is the area where personnel and equipment decontamination and hot zone support takes place. The designation of access control points reduces the spread of contamination. This is also referred to as the decontamination, contamination reduction, or limited access zone in other documents. The warm zone is the first place that patients will be decontaminated. Patients may receive antidotes and other lifesaving treatments in the warm zone. Once patients have been decontaminated, they will be transferred into the care of EMS Providers in the cold zone. Note: The administration of life saving treatments takes precedence over decontamination for radiologically contaminated patients and the safety of the responder is within a reasonable level of risk. Cold Zone. The cold zone serves as the control zone for a hazardous materials incident. The cold zone contains the Incident Command Post and other incident support facilities. This zone is also referred to as the clean zone or support zone. Decontamination Patient decontamination, if required, should be carried out in the warm zone by properly trained personnel wearing appropriate chemical-protective clothing and respiratory equipment. Refer to established procedures to: Determine the potential for secondary contamination, the necessity for and extent of decontamination. Select appropriate personal protective equipment for wear by personnel in the warm zone. Decontaminate patients when the exposure is to an unidentified gas, liquid, or solid material. 29 SEPTEMBER 2014

38 EOP / INCIDENT ANNEX H / APPENDIX 1 SCENE SET-UP Provide emergency decontamination for patients with critical injuries and illness requiring immediate patient care or transport. Identify and consider crime scene related issues such as the preservation of evidence, chain of custody, etc. In some cases victims may remove themselves from the contaminated area. It is important to channel these victims into a hasty decontamination corridor consisting of the strip, flush, and cover activities. This action may be necessary to save lives and protect first responders before a more formal contamination reduction corridor can be established. 30 SEPTEMBER 2014

39 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS APPENDIX 2 JOB AIDS 31 SEPTEMBER 2014

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41 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS Table of Contents 2.1 Incident Command Safety Officer Public Information Officer Medical Branch Director Medical Supply Coordinator Staging Area Manager Triage Unit Leader Triage Personnel Morgue Area Manager Treatment Unit Leader Treatment Area Managers Transportation Unit Leader Transport Recorder Transportation Loader Medical Communications Coordinator Air Ambulance Coordinator Ground Ambulance Coordinator Transportation Flow Coordinator SEPTEMBER 2014

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43 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS APPENDIX 2 JOB AIDS 2.1 INCIDENT COMMAND (FIRST ARRVING UNIT INITIALLY) REPORTS TO: Dispatch, Emergency Department(s) or EOC if activated POSITIONS REPORTING TO INCIDENT COMMAND: Safety Officer Public Information Officer Medical Branch Director RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Responsible for the overall management and coordination of personnel and resources responding to the incident. Specific duties include: Assumes command and announces name and title to the communications center. Dress in identifying vest. Identify potentially hazardous situations. Assess current situation. Estimate number of patients. Declare a Mass Casualty Incident Level Request additional resources as appropriate. Notify closest hospital / emergency department of the MCI. Establish a visible command post. Initiate, maintain and control communications. Assign ICS functions. Establish a personnel accountability systems for first responders Establish a victims/patient accountability system) Assign and direct resources. Track current resources committed. Develop, evaluate and revise operational plans. Coordinate with other agencies. Control and facilitate media. 35 SEPTEMBER 2014

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45 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.2 SAFETY OFFICER REPORTS TO: IC POSITIONS REPORTING TO THE SAFETY OFFICER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. Experience working in a Public Safety environment. GENERAL RESPONSIBILITIES: Monitor and assess hazardous and unsafe situations and develop measures for ensuring personnel safety. Specific duties include: Report to and obtain situation briefing from IC. Dress in identifying vest. Provide a ring of safety around the incident. Take immediate corrective action or stop unsafe situation or practice. Notify the IC if unsafe situations are observed. Monitor hazardous / toxic environments and exposure levels of emergency personnel. Investigate injuries to department personnel and ensure proper levels of care are provided. Ensures personnel accountability system is in use and operating effectively. Observe the rescue ground for: o unsafe practices o use of protective equipment o need for relief crews o need for personnel rehab o Observes structural integrity. o Consider setting up safety teams with safety officers. 37 SEPTEMBER 2014

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47 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.3 PUBLIC INFORMATION OFFICER REPORTS TO: IC POSITIONS REPORTING TO THE PUBLIC INFORMATION OFFICER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Disseminate factual and timely reports to the news media concerning the nature and extent of the incident, emergency medical care, and treatment of victims. Specific duties include: Report to and obtain situation briefing from IC. Dress in identifying vest. Contact the IC for a briefing. Develop complete and accurate information regarding the incident. Establish a media area away from the command post. Establish a Joint Information Center with other agency PIOs. Act as a liaison to the press 39 SEPTEMBER 2014

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49 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.4 MEDICAL BRANCH DIRECTOR REPORTS TO: IC or Operations Section Chief (OSC) if activated POSITIONS REPORTING TO THE MEDICAL BRANCH DIRECTOR: Triage Unit Leader Treatment Unit Leader Transportation Medical Supply Coordinator RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL OVERALL RESPONSIBILITIES: To ensure that supervision and coordination is provided for extrication triage, treatment, and transportation of all patients. Specific duties include: Report to and obtain situation briefing from IC or OSC. Report and provide frequent updates to the IC or OSC. The Medical role may be assumed by the Incident Commander on small incidents. Appoint Transportation Unit Leader. Dress in identifying vest. Locate in a visible position. Assume responsibility of Medical Branch. Coordinate, direct and manage all Medical Branch operations. Maintain accountability for all personnel assigned to this group/branch. Monitor safety and welfare of group personnel. Consider relief crews. Consider Critical Incident Stress Management (CISM) assistance. Appoint and assign Medical Branch Director / Unit Leaders and support staff. Establish and maintain accountability for all victim/patients. Verify the location of the staging area if needed. Demobilize resources in accordance with Demobilization Plan. Forward all reports to IC or OSC. 41 SEPTEMBER 2014

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51 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.5 MEDICAL SUPPLY COORDINATOR REPORTS TO: Medical Branch Director POSITIONS REPORTING TO THE TREATMENT AREA MANAGER: None RECOMMENDED TRAINING: I IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Acquire, distribute and maintain the status of medical equipment and supplies. Specific duties include: Report to and obtain situation briefing from Medical Branch Director. Dress in identifying vest. Locate medical supplies in a central position in the Treatment Area using caution not to block access & egress to and from the Treatment Area. Maintain an inventory list of equipment, supplies, and Disaster Medical Support Units received and distributed. Provide receipts upon request. Continually assess status of medical supplies and equipment. Request additional supplies and equipment through the Medical Branch Director as needed. Distribute medical supplies and equipment to the patient care areas. Request personnel to assist in the collection and distribution of supplies and equipment. Consider a need to have a vehicles(s) transport supplies and equipment. Demobilize resources in accordance with Demobilization Plan. Forward all reports to Medical Branch Director. 43 SEPTEMBER 2014

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53 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.6 STAGING AREA MANAGER REPORTS TO: IC or OSC if activated POSITIONS REPORTING TO THE STAGING AREA MANAGER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Maintain separate stockpiles of manpower, reserve equipment and expended equipment at a staging area away from the incident. Specific duties include: Report to and obtain situation briefing from IC or OSC. Dress in identifying vest. Locate in a visible position. Establish Staging Area in conjunction with the IC or OSC as needed. Provide appropriate staffing, vehicles, equipment and supplies as requested. Maintain status of number and types of resources in staging area. Recommend additional staffing, equipment, and resources when necessary. Order all personnel to remain with their units until assigned. Verify the equipment pool location. Control and document all resources entering and leaving the staging area. Ensures unimpeded access and egress to and from staging area. Coordinate security for staging area. Demobilize resources in accordance with Demobilization Plan Forward all reports to IC or OSC. 45 SEPTEMBER 2014

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55 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.7 TRIAGE UNIT LEADER REPORTS TO: Medical Branch Director POSITIONS REPORTING TO THE TRIAGE UNIT LEADER: Triage Personnel RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Assess and sort casualties to appropriately establish priorities for treatment and transportation. Specific duties include: Report to and obtain situation briefing from IC or Medical Branch Director. Dress in identifying vest. Locate in a visible position between the incident site and the treatment area. If the patients are in imminent danger, move all patients out of the Incident Area before establishing Triage. Establish controlled pathway from the incident site to the treatment area. Direct walking wounded to designated treatment area. If START/JumpSTART not yet completed by first arriving crews, appoint triage teams to perform START/JumpSTART using triage ribbons. Obtain an accurate count of all victims by triage category (Red/Yellow/Green/Black) & report the count to the Medical Branch Director. Continue to use START/JumpSTART algorithms, to continually reassess patients. Coordinate the transfer of patients to Treatment Unit Leader. Triage all patients upon entry into the Treatment Area. Appoint "porters" to transport patients via backboards to treatment area. At hazardous materials incidents, requiring patient decontamination, a team must be assigned to move patients from the warm zone/decontamination line to the cold zone treatment area. Maintain communications with the Medical Branch Director, and other units as needed. Work with the Treatment Unit Leader to account for all victims who were initially triaged to ensure they have all living patients been moved to the Treatment Area. Demobilize resources in accordance with Demobilization Plan Forward all reports to IC or Medical Branch Director. 47 SEPTEMBER 2014

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57 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.8 TRIAGE PERSONNEL REPORTS TO: Triage Unit Leader POSITIONS REPORTING TO THE TRIAGE PERSONNEL: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Triage patients and assign them to appropriate treatment areas. Specific duties include: Report to and obtain situation briefing from Triage Unit Leader Don position identification vest Report to designated on-scene triage location Secure and dawn a triage ribbon belt Assess situation Triage and apply appropriate colored ribbons to patients per Start / JumpSTART Direct movement of patients to proper Treatment Areas Provide appropriate medical treatment to patients prior to movement as incident conditions dictate Demobilize resources in accordance with Demobilization Plan Forward reports and records to Triage Unit Leader 49 SEPTEMBER 2014

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59 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.9 MORGUE AREA MANAGER REPORTS TO: Triage Unit Leader POSITIONS REPORTING TO THE MORGUE AREA MANAGER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Establish and maintain a temporary morgue area for deceased persons who die enroute to or in the Treatment Area. Specific duties include: Report to and obtain situation briefing from Triage Unit Leader. Dress in identifying vest. Contact Chatham County Coroner. Ensure that no bodies are moved from the incident site prior to the arrival and approval of the Coroner / Chief Law Enforcement Officers. Establish a morgue area remote from the Treatment Area and not readily accessible to vehicles (i.e. emergency vehicles, law enforcement). With the assistance of Law Enforcement, keep the area off limits to all unauthorized personnel and provide security to the morgue area. Coordination with the Coroner s office, funeral directors, and Law Enforcement as necessary. Maintain records, including victims identities (if available), location found, personal effects, etc. Demobilize resources in accordance with Demobilization Plan. Forward all reports to Triage Unit Leader. 51 SEPTEMBER 2014

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61 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.10 TREATMENT UNIT LEADER REPORTS TO: Medical Branch Director POSITIONS REPORTING TO THE TREATMENT UNIT LEADER: Treatment Area Manager Morgue RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Provide patient counts, triage, and treatment to patients awaiting transportation. Specific duties include: Report to and obtain situation briefing from IC or Medical Branch Director Dress in identifying vest. Locate in a visible position. Establish a TREATMENT AREA large enough to accommodate all patients allowing for a 3 foot clearance on all sides of each patient. Appoint a Treatment Area Manager for the Red, Yellow & Green patient care areas. Ensure that all patients are re-triaged upon entry into the Treatment Area. Attach a triage tag to each patient entering the Treatment Area. Establish and maintain accountability for all patients entering the treatment area. Ensure that patients are re-triaged using Secondary Triage and assigned to the appropriate respective red, yellow or green patient care areas. Appoint a MEDICAL SUPPLY COORDINATOR (if needed). Working with the Treatment Area Managers, determine the transportation priority & most appropriate transport method for each patient. Maintain contact with the appropriate Treatment Area Managers of each patient care area. Red Tagged/Immediate, Yellow Tagged/Delayed and Green/Minor. Continually reassess each patient s condition and triage status. Demobilize resources in accordance with Demobilization Plan Forward all reports to IC or Medical Branch Director 53 SEPTEMBER 2014

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63 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.11 TREATMENT AREA MANAGERS There will be a Treatment Area Manager for the Red, Yellow and Green Patient Care areas. REPORTS TO: Treatment Unit Leader POSITIONS REPORTING TO THE TREATMENT AREA MANAGERS: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Provide patient counts, triage and treatment to patients awaiting transportation. Specific duties include: Report to and obtain situation briefing from Treatment Unit Leader. Dress in identifying vest. Establish a Treatment Area large enough to accommodate all patients allowing for a 3 foot clearance on all sides of each patient. Clearly identify your treatment area with the appropriate colored flag, tarp, and/or chemical light. Ensure that patients are re-triaged upon entry to the treatment area using Secondary Triage and ensure a triage tag is applied to each patient. Maintain accountability of all patients in your treatment area. Determine the transportation priority and the most appropriate transport method for each patient. Report the transportation priority of patients and recommended transport method for each patient to the Treatment Unit Leader. Continually reassess each patient s condition and triage status. Request the establishment of special patient care teams (e.g. IV team, bandaging team, etc.) as necessary to support the care of your patients. Request additional personnel as needed to provide the care for your patients. Provide palliative care for catastrophically injured (Yellow Prime) patients until resources allow for their transportation to a hospital. Coordinate the relocation of any patient who perishes in the treatment area to the Incident Morgue (Black Tagged Treatment Area). Leave all medical devices in place. Demobilize resources in accordance with Demobilization Plan Forward all reports to Treatment Unit Leader. 55 SEPTEMBER 2014

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65 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.12 TRANSPORTATION UNIT LEADER REPORTS TO: Medical Branch Director POSITIONS REPORTING TO THE TRANSPORTATION UNIT LEADER Transport Recorder Transport Loader Medical Communications Coordinator RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Track and distribute patients to medical facilities by assigning the mode of transportation and destination for each patient. Specific duties include: Report to and obtain situation briefing from Medical Branch Director. Establish loading procedures for ambulances. Determine capabilities of potential receiving hospitals. Report patient numbers and categories to receiving hospitals. Establish patient loading area accessible to the treatment area. Establish communications with staging to request number and capabilities of available ambulances. Advise ambulance crew which hospital will be destination upon their departure. Ensure recording of patient destinations Demobilize resources in accordance with Demobilization Plan Forward all reports to IC or Medical Branch Director. 57 SEPTEMBER 2014

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67 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.13 TRANSPORT RECORDER REPORTS TO: Transportation Unit Leader POSITIONS REPORTING TO THE TREATMENT AREA MANAGER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Assist in ensuring proper documentation of victim/patient and unit movements. Specific duties include: Report to and obtain situation briefing from Transportation Unit Leader. Dress in identifying vest. Position yourself at the assigned patient egress point in the Transport area. Document patient transport information on triage tag and collect tag stubs. Complete an entry on the MCI Patient Tracking Form for each patient leaving the Transportation Area. Deliver triage tag Transportation Record to Medical Communications/Transport as directed. Demobilize resources in accordance with Demobilization Plan Forward all reports to Transportation Unit Leader. 59 SEPTEMBER 2014

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69 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.14 TRANSPORT LOADER REPORTS TO: Transportation Unit Leader POSITIONS REPORTING TO THE TREATMENT AREA MANAGER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Ensure patients are safely loaded into the assigned ground ambulance, air ambulance, or other vehicle, and verify vehicle destination and travel directions. Specific duties include: Report to and obtain situation briefing from Transportation Unit Leader. Dress in identifying vest. Ensure patients selected for transportation are o Ready for transport o Safely loaded aboard the ambulance or other vehicle designated by Transportation Unit Leader. Provide the following information to ambulance personnel: o Inform crews of the destination hospital/emergency Department. o Provide travel directions to the receiving hospital/emergency Department (Available in Annex 5). o Remind ambulance crews that they do not need to contact receiving facility unless there is significant deterioration in the patient s condition or if they need physician s orders. Remind crews to return to the Staging Area upon completion of their assignment unless otherwise directed. Ensure all patients being loaded have triage tags attached and the transport stub has been removed. Maintain close communications with Transportation Unit Leader and Transport Recorder. Demobilize resources in accordance with Demobilization Plan. Forward all reports to Transportation Unit Leader. 61 SEPTEMBER 2014

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71 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.15 MEDICAL COMMUNICATIONS COORDINATOR REPORTS TO: Transportation Unit Leader POSITIONS REPORTING TO THE TREATMENT AREA MANAGER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Maintain and Coordinate medical communications at the incident scene between Transport Unit Leader and the designated Coordinating Emergency Department. Specific duties include: Report to and obtain situation briefing from Transportation Unit Leader. Dress in identifying vest. Remain in close proximity to the Transport and Treatment areas. Establish and maintain a dependable communications link with the designated Coordinating Emergency Department. The following minimal information should be provided and updated: o Type of incident o Number of patients o Severity of injuries Coordinate patient distribution with the Coordinating Emergency Department. Report individual patient information to the Coordinating Emergency Department as relayed by Transportation Unit Leader to include: o Unit transporting o Destination hospital o Number of patients o Triage tag numbers o Triage category, major injuries and age of patients. Assist the Transportation Unit Leader with documentation. Demobilize resources in accordance with Demobilization Plan. Forward all reports to Transportation Unit Leader. 63 SEPTEMBER 2014

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73 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.16 AIR AMBULANCE COORDINATOR REPORTS TO: Transportation Unit Leader POSITIONS REPORTING TO THE TREATMENT AREA MANAGER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Assume responsibility for the coordination, landing, and communication with air ambulance aircraft. Specific duties include: Report to and obtain situation briefing from Transportation Unit Leader Dress in identifying vest. Assign a fire unit and personnel and establish a Landing Zone (HELISPOT) Secure and maintain a HELISPOT of sufficient size on the most firm and level surface available (less than 5 slope) and clear of debris. Night operations and low visibility conditions require a larger HELISPOT. Locate HELISPOT at least one mile upwind from HAZMAT incident sites when explosives, gases, vapors, or chemicals are in danger of exploding or burning on sites, or when a plume is present. For radioactive materials incidents with no steam or smoke the HELISPOT can be located ¼ mile upwind from the incident site. Clearly mark the area with five weighted cones, flares, or beacons. Maintain HELISPOT security. Request law enforcement assistance if needed. Maintain radio contact with incoming helicopters. Advise the pilot of the following Before landing: o Obstructions at the landing area, as well as "near-by" (e.g. radio or cell towers, antennas, telephone lines, other wires, cranes, tall buildings, etc.) o Wind direction or ground wind gusts. o Location of any HAZMAT incidents, plume location and direction. o Relay patient information from the Medical Communication Coordinator to the air ambulance crew (e.g. patient condition, patient weight, and airway status). Coordinate loading and transport of patients with Transportation Unit Leader. Demobilize resources in accordance with Demobilization Plan. Forward all reports to Transportation Unit Leader. 65 SEPTEMBER 2014

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75 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.17 GROUND AMBULANCE COORDINATOR REPORTS TO: Transportation Unit Leader POSITIONS REPORTING TO THE TREATMENT AREA MANAGER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Assume responsibility for the coordination and communication with ground ambulance. Specific duties include: Report to and obtain situation briefing from Transportation Unit Leader Dress in identifying vest. Establish appropriate staging area for ambulances. Consider: o Safety and accessibility o Traffic control must be monitored and directed o Area and resource location identifiers must be visible Establish appropriate routes of travel for ambulances for incident operations Establish and maintain communications with the Transportation Unit Leader or Medical Branch Director regarding Air Ambulance Transportation assignments (if an Air Ambulance Coordinator position is not filled). Establish and maintain communications with the Medical Communications Coordinator. Provide ambulances upon request from the Medical Communications Coordinator. Establish contact with all ambulance providers at the scene. Request additional transportation resources as appropriate - Consider equipment/time limitations. Provide an inventory of medical supplies available at ambulance staging area for use at the scene. Anticipate and advise on changing resource requirements Keep record of resource movement Staffing/equipment - Establish checkin/check-out function / accountability When ordered, secure activities and release personnel under your supervision. Demobilize resources in accordance with Demobilization Plan. Forward all reports to Transportation Unit Leader. 67 SEPTEMBER 2014

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77 EOP / INCIDENT ANNEX H / APPENDIX 2 JOB AIDS 2.17 TRANSPORTATION FLOW COORDINATOR REPORTS TO: Transportation Unit Leader POSITIONS REPORTING TO THE TREATMENT AREA MANAGER: None RECOMMENDED TRAINING: IS-100, IS-200, IS-700, IS-701a ICS-300 & ICS 400 Familiarity with NIMS & ICS structure. Maintain an operational knowledge of Chatham County s EOP Organization and ESF structure. GENERAL RESPONSIBILITIES: Assume responsibility for the coordination and communication with ground ambulance. Specific duties include: Report to and obtain situation briefing from Transportation Unit Leader Dress in identifying vest. Establish the Transportation Area in a location between the Treatment Area and the patient pick-up point The pick-up point is where the ambulances, or other designated transportation resources, will drive up to and park, while waiting for the patients to be loaded into the ambulances or other vehicles. All vehicles should follow a one-way traffic pattern into the Transportation Area. Every effort should be made to avoid having ambulances and other vehicles backing up to reduce the risk of having personnel, patients or equipment run over during the patient loading process. Transportation Flow o Staging Area Non-transport assignment Triage Treatment Assistant Transport o Patient Loading Area o Destination Hospital Demobilize resources in accordance with Demobilization Plan. Forward all reports to Transportation Unit Leader. 69 SEPTEMBER 2014

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81 EOP / INCIDENT ANNEX H / APPENDIX 3 ON-SCENE FORMS APPENDIX 3- ON-SCENE FORMS MASS CASUALTY WORKSHEET 73 SEPTEMBER 2014

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85 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING 77 SEPTEMBER 2014

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87 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING For information regarding a Family Assistance Center refer to ESF Appendix CRITICAL INCIDENT STRESS DEBRIEFING Debriefing is a specific technique designed to assist others in dealing with the physical or psychological symptoms that are generally associated with trauma exposure. Debriefing allows those involved with the incident to process the event and reflect on its impact. WHAT IS A CRITICAL INCIDENT? A "critical incident" is any event that has significant emotional power to overwhelm usual coping methods. These include a sudden death in the line of duty, serious injury from a shooting, a physical or psychological threat to the safety or well-being of an individual or community regardless of the type of incident. Moreover, a critical incident can involve any situation or events faced by emergency or public safety personnel (responders) or individual that causes a distressing, dramatic or profound change or disruption in their physical or psychological functioning. There are oftentimes, unusually strong emotions attached to the event which have the potential to interfere with that person s ability to function either at the crisis scene or away from it. Symptoms of Critical Incident Stress Critical incidents produce characteristic sets of psychological and physiological reactions or symptoms in all people, including emergency service personnel. Typical symptoms of Critical Incident Stress include: 1. Restlessness 2. Irritability 3. Excessive Fatigue 4. Sleep Disturbances 5. Anxiety 6. Startle Reactions 7. Depression 8. Moodiness 9. Muscle Tremors 79 SEPTEMBER 2014

88 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING 10. Difficulties Concentrating 11. Nightmares 12. Vomiting 13. Diarrhea 14. Suspiciousness The physical and emotional symptoms, which develop as part of a stress response, are normal but have the potential to become dangerous to the responder if symptoms become prolonged. Researchers have also concluded that future incidents (even those that are more normal ) can be enough to trigger a stress response. Prolonged stress saps energy and leaves the person vulnerable to illness. Under certain conditions, they may have the potential for life-long after effects. They are especially destructive when a person denies their presence or misinterprets the stress responses as something going wrong with him. CRITICAL INCIDENT STRESS MANAGEMENT (CISM) Critical Incident Stress Management (CISM) is a comprehensive, integrated, systematic, and multi-component approach to managing traumatic events. There are four group tools used in CISM are identified by the chart on the following page. The following is a brief description of the four tools used in group CISM: 1. Demobilization a one time (end of shift/end of deployment), large group information process usually used for emergency services, military or other operational staff who have been exposed to a significant traumatic event such as a disaster or terrorist event. 2. Crisis Management Briefings this is a structured town meeting style focusing on large community or organizational groups. It is designed to provide information about the incident, control rumors, educate abut symptoms of distress, inform about basic stress management, and identify resources available for continued support, if desired. This may be especially useful in response to community violence / terrorism and can be tailed to smaller group applications. 3. Defusing is a shortened version of the debriefing (3 phases) focused on small homogeneous groups within 8 hours of the conclusion of an event. If a delay beyond 8 hours occurs, it is best not to defuse but plan for a debriefing. It is best to provide separate defusing for each homogeneous group involved in the event. 4. Debriefing a structured group discussion concerning the critical incident which follows a CISD structure of 7 phases. Common ground rules of a CISD include: 80 SEPTEMBER 2014

89 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING a. Voluntary participation b. No note taking or recording devices c. Not used as an operational critique or investigation of events d. Not a blame session Type Demobilization Crisis Mgmt Briefing (CMB) Defusing When After Shift Anytime post-crisis Within 12 hours Who Large number of responders Organizations, Communities, Schools Small Groups Debriefing (CISD) 24 hours 10 days* Small Groups Format Passive Information and rest if the focus Semi-Active Info plus short Q&A, Resources Active, Loosely guided. Three stages Very Active Structured team, guided discussion through seven stages Leader Peer, Chaplain, or Mental Health Professional Peer, Chaplain, and/or Mental Health Professional Peer, Chaplain, or Mental Health Professional Trained Leader and one Mental Health Professional Length ½ hour 1 1 ½ hour minutes 1 ½ - 3 hours Follow-Up** CISD Assess need for CISD Assess need for CISD Closure or referral Chart H.4 CISD Four Group Tools *Debriefings for disasters may not be appropriate until 2-4 weeks (and sometimes longer) following the disaster. **During any CISM, the team members should be watching for individuals who might need 1:1 follow-up or referral for additional support. 81 SEPTEMBER 2014

90 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING Conducting a CISD The following outline bullet points the important things to think about as you prepare for a formal debriefing. This section is not intended to be a teaching chapter, as only trained individuals should initiate a CISD. The goal of a debriefing is to help normal people deal with abnormal situations. Untrained individuals, though well-intended, can cause more harm than good if they do not understand the reasons behind the methods and steps involved in a CISD. Preliminary/Prep Work 1. Facilitator a. Someone trained in CISM. b. Good people skills, ability to read the room and know how to keep the process moving forward. c. More skilled facilitators may be required for incidents that are particularly intense. 2. Time Frame a. Optimally within hours b. Effectiveness diminishes when the time between the incident and CISD is offered. There is minimal effectiveness after six weeks. 3. Ground Rules a. Absolute confidentiality b. Only people impacted by the traumatic event. No management or supervisory staff should be present. If a supervisory person was part of the traumatic event, consideration should be given to conducting an individual CISD as oppose to a group CISD. In some cases, they might be included but this should be the exception, not the norm. c. No comments or criticisms regarding other s feelings or reactions (this is not the time to assess performance it s about what did happen and how they felt about it). d. Positive, supportive, understanding atmosphere, based on concern e. Active listening f. Providing Structure 82 SEPTEMBER 2014

91 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING 4. Establish Guidelines for expected of all participants a. Clarify reason for the Debriefing (if you are the Facilitator) b. Identify the event or time period of the event the group will be discussing. Example, if the debriefing conducted with the first responders on the event, the facilitator would instruct that the debriefing would focus on the first phase of the event not on day two or day three of the event. Therefore only those who had responded within the first phase would be present at the debriefing. For group debriefings, assure the group that each person involved will have an opportunity to tell their story. Reassure the group that each person s viewpoint and contribution is important. c. Location i. Each person speaks for themselves, no I heard so-and-so say, bla, bla, bla. Keep things in the first person. ii. Important that each person talk about the crisis event. i. Private ii. Comfortable d. Systematic Approach (as outlined in the formal CISM training) The CISD Structure Once the debriefing begins, it follows a carefully designed structure that progresses through seven phases and provides important stress-reduction information. While participants are not required to speak, they are encouraged to discuss various aspects of the incident that distressed them. The whole process usually takes two to three hours to complete. During the debriefing, personnel should not be required to respond to calls; others in the system need to fill in for them. Also, only those involved in the incident should attend, including command officers. If the critical incident affected various types of emergency personnel at the scene, a joint multi-agency debriefing is often held. It is important then to pick peer-support personnel from each of the agencies for the CISD team. If an incident involves only law enforcement personnel, it is important to choose law enforcement peers since law enforcement are more likely to trust fellow officers. The same concept holds true for other agency personnel. 83 SEPTEMBER 2014

92 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING Phase 1: Introduction Phase The CISD begins with an introduction from the CISD team members at which point they state that the material to be discussed is strictly confidential. It should also be emphasized that the CISD is not an operation critique. Attendees are then told what to expect during the debriefing and assured that the major concern of the CISD team is to restore people to their routine lives as soon as possible with minimal personal damage to the individual. The basic rules of the debriefing are explained before the team member s move into the next phase. Phase 2: Fact Phase The second phase of the CISD is the fact phase in which people are asked to describe what happened at the scene. This is a relatively easy phase for law enforcement and emergency personnel who are used to talking about the operational aspects of an incident. Once the incident is described, the debriefing team leader will lead the discussion into the thought phase of the process. Phase 3: Thought Phase The usual question asked in this phase is, "Can you recall your first thought once you stopped functioning in an automatic mode at the scene?" This helps people to "personalize" their experiences. The events are no longer a collection of facts but an individual, meaningful recollection of how they personally experienced the incident. Phase 4: Reaction Phase The fourth phase of a debriefing is the reaction phase, the point at which people can describe the worst part of the event for them and why it bothered them. If a critical incident has any significant emotional content attached to it, it will usually be discussed during this phase. It can occasionally become a heavy emotional phase of the debriefing but is not necessarily intense. It is not the objective of a CISD team to promote emotional behavior but, instead, to foster discussion so that recovery is as rapid as possible. The reaction phase allows people to discuss the worst parts of an incident in a controlled environment that enhances venting thoughts and feelings associated with the event and prepare them for useful stress reduction information. Phase 5: Symptom Phase The fifth phase of the CISD process is the symptom phase. The group is asked to describe stress symptoms felt at three different times: The first being those symptoms experienced during the incident; the second are those that appeared three to five days after the incident; and the last being symptoms that might still remain at the time of the 84 SEPTEMBER 2014

93 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING debriefing. Changes, increases and decreases of symptoms are good indicators for the mental-health person of the need for additional help for some attendees. Phase 6: Teaching Phase The next phase of the CISD process is the teaching phase. The CISD team members furnish a great deal of useful stress-reduction information to the group. They also incorporate other information, such as the grief process, promoting communication with spouses and suggesting how to help one another through the stress. Phase 7: Re-Entry Phase The seventh phase of the debriefing process is called the re-entry phase, when personnel may ask whatever questions they have. A summary is given by the team and the CISD is concluded. After the debriefing, the CISD team remains at the debriefing center to talk with those needing additional individual assistance. Referrals are made for counseling if necessary. Finally, the CISD team holds a post debriefing meeting to quickly review the debriefing and discuss ways to improve their functions for future debriefings. However, the main reason for meeting is to make sure that everyone on the team is okay before going home hearing the pain that others experience may bring about some pain for the debriefers. CISD FUNCTIONS DURING AN INCIDENT On-scene support services During an incident, a debriefing team may be involved with providing on-scene support services that assist obviously distressed personnel. The team advises and counsels responders and gives direct and indirect support to the victims and agencies present. Defusings are shorter, unstructured debriefings that encourage a brief discussion of the events which can reduce acute stress. Defusings can be done anywhere from one to three hours following the incident, often at the station, and generally last from 30 minutes to an hour. Only those crews most affected are involved; not all workers from the scene attend, as would be the case in debriefings. If the defusing is not accomplished within 12 hours, a full formal debriefing is what should occur next. A well-run defusing can often eliminate the need for full formal debriefing. If both are necessary, a debriefing should be held three to seven days after the defusing. 85 SEPTEMBER 2014

94 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING Establishing a Critical Incident Stress Debriefing Team Some regional CISM teams have been established and may be available if a local CISD team cannot be pulled together. Formalized CISM teams are made up of personnel who have met nationally recognized requirements and are usually registered with the agency or locale in which they serve. When pulling a team together, keep the following things in mind: 1. Mental Health professionals who possess the diagnostic skills to help recognize issues more serious than stress alone 2. Peer professionals who understand the day-to-day stresses of the responders 3. Support personnel (Chaplains) who have on-going relationships with the first responders and can observe behavior change which could lead to a referral to a mental health professional (something most first responders are less likely to do). To obtain formalized training in CISD, check the courses offered through any of the reputable organizations specializing in CISM. The simplicity of the critical incident stress debriefing should not cause one to underestimate its value. Well-executed CISDs have an enormous potential to alleviate overwhelming emotional feelings and potentially dangerous physical symptoms. 86 SEPTEMBER 2014

95 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING POST TRAUMATIC STRESS DISORDER Recognizing It, Treating It Post-Traumatic Stress Disorder (PTSD) is the usual diagnosis that Mental Health Professionals apply to persons who have suffered severe trauma in their lives and develop certain symptoms as a result of that traumatic event. PTSD is characterized by psychologically re-experiencing the event through nightmares, daydreams, flashbacks and/or intense distress when reminded of the original event. There may be symptoms of avoiding things that remind one of the traumas, social isolation, a feeling of being different from other people and a general lack of interest in the world. Other symptoms include tension and anxiety, such as difficulty falling asleep, irritability, and outbursts of anger, trouble concentrating or being exceptionally jumpy. Any individual who has experienced trauma may suffer from these symptoms. Being in crisis, however, doesn't mean the individual will develop PTSD. PTSD may occur if the victim hasn't had the opportunity to work through their crisis. There are three distinct phases of acute post-trauma reactions: the shock phase, the impact phase and the recovery phase. Following, is a short description of each phase: 1. The Shock Phase a. Can last a few days or several weeks b. Common emotional responses. i. Immobilization confusion, disorganization, and inability to perform simple, routine tasks. (Example, during an armed robbery, the store clerk may have difficulty following the direction to open the cash register almost feeling like everything is happening in slow motion. Tunnel vision, which causes the victim to focus on one area of the trauma, is also not uncommon. In the store clerk example, the clerk may focus on the weapon to the point that they do not know what the robber looked like or anything else going on in the store. ii. Denial refusing to believe that the trauma is actually happening. c. Not all victims experience the shock phase. People trained to deal with trauma on a regular basis, such as police, military, medical emergency workers, may initially bypass the shock phase, though elements of the shock phase may be evident. 87 SEPTEMBER 2014

96 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING 2. The Impact Phase a. Anger and/or extreme anxiety i. Trembling ii. Crying iii. Subjective feelings of tension iv. Anxiety v. Outrage vi. Displacement (Store clerk example may become extremely angry with the store owner or the police as oppose to the perpetrator). b. What-if-and-maybe stage i. Self-Doubt 1. Invents different scenarios ignoring the actual fact and outcome of the trauma. 2. If only I d been five minutes earlier 3. If only I had reacted more quickly ii. Self-Blame (Common in police and ambulance crews) c. Depression i. Irritable 1. Guilt can last indefinitely if not dealt with ii. Misunderstood iii. Helpless iv. Isolation which leads to a loss of hope for the future v. Prevailing attitude: Leave me alone, there s nothing wrong with me. d. Mad/Sad Cycle. If the victim fails to face the trauma at this point, they will continue in an anger/anxiety and depression cycle and will be unable to progress to the recovery phase. PTSD becomes chronic. 88 SEPTEMBER 2014

97 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING 3. The Recovery Phase a. If the trauma is dealt with right away, the chances of getting stuck in the Impact Stage are slim. If a victim sees a crisis counselor at the scene or soon afterward, and the counselor explains what they re experiencing, why they are experiencing it, and what to expect next, the victim will feel reassured that what they are feeling is normal. b. Once the person resolves the guilt and returns to a relatively symptomfree mode of functioning, they may remain there for some time. A new disturbance or a reminder of the original trauma can cause recurring symptoms. c. Similarly, an accumulation of the stresses of daily life, such as financial problems, employment difficulties, or ill health, may also cause the trauma survivor to regress. With effective treatment, survivors can learn to control many of the symptoms of anxiety and depression which will allow them to function more productively. Victims who haven t worked through their trauma and don t understand what they are experiencing may become trapped in the anxiety / depression cycle. Those subject to constant high levels of stress, such as police or emergency response workers, are often unable to remain in a symptom-free mode because of constant immersion in trauma. It is important that first responders continually work through their trauma by taking advantage of programs offered through their agencies like, peer counseling, formal debriefings, the Employee Assistance Program or the Chaplaincy. People experiencing the anxiety / depression cycle tend to self-medicate in an attempt to alleviate their symptoms; with alcohol and drugs being the drug of choice abuse in these areas can become a severe problem. A less obvious form of self-medication is sensation seeking is to get symptom relief through an adrenaline rush. Some people suffering chronic post-traumatic stress disorder take a sudden interest in high risk activities like sky diving, motorcycles riding or rock climbing. Some will also seek out excitement through numerous sexual encounters. Survival Guilt When a victim suffering PTSD becomes trapped in the anxiety/depression cycle, their guilt overwhelms them. They feel guilty for surviving and responsible for the fate of others or for the event having happened in the first place. 89 SEPTEMBER 2014

98 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING Existential Guilt Existential guilt is characterized by the survivor's confusion over having lived and the meaning of this survival. For instance, if the trauma includes death of other individuals we sometimes see variations on this theme: the survivor wishes to change places with the person who died, and the guilt is expressed as "I should have died, and they should have lived." Because their own lives have been so chaotic since the trauma, they feel that the person who died would have had a better life with more to live for, failing to recognize that it's likely this person would be struggling with similar emotions. After hearing about the trauma during an interview, counselors may ask, "How come you lived through that?" A common response is, "I don't know, I ask myself that question all the time," or, on a more positive note, the victim may see a new purpose for their life after facing the probability of death. Content Guilt Content guilt, as opposed to existential guilt, is a result of a person's having done something to ensure their survival, such as hiding under a table during a shooting. This is a much easier form of survivor guilt to recover from because there are actual behaviors to talk about and understand. Because survivor guilt has both emotional and intellectual components, a major goal in counseling is to separate the feeling and thinking elements. The survivor must learn that it is okay to feel sad about someone's having died or been injured in a traumatic situation, but it is neither rational nor appropriate to feel totally responsible for the person's death. The situation or perpetrator should be blamed, not the survivor. Formal Counseling To keep the victim accessible to counseling, however, the counselor cannot say "You have nothing to feel guilty about," because victims often cling to their guilt for comfort. The counselor should attack the guilt through the issue or responsibility. Getting survivors to share responsibility for what happened starts with pointing out other factors involved in the incident. One of the factors may be time and space; they may have been in the wrong place at the wrong time. They may have been the victim of a random act. Survivors of trauma tend to remember the traumatic situation in an unchanged way; their initial perception of the event is the way they continue to view it, as if the traumatic event were frozen in their memories. The healing process involves looking at and discussing those memories realistically. Because the memories have a negative focus, the goal of re-thinking is simply to look at the original trauma in a different light. 90 SEPTEMBER 2014

99 EOP / INCIDENT ANNEX H / APPENDIX 4 CRITICAL INCIDENT STRESS DEBRIEFING Sometimes when victims have intrusive thoughts about the traumatic incident, the original thought may be followed by a host of what-if and maybe versions of the event. To help victims stop this negative thought process, the victim might find it helpful to physically rebuke the thought. Simply shaking their head and saying no or no, this is what happened, has the effect of training themselves to separate the intellectual from the emotional and deal only with the reality of the situation. They may also set a time limit, allowing themselves a certain amount of time to think about the incident (maybe five minutes) then, at the end of the five minutes, they can tell themselves, Okay, that is all. It is important to know that a victim may become confused when they begin to ponder the facts of the traumatic event. This confusion is a positive sign that indicates they are beginning to question their original perception. There is usually a realization that the traumatic event had other facets that may have been overlooked, ignored, forgotten, or devalued. Finally, if the victim has religious beliefs, those beliefs may need to be addressed. It is not uncommon for someone s beliefs to either be strengthened or weakened by their experience. It is recommended that trauma counselors be in contact with the clergy in their community, as talking to clergy can do much to alleviate individual guilt. 91 SEPTEMBER 2014

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101 EOP / INCIDENT ANNEX H / APPENDIX 5 DIRECTIONS TO HOSPITALS APPENDIX 5 DIRECTIONS TO HOSPITALS 93 SEPTEMBER 2014

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103 EOP / INCIDENT ANNEX H / APPENDIX 5 DIRECTIONS TO HOSPITALS APPENDIX 5 DIRECTIONS TO HOSPITALS DIRECTIONS TO ST. JOSEPH S HOSPITAL St. Joseph s Hospital is located at Mercy Blvd. in Savannah, GA. From I-95 North or South 1. Take the Hwy. 204 exit toward Savannah, which is Exit Travel approximately 8 miles. Cross the Forest River, pass the Savannah Mall on your left, then Armstrong Atlantic State University on the right. The next light is Mercy Boulevard. 3. Turn left on Mercy Boulevard. 4. St. Joseph's Hospital is on your left; the entrance is.10 of a mile after the turn. From I-16 East (coming from the west, Macon, GA) 1. After passing the I-95 interchange, pass two more interchanges: Dean Forest Road and Chatham Parkway. 2. Exit right at the next interchange: Lynes Parkway, Exit 164A, 516 Exit east, toward Savannah/Hunter Army Airfield. 3. In approximately 2 miles, take the Veterans Parkway/Southwest Bypass, which exits to the right. This approximately 5-mile stretch ends up at Hwy. 204, which is Abercorn Extension. At the end there is a traffic light; turn left toward Savannah. 4. Cross the Forest River, then pass the Savannah Mall on your left and eventually Armstrong Atlantic State University on your right. 5. Shortly after AASU (three traffic lights), you will come to a traffic light at Mercy Boulevard. Turn left here and the St. Joseph's Hospital main entrance is about.10 of a mile on your left. From South Carolina (via US-17 and the Savannah Bridge) 1. Cross the Savannah Bridge. The road becomes I-16. Take the 516 Exit east, which is Exit 164A. 2. In approximately 2 miles, take the Veterans Parkway/Southwest Bypass, which exits to the right. This approximately 5-mile stretch ends up at Hwy. 204, which is Abercorn Extension. 3. At the traffic light, turn left toward Savannah. Cross the Forest River, pass Savannah Mall on your left and Armstrong Atlantic State University on your right. Shortly after AASU (three traffic lights), you will come to a traffic light at Mercy Boulevard. Turn left here and the St. Joseph's Hospital main entrance is.10 of a mile on the left. 95 SEPTEMBER 2014

104 EOP / INCIDENT ANNEX H / APPENDIX 5 DIRECTIONS TO HOSPITALS Figure A 96 SEPTEMBER 2014

105 EOP / INCIDENT ANNEX H / APPENDIX 5 DIRECTIONS TO HOSPITALS DIRECTIONS TO CANDLER HOSPITAL St. Joseph s Candler Hospital is located at 5353 Reynolds Street in Savannah, GA. From I-16 East (coming from the west, Macon, GA) 1. After passing the I-95 interchange, pass two more interchanges: Dean Forest Road and Chatham Parkway. 2. The next interchange is Lynes Parkway, Exit 164A toward Savannah/Hunter Army Airfield. Exit right. 3. In approximately 3 miles, the road becomes Derenne Avenue. Pass lights at Montgomery Street, Bull St./White Bluff Avenue, Abercorn Street. and Habersham Street. 4. The next intersection is Reynolds Street. Turn left. Candler is on the right with the main entrance approximately 500 feet after the turn. From I-95 North 1. Take I-16 toward Savannah, Exit 99A. Pass two interchanges: Dean Forest Road and Chatham Parkway. 2. The next interchange is Lynes Parkway, Exit 164A toward Savannah/Hunter Army Airfield. Exit right here. 3. In about three miles, the road becomes Derenne Avenue. You will pass lights at Montgomery Street, Bull Street/White Bluff Avenue, Abercorn Street and Habersham Street. 4. The next intersection is Reynolds Street. Turn left. Candler is on the right with the main entrance approximately 500 feet after the turn. From I-95 South 1. Take Hwy. 204, exit 94 toward Savannah. Stay on Hwy. 204 (which eventually becomes Abercorn). 2. Cross the Forest River, pass the Savannah Mall on your left, then Armstrong Atlantic State University on the right. 3. Continue until you come to the intersection of Abercorn Street and Derenne Avenue. Turn right. 4. Pass through the intersection of Habersham Street. The next intersection is Reynolds Street. Turn left. The main entrance to Candler Hospital is about 500 feet on the right. 97 SEPTEMBER 2014

106 EOP / INCIDENT ANNEX H / APPENDIX 5 DIRECTIONS TO HOSPITALS From South Carolina (via US-17 and the Savannah Bridge) 1. Cross the Savannah Bridge. The road becomes I Take the 516 Exit East, which is Exit 164A toward Savannah/Hunter Army Airfield. Exit right here after passing under the overpass. 3. In about three miles, the road becomes Derenne Avenue. Pass lights at Montgomery Street, Bull Street/White Bluff Avenue, Abercorn Street and Habersham Street 4. The next intersection is Reynolds Street. Turn left. Candler is on the right with the main entrance approximately 500 feet after the turn Figure B 98 SEPTEMBER 2014

107 EOP / INCIDENT ANNEX H / APPENDIX 5 DIRECTIONS TO HOSPITALS DIRECTIONS TO MEMORIAL UNIVERSITY MEDICAL CENTER Memorial University Medical Center is located at 4700 Waters Avenue in Savannah, GA. From I-95 North 1. Take exit 94 toward Savannah 2. Turn east onto 204/Abercorn 3. Turn east (right) on DeRenne Avenue 4. Turn north (left) on Waters Avenue 5. Memorial Health is ahead on the right From I-95 South 1. Take exit 94 toward Savannah 2. Turn east (right) onto 204/Abercorn 3. Turn north (right) on the Truman Parkway 4. Take the DeLesseps Avenue exit 5. Turn right onto DeLesseps Avenue 6. Turn left at the traffic light onto the service road 7. Memorial Health is straight ahead From I-16 or Highway Take the exit for Georgia 21 South/516 East/Lynes Parkway 2. Lynes Parkway turns into DeRenne Avenue 3. Turn north (left) onto Waters Avenue 4. Memorial Health is ahead on the right From Highway Stay on 21 South/516 East/Lynes Parkway 2. Lynes Parkway turns into DeRenne Avenue 3. Turn north (left) onto Waters Avenue 4. Memorial Health is ahead on the right From the Islands, Traveling North 1. Follow 80 west toward Savannah 2. Turn onto Truman Parkway South 3. Take the DeLesseps Avenue exit 4. Turn right onto DeLesseps Avenue 5. Turn left at the traffic light onto the service road 6. Memorial Health is straight ahead 99 SEPTEMBER 2014

108 EOP / INCIDENT ANNEX H / APPENDIX 5 DIRECTIONS TO HOSPITALS Figure C 100 SEPTEMBER 2014