MASS CASUALTY INCIDENTS Daniel Dunham
WHAT IS A MASS CASUALTY INCIDENT? Any time resources required exceed the resources available. The number of patients is not necessarily large or small, and may be medical patients, trauma patients, or both. The severity of illness or injury is also not necessarily great or small Some of this information can be obtained from dispatch Don t be afraid to request a reasonable amount of additional resources based on it (like requesting an additional ambulance or two, or supervisor, fire dept, etc but this is probably not an appropriate time to launch a helicopter).
AS WITH EVERY CALL The first step is to determine the total number of patients, and the severity of their problems. Potential severity of illness/injury is of great importance. Each CLEMC ambulance can transport up to 5 (very) stable patients (if they can all be seated upright or 4 patients with two on backboards and two seated), but with potentially critical patients you may be limited to one critical and one stable patient in your ambulance. During this step, the goal is to figure out whether you have enough resources on hand for this event. If you believe you have enough resources on hand, you can begin a more thorough triage to confirm your decision. If you believe you need more resources, first determine what resources, in what quantity you will need (additional ground ambulances, air ambulances, fire personnel/equipment, law enforcement, etc.) Making several requests resources can get confusing you may end up with more or less resources than you expect: It s a good idea to declare an MCI (with an estimated number of patients), then take a short amount of time to find out exactly what you need before requesting it ( I need 6 ground ambulances and 2 helicopters ). If you are unsure, request enough resources so that you know you will be able to successfully manage the scene. If as you develop a better understanding of the situation you don t need those resources, you can disregard any unnecessary units.
SMALL SCALE MCIS OCCUR REGULARLY The easiest way to find yourself in a MCI situation is to have one critical patient who needs lots of attention, and then several stable patients Most commonly from MVAs where you have one critical or unconscious patient, and multiple stable patients. Don t get tunnel vision after finding the first critical patient. Make sure you ve performed enough of an evaluation on all potential patients to determine if they require immediate attention Multiple critical patients turn a small scale MCI into a large scale MCI quickly. Less commonly with structure fires, group overdoses, carbon monoxide exposure, mass pepper spray exposure
NOW YOU HAVE A MCI Once you determine you have a MCI, a command structure should be set up. This structure should follow NIMS ICS guidelines. EMS command (or their delegate) should be the only person to Request or decline additional resources If you feel you need additional resources, consult command, do not make the request yourself Interface with fire command or other group leadership Including prioritizing decon or rescue/extrication efforts Conflicting requests or information from multiple people can lead to inefficiency, confusion, and chaos. Assign EMS units to specific duties or patients If you are the only EMS unit on scene, the in-charge becomes command, triage, and in charge of all EMS responsibilities until relieved. Responsibilities must not overlap, or conflict could occur.
UNIFIED COMMAND BENEFITS A shared understanding of priorities and restrictions. A single set of incident objectives. Collaborative strategies. Improved internal and external information flow. Less duplication of efforts. Better resource utilization.
UNIFIED COMMAND FEATURES A single integrated incident organization Co-located (shared) facilities One set of incident objectives, single planning process, and Incident Action Plan Integrated General Staff Only one Operations Section Coordinated process for resource ordering
POSSIBLE ORGANIZATION Unified Command HazMat Incident Law Enforcement Public Works Commander Incident Commander Incident Commander Unified Incident Objectives Safety Officer Public Information Officer Liaison Officer Operations Section Chief Planning Section Chief Logistics Section Chief Finance/ Administration Section Chief
SMALL SCALE INCIDENTS Small incidents often do not require a rigid command structure, and decisions can often be made on the fly since communication amongst all responders can occur easily. A command structure would not inhibit this scenario, but it would not likely be helpful. Triage tags will not make decisions more difficult, but may be an unnecessary step Specific actions to be performed will depend on the type of patients, their needs, and the resources available (both immediately available on scene [ambulance crew, supervisor, fire dept] and that can be acquired easily [another available ambulance in district]).
LARGER SCALE INCIDENTS Larger incidents will require and benefit from a more systematic approach to both command structure and triage plan. Once you ve established that you do not have enough resources on scene, you must determine the number of patients and extent of illness or injury Triage tags are available on each ambulance and Squad 1, and can provide a fast reminder to how to perform triage, but will not give you enough information if you don t have a basic familiarity with triage before the incident. The START triage system is in our protocol book, and is the expected starting point for MCIs
BLACK (DEAD) Victim unlikely to survive given severity of injuries, level of available care or both Palliative care and pain relief should be provided Patients without a pulse in an MCI should not have any treatment performed. None, at all Patients with a pulse, but without respiratory effort despite opening or other basic airway maneuvers are also tagged black. Consider performing rescue breaths on children if arrest is likely the result of hypoxia. Pediatric patients arresting as a result of traumatic injury will not likely benefit from this. If no response to these interventions, a black tag is appropriate.
RED (IMMEDIATE) Victim can be helped by immediate intervention and transport Requires medical attention within minutes for survival (up to 60) Includes compromises to patient s airway, breathing, circulation If any of the following are present, the patient has earned a red tag (immediate) Patients with spontaneous respiration >30, or <8 Capillary refill >2 seconds, or no peripheral pulses Altered mental status (unable to follow simple commands this is different than a patient not being A&O x3) Uncontrollable bleeding
YELLOW (DELAYED) Victim s transport can be delayed Includes serious and potentially life-threatening injuries but status not expected to deteriorate significantly over several hours If any of the following are present, the patient has earned a yellow tag (delayed) Has a pulse Respirations greater than 8, less than 30 Capillary refill < 2 seconds Able to follow simple commands Does not qualify as green (walking wounded) Yellow patients typically Have multiple long bone fractures or Minor head injuries without AMS or Patients that are confused but able to following simple commands or Have underlying medical conditions exacerbated by an event
GREEN (WALKING WOUNDED) Victim with relatively minor injuries Status unlikely to deteriorate over days May be able to assist in own care If you can hear the sound of my voice and walk, go over there Announcing this prior to triaging will allow the walking wounded to triage themselves and give you a good idea of who needs your attention sooner If they don t fit any of the other colors, they re green These patients typically have Isolated injuries without anything that would make them a yellow or red Non-specific pain or Pain all over A desire to be checked out A stable medical condition Non-complicated asthma, angina, anxiety,
SO, YOU VE TRIAGED EVERYBODY If you are dedicated to triage only, after you ve tagged every patient, re-assess each patient to assure that you ve both categorized them correctly, and that their condition has not changed If you also have other responsibilities, you can begin treatment or tasks, but remember that it may be necessary to revisit these patients to reassess them.
PATIENT PRIORITY Patient priority and transport decisions should be made by a single person inside the command structure. A single crew changing destination on their own will not likely cause problems, but multiple crews doing this will lead to inefficient use of resources due to overcrowding and under usage of resources. When the number of patients will overwhelm local facilities, send stable patients further away, and critical patients that do not require specialty services to nearer facilites. Do not send stable patients to level 1 trauma facilites just because they are further away, you ll be taking beds that can be occupied by sicker patients Walking wounded that are still around when you get to them can be sent to someplace like San Jacinto Methodist, or even further away (The Woodlands, Hermann Southwest, Memorial City etc)
LEVEL III TRAUMA CENTERS IN THE HOUSTON AREA Bayshore Medical Center Brazosport Memorial Hospital CHRISTUS St. Elizabeth Hospital Conroe Regional Medical Center Houston Northwest Medical Center Lyndon B. Johnson General Hospital Memorial Hermann Northwest Hospital Memorial Hermann Southeast Hospital Memorial Hermann Southwest Hospital Memorial Hermann The Woodlands Hospital Oakbend Medical Center St. Joseph Medical Center Pasadena Lake Jackson Beaumont Conroe Houston Houston Houston Houston Houston The Woodlands Richmond Houston
A NOTE ON GREEN PATIENTS Green patients that have limb threatening, but not lifethreatening injuries may have to be transported very far away to receive the services they need in a timely fashion, if all local facilities are overwhelmed (very large MCIs, or following hurricanes etc.). Dallas, Austin, and San Antonio all have level I trauma facilities that can be reached reasonably quickly by air medical Bryan and Corpus Christi have Level II trauma facilities. Bryan is easily accessible by ground if necessary. Examples of injuries that could require this include Crush injuries to hands or feet Circumferential burns to hands or feet Extensive tendon or ligament damage Injuries that will require cosmetic plastic surgery It is best to discuss your plan with the victim before committing to this plan, but be sure to explain that this is the best way for them to receive the care they require for the best possible outcome.
THINGS TO REMEMBER WHEN TRANSPORTING Utilize all transport options available Helicopters can be used for red patients, but they can also be used to transport yellow or injured green patients to outlying hospitals School busses can be used to transport multiple stable patients at once Keep track of where you are sending patients if possible Triage tags have perforated portions with unique ID numbers
RULE BREAKING Injured first responders receive the highest priority of all patients It can be justified to code a first responder or other person if they coded for a reason other than the cause of the MCI, but should be at the discretion of the EMS incident command
MUTUAL AID CHANNELS Mutual Aid Channels on CLEMC radios A15 Harris County Mutual Aid 2 B16 HC Hazmat 4 F1-F6 HCMA 1-6 S Bank - State Mutual Aid Channels U Bank - CMOC and CIMA