Chapter 50

Medical Incident Command

 Objectives
 Identify components of an incident command
system (ICS)

 Outline activities in preplanning scene

management, and postdisaster follow-up of an
incident

 Identify FEMA’s five ICS components

 List command responsibilities during a major

incident response
 Objectives
 Describe FEMA ICS section responsibilities

 Identify situations classified as major incidents

 Describe steps needed to establish and operate

the ICS

 Given a major incident, describe sectors needed

and responsibilities of each
 Objectives
 List problems related to the ICS and
to mass casualty situations

 Outline principles and technology of

triage

 Identify resources for management

of critical incident stress
 Scenario
Icy wind and sleet pound your
ambulance as you arrive on the
scene of an overturned school bus in
a small creek. Size-up reveals 18
young children and an elderly driver,
with several apparently severe
injuries, difficult access to the
patients, and diesel fuel leaking from
the bus.
 Discussion
 What are your priorities on this call?

 What resources will you request?

 Describe your primary role until additional help

arrives

 List sectors that will need to be established on

this scene

 How will you decide which patients to transport

first?
 Major Incident
 Event in which the available resources
are insufficient to manage the number
of casualties or the nature of
emergency
 May stress local, regional, state, and
even national and international resources

 Examples of major incidents

Incident Command System
(ICS)
 Effective ICS allows for involvement
of:
 Single jurisdiction; single agency
 Single jurisdiction; multiagency

 Multijurisdiction; multiagency
Incident Command System
(ICS)
 Expands from nonmajor incident to
major incident in logical manner
 Using ICS as standard operating
procedure for small incidents permits
smooth transition in major incident
 ICS Terminology
 Apparatus  Medical direction

 Command  Mutual aid

 Command post  Sector

 Communications  Staging area

center
 FEMA ICS
 Federal law requires ICS for hazmat incidents
 Many states use ICS for all types of incidents

 Incident management or command system

 Developed by FEMA
 National standard for incident management

 Flexible system

 Used by both public and private sectors in some routine and

most large-scale emergencies
ICS Structure
 ICS Organization
 Five major components
 Command
 Planning

 Operations

 Logistics

 Finance/administration
The Command Function
 One person coordinates variety of emergency
activities
 Cornerstone of ICS structure

 Initial command determined in preplan

 Command established immediately

 Commander clearly identified

 Commander responsibilities
 Types of Command
 Singular command
 One individual responsible for operation

 Unified command
 Large events or as small incident evolves
 Specialized organizations identified and
personnel unify to complement command
 EMS, fire, police, health department, Red Cross
Application of Unified
Command
 ICS Organization
 Incident commander (IC) expands (or
contracts) ICS organization based on:
 Life safety
 Incident stability

 Property conservation

 If expansion is needed:
 Other command staff positions established
Possible Command Staff
Positions
 Section Responsibilities
 Sections assigned by IC to section
chiefs
 Planning
 Operations

 Logistics

 Finance/administration

 Section chiefs report to IC

 Command Section
Organizational Plan
 Section Chiefs
 Strong supervisors and managers

 Primary role
 “Make things happen”
 Ensure rescuers working toward common goal

 Number of sections varies by incident

 Determined by IC
 Section Chiefs
 Not involved in physical tasks
 Accomplish command objectives
 Monitor work progress
 Redirect activities if needed
 Coordinate activities with other sections
 Request other resources as needed
 Monitor welfare of personnel in section
 Provide command with frequent reports
 Reallocate resources within section
 Planning Section
 Provides past, present, and future
information about incident and status
of resources
 Creates incident action plan (IAP)
 Operational periods
Planning Section
 Operations Section
 Directs and coordinates emergency scene
operations

 Ensures safety of operational personnel

 EMS operations often fall under this section

 Operations section chief is in charge of actual

scene (“ground zero”)

 Responsibilities
Operations Section
 Logistics Section
 Supports logistical needs of incident

 Logistics appropriate to incident

size/duration

 Provides gear and support to

responders
Logistics Section
 Finance/Administration
Section
 Accounting and administration of incident

 Staff support function

 Monitors costs, careful accounting

 Seldom used on small incidents

 Essential as incident grows

 And on hazmat incidents

 Not used in routine daily incidents

Finance/Administration
Section
 Declaring a Major
Incident
 More than two ambulances needed
 Particularly in rural areas

 Situations involving hazardous or

radioactive materials or chemicals

 Situations needing special resources

 Helicopters, rescue teams, multiple rescue or
extrication units

 When in doubt, declare a major incident

 Preparing for a Major
Incident
 Phase 1: The preplan

 Phase 2: Scene management

 Phase 3: Post-disaster follow-up

 Major Medical Incidents
 Need to establish ICS at medical
incident determined by:
 Number of casualties
 Nature of the event

 Local/regional threshold
Examples of Medical ICS
 Establishing Command
 Group/sector functions or major functional areas
implemented by incident size and scope

 Groups and sectors may include:

 Support sector
 Staging sector
 Helicopter LZs and vehicle apparatus arrivals
 Treatment sector

 Unified EMS command with fire and police may be

needed
 Scene Assessment
 First unit on scene
 Rapid assessment of situation

 Full assessment as safety and time permit

 Type of incident and potential duration
 Entrapment or special rescue resources needed
 Number of patients in each triage category
 Additional resources needed

 Scene assessment continually updated

 Communications
 Command established by radio with dispatch
 EOC is where department heads, government
officers and officials, and volunteer agencies
gather to coordinate response to emergency
event
 Command and EOC share goals

 Different levels of responsibility

 IC is responsible for on-scene activities

 EOC responsible for community-wide response

 Obtaining Resources
 Request additional units as needed:
 Dispatch should have written standard
operating procedure (SOP) for requesting
mutual aid
 May need to obtain food, shelter, clothing

 IC responsible for deployment of resources

 Stay with vehicle until instructions received
 Staging techniques used to deploy resources
 Extrication Sector
 Manages entrapped patients

 Patient care activities in this sector

 Only assessment and treatment of life
threatening situations

 Additional responsibilities
 Treatment Sector
 Works with extrication sector in patient care
 As patients delivered, categorized by medical need

 Care and stabilization until patients transported to

medical facility
 Paramedics and hospital personnel

 With large numbers of patients:

 Divided into immediate and delayed treatment zones
 On-Scene Physicians at
MCIs
 Medical direction
 On-scene medical direction

 Triage function
 Increased ability to make difficult triage decisions
 In treatment area for secondary triage decisions
 Emergency surgery to facilitate extrication

 Treatment capabilities
 Invasive procedures
 Assessment and direction of specific treatments
 Disposition of the
Deceased
 Depends on scale of incident
 Personnel assigned to disposition of deceased

 Duties
 Work with medical examiner, coroner, law
enforcement to coordinate disposition
 Assist in establishment of secure area for morgue
if needed
 Monitor personnel for signs of stress
 Transportation Sector
 Communicates with hospitals, ambulances, and
aeromedical services for patient transport

 Works closely with treatment sector to

determine appropriate patient destinations

 Arrival and departure of vehicles coordinated

with staging sector

 Responsibilities
 Staging Sector
 Prevents vehicle congestion and
response delays

 All emergency vehicles should report

for direction
 Other agencies supervised by staging
sector (disaster relief, news media)

 Responsibilities
 Rehabilitation (Rehab)
Sector
 Standard operating procedures in many fire
and EMS agencies and major incident
response plans

 Set up outside operational area

 Monitors personnel
 Ensures proper rest and hydration

 Works with logistics sector

 Support Sector
 Coordinates equipment and supplies
for all sectors

 May obtain medical supplies from

hospitals, rescue supplies, and other
equipment

 Responsibilities
 Sector Identification
 All emergency responders must know ICS
structure and radio communication
procedure

 Clothing and identification vary by system

 Color-coded vests identify personnel
 Most communication face to face
 Exception
 Command and sector communications
 Radio use is for command operations
 Sector Identification
 Radio communications use operation
titles:
 "EMS sector to command" or "Fire sector
to rescue sector"
 Ensures reaching appropriate individual
by one radio designation
 Radio Communications
 Key function during major incident
 Preplanning includes identification of
radio frequencies

 Responding units should have radios

using common frequency
 Separate frequencies for EMS, fire, and
other support operations
 Radio Communications
 Sector officers’ radios on channel
that permits direct communications
with command
 Frequencies may be assigned in
advance
 Or by dispatching agency at incident
 Radio Communications
 Clear, concise, and in plain English
 Helps set orderly tone
 Avoid use of radio codes/signals

 Prepare messages before transmitting

 Clearly identify unit number or sector

 Minimize radio traffic

 Face-to-face communication preferred

 Common Problems of
MCIs
 Failure to notify everyone

 Lack of rapid patient stabilization

 Failure to collect patients in treatment area

 Failure to triage properly

 Administering too much care

 Transporting patients prematurely

 Common Problems of
MCIs
 Using personnel improperly

 Failure to distribute patients to hospitals

appropriately

 Lack of EMS command in field

 Lack of hospital communication

 Lack of preplanning and training

 Principles of Triage
 Triage
 Method to categorize patients for priorities of
treatment

 Assessment of injury severity based on:

 Abnormal physiological signs
 Anatomic injury (and mechanism of injury)
 Concurrent disease factors

 Triage is a continuous process during a major

incident
 Primary vs. Secondary
Triage
 Primary triage
 Categorizes patient condition for treatment
 Documents patient location and transport
needs
 Labels patient with triage labels, tags, or tape

 Focuses on speed to sort patients

 No care rendered during primary triage

 Except lifesaving airway or hemorrhage control
 Primary vs. Secondary
Triage
 Secondary triage
 At treatment area
 Patients retriaged and labeled

 Not always necessary

 Especially at small incidents
 START Triage
 START (simple triage and rapid
treatment)
 60-second assessment

 Evaluate:
 Ability to walk
 Respiratory effort

 Pulses/perfusion

 Neurological status
 START Triage
 Classify patients as:
 Urgent
 Delayed

 Dead or dying

 Critical
 START Triage
 Allows rescuers to:
 Identify patients at risk of early death
 Advise others of patient's need for
stabilization by tagging with disaster
tags
START Triage System

Insert
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 START Triage
 Assess ability to walk

 Evaluate breathing and rate

 Assess pulses/perfusion

 Assess mental status

 START Triage
 Repositioning of airway and
controlling severe hemorrhage are
only treatment efforts in primary
triage:
 In a mass casualty event, these
measures should not delay triage of
other patients
 Triage Tagging/Labeling
 Many tags, tape, and labels available

 International color coding and priorities

 Immediate Red Priority-1 (P-1)
 Delayed Yellow Priority-2 (P-2)
 Hold Green Priority-3 (P-3)
 Deceased Black Priority-0 (P-0)
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 Purpose of Tagging
 Identifies priority

 Prevents retriage of patient

 Tracking system during treatment/ transport

 Tags and labels should:

 Be easy to use
 Rapidly identify patient priority
 Allow for easy tracking
 Allow room for some documentation
 Prevent patients from retriaging themselves
 Tracking Systems for
Patients
 A destination log is maintained by
the transportation section officer
 Should have name or triage label ID
number
 Tracking log must contain:
 Patient identification
 Transporting unit

 Patient priority

 Hospital destination
ICS Patient Log
 Transportation of
Patients
 Method of transportation determined
by triage priority and situation

 Ambulance a typical method

 Buses considered for transporting a

large number of priority 3 patients

 Air ambulances for critical patients

 Critical Incident Stress
Management
 Critical incident stress
 Potential for rescuers at major events
 Critical incident stress debriefings part
of postdisaster SOP
 Types of services

 Other approaches to manage stress

 Conclusion
A major incident is an event for which available
resources are insufficient to manage the number
of casualties or the nature of the emergency. It
may overwhelm local, regional, state, and even
national and international capabilities.
Questions?