Chapter 38 Incident Command

Chapt 38 Incident Command National Incident Management System -The Secretary of Homeland Security implemented the NIMS in 2004. 1. It provides a framework to enable federal, state, and local governments, as well as private-sector and nongovernmental organizations, to work together effectively 2. The organizational structure must be flexible enough to be rapidly adapted for use in any situation. 3. The NIMS provides standardization in: a. Terminology, b. Resource classification, c. Personnel training, d. Certification 4. Another important feature is the concept of interoperability, which refers to the ability of agencies of different types or from different jurisdictions to communicate with each other. The ICS is one component of the NIMS. 1. The major NIMS components are as follows: a. Preparedness b. Communications and information management c. Resource management d. Command and management e. Ongoing management and maintenance Incident Command System -The ICS is sometimes referred to as the incident management system. The purpose of the ICS is: 1. Ensure responder and public safety 2. Achieve incident management goals 3. Ensure the efficient use of resources Communication is the building block of good patient care. 1. Common terminology and the use of “clear text” communications help responders from multiple agencies work efficiently together. -The goal of the ICS is to make the best use of your resources to manage the environment around the incident and to treat patients during an emergency. 1. The ICS is designed to control duplication of effort and freelancing. 2. One of the organizing principles of the ICS is limiting the span of control of any one individual. 3. Organizational levels may include sections, branches, divisions, and groups. The ICS roles and responsibilities 1. The general staff includes command, finance, logistics, operations, and planning. 2. Command staff includes the public information officer (PIO), safety officer, and liaison officer. 3. Command a. The incident commander (IC) is in charge of the overall incident. b. Large incidents require a multiagency or multijurisdiction response and need to use a unified command system. c. Single command system is one in which one person is in charge, even if multiple agencies respond. d. It is important that EMTs know who the IC is, how to communicate with the IC, and where the command post is located. i. If the incident is very large, EMTs will report to a supervisor working under the IC. e. An IC may transfer command to someone with more experience in a critical area. f. When an incident draws to a close, there should be a termination of command. 4. Finance a. Responsible for documenting all expenditures at an incident for reimbursement b. Various functions within the finance section: i. Time unit. ii. Procurement unit, iii. Compensation/claims unit 5. Logistics a. The logistics section or section chief has responsibility for: i. Communications equipment, Facilities, Food and water, Fuel, Lighting 7. Planning a. This section solves problems as they arise. i. Obtains data about the problem ii. Analyzes the previous incident plan iii. Predicts what or who is needed to make the new plan work iv. Works closely with the operations, finance, and logistics sections b. Another function is to develop an incident action plan, which is the central tool for planning during a response to a disaster emergency. 8. Command staff a. The safety officer monitors the scene for conditions or operations that may present a hazard to responders and patients. i. Has the authority to stop an emergency operation whenever a rescuer is in danger ii. A safety officer should remove hazards to EMS personnel and patients before the hazards cause injury. b. The public information officer (PIO) provides the public and media with clear and understandable information. c. The liaison officer relays information and concerns among command, the general staff, and other agencies. Communications and information management 1. Communication has historically been the weak point at most major incidents. 2. It is recommended that communications be integrated. a. All agencies should be able to communicate quickly and effortlessly via radios. b. Communications allow for accountability throughout the incident, as well as instant communication between recipients. Mobilization and deployment 1. When an incident has been declared and the need for additional resources has been identified, a request is made for additional resources. 2. Check-in at the incident a. On arrival at an incident, you should check in with the incident commander. b. Checking in accomplishes different functions: i. Allows you to be assigned to a supervisor for job tasking ii. Allows for personnel tracking throughout the incident iii. Ensures that costs, pay, and reimbursement can be calculated accurately 3. Initial incident briefing a. Report to your supervisor for an initial briefing that will allow you to get information regarding the incident, as well as specific job functions and responsibilities. 4. Incident record keeping a. If a large piece of equipment becomes inoperable, it may be possible for replacement costs to come from the incident. b. Record keeping allows for tracking of time spent on actual incident for reimbursement 5. Accountability a. Accountability means keeping your supervisor advised of your location, actions, and completed tasks. b. Includes advising your supervisor of the tasks that you have been unable to complete and what tools you need to complete them 6. Incident demobilization a. Once the incident has been stabilized and all of the hazards mitigated, the IC will determine which resources are needed or not needed and when to begin demobilization. b. This process allows for prompt return of resources to their parent organizations to be placed back in service. EMS Response Within the Incident Command System -Preparedness 1. Preparedness involves the decisions made and basic planning done before an incident occurs. 2. Preparedness in a given area involves decisions and planning about the most likely natural disasters for the area, among other disasters. 3. Your EMS agency should have written disaster plans that you are regularly trained to carry out. a. A copy of the disaster plan should be kept in each EMS vehicle. b. Your local EMS organizations should develop an assistance program for the families of EMS responders. The Medical Branch of Incident Command -Medical incident command is more commonly known as the medical (or EMS) branch of the ICS. 1. The medical branch director will supervise the primary roles of the medical branch—triage, treatment, and transport of injured people. 2. The medical branch director will help ensure that: a. EMS units responding to the scene are working within the ICS b. Each medical division or group receives a clear assignment before beginning work at the scene c. Personnel remain with their vehicle in the staging area until they are assigned their duties Triage supervisor 1. Ultimately in charge of counting and prioritizing patients 2. The primary duty of the triage division or group is to ensure that every patient receives initial assessment of his or her condition. 3. One of the most difficult parts of being a triage supervisor is that you must not begin treatment until all patients are triaged, or you will compromise your triage efforts. Treatment supervisor 1. The treatment supervisor will locate and set up the treatment area with a tier for each priority of patient. 2. Treatment supervisors ensure that secondary triage of patients is performed and that adequate patient care is given as resources allow. 3. Treatment supervisors assist with moving patients to the transportation area. Transportation supervisor 1. The transportation supervisor coordinates the transportation and distribution of patients to appropriate receiving hospitals and helps to ensure that hospitals do not become overwhelmed by a patient surge. 2. The transportation supervisor documents and tracks the number of transport vehicles, patients transported, and the facility destination of each vehicle and patient. Staging supervisor 1. Staging supervisor is assigned when an MCI or disaster requires multivehicle or multiagency response 2. Emergency vehicles must have permission from the staging supervisor to enter an MCI scene and should only drive in the directed area. 3. Staging area should be established away from the scene so that the parked vehicles are not in the way. Physicians on scene 1. Emergency physicians will have the ability to make difficult triage decisions. 2. They also provide secondary triage decisions in the treatment area, deciding which priority patients are to be transported first. 3. Physicians can provide on-scene medical direction for EMTs, and they can provide care in the treatment sector as appropriate. Rehabilitation supervisor 1. Rehabilitation supervisor establishes an area that provides responders with rest, fluids, food, and protection from the elements and the situation. 2. Rehabilitation area should be located away from exhaust fumes and crowds and out of view of the scene itself. 3. The rehabilitation supervisor must also monitor responders for signs of stress. Extrication and special rescue 1. An extrication supervisor or rescue supervisor determines the type of equipment and resources needed for the situation. 2. Because extrication and rescue are medically complex, the supervisors will usually function under the EMS branch of the ICS. Morgue supervisor 1. The morgue supervisor will work with area medical examiners, coroners, disaster mortuary assistance teams, and law enforcement agencies to coordinate removal of the bodies and body parts. 2. The morgue supervisor should attempt to leave the dead victims in the location found, if possible, until a removal and storage plan can be determined. 3. The morgue area should be out of view of the living patients and other responders, and it should be secured from the public. Mass-Casualty Incidents An MCI is: 1. An emergency situation that involves three or more patients, places great demand on the EMS system and/or has the potential to produce multiple casualties. Triage -“Triage” simply means “to sort” patients based on the severity of their injuries. 1. The goal of doing the greatest good for the greatest number means that the triage assessment is brief and the patient condition categories are basic. a. Primary triage is the initial triage done in the field. b. Secondary triage is done as patients are brought to the treatment area. 2. During primary triage, patients are briefly assessed and then identified in some way, such as by attaching a triage tag or triage tape. 3. After the primary triage, the triage supervisor should communicate the following information to the medical branch director: a. The total number of patients b. The number of patients in each of the triage categories c. Recommendations for extrication and movement of patients to the treatment area d. Resources needed to complete triage and begin movement of patients 4. When the initial triage has been completed, secondary triage (retriage) can occur, allowing for the EMT to reassess all remaining patients and to upgrade the triage category, if necessary. Triage categories 1. There are four common triage categories. a. Immediate (red) b. Delayed (yellow) c. Minor or minimal (green; hold) d. Expectant (black; likely to die or dead) Triage tags 1. Tagging patients early assists in tracking them and can help keep an accurate record of their condition. 2. Triage tags should be weatherproof and easily read. 3. The patient tags or tape should be color-coded and should clearly show the category of the patient. 4. The tags will become part of the patient’s medical record. 5. Whatever labeling system is used, it is imperative for the transportation officer to be able to identify which patient was transported by which unit and to which destination, and the priority of the patient’s condition. START triage 1. One of the easiest methods of triage a. Stands for Simple Triage And Rapid Treatment b. Uses a limited assessment of the patient’s ability to walk, respiratory status, hemodynamic status (pulse), and neurologic status 2. The first step is performed on arrival at the scene by calling out to patients at the disaster site and then directing them to an easily identifiable landmark. a. The injured persons in this group are the walking wounded and are considered minimal (green) priority, or third-priority patients. 3. The second step is directed toward nonwalking patients. a. Move to the first nonambulatory patient and assess the respiratory status. b. If the patient is not breathing, open the airway by using a simple manual maneuver. c. A patient who still does not begin to breathe is triaged as expectant (black). d. If the patient begins to breathe, tag him or her as immediate (red), place the patient in the recovery position, and move on to the next patient. 4. If the patient is breathing, make a quick estimation of the respiratory rate. 5. The next step is to assess the hemodynamic status of the patient by checking for bilateral radial pulses. 6. The final assessment is to assess the patient’s neurologic status by assessing the patient’s ability to follow simple commands. JumpSTART triage for pediatric patients 1. Intended for use in children younger than 8 years or who appear to weigh less than 100 lb 2. Begins by identifying the walking wounded a. Infants or children not developed enough to walk or follow commands (including children with special needs) should be taken as soon as possible to the treatment sector for immediate secondary triage. 3. There are several differences within the respiratory status assessment compared with that in START. a. If you find that a pediatric patient is not breathing, immediately check the pulse. b. If there is no pulse, label the patient as expectant (black). c. If the patient is not breathing but has a pulse, open the airway with a manual maneuver. d. If the patient does not begin to breathe, give five rescue breaths and check respirations again. e. A child who does not begin to breathe should be labeled expectant. 4. The next step is to assess the approximate rate of respirations. 5. The next assessment is the hemodynamic status of the patient. a. Assess the pulse that you feel the most competent and comfortable checking. b. If there is an absence of a distal pulse, label the child as an immediate priority and move to the next patient. 6. The final assessment is for neurologic status (modified AVPU score is used) Triage special considerations 1. Patients who are hysterical and disruptive to rescue efforts may need to be handled as an immediate priority and transported off the site, even if they are not seriously injured. 2. A responder who becomes sick or injured during the rescue effort should be handled as an immediate priority and be transported off the site as soon as possible. 3. Hazardous materials (HazMat) and weapons of mass destruction incidents force the HazMat team to identify patients as contaminated or decontaminated before the regular triage process. Destination decisions 1. All patients triaged as immediate (red) or delayed (yellow) should preferably be transported by ground ambulance or air ambulance, if available. 2. In extremely large situations, a bus may transport the walking wounded. 3. Immediate-priority patients should be transported two at a time until all are transported from the site. a. Then pts in delayed category can be transported two or three at a time until all are at a hospital. Disaster Management -Disaster is a widespread event that disrupts the functions and resources of a community and threatens lives and property. 1. Many disasters may not involve personal injuries. 2. On the other hand, many disasters such as floods, fires, and hurricanes will result in widespread injuries. a. Unlike an MCI, which generally lasts no longer than a few hours, emergency responders will generally be on the scene of a disaster for days to weeks and sometimes months. b. Only an elected official can declare a disaster. -Your role in a disaster is to respond when requested and to report to the IC for assigned tasks. 1. In a disaster with an overwhelming number of casualties, area hospitals may decide that they cannot treat all patients in their facility. 2. They may mobilize medical and nursing teams with equipment. 3. Using facility such as a warehouse near the disaster scene, they will set up a casualty collection area to: a. Perform triage, Provide medical care, Transport patients to the hospital on a priority basis 4. If a casualty collection area is established, it will be coordinated through the ICS in the same way as all other branches and areas of the operation. Introduction to Hazardous Materials -When you arrive at a possible HazMat incident, you must first step back and assess the situation. 1. Rushing into unsafe scenes can have catastrophic results. a. If overcome, you will be unable to assist patients. b. Requiring emergency care yourself, you will then further strain the EMS system. -Because of the unique aspects of responding to and working at a HazMat incident, OSHA has published a set of guidelines known as Hazardous Waste Operations and Emergency Response Standard (or HAZWOPER) 1. EMTs are required to have training at the First Responder Awareness Level. 2. First responders at the awareness level should have sufficient training or experience demonstrate the following competencies: a. An understanding of what hazardous substances are and the risks associated with them b. An understanding of the potential outcomes of an incident c. The ability to recognize the presence of hazardous substances d. The ability to identify the hazardous substances, if possible Recognizing a Hazardous Material -A hazardous material is any material that poses an unreasonable risk of damage or injury to persons, property, or the environment if it is not properly controlled during: 1. Handling, Storage, Manufacture, Processing, Packing, Use and disposal, Transportation -Hazardous materials may be involved in any of the following situations: 1. A truck or train crash in which a substance is leaking from a tank truck or railroad tank car 2. A leak, fire, or other emergency at an industrial plant, refinery, or other complex where chemicals or explosives are produced, used, or stored 3. A leak or rupture of an underground natural gas pipe 4. Deterioration of underground fuel tanks and seepage of oil or gasoline into the surrounding ground 5. Buildup of methane or other by-products of waste decomposition in sewers or sewage-processing plants 6. A motor vehicle crash resulting in a ruptured gas tank -It is important to approach the scene from a safe location and direction. 1. The traditional rules of staying uphill and upwind are a good place to start. 2. It may be wise to use binoculars and view the scene from a safe distance. 3. Be sure to question anyone involved in the incident. Containers 1. In basic terms, a container is any vessel or receptacle that holds a material. 2. Often the container type, size, and material of construction provide important clues about the nature of the substance inside. a. Don’t rely solely on type of container when making a determination about hazardous materials 3. One way to distinguish containers is to divide them into two categories based on their capacity: bulk and nonbulk storage containers. 4. Container volume a. Bulk storage containers include: i. Fixed tanks, Highway cargo tanks, Rail tank cars, Totes The Department of Transportation (DOT) marking system 1. Labels, placards, and other markings are used on buildings, packages, boxes, and containers. 2. Marking systems indicate the presence of a hazardous material from a safe distance and provide clues about the substance. a. Placards are diamond-shaped indicators that are placed on all four sides of highway transport vehicles, railroad tank cars, and other forms of transportation carrying hazardous materials. b. Labels are smaller versions of placards, placed on the four sides of individual boxes and smaller packages being transported. Other considerations 1. The DOT system does not require that all chemical shipments be marked with placards or labels. 2. In most cases, the package or cargo tank must contain a certain amount of hazardous material before a placard is required. a. Commercial package delivery services often carry small amounts of hazardous materials that fall below that weight limit. b. The vehicle exterior will not display placards to warn of the danger. 3. Conversely, some chemicals are so hazardous that shipping any amount of them requires the use of labels or placards, such as: a. Explosives, Poison gases, Water-reactive solids, High-level radioactive substances The Emergency Response Guidebook a. Offers a certain amount of guidance for responders operating at a HazMat incident b. Updated every 3 to 4 years c. Provides information on approximately 4,000 chemicals 2. Material safety data sheets (MSDS) a. A common source of information about a particular chemical b. Provides basic information about: i. Chemical makeup of a substance, The potential hazards it presents ii. Appropriate first aid in the event of an exposure 4. Chemical Transportation Emergency Center (CHEMTREC) a. CHEMTREC is operated by the American Chemistry Council. b. Provides invaluable technical information for first responders of all disciplines who are called upon to respond to chemical incidents c. When you call CHEMTREC, be sure to have the following basic information ready: i. The name of the chemical(s) involved in the incident ii. Name of the caller and callback telephone number iii. Location of the actual incident or problem iv. Shipper or manufacturer of the chemical (if known) Identification 1. Despite the availability of resources, identification may still be difficult. a. Little consistency is used on labels and placards, and dishonest transporters sometimes will not label containers or vessels appropriately. b. Always maintain a high index of suspicion when approaching the scene of a truck or train tanker accident. 2. In the event of a leak or spill, a HazMat incident is often indicated by the presence of the following: a. Visible cloud or strange-looking smoke from the escaping substance b. Leak or spill from tank, container, truck, or railroad car with/without HazMat placards or labels c. Unusual, strong, noxious, harsh odor in the area 3. A large number of hazardous gases and fluids are essentially odorless even when a substantial leak or spill has occurred. a. If you approach a scene where more than one person has collapsed or is unconscious or in respiratory distress, you should assume that there has been a HazMat leak or spill and that it is unsafe to enter the area. 4. The safety of you and your team, the other responders, and the public must be your most important concern. 5. If, as you approach, any signs suggest that a HazMat incident has occurred, you should stop at a safe distance and park upwind or uphill from the incident. a. After rapidly sizing up the scene, call for the HazMat team. b. If you do not recognize the danger until you are too close, immediately leave the danger zone. c. Try to rapidly assess the situation and try to provide as much information as possible when calling for the HazMat team. d. Don’t reenter scene and do not leave the area until you have been cleared by the HazMat team. HazMat scene operations 1. Focus your efforts on activities that will ensure the safety and survival of the greatest number of people. 2. Use the public address system on the ambulance to alert individuals near the scene and direct them to move to a safer area. 3. Establishing control zones a. Control zones are established at a HazMat incident based on the: i. Chemical and physical properties of the released material ii. Environmental factors at the time of the release iii. General layout of the scene b. Securing access to incident helps ensure that no one will accidentally enter contaminated area c. If the incident takes place inside a structure, the best place to control access is at the normal points of ingress and egress—doors. d. If the incident occurs outside, control intersections, on and off ramps, service roads, and other access routes to the scene. Classification of hazardous materials 1. The National Fire Protection Association (NFPA) 704, Hazardous Materials Classification standard classifies hazardous materials according to: a. Health hazard or toxicity levels, Fire hazard, Chemical reactive hazard, Special hazards 2. Toxicity levels a. Measures the health risk that a substance poses to someone who comes into contact with it b. The higher the number, the greater the toxicity, as follows: i. Level 0 includes materials that would cause little, if any, health hazard if you came into contact with them. ii. Level 1 includes materials that would cause irritation on contact but only mild residual injury, even without treatment. iii. Level 2 includes materials that could cause temporary damage or residual injury unless prompt medical treatment is provided. iv. Level 3 includes materials that are extremely hazardous to health. v. Level 4 includes materials that are so hazardous that minimal contact will cause death. c. All health hazard levels, with the exception of 0, require specialized training and respiratory and chemical protective gear that is not standard on most ambulances. Caring for patients at a HazMat incident 1. It is practical only to provide the simplest assessment and essential care in the hazard zone and the decontamination area because of the: a. Dangers, Time constraints, Bulky protective gear that team members wear 2. To avoid entrapment and spread of contaminants, no bandages or splints are applied (except pressure dressings that are needed to control bleeding). 3. The EMTs providing care in the treatment area should assess and treat the patient in the same way as they would a patient who has not been previously assessed or treated. 4. Your care of patients at a HazMat incident must address the following two issues: a. Any trauma that has resulted from other related mechanisms b. The injury and harm that have resulted from exposure to the toxic hazardous substance