What EMS Wants You to Know About Mass-Casualty Incidents


 
 

A.J. Heightman, MPA, EMT-P, Editor-in-Chief, JEMSChristopher L. Paris, JD | | Wednesday, June 13, 2007


Editor's note: After coming across the following article, which first appeared in August 2006 Law Officer Magazine, the Virginia Beach Police Department notified JEMS of how they are taking multiple injury response training further.

All VBPD officers attend a four day certified first responder class in which the START triage system is taught. Officers are trained to take command at an MCI, summon additional resources and establish a green zone for patients. Officers are also made aware that during certain emergencies, they may be tasked to operate ambulances, allowing EMS personnel to tend to patient care.

For more information on the VBPD and its multiple injury response training, please contact Sergeant Armand Rubbo, NREMT-P, at arubbo@vbgov.com.

You're first on the scene of a school bus rollover on a highway exit ramp. There are several injured lying on the roadway and multiple others trapped and injured inside. It's a mass-casualty incident, what emergency medical services (EMS) crews and firefighters commonly refer to as an MCI. You park your cruiser, begin to divert unauthorized traffic away from the scene, give a basic report to your communications center and await the arrival of EMS and fire crews to manage the carnage.

You wish you could do more to help, but no one's ever told you exactly what help EMS needs from law enforcement to make this type of scene run more smoothly until now. This article will give you a summary of important contributions law enforcement personnel can make to help EMS operations at an MCI run smoothly.

Command & Control

Regardless of the size of your department or the number of cruisers on scene, after scene safety and security are under control, one officer should join forces with the principle EMS and fire-service command officers at the scene to help coordinate responding police resources and activities. This frequently doesn't occur at MCIs because cops assume the EMS and fire officers are "doing their thing," and the predominantly patient-care and hazard-control scene doesn't require much police involvement. But that's not the case. There are multiple decisions and operational actions where police involvement can play an important role.

Establishing Incident Command

The National Incident Management System (NIMS) requires that incident command (IC) be clearly established from the beginning of incident operations and that when command is transferred, the process must include a briefing that captures all essential information for continuing safe and effective operations.

Therefore, if you're first on scene, announce your arrival and the fact that you will assume initial command of the incident. You should also identify the exact location of your vehicle.

The police officer who arrives first on scene and declares incident command does not have to remain the IC throughout the incident. If the incident is predominantly EMS, fire or rescue in nature, the initial police IC can relinquish command to a fire or EMS officer when they arrive. Example: "Comm center, Police A-12 is passing incident command to Fire Chief 7A. I will remain at the command post to coordinate the law enforcement branch."

If you're not the first unit on scene or command has already been established, ask your communications center for the location of the command post (CP) and join the fire and EMS leaders in establishing a unified command post. Unified command allows agencies with different legal, geographic and functional authorities and responsibilities to work together effectively without affecting their individual agency authority, responsibility or accountability.

Unified command ensures decisions such as early street closures, vehicle approach and staging areas, evacuation processes, scene safety, dispatch of the coroner or medical examiner, and use of buses to interview witnesses and transfer the injured or evacuees are made in a collective and coordinated manner.

Initial Scene Report

Several pieces of information you report to your communications center will be important to the center and the responding EMS and fire units. These include:

  • A detailed description of the incident;
  • Number of injured parties and your estimate of their severity;
  • Hazards present; and
  • The best vehicle access and approach routes.

Your report might sound something like this: "Comm center, Car 12A. Car 12A is on scene and assuming initial command at an MCI involving a fully-loaded school bus on its side with 45 children and six adults involved. There are two fatalities and at least a dozen critically-injured parties. The rest are walking wounded. The bus appears stable but there's significant diesel fuel, glass and debris on the roadway. Advise incoming units to access the scene via Eastbound I-84 and approach via the fast lane only due to the debris. Also advise them there's a rest area just east of exit 27 that could be used for secondary staging of vehicles."

Your initial report will trigger the communications center to dispatch the appropriate MCI resources, EMS task forces, hazmat teams, air medical services and medical examiner early to manage the incident.

Most communications centers will also notify area hospitals of the incident because of the size and scope of the incident reported.

Avoid 10-Codes

With the continual threat of mass casualty incidents in the post Sept. 11 world, every agency should endeavor to use plain-speak type communication when interacting with multiple agencies at a major incident. Once an integrated communication system is set up at a major incident, it does no one any good if radio traffic doesn't make sense or 10-codes mean different things to different agencies.

An example on a small scale would be a communications center transmission checking the welfare of an officer on a traffic stop. In the Pennsylvania State Police, a dispatcher would ask, "Are you 10-4?" meaning, "Are you OK?" In the Delaware State Police, a dispatcher checking status would ask, "Are you 10-1?" which, to a Pennsylvania trooper, would mean, "Do you have a poor radio signal?"

Imagine the difficulty trying to coordinate a multiple-agency response to an MCI if you use conflicting or confusing radio codes. NIMS training focuses on this concept and reminds us that the way an agency practices is the way it will play at game time. Think of every daily incident as a prelude to the big game and remember that the "players" will revert back to the way they practice.

The EMS/MCI Process

You must understand the EMS processes used in managing MCIs in order to assist in managing them efficiently and effectively.

When confronted by an incident that exceeds their initial treatment or transportation resources, EMS will often triage (sort) the injured by placing color-coded treatment/transportation priority tags on them. Simultaneously, EMS officers will request additional units and position (stage) ambulances in a strategic manner when they arrive.

As a police officer, you perform triage and staging functions on a daily basis but probably don't realize it. When you pull up on a multiple-vehicle collision with six people injured, you take a quick look at the injured, request the dispatch of additional ambulances and mentally note the ones you feel need EMS attention the most. You also note the safest and most convenient approach routes and areas to position arriving ambulances and fire rigs. When the first EMS crew arrives on scene, you tell the crews where it's safe to park their vehicles and which patients appear to have the worst injuries.

On arrival at an MCI, EMS personnel will appoint a triage officer who will oversee the rapid assessment, categorization and identification of each patient. This assists the crews in sending the most appropriate patients to hospitals in an organized and prioritized manner.

EMS personnel will triage the patients according to five basic categories by affixing triage tags, ribbons or other color-coded or numbered ID indicators to them:

  • The most severe injuries (those who will die if they don't get immediate and intensive treatment) are called Priority 1/Immediate patients and color-coded red.
  • Those who have significant injuries but aren't in immediate danger of dying (and can wait at least 20 minutes before being transported), are tagged as Priority 2/Secondary patients and color-coded yellow.
  • The walking wounded with minor injuries that are not of major concern (and can wait a while to be transported in ambulances, vans or buses) are referred to as 3rd Priority/Minor/Delayed patients and color-coded green. (Note: In some EMS systems, patients who have mortal wounds and are not expected to survive may also be tagged green because EMS cannot justify committing ambulances to manage patients who will probably expire before they can reach a hospital facility.)
  • The deceased (or, in some EMS systems, patients expected to die very soon) are tagged as Priority 4/Deceased and color-coded black.
  • Patients not injured (often referred to as the "walking well") who probably don't require EMS care or transport to a medical facility but need to be examined and signed off, will be labeled Uninjured/Walking Well and given a tag to easily identify them (color-coded differently from the other four categories, according to jurisdictional protocol).

Color-Coded Casualty Collection Areas

The primary objective of EMS and fire crews at an MCI is to rapidly treat, immobilize and transport the most critical patients (red tags) first, followed by the yellow- and green-tagged patients. If the number of ambulances is limited, or the incident is located in an area difficult for ambulances to access, EMS will often set up color-coded casualty collection points (CCPs) to temporarily separate and treat the injured prior to transporting them. These areas will routinely be established utilizing the same color code as the patient priorities to ensure their easy identification by all involved personnel.

The Police Role in EMS Access, Egress & Vehicle Staging

One of the most important areas where law enforcement personnel can assist EMS is with the establishment (and policing) of incoming and outgoing ambulance emergency vehicle routes and staging areas. This is critical to resource deployment and the rapid loading and transportation of patients from the scene.

It's important that open access routes be identified, controlled and kept flowing throughout the incident. Help EMS select the best area for units to park to access their treatment and loading area and begin to position incoming ambulances to access that area.

Many incidents become gridlocked because of inappropriately parked and locked vehicles. Direct incoming police, fire and EMS officers, and off-duty personnel who arrive in personal vehicles, to park their vehicles in areas that won't block access and egress routes of responding emergency vehicles.

Staging Areas

If the first-arriving ambulances at a large-scale incident are strategically staged in an identifiable pattern, additional responding units usually see and comply with the staging pattern. Advise your communications center to have the fire/EMS dispatcher direct incoming ambulances to approach and stage in the selected area.

Since space will often be limited in the immediate area around an MCI, law enforcement personnel can help EMS establish and secure primary and secondary vehicle staging areas for ambulances and other specialty vehicles. This may entail securing a portion of the roadway near the incident, a parking lot, adjacent street or, in extreme cases, shutting down lanes of a highway when a major incident totally blocks the southbound lanes.

Police officers are often in the best position to start staging incoming ambulances until an official fire or EMS staging officer is designated. Once in place, a staging officer will don a labeled scene vest and keep ambulances flowing into primary and secondary staging areas, advise drivers to remain with their units at all times and call up ambulances from secondary staging as necessary to keep them flowing into the primary staging area.

Primary staging is the closest area to the incident where ambulances will load patients for transport to hospitals. Ambulances staged in this area may be positioned in a variety of staging patterns. Examples include singe-file staging in tight, limited access locations, two-by-two staging on city streets and side-by-side staging in parking lots.

Secondary staging is for the stockpiling of additional responding ambulances and could involve 30 40 vehicles. Parking lots and adjacent roadways are best suited to serve as secondary staging areas.

"Walking" Ambulances to Key Locations

During MCIs, ambulances from well outside the incident area will be dispatched to assist and transport patients. Because they are unfamiliar with the geographic location and particular street locations, they will often be initially dispatched to respond to easy-to-find locations such as interstate exit ramps or intersections near the scene.

The law enforcement commander will frequently be requested to position an officer at this location, and at other key intersections along the route, to "walk" ambulances to primary or secondary staging areas.

The same assistance may be requested to walk ambulances to hospitals they are unfamiliar with. Example: One police unit may be asked to position itself at the base of an interstate exit ramp and provide initial directions to the exiting ambulances. Depending on the distance to the various hospitals or the complexity of directions, multiple cruisers may need to be positioned at various key intersections along the way to capture and direct ambulances to hospitals.

Scene Security

While security is normally a police function, MCIs require officers to be even more diligent in establishing and maintaining scene security. Curious bystanders and non-dispatched personnel from outlying areas often flock to the scene of an MCI like ants at a picnic, as do members of the media. Therefore, officers must establish a secure scene perimeter as soon as possible. A separate media area will also help keep media representatives from roaming the scene unattended.

The use of scene tape, rope obtained from rescue trucks and a whistle and/or bullhorn will greatly assist you in controlling unwanted visitors. You may initially need to enlist the assistance of a few bystanders to assist you in deploying scene tape until additional police resources arrive.

Inexpensive scene-access stickers can help police control unauthorized scene access. Non-uniformed responders and others with a specific need to proceed beyond the scene-taped perimeter can be screened, logged in at the command post and assigned a properly completed scene-access sticker to be worn on their clothing and returned when they are leaving the scene. This ensures you know who's approved to enter the scene, their name and agency, and where they're allowed to go on scene.

By requiring these individuals to return the ID sticker when leaving the scene, you have a method to ensure they did not become lost or trapped in debris, or leave the scene with souvenirs from the incident.

Summary

While law enforcement personnel are primarily concerned with overall life safety, scene stabilization and property conservation, it's important for officers to know they are a vital part of the MCI management team and need to be involved in MCI scene management early.

A police presence at the command post established at all major incidents will ensure law enforcement is a part of the unified command system required by the Department of Homeland Security and the NIMS. Plain-speak communications is better at a multi-agency scene than the use of conflicting or confusing 10-codes.

Scene security and the initial positioning (staging) of incoming ambulances is crucial to the safe, steady loading and transportation of victims from a scene. Keeping access and egress lanes open, and policing to ensure unauthorized vehicles aren't parked inappropriately at a scene, are also critical to MCI operations.

Armed with the knowledge of how EMS is going to handle the MCI, law enforcement can work from the same paradigm as a facilitator, making operations flow more smoothly.




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