In late fall of 2009, I was asked to join a team at the National Fire Academy (NFA) that would be developing a series of training programs to enhance the capability of the nation’s fire and EMS first responders to manage mass casualty incidents (MCIs).
NFA EMS Program Chairman, Michael Stern envisioned a series of progressive training programs, using scenario-based training that would evolve from introducing the student to the fundamental concepts of MCI management, to the student acting as an incident commander and MCI branch director for complex multi-agency/jurisdictional MCI scenarios. Stern’s direction was for best practices in MCI management to be the common theme “woven throughout all the programs.”
NFA completed and successfully piloted the two-day EMS Functions in Incident Command System in mid 2010 and immediately began working on the six-day Emergency Medical Services Incident Operation (EMSIO) program. This program primarily focuses on operations within the MCI branch and is similar to other command and control programs at the NFA in which the students actually perform the various functional roles within an incident command system (ICS) in dynamic, instructor-guided exercises.
On the evening of May 25, 2011, the development team, along with NFA staff and other senior NFA instructors, conducted a rehearsal of one scenario from the EMSIO program to test the format and work out any glitches before a pilot course was offered.
The rehearsal students were selected from several programs that were being conducted on the NFA campus. Having already been through four days of simulated mayhem in their regular classes, the students felt ready for whatever would be thrown at them. So we chose a challenging scenario for them–a major accident involving a fully loaded tour bus.
The students’ performances were outstanding, and the rehearsal was deemed a success by all the stakeholders present. As we “hot washed” the rehearsal, we felt confident that we had met the intent of Stern’s direction and incorporated best practices into the practical learning exercise.
Training Meets Reality
This training exercise turned into reality for me and many others less than a week after the scenario rehearsal. In the early morning hours of May 30, I was dispatched with Virginia’s Division 1 Heavy Tactical Rescue Team to a fully loaded, overturned tour bus on I-95 in Caroline County, Va. This accident resulted in a major MCI that required a multi-jurisdictional response to mitigate.
I arrived at the incident command post (ICP), and the incident commander (IC) said, “Lloyd, you have the MCI branch.” With those words echoing in my ears, and while listening to the incident briefing, I kept thinking about the best practices we drilled the NFA students about a few days earlier. I’d like to share with you a few of the best practices we learned from our experience in MCI management.
“˜Typing’ MCIs
One step you can take is to pre-type your MCI levels and have predetermined action levels for your agency and jurisdiction in your emergency operations plan (EOP). The National Incident Management System (NIMS) doesn’t “type” MCIs. In NIMS, however, incidents are typed by the number of operation periods and resource requirements. For example, here’s a comparative typing that has been adopted by many communities throughout the country to assist them in determining agency and community response objectives:
Type I: Greater than 100 patients (dollar)
Type II: 50—100 patients (50 cents)
Type III: 25—50 patients (quarter)
Type IV: 10—25 patients (dime)
Type V: Five to 10 patients (nickel)
A smaller or medium-sized community’s response objective would be for the community to declare a local emergency and staff their emergency operation center for a Type IV MCI to ensure adequate resources are maintained in the community for its baseline service volume.
Another best practice is to address the patient generator (PG) in your incident action plan (IAP). The patient generator refers to the hazard, action or situation that creates patient volume.
PG x human vulnerability = patient volume or casualties
Two kinds of PGs exist: static and dynamic. A static PG is inactive and no additional damage is expected (e.g., bleacher collapses and automobile crashes into a crowd). A dynamic PG is still active and may have to be mitigated before care begins (e.g., active shooter, hazmat, fire, environmental and flu pandemic). One of the incident management team’s primary objectives is ensuring a static PG doesn’t become a dynamic PG. Safety of response personnel is paramount. It may not be in your agency’s purview to control the PG, or the PG may be uncontrollable for several operational periods. But always address the PG in your IAP.
Another best practice is to request adequate resources and establish staging. Don’t lose your composure or “piece meal” your resource request as you conduct your size up and give your brief initial report. Estimate the number of potential causalities and request resources by NIMS compliant terms. It isn’t OK to say, “Send me everything you got.” Also, if you want transport units and you say, “Send me a bunch of rescues,” you might end up with a bunch of tandem axle toolboxes. Instead of medics, you may get wild-eyed starting linebackers for a pro-football team dressed in turnouts and looking to break something.
Resources
Your first consideration might be transport units. A good rule to follow is to plan to have roughly half the number of estimated patients. (You can fix it later when triage is completed.) It’s best to order units by strike teams rather than single resources.
Other resources to consider are the functions of triage, rescue and treatment that must be performed. Some tasks, such as rescue and triage, may require the use of firefighting personnel protective gear (PPE) for entry into the hot zone. These tasks are labor intensive and waste your typically limited transport capacities. Pulling people off transport units to do these functions may result in delaying transport of critical patients.
A proven technique for filling these roles is having predetermined MCI boxes or alarms. Arrange to use MCI boxes or alarms with strike teams or task forces to ensure adequate resources are available to effectively perform these functions. It also allows for rotation of personnel to rehab, promoting responder safety.
Staging
Staging is a temporary location at which resources assigned to the incident are held until they’re assigned to a specific function, with a goal of resources being deployable within three minutes. One benefit to staging is that it provides discretionary time to deploy units to the “right” locations at the “right” time, allowing first-in IC to conduct a good size-up. It also provides a pool of resources to address unexpected situations.
In incidents in which EMS transport resources are being deployed, two staging areas should be designated: one for fire or rescue apparatus and another for ambulances. Fire equipment will arrive at the scene and go to work on the incident, essentially staying on scene for the duration of the event. Ambulance resources, especially in communities with limited resources or rural settings, will be taxed. In incidents with multiple patients, ambulances may have to go to and from the scene several times.
This “circuit” starts at staging, then goes to the patient loading area, the hospital and then back to staging. It’s all controlled by the ground ambulance coordinator.
Use strike teams and task forces when possible to optimize and manage the span of control issues. Establish staging locations in areas large enough to accommodate incident resources and in areas secure from hazards. Position staging near major roads or highways, near the incident when possible, and have one entrance and a separate exit to prevent units from having to back up. Advise or pre-brief personnel on incident traffic, safety issues and plans before deployment. Provide units with incident maps that include hospital locations and the best travel routes and safety messages. Ensure resources in staging are operational ready or capable of being deployed in less than three minutes. It’s also imperative that personnel maintain situational awareness.
Benchmarking
In public safety, benchmarking is typically the process of comparing a performance metric (time of completion) to response objectives. When done correctly, the benchmarking process will provide the incident management team (IMT) with crucial situational-awareness information.
Transmission of a triage report to the IC and then to the emergency communications center is important. Triage is the foundation and is such an important part of the incident size up that I’ve modified the old fire service adage from “so goes the first line, so goes the fire,” to “so goes the triage, so goes the MCI.” Triage must be done as soon as possible, using a recognized process to provide the most benefit. It allows for the typing of an MCI and enhances the IC’s ability to provide a more detailed request for resources. It also provides the IC and the ECC with a focused situational awareness of the actual magnitude of the incident.
Completed rescue/extrication is the benchmark that indicates to the IC that the resources assigned to this function are exiting the “hot zone” and should be ready for redeployment if necessary. Last immediate patient (red) transported is the “Visine principle” and emphasizes the importance of quick stabilization and transporting the sickest patients. “Cold steel and bright lights” save patients in a trauma-mechanism PG–not a bunch of time-consuming ALS treatment on the scene. It also reduces the stress level on the entire operations team.
“Under control” is the benchmark we all want to hear. It signals to the IMT and field personnel that the situation has stopped escalating, and in most cases, indicates that it will be mitigated with the resources on scene.
Other Best Practices
Wear your “vest” and use a job-task check sheet or field operation guide (FOG). A common feature of an MCI is that it brings together a lot of players who don’t normally interact, and just because someone has the “white” helmet doesn’t necessarily mean they’re in charge. A statement heard too often in post-incident reviews (PIR) is, “I didn’t know who was in charge.” This is an easy problem to fix: Put on your vest.
Even the most trained and seasoned responder will have moments of confusion in the first minutes of an MCI response. I can’t recall anyone not saying the scene was chaos. The best way to overcome this and to organize the response is by using job-task cheek sheets or an FOG. These references are designed to give the responder a list of their responsibilities and provide a step-by-step guide to meeting the objectives. They work. Just ask any football coach. They all have one.
Another important feature of an MCI is communication. Have a communications plan with a primary and redundant system pre-established. This plan should include provisions for local, regional, state and federal partners to communicate. The plan should identify the method of communications between each of the primary first responder stakeholders: IC, emergency communications center, the receiving hospital(s) and the medical communications coordinator in the transportation group or unit.
Frequently test the primary and redundant systems during drills. Develop simple “work arounds” for those issues that can’t be resolved with technology. Train your staff on those issues, and document them. For example, maybe one issue is that two frequencies can’t be “patched” together because of technology. So get a portable radio on each frequency and assign an assistant to listen to each one to prevent information overload.
Finally, don’t overlook the importance of the triage tag; they’re crucial to patient tracking. Ensure every first-responder fire and EMS unit have at least 25 tags. Each unit should also have a patient tracking form. It’s often helpful to produce them on Rite-in-the Rain paper or laminate the tracking sheet for durability in poor weather conditions and reuse at other incidents.
Conclusion
No patient should leave the scene, regardless of criticality, without the triage tag number and hospital designation that’s recorded and maintained by a member of the IMT on the scene. This is important for many reasons.
If a mobile ambulance bus or a large number of patients are transported by EMS to a hospital that doesn’t know how to manage the large volume of patients, then you’ve simply moved the disaster from the site to the hospital. Remember the management and transfer of patients from the scene is only as good as your local hospital capabilities. JEMS
To request the NFA’s two day EMS Functions in ICS program, please follow the guidelines established by the agency responsible for fire service training in your state. To attend the NFA resident six-day Emergency Medical Services Incident Operation, see the schedule and application direction on the NFA website at www.usfa.dhs.gov/nfa.
Caroline County’s Department of Fire-Rescue and Emergency Management and its primary mutual aid partner for this incident, Hanover County’s Department of Fire and EMS, did an outstanding job of managing the incident. Go online to www.jems.com/journal to see a review of key MCI areas managed well by the responding agencies.
This article originally appeared in September 2011 JEMS as “Practice Makes Perfect: National Fire Academy debuts pilot incident operation course.”
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