Professional Documents
Culture Documents
FIRST RESPONDERS
Dario Gonzalez
OBJECTIVES:
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Understand the goals of emergency medical services activities at the disaster scene;
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Discuss the roles of the various first-responder agencies and teams;
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Describe the five key pieces of information for the hospital nurse to obtain from the field; and
Discuss local emergency management’s disaster role, including its relation to health care.
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if the hospital becomes damaged during the event, the nursing staff may need
to lead or coordinate directly with field agencies in triage, assessment, evalu-
ation and evacuation of victims and staff.
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Table 4.1: Comparison of Advanced Life Support (ALS) skills with Basic Life Support (BLS) skills.
(AED = automatic external defibrillator; ECG = electrocardiogram; CPAP = continuous positive
airway pressure)
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Yellow Treatment
Transportation
Black
Transportation Casualty
Collection
Point
Figure 4.1: Schematic depicting the field triage process and possible designated sectors
Under normal circumstances, EMS staff initiate field triage and establish an
organizational command presence. The actions at the scene of a disaster or mass-
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SECTOR FUNCTION
Staging location Destination point for arriving EMS services (not at the incident
site)
Transportation Location from which ambulances will depart with patients being
transported to the receiving healthcare facilities or other
designated receiving facilities
Casualty collecting point(s) Location(s) where victims are sequestered (after triage)
according to their triage level. Care may be provided in this
area and it can serve as a pre-transport staging victim
collection area as well. Ideally, the Red-tagged victims should be
removed immediately and not wait in a casualty collection area
(assuming sufficient transportation resources).
Hot zone/Exclusion zone The incident exclusion zone where the potential for worker
injury or exposure is high.
casualty incident (MCI) are directed at establishing a command and control pro-
cess for all EMS activities. This process begins with the first arriving EMS unit,
which assumes the responsibility of establishing a triage area and communicating
with the on-scene emergency responder Incident Commander (e.g., fire or po-
lice). The goal of this initial triage is to determine or estimate the number of vic-
tims and potential victims, and their general triage categories (Table 4.2).
Field EMS triage is a process by which patients are categorized on the basis
of medical transport acuity (Figure 4.1). The purpose of this triage process is to
ration limited medical and transportation resources to effect the most good for
the greatest number of victims.
The initial EMS crew communicates with the dispatch system and pro-
vides an immediate, on-scene status report. This allows for the dispatching of
necessary EMS resources and additional administrative personnel. This also
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begins the process of assessing the current status and capabilities of the local
hospitals and specialty resources (i.e., burn and trauma centers).
It is not the function of the initial, responding EMS crew to begin the
transport or immediate treatment of on-scene victims. Their initial priorities
are administrative, providing triage and essential communications until addi-
tional resources arrive at the scene. Often, this is a frustrating time for EMS
personnel and other emergency response personnel whose natural reaction is
to assist victims; however, it is necessary to ensure that all patients are
accounted for and correctly triaged, and that command is established to coor-
dinate other arriving EMS units and resources.
Once other EMS resources have arrived at the scene, the organizational
process begins by establishing the required sectors to manage the situation.
These sectors are outlined in Table 4.3, and may vary depending on the scope
and nature of the incident.
Health care at the scene of a disaster normally is limited to basic life sup-
port services. Intravenous medications and endotracheal intubation are late
treatment options depending on the number and degree of injuries and the
available emergency care providers. This limitation of care requires that hos-
pital personnel be prepared to provide immediate and aggressive interven-
tions of transported victims.
Mass-casualty disaster triage has very specific, yet limited, goals: to iden-
tify the most salvageable victims and deliver them to definitive medical
resources. Additionally, the EMS system is responsible for the transfer of a
large number of victims to a limited number of hospitals. This may require
the transport of victims to facilities beyond the immediate region based on
frequent hospital status updates.
Scene Difficulties
Delays in the transportation of victims should be expected; the first patients
transported by EMS likely will begin to arrive at the hospital within 90 min-
utes after the event. Transportation delays are an inevitable consequence of
standard operating EMS procedures compounded by scene confusion, scene
assessment, and the establishment of safe areas of operation. Access to the
immediate disaster area and to the victims may be delayed due to physical
barriers or distant locations (e.g., subway or train tunnel), as well as concerns
of potential, secondary, explosive devices or structurally unsafe areas.
Other common problems at mass-casualty incident sites include:
1. Failure to organize and separate victims based on triage categories;
2. Failure to transport critical Category 1/Red tag victims as soon
as transportation resources allow;
3. Failure to establish a safe, efficient, and appropriate patient
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careful disaster planning and preparedness incorporating the EMS along with
the medical infrastructure.
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located at 7 World Trade Center (WTC), was destroyed. The agency ultimately established its operations
at a local ship/passenger liner terminal (pier). The OEM continued to function out of this location and
coordinated the response to the NYC/WTC crisis and the subsequent anthrax events of 2001. The OEM
provided medical coordination with the NYC Commissioner of Health and served as the liaison between
the city government and the NYC healthcare system. In addition, it hosted, served as a link, and provided
logistical support to a senior medical advisory group composed of a cross-section of city healthcare
providers, both for the Mayor and the Commissioner of Health. The purpose of the group was twofold:
(1) to assist the city in developing an anthrax medical response plan; and (2) to provide public communica-
tion for the media. The OEM also assumed the role of assisting and facilitating the other emergency
One issue that was revealed in the aftermath of the 9/11 attacks was the need to address the concerns
and needs of the corporate sector of the community. The loss of this sector could have had devastating
consequences to the economy of NYC. It was necessary to coordinate and facilitate activities with the
corporate sector in order to reestablish vital city services and a sense of “normalcy” to the community.
Moves were made to assist the business sector in such a way as to allow them to re-establish the provi-
In addition, the OEM was responsible for coordinating large numbers of volunteers and response
agencies and collaborated with other city agencies to create the Family Assistance Unit. The latter provided
families a single location from which to achieve information and assistance immediately following the
events of 9/11.
able teams operating under the direction of the Federal Emergency Management
Agency (FEMA).7 In Australia, there are US&R teams throughout the states
and territories.8,9 The Japan Disaster Relief Team’s Search and Rescue Unit has
responded to earthquakes in Indonesia, El Salvador, and Turkey.10
Due to the relatively late arrival of US&R teams, most disaster victims will
have been removed from a disaster site by local fire department personnel or by
citizens prior to first-responder arrival. However, US&R teams have evolved into
primary response groups for large-scale events, such as terrorist events and disas-
ters from natural causes, when there are long-term and/or overwhelming needs for
rescue teams. In the United States, US&R team deployments were involved in the
2001 World Trade Center attack, the 1995 Oklahoma City bombing, the 2005
Hur-ricane Katrina disaster, and the 2003 Columbia Space Shuttle disaster.11–13
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EMERGENCY MANAGEMENT
Most governments have a designated department or agency that is responsible
for emergency or disaster management. Emergency Management (EM)
involves mitigating, preparing for, responding to, and recovering from major
crises through the coordination of available resources.14 Emergency Manage-
ment is a function of local, state, and national levels of government with organ-
ized responses beginning at the local levels and escalating up to higher levels of
responses if the local agencies’ resources become overwhelmed and unable to
effectively deal with the effects of the event.
Emergency Management reports directly to the governmental manager
and acts as his/her representative. The role of Emergency Management at the
time of a disaster is one of support and coordination of the responding agen-
cies, providing a single point of disaster management oversight. The specific
degree or scope of EM operations is determined by the particular jurisdiction.
The pre-event role of EM is to develop strategies for potential incidents
(based on their likelihood of occurrence and the potential impact), and to
ensure a degree of preparedness on the part of the local institution or munici-
pality. Emergency Management assists and facilitates the continued operation
of the municipal or state government in crisis resolution. The ultimate role of
the designated Emergency Management group is to ensure, or at least initiate, a
return of the impacted location (municipality), population, and health system
toward its pre-disaster state. This includes developing strategic plans that in-
volve multiple agencies and multiple jurisdictions.
Countries vary with regard to where the EM function resides. Within the
United Kingdom, the Civil Contingencies Secretariat, a department of the
British Cabinet, ensures the preparedness and resilience of responders at nation-
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CONCLUSION
During an emergency or a disaster, local first responders attempt to gain con-
trol of the scene, rescue victims, and provide prioritized medical care and
transportation. In general, the role of the first-response agencies is to effect an
overall reduction in morbidity and mortality of the victims. This is accom-
plished by an integrated and functional emergency response system that in-
cludes active nursing participation in disaster preparedness and response.
Healthcare facilities should be incorporated into the planning and prepared-
ness efforts of local first responders to ensure that there is a coordinated, seam-
less flow of patient care from the field into the hospital setting.
REFERENCES
1. US Department of Labor: Occupational Safety and Health Administration: Regulations (Standards-
29 CFR): Hazardous waste operations and emergency response. -1910.120; Occupational Safety
and Health Standards. Available at www.osha.gov/pls/oshaweb/owadisp.show_document?p_table
=standards&p_id=9765. Accessed 20 February 2009.
2. Institute of Medicine and Board on Environmental Studies and Toxicology: Chemical and Biological
Terrorism. Washington, DC: National Research Council; National Academy Press, 1999.
3. Oak Ridge National Laboratory: Don’t be a Victim! Medical Management of Patients Contaminated
with Chemical Agents. Course Student Guide of the Chemical Stockpile Emergency
Preparedness Program. Tennessee: Oak Ridge National Laboratory, 2003.
4. Agency for Healthcare Research and Quality: Pediatric Terrorism and Disaster Preparedness:
A Resource for Pediatricians. Available at www.ahrq.gov/research/pedprep. Accessed 20
February 2009.
5. Capitol Region Metropolitan Medical Response System (MMRS): The Capitol Region
Metropolitan Medical Response System Rapid Access Mass Decontamination Protocol. January
2003. Available at www.au.af.mil/au/awc/awcgate/mmrs/mass_decon.pdf. Accessed 27 March
2009.
6. Freyberg CW, Arquilla B, Fertel BS, et al: Disaster preparedness: Hospital decontamination
and the pediatric patient: Guidelines for hospitals and emergency planners. Prehosp Disaster
Med 2008;23(2):166–174.
7. Federal Emergency Management Agency (FEMA): About US&R. Available at www.fema.gov/
emergency/usr/about.shtm. Accessed 20 February 2009.
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