Incident Site Management:

Chain of Command and Inter-Agency Coordination

 Learning Objectives
At the end of this session, the participant should be able to:
• Initiate the work processes for the medical responder at the
incident site.
• Appreciate the hierarchy of command and standard
operating procedure used at the incident site.
• Establish an interagency networking.
Suggested Organizational Structure for Healthcare Providers

Credit to WHO 2018. IMS. OpenWHO.org

 Scenario 1
Your team arrived at the site of a Mass Casualty
Incident involving a bus which had overturned in a busy
highway. You can see the site is jammed with
bystanders, rescue personnel and a lot of vehicles.

What do you want to do?

Arrival at the Incident Site
Zoning Concept at the Incident Site
Forward Field Commander (FFC):
BOMBA
On Scene Commander (OSC):
POLICE
On Site Medical Commander
(OMC)
 Report to On Scene Commander (OSC)
• Usually a Police Officer.
• Located at the On scene
Command Post
(OCP/PKTK)
• Most of the time arrived
earlier than Medical
teams.
• Deputy OSC
– Fire Chief
 Report to On Scene Commander (OSC)

• Provide details of your

team/s
– Numbers
– Categories
– Names (if requested)
• Appoint MELO (Medical
Liaison Officer)
 MEDICAL TEAM ARRIVES AT THE SITE
WORK PROCESS FOR
ON- SITE MEDICAL
SERVICES (LOCAL) REPORT TO COMMAND CENTRE
(ON SCENE COMMANDER)

REPORT TO OMC
(ONSITE MEDICAL COMMANDER)

ESTABLISH STATION AT THE YELLOW ZONE

TRIAGE SORT
TRIAGE SIEVE
AT CASUALTY
TREATMENT AREA
COLLECTING POINT
TAG & TRANSFER
RED

YELLOW

ESTABLISH TEMP BODY AREA ORGANISE SEARCH & MGT.OF INJURED RESCUER
GREEN (POLICE) RESCUE TEAM

COORDINATION OF TEAM
DETERMINE ABILITY TO
EVACUATION MEMBERS WITH OTHER
CONTINUE WORKING
RESCUE PERSONEL
 ON SITE
MANAGEMENT
WORK MATRIX
YELLOW ZONE

OSC
(POLICE )
M.E.L.O.
FORENSIC
LO P.K.T.K.
CO
O.M.C.
VTO BOMBA
TO / EO
MEDICAL
BASE SAR
STATION M.E.S.A.R.O.
SAR
RED
FORWARD
YELLOW MEDICAL
POST (FMP) COMMAND POST
GREEN SJAM F.F.C. - BOMBA
MRCS
JPAM
WHITE EMRS

SAR TEAM

RED ZONE
 Reporting a Major Incident
Go through the appropriate channels so that all necessary personnel and services
are informed (METHANE, CHALETS)
Major incident declared. Casualties - number, type, severity.
Exact location. Hazards present.
Type of incident e.g. explosion/fire in a tall Access routes that are safe to use.
building, release of gas in the underground Location.
system. Emergency services present and
Hazards - present and potential. required.
Access - routes that are safe to use. Type of incident, as above.
Number, type, severity of casualties. Safety.
Emergency services now present and those
required.
 SITREP (Situational Report)
Standardized Format for Scene Assessment and Reporting Critical Information
Situation / Safety
Type of disaster, risks to responders
Injuries
General classification of injuries
Triage
Rapid determination of sick vs. non sick
Resources
Assessment of available resources
Escalation
In what phase is the disaster
Type of disaster
Pass on the plan
Establish role as OMC until relieved by superior/ experienced officer
Report SITREP
 INDICATORS OF POSSIBLE CHEMICAL AGENT USE
Dead or Dying Animals
-Lack of insects
Unexplained Casualties
-Multiple victims
-Serious illness,
-Nausea, disorientation, breathing difficulty, convulsions
-Definite casualty patterns
IHS Jane's CBRN Response Handbook 4th ed.

Liquid or Vapor
-Droplets, oily film, TYPES OF AGENTS
-Unexplained odors 1) Nerve: sarin, VX
-Low clouds / fog unrelated to weather 2) Blister: sulfur mustard, Lewisite
Suspicious Devices / Packages 3) Blood: cyanide, CO
-Unusual metal debris 4) Choking: phosgene; chlorine
-Abandoned spray devices 5) Irritating: tear gas
-Unexplained munitions
INDICATORS OF POSSIBLE BIOLOGICAL AGENT USE

Dead or Dying Animals

IHS Jane's CBRN Response Handbook 4th ed. -Sick or dying animals, people or fish
-Unusual swarms of insects
Unexplained Casualties
-Unusual illness for region/area
-Definite pattern of inconsistent with normal disease levels

Unusual Liquid, Powder or Vapor

-Suspicious devices or packages
Pre-Deployment Phase
 Pre-Deployment Phase
A. Brief your team members
• Details of the incident
• Potential hazards and advised on the correct PPE.
• Anticipated clinical syndromes
 Polytrauma, crush injuries, amputation, head injury, near drowning.
B. Horizontal task distribution
– Clinical Commander, MESARO, MELO, MRP, Logistic Officer,
Transport Officer.
– Initial phase : Multi-tasking – 1 person will have more than 1 role.
E.g – OMC double up as Clinical Commander and Base Medical Commander.
– Use of action cards.
 Pre-Deployment Phase
C. Request for extra resources via MECC (if needed).
• Depend on estimated number of victims, conditions/injuries expected, time to
manage the incident.
• Manpower
 Medical Teams – Level I/ Level II/ Level III.
 Related agencies – EMRS, Civil Defence, Red Crescent, SJAM.
• Equipments
 Anticipated clinical syndromes.
 Medical/ non-medical items.
• Ambulances
D. Re-assign communication channel.
• Separate channel for ground zero Ops.
MANAGING THE CASUALTIES
 Medical Management
3T Principles
TAG

TREAT

TRANSFER
 Casualties Flow and Evacuation

I TRIAGE

N TREATMENT
C Critical AREA
I Ambulance
D MEDICAL
Loading Area HOSPITAL
E BASE STATION
N Semi-Critical

T
Designated
Non-critical
S medical facility
I BODY HOLDING
AREA
T DEAD
E
TEMPORARY
MORTUARY
 Casualties Flow and Evacuation for
Contaminated Victims

I
N Critical (LTC)
T
C M
R Ambulance
I I
B Loading Area
HOSPITAL
D A S
E G
N E
T Semi-Critical

S Non-critical
Designated
I medical facility

T
E DEAD

BODY HOLDING
AREA
Search and Rescue
 Scenario 1 (cont.)
Your OMC informed the team that the estimated number
of victims are 30. The Fire & Rescue department are
currently stabilizing the bus before bringing out the
victims.

You have been appointed by the OMC to be the

MESARO. What is your plan?
 Learning Objectives
At the end of this session, the participant
should be able to:
• Understand the role of medical during Search
and Rescue Operations.
 Search and Rescue
The MESARO need to:
a) Know the location of Casualty Collecting Point.
b) Apply Field Triage to all the victims.
c) Enter the Red Zone (if needed) to manage patients.
d) Tag all the victims.
e) Document the numbers and severity of victims.
f) Communicate with OMC/CO for advice (if needed)
 Search and Rescue
The OMC need to:
a)Determine the number of personnel needed
for Search and Rescue activities.
b)Ensure the setting up of MBS to facilitate
arrival of victims.
Medical Base Station
 Scenario
Your team were called to respond to a Mass Casualty Incident
involving a bus which had overturned in a busy highway. Your
OMC informed the team that estimated number of victims are
30. The Fire & Rescue department are currently stabilizing the
bus before bringing out the victims.

You have been instructed by the OMC to set-up the treatment

area for patient management. What is your plan?
 Learning Objectives
At the end of this lecture, the participants should be able to:
• Understand the importance of setting up a Medical Base
Station (MBS) at the incident site.
• Understand the principles of a Medical Base Station lay-out.
• Prepare, organize and operationalize a Medical Base
Station.
 What is Medical Base Station?
• A temporary or permanent structure identified by the Medical team for
the purpose of planning and coordinating all medical related activities
e.g patient treatment, communication set-up, staff rest.
• Size will be determined by the severity and complexity of the incident.
• Located at the Yellow Zone.
• Choice of location depends on:
– Wind direction
– Terrain
– Presence of potential hazards
– Water and electricity source
 Why set-up a Medical Base?
• A proper treatment area to manage patients at the incident
site.
• A rendezvous point for all Medical personnel after reporting
for duty to the OSC.
• The focus point for all medical related activities at the
incident site.
• A distinct landmark to all other rescue agencies.
 Organizing the MBS
As a general, the principles
are:
 The ingress and egress of
patients, should be through
different routes.
 Scramble equipment are
placed near the MBS
entrance to facilitate rapid
action.
 ON SITE MANAGEMENT
AREA LAYOUT OF MEDICAL BASE STATION

WHITE ZONE M.E.L.O •REST AREA

•DEAD •RESCUER CLINIC
•BODY PARTS •PANTRY

FORENSIC REST ZONE

STRATEGIC
PLANNING AREA
YELLOW ZONE GREEN ZONE
O.M.C
Semi Critical Non Critical
COMMITTEE
1 Dr + 2 asst. Drs + Pts + asst.
DATABASE
Qx

Scramble
RED ZONE
Rescue
Critical Zone Equipment
1 Dr + 4 asst.
Smooth Transition for Evacuation of Casualties

EGRESS

TRIAGE
INGRESS

INGRESS
 SITE MANAGEMENT:
MBS

MBS
• Set up station
• Organization in station
• Triage
• Medical activities
 Triage Area
• Similar to ED set-up, the front receiving area
of the MBS is the triage area.
• Triage officer/s stationed here is to receive,
re-assess and re-triage in-coming patients
accordingly.
 Scramble Equipment Area
• For the rapid response team.
• Portable, mobile equipment such as foldable
stretcher, resus bag, related PPEs.
 Patient Treatment Area
• Depending on size, the MBS is usually for critical and
semi-critical victims.
• Non-critical patients are usually managed in a
separate area away from the MBS. This is to minimize
distraction to the personnel working in the MBS.
• This area should be equipped as similar as possible
to the Red and Yellow Zone set-up in the ED.
 Communications Area
• The communication center for MBS (similar to MECC). It is the lifeline
between the on-site medical team, coordinating healthcare facility
and other govt agencies.
• Types of communications equipment will depend on availability:
– GIRN
– Satellite phone
– handheld, desktop
• A dedicated personnel manning the area should be appointed to
monitor and control the on-going communications once there is
enough personnel.
 Staff Rest Area
• An important part of the MBS.
• Sometimes overlooked by the medical team.
• Usually needed if the incident is prolonged and
requires the medical team to always be on standby 24
hours a day.
• Area needed for sleeping, eating and drinking.
Victims tracking system (vts); documentation of casualties;
flow of casualties
Transfer Organization
 Transfer Organization
• The MBS is a temporary treatment area to give initial
emergency treatment and to stabilize patient.
• The decision to transfer need to be made as soon as
patient is deemed stable for transfer.
• A delayed transfer will congest the MBS and caused
undue stress to the medical personnel.
 Transfer Organization
A. DEFINITION
 Procedures implemented to ensure victims of MCI will be safely, quickly and
efficiently transferred by appropriate vehicles to appropriate and prepared
healthcare facilities
B. PREPARATION FOR EVACUATION
1. General Procedures for Evacuation
• Single Receiving Facility
• Multiple Receiving Facilities
2. Preparation for Transport
• Evacuation Officer
 Assess stability
 Assess security of equipment
 Ensure efficiency of immobilization measures
 Ensure triage is securely attached & clearly visible
C. Evacuation Procedures
1. Regulation of Evacuation
 Victim is in most stable condition
 Victim is adequately equipped for transfer
 Receiving health care facility is correctly informed and ready to receive the patient
 Best possible vehicle and escort is available
2. Control of Victim Flow
• The “Noria Principle” – one way, no crossing
• Ambulance Traffic Control
 Radio Links
- Personnel at MBS, MECC, ED.
 Responsibility of Ambulance Drivers
 Road Control
D. Evacuation of Non-Acute Victims
 At end of field operation or if primary healthcare facilities available, non-medical
transport available and no interference
 VICTIM FLOW
“Conveyor Belt” Management

Triage Evacuation Treatment

Triage
Treatment

Impact Collecting MEDICAL

Zone Point BASE TRANSFER HOSPITAL
STATION

Victim Flow

Transport Resource Flow

Roles of Responders
 Organization of Medical Personnel
OMC

B.M.C C.C

Victims
MBS Triage Rescue Transport Logistics Comms.
Tracking

Red T.L MTC MESARO

Yellow T.L MTO MRP

Green T.L
 On site Medical Commander (OMC)
Role
• Responsible for the Coordination of all Medical Activities at the Incident Site
• Oversees Set up of various clinical areas
• Oversees the coordination of Triage System
• Oversees medical management of casualties at the base station
• Responsible for the Appointment of MELO/MESARO and other medical officials
• Oversees the Coordination of the ambulances and transportation / evacuation of
casualties
• Responsible for coordination of the communication system
• Coordinate manpower resources including those from support services e.g.
MRCS, SJAM, JPAM etc
• Coordinate communication system between the Site / EDOC (MECC)
 Medical Search & Rescue Officer (M.E.S.A.R.O)
• Coordinate Medical Rescue Service
• Liaise with the FFC
• Coordinate all rescue work; MRCS, SJAM, JPA III.
• Perform Triage
• Communicate with OMC
• Render emergency medical treatment
• Coordinate manpower of all medical rescue workers in the
Red Zone
• Manage Stretcher Bearers
 Medical Liaison Officer (M.E.L.O)

• Acts as the Liaison Officer between the OMC and the OSC
• Gather and relay info to all concerned
• Responsible for maintaining communication between OMC
and OSC
• Communicate & coordinate between site and hospital
• Organize coordinator for strategic planning and
methodology
 Base Medical Commander (BMC)
• Responsible for the administrative management of activities
at medical base station
• Communicates with Clinical Commander, Evacuation
Officer, On Site Medical Commander (OMC) and MECC
Coordinating Hospital
• Responsible for the strategic planning of the medical
response activities
 Clinical Commander
• A clinical specialist preferably Emergency Physician
• Responsible for all clinical related activities ie clinical management and
disposition of casualties
• In charge of all clinical medical activities at site / medical base station ie triage,
resuscitation stabilization and evacuation
• Responsible for medical base station set up
• Ensure proper and adequate communication system being set up
• Ensure continuous triage performed at ingress and egress point and at clinical
zones
• Render expert advice when and where necessary
• Endure appropriate care being delivered
• Responsible for assignment duties of each health care worker
 Clinical Commander (cont.)
• Responsible for schedule of HCW and rotation so that working hours
do not exceed the 4-6 hour shift
• Ensure that victim tracking system is in place and all necessary
documentation being performed
• Responsible for the evacuation process ie triage of evacuated
casualties based on the principle right patient to the right facility at the
right time, mode of transport required.
• Communicates with the Base Medical Commander ( BMC)
• Communicates with Red and Yellow Team Leaders
 Medical Triage Commander ( MTC)

• Responsible for implementation of triage system at all points of

contact
• All casualties must be continuously triaged at site, before and after
transfer from point to point, ingress and egress points, before and
during evacuation process
• Assisted by Medical Triage Officers (MTO)
 Medical Triage Officer (MTO)
Responsible to perform triage on every casualty using the START / JUMP START
and /or SALT Triage system
Ensure that continuous triage is performed on every casualty:
1) Receives victims at the entrance of the MBS
2) Examine and assesses the condition of each victim
3) Categorize and tags patients as follows:
o Red – immediate stabilization necessary
o Yellow – close monitoring care can be delayed
o Green – minor delayed treatment or no treatment
o White – deaths
4) Directs victims to appropriate treatment area
5) Reports to the commander (MBC) of the MBS
 Red Team Leader

• Assist Clinical Commander at Medical Base Station

• In charge of the red zone
• Responsible for all medical activities in the red zone
• Ensure the delivery of appropriate care to all casualties
• Ensure safety of all casualties and HCW
• Perform triage, resuscitation, stabilization and evacuation of
casualties
• Communicate with Clinical Commander
 Yellow Team Leader
• Assist Clinical Commander at Medical Base Station
• In charge of the yellow zone
• Responsible for all medical activities in the yellow zone
• Ensure the delivery of appropriate care to all casualties
• Ensure safety of all casualties and HCW
• Perform triage, stabilization and evacuation of casualties
• Communicate with Clinical Commander
 Evacuation Officer (EO)
• Overall in charge of evacuation process of casualties
• Communicates with Clinical Commander
• Communicates with Transport Officer ambulances
• Communicates with Base Medical Commander for needs of
transportation
 Medical Rescue Personnel (MRP)

• Stretcher bearers
• Assisting in all the specific section
• Assist in managing the logistic
• Receive and carry duties under instructions of OMC /
MESARO /BMC
• Assist in SAR when ordered/approved by MESARO
• Coordinate food supplies
 Victim Tracking Officer (VTO)

• Responsible for the collective documentation of casualties

• Responsible for Victim tracking system
 Transportation Officer

• Vehicle management at Vehicle Staging Area

• Coordinate movement of vehicle
• Manage drivers and escort
• Vehicle arrangement
• Routing and Traffic
 Communication Officer
• Responsible for all communications
• Receive communications from Ground Zero to MBS
and/or from MBS to MECC
• All communications must go through him.
 Logistics Officer

• Manage resources end logistic

• Organize food, refreshment and treatment of rescuers
and victims
• Organize the medical management areas
• Manage inventories and storage
• Continuous assessment