I. 1.

Mass Casualty Incident is any incident in which emergency medical services resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties.[ DOH: In an event resulting in a number of victims large enough to disrupt the normal course of emergency and health care services. The event affects several victims which could be as few as three or as many as several hundreds. Managing the victims, however, entails resources greater than those of the initial responders. 2. Declaration of an MCI A mass casualty incident will usually be declared by the first arriving unit at the scene of the incident, though it can be declared by a dispatcher based on the information available from people who call an emergency number, such as 9-1-1 in the US, about the incident. A formal declaration of an MCI is usually made by an officer or chief of the agency in charge. Initially, the senior paramedic at the scene will be in charge of the incident, but as additional resources arrive, a senior officer or chief will take command, usually using an incident command system structure to form a unified command to run all aspects of the incident. In the United States, the Incident Command System is known as the National Incident Management System (NIMS), and according to the Federal Emergency Management Agency, "NIMS provides the template for the management of incidents."[ 3. Agencies and Responders A mass casualty incident can involve many and varied types of responders and agencies, including (but not limited to) the ones listed here:

 

 

 

  

Certified first responders may be part of local emergency medical services or may arrive on their own. They will assist with all aspects of patient care, including triage and treatment at the scene, and transport from the scene to the hospital. Paramedic and emergency medical technician (EMT) personnel may arrive in ambulances, in their personal vehicles, or from another agency. They will have the lead in all aspects of patient care as assigned by the medical officer or incident commander. Land ambulances will be assigned to the transport sector to transport patients and personnel to and from the incident scene, emergency departments of hospitals, and a designated helipad. These may be municipal services, volunteer services or from private corporations. Air ambulances will transport patients from the scene or from designated helipads to receiving hospitals. Firefighters will perform all initial rescue related operations, as well as fire suppression and prevention. They may also provide medical care if they are trained and assigned to do so. They may arrive on a fire truck, in their personal vehicles, or from another agency. Many areas near airports will have automatic mutual aid agreements with airport fire departments in the event of a plane crash outside of the airport boundaries. Police officers will secure the scene to ensure that only properly authorized people are present to ensure safety and smooth operation. Specialized rescue teams may be part of the local fire department; they may be dispatched and associated with the state, provincial, or federal governments; or they may be privately operated teams. These teams are specialists in specific types of rescue, such as Urban search and rescue (USAR) or Confined Space Rescue. Utility Services are responsible for ensuring that utilities to the area are turned off as necessary in order to prevent further injury or damage at the scene. HazMat teams are responsible for cleaning up and neutralizing any hazardous materials at the scene. Sometimes these will be specialized CBRNE (chemical, biological, radiological, nuclear and high-yield explosives) teams. Hospitals with emergency departments will have a mass casualty incident protocol which they initiate as soon as they are notified of a mass casualty incident in their community. They will receive all of the injured and have preparations in place to do so, including calling in more staff, pulling extra and spare equipment out of storage, and clearing non-acute patients out of the hospital. Some hospitals will send doctors to the scene of the incident to assist with triage, treatment, and transport of injured persons to the hospital. Railways and transportation agencies will be notified if an incident involves their tracks or right-of-way, or if they are required to cease operations in and through affected areas. Transportation agencies will provide buses for transportation of lightly injured people to the hospital, as well as to provide shelter at the scene if required.

 

The media play an important role in keeping the general public informed about the incident and in keeping them away from the incident area. Non-governmental organizations such as St. John Ambulance, the Red Cross, the Red Crescent and the Salvation Army will provide valuable assistance with all aspects of a mass casualty incident including trained medical staff, vehicles, individual registration and tracking, temporary shelter, food service, and many other important services. 4. MCI threshold MCI Threshold Definition The point at which the number of patients at an MCI and the severity of their conditions are beyond the ability of available resources to provide adequate care. The day-to-day EMS response is designed to assure scene safety and to triage, treat and transport no more than a few patients. If day-to-day procedures were followed at the scene of a large number of casualties, several problems could occur with scene management, triage, treatment, and transport. The threshold formula is . # Ambulances within 15 minutes X 2 victims +1 would constitute an MCI declaration for that community Example: 6 ambulances X 2 victims = 12 victims 12 victims + 1 = 13 (MCI declaration) MCI Threshold = 13 victims If the numbers of victims exceeds the threshold, but few, if any, appear to be seriously injured, consideration should be given to not declaring an MCI. 5. Ethical Justifications -beneficence -non maleficence -autonomy -justice 6. Professional Roles of Nurses in MCI s nursing roles in MCIs: Researcher Investigator/epidemiologist EMT or First Responder Direct care provider, generalist nurse Direct care provider, advanced practice nurse Director/coordinator of care in hospital/nurse administrator or emergency department nurse manager On-site coordinator of care/incident commander On-site director of care management Information provider or educator, particularly the role of the generalist nurse Mental health counselor Member of planning response team

ICS CONSIDERATIONS Mass casualties create the need for expansion of the ICS to include a Medical SectorOfficer to be appointed as soon as possible by the IC or Operations Officer. The MedicalOfficer shall in turn designate as needed: Triage Team(s), Treatment Team(s), and a Transport Officer within the ICS. If the incident is a HAZMAT or an intentional, chemical, biological or radiological release, etc, follow HAZMAT guidelines onappropriate decon and level of protection. The steps below will be undertaken with the 5 appropriate level of personal protective equipment, and decon (if applicable) will beperformed on all affected victims per the HAZMAT team guidelines. 1. MCI teams

1.

The First Responder will most likely be the first rescuer on scene The First Responder must be able to start triaging the wounded patient s and when appropriate, initiate medical care Once EMS personnel arrive on scene, the First Responder must be able to pass the required information on to the appropriate personnel

1. 1.

HAZMAT a. Hazardous materials vs. chemicals. The first step to survival is to recognize that any incident can involve chemicals. Despite our regular use of the term hazardous materials, the term chemical is really more appropriate, because terms such as hazardous materials and hazardous substances are often used in a regulatory context with specific definitions. 2. b. Chemical involvement that is known, suspected, or discovered. Incidents involving chemicals can be divided into three general categories: (1) those in which the involvement of the chemical is known (overturned gasoline tank truck), (2) those in which the presence of a chemical is suspected (three people unconscious at a chemical warehouse); or (3) those in which the involvement of chemicals is discovered after your arrival, such as when you respond on an EMS call for difficulty breathing and discover during patient assessment that the victim has been using a chemical without appropriate personal protective equipment (PPE). 3. c. Means to detect the presence of chemicals. You can determine that a chemical could be involved in an incident by detecting odors, visually observing various characteristics, and by comments from the complainant and bystanders. 4. d. Arrival on-scene. When you arrive at the scene of an incident where there is known or suspected involvement of hazardous materials, STOP a safe distance from the scene. Just because the complainant or a bystander is waving at you to come closer doesn't mean that all is well. 5. e. Isolate, evacuate, and deny entry, This is of the utmost importance because [took out comma] no matter the outcome of an incident that involves chemicals, it is always worse when there are injuries or deaths. 6. f. Obtain emergency response information. First responders are taught during basic training that they should use the Emergency Response Guidebook (ERG) and material safety data sheets (MSDS). 7. g. Defensive vs. offensive. When dealing with a release or a potential release of a chemical, you must decide on your level of intervention. 8. h. Anticipate the worst. Always thoroughly assess all incident factors before acting. They include aspects of the incident that may not be readily visible or that appear to be of no consequence at the time. 9. i. Notifications. Never forget that numerous individuals and agencies have an interest whenever a chemical is released from its container. 10. j. Establish an effective incident command system. Command and control of resources during incidents necessitates effectively delegating the responsibility for numerous tasks.

COMPONENTS OF AN MCI

1.

Initial Triage Hard to do for the inexperienced, but it is really very easy All responders must know what the goal is .. Sometimes most severely injured patient does not get treated and dies How to Triage using the Tags

 

Conduct an Initial Walkthrough Tag Patients as Red, Yellow, Green or Black

Remember - Triage is constantly conducted so don t panic with your first tag

1.

Patient Extraction Patient extraction is the act of removing the remaining victims from the affected areas and delivering them to designated treatment areas. Patient extraction can begin as soon as resources on scene allow. Extraction can commence prior to the completion of initial triage but shall begin as soon as initial triage has been completed or additional personnelin proper PPE are available.

1.

Secondary/Medical Treatment

The nature of a mass casualty event suggests that the affected areas will not be a safe place to establish treatment areas. Hazards may include chemical, biological or radioactive contamination, unstable building components, secondary device threats, fire involving structures and/or vehicles, limited space, utility issues, etc. The location of thetreatment areas will depend on these hazards and threats. If no additional hazard(s) exist, the treatment areas can be established at or near the scene.

  

Determine location for treatment area Coordinate with the Triage unit to move patients from the triage area to treatment areas Establish communication with Incident Command

Reassess patients, conduct secondary triage to match patient with resources

Direct movement to ambulance loading area

1.

Transportation of Patients Management of patient movement from the scene to the receiving Hospitals Works with Treatment unit to establish adequately sized, easily identifiable patient loading area Designates an ambulance staging area Maintain communication with Incident Command

   

IV. Levels of MCI

MCI MCI MCI MCI MCI

Level Level Level Level Level

1 2 3 4 5

(5-10 victims) (11-20 Victims) (over 21 Victims) (over 100 Victims) (over 1,000 Victim

V. MCI Management 1. . MULTI SECTORAL - Rescue chain The Rescue Chain, the essence of the Mass Casualty Management System, involves the Ministry of Health, private hospitals, police, fire service, NGOs, transport services, and communications (see Figure 1). This chain starts at the disaster site (with activities like initial assessment, command and control, search and rescue, field care), continues with transfer of victims to adapted facilities (using procedures for regulation of evacuation and ambulance traffic control), passes thought hospital reception (with activation of the hospital disaster response plan), and ends only when the victims have received all emergencycare needed to stabilize them. 2.Responders 1. 2. 3. First responders Second Responders Field Mangement -Field management encompasses procedures used to organize the disaster area in order to facilitate the management of victims. A.FIELD ORGANIZATION 1. Alerting process The alerting process is a sequence of activities implemented to achieve the efficient mobilization of adequate resources. This includes initial warning, assessment of the situation, and dissemination of the alert message. a.Purpose -To confirm the initial warning -To evaluate the extent of the problem -To ensure that appropriate resources are informed and mobilized b.DispatchCenter The core of the alerting process is the dispatch center: a communications center that receives all warning messages and is linked by radio and phone to all services involved in emergency management (e.g., "911"). The dispatch center must have the capacity to mobilize a small assessment team ("flying team"), composed of personnel from police, fire, or ambulance services, in order to confirm a warning message when necessary

c. Confirmation of Initial Warning Warning message from general public This message, issued by a non-qualified observer, must be confirmed, either by immediate call-back or by a second identical message from another source. If this is not immediately possible, the dispatch center must send a "flying team" to the site, while alerting potential responders (stand-by alerting process). Warning message from qualified observer Upon reception of a message from an individual working in emergency services and experienced in initial assessment, appropriate resources can be immediately dispatched. d. Initial Assessment The initial assessment is the procedure used to identify the immediate extent and the potential risk of the problem. Purpose -To know exactly what is happening and what could happen -To mobilize adequate resources - To correctly organize the field management e.Personnel Any first responder trained in initial assessment will be appropriate to carry out this procedure. f.Occasion Any accident should benefit from an initial assessment. Any major incident needs immediate initial assessment. g.Method Initial assessment is a sequence of activities identifying the following: -Precise location of event -Time of the event -Type of incident - Estimate of number of casualties Added potential risk - Exposed population h.Report to Central Level The initial assessment must be reported immediately to the dispatch center before any further action is taken. If the first responders start their work in the field before reporting, there will be a delay in mobilization of resources, or critical information may be lost if responders are trapped in a second accident. I. Dissemination of Information As soon as the warning message is confirmed, the dispatch center will issue the alert message, mobilizing necessary resources and informing specific persons and institutions. This alert message must be rapidly circulated using pre-established procedures, such as a cascade phone system (see Figure 2).

2. PRE-IDENTIFICATION OF FIELD ZONE The second role of the initial assessment team is to identify the field areas to be established. These will include: Impact Zone Command Post Area Advance Medical Post Area Evacuation Area VIP and Press Area Access Roads

Pre-identification of field areas will allow various incoming resources to reach their specific areas rapidly and efficiently. It constitutes the initial part of the on-site deployment. One of the best ways to realize and present this pre-identification is to draw a simple map of the area, including the main topographical and physical features such as roads, natural/artificial boundaries, ponds, rivers, buildings, etc. Using this map, potential risk areas, victims, access roads and the various field areas can be identified, including the boundaries of restricted areas. Compass rose and wind direction must also be provided. 3.SAFETY Safety measures are implemented to protect victims, responders and exposed population from immediate and/or potential risk (extension of the accident, responding to traffic accidents, hazardous materials, etc.). a. CASCADE PHONE SYSTEM b. Safety Measures Direct action includes risk reduction by fire fighting, confinement of hazardous material, use of protective clothing, and evacuation of exposed populations. Preventive actions include the establishment of the following restricted areas: - The impact zone strictly restricted to professional rescuers; adequately equipped. - Secondary area-restricted to authorized staff working in rescue operation, care delivery, command and control, communications, ambulance services, security/safety. The Command Post, the Advance Medical Post, the evacuation center and parking for the various emergency and technical vehicles will be set up in this area. - The tertiary area is to be accessed by press officials and to act as a "buffer" zone to keep onlookers out of danger. The size and design of the restricted areas depend upon the type of accident (toxic smoke, hazardous materials, intense fire, explosion risk), the wind and topography (see Figures 3-4). c.Personnel Safety measures will be implemented by the fire services, assisted in specific problems by specialized units (hazardous material, explosives experts, etc.). Restricted areas will be defined by fire services in coordination with specific services (for example, the airport manager, chemical plant's chief of security) when necessary. SECURITY MEASURES

Security measures are implemented to keep external elements from interfering with the rescue organization. Restricted access of each safety area is maintained by implementing crowd and traffic control. Security measures contribute to safety by: - Protecting workers from external influences (additional stress), - Avoiding obstruction of flow of victims and rescue resources, - Protecting the general public from exposure to risk. Security is ensured by police force, special units ( force, national guard), government security officers, airport security, and hospital security. 4. COMMAND POST The command post is a multi-sectoral control unit established to: - Coordinate the various sectors involved in field management, - Link with back-up systems to provide information and mobilize necessary resources, - Supervise victim management. This will only be possible if the command post has a comprehensive radio network. Purpose The field management of a disaster requires the mobilization and coordination of sectors which do not routinely work together. The efficiency of pre-hospital activities requires strong coordination of the various responders. In order to fulfil this need for coordination, the command post must be set up at the very beginning of the rescue operation. a. Location The main criterion for an effective command post is radio communications. This can be implemented from any sort of structure, ranging from a single police car to a specific mobile command post, or from a tent to an appropriately located building. The command post must be installed at the external boundary of the strictly restricted area (impact zone), close to the advance medical post and the evacuation area. It must be easily identified and accessible. Its location should accommodate all communication (visual, radio, road). b.Personnel The command post is staffed by the highest ranking personnel available from police, fire service, health sector, and defence force (where existing). This core group can co-opt volunteer organization representatives and, depending on the type of accident, specialized personnel (e.g., airport manager in the case of an airplane crash, prison governor in prison incident). It is generally agreed that the coordinator of this unit is a police officer. However, depending on the specific nature of the incident, the coordinator may be more specialized (e.g., an airport manager in case of an airport accident). Those likely to operate in the command post must be identified by name and position. They must be familiar with each other's roles, know each other, and have practiced and discussed issues during regular meetings. These meetings should include exercises to practice coordination of resources, and administrative discussions about changes in resources or procedures as they develop. Meetings should be held on a regular basis, but they need not be frequent.

c.Method The command post is the communication/coordination hub of the prehospital organization. The command post will, by constant reassessment of a situation, identify needs to increase or decrease resources in order to: - Release, as soon as the situation allows, the emergency services staff that are no longer needed in the field. In this way, the command post will contribute to the re-establishment of routine operations. - Organize the timely rotation of rescue teams exposed to stressful/exhausting situations in close cooperation with the backup system. - Ensure the provision of adequate supplies of equipment and manpower. - Ensure comfort/welfare of rescue teams (provide food and drink). - Provide information to back-up systems, and keep other officials and the media informed (through an official spokesperson). - Determine the termination of field operations. B. MANAGEMENT OF VICTIMS 1. Search and rescue Search and rescue operations depend strictly on skilled teams from the fire service and specialized units, assisted when necessary by volunteers. These teams will: Locate victims Remove victims from unsafe location to collecting point if necessary Assess victim status (on-site triage) Provide first aid, if necessary Transfer victims to the advance medical post, if necessary

Search and rescue teams work in the strictly restricted area (impact zone) under the command of a fire officer or, in specific situations, of specialized personnel. Depending on the risk (e.g., toxic smoke, hazardous materials), rescue teams will utilize special protective clothing and equipment. In exhausting working conditions, a quick turn over of rescue teams must be implemented. The situation could arise that, due to the location of the victim (trapped under a collapsed wall, for example), extrication will need time. If the status of the victim is bad, the rescue team leader can request, through the Command Post, on-site assistance of medical personnel in order to commence stabilization of the patient during extrication. This procedure requires specifically trained medical personnel and must only be used in exceptional cases. When the impact zone is large, it may be necessary to divide it into smaller "working areas", each assigned to a rescue team. In such a situation, or when the impact zone is unsafe, the Search and Rescue Officer will establish a Collecting Point in a safer area adjacent to the impact zone, where victims will be temporarily assembled (see Figure 5). This collecting point will be managed by emergency medical technicians (EMTs) and volunteers, and will ensure the initial triage, first aid and transfer to the advance medical post. 2. Field care When an area does not have adequate health care facilities available to face a mass casualty incident (e.g., one small secondary/tertiary hospital), rapid transportation of all victims to a hospital with limited resources will compromise the care of the seriously injured victims. In addition, this will profoundly disrupt the hospital care system, endangering patients

already in the hospital. It is not realistic to "push" 200 victims into a 300-bed hospital, with only 3 operating rooms, for example, and expect good results. One operating theater requires at least six highly specialized people to run it. A patient suffering from "major" trauma may take 3-4 hrs to "stabilize". Each region or area must identify its own resources and limitations: - How many operating theaters are available in a region? - How many of these operating theaters can be adequately staffed in a crisis? The answer to the second question may affect the answer to the first. In limited resource conditions, due to space and care available, transport of victims to hospital should be staggered. This supposes that victims will receive adequate field treatment, allowing them to tolerate this delay. 3. Evacuation management center (EMC) When disaster situations have multiple impact zones, each requiring the establishment of an Advance Medical Post (AMP), an intermediate level is required to coordinate evacuation. If each AMP dispatches directly to the tertiary care center without such coordination, the result will be loss of efficiency. To facilitate coordination, these multiple AMPs would dispatch to a center with greater stabilizing and evacuation facilities, which will coordinate the onward transfer. This may be a "field hospital", a polyclinic, a secondary hospital, or other ad hoc structures. This Evacuation Management Center (EMC) will: Collect/assemble all victims from attached AMPs Reassess victims Improve and/or follow stabilization Dispatch victims