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Emergency Medical Services

Scene Management

Kenneth T. Miller

OVERVIEW

Responses to large-scale emergencies in recent years have reaf- firmed what has long been said about disaster response: “all disasters are local.” Those jurisdictions whose plans rely pri- marily on outside assistance beginning with the initial stages of response are destined to fail. Stepwise, scalable incident orga- nization is essential to meet initial goals and objectives of the response to the emergency. Large-scale multicasualty emergen- cies and disasters involving large numbers of injuries or illness are complex and will initially or eventually involve many agencies at various levels of jurisdiction that may have little or no experi- ence working together. Local planning, preparedness, interdisci- plinary training, and exercises can improve familiarity with mul- tiagency strategic and tactical plans and improve understanding of missions, cooperation, and interoperability.

The emergency medical services (EMS) mission of triage, rapid clinical assessment, critical therapeutic interventions, med- ical communications, and capability and capacity-directed trans- port of victims in the management of a large-scale multicasualty emergency is part of a complex set of overlapping missions. Immediate hazard mitigation or containment for the protection of responders and protection of victims from further injury is the first priority. This may be possible quickly and the EMS mission may proceed rapidly. There may, however, be fire suppression, rescue, or hazardous materials concerns complicating the mis- sions of EMS and each response organization. Another critical early step is communication of the evolving situation to the local healthcare infrastructure to assist them with preparing to receive patients. That healthcare infrastructure will need to establish its own internal response organization to meet the needs of a poten- tially large number of new patients in addition to continuing to provide services to those patients already under their care and those regular patients who present for care unrelated to the dis- aster. This early notification may occur spontaneously through the news media or through structured lines of communication.

Preparedness and planning will include local assessment of EMS and healthcare resource depth. A jurisdiction’s decision and threshold to request mutual aid will be determined by this local depth of resources. Other factors influencing decision-making

include the size, scope, and anticipated duration of the multi- casualty emergency and whether the local emergency response infrastructure remains intact or is damaged or overwhelmed in the course of the evolving incident. The need for EMS spe- cial operations may also determine the threshold for mutual aid requests. The following are among the EMS and healthcare requirement that determine the timing and nature of mutual aid requests: 1) law enforcement (EMS tactical response); 2) techni- cal rescue (EMS operations); 3) waterborne or airborne rescue (EMS platforms); 4) victim emergency transportation; 5) inci- dent, victim, or healthcare facility patient evacuations; 6) clin- ically oriented evacuee sheltering; 7) trauma, burn, or pedi- atric intensive care; 8) anticipated long-term specialized medical care (e.g., hemodialysis for traumatic rhabdomyolysis); 9) antic- ipated incident-specific pharmaceutical needs; 10) public health surveillance, epidemiology, or laboratory support; and 11) sus- tained hospital outpatient and inpatient volume.

The scope of emergency management is mitigation, pre- paredness, response, and recovery. Effective EMS scene manage- ment will contribute to the success of the response and mitiga- tion phases. Because more than one jurisdiction will be involved, mutual aid resources must be requested, coordinated, and inte- grated at the local level with the assistance of a unified command structure. Resources may be requested through local jurisdic- tions, counties or regions, state, interstate, federal and, in some cases, international agencies.

CURRENT STATE OF THE ART

There are many international models for the management of multicasualty incidents. Some emphasize scene organization with the goal of rapid transport and limited focused prehospi- tal medical interventions. Others emphasize more extensive field medical operations prior to transport. The variations between these models include those with no apparent structure what- soever. The very nature of multicasualty and disaster medical operations makes it difficult to conduct longitudinal prospec- tive studies to identify, characterize, and validate optimal oper- ational parameters and practices that maximize victim survival

275 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 07:10:49.

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Table 19.1: Functions of the Plans Section

Plans Section Resources Situation Documentation Technical Specialists Demobilization

with practical application of available resources. The concepts discussed here are based on U.S. models of multicasualty inci- dent management.

DISPATCH, COMMUNICATIONS, AND INITIAL INTELLIGENCE GATHERING

EMS scene management begins with the initial calls for help. The recognition of and reaction to a large-scale multicasualty emergency may be immediate through cellular or landline calls to a public safety answering point (PSAP) or may be delayed if the emergency concurrently damages communications or facili- ties. The specific location or locations of the emergency may be immediately apparent or difficult to determine if there is con- flicting information from callers or widespread consequences. Emergency services access telephone numbers vary around the world and may function to allow voice communications with a public or private entity or may supply other information about the caller’s location. In the U.S. many communities are served by the emergency access number 911 or enhanced 911 (E-911). Other communities use a 7- or 10-digit telephone number to access emergency services. E-911 allows both voice communica- tion of the problem or emergency and displays the address of the telephone being used to make the call. If callers are unfamiliar with the area, unable to remember the location from which they are calling, or cannot identify where the emergency occurred, PSAP personnel will be able to assist because they will know the location of the telephone from which the call originates. E-911 also allows call backs from the PSAP to that telephone to recon- tact the caller for more information or clarification if necessary. The advantages of E-911 with caller address identification may be lost with calls from cellular telephones or voice-over-Internet calls or if there are no 911 services in the affected area. Global positioning systems technologies assist responders with caller and incident scene location. Telephones that operate over the Internet, however, may send U.S.-based 911 calls to distant oper- ators, potentially introducing delays in determining the nature and location of an emergency and in identifying the appropriate response agencies.

Table 19.2: Functions of the Logistics Section

Logistics Section Communications Medical (responder medical care)

Rehabilitation Supply Food Facilities Ground Support

Table 19.3: Functions of the Finance/ Administration Section

Finance/Administration Section Time Procurement Compensation and Claims Cost

When consequences of the evolving emergency are wide- spread, the local jurisdiction may dispatch fire suppression, law enforcement, and EMS resources to conduct a “windshield sur- vey” of their primary response areas. These units will report back on their observations to help prioritize initial responses when needs clearly exceed initially available resources. With the loss of communications infrastructure, emergency communications will originate from individual jurisdictional law enforcement, fire suppression, or EMS response stations or units.

The first point of medical decision making for EMS scene management may take place at the level of the dispatch center when a caller reports a situation and requests EMS. In the U.S., emergency medical dispatchers are trained to assist rapidly the caller in characterizing the nature of the emergency by using directed systematic questioning. This strategy permits construc- tion of an appropriate response to the emergency as well as provision of prearrival instructions to the caller in an attempt to mitigate immediate life-threatening problems. When emergency medical dispatchers are engaged in response unit coordination, they may no longer be able to triage medically calls for help or provide prearrival instructions to the caller to help reduce morbidity or mortality. However, they may be in contact with callers in immediate danger from the evolving hazards. Poten- tially life-saving advice may take the form of sheltering in place or evacuating the hazardous area as best assessed from information provided by the caller. Emergency medical dispatchers may be trained in the use of scripted protocols aimed at reducing imme- diate life threats at the scenes for special situations. Examples include a site where a perpetrator is firing a gun, a structure fire entrapment, a known evolving community infectious disease, a chemical or radiological release, or unknown evolving infec- tious disease. Syndromic or dispatch call type surveillance over time coordinated with local emergency management and public health resources may provide early information in an evolving, extended operations emergency. The situation may be dynamic, requiring case-by-case decisions based on dispatcher training and experience. Sufficient and accurate actionable information is frequently lacking and the most appropriate interventions for victim and public safety personnel are often not determined until

Table 19.4: Functions of the Operations Section

Operations Section Staging Air Operations Branches

Divisions Groups

Task Forces Strike Teams Individual Resources

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 07:10:49.

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EM E RG E N C Y ME D I C A L SE RV I C E S SC E N E MA NAG E M E N T ■ 277

Table 19.5: Initial Multicasualty Incident Functions

Incident Command Triage Medical Communications

after the arrival of first responder agencies. This can be an extraor- dinarily high stress time for emergency medical dispatchers who are attempting to construct a picture of the emergency, structure response configurations, coordinate the response with consider- able situational uncertainty, and manage calls from individuals in harms way.

INITIAL RESPONSE

As local media report on the emergency and local dispatch radio traffic is heard, there may be a self-dispatch of local or regional responders who may not be among the initial units sent. Agency and responder discipline and “freelancing” must be balanced with the judgment to dispatch the closest, most appropriate, and available response units. Such decisions are based on staffing, capabilities, proximity to the incident, immediate needs of the emergency, and information available to the public safety answer- ing points and dispatch centers. Emergency unit utilization must also be balanced with the need to maintain availabilities to meet other local nonincident-related calls for assistance. One strat- egy is to bring requested mutual aid units into the incident and hold in reserve some local and reserve units familiar with the geography, procedures, and practices to respond to concurrent emergency calls. In part, self-dispatched units can be managed by staging incoming responders at a designated location. These assets will be under the control of a staging manager in commu- nication with the incident command for operational assignments once an incident command structure is established.

Victim location may be known or readily apparent, or there may be the need for search operations. Search operations may take the form of systematic area searches by air, boat, or ground. Area searches are resource intensive and often are multiagency and multijurisdictional. A structural search may be initially lim- ited by the need to triage buildings for stability by structural engineers. With proper building triage and emergency shoring as needed, a structural search may proceed using technical assets such as acoustic and imaging devices or may involve search dogs.

Figure 19.1. Command and general staff (PIO: Public Information Officer, SO: Safety Officer, LNO: Liaison Officer).

Table 19.6: Expanded Multicasualty Incident Positions

Incident Command Triage Unit Leader Medical Communications Coordinator Ground Ambulance Coordinator Treatment Unit Leader Treatment Dispatch Manager

Although the objective of the search may be location of sur- vivors, the discovery of nonsurvivors must be anticipated and their locations mapped.

The priorities for the initial responding units are: 1) scene survey (within the primary response area of individual response units); 2) critical hazard mitigation or containment (that might immediately increase mortality of survivors and include haz- ards such as fires, unsecured utilities, and structural instability); and 3) assessment of the need for additional resources and then requesting them. In truly widespread emergencies, it may be necessary to make the very difficult decision to first conduct area surveys and accurately report conditions that will contribute to better resource allocation and early specific mutual aid requests. Attempting hazard mitigation or addressing life safety must be initially deferred. Such activities may ultimately reduce morbid- ity and mortality among those victims with the greatest potential for survival. With the nearly immediate availability of airborne television reporting in urban and suburban areas, a visual area assessment may begin with video from television news report- ing. Real-time surveillance is conducted by law enforcement or public safety agencies in some parts of the U.S. and within cer- tain industries (e.g., hotels, casinos, and secured facilities) and cities elsewhere in the world that utilize extensive video or closed circuit television. This may also be a source of information if that infrastructure is not disrupted. This visual assessment over several local television channels or other sources combined with emergency response dispatcher and first responder information helps to define the scope of the emergency.

Survivors might perform initial search, light rescue, and first aid. This local citizen-based assistance may be spontaneous or may be structured. Businesses may have organized emergency response teams designed to meet the immediate needs of employ- ees and trained in early mitigation of any hazards unique to that business. For example, businesses that manage secure infor- mation may have plans to care for their employees, mitigate hazards from building utilities, and maintain information secu- rity. Industries and universities may have hazardous materials

Figure 19.2. Operations section: geographic divisions, functional branches or groups.

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Multi-Casualty Incident ORGANIZATIONAL CHART

OPERATIONS

MULTI-CASUALTY BRANCH DIRECTOR

MEDICAL GROUP/ DIVISION SUPERVISOR

PATIENT TRANSPORTATION GROUP SUPERVISOR

MEDICAL SUPPLY COORDINATOR

MEDICAL COMMUNICATIONS COORDINATOR

TREATMENT DISPATCH MANAGER

TRIAGE PERSONNEL

AIR AMBULANCE COORDINATOR

TRIAGE UNIT LEADER

MORGUE MANAGER

TREATMENT UNIT LEADER

IMMEDIATE TREATMENT MANAGER

DELAYED TREATMENT MANAGER

GROUND AMBULANCE COORDINATOR

ORGANIZATIONAL LINES

COMMUNICATION LINES

Bolded positions are the minimum required.

Some may be combined on smaller

incidents. MINOR TREATMENT

MANAGER

Incident Command

Figure 19.3. Multicasualty incident organization (adapted from FIRESCOPE). See color plate.

teams that are solely responsible to their facilities and serve to identify and contain any hazardous materials breaches. U.S. nuclear power plants have response, assessment, and mitigation teams for potential radiation dispersion. Communities may have organized volunteer response teams (e.g., U.S. Community Emergency Response Teams) trained in light rescue, residen-

tial utilities control, first aid, sheltering, and sustainment until professional help can arrive (see Chapter 9).1 In larger emergen- cies these may be the earliest responders that victims encounter. Training and exercising of emergency responders should include anticipation of and coordination with spontaneous, business, or community citizen responders.

EXTENDED RESPONSE AND INCIDENT ORGANIZATION

In smaller-scope daily jurisdictional EMS incidents, the roles and responsibilities of first responders are well defined and frequently practiced. As the incident becomes larger or extends over a longer period of time, a few specific functions must quickly be estab- lished to manage the emergency. Incident organization can define success or failure of overall incident management. As resource availability and capacity allow, two initial and overlapping prior- ities will emerge: 1) immediate hazard mitigation and, 2) victim triage. To address these two priorities, two functional groups will be operating simultaneously: fire suppression/rescue and EMS. As the scope of the emergency is more completely determined and other priorities emerge, the response will become more complex. To address these complexities, an incident management system is necessary. Response organization can occur at many functional and jurisdictional levels, and terms used to describe functions and positions can vary. To create uniformity in incident man- agement, the U.S. National Incident Management System was developed.2 The adoption and implementation of the National Incident Management System at various jurisdictional levels is encouraged by tying its use in planning and preparedness to federal funding of eligible local jurisdictional programs.

Management of large and sustained incidents is structured around command and general staff in association with geo- graphical divisions, functional branches, and groups. If the inci- dent requires greater resources and organization, the functional branches are divided into groups. If that is not operationally necessary, however, the functional branches alone are adequate. Functional group resources can be further subdivided into task forces composed of multiple entities, strike teams composed of similar disciplines, or individual resources.

Area Commander

Assistant Area Commander

Planning Chief

Situation Unit Leader

Resource Unit Leader

Patient Transportation Coordinator

Incident Commander 1 Incident Commander 2 Incident Commander 3

Liaison Officer

Safety Officer

Aviation Coordinator

Mobilization Manager

Public Information Officer

Assistant Area Commander

Logistics Chief

(Unified Area Commander)

Figure 19.4. Example of area command organization.

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COMMAND AND GENERAL STAFF

Command and general staff consist of an incident commander or a unified command when multiple disciplines are needed to manage the incident (e.g., fire, EMS, law enforcement, and public health). The incident safety officer, public information officer, and any responding agency liaison officers all report to the incident commander. Also reporting to the incident commander is the general staff: operations section chief, plans section chief, logistics section chief, and finance/administration section chief.

PLANNING SECTION

The Planning Section is responsible for incident intelligence gathering, documentation, anticipation and requesting of spe- cialized resources, coordination of technical specialists necessary to support incident operations, and the briefing of responding agency leadership throughout operational periods. During sus- tained operations, the Planning Section has the responsibility for writing the Incident Action Plan with the concurrence of the command and general staff based on a standardized for- mat.3 The Planning Section is also responsible for organizing demobilization of resources as the incident resolves. For exam- ple, the Planning Section coordinates with local health depart- ment and hospital infrastructure to keep the Operations Section informed about hospital and specialty care resources (e.g., burn and trauma) and the ability to receive patients in an extended EMS incident. Incident EMS or medical supervisors coordinate with Safety and Hazardous Materials Officers to develop a safety plan that contributes to the Incident or Operations Action Plan and addresses occupational health hazards for remaining vic- tims and responders. The Planning Section gathers information on agencies with the ability to transport victims greater dis- tances to healthcare facilities remote from an emergency and writes the plan to guide the Operations Section on accessing those resources.

LOGISTICS SECTION

The Logistics Section is responsible for incident communica- tions, acquiring and managing all equipment and materiel nec- essary to support incident operations, and managing and sup- porting a base of operations. If on-site medical care is provided to incident responders, that medical unit is also the responsibility of the Logistics Section.

FINANCE AND ADMINISTRATION SECTION

The Finance/Administration Section is responsible for tracking incident costs and personnel time and facilitating purchases for the logistics section. This section also tracks claims resulting from injuries to responders.

OPERATIONS SECTION

The Operations Section runs the various missions of the incident and is supported by the other three general staff sections. The Operations Section may be divided into geographical divisions

based on incident priorities and physical boundaries that affect those priorities. The Operations Section is further divided into functional branches and/or groups. These functional branches or groups may include multicasualty, rescue, fire suppression, hazardous materials, or air operations branches/groups or any other function essential to the mission. Group supervisors report to branch directors, division chiefs, or the Operations Section chief depending on the level of organization necessary to manage the incident.

For extended EMS operations, the Operations Section will have a multicasualty branch. That multicasualty branch is divided into a medical group and a transportation group. If there are multiple sites in operation, geographical divisions can be assigned to further organize incident management. The med- ical group has a triage unit, treatment unit, and a morgue unit. The transportation group has a ground ambulance coordinator and medical communications coordinator. A treatment dispatch manager coordinates victim movement between the treatment unit leader and ground ambulance coordinator. If medical air transport services are in continuous use during victim move- ment, the transportation group supervisor coordinates with the air operations branch/group.

AREA COMMAND

In widespread emergencies with multiple incident sites, an area command can be established to manage the response. There may be one area command with a unified command, safety officer, public information officer, agency liaison officers, and section chiefs (planning, logistics, and finance/administration). Each operational site would then have an operations chief with geographical divisions or functional branches or groups.

Such extended incident organization develops over time, is structured to meet the needs of the incident, and is built from essential functions beginning with the initial responding units. To manage a multicasualty incident site, initial responders should establish an incident command system and appoint an inci- dent commander and personnel to function as triage unit leader and medical communications coordinator. These essential three functions will meet the initial needs of organizing resources, assessing the incident, reporting conditions and hazards (scene safety), requesting additional resources, initiating victim triage, and establishing communications with the EMS and healthcare infrastructure.

VICTIM TRIAGE AND TRANSPORT

Victim triage strategies and challenges are discussed in Chap- ter 12. Further organization depends on the availability of addi- tional resources to meet the needs of the incident. If sufficient ambulances are available to initiate immediate victim transport, a ground ambulance coordinator can be established and vic- tims can be moved directly from triage to ambulances by triage priority with destination hospital or specialty receiving center determined by the medical communications coordinator. Man- agement of arriving ambulances may be assigned to the ground ambulance coordinator on smaller incidents or may be assigned to a staging manager reporting to the medical group supervi- sor, medical branch director, or operations chief. If sufficient ambulances are not immediately available or the extent of the

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multicasualty incident exceeds local resources, a treatment unit will be necessary. Victims are moved to a treatment unit at a safe location by triage priority and subsequently transported in ambulances or other types of vehicles (e.g., buses or vans for minor casualties) as these resources become available. A treat- ment dispatch manager working with the treatment unit leader and ground ambulance coordinator controls victim movement based on triage category and ambulance availability. The medi- cal communications coordinator determines destination hospi- tals in association with the healthcare infrastructure. The phys- ical location of the medical communications coordinator will be determined by many incident-specific factors. One strategy is to geographically locate the medical communications coordi- nator so that the ambulances loaded by triage category receive their hospital or specialty center destination assignments as they are exiting the incident. This prevents slowing down the patient loading process by allowing the treatment dispatch manager and ground ambulance coordinator to load ambulances by triage category without waiting for destination decisions.

As incident organization increases, it is important to under- stand that these components are based on functions rather than on positions. If local responders are adequately trained and exercised on multicasualty incident management, the functions described will be accomplished without unnecessary focus on process and position titles.

Effective victim triage is essential to optimize use of limited on-scene resources and healthcare infrastructure in larger mul- ticasualty incidents. Although many EMS systems have robust patient distribution systems, it is not uncommon that a dispro- portionate number of casualties are transported to the closest general or specialty hospital (such as a trauma or burn center). Examples include events involving the World Trade Center in New York City and the Alfred P. Murrah Federal Building in Oklahoma City.5,6 Some degree of victim self-triage and self- transport can be expected, especially before effective incident management is established and adequate resources have arrived to the incident site. The magnitude of victim self-triage and transport can be substantial, even in industrialized societies with highly resourced EMS systems.6,7 Victims who have or find their own transportation can be expected to go to the closest hospitals or to those most familiar to them independent of any plan to optimally utilize healthcare resources. Even if scene managers use a good patient distribution system, this can result in a mal- distribution of casualties to local hospitals such that one or a few facilities are overwhelmed, while others receive few victims. Early communications about the nature and location of the incident is essential if healthcare facilities have only a very limited time to prepare for the arrival of victims. This is particularly true if decontamination of victims is necessary as part of their coordi- nated medical care. Hospital-based decontamination operations take time to establish. Hospitals may experience “reverse triage” such that self-transported victims with comparatively less severe injuries arrive before more seriously injured victims sent by the EMS system.6 Bidirectional communication between the medical communications coordinator and hospitals will help determine whether victims of lower triage priority should be transported to more distant hospitals to avoid those that are closer and more affected by victim convergence. Communication with healthcare facilities may be direct using radios and telephones or indirect through a dispatch or regional coordination center. Other com- munications modalities include web-based real-time tracking systems for victim transport and hospital capabilities. Electronic

victim and hospital tracking can take place via the Internet and can be backed up by microwave transmission. Effective hospital- based response to a multicasualty incident will depend on estab- lishing an internal command structure just as it does in field incident management. The Hospital Incident Command System (see Chapter 20) is an example of a framework that defines posi- tions and functions to assist hospitals with internal organization, requesting additional resources and optimal resource utilization for both in-house and on-call resources.8

Spontaneous responders can be a challenge to manage during a large incident. Spontaneous medical responders are unlikely to be trained, equipped, or experienced in providing medical care under hazardous conditions and unlikely to be familiar with EMS strategies and procedures. Informed and organized spontaneous medical responders can be an asset, however, when the size and scope of the multicasualty incident exceeds local capabilities. It is essential to have a plan to manage these well-meaning volunteers; otherwise they can distract resources from their primary func- tions and lead to inadequate scene management. One strategy is to attempt to collect spontaneous medical responders, brief them on the nature of the incident, and assign them to the treatment unit leader. The staging area for victims in the treatment unit awaiting transportation to hospitals will likely be in a compara- tively safe location and the approach to these patients’ care will be somewhat familiar to spontaneous medical responders who are healthcare providers.

MEDICAL MANAGEMENT

Specific treatment rendered during and subsequent to the triage process or in the treatment unit must be goal directed and will depend on the capabilities and capacity of the responding resources. Because the triage process is dynamic, an important function is interval victim reassessment and retriage if necessary after a victim arrives at the treatment unit. Newer triage tags are designed to display change in triage category with either improvement or deterioration. Treatment strategies likely to reduce morbidity and mortality among victims staged in the treatment unit include maintaining an open airway, decompress- ing a tension pneumothorax (needle thoracostomy), controlling external exsanguinating hemorrhage (wound packing or dress- ing, elevation, or arterial tourniquet) and spinal stabilization (if not already accomplished). Conversely, a clinical assessment to determine whether patients require or should remain in spine immobilization can be invaluable during multicasualty incidents. Such assessments can save scarce resources and reduce discom- fort and complications for patients who do not require spinal stabilization. Using a validated protocol, properly trained per- sonnel can systematically judge when spinal stabilization is nec- essary and when it is not.9,10 Patients in whom spinal immobi- lization is deemed unnecessary require far fewer personnel and transportation resources.

The gamut of EMS therapeutic interventions may not be available, depending on the number and acuity of victims, avail- able transportation resources, and capacity of the EMS system. Intravascular fluid resuscitation (intravenous or intraosseous) of profound hypovolemic shock with uncontrolled hemor- rhage to permissive hypotension endpoints may influence vic- tim outcome.11,12 However, insufficient evidence currently exists to create multicasualty victim clinical management strategies. Decisions on airway interventions will be determined by the

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availability of equipment and personnel, sustainment of those resources (e.g., oxygen), predicted victim survivability, and the number of other victims who may survive. Selected goal-directed therapies for injuries or for exacerbations of underlying illnesses subsequent to those injuries will be considered on a case-by-case basis as resources allow. Pain control can be both a humanitar- ian and practical intervention. Nonpharmacological pain con- trol may take the form of effective splinting and immobiliza- tion of fractures. Pharmacological pain control will depend on local scope of practice and available resources, but can pro- vide comfort to victims immobilized for long periods of time or with painful injuries awaiting transportation. Other measures to address victim comfort include providing oral hydration when clinically appropriate and shade or shelter for the treatment unit. This will reduce exposure to temperature extremes, sunlight, wind, precipitation, and the sights and sounds of the incident itself.

Medical management of entrapped victims can be complex. When resources are available and the survivability of entrapped victims is sufficiently favorable to support extended technical rescue operations, certain medical interventions can contribute to both the stabilization of the victim and the tempo of the rescue. The treatment of easily reversible conditions and pain may allow some downward triage of selected victims (i.e., moving patients to a lower, less severe level) and allocation of scarce medical resources to victims more acutely ill. Inhalation injury, blunt and penetrating trauma, traumatic rhabdomyolysis (crush syn- drome), hypothermia, dehydration, and exacerbation of chronic illnesses are among the conditions that may require field inter- ventions. Depending on the nature of a structure’s building mate- rials and the nature of the event causing its failure, emergencies involving structural collapse may result in void spaces capa- ble of supporting life. Rescuers can help reduce further risk of inhalational injury by providing void space ventilation and by administering a particulate respirator to the victim. Trapped casualties can receive void space ventilation either passively by opening the void space to the atmosphere or actively using venti- lation fans. Anticipating predictable physiologic consequences of prolonged entrapment and coordinating goal-directed medical interventions with the rescue operation are important consid- erations. Preparing for traumatic rhabdomyolysis, blood loss, and intravascular fluid shifts during extrication can reduce the risk of precipitous hemodynamic destabilization when the victim is freed.12 Pain management can substantially affect the tempo of a rescue effort by expediting extrication. Although extrica- tion can involve moving the victim in ways that are unavoid- ably painful, pain exacerbation can be a warning that part of the rescue effort is placing the victim at risk of further injury. If victim discomfort causes the rescue effort to be repeatedly stopped and readjusted with no appreciable progress, pharma- cological pain control should be used to facilitate the rescue process.

DECONTAMINATION AND SPECIAL HAZARDS

When chemical, radiological, and possibly biological hazards are present or when there is concern for secondary hazardous devices such as explosives, incident organization for the purpose of victim movement remains unchanged. Several other processes, however, must be inserted into multicasualty incident organiza- tion and structure. The first challenge is recognition and rapid

assessment of the hazard. Responders must quickly determine whether there are surviving and accessible victims and what level of responder personal protective equipment will be neces- sary to make rapid entry and remove survivors to a safe area. The suspected nature of the hazard and initial operational deci- sions will be communicated to responding personnel. Perfor- mance of triage may wait until victims are moved to a safe area or after emergency decontamination. If triage is accom- plished prior to emergency decontamination, triage personnel may need to work in personal protective equipment. Once the responders have recognized suspected hazard, donned personal protective equipment, accomplished initial victim rescue, and performed emergency decontamination, the process of organiz- ing secondary triage (or primary triage if not yet performed), treatment, medical communications, resource coordination, and victim transport remains the same.

When there is a need for victim decontamination, a sub- stantial layer of complexity and personnel requirements is added to EMS scene management. Within the U.S., if a need exists for emergency decontamination based on victim symptoms or known exposure, it will likely be the initial responding fire sup- pression units that will use handheld hose lines or elevated master streams with nozzles operated in a fog pattern as the initial approach. If contaminated victims are at risk from an immediate life or health threat, the U.S. Environmental Protec- tion Agency has stated that responders are not required initially to contain the water runoff (e.g., it can be managed downhill from operating units on grass or gravel).13,14 Runoff containment becomes a regulatory requirement after the life or health threat is mitigated. These regulations become effective when opera- tions transition from emergency decontamination to techni- cal decontamination during hazard mitigation, deceased victim recovery, or law enforcement investigation. An attempt should be made to cohort contaminated victims to the extent possible while establishing the emergency decontamination equipment. With proper training and exercising, decontamination systems can be synthesized very rapidly (within minutes) using equip- ment and devices carried on fire apparatus normally used for fire suppression. Victim contact for pre–decontamination coor- dination or life-threatening injury or illness intervention will likely occur with personnel wearing protective equipment and full-face, positive pressure self-contained breathing apparatus. If decontamination operations are sustained, the level of respira- tory and splash protection necessary can be re-evaluated based on a more objective risk assessment (see Chapter 14). Crit- ical pre–decontamination interventions may include removal of outer clothing (which results in substantial contamination reduction), containing important personal items (e.g., personal identification) and coordinating family or companion decon- tamination for ambulatory victims. For nonambulatory victims, pre–decontamination maintenance of an open airway, needle decompression of a tension pneumothorax, control of exter- nal exsanguinating hemorrhage, and spinal stabilization may be indicated. Pre–decontamination antidote administration may be impractical or medication may be unavailable. It is, how- ever, technically feasible for providers wearing protective equip- ment to administer intramuscular injections of atropine and pralidoxime by using autoinjectors for critically ill victims of organophosphate/nerve agent toxicity. This intervention can sta- bilize the victim sufficiently to permit necessary decontamina- tion prior to more definitive treatment. Exposure solely to vapors or gases (particularly less water-soluble gases) will not require

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immediate skin decontamination. Therefore, cyanide antidote administration to critically ill victims can proceed as soon as the victim is removed from the immediate inhalation hazard and the prehospital care provider can work safely without a respirator. Similarly, radioactive particulate contamination of victims from an explosive dispersion device is a lower priority than manag- ing critical blunt or penetrating trauma resulting from the blast injury.15,16 Removing the external layer of clothing, wrapping the victim to contain the radioactive contamination, perform- ing critical prehospital interventions, transporting the patient to a trauma center, and initial resuscitation and damage control surgery are all priorities over radiological decontamination (see Chapter 30). Radiological decontamination can be performed at any point during medical or surgical management when the victim is stabilized. Victims with minor injuries or illness can be decontaminated prior to transport. Wound irrigation is part of the decontamination process. Because hospitals may not be sufficiently prepared to manage patients with radiological con- tamination, emergency planners should anticipate requests from hospitals for decontamination assistance (supplies and trained personnel), particularly if large numbers of self-transported vic- tims arrive before hospital-based decontamination procedures are fully operational.

VICTIM TRACKING

Victim tracking is a challenging problem in EMS scene manage- ment of multicasualty incidents (see Chapter 25). With wireless telephone communications (including instant messaging and picture phones) widely available, victim involvement in an emer- gency can be known by family, friends, coworkers, and the media very early in the evolution of the incident. The status and loca- tions of multicasualty incident victims who require custodial care (e.g., children, elderly, or disabled) will likely be sought even before the last victim has left the scene, with some care- takers arriving on the scene in the midst of ongoing emergency operations. There is a balance between efficient victim movement from the incident to definitive medical care and documentation of important victim information at the scene. Electronic devices to connect a triage tag identifier with the identity and destination of a victim have not been rigorously and objectively compared to paper-based tracking systems in efficacy, effectiveness, or practi- cality under operational field conditions. Electronic devices can fail due to power or weather situations and would need to be immediately and widely available and operable by EMS system personnel. Any procedure or device that is used only rarely and under exceptional circumstances is at risk for failure when it may be needed most. Hospital-based patient identification and tracking is a common practice and may be augmented with the assistance of nongovernment organizations (e.g., American Red Cross chapters) or local EMS communications infrastructure. This process, although effective, incorporates an inherent delay in victim information transmission.

MULTIJURISDICTIONAL COORDINATION

Large or widespread multicasualty emergency response by a juris- diction will likely require outside assistance. “Automatic aid” refers to public safety answering points and dispatch centers sending the closest appropriate local units independent of geopo-

litical boundaries. “Mutual aid” refers to interjurisdictional assis- tance following a specific request for that assistance. Often, but not exclusively, this implies pre-event agreements defining avail- able resources, response parameters, and administrative issues such as reimbursement procedures. Mutual aid can be between local jurisdictions, within regions of a state, from state gov- ernment, between states (e.g., Emergency Management Assis- tance Compacts),17 from the federal government, and between countries. Each responding mutual aid entity will have its own command structure that will integrate into a unified command, division, branch, or group organization of the jurisdiction hav- ing authority. Local or regional entities may request EMS mutual aid to assist with victim management at the scene. More dis- tant EMS mutual aid may include ambulance strike teams18,19 to assist with victim transport from hospitals to specialty facilities (e.g., trauma, burn, or pediatric) or from hospitals with a large number of victims to more distant hospitals to better manage vic- tim distribution. EMS helicopters are less practical than ground transport units in multicasualty incidents. They require addi- tional resources to operate safely and coordinate landing zones and they can generally only carry one or possible two victims. Air EMS resources can have value if they are used to transport properly triaged victims to specialty care centers (e.g., trauma, burn, or pediatric) distant from the incident due to geographical location or saturation of closer specialty centers. If extended res- cue operations are necessary, specialty rescue teams or task forces with medical components may be deployed to the scene. Medical teams may be requested to support local healthcare infrastruc- ture by expanding: 1) local or regional emergency departments, critical care, or medical–surgical units, or 2) public health capac- ity. They may also provide free-standing treatment stations or medical support to the community and shelters for special pop- ulations. Individual resources or strike teams such as specialty nurses (e.g., critical care, burn, and dialysis), pharmacists, or physicians may also be requested. Disaster management systems and healthcare facility disaster management are discussed else- where (see Chapters 9 and 20).

RECOMMENDATIONS FOR FURTHER RESEARCH

Planning for multicasualty incident response requires more than an analysis of the organizational and technical aspects. Multi- casualty incident response plans must anticipate and incorpo- rate the potential effects of victim self-triage and self-transport. Hospital and scene incident management must anticipate mal- distribution of victims geographically and by acuity. In addition, response personnel must be knowledgeable, trained, exercised, and disciplined in the application of their multicasualty incident plan. The plan must be adaptive to allow flexibility and deviation to meet the specific needs of an incident. Frequent exercises and scaled application of the plan to more common smaller inci- dents will help achieve responder familiarity and comfort and improve plan compliance. Research on victim movement and incident organization will help identify those functions that are most critical to effective patient triage and transport and allow planning, training, and exercising to address those needs.

Healthcare resources in a community can be scarce, even during daily operations. To support multicasualty incident oper- ations, particularly for victims triaged as minor, transport to free-standing emergency departments, urgent care centers and other alternate care sites might help unload acute care facilities

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allowing them to manage greater numbers of higher acuity vic- tims. This is not common practice in the U.S. and will require research into the safest ways to distribute minor casualties into a broader healthcare system. In addition, regulators must address existing laws and the need for legislative relief to enable selected alternate care sites to receive victims from an incident.

Virtually every emergency incident or disaster after-action report mentions challenges with communications. Effective and sustainable communications within jurisdictional chains of com- mand and with outside resources are essential for command and control and optimal resource utilization. The capacity of rou- tinely used communications systems can be easily exceeded dur- ing major incidents. Cellular telephones and local emergency radio frequencies can be saturated with communications traffic, as can handheld satellite telephones. Distance from commu- nications centers or communications transmission equipment or terrain can compromise radio or cellular traffic. Collateral damage to communications infrastructure or power supply can render wireless telephones unusable and radio communications may be limited to line-of-sight with handheld units. Portable radio battery life as well as opportunities for replacement, and recharging may be limited. Multijurisdictional radio interop- erability may also be limited. Separation of law enforcement, fire suppression/rescue, and EMS radio communications may make coordination of resources difficult. Lack of redundancy in communications systems can compromise operations when one or more systems fail. Technological, political, and operational solutions are possible when combined with funding, equipment availability, familiarity, training, and exercising. As with triage strategies, communications solutions should be integrated into daily emergency services operations so that unfamiliar equip- ment and procedures will not be first used in times of high demand.

No triage decision scheme has been prospectively validated under large-scale multicasualty incident operational conditions. Retrospective studies on efficacy do not always translate to prospective operational effectiveness. Attempting to transport every “critical” victim to a specialty center by using advanced life support assets is not always the best use of resources or even pos- sible to achieve. Arguably, effective triage strategies during a large multicasualty emergency are more important to victim outcome and resource utilization than in daily single-victim trauma triage. Under- and overtriage can substantially impact the volume and acuity of victims arriving by EMS at healthcare facilities, com- promising the availability of these potentially limited resources for victims most likely to benefit and potentially compromising victim clinical outcomes.

Victim tracking from the scene, if done at all, can be as low- tech as paper documentation of victim name, triage category, hospital destination, and transporting unit identifier or as high- tech as encrypted electronic scanning and wireless transmission of victim data to multiple stakeholder agencies. Such informa- tion, secured as protected patient information, would promote improvements in victim management from the incident, health- care interfacility transfers for specialty care, family notifications, and postincident analysis. The more complex equipment and procedures become and the less they are used under daily oper- ational conditions, the more likely they are to fail. Practical, durable, affordable technological solutions or simple operational procedures should be developed.

Thoughtful, goal-directed, locally conceived and executed exercises and drills are essential to managing and coordinating

the many challenges of a large multicasualty incident. Both insuf- ficient funding and the process of obtaining funding through grants for exercises can result in training that is poorly con- ceived with goals that are too broad or general and with insuf- ficient attention to local needs. The lack of sophisticated local systems, equipment, and procedures does not necessarily trans- late to poor multicasualty incident performance. Understand- ing local resources, optimizing those resources, and supporting training and exercises can result in a well-managed incident.

Continuous quality improvement studies are increasingly applied within EMS systems. Documentation of patient demo- graphics and clinical condition may not be as thorough during multicasualty incidents as it is for incidents with few patients but postincident analysis can provide useful data for system and response evaluation. Time intervals for response, staging, victim transport by triage category, and ambulance departure-from- scene as well as cumulative victim transport numbers by triage acuity over time are parameters that can help characterize the timeframe of the response and of victim movement. Changes in these calculated intervals if operational changes were made on scene during the evolution of the incident can be very instructive. These time-related data may be more readily available in an EMS system than victim outcome data. When victim outcome data are available, this information can be useful to help assess triage sen- sitivity (false negative or undertriage rate) and specificity (false positive or overtriage rate). Typical data collected include: 1) hos- pital admission rates, 2) duration of stay, 3) admission diagnoses, 4) emergency department and hospital discharge diagnoses, 5) surgical intervention rates (e.g., trauma/general, orthopedic, and neurological surgery), 6) critical care unit admission rates, and 7) mortality rates. In well-designed multicasualty incident exercises with mock victims tagged with local triage scheme- specific parameters, both “victim” movement time analysis and triage scheme sensitivity and specificity can be assessed for the purposes of adjusting future training and system deployment. Such an exercise assessment is only an approximation of oper- ational effectiveness but can identify extremes in performance that can assist with defining future training needs. EMS systems with well-developed data management and continuous quality improvement processes may be able to capture more objective, operational data and contribute to the knowledge base for multi- casualty incident management by forming multicasualty incident registries.

REFERENCES

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4. Multi-Casualty Branch Worksheet. Available at: http://www .firescope.org/ics-multi-casual/forms/ICS-MC-305.pdf. Accessed January 6, 2009.

5. Centers for Disease Control and Prevention. Rapid assess- ment of injuries among survivors of the terrorist attack on the World Trade Center–New York City, September 2001. MMWR. 2002;51(1):1–5.

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9. Spinal Assessment Protocol, Maine EMS 2002. Available at: http://www.maine.gov/dps/ems/documents/spinal assessment book.pdf. Accessed January 6, 2009.

10. Domeier RM, Frederiksen SM, Welch K. Prospective perfor- mance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46(2):123–131.

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13. US EPA letter to US Army Soldier and Biological Chemi- cal Command, September 1999. Available at: http://cryptome .org/runoff.htm. Accessed January 6, 2009.

14. Bushberg JT, Kroger LA, Hartman MB, et al. Nuclear/ radiological terrorism: emergency department management of radiation casualties. J Emerg Med. 2007;32(1):71–85.

15. Koenig KL, Hatchett RJ, Mettler FA, et al. Medical treatment of radiologic casualties: current concepts. Ann Emerg Med. 2005;45(6):643–652.

16. Emergency Management Assistance Compact. Available at: http://www.emacweb.org/. Accessed January 6, 2009.

17. Ambulance Strike Team Guidelines, available at http://www .emsa.ca.gov/pubs/pdf/emsa215.pdf. Accessed January 11, 2009.

18. U.S. Department of Homeland Security, Federal Emergency Management Agency, Ambulance Strike Teams. Available at: http://www.nimsonline.com/resource typing/Ambulance% 20Strike%20Team.htm. Accessed January 6, 2009.

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