Mass-Casualty Incidents

1.9 Mass-Casualty Incidents
 
 

PURPOSE
To efficiently triage, treat, and transport victims of mass/multiple-casualty incidents (MCIs). The following protocol is applicable to all multiple-victim situations. This protocol is intended for the everyday MCI when the number of injured exceeds the capabilities of the first-arriving unit as well as for large-scale MCIs.

PROCEDURE

  1. The officer of the first-arriving unit will establish Command and:
    1. Perform a size-up, estimating the number of victims.
    2. Request a Level 1, 2, 3, 4, or 5 response, and request additional units and/or specialized equipment as required.
    3. Identify a staging area.
    4. Direct the remaining crew members and any additional personnel arriving to initiate triage.
    5. Triage will be performed in accordance with START or JumpSTART.
      Prioritize victims utilizing color-coded ribbons:
      Red = Immediate care
      Yellow = Delayed care
      Green = Ambulatory (minor)
      Black = Deceased (non-salvageable)
    6. Locate and direct the "walking wounded" to one location away from the incident, if possible. These victims need to be assessed as soon as possible. Assign someone to keep the walking wounded together.
  2. As additional units arrive, Command will designate the following officers:
    1. Triage (Initially the responsibility of the first-arriving officer).
    2. Treatment.
    3. Transport.
    4. Staging.
  3. Additional branches/sections may be required depending on the complexity of the incident. These officers may include, but are not limited to:
    1. Medical Branch.
    2. Landing Zone/Heli-spot.
    3. Extrication.
    4. Hazardous Materials (hazmat).
    5. Rehabilitation.
    6. Safety.
    7. Public Information Officer (PIO).
    8. Medical Intelligence — to assist with suspected or known WMD (weapons of mass destruction) events for decontamination, antidotes, and treatment.
  4. MCI: predetermined response plan.
    1. Considerations:
      1. An MCI shall be classified by different levels depending on the number of victims. The number of victims will be based on the initial size-up, prior to triage.
      2. Levels of response will augment the units already on the scene, and units en route will be included in the assignment. The exception would be in conjunction with a Fire Alarm assignment i.e., a fire with multiple victims may be a Second Alarm with an MCI Level 3 response; this will be two separate assignments).
      3. Command can downgrade or upgrade the assignments at any time.
      4. All units will respond to the staging area unless otherwise directed by Command. When announcing an MCI, specify the general category (e.g., trauma, hazardous materials, smoke inhalation).
      5. Any victim meeting trauma transport criteria must be reported to a state-approved trauma center for determination as to transport destination. Trauma transport criteria will be determined during the secondary triage in the treatment phase.
      6. All units are to respond to the staging area emergency response unless otherwise directed.
      7. Consider the use of air transport for patients with special needs, mass-transit resources for multiple "walking wounded" patients, and private BLS transport units.
      8. Consider the use of mobile command vehicles, medical supply trailers, and communication trailers as needed.
      9. Upon notification of an MCI, Medical Control (Medcom/MRCC) will gather information about each hospital's capability and relay this information to the Transport Officer or Medical Communication Officer.
      10. On a large-scale incident, consider sending a Hospital Coordinator to each hospital to assist with communications.
      11. Request law enforcement to set up a safety parameter.
    2. Definitions.
      1. Strike Team: A specified combination of the same kind and type of resources with common communications and a leader (i.e., an ALS Transport Unit Strike Team would consist of five ALS Transport Units with a leader).
      2. Task Force: A group of resources with common communications and a leader (i.e., an MCI Task Force would consist of two ALS Transport Units, two BLS Transport Units, and one Suppression Unit with a leader). Consider a support vehicle such as an MCI trailer.
      3. Litter Bearer: A team of personnel assigned to Triage to move victims from the incident site to the treatment area or Transport Units.

MCI Level 1 (5-10 victims)

  • 4 ALS Transport Units
  • 2 Suppression Units
  • 1 Shift Supervisor
  • 1 EMS Supervisor

Note - The two hospitals and trauma center closest to the incident will be notified by Medical Control (Medcom or local communications center).

MCI Level 2 (11-20 victims)

  • 6 ALS Transport Units
  • 3 Suppression Units
  • 2 Shift Supervisors
  • 2 EMS Shift Supervisors

Note - The three hospitals and two trauma centers closest to the incident will be notified by Medical Control (Medcom or local communications center).

MCI Level 3 (21-100 victims)

  • 8 ALS Transport Units
  • 4 Suppression Units
  • 3 Shift Supervisors
  • 3 EMS Shift Supervisors
  • Command Vehicle
  • MCI Trailer
  • Operations Chief

Note – The four hospitals and three trauma centers closest to the incident will be notified by Medical Control (Medcom or local communications center). The Warning Point will notify the Emergency Management Agency.

MCI Level 4 (101-1000 victims)

  • 5 MCI Task Forces (25 units)
  • 2 ALS Transport Strike Teams (10 units)
  • 1 Suppression Unit Strike Team (5 units)
  • 2 BLS Transport Strike Teams (10 units)
  • 2 Mass Transit Buses
  • 2 MCI Trailers
  • Command Vehicle
  • Communications Trailer
  • 5 Shift Supervisors
  • 3 EMS Shift Supervisors,1 EMS Chief
  • Operations Chief

Note - The 10 hospitals and 5 trauma centers closest to the incident will be notified by Medical Control. The Warning Point will notify the Emergency Management Agency. In an ongoing, long-term MCI, the Metropolitan Medical Response System (MMRS) and the State Medical Assistance Response Team (SMRT), Medical Reserve Corp (MRC) Disaster Medical Assistance Team (DMAT) may be notified.

MCI Level 5 (more than 1000 victims)

  • 10 MCI Task Forces (50 units)
  • 4 ALS Transport Strike Teams (20 units)
  • 2 Suppression Unit Strike Teams (10 units)
  • 4 BLS Transport Strike Teams (20 units)
  • 4 Mass Transit Buses
  • 2 Command Vehicles
  • 4 Supply Trailers
  • Communications Trailer
  • 10 Shift Supervisors
  • 6 EMS Shift Supervisors
  • 2 EMS Chiefs
  • 2 Operations Chiefs

Note -The 20 hospitals and 10 trauma centers closest to the incident will be notified by Medical Control. The Warning Point will notify the Emergency Management Agency. In an ongoing, long-term MCI, the MMRS, DMAT, SMRT, MRC and the International Medical and Surgical Response Team (IMSURT) may be notified.

Strike Team: Five of the same type of units, including common communications and leader.
Task Force: Five different types of units, including common communications and leader.
MCI Task Force: May be two ALS Transport Units, two BLS Transport Units, and one Suppression Unit, including common communications and leader.

OFFICER RESPONSIBILITIES - See Online Forms for Field Operating Guides.

  1. Command.
    1. Established by the first arriving officer. Radio designation = "Command."
    2. Follow Field Operation Guide (FOG) #1.
    3. Remain in a safe, fixed, and visible location, uphill and upwind of the incident.
    4. Determine the MCI Level (1, 2, 3, 4, or 5).
    5. Designate a staging area.
    6. Assign personnel to perform the functions of Triage, Treatment, Transport, and Staging.
    7. Advise the Communications Center of the number of victims and their categories once triage is complete.
    8. During large-scale or complex MCIs (e.g., a fire with multiple victims), designate a Medical Branch to reduce the span of control.
    9. If the incident is due to a known or suspected weapon of mass destruction (WMD event), refer to WMD FOG #8 and designate a Medical Intelligence Officer to assist with decontamination, antidotes, and treatment of victims.
    10. Ensure proper security of the incident site, treatment area, and loading area; also provide for traffic control and access for emergency vehicles, including law enforcement.
  2. Medical Branch.
    1. Radio designation = "Medical." Follow FOG #2.
    2. Assure Triage, Treatment, and Transport has been established. If established byCommand, Triage, Treatment, and Transport will now report to the Medical Branch.
    3. Work with Command, and direct and/or supervise on-scene personnel from agencies such as the Medical Examiner's Office, Red Cross, private ambulance companies, and hospital volunteers.
    4. Ensure notification of Medical Control (Medcom/MRCC).
    5. If the incident is due to a known or suspected WMD, refer to WMD FOG #8 and designate a Medical Intelligence Officer to assist with decontamination, antidotes, and treatment of victims.
    6. Ensure proper security of incident site, treatment area, and loading area; also provide for traffic control and access for emergency vehicles, including law enforcement.
  3. Triage Officer.
    1. Radio designation = "Triage." Follow FOG #3.
    2. Organize the Triage Team to begin initial triaging of victims, utilizing the START/JumpSTART triage system. Assemble the walking wounded and uninjured in a safe area. Use bullhorns or a public address (PA) system if necessary.
    3. Advise Command (or the Medical Branch, if established) as soon as possible if there is a need for additional resources.
    4. Coordinate with Treatment to ensure that priority victims are treated first.
    5. Ensure that all areas around the MCI scene have been checked for potential victims, walking wounded, ejected victims, and so forth.
    6. Supervise the Triage Personnel, Litter Bearers, and Medical Examiner's Office personnel.
    7. Maintain security and control of the triage area. Request the assistance of law enforcement.
    8. Report to Command/Medical Branch upon completion of duties for further assignments.
  4. Treatment Officer.
    Reports to Command or the Medical Branch. Supervises the Treatment Managers of the Red, Yellow, and Green Areas. Coordinates the retriage and tagging of all victims and the on-site medical care. Directs the movement of victims to the loading area(s).
    1. Radio designation = "Treatment." Follow FOG #4.
    2. Consider assigning a Documentation Aide to assist with paperwork.
    3. Direct personnel to either begin treatment on the victims where they lay or establish a centralized treatment area.
    4. Considerations for a treatment area:
      1. Capable of accommodating the number of victims and equipment.
      2. Consider weather, safety, and the possibility of hazardous materials.
      3. Designate entrance and exit areas, which are readily accessible (funnel points).
      4. On large-scale incidents, divide the treatment area into three distinct areas based on priority. Designate a Treatment Manager for each area (Red, Yellow, Green). Use appropriate-color tarps if available.
    5. Complete a Treatment Log as victims enter the area.
    6. Ensure that all victims are retriaged through a secondary exam and the assessment is documented on a triage tag (Disaster Management System [DMS] - All Risk Triage tag). The rescuer filling out the All Risk Triage tag will keep a corner of the tag for future documentation.
    7. All red-tagged victims will be transported immediately as transport units become available. These victims should not be delayed in the treatment area.
    8. Ensure that enough equipment is available to effectively treat all victims.
    9. Establish communications with Transport to coordinate proper transport of the appropriate victims. Direct movement of victims to the ambulance loading areas.
    10. Provide periodic status reports to Command/Medical Branch.
  5. Note:
    Red, Yellow, and Green Treatment Manager: Report to the Treatment Officer and are responsible for the treatment and continual retriaging of victims. Notify the Treatment Officer of victim readiness and priority for transportation. Assure that appropriate victim information is recorded.

  6. Transport Officer.
    Reports to Command or the Medical Branch. Supervises the Medical
    Communication Coordinator and Documentation Aide(s). The Transport Officer is responsible for the coordination of victims and maintenance of records relating to victim identification, injuries, mode of transportation, and destination.
    1. Radio designation = "Transport." Follow FOG #5.
    2. Assign a Documentation Aide with a radio to assist with paperwork and communications.
    3. Assign a Medical Communication Coordinator to establish continuous contact with Medical Control (Medcom or MRCC).
    4. Establish a victim loading area. Advise Staging of the location and direction of travel. Consider requesting law enforcement assistance for ensuring the security of the loading area.
    5. Arrange for the transport of victims from the treatment area. Maintain a Hospital Transportation Log #5B. Keep a piece of the triage tag for future documentation.
    6. Communicate with the Landing Zone (LZ)/Heli-spot Officer and relay the number of victims to be transported by air. Air-transported victims should be assigned to distant hospitals, unless the victims' needs dictate otherwise (e.g., trauma center, burn unit).
  7. Medical Communications Coordinator.
    Reports to the Transport Officer and is responsible for maintaining communication with Medical
    Control to assure proper victim transport information and destination.
    1. Radio designation = "Communication." Follow FOG #5A.
    2. Establish communication with Medical Control (Medcom or MRCC1). Advise Medical Control of the overall situation (e.g., smoke inhalation, trauma, burns, hazardous materials exposure) and the number and categories of victims. Medical Control will survey area hospitals to determine their capabilities and capacities and then relay this information to the field. Document this information on the Hospital Capability Worksheet #5C and maintain this document for the duration of the incident.
    3. When units are prepared to transport, advise Medical Control and supply of the following information:
      1. The unit transporting.
      2. The number of victims to be transported.
      3. Their priority: Red, Yellow, or Green.
      4. Any victims with special needs (e.g., cardiac, burn, trauma).
    4. The Medical Communication Coordinator, in conjunction with Medical Control, will determine the most appropriate facility. Ground-transported victims should be assigned to hospitals on a rotating basis.
    5. Once Medical Control receives the information from the Medical Communication Coordinator, Medical Control will notify the appropriate hospital. Transporting units will not contact the individual hospital on their own, unless there is a need for medical direction/care outside of protocols.
  8. Note - Medical Resource Coordination Center (MRCC): The MRCC's prime function is to maintain status information—that is, the number of victims and the hospital readiness status to accept victims, to coordinate transportation, and to direct patients to the appropriate hospital during a disaster or other situation characterized by a high demand for medical resources

  9. Medical Supply Coordinator.
    Reports to the Medical Branch and is responsible for acquiring and maintaining control of all medical equipment and supplies.
    1. Radio designation = "Supply." Follow FOG #6.
    2. Assure necessary equipment is available on the transporting vehicle.
    3. Provide an inventory of medical supplies at the staging area for use on scene.
    4. Assure support vehicles are requested. (Broward County has four MCI supply trailers and Region 7 has three large MCI supply trailers available for use during a large-scale MCI.)
  10. Staging Officer.
    Reports to Command and is responsible for managing all activities within the staging area.
    1. Radio designation = "Staging." Follow FOG #7.
    2. Establish the location of a staging area and notify the Communication Center to direct any incoming units.
    3. Maintain a Unit Staging Log #7A.
    4. Ensure that all personnel stay with their vehicles unless otherwise directed by Command. If personnel are directed to assist in another function, ensure that the keys stay with each vehicle.
    5. Coordinate with the Transport Officer the designation of a location for victim loading and the best route to the area.
    6. Maintain a reserve of at least two transport vehicles. When the reserve is depleted, request additional units through Command.

DOCUMENTATION

  1. The Incident Commander will, at the completion of the incident, coordinate the gathering of all pertinent documentation.
  2. A Post-Incident Analysis (PIA) will be completed.

 

MCI Kits For Responder Vehicles
Each unit will carry an MCI bag. Included in the bag will be the following items:

  1. Two (2) triage packs recommend to have:
    1. Four (4) combine dressings.
    2. Four (4) 4 × 4's.
    3. Six (6) pairs of gloves.
    4. One (1) pediatric face mask, assorted oropharyngeal airways (OPAs) and nasopharyngeal airways (NPAs) optional.
    5. Colored ribbons (Red, Yellow, Green & Black) either rolls or ribbons. If separate ribbons, two (2) clip rings containing triage ribbons paired in red and yellow, green and black. There are 15 ribbons of each color per ring.
  2. One (1) additional set of triage ribbons if on clips.
  3. Fifty (50) triage tags—Disaster Management Systems (DMS) All Risk Triage tags.
  4. Three (3) mechanical pencils and three (3) grease pencils.
  5. The following MCI FOGs, logs, and associated paperwork for each officer:
    1. Command FOG #1 - White.
    2. Medical FOG #2 - Blue.
    3. Triage FOG #3 - Yellow.
    4. Treatment FOG #4 - Red.
    5. Treatment Area Log #4A - Red.
    6. Transport FOG #5 - Green.
    7. Medical Communication FOG #5A - Green.
    8. Hospital Transport Log #5B - Green. (10 logs)
    9. Hospital Capability Worksheet #5C - Green.
    10. Medical Supply FOG #6 - Blue.
    11. Staging FOG #7 - Orange.
    12. Unit Staging Log #7A - Orange.
    13. MCI-WMD/Terrorist Event FOG #8 - Beige.

MCI SUPERVISOR KIT

  1. Complete vest set with the following identification vests:
    1. White for Command.
    2. Blue for Medical Officer.
    3. Yellow for Triage Officer.
    4. Red for Treatment Officer.
    5. Green for Transport Officer.
    6. Green Striped for Medical Communication Coordinator.
    7. Blue Striped for Medical Supply Officer.
    8. Orange for Staging Officer.
  2. Portfolio for each officer that contains a clipboard, paperwork for each officer, pens, pencils, grease pencils, and a pad of paper.
  3. EMS tactical EMS Command Board.
  4. Tarp set: red, yellow, green, black tarps.
  5. Patient tracking device/Scanner (if available)
  6. Bullhorn.

START SYSTEM OF TRIAGE
This procedure is based on the Simple Triage and Rapid Treatment (START) process for adult victims and the JumpSTART adaptation for pediatric victims. These methods of triage are designed to assess a large number of victims objectively, efficiently, and rapidly and can be used by personnel with limited medical training.

PROCEDURE

  1. Initial triage: Using the START or JumpSTART method (described in the following two sections):
    1. Locate and direct all of the walking wounded to one location away from the incident if possible. Assign someone to keep them together (Fire Department personnel, law enforcement officer, or capable bystander).
    2. Begin assessing all non-ambulatory victims where they are found.
    3. Utilize the triage ribbons (color-coded plastic strips). One should be tied to an upper extremity in a visible location.
      1. Red: Immediate care.
      2. Yellow: Delayed care.
      3. Green: Ambulatory (minor).
      4. Black: Deceased (non-salvageable).
    4. Independent decisions should be made for each victim. Do not base triage decisions on the perception of too many reds, not enough greens, and so forth.
    5. If borderline decisions are encountered, always triage to the most urgent priority (e.g., for a Green/Yellow patient, tag as Yellow).
  2. Secondary triage.
    1. Performed on all victims during the Treatment phase. If a victim is identified in the initial Triage phase as a Red and transport is available, do not delay transport to perform a secondary assessment.
    2. Utilize a triage tag (Disaster Management System [DMS] All Risk Triage tag) and attempt to assess for and complete all information required on the tag (time permitting). Affix the tag to the victim and remove the ribbon.
    3. The Triage priority determined in the Treatment phase should be the priority used for transport. If trauma-related, the trauma transport criteria will be applied to trauma victims during the secondary triage in the Treatment phase.

Remember the mnemonic RPM (Respiration, Perfusion, Mental status). The first assessment that produces a Red stops further assessment. Only correction of life-threatening problems, such as airway obstruction or severe hemorrhage, should be managed during triage.

  1. Assess Respirations.
    1. If respiratory rate is 30/min or less, go to the Perfusion assessment.
    2. If respiratory rate is more than 30/min, prioritize as Red.
    3. If the victim is not breathing, open the airway, remove obstructions, if seen, and assess for (1) or (2).
    4. If the victim is still not breathing, prioritize as Black.
  2. Assess Perfusion.
    1. Performed by assessing a radial pulse.
    2. If radial pulse is present, go to the Mental Status assessment.
    3. If no radial pulse, prioritize as Red.
      Note - Any major external bleeding should also be controlled at this time.
  3. Assess Mental Status.
    1. Assess the victim's ability to follow simple commands and his/her orientation to time, place, and person (CAO x 3).
    2. If the victim does not follow commands, is unconscious, or is disoriented, prioritize as Red.
    3. If the victim follows commands and is oriented × 3, prioritize as Green.
      Note - Depending on the victim's injuries (burns, fractures, bleeding), it may be necessary to prioritize him/her as Yellow.

JUMPSTART TRIAGE
Physiological differences in children necessitate adaptation of the standard START triage method in children 8 years of age or younger, or in those victims with the anatomical or
physiological features of a child in the age group. The same parameters (RPM) are utilized, with
the adaptations indicated here.

  1. Assess Respirations.
    1. If the respiratory rate is between 15 and 45/min, go to the Perfusion assessment.
    2. If the respiratory rate is more than 45/min or less than 15/min, prioritize as Red.
    3. If the victim is not breathing, open the airway, remove obstructions, if seen, and assess for (1) or (2).
    4. If the victim is not breathing and no obstructions are present, check a peripheral (radial or pedal) pulse. If a peripheral pulse is present, provide five (5) ventilations (approximately 15 seconds) via any type of barrier device. If spontaneous respirations resume, prioritize as Red.
    5. If the victim is still not breathing, prioritize as Black.
  2. Assess Perfusion.
    1. Performed by assessing a peripheral pulse.
    2. If a peripheral pulse is present, go to the Mental Status assessment.
    3. If no peripheral pulse is present, prioritize as Red.
      Note - Any major external bleeding should also be controlled at this time.
  3. Assess Mental Status.
    1. Assess the child using the AVPU scale. Assess whether the victim is alert, responds to verbal stimuli, responds to painful stimuli, or is unconscious.
    2. If the victim is unconscious or only responds to painful stimuli, prioritize as Red
    3. If the victim is alert or responds to verbal stimuli, assess for further injuries and prioritize as Yellow or Green.

Note -Infants who are developmentally unable to walk should be triaged using the JumpSTART algorithm either during initial triage or in the Green area if carried out by a nonrescuer. During triage, if the infant does not fulfill the criteria of a Red victim and has no other outward signs of significant injury; he/she may be triaged as a Green victim.

Note -The START Triage system was developed by Newport Beach Fire Rescue and Hoag
Hospital. The JumpSTART Triage system was developed by Dr. Lou Romig.