Mass Casualty Incidents and Staging

Over the weekend we've seen how one gunman can easily create, along with panic and hysteria, a mass casualty/multi-casualty incident. For this forum discussion, we ask you how your department or agency deals with known or developing mass casualty incidents.

- Does you department utilize a specific alarm assignment for dispatching such incidents? (i.e. EMS Task Force; Mass Casualty Task Force; EMS "box" - 3 ALS, 2 BLS, 1 EMS Chief)

- What is your department's initial incident command structure for a mass casualty incident? (as the incident develops, who is your initial IC or EMS Group leader?) Does the second arriving BLS/ALS unit assume command or does it fall to a EMS chief/supervisor?

- What would be your typical ICS structure for an incident similar to the ones in Texas and Florida, in your area? (Command - Triage - Staging - Transport - Safety)

- How are private EMS agencies incorporated into such an assignment/incident?

- For departments utilizing "tactical medics", are those personnel organized to respond with the local law enforcement or as part of your EMS assignment (are tactical medics "gathered together" once on the scene)?

- When was the last time your department or agency trained with local law enforcement on active shooter or other tactical incidents?

- What is the average response time for a mass casualty transport unit (or other apparatus designed for transporting/treating large numbers of patients) in your area? Can your department quickly utilize public transportation servies (buses)?

Related Webcast: The Role of Staging at MCIs

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Wow. This one could be fun.

Let's see, where to start.

We have "EMS alarm" levels that dispatch pre-determined response packages (3 ambulances, 1 APP, and a chief) for each alarm. Each alarm also carries certain notifications (command staff, medical directors) and specialty vehicles (major response truck, multi-patient bus).

We're fortunate in that we have lots of resources. We can assemble many ambulances, immediately. In fact, "backup" gets there so quick that if you don't identify staging areas immediately, you will get swamped at the scene. So our protocol calls for the first ambulance to COMMAND and STAGING, the second ambulance to do TRIAGE, and then to fill out the ICS structure with arriving units and chiefs, BEFORE patient care begins. Supervisors and command staff fill in as they arrive, which is usually later. We've learned the hard way that you don't need a TRANSPORTATION OFFICER, you need a TRANSPORTATION GROUP of about 5 people to do all the communicating, loading and patient accountability.

We try to be really ICS-proficient. Our fire first responders usually get there first and establish COMMAND, but they rely on us to quickly establish a MEDICAL branch and manage all EMS aspects of the operation. Everybody has initial ICS training and all command staff and supervisors have ICS 300, 400, and have attended the major incident command course (E/IMUC) at TEEX in College Station, Texas (a GREAT course recommended for ANYBODY who might have to run an MCI or major incident, and it’s FREE too!). Our community is a bit different, in that one large EMS system serves 20+ fire jurisdictions and 15+ police jurisdictions, so except for our largest cities (Raleigh and Cary), EMS has the resources to staff large and long-term ICS structures. We’ve had several cycles of Incident Management Team (IMT) training and position specific training for PLANS and LOGS chiefs.

We can get city busses pretty quickly from 0600 – 2300. After that it might take a bit longer because people have to be called in. We have a non-transporting MCI/REHAB "major incident support unit." But we have just taken delivery on a multi-patient bus that can transport 14 supine patients, 12 wheelchairs, or do rehab for about 20 at a time. We can roll that out on 15 minute notice, along with our mobile command vehicle. A neighboring county EMS agency runs a para-transit service and we’ve called them for “wheelchair busses” on occasion.

We are authorized 12 tactical medics plus a supervisor – we currently have 9 medics and the supervisor. For “immediate” callouts we use on-duty TEMS medics (one of the supervisors keeps track of who and where they are) and for pre-planned events we sometimes use on-duty and sometimes we use off-duty TEMS personnel. We put ~250 medics through a full day of active shooter training utilizing real SWAT teams 18 months ago (and we will do it again this summer).

In our system we have “emergency” agencies and “non-emergency” agencies. Some of both are “private.” The “emergency” contract agencies work just like the county service and have the same training. When you ask for a “third EMS alarm” you get fully qualified and staffed units, no matter whether public or private. We don’t use our non-emergency services on emergency responses, but we HAVE called them for assistance when we’ve had to evacuate nursing homes or receive evacuees.

We’ve had some practice recently. We had an industrial explosion where all critical patients were transported within the first 30 minutes and all patients (38?) were gone within the hour. We also had a 30+ patient hazmat MCI (overcome by probable ammonium chloride) last weekend which was handled very well by a multi-agency response on an otherwise quiet Sunday morning. You can never get enough practice, and we’re working to figure out a way to train individual EMS crews (and get them enough practice) to be comfortable in doing the ICS associated with small to medium incidents.

Wow – lots of information. This is one of my favorite topics. Individuals with interest are invited to join the jemsconnect group on Incident Management and Special Operations. We’ve got some big city folks there who have some great stuff to share!
In terms of access, who provides support of ingress and egress? For example, if roads are blocked by debris. Here that is the responsibility of the Fire service. We don’t have to contend with much of that, but in a disaster (most likely a hurricane or ice storm) we would use whatever resources are available. As a first-line practice, we place chain saws and related safety equipment on our 4 wheel-drive SUVs, which we staff up to two people. Our fire service colleagues assist, and we would call upon resources from the city streets/public works departments, the parks & recreation people (they are part of our EOC operation and have lots of tractors, chain saws, etc.), and even commercial contractors. Our EMS officers are part of the county EOC operation, serving as IC/EOC manager, OPS section chief, and staffing an EMS desk, so we can call upon what we need in a timely manner.

Do you have an officer or posting for somebody to plan/monitor routes of transit for your units? That way if you have to shuttle, it is kept orderly. No, we rely on our units to get themselves to staging, and from the incident to the hospital. If there were particular problems, we would communicate them by voice and mobile data broadcast. If there were long-term disruption (e.g., bridge out), we can adjust the transportation network in MARVLIS (or in-vehicle navigation system that is tied to dispatch). We will have ICs running major incident centers, municipal or regional Area Commands coordinating, and a county EOC supporting.

What are your regional hospital capabilities? Trauma centers? Burn centers? Major medical centers? In the event one of these was compromised what would your transport times be? Would you utilize private EMS for such? Our primary destination hospital on a day-to-day basis is a level I trauma center that also has PICU, PCI, stroke, etc. Our other two hospitals are PCI centers, stroke centers, etc. The state burn center is only about 20 minutes away. Those transports go directly from the scene in our emergency ambulances.

Are your providers required to respond from home off duty? What arrangements do you make for families, etc? How do you contact your personnel? We’ve not had anything in the last five years that required consideration of that option. When we’ve had big events, quite a few of our staff have stepped up and volunteered without being asked. If we needed to, we use a system called Telestaff that can dial phones and leave messages. We don’t have much in the way of plans to care for families – individual desires and support systems make that pretty complex. We do have lots of county buildings where we could arrange something if needed.

Are local hospital personnel required to respond to their employment off duty? Don’t know about that – probably key management people are on call.

Where/how do you set up work/sleep rotations? Multiple stations, Hotel contracts? All of our stations have sleeping quarters, generators, refrigerators, washing machines, kitchens, etc. I’ve been told that our headquarters staff once used the downtown Hilton for a multi-day operation.

Do your hospitals have significant surge capacity or are they already at or past maximum? Like most US hospitals, ours are at or above 100% nearly every day. However, some of that is elective. The state of North Carolina also has the SMAT (state medical assistance team) system. SMAT-2 teams are mobile field hospitals that could be set up to add in patient capacity if needed. I think that there are 8 of those in the state, plus Carolinas MED-1 in Charlotte and SORT (the Special Operations Response Team, a DMAT-like organization) in Winston-Salem. The state has been very diligent about establishing deployable resources and organizations since Katrina etc. The state also has 8 multiple-patient bus vehicles, of which we have one in Wake County.

We’re working with our private (non-emergency) ambulance providers on a way to “bring them in” to the EMS system in times of major emergency. This could add a surge capacity of maybe 50 more ambulances to the system if we really needed them.

Do you have a system in place to set up a patient care area in order to reduce the surge to hospitals by delaying transport, so at the receiving facilities they can turn around their resources like CTs, ORs, etc? Nope! We do our job and have faith that they will do theirs. So far, maintaining the standard of care as much as possible seems to be our approach of choice. If the hospitals have capacity issues, they will call for mutual aid, activate an SMAT, etc.

Do you have agreements/plans in place to send providers to facilities in order to add manpower in EDs? Nope. We need all the EMS providers to do EMS in such a situation. If the hospitals require EMS assistance like evacuation, of course we would handle that for them.

How do you communicate at the hospitals the number and severity of patients they can care for? I have worked a major incident where critically ill people were arriving by personal vehicle in the front door, and medic units with the same through the back. Is there a designated person at the facility you will have immediate contact with or will you get a secretary who can only put you on hold?
Currently we do this from the field – it is the assignment of the hospital DESTINATION coordinator in the TRANSPORT group. After our last MCI, we decided that we needed a single point of contact for this, so we are working with our hospitals to have one of their communications centers fulfill this function as the REGIONAL HOSPITAL COORDINATOR.

Who/how provider water, food, basic needs? How do you coordinate rehab through multiple agencies including fire/law enforcement/EMS/and other departments like city or county service? We’re in a major metropolitan area, and we don’t face a credible threat that would fully wipe out our infrastructure. We can and do stock up stations a little bit with bottled water, powerbars and such.

Is there a system in place to work with or move physicians from the hospital to the field? To move patients from local facilities out of the region? Not from the EMS per perspective. See above re the SMATs and the medical evacuation busses.

What is your procedure for resupply of field units that will not be rotating through hospitals or for equipment malfunction? How about vehicle breakdown? Our stations are stocked for 7 days worth of operations, and we have a logistics warehouse that has a 30 day supply. We’d probably ignore minor vehicle issues that would ordinarily go to our fleet service for repair (light bulbs, noises, etc.). Otherwise, business as usual…..

It is probably not a major issue for you, but here, snow and cold is very significant, how do you handle providing shelter or support for elemental conditions. (dry clothing, temporary shelter, cooling, etc?) I realize that in such a disaster outside aid will be coming to your location, but I am under the impression not for 24-48 hours in the continental US. I am sure you are aware that can be an eternity. We’re a large county. We have 50 EMS and fire stations that are equipped with emergency generators and such, as well as schools and all manner of public facilities. The stations all have laundry facilities where we can clean and dry turnouts and work clothes. We also promote evacuation out of the area if we are the target of something major (like a huge hurricane heading our way), and our medical evacuations busses are intended for that specific purpose – evacuate nursing homes etc. in the path of the storm.

I know this is an awful lot, but if you would be willing to answer any of it I would be greatful. I hope that the information is useful to somebody!

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