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The speaker discusses the criteria for determining when a mass casualty incident is declared and the protocols that are followed during such incidents. They explain the different levels of mass casualty incidents and how they are managed. The Incident Command System is introduced as a framework for coordinating emergency incidents at various levels. The importance of communication and resource management in disaster response is emphasized. The main goals of incident management are identified as recognizing and stabilizing the scene, rescuing and recovering victims, mitigating the situation, and demobilizing. The speaker also mentions the need for efficient use of resources and preventing duplication of efforts. take three or more, because in an emergency situation, an ambulance can take two BLS patients. I've done that many times. For a motor vehicle crash, you have two patients, and they're BLS, they don't require any significant intervention. We transport your patients to the hospital. You can do that. So three or more patients require another ambulance, right? So that's why we call it three or more patients. But it's gotta be three or more patients that overwhelm the system, like in Worcester. If you have a bus accident, you have 20 patients on the bus, you can generate 20 ambulances in Worcester in 10 minutes. It's not necessarily a mass casualty incident. If you had that same situation in Brookfield, there's no way you're gonna generate 20 ambulances in that area. That becomes a mass casualty incident. Anybody can set up a mass casualty incident. Anybody can call for it. You, your partner, the fire department, the police department, whoever calls can call a hazmat. You basically call into your dispatcher, you call directly to CMED, Central Mass EMS, and then you say, I need to activate a mass casualty. And then you go from there. Now, when you do that, if you're the first person on scene, you guys could be just starting, right? Brand new EMTs, just got your ticket, came up on the bus accident. You arrive on scene, you're incident commander. One of you is incident commander, one of you is the triage officer, until you're relieved by somebody with equal or higher training. And they have to come in and physically say, I am taking command. And you go, thank God, all right. Right? So, a disaster of mass casualty incident can be overwhelming, three or more patients, and a lack of resources, where you don't have the resources to cover. I wanna say about eight years ago, we had a mass casualty incident on 290. We're at 190, and you turn, you're coming up onto 290, there was an icy road. It was just ice, it was a flash ice thing. And we had 90 some odd patients. It was like a hundred car pileup. And it was like an hour getting ambulances in and out and transporting patients. The beauty of a mass casualty incident, if you can say there's a beauty to it, is there's really no paperwork. You use the triage tabs, and you transport to a hospital that they tell you to go to, and you go get the next patient. And it's all sorted out afterwards, right? So, that's kind of the beauty of it, is you don't have to do PCRs. And, BLS can do anything. You can transport blood products, you can transport patients on a cardiac monitor. Like, all the protocols kind of go out the window. The idea is we get the patient from the scene to the hospital, and get back to the scene, and move the patient. So that's the whole idea of incident commanding, mass casualty incident. So it sends three or more patients, and Massachusetts actually has in your protocol guide, which you should have downloaded on your phone if you have not already done so, from the OMS website. But there is a section that talks about mass casualty. It's H-2. Talks all about mass casualty incidents, MTIs. So in Massachusetts, we have six levels. A level one is one to 10 patients. Well, one to 10 patients, that overloads the system. Well, I know if I arrive on scene, and there's five or less patients, I become incident command, I need one more ambulance. Because for every five patients, at least one of them will be transported. If I have 10, I need two more ambulances, at a minimum. Right? So we know this. A level two is 11 to 30 patients. That's not uncommon if you have a multi-car pileup with a bus, or you have an incident, like a fire, or some kind of incident in a building, like a school, or some kind of commercial building. Three is 31 to 50 patients. Now, that's beginning to get significant. A level four is 51 to 200 patients. Now, we were a level four, because we had over 90 patients that day. And I mean, every ambulance continual did. Catalgo there, we had Catalgo, AMR. We had Catalgo, AMR, Alert, East Air, MedStar. Armstrong. Armstrong. What's that? Armstrong. No, Armstrong wasn't there. Alert was there, I think it's Alert. And Patriot was there, too. They had trucks from Patriot. So we had quite a few. Oh, and of course, Vital was there. We were partners with Vital, so Vital was there. And then, a level five is greater than 200. That's a huge number right there. And then a level six is long-term operations. That's where you're gonna be there. Like, long-term operations would be like the cold storage fire, right? There were 200 patients, but we were there on scene. EMS was on scene for days there. Or like, they had the bad storms, the bad winter storms, a few years ago along the Cape and on the shore. And I mean, EMS was staged for days, and even some for a couple weeks. Okay. The Incident Command System makes it possible to do the greatest good for the greatest number of people. It's like triage, right? Doing the greatest good for the greatest number of people. The National Incident Management System promotes efficient coordination of emergency incidents at state, regional, and national levels. It can go anywhere from a town to county to state to region, like New England to the East Coast. It could be a national response. This was, this division, this system was set up in 2004. Basically, it was set up after 9-11 and Katrina. This is when they devised this system. It's a prize, a national framework to enable federal, state, and local governments to work together. Includes private sector and non-governmental organizations. Organizational structure must be flexible enough to be rapidly adaptable. I wanna have a huge one for a huge response, like a New England response, or maybe I just have a localized response and I don't need as many branches, I don't need as many rescuers. So it has to be rapidly adaptable and it has to be able to flex based upon the needs. Provides standardization and terminology, especially like, there are companies like AMR that does national go-to disaster response. And they go all over the country. They go to New York, they might go to Florida, wherever the emergency is. So we have different terminology here than they use in other parts of the country. So we have to standardize terminology so everybody speaks the same language. Resource classification, ALS, BLS, critical care, right? We have to classify what we have. Personnel training, making sure that everybody understands how the system works, how management, how the ICS works. And certifications, make sure everybody's certified to work in the system. Major NIMS components, communication and information management. This is the biggest, this has always been the linchpin or the biggest problem in any disaster service or disaster response is communication. This is why we lost 300 first responders in the Twin Towers. Because they were going out and it was called for them to come down, but it was police were calling Port Authority to come down and they didn't communicate, the fire was calling the police and they couldn't communicate. There was no standardized communication because nobody was able to talk to each other. And that was the problem. So now communication is standardized. Matter of fact, in Massachusetts, you can get each municipality have these radios. If you see them, they're kind of like fluorescent orange or green. They're like five grand. And they have every municipality, every emergency municipality in the state on that radio. So you could technically talk with anybody in the state provided you have access to a repeater, which we talked about. Resource management. Now I don't know what we have for ALS, what we have for VF, what other resources do we have? Transportation, vehicles, you know, we also have to talk about logistics. You know, water bodies and water and generators and shower and sleeping facilities and shelters and all kinds of stuff. And then command and management, right? You have to have somebody in charge and you have to have managers. The incident command system is sometimes referred to as the incident management system, IIMS or the ITS, however you see it. It ensures responder and public safety, it's number one goal. Achieve incident management goals. Well, what is the incident management goal? Let's talk about that. The first thing we have to do is realize we have a problem. What do we have? What's going on? What do we have and what do we need to do? So you have to recognize it's a problem, that's your first goal. Your second goal is to stabilize the scene so you can work in it. If it's not safe to go in, nobody's getting help. The third one is rescue. You wanna rescue those that need rescue. Now some disasters don't have any need for rescue, there are no injuries. But the third is rescue. So I have to recognize it's a problem, I have to identify the problem, secure it, then I have to rescue, then recovery. For those that we don't get to rescue, we have to recover, we have to recover the bodies. Then we have to mitigate, we have to fix the problem, clean up, and then demobilization, okay? So you've gotta identify the problem, you have to secure and make the scene safe, then you have to go in and rescue, then you have to recover the bodies, then you have to clean up and mitigate the situation, and then you have to demobilize. Do we do recovery? We do recovery? Well, we'd be involved, because you never know, recovery may be a rescue. So we would be involved in that, at least we would be on scene. We don't take the bodies, right? No, we don't take the bodies, and Massachusetts, you don't, but you might be involved in recovery. Because you wanna be, just in case, the patient is not there. And then ensure efficient use of resources, right? We wanna make sure that we're using the proper resources in the proper place. Allocating what I have for the best use. It controls duplication of efforts in freelancing. That was one of the big problems during 9-11, during the, at the Twin Towers, is you had thousands of rescuers from around the country, firefighters, police, EMS, who just didn't feel a connection, it's that brotherhood, right? So they wanna go and help, and they come straight on the scene. That scene was not safe. And that was a crime scene. And so you have thousands of people scraping all over it, you're chewing up evidence, you're making it unsafe for those that still may be trapped underneath, and it's unsafe for you. That's the whole point. We don't want freelancing. Great if you wanna volunteer. Alleluia, thank you very much. We'll have you go to a collection point, or a check-in point, and you'll be called when you need it, right? Limit span of control. One supervisor for three to seven workers. It's like a pyramid scheme. So like I'm in charge of three to seven workers. It's easy to get, in an emergency situation, in a mass casualty, it's easy to get three to seven people together. It's difficult to get 40. So if I limit my span to three to seven, then I have my information, and I disseminate it to you when you need it. Now you go off, you've got three to seven, you've got three to seven, you've got three to seven, you've got three to seven, you've got three to seven, and you see how it works? So you could have 200 people, 300, 400, 1,000 rescuers, but no supervisor or manager has responsibility for more than seven people. So it's very easy to communicate. And then as long as you train your staff to report to you, then you always know where your staff is. I don't have to worry about where 100 people are. I just have to worry about three to seven. And same with the commander. The incident commander will have three to seven people, maybe deputy commanders, and we're gonna talk about that in a minute. So he doesn't have to worry about the 300 ground pounders. He's gotta worry about his three to seven. Organization levels include sections, branches, divisions, and groups. And this is basically how it works. So I would have an incident commander here. Then I'd have a deputy commander of operations, a deputy commander of planning, a deputy commander for logistics, a deputy commander for finance, maybe a deputy commander for EMS, right? Or for medical services. And then below that, so there's my incident commander, and there's his three to seven stand. Now those deputy commanders might have section chiefs, and so branch, maybe operations, maybe they'd be section chiefs for different, like maybe one would be rescue, one would be high angle rescue, one would be operations, one might be security, whatever the case may be. And so you go from there. So as you go down, you see it grows out this way. So by the time you get to the individual ground pounder, you could have 400 people working in scenes, but it's only three to seven at a time. Roles and responsibilities, you have to have command. Somebody's gotta be in charge. And the rule is, is that you wanna make sure that whoever is in charge, there is somebody below him who can take his job if he gets injured, and he needs to be able to do their job if they get injured. So in other words, let's say I'm mid-level. I need to do the job of my boss, and somebody below me needs to be able to do my job, and I need to be able to do theirs. Does that make sense? So if I get injured, or one of them gets injured, I can step in for them, or somebody can step in for me. Or if I have to go home, I have a family emergency. Or something comes up, somebody can step in for me. So somebody below you needs to know. You need to keep them in a loop and make sure you pick somebody, maybe two people, and say, you need to make sure you know what I'm doing in case you have to take over. Finance, something's gotta be paid for. And when we talk about emergencies, we've got NEMA, which is Massachusetts Emergency Medical. Each state has their own emergency services. But you have FEMA, which is federal. FEMA has about $30 billion in a war check that they use in case of an emergency, and they can go to Congress at any time and get more. That's what pays for that. When you go, when you see one of these big, you see FEMA down at Sub-Carolina or Florida, and they're giving out water, and generators, and tents, and food. Where do you think this comes from? Do you think people just donate it? They do, to charitable organizations, but from FEMA, it's all paid for. Around the country, there are stockpiles of generators, and water pallets, and trailers, and tents, and medical supplies, and all kinds of stuff. And at any time, FEMA can call, and usually what they get is either the Army Corps of Engineers, or maybe the 82nd Airborne, or the Air Force, and they'll go, or the Air Guard, and they'll transport, they'll go pick them up, and they'll deliver them anywhere in the country within 24 hours. That's how it's supposed to work. So, somebody's gotta pay for it. It's all gonna be tracked. Things like FEMA. Let's say, things like AMR. AMR, again, goes around the country, and they do these disaster responses, right? So, let's say they have a BLS ambulance. So, they charge FEMA a rate for the BLS ambulance. Now, let's say you guys decide, hey, let's go on that two, it's usually two weeks, or three weeks, let's go on a two-week deployment, they call it a deployment. So, you guys volunteer, you take your truck, and you drive to wherever it is, and you check in. The way you're paid, you get paid a federal rate, like 25 bucks an hour. So, for the first, so you're paid $25 an hour, and then anything over 40 is overtime. The beauty of this, you're on call 24 hours a day. So, which means, in the first day and a half, you've hit your 40. Above that, for the rest of the week, it's 164 hours in a week. You hit 40 in the first day and a half. The rest of it's all overtime. So, because you get paid 24 hours a day, usually you work like 12 hours on, 12 hours off, and you work six days, seven days a week. I mean, it's a two-week deployment, you don't work every day. But, you get your downtime, you still get paid. When you're sleeping, you still get paid. So, it's not uncommon, I know paramedics that have gone on deployments, and they buy $6,000 on a two-week deployment. That's why they always go, whenever they get to go, because they make huge money. So, they're getting paid, so AMR will pay them. AMR charges FEMA a fee, the federal government, a fee to rent the ambulance. $300 an hour, $400 an hour, and it's on 24 hours a day, seven days a week, for two weeks. I mean, AMR makes millions of dollars on these deployments. So, if you ever get a chance to work with a company that we don't do it at MedStar, we don't have enough staff. But, if you get a company that does that, you wanna do a deployment, you can make some good money on it. Logistics, GI socks, pistol belts, boots, food, clothing, porta-potties, generators, showers, sleeping facilities, radios, heavy equipment. All of this stuff has to get paid for, and it's gotta be tracked. That's what logistics does. Logistics knows, they have a program where they know, FEMA knows where all of it is, and they know how to get it, and who's gonna ship it, and where it needs to go to. That's the job of logistics. Logistics is a constantly, it's like finance, it's an ever-evolving thing. Things get bigger, bigger, bigger, and they get smaller, smaller, smaller, but you have to track it. Operations, this is the guys that actually do the work. In the military, this is the infantry, right? The infantry does the job, they fight the war. In the military, like I was a combat medic, so I was part of an infantry unit, so I was the ground power. There are seven to 10 support personnel for every infantry member in the US military. So every member that actually fights the war, there are seven to 10 support personnel that support them, whether it be supply, food, logistics, whatever the case may be, right? So these are the guys that actually do the job. You guys, as EMS, would be under operations. Planning, that's setting up a plan, having a plan ready to go. Then when a disaster happens, implementing that plan. That plan has to be flexible to adjust based upon the findings and the needs. And then demobilization, that's the, they go, the incident commander will go to the planning board, the planning department of section, say, okay, we're ready to demobilize now. Let's get a plan together. And then they'll make a plan of who they want to demobilize and how they want to do it. Usually EMS is one of the last groups off of the scene because you're there for the last few weeks. And then, of course, the command staff. Command, the incident commander is in charge of the overall incident. Sometimes it is possible for the incident commander to pass command of the scene to somebody who has a higher level of training in a particular area. So we have an incident commander who's a fire, let's say he's a fire chief or a fire marshal or a state fire, whatever. And he's on scene. And now all of a sudden it becomes tactical. There's a shooter. Well, he can pass tactical command to the police. He retains overall command, but he gives that tactical or technical command to them. Same with TASNAP, same with triangle rescue or some kind of special rescue. He can pass along to them. He still retains complete command or overall command, but they can take command of an incident scene. It's important to know who the IC is, how to communicate with the IC, and where the command post is located. This is true in a small emergency. If you go to a fire scene or you go to some town emergency or city emergency, yeah, you wanna know who the incident commander is and where the command post is located. But if you're gonna go to some statewide emergency or regional emergency, you're not gonna know who the incident commander is or where the command post is. You're not gonna report to them. You're gonna report to your supervisor in your sector. An IC has made turnover command to someone with more expertise, as we've talked about. Finance, responsible for documenting all expenditures. Again, this is reimbursed. Sometimes it takes a year before, like you guys would get paid, but sometimes it's a year before AMR gets their money from FEMA because they have to correlate all of their expenses and then submit them in a proper billing format to FEMA. Logistics, responsible for communications equipment, facilities, food, water, lighting, fuel, medical supplies, equipment, everything. Housing, porta potties, heavy equipment, whatever you need. Operations at a very large and complex incident, responsible for managing tactical operations, usually handled by the IC. That's actually not true. In a very large scene, it wouldn't be the IC. It would be his deputy commander for, deputy command for operations. In smaller scenes, the incident command, like in a fire scene, especially even a big city scene, the incident commander will be in charge of the operations, but in big scenes, no, it would be an incident commander for operations. Supervises people in the field. Planning, solve problems as they arise, develop an incident action plan, and then a demobilization plan. The command staff, the safety officer monitors the scene for conditions and operations that may present a hazard. Anybody can call on a safe scene. You don't have to be a safety officer to call on a safe scene, but the safety officer is responsible for your safety. I was a range safety NCO when I was first in the military, before you came in your dad's work. And as a range safety NCO, my job was to ensure the safety of the range. I was in the military for the tragedy. So I was in charge of the range. And so, especially when range call would come up, we'd have brigades or divisions or brigades or battalions that would come in to do their range call, and these would be guard units, and they'd have a weekend to get 500 guys through the range. So they needed the range on. So my job was to make sure the scene was safe. If the scene was unsafe, if there's lightning, if there's something downrange, if there's something that, I would shut down the scene. I had a colonel get in my face, piss off, because you can't close my scene, I gotta get my guys through. But if I call on a safe scene, the base commander, Major General, would back me up, because safety is of paramount importance. And the point of that is, make sure you're paying attention to the scene at all times.