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The main ideas from this information are: - Safety is the top priority, and it is important to not talk to the press or give out sensitive information. - A liaison officer is needed to communicate and interact between different agencies involved in a major incident. - Communication should be integrated and efficient, with limited use of radios and face-to-face meetings for important discussions. - Accountability is important, and supervisors should be kept informed of locations, actions, and completed tasks. - Preparedness involves planning and training for various types of natural disasters and emergencies. - Command should be established by the most senior or experienced official, and necessary resources should be requested early on. - Reliable equipment and backups are important, and cell phone numbers of supervisors should be available in case of communication failures. - The medical branch of Incident Command System (ICS) is responsible for triage, treatment, and transportation of or any supervisor to call an unsafe scene. Your safety is of paramount importance. Me, my partner, my patient, and everybody else. The public information officer provides details and clear and understandable information. Never talk to the press. That's not your job. Your job is incident mitigation or patient care, all right? Redirect all of MedStar employees if they ever have anybody coming up looking for information, they need to come to me. And most of the time, I can look up. The reason why is because especially in big scenes or especially a scene that may be a crime scene, you, by talking to a reporter, may give information that they don't want out. There's information called hold back information. When you're investigating a crime, there's information that you don't put out to the public. So that if somebody calls or somebody talking to somebody, they know this information. The only person that would know it was somebody who was involved in it. You give out hold out information, that ruins their chances of catching the person. That's one of the reasons why we don't give it out. Also, you don't want to put yourself in any form of liability by saying you do something that you shouldn't have done, because again, what happens on scene stays on scene. The liaison officer relates information and concerns among command, general staff, and other agencies. The liaisons between multiple agencies. You could have the ABCDEFG of government agencies, right? So you have to liaise between all of these. Fire, police, maybe state police, maybe National Guard, maybe the FBI's on scene, or the DEA, or the ACF, whatever the case may be, these interact. So you need a liaison officer to do all that interaction. Communications has historically been the weak point at most major incidents. We talked about this, and this is one of the big things that came out with NIMS in 2004, and the increase, or the upgrades to ICS 100 and 200 is the fact that we focus on communication. It is recommended that communication be integrated. All agencies should know how to communicate quickly and efficiently, and it allows for accountability and communication. I will say that we do not use, like for the radios, right? If you've got 400 rescuers on a scene, and everybody's got a portable radio, if you start having communications, you're not gonna get anywhere. It's just gonna be a jumble of speaking. So what we usually do is limit radio communications for things that need to immediately be communicated less than 30 seconds. Tell them where you are, tell them what you need, that kind of thing. Any kind of meeting that you do should be done face-to-face. We don't do meetings over radios, because it eats up too much of that, the bandwidth. Check in with incident command when you arrive. Usually you're gonna check in on a small scene, fire scene, city scene, you'll check in with an incident commander or a deputy commander. With a large scene, you're gonna go to a rescuer or a first responder, usually rally point, or some form, they'll tell you where to report. Report to your supervisor for your initial briefing, and then you wanna make sure that all of your time is tracked, all of everything that you use is tracked, because you want to get reimbursed. So you wanna make sure those records are accurate. Accountability means keeping your supervisor advised that locations, actions, and tasks completed. All right, you're going to a hurricane, let's say Katrina, right? And so your job is to do rescue or recovery. So you're going down the streets. Now, let's say you have to do street one, two, and three today. But you know what, it's 2.30, we still got time left, child's not until six, let's do street four. So you go, you don't tell anybody, you're just thinking, let's do it, let's get ahead of the game. So you go down street four, and then something happens, you get lost, you get injured, your crew, you get separated, nobody knows where you are, because you never told anybody. So it's okay to go beyond what your requirements are, to do more, make sure you keep your commander or your supervisor advised of everything you're doing and where you are at all times. Once the incident has been stabilized, the incident command will determine which resources are needed, and when you can begin to mobilize. Preparedness involves the decisions made and basic planning done before an incident occurs. This is part of planning, right? You set up an incident action plan. Involves decisions and planning about the most likely natural disasters in your area. We pretty much can have everything, right? In this area, we can have earthquakes, not serious ones, but we could. We have hurricanes, tornadoes, we have blizzards, we have floods, we have fires, we have terrorist bombings, we've got pretty much everything here. So you have to be prepared. Your EMS agency should have a disaster plan, and you should regularly train to carry it out. Any municipality and state does, we at MedStar tell me where to go when I go, if I've got the trucks available. So we don't really, we do, but we don't really follow up any kind of disaster plan. A lot of private services don't. So scene size, I make an initial assessment and some preliminary decisions. So you get on scene, look at the scene, and you've got to assess it. Scene safety DSI, right? Assess the scene. Stringing by three questions, what do I have, what do I need, and what do I need to do? And obviously the first thing I need to do is establish what's happening. I need to make it safe, and then I need to start rescuing those who need to be rescued. So those are the three top, or the three priorities right as you get on scene. So that's just a mobile emergency response for the New York Fire Department. The Emergency Vehicle One, I guess you'd say. And of course, they probably have multiple of these across the city. Most of your big city fire departments will have some form of a command vehicle. Establishing command. Command should be established by the most senior official or the one with the most experience. Again, brand new EMT, ain't still wet on your ticket, and you go to a mass casualty. You're in charge until somebody takes over for you. But whoever takes over has to physically take command, they have to say, hey, I got command. And you get on the radio when you say, you know, Chris is taking command. Notification to other responders should go up. Necessary resources should be requested. Police, fire, ALS, the electric company, gas company, whatever. And command must be established early. If possible, use face-to-face communication to limit radio traffic, we talked about that. Never use 10 codes. Always use plain English, especially when you get into these regional and interstate emergencies. We always use plain English. Does anybody know what a 10-100 is? He's in the bathroom. He's gonna go pee. It's better than a 10-200, if you get my drift. So, if you don't know codes, not gonna do you any good. That's why we don't use 10 codes. Equipment must be reliable, durable, and field-tested. There must be backups. Backups today consist of cell phones, right? Make sure you have cell phone numbers of your supervisor, in case your radios don't work. I will tell you, there are places in the state where nothing works. Cell phone, next cell, the radios. You go up in the Berkshires, right? There are places where you get no service whatsoever. The Medical Incident Command is also known as the medical or EMS branch of ICS. Our roles are to triage, treat, and transport injured patients. I don't see hazmat mitigation. I don't see tactical support. I don't see fire suppression, right? This is our job. And I say that because a lot of guys that work with me also are fire guys. And we will respond to local fire departments that they work on. Well, the first thing I'm gonna do is jump off the ambulance and go jump, put on that burnout gear, get on that hose. No, back here. You have one job to do, right? Everybody has a job to do. And if everybody does their job on the scene, it goes more smoothly. So the EMS branch is responsible for triage, treatment, transportation, and then maybe a staging, right? So here's my deputy director or deputy commander for EMS. And then I have a triage officer, a treatment officer, a transportation officer, and maybe a staging officer. So there's his span of four to seven. And then below that, each one of them might have three to seven people. The triage officer is responsible for triaging and cataloging all patients based upon the start triage system, which we'll talk about in a minute. We've already talked about it. We'll talk about it again. That's that start, you know, that the word triage means to sort. From there, the triage officer will triage red, yellow, green, gray, and black. And then those patients will be brought over to the treatment area. The treatment officer is in charge of ensuring that patients get a secondary triage the moment they get to treatment because mistakes can happen, things can change. Then the patients are processed. Some get treated, and some go directly, like the red, go directly to the transportation where the transportation officer pulls up their assets. You might even have a staging officer. The staging officer is responsible to ensure that the ambulance is staged. You know exactly the ingress and egress. Usually it's a loop. The ambulances will park over there, and by radio, the transportation officer will call the staging officer. I need three Ls and a Vls ambulance. So the staging officer will pick four ambulances, three Ls and a Vls, and you'll drive up to the front, grab your patient, and drive out. And so you never, like you're never gonna come. It's always gonna be a one way. That's the best way to do it. That way it always flows. Your transportation officer is responsible for receiving the patients, getting them to the designated ambulances and to the hospitals, and tracking them using the triage number. Each triage tag has a number, and that corresponds with the patient. So I write a number down, and I say what hospital it goes to. So when I have to go back and I have to research, I know this particular, 1-2-3-4-5-6-7, was one male patient transported by MedStar to St. V. 1-2-3-4-5-6-8, transported by Coastal, you know, one female patient transported by Coastal to UMass, and I track all that. And so that way we can ensure that all the patients were sent to the proper place. The worst thing you can do is responsible to do this and lose a patient. You never want to do that. I've never done this in actual, but I've done a lot of simulations, and I've been responsible for, I've been EMS Brace Commander, and I've been each one of these, and transportation I think is the worst. It's the most detailed, because you've got to make sure you've got the right assets, you've got to track your assets, you've got to know where to bring them, what hospital is available, so you have to be in communication with the hospitals, and you have to track each one of those patients. Three-hour supervisors in charge of counting and prioritizing patients. You might have five or six people working for you, but you're going to run down the line, and you're going to assess the patient, 30 seconds or less, and move on to the next one, and move on to the next one. And then you could say, okay, this one is a red patient, I see this, this, and this injury. This one is gray, for the gray tag, skip them. This one is a black patient, skip it. Move on to this patient, this is a yellow, tag it with this, and that's what you're, if you're alone, you do all that. If you're with somebody, or you're with crew, then you can have them do the tags as you move on. And we'll talk about the tags in a minute. You never treat in the triage area. Once all the patients are tagged, and they're moved out, then you can go back to the gray patients, and you can check them. Maybe they're viable, maybe you want to work them. The black ones, obviously you don't, but the gray ones you might. But you don't do any patient care until after all the patients have been moved into the treatment area. The treatment supervisor location sets up a treatment area, with a tier for each priority of patients. So I have a red area, a yellow area, and a green area. It ensures that the secondary triage is performed. Usually the person that does the secondary triage, just like the triage officer, is the highest medically trained person. If you have a doctor on scene, I want the doctor doing triage. If I have two doctors on scene, one is the triage, and one is the treatment officer. These are the ones you want the highest level of care. You don't want the first responder triaging patients. You want the top level experience. And then assist with moving patients to the transport area. It's everybody's job. Your job is to get them off out of the triage area and into the treatment and then the transportation area. So everybody does that. That's everybody's job, right? Sometimes the triage area is close to the treatment area, and sometimes it's a casualty collection point where patients are brought from all over to you. You will triage them there, and then the treatment area might be a half a mile away. Who knows? It depends. You never want the triage area close to the treatment area because you don't want the people in the treatment area to look at the triage area. You always want that separate, right? You don't want them to be able to see that. Transportation supervisor coordinates the transportation and distribution of patients to the appropriate facilities and tracks them. And again, he may actually be dealing with or communicating with a staging officer and a very large, if you've got 50 ambulances, you're probably gonna need a staging officer who can stage the ambulances and ensures that they're ready to go at all times. Documents to track the number of vehicles, patients transported, and destination facilities. Staging supervisor, again, usually when this is a multi-vehicle or multi-agency response, emergency vehicles must have permission to enter the scene and only drive to the directed area. That's the staging officer's job. He might have four or five people working for him, and all they do is go up and down the line, making sure the ambulances are ready to go, the crews have what they need, and they're set up. Staging area should be established away from the scene, right? You don't want those ambulances near your scene because you want them to be able to get in and out real quick. You don't want them driving through your scene to get patients. Physicians on scene make difficult triage decisions and provide secondary triage decisions in the treatment area. We always do a secondary triage because patients change. Provide on-scene medical directions for EMTs. Once, you know, the treatment officer, if he's a doctor or high level of care, he might just go and say, okay, that one needs an airway. Okay, that one needs, stop that bleeding. Okay, that one needs a chest decompression. He may not do any physical treatments. He may direct the staff to do it. And then if no staff member knows how to do something, he might do an intervention. Rehabilitation supervisors, this is common for EMS. If at a fire scene, you would be the rehabilitation vehicle, right? Like we have Millery Sutton-Grafton. We have a paramedic ambulance in each one of those. In Pittsburgh, we have two paramedic ambulances. When they go to a fire scene, which they usually go to all fires because an ambulance is on scene, you're not there for patients. You're there for the rescuers. You're part of rehab. If somebody comes in who's injured, we'll go and treat them and we'll bring in an ambulance to transport them. We never leave the scene. Our job is rehab. Our job is to make sure the rescuers are healthy, that there's no problem. Rehab officers and rehab staff or EMS, we'll go to each, as each firefighter comes off the line to change a Scott pack, we'll go in, we'll do blood pressure and pulse. We'll ask them some questions and we'll take a look. If their pulse is too high, their blood pressure is too high, they're breathing too hard, we'll have them sit out for a few minutes, have them get a drink, have them get something to eat. And if it doesn't come down, we can pull them off the line. And let me tell you what, hardest thing to do is to tell a bucket head, you can't go back in the fire because that's what they want to do. They want to do this. But that's our job, so that they don't die in the scene. Because there are firefighters that will go, I know firefighters that will go in on their deathbed and fight a fire because it's what they want to do. God bless them, I know what they feel, but we have to make sure they're safe. So that's what the rehab, usually the rehab supervisor, the rehab service, will be with where they refill the Scott packs or with the rehab truck. And your job, you'll have the ambulance open and you'll just check people as they come off the line. Extrication and special rescue, this actually falls under the EMS grant. This doesn't fall necessarily under operations. The reason why is because extrication and special rescue is responsible for direct patient contact. They're going to get the patient, so they're going to be coming directly to us. So they would actually fall under us. We would work together with them. Morgue supervisor works with the area medical examiners, coroners, execs, and mortuary teams and law enforcement to coordinate removal of bodies and body parts and personal belongings. So what happens is we have the triage area, the treatment area, the transport, maybe the staging area all over here. And then downhill, downwind, you're going to have the morgue area. It's got to be enclosed. You're going to have to have some form of protection or some form of security. And all the bodies and body parts and all the personal belongings come there. Anybody who falls under that black category goes to the morgue. Anybody who falls under the gray category, who you're not going to work, they go to the morgue. And the morgue stays with them. The problem with that is because photographers love to take pictures of dead bodies. And people love to steal things from dead bodies. Rings off the hands, gold teeth, necklaces. So you really have to have security and you have to make sure you keep an eye on it. And you're not going to stay with that until somebody takes over. You want to keep the morgue area out of view of everybody else. Downhill, downwind, in the woods, where nobody can see it. Because you don't want the triage or the treatment area to see the morgue, obviously. A mass casualty incident involves three or more patients that outstretches the access availability of ambulances. If I have 10 patients but I can generate 10 ambulances, it's not necessarily a mass casualty incident. Involves three or more patients that overstretches the access to services. Does a mass casualty have to be dead, like people are dead there? No, no. It could all be minor. They could all be green walking movies. So we had like a sort of mass casualty where we had to do an ambulance task force in Sudbury like a few years ago because we had like a water main burst and we had to call an ambulance strike. Like we had to get like a bunch of ambulances all over. And they might not have even taken anything. That's a mass casualty. And they determine the number of ambulances based upon the number of potential. A potential patient is still a patient until it's no longer a patient. So it's the same thing. Okay, so it doesn't need to be dead. They don't have to be dead, no. These mass casualties place a great demand on the EMS system. It has the potential to produce multiple casualties. It might not be any. All systems have different protocols for when to declare an MCI and initiate. Matter of fact, I will tell you, we've had MCIs in nursing homes. Nursing homes, the power goes out and they don't have, their backup generator won't come on. And they'll call a mass casualty and we'll send every ambulance we have. All you're doing is transporting the patients out of the facility to the hospital. There's nothing wrong with them other than their chronic illness. But because they have to be moved, it becomes a mass casualty. They don't necessarily even have to be injured. But it's just patients. You and your team can actually, you, all systems have different protocols when to declare for MCI and initiate the ICS. But a situation where you and your team cannot treat and transport all of the patients at the same time, again, you can only transport a maximum of two. Never leave the scene with a patient where there are other patients who are sick or wounded. This happens a lot in motor vehicle crashes. We arrive on scene with three car pileups. There's seven patients around, standing around that were involved in the crash. One of them's really injured and the other's kind of just standing around. So we scoop up the injured patient and we drive off because they really need to go to the hospital. What about the other six? Sure, they may look okay. Maybe one of them's got a brain bleed. Maybe one of them's got an aneurysm. Maybe one of them is having a heart attack. So you never leave a scene until you have somebody there of equal or higher training to care for that patient. Does that make sense? Even if all they're gonna do is take refusals, the refusal means that the patient was assessed. So don't just leave a scene until you have, you've ensured that there is care available for those patients on scene. If there are multiple patients and none have resources, call an MCI and you can do that by calling your dispatch. You can call CMED directly. Fire chief can do it, police can do it. Request additional resources and initiate the ICS and triage procedures. Triage means to sort based on, God bless you, the patient is based on severity of their injuries. Assessment is brief and the patient's conditions are categorized as basic. Primary triage is done in the field and then the secondary is done in the treatment area. We talked about the four common categories. Delayed, immediate, which is red. Delayed, which is yellow. Minimal, which is green. We call that the walking wounded. And then gray and black.