medical incident command
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Chapter 50Chapter 50
Medical Incident CommandMedical Incident Command
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ObjectivesObjectives
Identify components of an incident commandIdentify components of an incident commandsystem (ICS)system (ICS)
Outline activities in preplanning sceneOutline activities in preplanning scene
management, and postdisaster follow-up of anmanagement, and postdisaster follow-up of anincidentincident
Identify FEMAs five ICS componentsIdentify FEMAs five ICS components
List command responsibilities during a majorList command responsibilities during a major
incident responseincident response
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ObjectivesObjectives Describe FEMA ICS section responsibilitiesDescribe FEMA ICS section responsibilities
Identify situations classified as major incidentsIdentify situations classified as major incidents
Describe steps needed to establish and operateDescribe steps needed to establish and operatethe ICSthe ICS
Given a major incident, describe sectors neededGiven a major incident, describe sectors needed
and responsibilities of eachand responsibilities of each
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ObjectivesObjectives
List problems related to the ICS andList problems related to the ICS and
to mass casualty situationsto mass casualty situations
Outline principles and technology ofOutline principles and technology of
triagetriage
Identify resources for managementIdentify resources for management
of critical incident stressof critical incident stress
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ScenarioScenario
Icy wind and sleet pound yourIcy wind and sleet pound your
ambulance as you arrive on theambulance as you arrive on the
scene of an overturned school bus inscene of an overturned school bus in
a small creek. Size-up reveals 18a small creek. Size-up reveals 18
young children and an elderly driver,young children and an elderly driver,
with several apparently severewith several apparently severe
injuries, difficult access to theinjuries, difficult access to thepatients, and diesel fuel leaking frompatients, and diesel fuel leaking from
the bus.the bus.
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Major IncidentMajor Incident
Event in which the available resourcesEvent in which the available resources
are insufficient to manage the numberare insufficient to manage the number
of casualties or the nature ofof casualties or the nature of
emergencyemergency May stress local, regional, state, andMay stress local, regional, state, and
even national and international resourceseven national and international resources
Examples of major incidentsExamples of major incidents
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Incident Command SystemIncident Command System
(ICS)(ICS)
Effective ICS allows for involvementEffective ICS allows for involvement
of:of: Single jurisdiction; single agencySingle jurisdiction; single agency
Single jurisdiction; multiagencySingle jurisdiction; multiagency
Multijurisdiction; multiagencyMultijurisdiction; multiagency
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Incident Command SystemIncident Command System
(ICS)(ICS)
Expands from nonmajor incident toExpands from nonmajor incident to
major incident in logical mannermajor incident in logical manner Using ICS as standard operatingUsing ICS as standard operating
procedure for small incidents permitsprocedure for small incidents permits
smooth transition in major incidentsmooth transition in major incident
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FEMA ICSFEMA ICS
Federal law requires ICS for hazmat incidentsFederal law requires ICS for hazmat incidents Many states use ICS for all types of incidentsMany states use ICS for all types of incidents
Incident management or command systemIncident management or command system
Developed by FEMADeveloped by FEMA
National standard for incident managementNational standard for incident management
Flexible systemFlexible system
Used by both public and private sectors in some routine andUsed by both public and private sectors in some routine and
most large-scale emergenciesmost large-scale emergencies
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ICS StructureICS Structure
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ICS OrganizationICS Organization
Five major componentsFive major components CommandCommand
PlanningPlanning
OperationsOperations
LogisticsLogistics
Finance/administrationFinance/administration
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The Command FunctionThe Command Function
One person coordinates variety of emergencyOne person coordinates variety of emergencyactivitiesactivities Cornerstone of ICS structureCornerstone of ICS structure
Initial command determined in preplanInitial command determined in preplan
Command established immediatelyCommand established immediately
Commander clearly identifiedCommander clearly identified
Commander responsibilitiesCommander responsibilities
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Types of CommandTypes of Command
Singular commandSingular command One individual responsible for operationOne individual responsible for operation
Unified commandUnified command Large events or as small incident evolvesLarge events or as small incident evolves
Specialized organizations identified andSpecialized organizations identified and
personnel unify to complement commandpersonnel unify to complement command EMS, fire, police, health department, Red CrossEMS, fire, police, health department, Red Cross
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Application of UnifiedApplication of Unified
CommandCommand
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ICS OrganizationICS Organization
Incident commander (IC) expands (orIncident commander (IC) expands (or
contracts) ICS organization based on:contracts) ICS organization based on: Life safetyLife safety
Incident stabilityIncident stability
Property conservationProperty conservation
If expansion is needed:If expansion is needed: Other command staff positions establishedOther command staff positions established
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Possible Command StaffPossible Command Staff
PositionsPositions
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Section ResponsibilitiesSection Responsibilities
Sections assigned by IC to sectionSections assigned by IC to section
chiefschiefs PlanningPlanning
OperationsOperations
LogisticsLogistics
Finance/administrationFinance/administration
Section chiefs report to ICSection chiefs report to IC
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Command SectionCommand SectionOrganizational PlanOrganizational Plan
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Section ChiefsSection Chiefs
Strong supervisors and managersStrong supervisors and managers
Primary rolePrimary role
Make things happenMake things happen Ensure rescuers working toward common goalEnsure rescuers working toward common goal
Number of sections varies by incidentNumber of sections varies by incident Determined by ICDetermined by IC
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Section ChiefsSection Chiefs
Not involved in physical tasksNot involved in physical tasks Accomplish command objectivesAccomplish command objectives Monitor work progressMonitor work progress
Redirect activities if neededRedirect activities if needed Coordinate activities with other sectionsCoordinate activities with other sections Request other resources as neededRequest other resources as needed
Monitor welfare of personnel in sectionMonitor welfare of personnel in section Provide command with frequent reportsProvide command with frequent reports Reallocate resources within sectionReallocate resources within section
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Planning SectionPlanning Section
Provides past, present, and futureProvides past, present, and future
information about incident and statusinformation about incident and status
of resourcesof resources Creates incident action plan (IAP)Creates incident action plan (IAP)
Operational periodsOperational periods
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Planning SectionPlanning Section
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Operations SectionOperations Section
Directs and coordinates emergency sceneDirects and coordinates emergency scene
operationsoperations
Ensures safety of operational personnelEnsures safety of operational personnel EMS operations often fall under this sectionEMS operations often fall under this section
Operations section chief is in charge of actualOperations section chief is in charge of actual
scene (ground zero)scene (ground zero)
ResponsibilitiesResponsibilities
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Operations SectionOperations Section
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Logistics SectionLogistics Section
Supports logistical needs of incidentSupports logistical needs of incident
Logistics appropriate to incidentLogistics appropriate to incidentsize/durationsize/duration
Provides gear and support toProvides gear and support torespondersresponders
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Logistics SectionLogistics Section
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Finance/AdministrationFinance/Administration
SectionSection Accounting and administration of incidentAccounting and administration of incident
Staff support functionStaff support function
Monitors costs, careful accountingMonitors costs, careful accounting
Seldom used on small incidentsSeldom used on small incidents
Essential as incident growsEssential as incident grows And on hazmat incidentsAnd on hazmat incidents
Not used in routine daily incidentsNot used in routine daily incidents
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Finance/AdministrationFinance/Administration
SectionSection
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Declaring a MajorDeclaring a Major
IncidentIncident More than two ambulances neededMore than two ambulances needed
Particularly in rural areasParticularly in rural areas
Situations involving hazardous orSituations involving hazardous or
radioactive materials or chemicalsradioactive materials or chemicals
Situations needing special resourcesSituations needing special resources Helicopters, rescue teams, multiple rescue orHelicopters, rescue teams, multiple rescue or
extrication unitsextrication units
When in doubt, declare a major incidentWhen in doubt, declare a major incident
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Preparing for a MajorPreparing for a Major
IncidentIncident Phase 1: The preplanPhase 1: The preplan
Phase 2: Scene managementPhase 2: Scene management
Phase 3: Post-disaster follow-upPhase 3: Post-disaster follow-up
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Major Medical IncidentsMajor Medical Incidents
Need to establish ICS at medicalNeed to establish ICS at medical
incident determined by:incident determined by: Number of casualtiesNumber of casualties
Nature of the eventNature of the event
Local/regional thresholdLocal/regional threshold
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Examples of Medical ICSExamples of Medical ICS
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Establishing CommandEstablishing Command
Group/sector functions or major functional areasGroup/sector functions or major functional areasimplemented by incident size and scopeimplemented by incident size and scope
Groups and sectors may include:Groups and sectors may include:
Support sectorSupport sector Staging sectorStaging sector
Helicopter LZs and vehicle apparatus arrivalsHelicopter LZs and vehicle apparatus arrivals
Treatment sectorTreatment sector
Unified EMS command with fire and police may beUnified EMS command with fire and police may be
neededneeded
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Scene AssessmentScene Assessment
First unit on sceneFirst unit on scene Rapid assessment of situationRapid assessment of situation
Full assessment as safety and time permitFull assessment as safety and time permit
Type of incident and potential durationType of incident and potential duration Entrapment or special rescue resources neededEntrapment or special rescue resources needed
Number of patients in each triage categoryNumber of patients in each triage category
Additional resources neededAdditional resources needed
Scene assessment continually updatedScene assessment continually updated
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CommunicationsCommunications
Command established by radio with dispatchCommand established by radio with dispatch EOC is where department heads, governmentEOC is where department heads, government
officers and officials, and volunteer agenciesofficers and officials, and volunteer agencies
gather to coordinate response to emergencygather to coordinate response to emergency
eventevent
Command and EOC share goalsCommand and EOC share goals
Different levels of responsibilityDifferent levels of responsibility
IC is responsible for on-scene activitiesIC is responsible for on-scene activities
EOC responsible for community-wide responseEOC responsible for community-wide response
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Obtaining ResourcesObtaining Resources
Request additional units as needed:Request additional units as needed: Dispatch should have written standardDispatch should have written standard
operating procedure (SOP) for requestingoperating procedure (SOP) for requesting
mutual aidmutual aid
May need to obtain food, shelter, clothingMay need to obtain food, shelter, clothing
IC responsible for deployment of resourcesIC responsible for deployment of resources Stay with vehicle until instructions receivedStay with vehicle until instructions received
Staging techniques used to deploy resourcesStaging techniques used to deploy resources
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Extrication SectorExtrication Sector
Manages entrapped patientsManages entrapped patients
Patient care activities in this sectorPatient care activities in this sector Only assessment and treatment of lifeOnly assessment and treatment of life
threatening situationsthreatening situations
Additional responsibilitiesAdditional responsibilities
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Treatment SectorTreatment Sector
Works with extrication sector in patient careWorks with extrication sector in patient care As patients delivered, categorized by medical needAs patients delivered, categorized by medical need
Care and stabilization until patients transported toCare and stabilization until patients transported to
medical facilitymedical facility Paramedics and hospital personnelParamedics and hospital personnel
With large numbers of patients:With large numbers of patients: Divided into immediate and delayed treatment zonesDivided into immediate and delayed treatment zones
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On-Scene Physicians atOn-Scene Physicians at
MCIsMCIs Medical directionMedical direction
On-scene medical directionOn-scene medical direction
Triage functionTriage function Increased ability to make difficult triage decisionsIncreased ability to make difficult triage decisions In treatment area for secondary triage decisionsIn treatment area for secondary triage decisions
Emergency surgery to facilitate extricationEmergency surgery to facilitate extrication
Treatment capabilitiesTreatment capabilities Invasive proceduresInvasive procedures
Assessment and direction of specific treatmentsAssessment and direction of specific treatments
i i i f hDi i i f h
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Disposition of theDisposition of the
DeceasedDeceased Depends on scale of incidentDepends on scale of incident
Personnel assigned to disposition of deceasedPersonnel assigned to disposition of deceased
DutiesDuties Work with medical examiner, coroner, lawWork with medical examiner, coroner, law
enforcement to coordinate dispositionenforcement to coordinate disposition
Assist in establishment of secure area for morgueAssist in establishment of secure area for morgue
if neededif needed Monitor personnel for signs of stressMonitor personnel for signs of stress
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Transportation SectorTransportation Sector
Communicates with hospitals, ambulances, andCommunicates with hospitals, ambulances, andaeromedical services for patient transportaeromedical services for patient transport
Works closely with treatment sector toWorks closely with treatment sector todetermine appropriate patient destinationsdetermine appropriate patient destinations
Arrival and departure of vehicles coordinatedArrival and departure of vehicles coordinatedwith staging sectorwith staging sector
ResponsibilitiesResponsibilities
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Staging SectorStaging Sector
Prevents vehicle congestion andPrevents vehicle congestion andresponse delaysresponse delays
All emergency vehicles should reportAll emergency vehicles should reportfor directionfor direction Other agencies supervised by stagingOther agencies supervised by staging
sector (disaster relief, news media)sector (disaster relief, news media)
ResponsibilitiesResponsibilities
h bili i ( h b)
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Rehabilitation (Rehab)Rehabilitation (Rehab)
SectorSector Standard operating procedures in many fireStandard operating procedures in many fire
and EMS agencies and major incidentand EMS agencies and major incident
response plansresponse plans
Set up outside operational areaSet up outside operational area
Monitors personnelMonitors personnel Ensures proper rest and hydrationEnsures proper rest and hydration
Works with logistics sectorWorks with logistics sector
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Support SectorSupport Sector
Coordinates equipment and suppliesCoordinates equipment and supplies
for all sectorsfor all sectors
May obtain medical supplies fromMay obtain medical supplies from
hospitals, rescue supplies, and otherhospitals, rescue supplies, and other
equipmentequipment
ResponsibilitiesResponsibilities
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Sector IdentificationSector Identification
All emergency responders must know ICSAll emergency responders must know ICSstructure and radio communicationstructure and radio communicationprocedureprocedure
Clothing and identification vary by systemClothing and identification vary by system Color-coded vests identify personnelColor-coded vests identify personnel Most communication face to faceMost communication face to face
ExceptionException Command and sector communicationsCommand and sector communications
Radio use is for command operationsRadio use is for command operations
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Sector IdentificationSector Identification
Radio communications use operationRadio communications use operation
titles:titles: "EMS sector to command" or "Fire sector"EMS sector to command" or "Fire sector
to rescue sector"to rescue sector" Ensures reaching appropriate individualEnsures reaching appropriate individual
by one radio designationby one radio designation
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Radio CommunicationsRadio Communications
Key function during major incidentKey function during major incident Preplanning includes identification ofPreplanning includes identification of
radio frequenciesradio frequencies
Responding units should have radiosResponding units should have radios
using common frequencyusing common frequency Separate frequencies for EMS, fire, andSeparate frequencies for EMS, fire, and
other support operationsother support operations
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Radio CommunicationsRadio Communications
Sector officers radios on channelSector officers radios on channel
that permits direct communicationsthat permits direct communications
with commandwith command Frequencies may be assigned inFrequencies may be assigned in
advanceadvance
Or by dispatching agency at incidentOr by dispatching agency at incident
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Radio CommunicationsRadio Communications
Clear, concise, and in plain EnglishClear, concise, and in plain English Helps set orderly toneHelps set orderly tone Avoid use of radio codes/signalsAvoid use of radio codes/signals
Prepare messages before transmittingPrepare messages before transmitting
Clearly identify unit number or sectorClearly identify unit number or sector
Minimize radio trafficMinimize radio traffic
Face-to-face communication preferredFace-to-face communication preferred
C P bl fCommon Problems of
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Common Problems ofCommon Problems of
MCIsMCIs
Failure to notify everyoneFailure to notify everyone
Lack of rapid patient stabilizationLack of rapid patient stabilization
Failure to collect patients in treatment areaFailure to collect patients in treatment area
Failure to triage properlyFailure to triage properly
Administering too much careAdministering too much care
Transporting patients prematurelyTransporting patients prematurely
C P bl fCommon Problems of
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Common Problems ofCommon Problems of
MCIsMCIs Using personnel improperlyUsing personnel improperly
Failure to distribute patients to hospitalsFailure to distribute patients to hospitals
appropriatelyappropriately
Lack of EMS command in fieldLack of EMS command in field
Lack of hospital communicationLack of hospital communication
Lack of preplanning and trainingLack of preplanning and training
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Principles of TriagePrinciples of Triage
TriageTriage Method to categorize patients for priorities ofMethod to categorize patients for priorities of
treatmenttreatment
Assessment of injury severity based on:Assessment of injury severity based on: Abnormal physiological signsAbnormal physiological signs
Anatomic injury (and mechanism of injury)Anatomic injury (and mechanism of injury)
Concurrent disease factorsConcurrent disease factors
Triage is aTriage is a continuouscontinuous process during a majorprocess during a major
incidentincident
Primar s SecondarPrimary vs Secondary
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Primary vs. SecondaryPrimary vs. Secondary
TriageTriage Primary triagePrimary triage
Categorizes patient condition for treatmentCategorizes patient condition for treatment
Documents patient location and transportDocuments patient location and transport
needsneeds Labels patient with triage labels, tags, or tapeLabels patient with triage labels, tags, or tape
Focuses on speed to sort patientsFocuses on speed to sort patients
No care rendered during primary triageNo care rendered during primary triage
Except lifesaving airway or hemorrhage controlExcept lifesaving airway or hemorrhage control
Primary vs SecondaryPrimary vs Secondary
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Primary vs. SecondaryPrimary vs. Secondary
TriageTriage Secondary triageSecondary triage
At treatment areaAt treatment area
Patients retriaged and labeledPatients retriaged and labeled
Not always necessaryNot always necessary Especially at small incidentsEspecially at small incidents
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START TriageSTART Triage
START (simple triage and rapidSTART (simple triage and rapid
treatment)treatment) 60-second assessment60-second assessment
Evaluate:Evaluate: Ability to walkAbility to walk
Respiratory effortRespiratory effort Pulses/perfusionPulses/perfusion
Neurological statusNeurological status
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START TriageSTART Triage
Classify patients as:Classify patients as: UrgentUrgent
DelayedDelayed
Dead or dyingDead or dying
CriticalCritical
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START TriageSTART Triage
Allows rescuers to:Allows rescuers to: Identify patients at risk of early deathIdentify patients at risk of early death
Advise others of patient's need forAdvise others of patient's need for
stabilization by tagging with disasterstabilization by tagging with disastertagstags
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START Triage SystemSTART Triage System
Insert
Fig 50-10
Insert
Fig 50-10
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START TriageSTART Triage
Assess ability to walkAssess ability to walk
Evaluate breathing and rateEvaluate breathing and rate
Assess pulses/perfusionAssess pulses/perfusion
Assess mental statusAssess mental status
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START TriageSTART Triage
Repositioning of airway andRepositioning of airway and
controlling severe hemorrhage arecontrolling severe hemorrhage are
only treatment efforts in primaryonly treatment efforts in primary
triage:triage: In a mass casualty event, theseIn a mass casualty event, these
measures should not delay triage ofmeasures should not delay triage of
other patientsother patients
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Triage Tagging/LabelingTriage Tagging/Labeling
Many tags, tape, and labels availableMany tags, tape, and labels available
International color coding and prioritiesInternational color coding and priorities
ImmediateImmediate RedRed Priority-1Priority-1 (P-1)(P-1) DelayedDelayed YellowYellow Priority-2Priority-2 (P-2)(P-2)
HoldHold GreenGreen Priority-3Priority-3 (P-3)(P-3)
DeceasedDeceased BlackBlack Priority-0Priority-0 (P-0)(P-0)
Kim McKenna:
Kim McKenna:
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METTAG CardMETTAG CardEd: need figure50-11Ed: need figure50-11
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Purpose of TaggingPurpose of Tagging
Identifies priorityIdentifies priority
Prevents retriage of patientPrevents retriage of patient
Tracking system during treatment/ transportTracking system during treatment/ transport
Tags and labels should:Tags and labels should: Be easy to useBe easy to use Rapidly identify patient priorityRapidly identify patient priority Allow for easy trackingAllow for easy tracking Allow room for some documentationAllow room for some documentation Prevent patients from retriaging themselvesPrevent patients from retriaging themselves
Tracking Systems forTracking Systems for
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Tracking Systems forTracking Systems for
PatientsPatients A destination log is maintained byA destination log is maintained by
the transportation section officerthe transportation section officer Should have name or triage label IDShould have name or triage label ID
numbernumberTracking log must contain:Tracking log must contain:
Patient identificationPatient identification
Transporting unitTransporting unit Patient priorityPatient priority
Hospital destinationHospital destination
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ICS Patient LogICS Patient Log
Transportation ofTransportation of
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Transportation ofTransportation of
PatientsPatients Method of transportation determinedMethod of transportation determined
by triage priority and situationby triage priority and situation
Ambulance a typical methodAmbulance a typical method
Buses considered for transporting aBuses considered for transporting alarge number of priority 3 patientslarge number of priority 3 patients
Air ambulances for critical patientsAir ambulances for critical patients
Critical Incident StressCritical Incident Stress
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Critical Incident StressCritical Incident Stress
ManagementManagement
Critical incident stressCritical incident stress Potential for rescuers at major eventsPotential for rescuers at major events
Critical incident stress debriefings partCritical incident stress debriefings part
of postdisaster SOPof postdisaster SOPTypes of servicesTypes of services
Other approaches to manage stressOther approaches to manage stress
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ConclusionConclusionA major incident is an event for which availableA major incident is an event for which available
resources are insufficient to manage the numberresources are insufficient to manage the number
of casualties or the nature of the emergency. Itof casualties or the nature of the emergency. It
may overwhelm local, regional, state, and evenmay overwhelm local, regional, state, and evennational and international capabilities.national and international capabilities.
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Questions?Questions?
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