Chapter 39: Incident Management

Mobilization and Deployment

Check-in at the Incident Initial Incident Briefing Incident Record Keeping Accountability Incident Demobilization

Signal words to indicate the relative toxicity of the material:

Danger—Poison: Highly toxic by all routes of entry- Danger: Severe eye damage or skin irritation- Warning: Moderately toxic- Caution: Minor toxicity and minor eye damage or skin irritation

Carboys

Glass, plastic, or steel containers, ranging in volume from 5 to 15 gallons.

unified command system

In this case, plans are drawn up in advance by all agencies that assume a shared responsibility for decision making. The response plan should designate the lead and support agencies in several kinds of MCIs. (For example, the HazMat team will take the lead in a chemical leak, while the medical team will take the lead in a multivehicle crash.) Agencies that share a border should train often with each other to ensure that a unified command system will function well and that communication among the responders is well established before a real incident occurs.

causualty collection action

In this case, they may mobilize medical and nursing teams with equipment and set up a casualty collection area at a facility near the disaster scene, such as a warehouse. Once at the casualty collection area, the teams can perform triage, provide medical care, and transport patients to the hospital on a priority basis. If a casualty collection area is established, it will be coordinated through the ICS in the same way as all other branches and areas of the operation.

termination of command

Make certain to follow the standard operating procedures. When an incident draws to a close, there should be a

Pesticide bags must be labeled with specific information Figure 39-17 . You can learn a great deal from the label, including the following details:

Name of the product▪ Active ingredients▪ Hazard statement▪ The total amount of product in the container ▪ The manufacturer's name and address ▪ The Environmental Protection Agency (EPA) registration number, which provides proof that the product was registered with the EPA

span of control

One of the organizing principles of the ICS is to limit the span of control of any one individual. This principle refers to keeping the supervisor/worker ratio at one supervisor for three to seven workers. A supervisor who has more than seven people reporting to him or her is exceeding an effective span of control and needs to divide tasks and delegate the supervision of some tasks to another person.

bills of lading

Shipping papers for road and highway transportation are called bills of lading or freight bills and are located in the cab of the vehicle Figure 39-24 . Drivers transporting chemicals are required by law to have a set of shipping papers on their person or within easy reach inside the cab at all times.

freelancing

The ICS is designed to avoid duplication of effort and freelancing, in which individual units or different organizations make independent and often inefficient decisions about the next appropriate action.

cold zone

The cold zone is a safe area where personnel do not need to wear any special protective clothing for safe operation. Personnel staging, the command post, EMS providers, and the area for medical monitoring, support, and/or treatment after decontamination are all located in the cold zone.

joint information center

The designated PIO may cooperate with PIOs from other agencies in a joint information center (JIC). In some circumstances, the PIO/JIC may be responsible for distributing a message designed to help a situation, prevent panic, and provide evacuation directions.

When you call CHEMTREC, be sure to have the following basic information ready:

The name of the chemical(s) involved in the incident (if known) ▪ Name of the caller and callback telephone number▪ Location of the incident or problem▪ Shipper or manufacturer of the chemical (if known) ▪ Container type▪ Railcar or vehicle markings or numbers▪ The shipping carrier's name▪ Recipient of material▪ Local conditions and exact description of the situation

Triage Special Considerations

There are a few special situations in triage. Patients who are hysterical and disruptive to rescue efforts may need to be handled as an immediate priority and transported off the site, even if they are not seriously injured. Panic breeds panic, and this type of behavior could have a negative impact on other patients and on the responders. A responder who becomes sick or injured during the rescue effort should be handled as an immediate priority and be transported off the site as soon as possible to avoid negative impact to the morale of remaining responders. HazMat and weapons of mass destruction incidents force the HazMat team to identify patients as contaminated or decontaminated before the regular triage process. Contamination by chemicals or biologic weapons in a treatment area, a hospital, or trauma center could obstruct all systems and organizations coping with the MCI or disaster. Bear in mind that some incidents may require multiple triage areas or teams because the victims are located far apart.

extrication supervisor

These officers determine the type of equipment and resources needed for the situation. In some incidents, victims may need to be extricated or rescued by specially trained personnel before they can be triaged and treated. Because extrication and rescue are medically complex, the supervisors will usually function under the EMS branch of the ICS. Extrication and rescue can be dangerous, so team member safety is of utmost importance.

There are four common triage categories.

You can remember them using the mnemonic IDME, which stands for Immediate (red), Delayed (yellow), Minor or Minimal (green; hold), and Expectant (black; likely to die or dead) Table 39-1 . This is the order of priority for treatment and transport of the patients at an MCI.

hazardous material

any material that poses an unreasonable risk of damage or injury to people, property, or the environment if it is not properly controlled during handling, storage, manufacture, processing, packaging, use and disposal, and transportation. Recognizing a HazMat incident, determining the identity of the material(s), and understanding the hazards involved often require some detective work.

nonbulk storage vessels

are all types of containers other than bulk containers. Nonbulk storage vessels can hold a few ounces to 119 gallons (450 L) of product and include vessels such as drums, bags, compressed gas cylinders, cryogenic containers, and more. Nonbulk storage vessels hold commonly used commercial and industrial chemicals such as solvents, industrial cleaners, and compounds. This section describes the most commonly encountered types of nonbulk storage vessels.

Intermodal tanks

are both shipping and storage vessels. They hold between 5,000 and 6,000 gallons

Placards

are diamond-shaped indicators (10.75 inches [27 cm] per side) that are placed on all four sides of highway transport vehicles, railroad tank cars, and other forms of transportation carrying hazardous materials

drums

are easily recognizable, barrel-like containers. They are used to store a wide variety of substances, including food-grade materials, corrosives, flammable liquids, and grease. Drums may be constructed of low-carbon steel, polyethylene, cardboard, stainless steel, nickel, or other materials.

control zones

are established at a HazMat incident based on the chemical and physical properties of the released material, the environmental factors at the time of the release, and the general layout of the scene.

material safety data sheet (MSDS)

(or safety data sheet [SDS]) specific to that substance Figure 39-23 . Essentially, the MSDS provides basic information about the chemical makeup of a substance, the potential hazards it presents, appropriate first aid in the event of an exposure, and other pertinent data for safe handling of the material. The MSDS will typically include the following details:

decontamination are

A patient's skin and clothing may contain hazardous material, so the decontamination area is set up in the warm zone. The decontamination area is the designated area where contaminants are removed before an individual can go to another area. Decontamination is the process of removing or neutralizing and properly disposing of hazardous materials from equipment, patients, and rescue personnel. The decontamination area must include special containers for contaminated clothing and special bags to isolate each patient's personal effects safely until they can be decontaminated Figure 39-26 . The area will also contain a number of special facilities to thoroughly wash and rinse patients and backboards. The water that is used must be captured and delivered into special sealable containers.

Incident Command System

A system implemented to manage disasters and mass- and multiple-casualty incidents in which section chiefs, including finance, logistics, operations, and planning, report to the incident commander. Also referred to as the incident management system.

In the event of a leak or spill, a HazMat incident is often indicated by the presence of the following:

A visible cloud or strange-looking smoke resulting from the escaping substance▪ A leak or spill from a tank, container, truck, or railroad car with or without HazMat placards or labels ▪ An unusual, strong, noxious (harmful), harsh odor in the area

Toxicity levels

are measures of the health risk that a substance poses to someone who comes into contact with it. There are five toxicity levels: 0, 1, 2, 3, and 4. The higher the number, the greater the toxicity, as follows: ▪ Level 0 includes materials that would cause little, if any, health hazard if you came into contact with them.▪ Level 1 includes materials that would cause irritation on contact but only mild residual injury, even without treatment. ▪ Level 2 includes materials that could cause temporary damage or residual injury unless prompt medical treatment is provided. Both levels 1 and 2 are considered slightly hazardous but require use of self-contained breathing apparatus (SCBA) if you are going to come into contact with them.▪ Level 3 includes materials that are extremely hazardous to health. Contact with these materials requires full protective gear so that none of your skin surface is exposed.▪ Level 4 includes materials that are so hazardous that minimal contact will cause death. For level 4 substances, you need specialized gear that is designed for protection against that particular hazard.

Cylinders

are used to hold liquids and gases. Uninsulated compressed gas cylinders are used to store substances such as nitrogen, argon, helium, and oxygen.

transportation supervisor

coordinates the transportation and distribution of patients to appropriate receiving hospitals and helps to ensure that hospitals do not become overwhelmed by a patient surge. The transportation supervisor coordinates with the incident commander to ensure that enough personnel and ambulances are in the staging area or have been requested. Some regions may plan for a designated hospital to coordinate with area hospitals on destination decisions. An MCI typically disrupts the everyday functioning of the region's trauma system, so good coordination is needed. The transportation supervisor documents and tracks the number of transport vehicles, patients transported, and the facility destination of each vehicle and patient.

rehabilitation supervisor

establishes an area that provides protection for responders from the elements and the situation. The rehabilitation area should be located away from exhaust fumes and crowds (especially members of the media) and out of view of the scene itself. Rehabilitation is where a responder's needs for rest, fluids, food, and protection from the elements are met. The rehabilitation supervisor must also monitor responders for signs of stress. These signs may include fatigue, altered thinking patterns, and complete collapse. Remember that all EMS personnel must be aware of signs of stress. Your service might consider having a defusing or debriefing team in this area. Responders should be encouraged to take advantage of these services but should never be forced to participate.

bulk storage containers

include fixed tanks, highway cargo tanks, rail tank cars, totes, and intermodal tanks.

Destination Decisions

All patients triaged as immediate (red) or delayed (yellow) should preferably be transported by ground ambulance or air ambulance, if available, to the most appropriate facility (trauma, burn, or pediatric center, etc). In extremely large situations, a bus may transport the walking wounded. If a bus is used for minimal-priority patients, it is strongly suggested that they be transported to a hospital or clinic distant from the MCI or disaster site to avoid overwhelming the local area hospital resources.

hazardous materials (HazMat) incident

An incident in which a hazardous material is no longer properly contained and isolated.

open incident

An incident that is not yet contained; there may be patients to be located and the situation may be ongoing, producing more patients.

Personal protective equipment (PPE) levels

indicate the amount and type of protective gear that you need to prevent injury from a particular substance. Level A, the most hazardous, requires fully encapsulated, chemical-resistant protective clothing that provides full body protection, as well as SCBA and special, sealed equipment. ▪ Level B requires nonencapsulated protective clothing or clothing that is designed to protect against a particular hazard Figure 39-29 . Usually, this clothing is made of material that will let only limited amounts of moisture and vapor pass through (nonpermeable). Level B also requires eye protection and breathing devices that contain their own air supply, such as SCBA. ▪ Level C, like Level B, requires the use of nonpermeable clothing and eye protection. In addition, face masks that filter all inhaled outside air must be used. ▪ Level D requires a work uniform, such as coveralls, that affords minimal protection.▪ All levels of protection require the use of gloves. Two pairs of rubber gloves are needed for protection in case one pair must be removed because of heavy contamination.

disaster

is a widespread event that disrupts functions and resources of a community and threatens lives and property.

secondary containment

is an engineered method to control spilled or released product if the main containment vessel fails.

staging supervisor

is assigned when an MCI or disaster requires a multivehicle or multiagency response. Emergency vehicles must have permission from the staging supervisor to enter an MCI scene and should drive only in the directed area. The staging area should be established away from the scene so that the parked vehicles are not in the way. The staging supervisor locates an area to stage equipment and responders, tracks unit arrivals, and releases vehicles and supplies when ordered by command. This position plans for efficient access to and exit from the scene and prevents traffic congestion among responding vehicles.

single command system

s one in which one person is in charge, even if multiple agencies respond. It is generally used with incidents in which one agency has the majority of responsibility for incident management. Ideally, it is used for short- duration, limited incidents that require the services of a single agency.

finance

section chief is responsible for documenting all expenditures at an incident for reimbursement. Finance personnel are not usually needed at smaller incidents, but at larger incidents it is necessary to keep track of personnel hours and expenditures for materials and supplies. Ultimately, that information is reported at meetings of the general staff. Responding agencies and organizations may be eligible for reimbursement after the incident, and an efficient finance section chief will help your agency to succeed in the reimbursement process. Finance personnel should be trained in the process of assessing expenditures with an eye to reimbursement long before an actual incident. The various functions within the finance section include: (1) the time unit, (2) the procurement unit, (3) the compensation and claims unit, and (4) the cost unit. The time unit is responsible for ensuring the daily recording of personnel time and equipment use. The procurement unit deals with all matters concerning vendor contracts. The compensation and claims unit has two major purposes: dealing with claims as a result of the incident, and injury compensation. Finally, the cost unit is responsible for collecting, analyzing, and reporting the costs related to an incident.

operations

section chief, who is responsible for managing the tactical operations usually handled by the IC on routine EMS calls. This frees the IC to coordinate with other agencies and the media, engage in strategic planning, and ensure that logistics are functioning effectively. The operations section chief will supervise the people working at the scene of the incident, who will be assigned to branches, divisions, and groups. Operations personnel often have experience in management within EMS.

logistics

section is responsible for communications equipment, facilities, food and water, fuel, lighting, and medical equipment and supplies for patients and emergency responders. Local standard operating procedures will list the medical equipment needed for the incident, depending on the type of incident. Logistics personnel are trained to find food, shelter, and health care for you and the other responders at the scene of an MCI. In a large incident, it is often necessary for many people to handle logistics, but only the section chief will report to the IC.

planning

section solves problems as they arise during the incident. Planners obtain data about the problem, analyze the previous incident plan, and predict what or who is needed to make the new plan work. They need to work closely with the operations, finance, and, especially, logistics sections. Planners can and should call on technical experts to help with the planning process. They should document their decisions and what they learned from the incident and also set out a course for demobilizing the response when necessary.

Triage

simply means to sort your patients based on the severity of their injuries Figure 39-9 . The goal of doing the greatest good for the greatest number means that the triage assessment is brief and the patient condition categories are basic.

command

staff include the public information officer (PIO), safety officer, and liaison officer.

liason officer

relays information and concerns among command, the general staff, and other agencies. If an agency is not represented in the command structure, questions and input should be given through the liaison officer.

The ICS is one component of the NIMS. The five major NIMS components are as follows:

Preparedness. The NIMS establishes measures for all responders to incorporate into their systems to prepare for their response to all incidents at any time, including procedures and protocols, licensure, and equipment certification. 2. Communications and information management. Effective communications, information management, and sharing are critical aspects of domestic incident management. The NIMS communications and information systems enable the essential functions needed to provide interoperability. Resource management. The NIMS sets up mechanisms to describe, inventory, track, and dispatch resources before, during, and after an incident. The NIMS also defines standard procedures to recover equipment used during the incident. 4. Command and management. The NIMS standardizes incident management for all hazards and across all levels of government. The NIMS standard incident command structures are based on three key constructs: ICS, multiagency coordination systems, and public information systems. 5. Ongoing management and maintenance. The multijurisdictional, multidisciplinary NIMS Integration Center (NIC) provides strategic direction for and oversight of the NIMS. It supports routine maintenance and continuous improvement of the system in the long term, including research and development of supporting technologies.

Keep the following priorities in mind:

Safety▪ Incident stabilization▪ Preservation of property and the environment

START triage

is one of the easiest methods of triage. START stands for Simple Triage And Rapid Treatment. The first step of the START triage system is performed on arrival at the scene by calling out to patients at the disaster site The second step in the START process is directed toward nonwalking patients. Move to the first nonambulatory patient and assess the respiratory status. If the patient is not breathing, open the airway by using a simple manual maneuver. A patient who still does not begin to breathe is triaged as expectant (black). If the patient begins to breathe, tag him or her as immediate (red), place in the recovery position, and move on to the next patient The next step is to assess the hemodynamic status of the patient by checking for bilateral radial pulses. An absent radial pulse implies the patient is hypotensive; tag him or her as an immediate priority. If the radial pulse is present, go to the next assessment. The final assessment in START triage is to assess the patient's neurologic status, which simply means to assess the patient's ability to follow simple commands, such as "Show me three fingers." This assessment establishes that the patient can understand and follow commands. A patient who is unconscious or cannot follow simple commands is an immediate priority patient. A patient who complies with a simple command should be triaged in the delayed category (yellow).

closed incident

is one that is contained and in which all casualties are accounted for. However, as with any situation, a closed incident may quickly become an open incident as situations change.

hotzone

is the area immediately surrounding the release, which is also the most contaminated area.

primary triage

is the initial triage done in the field, allowing you to quickly and accurately categorize the patient's condition and transport needs, whereas secondary triage is done as patients are brought to the treatment area. During primary triage, patients are briefly assessed and then identified in some way, such as by attaching a triage tag or triage tape

incident commander

is the person in charge of the overall incident. The IC will assess the incident, establish the strategic objectives and priorities, and develop a plan to manage the incident Figure 39-2 . The number of command duties the IC takes on often varies by the size of the incident. Small incidents often mean the IC will do it all. In an incident of medium size or complexity, the IC may delegate some functions but retain others. For example, at a motor vehicle crash site with multiple patients, the IC may designate a safety officer or assign a PIO but maintain responsibility for the other command functions. In a complex situation, the IC may appoint team members to all of the command roles.

triage supervisor

is ultimately in charge of counting and prioritizing patients. During large incidents, a number of triage personnel may be needed. The primary duty of the triage division or group is to ensure that every patient receives initial assessment of his or her condition. One of the most difficult parts of being a triage supervisor is that you must not begin treatment until all patients are triaged, or you will compromise your triage efforts.

warm zone

is where personnel and equipment transition into and out of the hot zone. It contains control points for access to the hot zone as well as the decontamination area. Only the minimal number of personnel and the equipment necessary to perform decontamination, or support those operating in the hot zone, should be permitted in the warm zone.

safety officer

monitors the scene for conditions or operations that may present a hazard to responders and patients. The safety officer may need to work with environmental health and HazMat specialists. The importance of the safety officer cannot be underestimated—he or she has the authority to stop an emergency operation whenever a rescuer is in danger. A safety officer should remove hazards to EMS personnel and patients before the hazards cause injury.

Chemical Transportation Emergency Center (CHEMTREC),

now operated by the American Chemistry Council, is an agency that provides invaluable technical information for first responders of all disciplines who are called upon to respond to chemical incidents. The toll-free number for CHEMTREC is 1-800-262-8200. CHEMTREC can provide you with technical chemical information via telephone, fax, or other electronic media. It also offers a phone conferencing service to connect you with thousands of shippers, subject matter experts, and chemical manufacturers.

demobilization

procedures as the situation deescalates or comes to an end.

public information officer

provides the public and media with clear and understandable information. A wise PIO positions his or her headquarters well away from the incident command post and, most important, away from the incident, to minimize distractions.

JumpSTART triage

system for pediatric patients. JumpSTART is intended for use in children younger than 8 years or who appear to weigh less than 100 pounds (45 kg). As in START, the JumpSTART system begins by identifying the walking wounded. Infants or children not developed enough to walk or follow commands (including children with special needs) should be taken as soon as possible to the treatment area for immediate secondary triage. This action assists in getting children who cannot take care of their own basic needs into a health care provider's hands. There are several differences within the respiratory status assessment compared with that in START. First, if you find that a pediatric patient is not breathing, immediately check the pulse. If there is no pulse, label the patient as expectant (black). If the patient is not breathing but has a pulse, open the airway with a manual maneuver. If the patient does not begin to breathe, give five rescue breaths and check respirations again. A child who does not begin to breathe should be labeled expectant. The primary reason for this difference is that the most common cause of cardiac arrest in children is respiratory arrest. The next step of the JumpSTART process is to assess the approximate rate of respirations. A child who is breathing fewer than 15 breaths/min or more than 45 breaths/min is tagged as an immediate priority (red), and you move on to the next patient. If the respirations are within the range of 15 to 45 breaths/min, the patient is assessed further. The next assessment in JumpSTART triage is also the hemodynamic status of the patient. Just like in START, you are simply checking for a distal pulse. This does not need to be the brachial pulse; assess the pulse that you feel the most competent and comfortable checking. If there is an absence of a distal pulse, label the child as an immediate priority and move to the next patient. If the child has a distal pulse, move on to the next assessment. The final assessment is for neurologic status. Because of the developmental differences in children, their responses will vary. For JumpSTART, a modified AVPU score is used. A child who is unresponsive or responds to pain by posturing or with incomprehensible sounds or is unable to localize pain is tagged as an immediate priority. A child who responds to pain by localizing it or withdrawing from it or is alert is considered a delayed-priority patient (yellow).

medical branch director

the IC should appoint someone as the medical branch director. This person will supervise the primary roles of the medical branch—triage, treatment, and transport of injured people.

incident action plan

which is the central tool for planning during a response to a disaster emergency. The incident action plan is prepared by the planning section chief with input from the appropriate sections and units of the incident command team. It should be written at the outset of the response and revised continually throughout the response. In an initial response for an incident that is readily controlled, a written plan may not be necessary. Larger, more complex incidents will require an incident action plan to coordinate activities. The level of detail required in an incident action plan will vary according to the size and complexity of the response.

treatment supervisor

will locate and set up the treatment area with a tier for each priority of patient. The treatment supervisor ensures that secondary triage of patients is performed and that adequate patient care is given as resources allow. The treatment supervisor also assists with moving patients to the transportation area. As the treatment supervisor supervises the responders, he or she must communicate with the medical branch director to request sufficient quantities of supplies, including bandages, burn supplies, airway and respiratory supplies, and patient packaging equipment.

morgue supervisor

will work with area medical examiners, coroners, disaster mortuary assistance teams, and law enforcement agencies to coordinate removal of the bodies and even, possibly, body parts. The morgue supervisor should attempt to leave the dead victims in the location found, if possible, until a removal and storage plan can be determined. The location of victims may help in the identification of the dead victims in mass-fatality situations, or there may be crime scene considerations. If it is determined that a morgue area is needed, the morgue supervisor should ensure that the morgue is out of view of the living patients and other responders because the psychologic impact could worsen the situation. In addition, the morgue should be secured from the public to prevent theft of any personal effects of the dead victims.

organizational levels

▪ Sections are responsible for a major functional area such as finance, logistics, planning, or operations.▪ Branches are managed by the branch director, and may be functional or geographic in nature. These tend to be established when span of control is a problem; for example, at larger incidents, where more oversight may be needed. Branches are in charge of activity directly related to the section (ie, fire, law enforcement, EMS, operations, etc). ▪ Divisions and groups serve to align resources and/or crews under one supervisor. Divisions usually refer to crews Incident Command System working in the same geographic area. Groups usually refer to crews working in the same functional area, but possibly in different locations.

After the primary triage, the triage supervisor should communicate the following information to the medical branch director:

▪ The total number of patients▪ The number of patients in each of the triage categories▪ Recommendations for extrication and movement of patients to the treatment area ▪ Resources needed to complete triage and begin movement of patients