Chapter 38 - EMT (Incident Management)

national incident management system (NIMS) -provides a consistent nationwide template to enable organizations to work together effectively

A Department of Homeland Security system designed to enable federal, state, and local governments and private-sector and nongovernmental organizations to effectively and efficiently prepare for, prevent, respond to, and recover from domestic incidents, regardless of cause, size, or complexity, including acts of catastrophic terrorism and hazardous materials (HazMat) incidents

hazardous material =any material that poses an unreasonable risk of damage or injury to persons, property, or the environment if not properly controlled during handling, storage, manufacture, processing, packaging, use and disposal, and transportation

Any substance that is toxic, poisonous, radioactive, flammable, or explosive and causes injury or death with exposure

-starts with dispatch -when you arrive first on the scene of an MCI, you will make an initial assessment and some preliminary decisions -size-up will be driven by 3 basic questions: 1. What do I have? 2. What do I need to do? 3. What resources do I need? -these questions have a symbiotic relationship

EMS Response within the ICS -- Scene Size-Up

morgue supervisor -should attempt to leave dead victims in the location found until a removal and storage plan can be determined

In incident command, the person who works with area medical examiners, coroners, and law enforcement agencies to coordinate the disposition of dead victims (removal of bodies and/or body parts)

finance section chief -documents all expenditures at an incident for reimbursement -not needed at small incidents -the various functions within the finance are the time unit, the procurement unit, the compensation/claims unit, and the cost unit time unit --> ensures daily recordings of personnel time and equipment use procurement unit --> deals with all matters concerning vendor contracts compensation and claims unit --> deals with claims as a result of the incident and injury compensation cost unit --> collects, analyzes, and reports the costs related to the incident

In incident command, the position in an incident responsible for accounting of all expenditures

operations section chief -responsible for managing tactical operations usually handled by the IC on routine EMS calls -in large complex incidents, IC should appoint an operations section chief who supervises people working at the scene -operations personnel often have experience in management in EMS

In incident command, the position that carries out the orders of the commander to help resolve the incident

logistics section/section chief -has responsibility for communications equipment, facilities, food and water, fuel, lighting, and medical equipment and supplies for patients and emergency responders -logistics personnel are trained to find food, shelter, and health care for you and other responders at scene of MCI -only one person will report it to IC

In incident command, the position that helps procure and stockpile equipment and supplies during an incident

Command

In incident command, the position that oversees the incident, establishes the objectives and priorities, and from there develops a response plan

planning section chief -solves problems as they arise during the MCI -obtain data about the problem, analyze previous plan, and predict what/who is needed -develops an incident action plan = central tool for planning during a response to a disaster emergency, helps to coordinate activities in large complex incidents ^^should be written at outset of the response and revised continuously throughout response

In incident command, the position that ultimately produces a plan to resolve any incident

span of control -one of the organizing principles of the ICS is limiting the span of control of any one individual --> refers to keeping the supervisor/worker ratio at one supervisor for 3-7 workers -a supervisor who has more than 7 workers reporting to him is exceeding an effective span of control and needs to divide tasks and delegate the supervision of some tasks to another person

In incident command, the subordinate positions under the commander's direction to which the workload is distributed; the supervisor/worker ratio

personal protective equipment (PPE) levels -indicate the amount and type of protective gear that you need to prevent injury from a particular substance -the 4 recognized protection levels are A, B, C, and D

Measures of the amount and type of protective equipment that an individual needs to avoid injury during contact with a hazardous material

toxicity level = measures of the health risk that a substance poses to someone who comes into contact with it -there are 5 toxicity levels (0,1,2,3,4) and the higher the number, the greater the toxicity

Measures of the risk that a hazardous material poses to the health of an individual who comes into contact with it

once a request for additional resources is made, these resources are mobilized and deployed to the scene -it's important to wait until request is made to minimize the potential for freelancing

Mobilization and Deployment

airway and breathing problems -therefore be sure to maintain airway and if patient appears to be in distress, give oxygen at 12-15 L/min with a NRB mask -monitor patients breathing at all times and if you see signs that indicate resp, distress is increasing, you may need to provide assisted ventilations with a BVM and high-flow oxygen

Most serious injuries and deaths from hazardous materials result from ______.

3-7 workers -a supervisor who has more than 7 workers reporting to him is exceeding an effective span of control and needs to divide tasks and delegate the supervision of some tasks to another person

Regarding span of control in ICS, the supervisor/worker ratio should be kept at one supervisor for ____ workers.

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 -requires coordination with IC to help ensure enough personnel and ambulances are in staging or have been requested -transportation supervisor also documents and tracks the # of vehicles transporting, patients transported, and the facility destination of each vehicle and patient

The individual in charge of the transportation sector in a MCI who assigns patients from the treatment area to awaiting ambulances in the transportation area

flexibility and standardization -the organizational structure must be flexible enough to be rapidly adapted for use in any situation -the NIMS provides standardization in terminology, resource classification, personnel training, certification, and more -another important feature of the NIMS is the concept of interoperability = the ability of agencies of different types or from different jurisdictions to communicate with each other

Two important underlying principles of the NIMS are ____ and _____.

medical incident command (also known as the medical (or EMS) branch of the ICS) -components/primary roles of this medical branch include triage, treatment, and transport of injured people -at incidents that have a significant medical factor, IC should appoint someone as the medical branch director to oversee -depending on scale of incident, EMS may be a branch or may fall under the logistics section as a unit

A branch of operations in a unified command system, whose 3 designated sector positions are triage, treatment, and transport

single command system -only one person is in charge even if multiple agencies respond

A command system in which one person is in charge, generally used with small incidents that involve only one responding agency/jurisdiction

unified command system -large MCIs (i.e. HazMat incident) require a multiagency or multijurisdiction reponse -in this case, all cooperating agencies assume a shared responsibility for decision-making and the response plan should designate the lead and support agencies in several kinds of MCIs (i.e. HazMat team will take the lead in a chemical leak, but the medical team may take the lead in a multiple vehicle MVA)

A command system used in larger incidents in which there is a multiagency response or multiple jurisdictions are involved

material safety data sheet (MSDS) -source about a particular chemical -all facilities that use or store chemicals are required by law to have an MSDS on file for each chemical used or stored in facility -can also be obtained from the transporting vehicle MSDS includes additional information on chemical including: -physical and health hazards of material -signs/symptoms of exposure and routes of entry -permissible exposure limits -responsible-party contact -precautions for safe handling (protective measures and procedures for cleaning up spills and leaks) -applicable control measures, including PPE -emergency and first-aid procedures -appropriate waste disposal

A form, provided by manufacturers and compounders (blenders) of chemicals, containing information about chemical composition, physical and chemical properties, health and safety hazards, emergency/first aid response, and waste disposal/safe handling of a specific material

disaster -many disasters may not involve personal injuries (e.g. droughts causing widespread crop damage) whereas others will (i.e. fires, hurricanes) -unlike an MCI, which usually lasts no longer than a few hours, emergency responders will generally be on scene of a disaster for days to weeks and sometimes months (i.e. Hurricane Katrina) -although you can declare an MCI, only an elected official can declare a disaster

A widespread event that disrupts community resources and functions, in turn threatening public safety, citizens' lives, and property

START triage = one of the easiest methods of triage (system) -first step is performed on arrival at scene by calling out patients at disaster site, "If you can hear my voice and are able to walk..." and then directing patients to an easily identifiable landmark --> the injured persons in this group are the "walking wounded" and are considered minimal (green priority) -second step is directed toward nonwalking patients. Move to first nonambulatory patient and assess respiratory status. If patient is NOT breathing, manually open airway. If they don't begin to breathe is triaged as expectant (black). If the patient begins to breathe, tag as immediate (red), place in recovery position, and move onto next patient -if patient is breathing, make quick estimation of the respiratory rate --> faster than 30/slower than 10 breaths/min is triaged as immediate (red). If patient is breathing 10-29 breaths/min, move to next step and assess hemodynamic status -assess hemodynamic status by checking for bilateral radial pulses --> absent radial pulse implies patient is hypotensive and should be triaged as immediate priority (red). If radial pulse is present, go to next assessment -next assessment = assessing patient's neurologic status (ability to follow simple commands). Ask patient to show you three fingers, etc. (give simple commands for them to do). A patient who is unconscious or cannot follow simple commands is an immediate priority patient (red). A patient who complies with simple command should be triaged in the delayed category (yellow)

A patient sorting process that stands for Simple Triage and Rapid Treatment and uses a limited assessment of the patient's ability to walk, respiratory status, hemodynamic status (pulse), and neurologic status

Emergency Response Guidebook -a reference used as a base for your initial actions at a hazardous materials incident -jointly created by DOT, Secretarial of Communications and Transportation of Mexico, and Transport Canada -updated every 3-4 years and provides info on ~4,000 chemicals

A preliminary action guide for first responders operating at a hazardous materials incident in coordination with the US DOT's labels and placards marking system

JumpSTART triage -developed for pediatric patients since START triage system does take into account the physiologic and developmental differences of pediatric patients -begins by identifying the walking wounded (green)--> infants or children not developed enough to walk or follow commands (including children with special needs) should be taken asap to treatment sector for immediate secondary triage -if you find that pediatric patient is not breathing, immediately check the pulse. If there is no pulse, label patient as expectant. If patient is not breathing but has a pulse, manually open airway. If patient still does not begin to breathe, give 5 rescue breaths and check respirations again. A child who does not begin to breathe should be labeled as expectant. -next step is to assess and approximate rate of respirations. Child who is breathing fewer than 15 breaths/min or more than 45 is tagged as immediate (red) and move onto next patient. If respirations are within range of 15-45 breaths/min, patient is assessed further -next step = assess hemodynamic status of patient. Just like in START, you are simply checking for distal pulse (does not have to be brachial pulse). If distal pulse is absent, label child as immediate (red) and move onto next patient. If child has distal pulse, move onto next assessment. -final assessment = neurologic status; a modified AVPU score is used. A child who is unresponsive or responds to pain by posturing (decorticate vs. decerebrate) or with incomprehensible sounds or is unable to localize pain = immediate (red). A child who responds to pain by localizing it or withdrawing from it or is alert is considered a delayed (yellow) patient

A sorting system for pediatric patients younger than 8 years or weighing less than 100 lb. There is a minor adaptation for infants since they cannot ambulate on their own

incident command system (ICS) (incident management system) -purpose = ensuring responder and public safety, achieving incident management goals, and ensuring the efficient use of resources -using it gives you a modular organizational structure that is built on the size and complexity of the incident -goal of ICS = make the best use of your resources to manage the environment around the incident and to treat patients during an emergency -follow your local standard operating procedures for establishing the ICS -the individuals who will participate in the many takss in an MCI or disaster should use the ICS (find out from your service if one exists, who is in charge, how it is activated, and what your expected role will be)

A system implemented to manage disasters and MCIs in which section chiefs (including finance, logistics, operations, and planning) report to the incident commander

3 or more patients

An MCI refers to any call that involves ______ patients.

CHEMTREC = Chemical Transportation Emergency Center, located in Arlington, VA -an emergency call center (1800-262-8200) -can provide you with technical chemical information When you call CHEMTREC, be sure to have the following basic information ready: -the name of the chemical(s) involved in incident (if known) -name of caller and callback telephone number -location of actual incident or problem -shipper or manufacturer of the chemical (if known) -container type -railcar or vehicle markings or numbers -shipping carrier's name -recipient of material -local conditions and exact description of situation -when speaking to CHEMTREC, spell out all chemical names

An agency that assists emergency personnel in identifying and handling hazardous materials transport incidents

mass-casualty incident (MCI) mutual aid response = an agreement between neighboring EMS systems to respond to MCIs or disasters in each other's region when local resources are insufficient to handle the response e.g. a residential building fire confined to one apartment that may only produce one patient but has the potential to generate dozens of patients e.g. loss of power to hospital or nursing home with ventilator-dependent and nonambulatory patients is considered an MCI, although no one is injured -by using the ICS and the NIMS and understanding the various roles, responders and/or IC can manage the incident in a smooth, organized manner

An emergency situation involving 3 or more patients or that can place great demand on the equipment or personnel of the EMS system that the system would require a mutual aid response (an agreement between neighboring EMS) or has the potential to produce multiple casualties

hazardous materials (HazMat) incident -in these incidents, you must first step back and assess the situation -because of the unique aspects of responding to these incidents, OSHA has set specific training (HAZWOPER) and first responder awareness level requirements/regulations which all individuals (including EMTs) must meet before becoming involved in these situations -you should be able to recognize a HazMat incident, determine presence and identity of material(s), and understand the hazards (and your role and being able to determine need for additional resources and notify the communication center) -remember to stay upwind and uphill if you suspect HazMat incident -use binoculars and view scene from safe distance -question anyone involved in scene -take time to assess scene and interpret clues (i.e. dead animals near release, discolored pavement, dead grass, visible vapors or puddles, or labels that may identify hazardous material) -then you can begin to formulate a plan

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

control zones -established at a HazMat incident based on the chemical and physical properties of it, environmental factors at the time of release, and the general layout of the scene -helps to ensure that no one will accidentally enter a contaminated area -spread outward from the center of a hazardous materials incident, with the warm zone containing a decontamination corridor, and IC and command post located in cold zone -control zones may be changed as IC gets more information or due to wind, etc. -if incident occurs inside a structure, control access/secure at the doors (points of ingress and egress) -if incident occurs outdoors, the goal is to secure logical access points around the hazard -start by controlling intersections, on and off ramps, service roads, and other access routes to the scene -police officers should assist by diverting traffic at a safe distance outside the hazard area. They should block off streets, close intersections, and redirect traffic as needed -whatever methods or devices are used to restrict access, they should not limit or prevent a rapid withdrawal from the area by personnel working inside the hot zone

Areas at a hazardous materials incident that are designated as hot, warm, or cold, based on safety issues and the degree of hazard found there

drums -- type of nonbulk storage vessel -nature of chemical dictates construction of the storage drum e.g. steel utility drums contain flammable liquids, cleaning fluids, oil, and other noncorrosive chemicals -polyethylene drums are used for corrosives, such as acids, bases, oxidizers, and other materials that cannot be stored in steel containers -stainless steel drums hold materials too aggressive (i.e. too reactive) for either plain steel or polyethylene -cardboard drums hold solid materials such as food-grade materials, pellets, flakes, etc.

Barrel-like containers used to store a wide variety of substances including food-grade materials, corrosives, flammable liquids, and grease. May be constructed of low-carbon steel, polyethylene, cardboard, stainless steel, nickel, or other materials

-generally HazMat team members who are trained in hospital emergency care will initiate emergency care patients who have been exposed to a hazardous material -in these cases, only essential care and the simplest assessment is provided; no bandages or splints are applied except for pressure dressings to control bleeds (due to possible spread of contamination) -Because this assessment is so simple/basic, EMTs providing care in the treatment area should treat the patient as if they have not been previously assessed or treated The two issues that your care of patients at these incidents must address are: 1. any trauma that has resulted from other related mechanisms such as vehicle collision, fire, or explosion 2. the injury and harm that have resulted from exposure to the toxic hazardous substance -there are few specific antidotes or treatments for exposure to most hazardous materials and different people respond in different ways -Therefore, your treatment for the patient's exposure to the toxic substance should focus mainly on supportive care and initiating transport to hospital without much delay -if special treatments/antidotes need to be initiated in the field, they will be ordered by medical control and relayed to the officer in charge of EMS operations at the scene

Caring for Patients at a HazMat Incident

-National Fire Protection Agency (NFPA) standard classifies hazardous materials according to health hazard or toxicity levels, fire hazard, chemical reactive hazard, and special hazards (such as radiation and acids) for fixed facilities that store hazardous materials -toxicity protection levels are also classified according to the level of personal protection required -for your safety, you need to know the type and degree of health, fire, and reactive hazard protection you need to operate safely near these substances before you enter the scene

Classification of Hazardous Materials

-communication has historically been the weak point at most major incidents -all agencies involved should have integrated communication (able to communicate quickly and effortlessly via radios)

Communications and Information Management

often the container type, size, and material of construction provide important clues about the nature of the substance inside, but do not rely on this alone -steel or polyethylene drums, bags, high-pressure gas cylinders, railroad tank cars, plastic buckets, above-ground and underground storage tanks, cargo tanks, and pipelines are all examples of how hazardous materials are packaged, stored, and shipped -drums (e.g. 55 gallon steel drum for gasoline or waste solvents) may be constructed of many different types of materials including cardboard, polyethylene, and stainless steel -materials stored in a cardboard drum are usually in solid form -stainless steel containers hold particularly dangerous chemicals -cold liquids are kept in containers designed to maintian the appropriate temeprature

Containers of hazardous materials

-presence of labels, placards, and other markings on buildings, containers, etc. enables EMTs to identify a released chemical -marking systems indicate the presence of a hazardous material from a safe distance and provide clues about the substance -DOT marking system = identification system characterized by labels, placards, and markings; used when materials are being transported from one location to another in the US

DOT Marking System for Hazardous Materials

-all immediate (red) and delayed (yellow) should be transported via ground or air ambulance -immediate (red) patients should be transported 2 at a time until all are transported from site -delayed (yellow) patients can be transported 2-3 at a time until all are at a hospital -then the slightly injured are transported -in large situations, a bus may be used to transport the walking wounded (green) preferably to a hospital or clinic distant from MCI to avoid overwhelming the local area hospital's resources. One EMT or paramedic should ride along and an ambulance should follow the bus in case a patient's condition on bus suddenly worsens -any worsening of a patient's condition must be relayed to the receiving hospital asap -at this time, expectant patients who are still alive would receive treatment and transport while dead victims are handled or transported according to standing operating procedures for the area

Destination decisions

-communications is often the key problem at an MCI or disaster -if possible, use face to face communications to limit radio traffic -if you communicate via radio, do NOT use codes or signals -before disaster happens, designate channels strictly for command during a disaster -be sure there are back-ups in place if the primary communications system does not work (e.g. mobile self-contained communication centers or local radio groups such as ham radio operators)

EMS Response within the ICS -- Communications

once you have performed a good scene size-up and answered the three basic questions, command should be established by the most senior official, notification should go out to other responders, and necessary resources should be requested -command should be established early, preferably by the first arriving, most experienced public safety official (police, fire, or EMS personnel)

EMS Response within the ICS -- Establishing Command

Preparedness involves the decisions made and basic planning done before an incident occurs (prepare for most likely disasters in your area, among other disasters) -Your EMS agency should have written disaster plans that should be kept in each EMS vehicle -EMS facilities should have disaster supplies for at least a 72-hour period of self-sufficiency and should have mutual aid agreements with surrounding organizations so that requests for help can be expedited in an emergency -Also, your local EMS organizations should develop an assistance program for the families of EMS responders and YOU should have a personal disaster plan for your family (families need to be prepared and know what to expect should you be required to be a disaster responder) -you should be up to date on immunizations for influenza, hepatitis A and B, and tetanus

EMS Response within the ICS -- Preparedness

-should be weatherproof and easily read -should be color-coded -use of symbols and colors to indicate triage categories is impt. in case some rescuers are color blind -tags will become part of patient's medical record -most have a tear-off receipt with a # corresponding to the # on the tag. When torn off by transportation officer, it will assist him in tracking a patient -some areas use digital photography of patients to assist in later identification -another way to track and account for patients is to issue 20-25 cards/tags at a time with a scorecard to mark how patients are triaged and their priority. When the responder returns for more tags, the scorescard will provide a patient count to help command and staff to develop a plan to respond and ensure that appropriate resources are either available or summoned

Facts about Triage Tags

carboys -glass carboys are often placed in a protective wood, foam, fiberglass, or steel box to prevent breakage -strong acids such as sulfuric and nitric acids, are often transported and stored in thick glass carboys

Glass, plastic, or steel containers, ranging in volume from 5-15 gallons, a type of nonbulk storage vessel that is used to transport some corrosives and other types of chemicals

Once you have recognized incident as a HazMat incident and have called for a HazMat team, focus your efforts on activities that will ensure safety and survival of the greatest number of people -use the ambulances PA system to alert individuals who are near the scene and direct them to move to a location where they will be sufficiently far from danger -try to set up a perimeter to stop traffic and individuals from entering the danger zone -establish control zones (hot, warm, or cold)

HazMat Scene Operations

-the 4 recognized protection levels are A, B, C, and D 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 -usually this clothing is made of material that will let only limited amounts of moisture and vapor pass through (nonpermeable) -also requires breathing devices that contain their own air supply, such as SCBA, and eye protection 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

How many personal protective equipment levels are there and what are they?

-there are 5 toxicity levels (0,1,2,3,4) and the higher the number, the greater the toxicity 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 SCBA (self-contained breathing apparatus) 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 *all health hazard levels (except for 0) require respiratory and chemical protective gear that is not standard on most ambulances, and specialized training

How many toxicity levels are there and what are they?

Four, can be remembered using mnemonic IDME Immediate (red) = first priority; need immediate care and transport Delayed (yellow) = second priority, need treatment and transport but it can be delayed Minor/Minimal (green; hold) = third priority; may require no field or only "minimal" treatment ^^in some parts of world this is the hold category (these are the "walking wounded"), usually only have soft-tissue injuries such as contusions, abrasions, and lacerations Expectant (black; likely to die or dead) = may include patients in cardiac arrest, open head injury, etc. and receive treatment and transport only after patients in the other three categories have received care

How many triage categories are there and what are they?

-start with scene safety --> assess scene for hazards and warn all other responders of any hazards/safety concerns -confirm incident location and establish whether it is open or closed -estimate # of casualties and report immediately to dispatch e.g. "EMT unit number one arriving on scene, multiple vehicles involved, full road blockage, no apparent hazards at this time, EMT unit number one is assuming command"

ICS Scene Size-up Q1: What do I have?

Keep the following priorities in mind: -safety -incident stabilization -preservation of property and the environment -put yourself and your partner first -you may have to initially work to isolate or stabilize the incident before providing care to injured persons --> remember you cannot help the injured if the scene is unstable

ICS Scene Size-up Q2: What do I need to do?

-decide what resources are needed -you may need more EMS responders, ambulances or other forms of transportation -many large EMS systems deploy specialized MCI units or mobile emergency room vehicles that are able to treat dozens of patients on scene -the mobile emergency room is staffed by EMTs, paramedics, and physicians who are able to provide ALS to multiple patients simultaneously on the scene of a MCI

ICS Scene Size-up Q3: What resources do I need?

extrication supervisor (rescue supervisor) -some disasters will involve extrication or search and rescue -function under EMS branch of the ICS

In incident command, the person appointed to determine the type of equipment and resources needed for a situation involving extrication or special rescue; also called rescue officer

rehabilitation supervisor --> must also monitor responders for signs of stress -in disasters/situations that will last for extended periods, a rehabilitation sector for responders should be established that provides food, fluid, and protection -rehabiliation area = the area that provides protection and treatment to firefighters and other personnel working at an emergency. Here, workers are medically monitored and receive any needed care as they enter and leave the scene -Area should be located away from exhaust fumes, crowds, media, and out of view of the scene itself

In incident command, the person who establishes an area that provides protection for responders from the elements and the situation

safety officer -monitors the scene for conditions/operations that may present a hazard to responders and patients -has the authority to STOP an emergency operation whenever a rescuer is in danger

In incident command, the person who gives the "go ahead" to a plan or who may stop an operation when rescuer safety is an issue

public information officer (PIO) -provides public and media with clear understandable information -positions headquarters away from IC and the incident to minimize distractions -must keep media safe -may work in cooperation with PIOs from other agencies in a joint information center (JIC) to disseminate/spread a message designed to help a situation, prevent panic, and provide evacuation directions

In incident command, the person who keeps the public informed and related any information to the press

staging supervisor -should be assigned to MCIs/scenes that require response by numerous emergency vehicles or agencies -vehicles should NOT drive into scene of MCI without direction from the staging supervisor -staging area should be located away from the scene -helps to prevent traffic among responding vehicles and releases vehicles and supplies when ordered by command

In incident command, the person who locates an area to stage equipment and personnel and tracks unit arrival and deployment from staging area

liaison officer -if an agency is not represented in the command structure, questions and input should be given through the liaison officer

In incident command, the person who relays information, concerns, and requests among responding agencies

-a visible cloud of 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, acrid odor in the area -to indicate presence of a normally odorless toxic gas or fluids during a leak, manufacturers may add a substance that produces a strong noxious odor However, a large number of hazardous gases and fluids are essentially odorless even when a substantial leak has occurred -if you approach a scene where more than one person has collapsed or is unconscious or in resp. distress, you should assume there has been a HazMat leak or spill and it is unsafe to enter that area

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

ICS defines many roles -the general staff includes command, finance, logistics, operations, and planning --> each has specific duties and they work together in coordinating the response Command functions include the public information officer (PIO), safety officer, liaison officer

Incident Command System Roles and Responsibilities

-package or cargo tank must contain a certain amount of hazardous material before a placard is required; therefore the DOT system does NOT require that all chemical shipments be marked with placards or labels (1,000 lb. rule) ^^^1,000 lb. rule applies to blasting agents, flammable and nonflammable gases, flammable/combustible liquids, flammable solids, air-reactive solids, oxidizers and organic peroxides, poison solids, corrosives, and misc. class 9 materials --> placards are required for these materials only when the shipment weighs more than 1,000 pounds -however other chemicals are so hazardous that shipping any amount requires use of labels or placards. These materials include explosives, poison gases, water-reactive solids, and high-level radioactive substances -a 4-digit United Nations may be required on some placards, which identifies the specific material being shipped (in Emergency Response Guidebook)

Other Considerations for Recognizing Hazardous Material

cylinders -- type of nonbulk storage vessel -uninsulated compressed gas cylinders are used to store substances such as nitrogen, argon, helium, and oxygen -they have a range of sizes and internal pressures

Portable, compressed gas containers used to hold liquids and gases

Problem = laws and regulations that cover labeling of packages and transport vehicles can be misleading e.g. a truck carrying 99 lb. of hazardous material No. 1 and 99 lb. of hazardous materials No. 2 and No.3 (small quantities), this truck may not be required by law to display any labels or placards. Instead, it may just have a "Please drive carefully" placard, which implies that it carries no hazardous materials Another problem = some substances alone may not be hazardous, yet when mixed with another substance they become highly toxic. There may be no regulations against carrying such substances together on one truck or railroad car. However, driver will have shipping papers on all substances being shipped/transported, which may be your first clue that there is a possible HazMat problem

Problems with Identification of Hazardous Materials

intermodal tanks -- type of bulk storage vessel -hold between 5,000 - 6,000 gallons of product -can be used to ship and store gaseous substances that have been chilled until they liquefy such as liquid nitrogen -in most cases intermodal tank is shipped to a facility where it is stored and used and then returned to shipper for refilling -can be shipped by all methods of transportation (air, sea, and land)

Shipping and storage vessels that can be either pressurized or nonpressurized

placards -the sign identifies the hazardous contents of the vehicle, using a standardiztion system with 10 3/4" diamond-shaped indicators -identifies the broad hazard class (flammable, poison, corrosive) to which the material inside belongs labels = smaller versions of placards (4" diamond-shaped indicators) that are placed on the four sides of individual boxes and smaller packages being transported -label on a box inside a delivery truck relates only to the potential hazard inside that particular package

Signage/diamond-shaped indicators required to be placed on all four sides of highway transport vehicles, railroad tank cars, and other forms of hazardous materials transportation

-if additional delay for proper/full decontamination seems life threatening in nontoxic exposure situations, it may be necessary to simply cut away all of the patient's clothing and do a rapid rinse to remove the majority of the contaminating matter before transport -this decision rests with IC, who bases his decision on recommendations made by HazMat team -if you are treating and transporting a patient who has not been fully and properly decontaminated, you will need to increase the amount of protective clothing you wear, including use of SCBA. At the least this should include 2 pairs of gloves, goggles or a face shield, a protective coat, respiratory protection, and a disposable fluid-impervious apron or similar outfit (such as fluid-impervious protective suits carried by HazMat teams) -to make decontaminating the ambulance easier, tape cabinet doors shut, any equipment, kits, monitors, etc. that will not be used en route should be placed in front of ambulance or outside compartment (removed from patient compartment) -before loading the patient, you should turn on the power vent ceiling fan and patient compartment air-conditioning unit fan and windows in driver's area and sliding side windows should be partially opened to prevent creating a "closed box" inside ambulance and to ensure that it is properly ventilated (if weather isn't too severe) -when you leave scene, inform hospital that you are transporting a critically injured patient who has not been fully decontaminated at the scene -make sure that one EMT enters the emergency department and, after giving hospital staff the report and advising them again of the incomplete decontamination, obtains directions before the patient is unloaded and brought in -remember ambulance needs to be decontaminated before transporting another patient

Special Care/instances for patient care in HazMat incidents

triage supervisor (or group in large incidents) -ultimately in charge of counting and prioritizing patients -primary duty = ensure that every patient receives initial assessment of his/her condition -EMTs doing triage will help move patients to the appropriate treatment sector -you must NOT begin treatment until all patients are triaged or you will compromise your triage efforts

The individual in charge of the incident command triage sector who directs the sorting of patients into triage categories in a MCI

command post (on scene) -IC typically wears some type of garment that makes him easily identifiable such as a bright vest with COMMAND on it -if transfer of command needs to occur (goes to someone with more experience), it should occur face to face (in extreme situations it can be done by radio, phone, email)

The designated field command center where the IC and support personnel are located

termination of command -your agency should have demobilization procedures to implement as the situation decelerates or comes to an end

The end of the incident command structure when an incident draws to a close

treatment supervisor -will locate and set up the treatment area with a tier for each priority of patient -treatment area = location in a MCI where patients are brought after being triaged and assigned a priority, where they are reassessed, treated, and monitored until transport to hospital -treatment supervisors ensure that secondary triage of patients is performed and that adequate patient care is given as resources allow -also have responsibility of assisting with moving patients to transportation area -transportation area = area in a MCI where ambulances and crews are organized to transport patients from the treatment area to receiving hospitals -treatment supervisors must communicate with medical branch director to request sufficient quantities of resources including bandages, burn supplies, airway and resp. supplies, and patient packaging equipment

The individual, usually a physician, who is in charge of and directs EMS personnel at the treatment area in a MCI

primary triage vs. secondary triage -during primary triage, patients are briefly assessed and then identified in some way, such as by attaching a triage tag or triage tape -main information needed on this tag = a unique number and a triage category After the primary triage, the triage supervisor should communicate the following information to the medical branch director: -the total # of patients -the # 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 -when the initial triage has been completed, secondary triage (or retriage) can occur, allowing for the EMT to reassess all remaining patients and to upgrade the triage category if necessary (in smaller MCIs, this step may not be necessary if enough resources have arrived on scene at this point)

The initial triage done in the field, allowing the EMT to quickly and accurately categorize the patient's condition and transport needs vs. The triage done as patients are brought to the treatment area

incident commander (IC) -will assess the incident, establish objectives and priorities, and develop a plan to manage the incident -person in command at a MCI and oversees incident and develops a plan for the response -the number of command duties (public information, safety, and liaison) the IC takes on varies by SIZE of the incident (small incident, does it all....large complex incident, may appoint team members to do all of the command roles)

The person in charge of the overall incident

demobilization

The process of direction responders to return to their facilities when work at a disaster or MCI has finished, at least for those particular responders

freight bills or bills of lading -located in cab of vehicle (within easy reach) -drivers transporting materials are required by law to have these on their person or within easy reach inside cab at all times

The shipping papers used for transport of chemicals over roads and highways

shipping papers -include names and addresses of shipper and receiver, identify the material being shipped, and specify the quantity and weight of each part of the shipment -shipping papers for road and highway transportation are called bills of lading or freight bills and are located in the CAB of vehicle

These are required whenever materials are transported from one place to another

totes (or intermediate bulk containers) -can contain any type of chemical including flammable liquids, corrosives, food-grade liquids, or oxidizers

These bulk containers can hold 119-703 gallons, are portable plastic tanks surrounded by stainless steel web, can contain any type of chemical, are stacked on top of one another and moved via forklift, and have no secondary containment system

True although this may cause some delay in initiating treatment to all patients, it will not adversely affect the patient care -always follow local protocols

True or False: If there are multiple patients and not enough resources to handle them without abandoning victims (leaving scene with patients while other wounded patients remain alone on scene), you should declare an MCI (at least for the present time), request additional resources, and initiate the ICS and triage procedures

True

True or False: In an MCI, sometimes physicians are on scene who can make difficult triage decisions, provide secondary triage decisions in the treatment sector, and can provide on-scene medical direction for EMTs.

True e.g. Operations -- branch -- division or group Planning -- branch -- division or group Logistics -- branch -- division or group Finance -- branch -- division or group -in some regions, emergency operations centers may exist which are operated by city, state, or federal government and will usually only be activated in a large catastrophic event that may go on for days, involve hundreds of patients, and taxes the whole system

True or False: Organizational divisions of ICS may include sections, branches, divisions, and groups

bags -- type of nonbulk storage vessel -come in different sizes and weights, depending on their contents Pesticide bags must be labeled with specific information such as: -name of product, active ingredients, hazard statement -total amount of product in container -manufacturer's name and address -EPA registration #, which provides proof that the product was registered with the EPA -EPA establishment #, which shows where product was manufactured -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 -practical first-aid treatment description -directions for use -agricultural use requirements -precautionary statements such as mixing directions or potential environmental hazards -storage and disposal information -classification statement on who may use the product **all pesticide labels must say, "Keep out of reach of children"

Type of nonbulk storage vessel used to store solids and powders such as cement powder, sand, pesticides,k soda ash, and slaked lime. May be constructed of plastic, paper, or plastic-lined paper bags

-the DOT's Emergency Response Guidebook -Material Safety Data Sheets (MSDS) -shipping papers -CHEMTREC -Jones and Barlett's Publisher's Fire Fighter's Handbook of Hazardous Materials

What are some references available to the responder to aid in identifying hazardous materials?

-a truck or train crash in which a substance is leaking -a leak, fire, or other emergency at an industrial plant, refinery, or other complex where chemicals or explosives are produced, used, or stored -a leak or rupture of an underground natural gas pipe -deterioration of underground fuel tanks and seepage of oil or gasoline into surrounding ground -buildup of methane or other by-products of waste decomposition in sewers or sewage-processing plants -a MVA in which a gas tank has ruptured

What are some situations in which hazardous materials may be involved?

-patients who are hysterical and disruptive to rescue efforts may need to be made an immediate priority and transported out of disaster site, even if they are not seriously injured since panic breeds panic -a rescuer who becomes sick or injured during rescue effort should be handled as an immediate priority and be transported off site asap to avoid negative impact to the morale of remaining rescuers -HazMat and weapons of mass destruction incidents force the HazMat team to identify patients as contaminated or decontaminated BEFORE the regular triage process because contamination by chemicals or biologic weapons in a treatment area, hospital/trauma center could obstruct all systems and organizations -some incidents may require multiple triage areas/teams if patients are located far apart

What are some special situations in triage?

1. location and type of building 2. use your senses 3. look at containers 4. Department of Transportation Marking System (presence of placards)

What are some ways to detect/suspect the presence of hazardous materials?

Level 0 = little or no hazard -No protection needed Level 1 = slightly hazardous -SCBA (level C suit) only Level 2 = slightly hazardous -SCBA (level C suit) only Level 3 = extremely hazardous -Full protection with no exposed skin (level A or B suit) Level 4 = minimal exposure causes death -Special HazMat gear (level A suit)

What are the corresponding protective equipment needed for each toxicity level of hazardous materials?

1. Hot zone = the area immediately surrounding a hazardous materials spill/incident site that is directly dangerous to life and health -all personnel working within this zone must wear complete appropriate protective clothing and equipment -entry requires approval by the incident commander or other designated officer -all personnel and equipment must be decontaminated when they leave the hot zone, ensuring that contamination is not spread to "clean" areas of the scene 2. Warm zone = the area located between the hot zone and the cold zone -contains the decontamination corridor -only the minimal number of personnel and equipment necessary to perform decontamination, or support those operating in the hot zone, should be permitted in the warm zone -decontamination is the process of removing or neutralizing and properly disposing of hazardous materials from equipment, patients, and rescue personnel -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 -area will also contain a number of facilities to thoroughly wash and rinse patients and backboards. The water that is used must be captured and delivered into special sealable containers -patients should be decontaminated before they are taken to treatment areas 3. Cold zone = a safe area at a hazardous materials incident for the agencies involved -IC, command post, EMS providers, and other support functions such as treatment after decontamination should be located in this zone -also referred to as the clean zone, or support zone -here, personnel do not need to wear any special protective clothing for safe operation

What are the different control zones at a hazardous materials incident?

1. Command and management -NIMS standardizes incident management for all hazards and across all levels of government -the NIMS standard incident command structures are based on 3 key constructs: ICS, multiagency coordination systems, and public information systems 2. Preparedness -NIMS establishes measures for all responders to incorporate into their systems to prepare for their response to all incidents at any time 3. Resource Management -NIMS sets up mechanisms to describe, inventory, track, and dispatch resources before, during, and after an incident -NIMS also defines standard procedures to recover equipment used during the incident 4. 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 5. Supporting technologies -NIMS promotes national standards and interoperability for supporting technologies to successfully implement the NIMS and standard technologies for professions or incidents -NIMS provides the structure for the science and technology used in incident management 6. Ongoing management and maintenance -the US Dept. of Homeland Security will establish a multijurisdictional, multidisciplinary NIMS Integration Center, which will provide strategic direction for and oversight of the NIMS, supporting routine maintenance and continuous improvement of the system in the long term

What are the major NIMS components?

1. Safety officer 2. Public Information officer (PIO) 3. Liaison officer

What are three important positions that help the general staff (all staff described previously) and the IC?

location and type of building e.g. a biomedical laboratory is more likely to have chemicals that could be hazardous on site than a preschool

What are two good indicators of the possible presence of a hazardous material?

Immediate (red tag) -airway and breathing difficulties -uncontrolled or severe bleeding -severe medical problems -signs of shock (hypoperfusion) -severe burns -open chest or abdominal injuries Delayed (yellow tag) -burns without airway problems -major or multiple bone or joint injuries -back injuries with or without spinal cord damage Minor/Minimal (green tag) -minor fractures -minor soft-tissue injuries (contusions, abrasions, and lacerations) Expectant (black tag) -obvious death -obviously non-survivable injury (i.e. major open brain trauma) -respiratory arrest (if limited resources) -cardiac arrest

What are typical injuries within each triage category?

SALT triage system (Sort, Assess, Lifesaving interventions, Treatment and/or Transportation) -attempts to decrease the number of patients leaving the scene and overwhelming local hospital resources before EMS can begin to move highest priority patients

What is another triage method that begins by using a global sorting of patients via verbal instructions (which indicates patient has good perfusion) and differs from other triage systems in its lifesaving intervention steps, which include bleeding control, opening the airway, two rescue breaths for children, needle decompression for tension pneumothorax, and auto-injector antidotes

Divide them into two categories based on their capacity: bulk and nonbulk storage containers Bulk storage containers include fixed tanks, highway cargo tanks, rail tank cars, totes, and intermodal tanks -found in buildings that rely on and need to store large quantities of a particular chemical (i.e. manufacturing companies) -bulk storage containers are often surrounded by a supplementary containment system to help control an accidental release -secondary containment = an engineered method to control spilled or released product if the main containment vessel fails (e.g. a 5,000 gallon vertical storage tank may be surrounded by a series of short walls that form a catch basin around the tank) -large volume horizontal tanks are stored above ground or underground and are made of aluminum, steel, or plastic -another type of bulk storage container = tote (an intermediate bulk container) -another example = intermodal tanks (shipping and storage vessels) Nonbulk storage vessels = all types of containers other than bulk containers, including drums, bags, compressed gas cylinders, and cryogenic containers -hold commonly used commercial and industrial chemicals such as solvents, industrial cleaners, and compounds -can hold a few ounces to 119 gallons of product -main ones = drugs, bags, carboys, and cylinders

What is one way to distinguish containers?

to respond when requested and to report to IC for assigned tasks -when there are an overwhelming number of casualties (injuries), a facility such as a warehouse near disaster scene may be used as a casualty collection area (an area set up by physicians, nurses, and other hospital staff near a major disaster scene where patients can receive further triage and medical care and be transported to hospital on priority basis) ^^usually only done in a major disaster when transportation to hospital facility is impossible or involves prolonged delays

What is your role in a disaster?

EMTs should report to a designated area outside the hot and warm zones and provide triage, treatment, transport, or rehabilitation when HazMat team members bring patients to you

What is your role when a leak/spill occurs at a hazardous materials incident?

sight and sound -leading with your nose is not a good idea (you could become contaminated); however using binoculars to visualize scene from distance is a good idea Things to look for that may provide warning from a distance: -vapor clouds at the scene -sound of an alarm from a toxic gas sensor in a chemical storage room or lab -chlorine and ammonia (highly vaporous and odorous chemicals) may be smelled a long way from actual point of release

What senses can be safely used to help detect the presence of hazardous materials?

-stop a safe distance and park upwind/uphill from the incident -after rapidly sizing up the scene, call for a HazMat team -if you do not recognize the danger until you are too close, immediately leave the danger zone and go to a safe place where you can rapidly assess the situation in order to provide as much information as possible to HazMat team -include your specific location, size and shape of containers of hazardous material, and what you have observed and have been told has occurred -do NOT reenter the scene and do not leave the area until you have been cleared by the HazMat team, or you may contribute to the situation by spreading hazardous materials -do not allow civilians to enter the scene if possible Above all, avoid contact with material!

What should you do if you're the first to arrive at the scene that suggests a HazMat incident has occurred?

Check in with the finance section, allowing you to be assigned to a supervisor for job tasking, allowing for personnel tracking throughout the incident, and ensures that costs, pay, and reimbursement can be calculated accurately After check-in is complete, you should report to your supervisor for an initial briefing that will allow you to get information regarding the incident, as well as specific job functions and responsibilities -make sure to keep records of inoperable equipment and tracking of time spent on the actual incident (for reimbursement purposes) -practice accountability --> keep your supervisor advised of your location, actions, and completed tasks ^^also includes advising your supervisor of the tasks you've been unable to complete and what tools you need to complete them

What should you do when you arrive at an incident?

national incident management system (NIMS) -the ICS (incident command system) is one component of the NIMS

What was developed to promote more efficient coordination of emergency incidents at the regional, state, and national levels?

freelancing -the ICS is designed to control duplication of effort and freelancing

When individual units or different organizations make independent and often inefficient decisions about the next appropriate action

communication -common terminology and the use of "clear text" (plain English rather than 10-codes) help responders from multiple agencies work efficiently together

_____ is the building block of good patient care.