Chapter 39: Incident Management

The purpose of Incident Command System (ICS)

*AKA Incident Management System 1. Ensure responder and public safety 2. Achieve incident management goals 3. Ensure the efficient use of resources

The most challenging situation you can be called to are disasters and mass casualty incidents (MCIs)

1. A mass-casualty incident refers to any call that involves three or more patients, or any situation that places such a great demand on available equipment or personnel that the system would require a mutual aid response. a. An agreement between neighboring EMS systems to respond when local resources are insufficient to handle the response 2. These incidents can be overwhelming, because you will find a large number of patients and not enough resources.

Staging supervisor

1. A staging supervisor is assigned when an MCI or disaster requires a multivehicle or multiagency response. 2. Emergency vehicles must have permission from the staging supervisor to enter an MCI scene and should only drive in the directed area. 3. The staging area should be established away from the scene so that the parked vehicles are not in the way.

Hazardous materials may be involved in any of the following situations:

1. A truck or train crash in which a substance is leaking from a tank truck or railroad tank car 2. A leak, fire, or other emergency at an industrial plant, refinery, or other complex where chemicals or explosives are produced, used, or stored 3. A leak or rupture of an underground natural gas pipe 4. Deterioration of underground fuel tanks and seepage of oil or gasoline into the surrounding ground 5. Buildup of methane or other by-products of waste decomposition in sewers or sewage-processing plants 6. A motor vehicle crash resulting in a ruptured gas tank

Occupancy and location

1. A wide variety of chemicals are stored in: a. Warehouses b. Hospitals c. Laboratories d. Industrial complexes e. Residential garages f. Bowling alleys g. Home improvement centers h. Garden supply stores i. Restaurants 2. The location and type of building are two good indicators of the possible presence of a hazardous material.

The Secretary of Homeland Security implemented the NIMS in 2004.

1. It provides a framework to enable federal, state, and local governments, as well as private-sector and nongovernmental organizations, to work together effectively. 2. The organizational structure must be flexible enough to be rapidly adapted for use in any situation. 3. The NIMS provides standardization in: a. Terminology b. Resource classification c. Personnel training d. Certification 4. Another important feature is the concept of interoperability, which refers to the ability of agencies of different types or from different jurisdictions to communicate with each other.

The Department of Transportation (DOT) marking system

1. Labels, placards, and other markings are used on buildings, packages, boxes, and containers. 2. Marking systems indicate the presence of a hazardous material from a safe distance and provide clues about the substance. a. Placards are diamond-shaped indicators that are placed on all four sides of highway transport vehicles, railroad tank cars, and other forms of transportation carrying hazardous materials. b. Labels are smaller versions of placards, placed on the four sides of individual boxes and smaller packages being transported.

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

1. Many disasters may not involve personal injuries. 2. On the other hand, many disasters such as floods, fires, and hurricanes will result in widespread injuries. a. Unlike an MCI, which generally lasts no longer than a few hours, emergency responders will generally be on the scene of a disaster for days to weeks and sometimes months. b. Only an elected official can declare a disaster.

Triage Special Considerations

1. 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. 2. 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. 3. Hazardous materials (HazMat) and weapons of mass destruction incidents force the HazMat team to identify patients as contaminated or decontaminated before the regular triage process.

Preparedness

1. Preparedness involves the decisions made and basic planning done before an incident occurs. 2. Preparedness in a given area involves decisions and planning about the most likely natural disasters for the area, among other disasters. 3. Your EMS agency should have written disaster plans that you are regularly trained to carry out. a. A copy of the disaster plan should be kept in each EMS vehicle. b. Your local EMS organizations should develop an assistance program for the families of EMS responders.

Scene-size up

1. Sizing up a scene starts with dispatch. 2. When you arrive first on the scene, you will make an initial assessment and some preliminary decisions. 3. The size-up will be driven by three basic questions: a. What do I have? i. Assess the scene for hazards. ii. Confirm the incident location. iii. Establish whether the incident is open or closed. (a) An open incident is not yet contained and is producing more patients (b) A closed incident is contained and all casualties are accounted for iv. Estimate the number of casualties. v. Report immediately to dispatch. b. What do I need? i. Decide what resources are needed. ii. You may need more EMS responders, ambulances, or other forms of transportation. c. What do I need to do? i. Consider the safety of yourself, your partner, other rescuers, the patient, and any bystanders. ii. You may have to initially work to isolate or stabilize the incident before providing care for injured persons. iii. Remember, you cannot help the injured if the scene is unstable.

Triage tags

1. Tagging patients early assists in tracking them and can help keep an accurate record of their condition. 2. Triage tags should be weatherproof and easily read. 3. The patient tags or tape should be color-coded and should clearly show the category of the patient. 4. The tags will become part of the patient's medical record. 5. Whatever labeling system is used, it is imperative for the transportation officer to be able to identify which patient was transported by which unit and to which destination, and the priority of the patient's condition.

Other considerations

1. The DOT system does not require that all chemical shipments be marked with placards or labels. 2. In most cases, the package or cargo tank must contain a certain amount of hazardous material before a placard is required. a. Commercial package delivery services often carry small amounts of hazardous materials that fall below that weight limit. b. The vehicle exterior will not display placards to warn of the danger. 3. Conversely, some chemicals are so hazardous that shipping any amount of them requires the use of labels or placards, such as: a. Explosives b. Poison gases c. Water-reactive solids d. High-level radioactive substances

When you arrive at a possible HazMat incident, you must first step back and assess the situation.

Rushing into such unsafe scenes can have catastrophic results. a. If overcome, you will be unable to assist patients. b. Requiring emergency care yourself, you will then further strain the EMS system.

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.

Shipping papers

a. Required whenever materials are transported from one place to another b. They include the names and addresses of the shipper and the receiver, identify the material being shipped, and specify the quantity and weight of each part of the shipment. c. Shipping papers for road and highway transportation are called bills of lading or freight bills and are located in the cab of the vehicle.

Level D PPE

a. Requires a work uniform, such as coveralls, that affords minimal protection

Level B PPE

a. Requires nonencapsulated protective clothing or clothing that is designed to protect against a particular hazard b. Also requires eye protection and breathing devices that contain their own air supply, such as SCBA

Finance

a. Responsible for documenting all expenditures at an incident for reimbursement i. Not usually needed at smaller incidents b. Various functions within the finance section: i. Time unit ii. Procurement unit iii. Compensation/claims unit iv. Cost unit

START triage

a. Stands for Simple Triage And Rapid Treatment b. Uses a limited assessment of the patient's ability to walk, respiratory status, hemodynamic status (pulse), and neurologic status

Primary triage

patients are briefly assessed and then identified in some way, such as by attaching a triage tag or triage tape.

Destination decisions

1. All patients triaged as immediate (red) or delayed (yellow) should preferably be transported by ground ambulance or air ambulance, if available. 2. In extremely large situations, a bus may transport the walking wounded. 3. Immediate-priority patients should be transported two at a time until all are transported from the site. a. Then patients in the delayed category can be transported two or three at a time until all are at a hospital. b. Finally, the walking wounded are transported. c. Expectant patients who are still alive would receive treatment and transport at this time. d. Dead victims are handled or transported according to the standard operating procedure for the area. 4. Early notification to receiving facilities will allow for the hospitals to increase staffing and move patients within their facility as required.

Extrication and special rescue

1. An extrication supervisor or rescue supervisor determines the type of equipment and resources needed for the situation. 2. Because extrication and rescue are medically complex, the supervisors will usually function under the EMS branch of the ICS.

All systems have different protocols for when to declare an MCI and initiate the ICS

1. As the EMT, ask yourself the following questions when considering whether the call is an MCI: a. How many seriously injured or ill patients can you care for effectively and transport in your ambulance? b. What happens when you have three patients to deal with? c. How long will it take for additional help to arrive? d. What happens if the number of patients exceeds the number of available ambulances? 2. You and your team cannot treat and transport all injured patients at the same time. a. At an MCI, you will often experience an increased demand for equipment and personnel. b. You should never leave the scene with patients if there are still other patients present who are sick or wounded. c. This would leave patients at the scene without medical care and can be considered abandonment. 3. If there are multiple patients and not enough resources to handle them without abandoning victims, you should: a. Declare an MCI. b. Request additional resources. c. Initiate the ICS and triage procedures.

Establishing command

1. Command should be established by the most senior official, notification to other responders should go out, and necessary resources should be requested. 2. A command system ensures that resources are effectively and efficiently coordinated. 3. Command must be established early, preferably by the first-arriving, most experienced public safety official.

Communication is the building block of good patient care

1. Common terminology and the use "clear text" communications help responders from multiple agencies work efficiently together

Communications and information management

1. Communication has historically been the weak point at most major incidents. 2. It is recommended that communications be integrated. a. All agencies should be able to communicate quickly and effortlessly via radios. b. Communications allow for accountability throughout the incident, as well as instant communication between recipients.

Because of the unique aspects of responding to and working at a HazMat incident, OSHA (Occupational Safety and Health Administration) has published a set of guidelines known as Hazardous Waste Operations and Emergency Response Standard (or HAZWOPER).

1. EMTs are required to have training at the First Responder Awareness Level. 2. First responders at the awareness level should have sufficient training or experience to demonstrate the following competencies: a. An understanding of what hazardous substances are and the risks associated with them b. An understanding of the potential outcomes of an incident c. The ability to recognize the presence of hazardous substances d. The ability to identify the hazardous substances, if possible e. An understanding of the role of the first responder awareness individual in the emergency response plan f. The ability to determine the need for additional resources and to notify the communication center

Physicians on scene

1. Emergency physicians will have the ability to make difficult triage decisions. 2. They also provide secondary triage decisions in the treatment area, deciding which priority patients are to be transported first. 3. Physicians can provide on-scene medical direction for EMTs, and they can provide care in the treatment sector as appropriate.

HazMat scene operations

1. Focus your efforts on activities that will ensure the safety and survival of the greatest number of people. 2. Use the ambulance's public address system to alert individuals near the scene and direct them to move to a safer area.

A hazardous material is any material that poses an unreasonable risk of damage or injury to persons, property, or the environment if it is not properly controlled during:

1. Handling 2. Storage 3. Manufacture 4. Processing 5. Packing 6. Use and disposal 7. Transportation

Communications

1. If possible, use face-to-face communications to limit radio traffic. a. If you communicate via radio, do not use 10-codes or signals. 2. Most communications problems should be worked out before a disaster happens by designating channels strictly for command during a disaster. 3. Communications equipment must be reliable, durable, and field-tested. 4. Be sure there are backups in place. 5. Your plan should include a "plan B" in case of communications failure.

Your role in a disaster is to respond when requested and to report to the IC for assigned tasks.

1. In a disaster with an overwhelming number of casualties, area hospitals may decide that they cannot treat all patients in their facility. 2. They may mobilize medical and nursing teams with equipment. 3. Using a facility such as a warehouse near the disaster scene, they will set up a casualty collection area to: a. Perform triage b. Provide medical care c. Transport patients to the hospital on a priority basis 4. 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.

Containers

1. In basic terms, a container is any vessel or receptacle that holds a material. 2. Often the container type, size, and material of construction provide important clues about the nature of the substance inside. a. Do not rely solely on the type of container when making a determination about hazardous materials.

JumpSTART triage for pediatric patients

1. Intended for use in children younger than 8 years or who appear to weigh less than 100 lb

The goal of the ICS is to make the best use of your resources to manage the environment around the incident and to treat patients during an emergency

1. The ICS is designed to control duplication of effort and freelancing. a. Freelancing is when individual units or different organizations make independent and often inefficient decisions about the next appropriate action. 2. One of the organizing principles of the ICS is limiting the span of control of any one individual. a. Refers to keeping the supervisor/worker ratio at one supervisor for three to seven workers 3. Organizational levels may include sections, branches, divisions, and groups. a. Sections are responsible for a major functional area such as finance, logistics, planning, or operations. b. Branches tend to be established when span of control is a problem and are in charge of activity directly related to the section (ie, fire, law enforcement, EMS, etc) c. Divisions usually refer to crews working in the same geographic area. i. The larger the incident, the more divisions there will be. d. Groups usually refer to crews working in the same functional area, but possibly in different locations.

The ICS (Incident Control System) roles and responsibilities

1. The general staff includes command, finance, logistics, operations and planning 2. Command staff includes the public information officer (PIO), safety officer, and liaison officer

"Triage" simply means "to sort" patients based on the severity of their injuries

1. The goal of doing the greatest food for the greatest number means that the triage assessment is brief and the patient condition categories are basic: a. Primary triage is the initial triage done in the field. b. Secondary triage is done as patients are brought to the treatment area.

Medical incident command is more commonly known as the medical (or EMS) branch of the ICS.

1. The medical branch director will supervise the primary roles of the medical branch—triage, treatment, and transport of injured people. 2. The medical branch director will help ensure that: a. EMS units responding to the scene are working within the ICS b. Each medical division or group receives a clear assignment before beginning work at the scene c. Personnel remain with their vehicle in the staging area until they are assigned their duties

Morgue supervisor

1. The morgue supervisor will work with area medical examiners, coroners, disaster mortuary assistance teams, and law enforcement agencies to coordinate removal of the bodies and body parts. 2. 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. 3. The morgue area should be out of view of the living patients and other responders, and it should be secured from the public.

Rehabilitation supervisor

1. The rehabilitation supervisor establishes an area that provides protection for responders from the elements and the situation. 2. The rehabilitation area should be located away from exhaust fumes and crowds and out of view of the scene itself. 3. Rehabilitation is where a responder's needs for rest, fluids, food, and protection from the elements are met. 4. The rehabilitation supervisor must also monitor responders for signs of stress, including: a. Fatigue b. Altered thinking patterns c. Complete collapse

Senses

1. The senses that can be safely used are those of sight and sound. 2. Using any of your senses that bring you in proximity to the chemical should be done with caution or avoided. 3. Clues that are seen or heard from a distance may enable you to take precautionary steps.

It is important to approach the scene from a safe location and direction.

1. The traditional rules of staying uphill and upwind are a good place to start. 2. It may be wise to use binoculars and view the scene from a safe distance. 3. Be sure to question anyone involved in the incident.

Transportation supervisor

1. The 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. 2. The transportation supervisor documents and tracks the number of transport vehicles, patients transported, and the facility destination of each vehicle and patient.

Treatment supervisor

1. The treatment supervisor will locate and set up the treatment area with a tier for each priority of patient. 2. Treatment supervisors ensure that secondary triage of patients is performed and that adequate patient care is given as resources allow. 3. Treatment supervisors also assist with moving patients to the transportation area.

Triage supervisor

1. Ultimately in charge of counting and prioritizing patients 2. The primary duty of the triage division or group is to ensure that every patient receives initial assessment of his or her condition. 3. 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.

Mobilization and deployment

1. When an incident has been declared and the need for additional resources has been identified, a request is made for additional resources. 2. Check-in at the incident a. On arrival at an incident, you should check in with the incident commander. b. Checking in accomplishes different functions: i. Allows you to be assigned to a supervisor for job tasking ii. Allows for personnel tracking throughout the incident iii. Ensures that costs, pay, and reimbursement can be calculated accurately 3. Initial incident briefing a. 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. 4. Incident record keeping a. If a large piece of equipment becomes inoperable, it may be possible for replacement costs to come from the incident. b. Record keeping allows for tracking of time spent on the actual incident for reimbursement purposes. 5. Accountability a. Accountability means keeping your supervisor advised of your location, actions, and completed tasks. b. Includes advising your supervisor of the tasks that you have been unable to complete and what tools you need to complete them 6. Incident demobilization a. Once the incident has been stabilized and all of the hazards mitigated, the IC will determine which resources are needed or not needed and when to begin demobilization. b. This process allows for a prompt return of resources to their parent organizations to be placed back in service.

The final assessment in JumpSTART assessment is checking neurologic status

A modified AVPU is socred

Mass-Casualty Incidents

An MCI is an emergency situation that involves three or more patients, places great demand on the EMS systems and/or has the potential to produce multiple casualties

A large number of hazardous gases and fluids are essentially odorless even when a substantial leak or spill has occurred.

If you approach a scene where more than one person has collapsed or is unconscious or in respiratory distress, you should assume that there has been a HazMat leak or spill and that it is unsafe to enter the area.

ICS

Incident Command System; allow us to do the greatest good for the greatest number of people a. As an EMT, you will typically be assigned to work within the EMS/medical branch under an ICS.

JumpSTART begins by identifying the walking wouned

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 sector for immediate secondary triage.

Personal protective equipment level

Personal protective equipment levels indicate the amount and type of protective gear that you need to prevent injury from a particular substance.

Your care of patients at a HazMat incident must address the following two issues:

a. Any trauma that has resulted from other related mechanisms, such as vehicle collision, fire, or explosion b. The injury and harm that have resulted from exposure to the toxic hazardous substance

NIMS

The National Incident Management System (NIMS) was developed to promote efficient coordination of emergency incidents at the regional, state, and national levels.

Cold zone

The cold zone is a safe area where personnel do not need to wear any special protective clothing for safe operation; it includes: . Personnel staging ii. The command post iii. EMS providers iv. The area for medical monitoring, support, and/or treatment after decontamination

Hot zone

The hot zone is the area immediately surrounding the release, which is also the most contaminated area. i. The physical characteristics of the released substance will significantly affect the size and layout of the hot zone. ii. All specially trained responders entering the hot zone should avoid contact with the product to the greatest extent possible. iii. All personnel and equipment must be decontaminated when they leave the hot zone.

The ICS (Incident Command System) is one component of the NIMS (National Incident Management System).

The major NIMS components are as follows: a. Preparedness b. Communications and information management c. Resource management d. Command and management e. Ongoing management and maintenance

After breathing in JumpSTART triage, assess hemodynamic status of the patient

a. Assess the pulse that you feel the most competent and comfortable checkin b. If there is an absence of a distal pulse, label the child as an immediate priority and move to the next patient.

Warm zone

The warm zone is where personnel and equipment transition into and out of the hot zone. i. It contains control points for access to the hot zone as well as the decontamination area. ii. Decontamination is the process of removing or neutralizing and properly disposing of hazardous materials from equipment, patients, and rescue personnel.

Operations

a. At a very large or complex incident, the operations section is responsible for managing the tactical operations usually handled by the IC. b. The operation section chief will supervise the people working at the scene of an incident, who will be assigned to branches, divisions, and groups.

If, as you approach, any signs suggest that a HazMat incident has occurred, you should stop at a safe distance and park upwind or uphill from the incident.

a. After rapidly sizing up the scene, call for the HazMat team. b. If you do not recognize the danger until you are too close, immediately leave the danger zone. c. Try to rapidly assess the situation and provide as much information as possible when calling for the HazMat team. d. Do not reenter the scene and do not leave the area until you have been cleared by the HazMat team. e. Do not allow civilians to enter the scene, if possible. f. Avoid all contact with the material.

Secondary triage

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.

Material safety data sheets (MSDS)

a. A common source of information about a particular chemical b. Provides basic information about: i. The chemical makeup of a substance ii. The potential hazards it presents iii. Appropriate first aid in the event of an exposure iv. Other pertinent data for safe handling of the material c. An MSDS will typically include the following details: i. The name of the chemical, including any synonyms for it ii. Physical and chemical characteristics of the material iii. Physical hazards of the material iv. Health hazards of the material v. Signs and symptoms of exposure vi. Routes of entry vii. Permissible exposure limits viii. Responsible-party contact ix. Precautions for safe handling x. Applicable control measures, including PPE xi. Emergency and first aid procedures xii. Appropriate waste disposal d. All facilities that use or store chemicals are required by law to have an MSDS on file for each chemical used or stored in the facility.

Nonbulk storage vessels

a. All types of containers other than bulk containers b. Hold commonly used commercial and industrial chemicals such as solvents, industrial cleaners, and compounds

Chemical Transportation Emergency Center (CHEMTREC)

a. CHEMTREC is operated by the American Chemistry Council. b. Provides invaluable technical information for first responders of all disciplines who are called upon to respond to chemical incidents c. When you call CHEMTREC, be sure to have the following basic information ready: i. The name of the chemical(s) involved in the incident ii. Name of the caller and callback telephone number iii. Location of the actual incident or problem iv. Shipper or manufacturer of the chemical (if known) v. Container type vi. Railcar or vehicle markings or numbers vii. The shipping carrier's name viii. Recipient of material ix. Local conditions and exact description of the situation

Establishing control zones

a. Control zones are established at a HazMat incident based on the: i. Chemical and physical properties of the released material ii. Environmental factors at the time of the release iii. General layout of the scene b. Securing access to the incident helps ensure that no one will accidentally enter a contaminated area. c. If the incident takes place inside a structure, the best place to control access is at the normal points of ingress and egress—doors. d. If the incident occurs outside, control intersections, on and off ramps, service roads, and other access routes to the scene. e. Control zones may be expanded or contracted as needed.

It is practical only to provide the simplest assessment and essential care in the hazard zone and the decontamination area because of the:

a. Dangers b. Time constraints c. Bulky protective gear that team members wear

The National Fire Protection Association (NFPA) 704, Hazardous Materials Classification standard classifies hazardous materials according to:

a. Health hazard or toxicity levels b. Fire hazard c. Chemical reactive hazard d. Special hazards

There are several differences within the respiratory status assessment compared with that in START

a. If you find that a pediatric patient is not breathing, immediately check the pulse. b. If there is no pulse, label the patient as expectant (black). c. If the patient is not breathing but has a pulse, open the airway with a manual maneuver. d. If the patient does not begin to breathe, give five rescue breaths and check respirations again. e. A child who does not begin to breathe should be labeled expectant. f. The most common cause of cardiac arrest in children is respiratory arrest. *The next step is to assess the approximate rate of respirations.

Triage categories

a. Immediate (red) b. Delayed (yellow) c. Minor or minimal (green, hold) d. Expectant (black; likely to die or dead)

Special care

a. In some cases, before the decontamination area has been completely set up, the HazMat team will find one or two patients who need immediate treatment and transport without further delay if they are to survive. b. 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. c. You will need to increase the amount of protective clothing you wear, including: i. SCBA ii. Two pairs of gloves iii. Goggles or a face shield iv. A protective coat v. Respiratory protection vi. A disposable fluid-impervious apron or similar outfit d. To make decontaminating the ambulance easier, tape the cabinet doors shut. i. Any equipment kits, monitors, and other items that will not be used en route should be removed from the patient compartment and placed in the front of the ambulance or in outside compartments. ii. Before loading the patient, turn on the power vent ceiling fan and patient compartment air-conditioning unit fan. e. When you leave the scene, inform the hospital that you are transporting a critically injured patient who has not been fully decontaminated at the scene.

Level C PPE

a. Like Level B, requires the use of nonpermeable clothing and eye protection b. In addition, face masks that filter all inhaled outside air must be used

Despite the availability of resources, identification may still be difficult.

a. Little consistency is used on labels and placards, and dishonest transporters sometimes will not label containers or vessels appropriately. b. Always maintain a high index of suspicion when approaching the scene of a truck or train tanker accident.

Most serious injuries and deaths from hazardous materials result from airway and breathing problems.

a. Maintain the airway and, if the patient appears to be in distress, give oxygen at 12 to 15 L/min with a nonrebreathing mask. b. Monitor the patient's breathing at all times. c. If there are signs that indicate that respiratory distress is increasing, you may need to provide assisted ventilation with a bag-valve mask (BVM) and high-flow oxygen.

Toxicity levels

a. Measures the health risk that a substance poses to someone who comes into contact with it b. The higher the number, the greater the toxicity, as follows: i. Level 0 includes materials that would cause little, if any, health hazard if you came into contact with them. ii. Level 1 includes materials that would cause irritation on contact but only mild residual injury, even without treatment. iii. Level 2 includes materials that could cause temporary damage or residual injury unless prompt medical treatment is provided. iv. Level 3 includes materials that are extremely hazardous to health. v. Level 4 includes materials that are so hazardous that minimal contact will cause death. c. All health hazard levels, with the exception of 0, require specialized training and respiratory and chemical protective gear that is not standard on most ambulances.

The Emergency Response Guidebook

a. Offers a certain amount of guidance for responders operating at a HazMat incident b. Updated every 3 to 4 years c. Provides information on approximately 4,000 chemicals

Command

a. The incident commander (IC) is in charge of the overall incident. i. Assesses the incident ii. Establishes the strategic objectives and priorities iii. Develops a plan to manage the incident b. Large incidents require a multiagency or multijurisdiction response and need to use a unified command system. c. A single command system is one in which one person is in charge, even if multiple agencies respond. i. Ideally, it is used for short-duration, limited incidents that require the services of a single agency. d. It is important that EMTs know who the IC is, how to communicate with the IC, and where the command post is located. i. If the incident is very large, EMTs will report to a supervisor working under the IC. e. An IC may turn over command to someone with more experience in a critical area. i. This change, or transfer of command, must take place in an orderly manner and, if possible, face to face. f. When an incident draws to a close, there should be a termination of command. i. Your agency should have demobilization procedures to implement as the situation deescalates or comes to an end.

The first step of START triage is performed on arrival at the scene by calling out to patients at the disaster site and then directing them to an easily identifiable landmark

a. The injured persons in this group are the walking wounded and are considered minimal (green) priority, or third priority patients

Logistics

a. The logistics section or section chief has responsibility for: i. Communications equipment ii. Facilities iii. Food and water iv. Fuel v. Lighting vi. Medical equipment and supplies for patients and emergency responders

Level A PPE

a. The most hazardous b. Requires fully encapsulated, chemical-resistant protective clothing that provides full body protection, as well as SCBA and special, sealed equipment.

Command staff

a. The safety officer monitors the scene for conditions or operations that may present a hazard to responders and patients. i. He or she has the authority to stop an emergency operation whenever a rescuer is in danger. ii. A safety officer should remove hazards to EMS personnel and patients before the hazards cause injury. b. The public information officer (PIO) provides the public and media with clear and understandable information. i. The designated PIO may cooperate with PIOs from other agencies in a joint information center. c. The liaison officer relays information and concerns among command, the general staff, and other agencies.

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

a. The total number of patients b. The number of patients in each of the triage categories c. Recommendations for extrication and movement of patients to the treatment area d. Resources needed to complete triage and begin movement of patients

Planning

a. This section solves problems as they arise. i. Obtains data about the problem ii. Analyzes the previous incident plan iii. Predicts what or who is needed to make the new plan work iv. Works closely with the operations, finance, and logistics sections b. Another function is to develop an incident action plan, which is the central tool for planning during a response to a disaster emergency. i. Should be written at the outset of the response and revised continually throughout the response ii. The level of detail required will vary according to the size and complexity of the response.

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 from the escaping substance b. Leak or spill from a tank, container, truck, or railroad car with or without HazMat placards or labels c. Unusual, strong, noxious (harmful), harsh odor in the area

The second step is directed toward nonwalking patients

a. You move to the first nonambulatory patient and assess the respiratory status b. If the patient is not breathing, open the airway by using a simple manual maneuver c. A patient who still does not begin to breathe is triaged as expectant (black) d. If the patient begins to breathe, tag him or her as immediate (red), place the patient in the recovery position and move on to the next patient

Role of the EMT

a. Your job is to report to a designated area outside of the hot and warm zones and provide: i. Triage ii. Treatment iii. Transport iv. Rehabilitation

The final assessment is to assess the patient's neurologic status

assess the patient's ability to follow simple commands

Cylinders (nonbulk storage vessel)

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

In general, bulk storage containers are found in buildings that rely on and need to store large quantities of a particular chemical.

c. Often these bulk storage containers are surrounded by a secondary containment system to help control an accidental release. d. Large-volume horizontal tanks are also common. i. These tanks can hold a few hundred gallons to several million gallons of product and are usually made of aluminum, steel, or plastic. e. Totes have capacities ranging from 119 gallons to 703 gallons. i. They can contain any type of chemical, including flammable liquids, corrosives, food-grade liquids, or oxidizers. ii. Shipping and storing totes can be hazardous because they have no secondary containment system. f. Intermodal tanks are both shipping and storage vessels. i. Hold between 5,000 and 6,000 gallons of product ii. Can be pressurized or nonpressurized

The next step is to assess the hemodynamic status of the patient

check bilateral radial pulses!

Bags (nonbulk storage vessel)

i. Commonly used to store solids and powders such as cement powder, sand, pesticides, soda ash, and slaked lime ii. May be constructed of plastic, paper, or plastic-lined paper iii. Pesticide bags must be labeled with specific information: (a) Name of the product (b) Active ingredients (c) Hazard statement (d) The total amount of product in the container (e) The manufacturer's name and address (f) The EPA registration number (g) The EPA establishment number (h) Signal words to indicate the relative toxicity of the material (i) Practical first aid treatment description (j) Directions for use (k) Agricultural use requirements (l) Precautionary statements (m) Storage and disposal information (n) Classification statement on who may use the product (o) "Keep out of reach of children" statement

Drums (nonbulk storage vessel)

i. Easily recognizable, barrel-like containers ii. Used to store a wide variety of substances, including food-grade materials, corrosives, flammable liquids, and grease iii. Generally, the nature of the chemical dictates the construction of the storage drum.

Immediate (red)

i. First-priority patients ii. Need immediate care and transport iii. Usually have problems with the ABCs, head trauma, or signs and symptoms of shock

Bulk storage containers include

i. Fixed tanks ii. Highway cargo tanks iii. Rail tank cars iv. Totes v. Intermodal tanks

Expectant (black; likely to die or dead)

i. Last-priority patients ii. Patients who are dead or whose injuries are so severe that they have, at best, a minimal chance of survival iii. May include patients who are in cardiac arrest or who have an open head injury iv. Patients in this category receive treatment and transport only after patients in the other three categories have received care.

Delayed (yellow)

i. Second-priority patients ii. Need treatment and transport, but it can be delayed iii. Usually have multiple injuries to bones or joints, including back injuries with or without spinal cord injury

Minor or minimal (green; hold)

i. Third-priority patients ii. May require no field or only "minimal" treatment iii. If they have any apparent injuries, they are usually soft-tissue injuries such as contusions, abrasions, and lacerations.

Carboys (nonbulk storage vessel)

i. Transport and store corrosives and other types of chemicals ii. Glass, plastic, or steel container that holds 5 to 15 gallons of product iii. Glass carboys are often placed in a protective wood, foam, fiberglass, or steel box to help prevent breakage.