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May 01, 2011

Managing an MCI with limited resources

Bound Tree University

A bus loaded with college athletes has rolled off the highway in a rural area. There are multiple casualties with a limited number of ambulances available, although medical helicopters are available to assist.

Your role as a first arriving rescuer? Priorities only, please! This emergency scene will need to be managed safely, and timely victim care provided, with fewer resources then could be applied in an urban or suburban environment.

Rural EMS providers have often adapted operations to work with smaller crews, and to be comfortable recruiting bystanders to assist in safe parts of the operation. But any provider in any location could be in a position to have to manage an emergency incident with fewer resources, at any time.

All it takes in most communities is a bad weather event to stretch rescue resources to the point where any individual incident must be managed with scarce numbers of people and transport vehicles.

In a rural incident with multiple patients, the rescuers, transport vehicles, and talents of the advanced life support providers must be allocated to deliver the best response for the victims, and a safe operation for everyone.

Successful and safe emergency scene management begins with the day-to-day use of the Incident Command System (ICS). This system allows for a focused, administrative approach to the safe mitigation of emergencies of all types, and effective use of emergency vehicles and personnel.

As the emergency gets larger, the system is scaled up in a routine matter. Incident Command must organize any available resources to build the operation, from size up, through triage, fire and fuel management, treatment, victim transport, perimeter control, stabilization, and documentation.

Especially in a rural environment, the operation must be carefully integrated with law enforcement, and any other needed resources like public works, environmental protection, heavy rescue, towing and salvage, and even the charitable relief organizations.

Two sets of priorities
At an emergency scene with multiple victims, there are two sets of priorities, the first being managerial and the second being medical. As an emergency incident unfolds, it is important to acknowledge that scene management skills take priority over any individual victim care.

The prioritization of scene management then provides a more stable and safe environment to facilitate medical care for all victims. The most important scene management priority is scene safety.

The emergency scene may contain hazards for the original victim, bystanders, and rescue personnel who are operating at the scene. The command system allows Incident Command to review the emergency operation in its entirety and prioritize areas for safety.

Dangers and potential hazardous situations can be identified and modifications in emergency operations carried out to minimize the dangers. At a rural bus crash, early hazards are:

  • Fuel and fire
  • Damaged electrical lines
  • Ongoing traffic
  • The actions of bystanders, which may inadvertently be creating more dangers (like placing flares out to divert traffic in the road where leaking fuel is heading).

The first arriving crews of fire, EMS, and law enforcement must identify and stabilize these early hazards, almost certainly utilizing bystanders for manual help. Fire personnel must contain any fire, begin to ventilate smoke, and control other hazards from the bus or other involved vehicles.

All personnel must identify and keep everyone clear of down and damaged electrical lines, and make sure any arcing does not ignite flammable materials or strike any bystanders. Vehicle traffic around the scene must be controlled by some combination of law enforcement, big vehicles, other physical barriers, and safety-oriented bystanders.

On an ongoing basis, emergency personnel need to recognize that all emergency scenes contain hazards, some of which cannot be avoided. Each individual should practice with his/her own safety in mind, as well as the safety of the patient, bystanders, and the emergency team.

There is an ABCDEF system to organize safe rapid scene size-up by responding fire and EMS personnel.

"A" stands for anticipation of victims and their injuries. The responding crew will then perform for triage operations.

"B" for breathing means emergency personnel must consider the presence of toxic materials, which could be a further threat to victims and rescuers. Emergency responders will not want to enter a scene without appropriate protection if there is a possibility that a toxic environment is present.

"C" is for cars/crowds. When emergencies occur in or along roadways, there is a definite hazard to victims and rescuers from oncoming traffic. It is important to minimize the dangers of nearby traffic flow throughout the operation. It will be critical for first arriving police and EMS/fire units to initiate traffic control as they pull up to the scene, then expand to have formal perimeter control later in the operation.

Emergency personnel must note the crowd size and behavior of bystanders. A crowd can represent a useful source of untrained ancillary personnel, and they may have identified hazards, additional victims, or begun some victim care and psychological first aid.

The final component of the scene size-up is searching for further scene hazards, which are the important risks for victims and rescuers. "D" is for disability factors, which includes elements as diverse as unfriendly animals, inclement weather, an unstable vehicle, or unseen hazards being carried in one of the involved vehicles like oxygen cylinders, propane tanks (and the recent rash of rolling meth labs). The typical "E" for electrical and "F" for fuel or fire hazards are other immediate threats.

At some point during the initial operation, Incident Command must look around the incident scene completely to identify all components of the emergency. Through this "six sided review," the Command staff will understand the full breadth of the emergency scene, and all needs.

Establishing Incident Command requires proper utilization of emergency resources. The original size-up will identify many of the hazards to the incident scene. As Command is established and the potential scope of the emergency identified, the communications and logistic plans are established. Once again, an ABCDEF approach can be used.

  • Apparatus: What resources are responding and what resources are needed to manage the incident?
  • Building or emergency ground sketch for scene logistics
  • Climate and its effects on operations
  • Deployment of initial and incoming resources
  • Exposures
  • Fire or hazard containment

An initial response will be dispatched and will compose the "A" element of the initial operation. Once those vehicles and personnel approach the scene, they are deployed to achieve maximal efficiency.

The Incident Command establishes an emergency ground sketch to allow equipment and people appropriate access to the emergency scene. It is critical to establish logistics early, particularly as it involves traffic flow in and around the emergency site.

Careful coordination with law enforcement personnel is necessary, and proper placement of emergency vehicles will be critical. In general, big vehicles with flashing lights will provide the best shield for personnel working on the scene.

Climate, particularly inclement weather, may have a major effect on operations. All victim care decisions will be impacted if that bus crash occurred in ice, snow, pouring rain, or extreme heat. Usually, this results in the need for more personnel, and appropriate equipment to handle temperature extremes, freezing precipitation, and damaged infrastructure.

The incident commander will identify as a high priority those scene safety factors that are identified in the initial scene size-up, such as a hostile crowd, oncoming traffic, dangling electrical lines, spilled fuel, and fire hazards. Early control of these scene hazards will allow improved operating conditions for the rescuers as well as the victims.

Communication and mutual aid
The communication system is another integral component of emergency ground logistics. In a rural area, one dispatcher may be on duty and have to handle all incident communications and resource coordination for police, EMS and fire.

Resources should be identified in a preplan, especially in rural communities, so that dispatching time is not taken searching for phone numbers, and access points. Not uncommonly, rural incident management requires the use of air ambulances, heavy wreckers or salvage vehicles, state department of transportation resources, and environmental protection agency personnel.

Mutual aid sources for public safety assets are a mandate. Community public safety centers should be able to make one phone call to a neighboring agency to have them organize a response of needed fire and EMS resources: "Smith County, this is Dispatcher Jones in Acme County. We have a major incident with a bus crash on our interstate at mile marker 100. I am requesting five ambulances and five engines to respond directly to the scene. The staging area is north of the scene at mile marker 99, or the Main Street exit, and Command is using tactical channel 1. Since you are our closest county, I need you to also provide immediate backup for any emergencies that may occur away from the bus crash. So I am asking you to keep resources available and any other calls for fire or ambulance (or law enforcement) responses, I am immediately transferring the call to you. We will advise when the situation is under control and can resume normal duties."

Boom, 30 seconds, done; resources coming to a specific location where staging will be in touch on a tactical channel. Other emergency calls in the response district need to be transferred so that this dispatcher can be dedicated to supporting the major incident.

Beginning victim care
Once these important priorities for scene management have been addressed, victim care can appropriately begin. Victim care itself must be conducted in a safe manner, recognizing the lengthy times that may have to be endured until a victim can arrive at a hospital.

Climate factors will need to be factored in, as victims will be further at risk if extremes of temperature are present. Responding ambulances will also be delayed, and air ambulances may not be available, if extremes of precipitation are occurring.

Victim care is initiated using triage principles based on the type of incident and patients. The CDC National Center for Injury Prevention and Control has recently printed triage guidelines, and these will be helpful for training in a multiple casualty incident. These are the "Recommendations of the National Expert Panel on Field Triage" and copies are available for training. Victim treatment is initiated based on the patient needs, expected prehospital time, the availability of advanced life support personnel, the climate, and the availability of transport vehicles.

There are situations where advanced life support personnel may be available from sources other than the EMS organizational responders. Bystanders at the scene may include some physicians, nurses, paramedics and other trained personnel. Air ambulances called to the scene typically have advanced providers, medications, and procedural capabilities.

All of these skilled personnel may be able to contribute significantly to patient care, as long as they understand their role as Good Samaritans, do not attempt to take over control from the responsible EMS providers, and can adequately identify themselves (with a license or equivalent) as possessing the degree they report they have.

Air ambulance personnel may be very valuable contributors at the scene, and some agencies have arrangements where a skilled flight nurse can remain at the scene to assist patient care, while his or her partner does patient transports using a safe provider from the scene. This allows the flight crew responding to a rural multiple casualty incident to maximally use their skills, and the capability of the helicopter as a transport vehicle.

Case summary
Thirty-five victims were triaged, with six being immediate fatalities. They are covered with sheets, then moved to a temporary collection point until identified and released to the medical examiner.

Ambulances and air ambulances remove six critical injured victims in the first 20 minutes, and five additional "yellow" triage victims are stabilized and transported in ambulances as they arrive later in the operation, since mutual aid response had to come from a distant county.

The 18 minor injured victims were loaded into another bus to be transported together to a hospital for evaluation. A significant customer satisfaction program was initiated for the survivors, the families, and the university. First responders underwent stress counseling in the immediate time after the event, and then a month later.

In conclusion, rural incidents of all types present more challenges for EMS victim care, and longer prehospital times. Good organization using Incident Command and application of safety skills will benefit victims and rescuers. Emergency personnel must be familiar with scene priorities, and utilize Incident Command functions that facilitate safe prehospital operations and patient care. 

Reference
Recommendations of the National Expert Panel on Field Triage Morbidity and Mortality Weekly Report January 23, 2009 / Vol. 58 / No. RR-1 www.cdc.gov/mmwr

About the Author

James J Augustine, M.D., is medical advisor for Washington Township Fire Department in the Dayton, Ohio, area. He is Director of Clinical Operations at EMP Management in Canton, Ohio, and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He formerly served as Assistant Fire Chief and Medical Director for Washington, DC Fire EMS. He has served 29 years as a firefighter, and was the first Chair of the Ohio EMS Board.
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