MULTIPLE CASUALTY INCIDENT MANAGEMENT, PART 2
BY GORDON M. SACHS
In Part 1 (December 1997), we established the organization needed to efficiently manage a multiple casualty incident.
With the multiple casualty organization in place, additional arriving resources are assigned to existing divisions, groups, sectors, or units. These additional resources work for, report to, and communicate with the Division/Group supervisor or Sector/Unit leader. On arrival, however, it is important that these additional units report to a staging area.
The proper positioning of vehicles at an emergency incident is essential for success. All too often, responding units arrive at the scene, leave their vehicles wherever they can find a space, and depart to the incident site with equipment in hand. Abandoned vehicles can obstruct resource management and redeployment and the effective use of available resources. They also have the potential to disrupt the transport of victims to receiving hospitals, creating a situation that could lead to the death of a victim in critical condition.
Staging Area Manager
The strength and efficacy of a Staging Area manager are integral to the success of the incident`s overall management. The Staging Area manager is responsible for the following:
Managing an area for resources to be temporarily located while awaiting tactical assignment.
Reporting to the Operations Section chief or incident commander (IC), as determined by the scope of the incident.
Assembling, coordinating, and controlling resources assigned to staging (personnel, vehicles, and equipment).
Ensuring unimpeded access to and egress from the staging area and accessibility and mobility of resources within the staging area.
Determining required reserve level(s) for assigned resources by type and kind (e.g., backup resources).
Advising the IC when a particular type of resource is at or near minimum reserve level.
Coordinating access to EMS vehicles with the Ground Ambulance coordinator.
Ensuring the safety of members operating in the staging area.
EXPANDING THE ORGANIZATION
The organization as described is the command structure that typically may be developed for a reinforced response of rescuers. Occasionally, the rescuers will be faced with a major incident or disaster-level incident that requires the incident command organization to be expanded to support the total rescue effort.
ESCALATING OPERATIONS TO BRANCHES AND SECTIONS
Branches are used as a span-of-control mechanism. As the number of organizational positions expands beyond the IC`s ability to control and manage effectively or if the geography of the incident precludes effective management (patients are located at two widely separated areas) or if there are two or more distinctly different situations at the incident (a major fire and a mass-casualty problem), the incident may be split into two or more branches (e.g., Fire Branch and Multiple Casualty Branch).
As the incident continues to escalate and expand, the IC can quickly become overwhelmed and overloaded with managing information, assigning units, managing tactical worksheets, planning, forecasting, talking on the radio, and trying to provide resources to support the incident.
The IC must offload some of these responsibilities onto someone else. A command team of section chiefs is implemented to take on some of the supporting activities by managing the incident`s Operations, Planning, Logistics, and Finance/Administration functions.
DEESCALATING AND TERMINATING THE INCIDENT
Incident demobilization and termination should be managed as aggressively as the initial commitment of resources. The process of demobilization must be a deliberate act: All external and internal influences associated with the incident are incorporated in the decision-making process to develop the demobilization plan. Issues such as call volume, mutual-aid responders, distance to return to their own jurisdictions, length of time committed at the incident, change of tour, and potential for additional victims weigh heavily in the decision of who and how much of your resource pool to release back into service. In addition to the actual units, members` needs for rehab and the gathering of equipment that may have been issued at the scene must be considered.
During the termination phase, the same parameters must be used to reach a prudent decision as to when to secure the operation. It may not be possible to remove all EMS units from the scene; therefore, placing one unit and a supervisor for the duration of the other agencies` extended operation may be an option. A full risk assessment must be made before reducing the number of on-site units.
Demobilization Unit Leader
Demobilizing large incidents can be quite complex and may necessitate a separate planning activity. The Demobilization Unit leader is responsible for developing the Incident Demobilization Plan. Not all agencies require specific demobilization instructions.
The responsibilities of the Demobilization Unit leader include the following:
Reviewing incident resource records to determine the likely size and extent of the demobilization effort.
Adding additional resources as needed for demobilization.
Coordinating demobilization with agency representatives.
Monitoring ongoing Operations Section resource needs.
Identifying surplus resources and probable release time.
Developing incident check-out function for all units.
Evaluating logistics and transportation capabilities to support demobilization.
Establishing communications with off-incident facilities, as necessary.
Developing an Incident Demobilization Plan that details specific responsibilities and release priorities and procedures.
Preparing appropriate directories (e.g., maps, instructions, and so on) for inclusion in the demobilization plan.
Distributing the demobilization plan (on- and off-site).
Ensuring that all sections/units understand their specific demobilization responsibilities.
Supervising the execution of the Incident Demobilization Plan.
Briefing the Planning Section chief on the demobilization progress.
The documents from the incident need to be collected to ensure their availability for the operational postincident analysis (PIA); potential cost recovery; members` injury, exposure, and compensation claims; as well as their availability for potential litigation. The documents should be collected from incident management system positions, collated, and delivered to the Plans Section for proper processing and later review by authorized individuals.
CRITICAL INCIDENT STRESS MANAGEMENT (CISM)
The very nature of most multiple casualty incidents exposes members to extremely stressful situations and sights. In recent years, with the advent of CISM, long-term stress disorders have been managed or prevented by the early intervention of a CISM team. Identifying and treating critical incident stress should commence at the scene, if appropriate. The CISM team should be incorporated in your predefined multiple casualty incident response matrix. The team should automatically respond to high-impact incidents. With this accessibility, the decisions of top team members, such as whether to start CISM defusing/debriefing sessions on-site or at a formally scheduled session at a later date, can be made by competent and trained individuals. All personnel participating in an incident are encouraged to take part in a critical incident stress awareness program at the local level so they can become more adept at identifying the signs and symptoms of critical incident stress.
Because of the dynamics of a multiple casualty incident response, the scene can quickly become littered with medical and biohazardous waste. These agency-generated waste items need to be collected and packaged for proper disposal prior to the operation`s termination to minimize exposure risks to personnel and the public and to comply with Occupational Safety and Health Administration (OSHA) regulations. The organization may be cited and fined for failure to comply.
POSTINCIDENT ANALYSIS (PIA)
All major responses should have a PIA. PIAs permit the agencies and responders to evaluate performance, identify organizational needs (i.e., equipment and other resources), identify training needs, and enhance performance at similar incidents in the future.
PIAs may be informal or formal. Informal PIAs usually occur on-scene or shortly thereafter (i.e., the back-step review/critique of incident operations), sometimes referred to as “mini-PIAs” or incident debriefings. Formal PIAs are scheduled in a controlled environment, usually days after the incident. PIAs are required by OSHA and the Environmental Protection Agency (EPA) after a hazardous-materials operation.
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Although multiple casualty incidents are not common for most fire departments, they can happen anywhere. The key to successfully managing such an incident is to use incident command principles and break the incident down into appropriate sectors/divisions/groups–usually rescue/extrication, medical, and patient transportation. To make sure this system will work at a real incident, however, departments must train on this concept and practice using it in drills and exercises. n
GORDON M. SACHS is director of the IOCAD Emergency Services Group, based in Maryland, which provides management and technical support to the emergency services nationwide. He has more than 19 years of fire and EMS experience in both the career and volunteer services. In addition to many journal articles and U.S. Fire Administration publications, Sachs wrote the EMS chapter in The Fire Chief`s Handbook, Fifth Edition (Fire Engineering Books, 1995). He is a National Fire Academy instructor in EMS management and health and safety and is a member of the Fire Engineering editorial advisory board.