To: All City of Waltham, Emergency Service Providers,

A Mass Casualty Incident exists when a system has reached the "threshold". This threshold will vary from region to region, town to town and day to day. It is when the system exceeds the point at which the routinely and immediately available EMS resources become over taxed.

Therefore, it is important to have procedures in place to ensure timely and quality patient care and transport. This Manual serves to educate all safety personnel in the procedures for EMS management at a Mass Casualty Incident. The procedures used in the Waltham system are standard procedures recognized throughout the region. Much of the information in this manual is from the American Medical Response policy and procedure manual volume six and from the Region IV Metropolitan Boston, Emergency Medical Services Council.

American Medical Response and the members of the Waltham EMS team are dedicated to the continuous improvement of the EMS service to the City of Waltham. We recognize the benefits of advanced planning and preparedness. I hope this MCI Procedure manual will aid in educating the firefighters, police officers, E911 dispatchers and EMS personnel in the City of Waltham.
Yours Truly,

Jeffrey B. Scafidi, EMT
Waltham Division Supervisor

MAIN OFFICE
1 Westinghouse Plaza
Hyde Park, MA 02136
(617) 360-1000 FAX (617) 360-1020

Section I

1. Purpose
2. Command Structure
3. Command Areas
4. Critical Steps
5. Triage Procedures
6. MCI Phase System
7. Haz- Mat Response
8. Termination of MCI

The purpose of MCI (Mass Casualty Incident) plans and guidelines is to insure that sound medical practice is instituted and followed in the treatment of multiple casualties and to provide means and standardization of approach, terminology, communication and command.

In most scenarios, there will be multiple agencies with varied levels of training that must function under an extraordinary command structure, working in a chaotic and stressful atmosphere. a truly standardized approach is absolutely necessary to insure that order emerges promptly from this chaos.

There are many common failures that are evident at many MCIs:

1. Poor Planning.
2. Inadequate on-scene needs assessment.
3. Inadequate or inappropriate communications.
4. Inadequate on-scene command structure.
5. The absence of sound medical approaches to the sorting of patients and prioritizing of their care.

• Ambulances
• Police Department
• Fire Department
• Hospitals

This must be accomplished before large numbers of responding units and personnel arrive otherwise there is the creation of mass confusion and loss of control.
 

1. Triage officer
2. b. Treatment officer
3. Loading officer
4. Staging officer
5. Communications officer

It is vitally important to the success of an MCI that all responding personnel be educated on the role and function of each member of the command structure.

The EMS Commander supervises and manages the EMS network. The senior EMT or Paramedic on the first arriving EMS unit will assume the responsibility of EMS command. At a large or on-going incident this person may be relieved by a supervisor or more experienced person. The EMS Commander reports to the Incident Commander.

It is the responsibility of the EMS Commander to determine the location of the EMS command post and announce via radio to all responding units. The location should be near the police and fire command positions.

Notification to C-Med shall be high priority to facilitate a coordinated response to a staging area away from the active incident site. C-Med should be advised of extent, nature, severity and anticipated additional resources. The EMS commander should request a separate C-Med channel for the incident as necessary. The Deaconess Waltham Hospital, Emergency Room should be notified of the incident so preparations can be made for the possible influx of patients.

The EMS Commander will supervise the placement of the treatment, loading and staging areas. Then designate and supervise a Triage Officer, Treatment Officer, Loading Officer, Staging Officer and Communications Officer.

The EMS Commander is a manager who does not perform medical tasks but delegates them.

The Triage Officer reviews and classifies all victims for life-threatening injuries. The Triage Officer reports to the EMS Commander and is usually the junior EMT or Paramedic on the first arriving ambulance. At a large or on-going incident this person may be relived by a more experienced person.

The Triage officer shall quickly view and classify each patient (15 seconds per patient). During review of each patient the S-T-A-R-T triage will be utilized. It is a universal standard of Simple-Triage-And-Rapid-Tagging of patients that relies on a three part assessment; ventilation status, perfusion status and mental status. The major role is assessment with actual care limited to airway support, by ensuring an open airway and perfusion support, by control bleeding with a tourniquet and place patient in shock position.

Once triage and tagging are performed, the Triage Officer will supervise the evacuation of all victims to the proper treatment areas. All data on actual numbers of victims is communicated to the EMS Commander. The Use of METTAGs will serve as documentation on number of victims, injuries and care provided.

The Treatment Officer has overall responsibility for the treatment of all victims. The Treatment Officer is usually the senior EMT or Paramedic on the second arriving ambulance. At a large, on-going incident this person may be relived by a more experienced EMT or Paramedic. The Treatment Officer reports to the EMS Commander.

The Treatment Officer shall quickly set up treatment areas for immediate, delayed and walking wounded as well as a morgue area, prior to the first victims being ready for evacuation to the treatment area. The location for each area must be coordinated with the EMS Commander and be adjacent to the loading area.

Initial supplies should be gathered from the first two arriving ambulances. As additional supplies and personnel arrive they will be assigned to each treatment area.

The Treatment Officer (if a paramedic) should contact medical control if ALS orders are needed. Initial treatment of all patients should be at least to the B-A-S-I-C level:

B- Bleeding control

A- Airway support

S- Shock therapy

I- Immobilization

C- Classification

All victims must be triaged, tagged, backboarded, evacuated and treated before any personnel are designated to load and transport. The Treatment Officer should be the last person utilized for transport. This officers knowledge of the incident and victims is a resource for the EMS Commander.

The Loading Officer supervises the loading of all victims. If triage is completed, the Triage Officer will then become the Loading Officer or the EMS commander will designate another individual. The Loading Officer reports to the EMS Commander.

The Loading Officer will supervise the loading of all victims who have been stabilizes and treated. The Loading Officer in cooperation with the Treatment Officer, decides the order of transportation.

Destination of each victim is determined by information gathered by C-Med. Once the Loading Officer has supervised the patient loading, the crew will continue care until arrival at the designated hospital. The Loading Officer must keep the Communications Officer well informed, since the Communications Officer has to notify the hospital of impending arrival of victims

The Staging Officer coordinated all incoming ambulances, EMTs and supplies. This person is designated by the EMS Commander and does not have to be an EMS provider. If resources are limited a Police Officer can be assigned this responsibility. The Staging Officer reports to the EMS Commander.

The Staging Officer will organize all responding units for an orderly approach to the loading area by establishing a staging area within a short travel time to the scene. Equipment will also be stock piled here and moved as needed. Flow of all ambulances is controlled by the Staging Officer so that a bottle neck does not occur.

The Communications Officer is responsible for coordinating the communication between the scene and outside agencies, such as C-Med and the Hospitals. The Communications Officer reports to the EMS Commander. Many times if the resources are not available the EMS Commander will assume the role as Communications Officer.

The Communications Officer establishes hospital communication through C-Med. Once communication is established with all local hospitals that will be accepting patients directly from the scene, the Communications Officer will update all hospitals with a broadcast of general information, number of patients and types of injuries. The Communications Officer will poll the local hospital to find the availability of each and to determine the number and severity of injury each can accept. After this, information will be given only when patients leave the scene. Departure information will be limited to notifying hospitals of the impending arrival of patients, the triage category and types of injuries.

The Communications Officer can also serve as a documentation recorder to begin the massive paper trail.

It is the responsibility of the first arriving ambulances to establish command areas, these will include command post, staging and equipment area, treatment area and loading area.

The Command Post will be established by the first arriving unit from each agency, police, fire and EMS. A configuration of vehicles similar to the "circling of covered wagons" is the most effective arraignment. This provides for a timely passage of information and orderly coordination between all agencies.

The Staging and equipment area should be established away from the scene of the incident, but must have easy access to the loading area. All incoming ambulances may be requested to off load medical equipment and supplies at the designated area including:

• Backboards with straps
• Dressings and bandages
• Collars
• Portable oxygen

The Treatment Area should be located in a safe place near the incident site that will have easy access for loading and can be expanded if necessary. The treatment area should be divided into three sections or categories.

• Category I (RED)

• Category II (YELLOW)

• Category III (GREEN)

The Loading area should be set up directly next to the treatment area. There should be easy access from the staging area and easy access out of the incident site. Incoming ambulance crews will await patient assignment by the Loading Officer. Receiving facilities will be determined by the Loading Officer with input from C-Med and Medical Control Physician at the Deaconess Waltham Hospital. The Communications Officer will notify the receiving facility through C-Med.

After the patient has been transported to the hospital, contact AMR Dispatch for further instructions.
 
 

There are ten Critical Steps or functions that must take place during an MCI response, to ensure proper delivery of care.

1. Needs assessment or size-up; To determine what resources are needed i.e. fire suppression, protective equipment, crowd control etc. What is the extent, nature, severity and spread of the incident?
  2. Initial notification/communication; An accurate and brief notification to C-Med, AMR and Waltham Fire as to the extent, nature, severity and spread of the incident. Also include the number of victims, general types of injuries, location of the command post and the location of the staging area.
  3. Establishment of a command system; This would include the delegation of key responsibilities to incoming responders. The location of key areas must also be defined: command post, treatment area, loading area, staging area, equipment/tools etc.
  4. Triage, identification of patient status; Triage is the sorting of victims, an on-going multiple step, multiple location process.
  5. Tagging the victims; METTAG or a similar tag system must be used to visibly separate and classify victims into four distinct priority groups.
  6. Treatment of victims;
The rendering of treatment will only include the management of airway problems, arterial bleeding and shock.


7. Evacuation;

Following a prioritized classification of all victims, they are moved on backboards to a more controlled treatment area.
8. Stabilization; Additional treatment and stabilization of victims will occur as personnel and resources allow.
  9. Coordination of medical communications;
Communications to hospitals are coordinated through C-Med. The C-Med will have polled hospitals to determine how many victims each facility can handle and will then designate hospital destinations for each patient. When departing the scene, The Communications Officer will notify the hospital through C-Med supplying triage category and chief complaint.
10. Loading and transporting
Victims will be loaded and transported in a prioritized manner. Red before yellow, yellow before green (as per triage-tag color-coding system).

 
 
 
 
 

• Black- Dead/Non-salvageable
• Red- Critical, must be at a hospital to survive.
• Yellow- Serious, can be delayed
• Green- Ambulatory patients, Non-ambulance transport
• Any pertinent information such as chief complaint, injuries, vital signs and treatment are written on the back of the METTAG.

To aid in the deployment or resources to a mass casualty incident, The responses have been broken down into phases. Those phases include MCI Alert, Phase I MCI, Phase II MCI and Phase III MCI.

MCI Alert is for a potential or unconfirmed MCI. Arriving ambulances will advise Waltham Fire of the MCI Alert. This will give the dispatcher warning that there is a potential for multiple injuries and give them time to located and prepare additional resources. AMR dispatch should also be informed so additional units can be deployed to the area if needed. The AMR dispatcher will inform the Waltham Fire dispatcher of the number of units available with a time frame. The Waltham Fire dispatcher may choose to poll other resources such as other ambulance companies as well as surrounding fire departments for the availability of resources should the need arise.

Phase IMCI is an Incident that requires at least three ambulances. An EMS Commander should be assigned to manage all EMS branch activities. The EMS Commander must notify Waltham Fire and AMR of the Phase I MCI and request additional ambulances. The EMS Commander must notify C-Med of location of incident, type and hazards. The number of victims and the staging area. The Deaconess Waltham Hospital, Emergency Room should also be notified.

Phase II MCI is an incident that requires at least five ambulances. An EMS Commander should be assigned and he or she should appoint a Triage Officer, Treatment Officer, Staging Officer and Loading Officer. The EMS Commander will notify AMR and Waltham Fire of the Phase H MCI, additional ambulances should be dispatched to the scene. C-Med should be notified and a channel assignment should be requested. The Deaconess Waltham Hospital Should be updated on the situation. An updated should be given to AMR and Waltham Fire of the type of incident and number of injuries. The EMS Commander should be given an update as to how many ambulances are en route and an estimated time for the their arrival.

Phase III MCI is an incident requiring at least ten ambulances. An EMS Commander should be assigned. He or She should appoint a Triage Officer, Treatment Officer, Staging Officer, Loading Officer and Communications Officer. The EMS Commander should notify AMR and Waltham Fire of the Phase HI MCI. The Communications Officer should contact C-Med and notify them of the incident. C-Med should poll the local hospitals for availability. The Deaconess Waltham Hospital Should be notified. AMR and Waltham Fire should be updated with the type of incident and the number of injured. The communications Officer should keep in close contact with Waltham Fire and AMR for continuing updates.

In many cases mutual aid assistance will be needed, from other ambulance companies or local fire departments. Whenever possible ALS units should be sent to any MCI. During large scale disasters the first two arriving ambulances may not be available to transport. So it is important that during a Phase II or Phase 1111 that extra ambulances be sent to cover theses two units.

For all Phases the following information should be giving to AMR and

Waltham Fire to assure the proper resources are dispatched.

• Location of incident, Type and Hazards
• Number of victims(estimated)
• Identity and location of EMS Command
• Location of ambulance staging area

When approaching an accident or incident site that may involve hazardous materials, all personnel should approach from the up wind side of the incident. Stop at a safe distance to observe and wait for the fire department to instruct you on where to set up a treatment area. DO NOT approach the scene until instructed to do so. Incident sites that may involve hazardous materials would include but not be limited to:

• Commercial truck accidents
• Industrial chemical sites
• Structure or vehicle fire scenes

Note the presence of victims at the site and their specific location. Provide this information to the Haz-Mat Response Team immediately upon their arrival.

Do not attempt to enter the contaminated area if you are not wearing the proper personal protective equipment and unless you are properly trained in such rescues and in the decontamination procedures involved with the hot zone of a Haz-Mat site.

If any personnel become contaminated, report to the decontamination area established by the Haz-Mat Response team and follow the decontamination procedure prescribed for the material involved.

Receiving hospitals must be notified at the earliest possible moment and

provided with the following information:

• Nature of injuries sustained by the contaminated patients.
• Hazardous substance involved
• Decontamination procedures utilized on the patient at the site prior to transport.

An orderly and timely termination will be announced after the EMS Commander is notified by the Loading Officer that the last patient has been transported. The EMS Commander will notify the Incident Commander when no further resources or EMS support is needed. The EMS Commander, in consultation with the Incident commander, will decide which units will remain on scene.

Following the incident, it is the responsibility of the EMS Commander to submit a list with the number of patients treated and the names of those transported and the name of the receiving hospital. A list will be submitted to the Incident Commander and a list forwarded to the Director of Operations at AMR.

Any equipment left on scene will be gathered and taken to the station. All AMR equipment will be collected from the hospitals and dispersed as needed. Each crew transporting a patient is responsible for filling out a Patient Care Report.