Manage Multi-Casualty Incidents -Don’t Just Survive Them!
FEATURES
DISASTER MANAGEMENT
Photo by Brian Dixon
Westwood Village, a complex of restaurants, stores, and movie theaters in the heart of the west side of Los Angeles, CA, draws crowds of thousands on weekend evenings.
On July 27, 1984, the evening before the 1984 Olympic Games would open in Los Angeles, the village was especially alive with people of all nations.
At 8:50 p.m., a report of a traffic accident in the Westwood Village was received by the Los Angeles City Fire Department dispatch center. The large crowd around the accident prevented the firstarriving rescue units from seeing the entire scope of the incident, and paramedics and firefighters thought they had an auto vs pedestrian situation at a bus bench with several injuries. However, citizens reported to emergency personnel that there were many others injured farther down the street. Additional ambulances and fire companies were requested.
The Los Angeles City police also responded to assist the fire department in securing the immediate area, administering first aid, and transporting victims.
Only after the crowd was under control and cleared away from the incident area was the full magnitude of the situation realized. An automobile had cut a path down 550 feet of sidewalk, leaving 53 victims and one fatality. Fifteen fire companies, 12 fire ambulances, 7 private ambulances, and several supervising officers were required at this incident. Coordination between fire, police, private ambulances, and hospital staff from the area hospitals was another important factor.
Forty-two victims (30 minor cases, 12 critical) were processed through the fire department’s system of multi-casualty protocol. The others were transported to hospitals via police vehicles and private autos and ambulances.
This incident, which can and does occur in cities across the United States, needs to be analyzed in order for fire departments having emergency medical services as part of their operations to make improvements in their systems.
MULTI-CASUALTY PLANS
Most fire departments, along with emergency medical services, have pre-arranged plans to activate when confronted with major medical incidents. These standard operating procedures allow for the effective management of an emergency incident by establishing a span of control, assuring that functions and responsibilities are identified, and setting up triage, care holding areas, and transportation routes.
However, these plans do not improve tactical training, such as administering first aid, assuring the efficiency and readiness of units, equipment, and communications. The efforts and participation of all members in multi-casualty incident training is necessary or you will not manage the next large incident, you will only survive it.
AREAS OF IMPROVEMENT
Triage/treatment analysis
Triage means the sorting of and allocation of treatment to patients and disaster victims according to a system of priorities designed to maximize the number of survivors.
Treatment is the techniques or actions customarily applied in a specific situation such as first aid and victim transport.
Emergency medical service personnel and firefighters are in the treatment mode 98% of the time because generally there are only one or two patients requiring treatment at a time. However, when we are confronted with a major medical emergency, when the number of victims is greater than the number of emergency personnel at the scene, the question of who receives priority for care and transport comes into play. This is triage, which must be done before treatment is given for stabilization and transportation readiness.
In the Westwood incident, many resources were used to treat the victims where they were found, moving them to care holding areas and then transporting by a priority system.
A true triage system quickly identifies critical victims, allows for the treatment and transport of these victims first, then continues with assessment, treatment, and stabilization of other victims. The triage officer should train with the objective in mind of interrupting triage to provide immediate care for patients with life-threatening injuries first.
Consider being faced with an incident involving 300 victims. Without an immediate triage to assess the victims’ conditions, there is no way you’ll be able to successfully manage this incident.
Ambulance routing
When we are confronted with the multi-casualty incident, we should immediately consider the available resources and their route into and out of the emergency scene. This routing should be announced over the radio or telephone and strictly complied with as much as possible. However, road conditions must be constantly monitored and alternate routes must be evaluated by chauffeurs and ambulance drivers as changing conditions could affect response time. Law enforcement and other responding emergency personnel should also be aware of routing patterns because they will be extremely helpful in managing the perimeter control of the incident.
Staging locations
Staging areas should be identified early in the incident in order to assess and manage available resources. Routes to staging areas should be announced so that all responding units will not enter the incident scene from all directions. If the space is available, fire apparatus should be staged separately from ambulances to allow the transportation officer to see exactly what resources he has on hand and to allocate them in an effective manner.
Private ambulance resources
Private ambulances are a much needed resource at major incidents. However, the expertise and capability of private sector personnel are, for the most part, an unknown quantity. In many cases, private ambulance personnel are not familiar with the department’s multi-casualty incident procedures. Therefore, all fire department preplanning and training in handling multi-casualty situations should include the private sector. Lacking this, private ambulance companies should dispatch supervising personnel to the incident. These supervisors should report to the incident commander or the medical group commander for assignments.
Identification of care holding areas
Critical and non-critical holding areas, the areas to which victims are moved prior to transportation, need to be identified. One system uses 12X18 salvage covers, a red or orange salvage cover indicating critical patients and a yellow cover indicating non-critical patients. Flags, cones, and signs are also used for identification.
identification of key positions
When a major incident is in progress, the view from the command post may be a variety of helmets, coat colors, and uniforms, mixed with victims, onlookers, media, and other people. This is a picture of mass confusion.
Identification vests worn by key personnel will eliminate this confusion. In the mass casualty incident, it is critical for management to identify the key players, and incident command system vests are now employed by many departments. I suggest that the vest be bright in color with large signs on back and front to designate the key positions of:
- Medical group commander
- Triage officer
- Transportation officer
- Care holding officers.
Private medical personnel
Doctors and nurses should be made aware of your department’s multicasualty plans, especially the plans for their involvement, whether it be at the emergency scene or at the medical facility. An understanding of your organization is also helpful for a smooth transition from prehospital to hospital emergency care. Training physicians in triage procedures is another important and useful factor in multi-casualty incidents (see “Medical Responsibility in Disaster Management,” FIRE ENGINEERING, April 1985).
Law enforcement personnel involvement
Are your local law enforcement personnel familiar with your multi-casualty plan and organization? They should be! Just as with the private sector, all aspects of your medical response training should include law enforcement personnel.
Coordination with local hospitals
Hospital personnel need to be kept abreast of on-scene conditions, the number of injured victims, special problems, etc. This awareness will improve their ability to be prepared. A scanner radio may be useful, provided the incident commander gives frequent size ups.
Communications between the hospital and emergency personnel transporting the victim is another area that must be addressed. Valuable information that can be transmitted within seconds could prove vital to the patient by allowing the hospital staff to plan a definitive course of treatment before seeing the victim. Information should include:
- A brief description of the situation;
- A review of both the subjective interview and the objective examination, including vital signs;
- The suspected medical problem or injuries;
- The emergency care being provided;
- The estimated time of arrival at the medical facility.
Medical supplies
Your next medical emergency may require all medical supplies currently carried on ambulances and fire apparatus. Are you prepared for that maximum use of supplies? Would you run out?
Consideration should be given to the establishment of medical supply caches. These caches should be at various key locations; readily available; and packaged for easy delivery in standard pickup trucks or by helicopter. They should contain dressings, bandages, splintering materials, stabilizing liquids, backboards, and collapsible stretchers. Other material may also be included, but caution should be used in the case of limited shelf life materials.
It may be necessary to establish a medical supply officer who will be responsible for an ongoing assessment of the use of supplies, how to acquire them, and what special supplies are needed.
Coordination between emergency medical services and fire suppression personnel
We all think of ourselves as “experts” in our various fields. A firefighter is a fire suppression technician. A paramedic has the technical knowledge regarding a medical emergency. With proper management, the two skills can be effectively merged at a multi-casualty incident.
In the organization of the incident, emergency medical personnel should be used in medically oriented positions: triage officer; transportation officer; care holding officers; and, in some cases, medical group commanders. Fire officers should be used as the incident commander; medical group commander; staging officers; planning officer; and supervisors of fire crews for treatment and transportation needs.
I have personally used both fire and medical personnel as the medical group commander. I recommend using a fire officer as the medical commander with a medical officer in the role of his advisor or assistant.
Incident stress debriefing
Until recently, the problem of emotional stress in rescue workers was never given much thought. Trying to keep your emotions in check while faced with destruction, exhaustion, exposure to the elements, and providing care to the sick and injured offers a good foundation for a potential emotional crisis. Many paramedics and firefighters have indicated that they have a stress reaction following a significant or major incident. A classic case of this was the PSA Airplane crash in the early 1970s in San Diego, CA, when a large commuter jetliner collided with a light plane in midair. There were no survivors.
It was also learned at this incident and at others that members of the hospital community who normally work in a clinical clean environment experience similar stress reactions when out in the field and faced with disorganized trauma.
Fire departments and other agencies need to develop specific procedures and guidelines to help alleviate stress following an incident. Supervisors should be given special training on identifying the symptoms of stress and on how to follow through with professional help, if needed.
CONCLUSION
I have presented some management concepts for your next multi-casualty incident. These ideas are a result of the lessons learned at actual incidents.
Proper training of all emergency personnel is the key factor to successfully preparing for and mitigating that major medical incident. Law enforcement, emergency medical services, hospitals, and private ambulances must be an integral part of our total training program.
We must learn to manage the multi-casualty incident, not just survive it.
