START and the
Incident Command System (ICS) --
Those who are responsible for organizing the operations of a multi-casualty
incident are probably familiar with the Incident Command System (ICS). START was
designed to work within the ICS. While it is not our intent to teach the
Multi-Casualty Branch of the Incident Command system in these few pages, we did
want to give you an overview and share some of our philosophies with you. Every
area has its unique situations, resources and operational procedures that need
to be considered when developing a plan. We hope this will help you to see what
needs to be done to mange a successful multi-casualty incident.
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[START triage is a vital element in the key to successful
incident]
A Management Philosophy
When the first units arrive at a multi-casualty incident, they are certainly
going to be overwhelmed. There is a temptation to set up the management levels
of the organization first, so the operational levels will have supervision when
they are assigned. To do this, most organizations have to use personnel from the
first or second wave of responding resources. This removes them from the triage
/ transportation / treatment provider role, creating a delay in getting patients
to the hospital. After 10 to 20 minutes, it’s a sad sight to see many rescuers
in ICS vests, setting up their operations and no one attending to the victims.
Remember that it is not necessary to assign mid-management positions until
the maximum span of control is exceeded. An incident commander can easily handle
5 to 7 direct reporting positions before an Operations Chief or medical group
supervisor is needed. Assigning your first arriving operational units to hands-on
functions as much as possible will speed up your ability to triage, transport and treat your patients. This is
referred to as the bottom up approach to ICS.
If you think about the things that need to be done before you can transport a
patient, it becomes clear where you need to assign your initial resources.
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Before you can send a
patient to a hospital, you must have an ambulance available and get a
destination from an area coordinator.
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Before you can get a destination, you need to know how many
of what category of patients are loaded in the ambulance.
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Before you can identify what category a patient is in, they
must be tagged and carried to the ambulance loading area.
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Before they can be tagged, they must be triaged.
Take It From The Top
Let’s work from the beginning and assign our resources in a sequential
order.
For the purpose of focusing on the medical aspects of a multi-casualty
incident, we’ll assume there are no other life threatening factors such as
fire, heavy rescue or hazardous material releases. If there are, of course they
must be considered.
Triage
Since nothing much can happen until patients get tagged, it makes sense to
assign the first company to triage. The company officer can assume the role of
triage unit leader, assess the situation and order the necessary resources while
the other members are performing START triage. Something is immediately
happening. The first rescuers on the scene are taking an action that must
precede all others.
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[Company Officer describes the first few moments on scene.]
How many rescuers need to be assigned to triage? Of course, that depends on
how many patients you have, but keep this in mind. It will take no longer than
one minute to triage each patient, and probably less time. That means two
rescuers will triage two patients per minute. In ten minutes, 20 patients will
have been triaged. The question for you is, how fast can I move these patients
to waiting ambulances and can my triage team stay ahead of the litter bearers?
It does little good to have a lot of patients tagged if there is no one to move,
transport or treat them.
The Movement of Patients
The next major consideration is how to move your patients to either
ambulances, or if none are available, to treatment areas. This will require
methods to carry them (flats, stretchers, backboards) and personnel (litter
bearers). Litter bearers are grouped as Litter Teams and report to the Triage
Unit Leader for assignments. The preferred number of people for a litter team is
four, however it can be done by three in most cases. Plan to assign many of your
initial resources to this function or you will get way behind the curve.
Be sure the equipment you use to carry patients arrives with the personnel.
Having a stash of equipment somewhere that may not arrive until later will have
a devastating effect on the speed of your operation. As the equipment gets used,
it must be replaced. Have a plan that will keep you in carrying devices, such
as, having the ambulance leave backboards to replace the ones they are taking
with patients.
Transportation
Transportation will have to be organized early if you don’t want to end up
with a mess that can’t be straightened out. An ambulance staging and loading
area has to be established and personnel assigned to keep it organized. This
function is managed by the Ground Ambulance Coordinator. The additional staff
required should include someone to manage ambulance staging and another assist
with documentation.
Patient Destination Coordinator
Coordinating patient destination is one of the more complicated functions. In
areas where there are more than one hospital, it’s imperative that we not
relocate the disaster to the closest hospital. A system for the distribution of
patients to area hospitals must be established in advanced and utilized properly
by emergency personnel. The Medical Communications Coordinator performs this
function by notifying the Area Coordinator of the incident and setting the
system into action. Since most systems of this nature take time to get
organized, notification should be given as soon as possible so destinations are
available when the first patient is ready for transport.
Keep Things Moving
Someone needs to direct the litter teams where to go with their patients.
This is the job of the Treatment Dispatch Manager, the traffic cop for the
movement of patients. In the beginning, patients can be moved directly out of
triage and into waiting ambulances, if available. Once the litter teams can move
patients faster than they can be loaded, they will have to go to treatment areas
and be sent from there to loading. It’s the Treatment Dispatch Manager who
keeps this organized and moving.
In Summary
There
are whole courses devoted to this subject. It will take a lot of planning,
training, and multi-agency coordination if you want it to go well. Although
multi-casualty incidents are not that frequent, it is well worth the energy to
prepare for them. These principles can be applied on a smaller scale to the more
frequent multiple patient (3-12) incidents. The more these concepts are used in
the routine setting, the better they will be applied to the larger incidents. |
