Mass Casuality Events

Responding to Mass Casualty Events

Abstract The purpose of this research is to inform the reader on how emergency response teams would work in a coordinated effort to respond to a mass casualty event. The general public does not typically understand how much is involved in declaring a mass casualty event and activating all the moving parts to achieve the greatest outcome possible. This information will be passed to the reader through explanation of terminology, responsibilities of responders or agencies, flow of events, and numerous examples. These techniques have been tried and found successful in numerous, natural disasters, terrorist acts, school shooting, and other mass events. With this information
presented to the reader they have a better understanding of the procedures if they were to ever find themselves in one of these traumatic events. This knowledge can lead to a calmer atmosphere when waiting for the initiation for rescue workers.

Responding to Mass Casualty Events In recent years the US has seen an increase in school shootings, terrorist attacks, natural disasters, and vehicular accidents have lead to an increased need for executing multi agency response coordination systems. There are guidelines in place that are similar for all agencies so that any group who happens to respond first is able to initiate the process in the same manner as any other group. Insuring this continuity is important to assure that no steps are left out in the process of coordinating care. Mass Casualty events are not taken lightly by any agency and all understand the importance of working together when a situation such as this arises. Each agency has their own part of a larger plan these plans are then discussed among the higher ups and formulated to combine into a working system that will allow for a flowing network of safety and care if the need were to arise (Little, Stepps, & Lamps, 2011). Each section practices and runs scenarios to maintain their own personal skills but then must also come together with other specialties to learn to combine the portions of the plan so that they know it is workable and that it will be successful when the time comes to use it. This could simply mean having the fire department work with the electric company to make sure they know how to correctly communicate the power has been disconnected before cutting through certain lines. This training should insure that any groups is willing and able to initiate and participate in a mass casualty event. The declaration of a mass casualty event is usually declared by the unit who arrives first on the scene, though it could also be initiated by the dispatcher receiving the call if enough information is received to support the activation.
This does not mean they start calling other local agencies telling them to respond. Instead the information is sent up to the responding agencies officer or chief who finalizes the decision starting the formal declaration. This unit will usually maintain leadership throughout the incident unless it has been found to be a matter of national security then it would be turned over to a federal agency. There are incidences when the command can be transferred as in when the incident grows to large and needs a more experienced individual to handle the problems involved or maybe it has grown smaller and does not need someone of as much importance (Hoffstler, 2012). This transfer of command will always include a transfer of command briefing to bring everyone up to date on what has been done so far and what agencies are
where. Immediately an on scene command presence will need to be established. This is known as the Incident Command System (ICD). This presence is responsible for communication between the larger groups and for the safety as the mass population as a whole. The Incident Commander is the top of the command pyramid. This individual is responsible for everyone’s safety on the scene, determines objectives and strategy to accomplish the most in a cost effective manner, monitors all operations, approves all reports and action plans (Young, 2012).
Three people will work directly beneath the incident commander. These people will be the information officer, liaison officer, and safety officer. This group is known as the command staff. The information officer is in charge of developing accurate information for release to the media in regard to the indecent. They will also process info to share within the agencies to update changes, in locations and personnel. The liaison officer’s role is as a point of contact between the agencies, groups and the incident commander. In some events this could include political parties and criminal investigation units. Safety officers provide guidance to the incident commander on appropriate actions to take to care for active personal to keep them safe and to anticipate any safety risks (Little, Stepps, & Lamps, 2011). They will also work to develop temporary safety plans for the location. Branching off from the command staff is the general staff. The general staff is made up of the logistics staff, planning staff, financial and administrative staff, and the operations staff. Most of these are very self explanatory. Logistics is in charge of gathering facilities, services and needed materiel to correctly respond. The planning staff collects, evaluates and provides the tactical information about the incident and gives information for preparing reports. Financial and administrative staffing handles all financing of projects, administrative issues, and cost aspects. The operations staff initiates all operations that are applicable to the mission of the response (Little, Stepps, & Lamps, 2011). Not all mass casualty incidents will require this much of a set up. For example: An ambulance arrives at a two car collision three people are injured. The ambulance has two workers so they are technically outnumbered and will require back up. This will not require setting up a scene command network. If the incident had been larger though say a bridge had collapsed during heavy traffic flow sending vehicles into the water then yes at that point the Incident command system would need to be set up.
During a Mass Casualty Incident (MCI) there are numerous agencies or responders who could be involved outside the traditional police, firefighters, or EMS.
These agencies each have their own specialty skill to bring to the table. Certified first responders may be the first to arrive on scene they will not take charge of the scene but can initiate triage and scene set up. Specialized rescue teams may be needed for urban search and rescue, confined space rescue, or water rescue. Utility services can work in conjunction with any team to insure that electricity does not become a danger to any of the rescue workers. Hazmat teams are responsible for cleaning up hazardous materials and can help with decontamination of not only the area but of the patients as well (Young, 2012). Even the media can play a part in helping in incidents such as these. By spreading the word they can help to notify off duty workers that they may be needed and to keep the general public away from the
site. With the MCI declared, ICD in control and the secondary agencies recognized a flow of events will occur. The first of these events will be triage. Triage is a rapid evaluation of injured individuals who are then placed into four possible categories. These categories include the walking wounded usually coded with a green tag are able to walk to where they need to be, have minor injuries and will not need to be transported at any urgency. Delayed treatment or yellow tagged individuals have non life threatening injuries but are injured to the point that they cannot make it to the treatment facility without medical transport. The most urgently wounded are the red tag individuals or immediate have life threatening injuries that must be cared for as quickly as possible. The last category is the black tag. This group is separated as far as possible from all the others. This group is the individuals who have lost their lives during the tragedy (Goatherman, 2011). This separation will usually designate the set up of a temporary morgue. The on sight morgue can be very useful in mass casualty situation. This allows for the coroner and their team to be centrally located. The identification process can begin at this point allowing for the families to have a place to gather for confirmation on who may be on the list of deceased or injured. This will also allow for any clues related to the incident to be collected in one location instead of spread around at local hospital morgues. Depending on the extent of the mass casualty incident sometimes treatment areas will be set up on site. These areas will be for the lesser injured. After they are triaged they will be moved to the onsite treatment facility either by their own ability to walk or by litter bearers (Goatherman, 2011). Their injuries will be reassess by the onsite medical personal and if the injury is determined to be fixable on site then they will do so but upon reevaluation the injury is deemed worse or surgical then they will be relabeled into the advanced category and moved into the area with those awaiting evacuation. These areas are staffed by a mixture of first responders, nurses, doctors, and firefighters with medical training. Transport is a huge problem area during a mass incident. With so many people needing to be moved around and limited hospitals it can be a very complicated puzzle to put together. It usually takes a team all by of its own to keep it in order. The lack of available ambulances can also be an issue. Often if nearby communities have not been effected they will volunteer the use of people and equipment (Goatherman, 2011). Locations that are near military post are fortunate to have large amounts of help when issues arise. The military sees these times as opportunities to raise awareness and to build community interaction between the civilians and their personal. Once transportation is established and locations are selected the most severely injured will be transferred first. The only time this will not be the case is when the most severely injured are involved in difficult rescue maneuvers at that time the less serious would be transferred instead of having the ambulances sit sedentary. Ambulances are not the only mode of transporting patients to treatment facilities. As many know there are medevac helicopters that as long as weather allows can transport the most critically injured quickly to treatment facilities even further out then the most burdened of hospitals. Many police departments have swat teams and the larger swat teams are allotted a combat medical support vehicle with proper coordination this vehicle can be used to transport up to 4 patients at a time laying down or eight who are able to sit up. Mass incidents that happen near military post with good working relations may be able to enlist the use of a military transport vehicle known as an MRAP. The MRAP is very similar to the swat vehicle as it can also be reconfigured to handle numerous patients and outfitted to supply oxygen and allow providers room to continue to monitor care (Goatherman, 2011). In many states off duty personal have it signed into their contracts or will feel morally obligated to come into work in situations such as these but many times it is the volunteers that make the difference in how the operations are staffed. Many states offer free training prior to events on how to use some of the most common emergency equipment, safety regulation, communication techniques between emergency agencies, first aid, light search and rescue, and personal safety. These volunteers are then certified to help when a crisis arise with little supervision or support. Other states that do not offer such classes will still accept volunteers but set up groups where one individual is trained in the skill that is needed then the volunteers are paired up with them and then taught while they go. The above procedures can be used in almost all incidents, the most obvious time there will be a large deviation to the plan is if there is a biological, chemical, or radiological attack. This is a very sensitive area due to the risk of injury to the rescue personal. The responders will not be able to run onto the scene no matter how horrific it may appear which will go against their nature as care providers but the goal is to not add more injuries to the work load. A perimeter will need to be set up around the area to keep people from wondering into the contamination. The location will then be divided into three zones.
The 1st zone is the hot zone. The hot zone includes the location of the incident and all the injured. The walking wounded will be encouraged to move toward the rescue workers on their own accord allowing the workers in proper safety gear to spend less time in the hot zone and to retrieve the more seriously wounded. The 2nd zone is the warm zone. All individuals will be moved through a make shift corridor no matter their injury that is being bombarded with cascades of water and their clothes will be removed. They are then moved to an observation area to be evaluated for lateen symptoms of exposure; those with injuries are further decontaminated and triaged for transport to local treatment facilities. Zone 3 is the cold zone. This zone is for treatment of symptoms and injuries. This is known as an all clear and or safe zone. No hazardous materials are to be brought into this location (Hoffstler, 2012). All individuals who assisted with search and rescue, treatment, transportation, and clean up will have to be put through the full decontamination process to insure that it is not spread to other areas or so that they do not become sick themselves.
When the last person has been sent to the hospital or the last casualty has been recover the day is not over the event is only half done. Supplies have been depleted equipment has been scattered and everyone is exhausted but it is not time to shut the doors. Teams must be reset there is no guarantee when the next disaster will strike and agencies do not want to be caught unprepared. For example: If an apartment building collapsed due to an earthquake and the crews worked six hours to free everyone that was trapped then went home, but two hours later an aftershock hits sending a second building tumbling down these same agencies need to be prepared to respond with the same diligence they had previously in the day. Secondary victims may continue to turn up long after the initial area has been cleared. Many may have left the scene believing they were ok only to find a few hours later that they were in shock and now realize they truly have an injury.
While the emergency responders have mostly completed their part up to this point the emergency department which works hand in hand with the agencies has been in a level pf preparedness since the declaration of the event was made. As a full time care facility it will already be set to a specific standard but do to the increased flow of patients it will make some changes of its own. More staff will be called in, equipment will be pulled from storage, all non-emergent surgeries will be postponed, non-acute patients will be discharged from the hospital to free up beds and many hospitals will send their doctors to the site to evaluate patients and assist with transport when necessary (Little, Stepps, & Lamps, 2011). Once the patient leaves the emergency room they have left the mass casualty cluster and will from that point on be dealt with on a calmer one on one bases dictated by the injury they sustained.
These events are not forgotten after a good night’s sleep. Even the most seasoned of responders can struggle with what they have seen, decisions they had to make, lives they could not save. The debriefing that follows such a crisis is usual handled in a semi-formal manner. A few questions are asked. These questions include: What happened? What was our mission? Did we accomplish our mission in a safe manner? After these questions are answered they will be asked to give three sustainable actions. It does not have to be limited to three. These can be anything from positive communication skills to seeking teaching opportunities for new employees even during difficult times. Next will be three things that didn’t go very well. This is usually the time people mention safety issues or time management issues. The next portion is less formal those who are struggling to deal with what happened are either allowed to speak to the group or to deal privately with a provided counselor (Schmidt, 2011). With the work that these workers face on a daily bases many mistakenly believe themselves to be hardened to the horrors of life but when reality sets in they will need that outlet to reach for. These counselors are trained to deal with medical personal and trauma type situation helping them to be able to return to work as soon as they feel comfortable.
In conclusion the actions of emergency care workers can mean the difference between life and death for many. The must have the courage to act to make quick decisions and to make the tough calls. Training is an ongoing situation among multiple groups so that if and when disaster strikes they are able to combine as a well maintained team and support the community that the serve. In reading this report the reader should now have a basic understanding of the steps of responding to a mass casualty event, its general terminology and what is expected from each section before during and after a disaster.

References
Goatherman, S. (2011). Triage and Transport. Military Life, 12-15.
Hoffstler, J. (2012). Mass Casualty Events Step by Step. Journal of Emergency Medicine, 62-68.
Little, A., Stepps, H., & Lamps, P. (2011). Mass Casualty Planning . San Antonio: Tillman House.
Schmidt, B. (2011, July 22). How & Why to Conduct an Incident Debriefing. Retrieved from Fire Fighter Nation: http://www.firefighternation.com/article/incident-command-0/how-why-conduct-incident-debriefing
Young, J. (2012). Emergency Preperations in Disaster. Little Rock: Critter Press.