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MASS CASUALTY MANAGEMENT DERICK D. NYASEBWA M.D, Fel HSM EMERGENCY DEPARTMENT BUGANDO MEDICAL CENTRE Mass Casualty Management is the one that, because of the number and severity of casualties, properties damaged or its location requires special arrangements such as information management, safety measures, dispatch of teams, and activation of the contingency plan, scene management, triage, evacuation, code of conduct and debriefing. Factors for consideration at all levels are available resources, magnitude of the incident, location, and distance from the health facilities and possibilities of other incidents happening. Examples of major incidents include: health threats like cholera epidemics, major accidents like marine accidents, road traffic accidents, major explosions etc. INTRODUCTION Scene Management: is a command system established immediately at the scene of an incident to assure the coordination of multiple responding agencies and provides safety measures of all responders; it enables assessment and determines the magnitude of the incident where complex scenes can be split into tiers of command, thus simplifying rescue operations and coordination at the scene or incident. It also describes duties and responsibilities of each responding agency. Learning objectives: At the end of this lesson learners will be able to: • To learn the Tiers of Command in Scene management • To understand the elements of Scene Control • To understand Scene Organization AIMS OF RESPONDING HEALTH WORKERS To save life To limit worsening of the condition To promote recovery Definition of Terms: Tiers of Command – these are the three levels represents command structure at the scene or incident describes responsibilities, namely Bronze Command cordon), Silver Command (outer cordon) and Command(at vicinity of scene). which which (inner Gold Command Post – The joint post where authority and responsibility of all emergency responders reports for coordination, directives and actions plans made. Incident Commander - The officer having overall responsibility for managing the incident and dictating tactics and resource management. Ambulance Loading Area - This is the point through which all casualties requiring hospital treatment pass through, ensures a free flow of ambulances and assists by collating the numbers of casualties and their destination and ensuring records are kept. Marshalling area – A location in the vicinity of an incident or scene prepositioned storage site where arriving emergency vehicles, personnel, equipment and accompanying supplies are reassembled and prepared for onward movement. Casualty Clearing Area – is the area at the scene of an incident which is the part of the casualty evacuation chain to facilitate movement of casualties from the inner cordon, before transferred on to the health facilities. Survivor Reception Area - All uninjured survivors will be directed to the area where details are collected this ensures a record of everybody involved in such incident or scene is kept. Tiers of Command in Scene Management (Command levels) are: Gold Level (Strategic) – is usually located at remote into necessarily within the scene or incident area, it represents the highest level of command for the incident. It involves the local authorities’ administrative powers and decision making on how to manage the scene or incident with resources. Silver Level (Tactical) – is the outer cordon area is the entire scene within the incident with all responding agent’s representation. It gives all tactical approaches on operations and rescue. The outer cordon is established in order to prevent anybody who is not involved in responding to the incident to keep away from the site for their own personal protection and also to allow the responding services the necessary space to carry out their duties effectively. Bronze Level (Operational) –is the inner cordon area is the area of immediate hazard and casualty rescue. Only those personnel who are responsible for immediate rescue operations enter this cordon area and keeping record of who goes in and out of it. Each command level has a Leading Commander at each cordon. PROCEDURES RECEIVING AN ALARM / EMERGENCY CALL RESPOND TO THE SCENE / INCIDENT AREA(Maintain scene control, Initiate response actions/plans, Ref info & sources) SAFETY MEASURES FIRST(Personal, Scene, Casualties) INIATE OTHER EMERGENCY SERVICES FROM EOC / CONTROL CENTRE(Police, Army, Local Authorities etc) REPORT THE INCIDENT IN 5 –W`s sequence (WHO,WHERE,WHAT HAPPENED,WHEN,HOW) PROTECT YOURSELF FROM HAZARDS – P.P.E (Helmets, Filter masks, Chemical respirator's, Aprons, Clinical suits, Safety boots etc). PROCEDURES cont.` Ensure; TRIAGE,PRIMARY ASSESSMENT,SECONDARY ASSESSMENT & TRANSFER TO DEFINITIVE CARE FLEET MANAGEMENT(Bikes,Motorcycles,Vehicles,Air Ambulances) DEPLOY RELIABLE EQUIPTMENTS/ MONITORS COMMAND POST / CASUALITY HOLDING POINTS RECORDS FOR POST-INCIDENT DEBRIEF SCENE ORGANISATION The following three elements of immediate incident control are; Confirm – the nature if the incident and any hazards. Clear – the area of bystanders and walking casualties. Cordon – the area to control crowd / unauthorized entries and prevent further casualties. MASS CASUALTY INCIDENTS A Mass Casualty incident is one that, because of the number and severity of live casualties, properties damaged or its location, requires special arrangements to be implemented by the Local / Emergency Services authorities. Factors for consideration are: Available resources ( man-power, equipments and financial support). Number of casualties and types of injury. Location and distance from definitive care hospitals. Accessibility. Possibility of further incidents happening RESPONSE TEAMS IN TANZANIA TRAIN ACCIDENT RESPONSE TEAMS FIRST RESPONDER ASSESSING VICTIMS IDENTIFICATION OF VICTIMS UNIVERSAL PRECAUTIONS Before beginning the scene assessment, always consider the need for universal precautions. “Your Primary responsible is your own Safety”. Protect yourself from possible injuries and blood / fluids contamination. Wear protective Gloves (how to put them on and take them off without contaminating yourself). Wear Goggles – for eye protection. Wear filter masks – prevent smoke / fumes inhalation. Wear Helmets – protection for possible head injuries. METHANE REPORT M– My call sign, or name and appointment. (Major Incident Standby & Declared ) E– Exact Location. T– Type of Incident. H– Hazards, Present & Potential A– Access to scene and exit route. N– Number & Severity of causalities. E– Emergency services, present and required. LEVELS OF INCIDENT COMMAND GOLD SILVER BRONZE STRATEGY TACTICS OPERATIONAL TASKS OF COMMAND STRUCTURE GOLD What we intend to do SILVER How we intend to do it BRONZE Do it INCIDENT AREA - 1 OUTER CORDEN – GOLD INNER CORDON – SILVER BRONZE TIERS OF COMMAND BRONZE The Bronze area is the area of immediate hazard & casualty rescue. The boundary of the Bronze area is the inner Cordon. Each department / Service provider may designate a Bronze Commander. There can be more than 1 Bronze area ( and set of Bronze Commanders) within an incident. INCIDENT AREA - 2 OUTER CORDEN – GOLD INNER CORDON – SILVER BRONZE TIERS OF COMMAND SILVER The Silver area is the entire scene. The boundary of the Silver area is the Outer Cordon. Each department / Service provider will provide Silver Commander. There is only one Silver area for an incident (Exception, for example earthquake with multiple “Major Incidents”) INCIDENT AREA - 3 OUTER CORDEN – GOLD INNER CORDON – SILVER BRONZE TIERS OF COMMAND GOLD Gold represents the Highest Level of Command for the incident. Gold is remote from the scene. Gold maybe identified by a Local Authority, Regional, State or National Boundary. SCENE ORGANISATION + ----------------- (OFFSCENE MARSHALLING AREA) ENTRANCE MEDIA / LIAISON POINT Ambulance Parking Area SILVER AREA Command Post Incident Commander Patients INNER CORDON Casualty Clearing Station BRONZE INCIDENT Survivors’ Reception Survivors EXIT Area Ambulance Loading Point RESPONSIBILITIES OF THE HEALTH WORKER RESPONDER Maintain communication with control/ communication centre Identify and activate the resources as needed Ensure appropriate mobilization of all subsequent resources e.g. Police, Fire & Rescue services, Ambulance service etc. Do not cause a delay in mobilization by treating patients Risk-evaluation Be aware of the potential hazards in large industrial plants, docks, airports, motorways, public offices etc. RESPONSIBILITIES OF THE HEALTH WORKER RESPONDER - 2 The following are main considerations when managing Mass Casualty scenario; Do not become a victim yourself. Address potential safety threats to the crew / fellow workers and patients immediately upon arrival at the scene (Protect the health and safety of all personnel at the scene). Assist the extraction of, triage, treat and stabilize casualties Transport / Evacuate all casualties without delay to an appropriate facility. CODE OF CONDUCT HAVE HIGH PERSONAL STANDARDS Personal hygiene & cleanliness. Personal appearance. Effectiveness & Efficiency Fitness & Health CONDUCT & BEHAVIOUR TOWARDS PATIENTS & OTHERS Honesty – do remember that you’re in a position of trust. Maintain the ethics of patient confidentiality. Always be respectful & avoid over-familiarity. Cooperate with other services, patients relatives/friends or others who are concerned. Liaise with emergency services. Sense of responsibility - Self discipline. - Maintain a record of events. - Be identifiable – distinctive clothing (Reflective Jackets) - Be in a safe & Prominent position. - Have access to reliable communication REMEMBER At first there can be a great deal of confusion at a Mass Casualty Incident. How quickly, order and efficiency are established may depend on your prompt response and strict adherence to instructions given. Finally remember that ; MAINTAIN CALMNESS,EARLY STABILIZATION / EVACUATION AND RAPID TRANSFER TO HOSPITAL IMPROVES OUTCOME OF CASUALITIES. Introduction to TRIAGE : It is conducted to facilitate identification of injured persons according to their severity to ensure that they are transported to an appropriate hospital or trauma center. It also minimizes scene time for rapid assessment of casualties and prioritizes transportation requirement and treatment. At the end of this lesson learners will be able to: • To learn categories and color’s codes of TRIAGE • To understand need to perform Triage Definition of Terms in TRIAGE: Mass Casualty – is any incident in which emergency medical services resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties. Evacuation – is an operation whereby all or part of a particular population is temporarily relocated, whether individually or in an organized manner, from an area in which a disaster or emergency is imminent or has occurred. Priority – the state or quality of being earlier in time,occurrence,order,ank etc. Triage Sieve - is a tag which first responders and medical personnel use during a mass casualty incident with the aide of the triage tags, the first-arriving personnel are able to effectively and efficiently distribute the limited resources and provide the necessary immediate care for the victims until more help arrives. Categories for Triage and Color codes: •PRIORITY 1 - Any serious ABCD problem, (Red label, immediate treatment and evacuation). •PRIORITY 2 - No ABCD problem, but potential or actual other serious injury, (Yellow label, urgent but may be delayed treatment and evacuation). •PRIORITY 3 – Walking wounded, (Green label, non-urgent delayed treatment and evacuation). •PRIORITY 4 – Dead, no treatment to be evacuated after all injured people cleared (White / Black label). Keep re-assessing and re-triage as necessary as possible. Evacuate and treat patients in strict triage priority order. Need for Triage? • It aids to identify injured persons with potential serious injuries to ensure that they are transported to an appropriate hospital or trauma center. • Minimizing scene time for rapid assessment of casualties and prioritize transportation requirement and treatment TRIAGE TOP PRIORITY 2ND DEAD PRIORITY WALKING WOUNDED EVACUATIONS : Casualty Evacuation should be dynamic, because mode of transport, evacuation priority and final destination will be influenced by triage and treatment decisions. • Extricate, assist and stabilize injured people • Provide ambulances, medical staff, equipment and resources • Establish effective triage points and systems • Provide a central point for medical resources • Provide communication facilities • Alert receiving hospitals • Provide transport for medical teams and their equipment • Arrange transport for injured people • Make a flood kit: medications, warm clothing, sealed food, blankets, matches, candles, flashlights, portable radio, spare batteries, rubber gloves, personal documents etc.