ROMEO ALMAZAN BITUIN, MD, MHA Health Emergency Management Staff Coordinator

1. MASS CASUALTY MANAGEMENT SYSTEM ROMEO ALMAZAN BITUIN, MD, MHA Health Emergency Management Staff Coordinator Dr. Jose Fabella Memorial Hospital Department of Health

2. OUTLINE OF PRESENTATION I. Overview of Mass Casualty II. Establishing Mass Casualty Management System III. Field Management IV. Management of Victims V. Transfer Organization

3. QUESTION 1 Define Mass Casualty

4. QUESTION 2 What is a Mass Casualty Management System

5. Overview of Mass Casualty • GLOBAL TREND • 1. Kobe Earthquake, Japan 1995 • 2. Sarin attack in Tokyo, 1995 • 3. New York 911 Tragedy, 2001 • 4. Iraq Crisis, 2003 • Terrorism – WMD • Asian Tsunami • Leyte Landslide, 2006

6. Overview of Mass Casualty WORLDSince 1900% Top 5 hazards by mass accidents 32.8 frequency of wind storm 19.6 occurrence flood 18.0 earthquake 7.5 drought 6.0 83.9 ASIA Top 5 hazards by mass accidents 37.2 frequency of wind storm 19.7 occurrence flood 18.4 earthquake 8.0 epidemic 4.0 87.4 CRED Disaster Data

7. Overview of Mass Casualty Mass Casualty Incident Produces several patients As few as six or as many as several hundred Affects local hospitals Patients are greater than resources of the initial responders

8. Overview of Mass Casualty Pre-planning and training are critical Establish guidelines and procedures Early implementation of Incident Command First five minutes will determine next five hours Preparation for Mass Casualty

9. Overview of Mass Casualty Response Categories for Mass Casualties Mass Casualties can occur in a variety of ways Effect on emergency response and community impact Include transportation, violent crimes and building collapse

10. Overview of Mass Casualty Hazardous materials incidents Civil disturbances Natural disasters Major fires Terrorist attacks Response Categories of Mass Casualties

11. Overview of Mass Casualty Most common being: • Who is in command of the incident • Location of the Command Post • Lack of communication between agencies leading to conflicting priorities and orders Problems in Mass Casualty Incidents

12. Overview of Mass Casualty Problems in Mass Casualty Incidents Perimeter establishment delayed or not done at all Large crowds of people Media involvement Political involvement Inadequate resources

13. Establishing Mass Casualty Management System

14. Establishing a Mass Casualty Management System Any event resulting in a number of victims large enough to disrupt the normal course of emergency and healthcare services Mass Casualty Incident

15. Establishing a Mass Casualty Management System Casualty Management • Management of victim of a mass casualty event • Objective is to minimize loss of life and disabilities

16. Establishing a Mass Casualty Management System Mass Casualty Management System The group of Units, Organizations, Sectors which work jointly during a mass casualty event Based on: - Pre-established procedures - Maximization of use of existing resources - Multi-sectoral preparation and response - Strong pre-planned and tested coordination

17. Establishing a Mass Casualty Management System Different Approaches to MCI 1. “Scoop and Run” 2. Classical Approach 3. Mass Casualty Management System

18. Establishing a Mass Casualty Management System Scoop and Run • Most common • Does not require specific technical ability from rescuers • Justified for small numbers occurring near a hospital • May just transfer problem to the hospital

19. Establishing a Mass Casualty Management System Classical Approach • First responders are trained (basic triage and field care) • Disregard the receiving hospitals from the field • Quickly result to chaos

20. Establishing a Mass Casualty Management System Mass Casualty Management Approach • Most sophisticated approach includes pre-established procedures for: • a. resource mobilization • b. field management • c. hospital reception

21. Establishing a Mass Casualty Management System Mass Casualty Management Approach • Training of various level of responders • Incorporates links between field and health care facilities • Command Post • Multi-sectoral Response • Dependent on the availability of large amounts of human & material resources

22. Establishing a Mass Casualty Management System Problems in Developing MCM • Limited human resources • limited material resources • facility • transport • communication • Poor communication • topography • isolation • Political

23. Establishing a Mass Casualty Management System Activities at various levels of responses: alerting process initial assessment command / control / coordinate manage information search/rescue field care-- mostly health activities transport/traffic control facility reception at ER / A&ED hospital mass casualty mgt. & command system ‘E’/Disaster Site/Scene

24. Establishing a Mass Casualty Management System Field Management Definition: Encompass procedures used to organize the disaster area in order to facilitate the management of victims Components Alerting Process Pre-identification of Field Areas Safety/ Security Command Post Search and Rescue Field Care Evacuation (EMC) Emergency Management Center

25. Establishing a Mass Casualty Management System RESCUE CHAIN---SECTORAL Impact Zone *SEARCH* *RESCUE* *First Aid* Command Post ER or A&ED Triage Stabilization Evacuation Traffic Control Regulation of Evacuation CP / AMP Pre-Hospital Organization Hospital Organization

26. Establishing a Mass Casualty Management System Field Organization Alerting Process Definition: Sequence of activities implemented to achieve the efficient mobilization of adequate resources Aim: - Confirm the initial warning - Evaluate the extent of the problems - Ensure that appropriate resources are informed and mobilized

27. Establishing a Mass Casualty Management System Field Organization Alerting Process Dispatch Center: • Core of the Alerting Process (Operation/Communication Center) • Functions: • receives all warning messages (radio/phone) • mobilize a small assessment team (Flying Team) from police, fire or ambulance services

28. Establishing a Mass Casualty Management System Initial Assessment Precise location of the event Time & type of the event Estimated number of casualties Added potential risk Exposed population Resources needed

29. Establishing a Mass Casualty Management System Pre-Identification of Field Areas Impact Zone Command Post Collecting Area in unstable location Advance Medical Post Area (3-T Principle) Evacuation Area VIP & Press Area (Information Officer) Access Roads (geographical presentations if available) Check point for resources (Staging Area)

30. Establishing a Mass Casualty Management System Safety • Best practice technique to protect victims, responders & exposed population: immediate/potential risk • Measures: • Direct action: • - risk reduction - fire fighting • - contain hazardous material • - evacuation of exposed population • Preventive actions:establish field areas • - primary- impact zone • - secondary- rescue/ICP/AMP • - tertiary-“buffer zone”; tri-media

31. Establishing a Mass Casualty Management System Safety • Personnel: fire services; specialized units hazardous • materials & explosives (bio-nuclear and radioactive materials) experts, etc., airport manager, chemical plant expert

32. Establishing a Mass Casualty Management System Security Measures • Non-interference of external elements: • - crowd/traffic control • Contribute to safety: • protect workers from external influence; additional stress • free flow: victims/resources • protect general public from risk exposure • ensured by police officers / special units (security: airport/building/hospital/establishments, etc..)

33. Establishing a Mass Casualty Management System Command Post ( CP / or ICP) Multi-sectoral control unit to: • Coordinate sectors involved in field/scene management • Linked w/ back-up system: provide information & mobilization resources • Supervise victim management REQUISITE: radio communication network: main criterion to be effective Purpose: coordination / communication hub of people who don’t work routinely (pre-hospital setting) Location: external boundary of restricted area (impact zone) close to AMP/ Evacuation Area/ accessible/easily identified * should accommodate: com./visuals/maps/boards

34. Establishing a Mass Casualty Management System Personnel • High ranking officer (government police, fire, health, defense) - plant manager/ airport manager/ chief security, etc… - fire officer / police officer skilled in ICS / MCM • Identified by name/position, coordinator / commander • May depend on what type of incident • Must be familiar with each other’s roles during previous meetings/ drills/ simulation exercises (policy) • This core group cooperate with volunteer organizations

35. Establishing a Mass Casualty Management System METHOD • The communication / coordination hub of the pre- hospital organization. By constant re-assessment, CP will identify needs to increase / decrease resources: - organize timely rotation of rescue workers exposed to stressful/exhausting conditions in close coordination w/ back-up system - ensure adequate supply of equipment / manpower - ensure welfare / comfort of rescue workers - provide info to back-up system, other officials, and tri-media thru an Information Officer - release as soon as situation allows “E” staff and re- establish normal operations - determine termination of field operations

36. Establishing a Mass Casualty Management System MANAGEMENT OF VICTIMS • Search & Rescue - locate victims - remove victims from unsafe locations – collecting area - assess victim’s status (on-site triage) - provide first aid , if necessary (no CPR on-site in MC Event) - transfer victims to AMP thru entry triage (medical triage) - under supervision of the CP/ IC/ or Commander/Coordinator - may in special situation, require medical personnel (trained) - to stabilize/resuscitate/amputate (trapped) victim before extrication.

37. Establishing a Mass Casualty Management System Management of Victims • Field Care • - Pre-established capabilities / inventory: pre-planning • - Integrated community plan: practiced w/ policy support • - The “Golden Hour” Principle

38. Establishing a Mass Casualty Management System Recent progress in pre-hospital emergency / disaster medicine Establish AMP with specially skilled /trained ---- “disaster field medical teams” - good triage / stabilization capacity - specifically trained / up-skilled medical teams - good (radio) communications between the field scene & medical facility “ Don’t transfer chaos in the scene, to the hospital……”

39. Establishing a Mass Casualty Management System TRIAGE Basis:urgency (victim’s status) survival (chance or likelihood) care resource availability and capability Objectives: Quick identification for immediate stabilization for life-saving (measures) and surgery Levels: On-site–----- ‘where they lie’ Medical ----- at Advance Medical Post Evacuation --- transport

40. Establishing a Mass Casualty Management System On-site T: Acute Non-acute Medical T: Red Yellow Green Black Evacuation T - transport: Red Yellow Green Black Red: transferred as soon as possible to tertiary facilities in an equipped ambulance with medical escort Yellow: after evacuation of Red, without life-threatening problem Green: ‘walking wounded’-to AS/OPD Black: to morgue Forensic Services Public Health & Psycho-Social interventions to relatives/kin

41. Establishing a Mass Casualty Management System First Aid Personnel: • volunteers, fire, police staff, special units, EMT’s, and medical personnel Location: • on-site, before moving victim • at collecting point/ area in an unstable environment. • “Green Area” of “AMP” • ambulance in transit to facility Action: • primarily to transfer with consideration of the ABC’s order of priority

42. Establishing a Mass Casualty Management System Advance Medical Post (AMP) Purpose: • reduce loss of life & limb - save as many as possible in the context of existing & available resources/ situation • victim’s status; chance of survival; resources Location: • 50-100 meters from Impact Zone (walking distance ) • direct access to: Evacuation Road. / Command Post • Clear Radio-Com Zone… and SAFE (Upwind) • tent / bldg / open / mobile field hospital..??

43. Establishing a Mass Casualty Management System Advance Medical Post (AMP) Role: • Provide “entry” medical triage • Effective stabilization for victims of a MCI/Situation • intubation, tracheostomy, chest drainage, • shock mgt , analgesia , fracture immobilization • fasciotomy, control external bleed & dressing • Convert red to yellow category as maybe possible • Organize patient transfer to designated care facility/ties • AMP 3-T principle: Tag – Treat – Transfer…. Personnel: • ER (A&ED), physicians/ nurses (trained & skilled) • support: Anesthetists / Surgeons / EMT’s / Nurses / Aiders, etc.

44. Establishing a Mass Casualty Management System AMP NON-ACUTE BlackGreen RedYellow ACUTE TRIAGE NON-ACUTE C P evacuation ACUTE C P– CollectingPoint

45. Establishing a Mass Casualty Management System COLLECTION AREA (in unstable condition) TRIAGE AREA (color tagging of victims) COMMAND POST TREATMENT AREA (management and stabilization) 1st 2nd 3rd PRIORITY III PRIORITY II PRIORITY I T R A N S P O R T A R E A

46. Establishing a Mass Casualty Management System Field Management Plan: Diagram Traffic Control Working Area Triage Evacuation AMP Impact Zone Command Post Strictly Restricted Restricted Traffic Access Route

47. Establishing a Mass Casualty Management System Transfer Organization • Procedures used to ensure that victims of a MC situation is safely, quickly, and efficiently transferred by appropriate vehicles to the appropriate and prepared facility • Preparation for Evacuation: 1. Single Reception Facility 2. Multiple Reception Facilities * type of vehicle required * type of escort required * destination

48. Establishing a Mass Casualty Management System Transfer Organization • Preparation for Transport Evacuation Officer reporting to ATM: • assess patient’s status: vital signs, ventilation / hemostasis • check security of equipment / & accessories • ensuring efficiency of immobilization measures • ensure triage tags: secure/& clearly visible • Evacuation Procedures: Regulation Principles - not to overwhelm care facility - avoid spontaneous evacuation of unstable patients.

49. Establishing a Mass Casualty Management System Transfer Organization • Evacuation Procedures: Regulation Rules: - victim is in most possible stable condition - victim is adequately equipped for transfer - receiving facility correctly informed and ready - the best possible vehicle and escort– available Victim Flow - “Noria” Principle, Spanish word from Arabic--… ”wheel”WW I Battle of Chemin de Dames, Verdun, France * conveyor belt’ flow from first aid to the most sophisticated care level..

50. Establishing a Mass Casualty Management System Victim Flow : “Conveyor Belt” Management Diagram TriageTreatment 3-T Tag Treat and Transfer Triage Evacuation Impact Zone Collecting Point AMP TRANSFER HOSPITAL Victims FlowTransport Resource Flow