Beyond the Basics: Five Pitfalls in Medical Incident Management

CEU Review Form Five Pitfalls in Medical Incident Management (PDF)Valid until April 6, 2007

     In the past, mass-casualty incidents described as plane or bus crashes or other similarly devastating events were taught at the end of an EMT class.

     Current events highlighting terrorist incidents and natural disasters have changed our perspective on both the type and probability of incidents we are likely to encounter. This continuing education article discusses some of the overall considerations of managing incidents involving multiple patients from both medical and operational standpoints.

Case Study (Part 1)
     Your ambulance is dispatched to a motor vehicle collision in a neighboring district. En route you are advised by the local fire department that a small pick-up truck has collided with a cement truck.

     Upon arrival at the scene, you approach the incident commander, who reports, "Four people were in the pick-up; they are standing there against the guardrail." You look over at the four lined up against the guardrail: two men and their two sons. As part of a two-person crew, you ask the chief to call for additional help. "I don't think they're hurt that bad," he says.

     Looking at the mechanism of injury, you observe that the cement truck collided with the driver's side front of the truck in what was fortunately a glancing blow. While there is considerable impact, it could have been much worse.

     You walk to the patients with a feeling in your gut that something just isn't right...

1. Small Incidents Can Cause Big Problems
     That gut feeling should be telling you that you need more help. This feeling underscores one of the biggest misconceptions in multiple-casualty incident management: that you need a huge incident to use the incident command system and principles of triage. In fact, the three- to 10-person incident can cause considerable stress on most EMS systems.

     One big problem is that many responders define an MCI as a mass-casualty incident, implying a major disaster, while the simplest definition of an MCI is actually a "multiple-casualty incident" that can't be handled with readily available resources. The collision scene discussed above could likely be easily handled by an urban or suburban EMS system-assuming units were available. Rural systems may only have one or two available ambulances, with the next available unit more than 30 minutes away.

     Traditionally, and from the EMS standpoint, there are three broad levels of multiple-casualty incidents:

• Level 1: 3-10 patients
• Level 2: 11-25 patients
• Level 3: more than 25 patients.

     From a strictly EMS perspective, our response level to an incident will depend on the number of patients.

2. Not Calling Early/Not Calling for Enough HELP
     Even when we realize that an incident is a multiple- (not mass-) casualty, two major pitfalls are not calling for help early and not calling for enough help.

     A tenet in MCI management is that the size-up sets a foundation for how the remainder of the call will progress (see Table I). Rushing or tunneling in prevents adequate size-up and causes cracks in that foundation. Key components of sizing up the multiple-casualty incident include:

• Number of patients
• Begin or direct triage activities
• Nature of the incident

• Hazards (fire, natural disaster, hazmat, CBRNE)

• Entanglement or access issues.

     When determining the number of ambulances needed for a multiple-casualty incident, a general rule is:

• Level 1 (3-10 patients): 2-5 ambulances minimum

• Level 2 (11-25 patients): 5-10 ambulances minimum

• Level 3 (25+ patients): >10 ambulances, plus alternative transportation (e.g., school bus).

     Most commonly, the number of patients and the severity of each are the deciding factors for how many ambulances are needed. In smaller incidents, the number of ambulances needed may be increased by patients who request transport to different hospitals. Incidents involving violence or highway collisions may require additional ambulances to avoid combatants or intoxicated drivers being transported with victims.

     Remember that you will also need to cover your jurisdiction in the event of other emergencies. Murphy's Law will almost always guarantee this additional strain on the system.

Case Study-Continued
     You approach the four patients. The first complains of neck pain, and c-spine stabilization is being held by a firefighter. His 11-year-old son is next in line. As you approach, he vomits copious quantities of barely chewed SpaghettiO's with hot dogs. He has no complaints (and, in fact, suddenly feels better). The third patient, also an 11-year-old boy, has lower back pain. The father of patient #3 says he is "OK. Just take care of my boy."

     As the case study develops, additional flaws are evident. In this call, a real-life incident, the lack of meaningful triage continues the recipe for disaster.

     A new paramedic on the crew believes that patient #2 (vomiting-SpaghettiO's boy) probably has a head injury; his experienced partner thinks he is more likely simply overwhelmed by the accident. Regardless of the outcome of their speculation, the triage process here was virtually nonexistent.

3. Triage, Triage, Triage
     The triage process will differ depending on the nature of the incident. A two-vehicle MVC may simply entail an "I'll check this car, you check the other" approach, then comparing notes to determine the number of injuries and severity. Larger incidents will require a more formal triage plan with a designated triage officer and tagging system.

     Following are practical recommendations for successful triage:

• Initial triage is quick and functional. Triage will continue in other settings, including the treatment area, ambulance and hospital.

• Triage involves difficult decisions. Be prepared to do the greatest good for the greatest number of patients.
• The time you spend with any one patient must be limited.
• Triage must include tags or another marking device (e.g., tape). When there are more patients than on-scene crews can handle, patients must be tagged for continuity and to prevent unnecessary, confusing and time-consuming re-triage.
• The most common error in triage is to classify patients as more severe than they actually are. Become familiar with your triage criteria. A popular triage system, START, uses three components: respirations, circulation and mental status.

Case Study-Conclusion
     After realizing you are in over your head, you tell the incident commander you are requesting two additional ambulances, with the philosophy that you would like one more than you expect to need-just in case.

     You end up with three backboarded patients: #s 1, 3 and 4. Spaghetti-O's boy was uninjured. The most serious was patient #4, who was taken to a trauma center with suspected internal bleeding. The other ambulances were used to transport the two remaining immobilized patients to the community hospital.

     A follow-up critique of the call revealed several areas for improvement. Additional help should have been requested immediately. Triage was not really triage. A simple scan of chief complaints or signs and symptoms is not the most efficient method of determining severity. Using more objective indicators like pulse, skin color, temperature and condition, and mental status, along with the complaint, would have likely identified latent shock in the most serious patient.

4. Large Incident Logistical Problems
     While the case study in this article focused on the pitfalls of smaller incidents, large incidents are not without problems. In large incidents, the logistical issues often cause the greatest headaches.

     In terms of manpower, the issue at larger incidents is sometimes the abundance of personnel rather than the scarcity. With abundance comes issues like freelancers-those who jump into the system without direction-and appropriate staging and assigning of rescuers to appropriate tasks.

     Access to and egress from the scene can also be problematic. If too many vehicles crowd the scene, ambulances may be blocked from leaving. Create an appropriate staging area and flow of vehicular traffic to and from the scene.

     Depending on the size of the incident, additional sectors will be required. In smaller incidents (e.g., MVC with entrapment), an EMS command officer (to coordinate EMS response and interact with other agencies) and possibly a triage officer will be utilized.

     Incidents greater than Level 1 usually necessitate triage, treatment and transport officers. Level 2-3 MCIs require safety and staging officers.

     As a general rule, if you aren't able to move every patient immediately from the scene to an ambulance, you will need a treatment sector to stage patients for care and prioritize subsequent transportation. There should be no delay in transporting patients when ambulances are available and waiting.

     Weather conditions must be considered when setting up a treatment area, as shelter from temperature extremes may be necessary. Again, the treatment area should never delay transport.

     The transportation officer has several important tasks, some of which aren't evident until the incident is almost over. In addition to determining hospital availability, coordinating patient transport and notifying hospitals about the patients they will receive, the hidden value of the transport officer is record-keeping. Not long after the first wave of patients leaves the scene, the police will ask where a suspected perpetrator was taken, or concerned relatives will want to know where a loved one was transported. It will be the organized transport officer who will put out these secondary and time-consuming "fires."

5. Lack Of Practice
     How many ambulances carry sealed or taped-shut MCI kits? This is usually done because items inside will be lost (or stolen) if not secured. Unfortunately, this creates a situation where providers get their first look at the contents of the triage kit at a major incident.

     Using a sports analogy, "People will play the game the way they practice." It is vital to keep the concepts of incident command and triage fresh. There are several ways to do this without the major MCI drills where most participants only get to play one part.

• Bottle drills

     Using several two-liter soda bottles, stick-on labels and colored tape, triage can be easily and effectively simulated on the floor in the equipment bay (described in Educator's Corner in the July 2006 issue of EMS Magazine).

Tag days

     One EMS system assigns one day a month as a "tag day," when all patients transported get a triage tag-regardless of their problem. Rotating days over a year gets all providers used to filling out triage tags before the pressure is on.

• Treat the little ones as big ones

     Consider any call with three or more potential patients as an MCI, even if they won't all be transported. Keep an EMS command vest in the cab of all ambulances, and wear it in these situations. It will help put you in the frame of mind before the big one happens, and get your police and fire departments used to seeing it on calls.

     Multiple-casualty incidents aren't particularly common. We are quick to dismiss them as "mass-confusion incidents" without taking steps to make the next one better. It is our hope that this practical primer will help your next MCI function more smoothly.

CEU Review Form Five Pitfalls in Medical Incident Management (PDF)Valid until April 6, 2007

The authors thank Jonathan Politis, MA, NREMT-P, Chief of Colonie, NY, Emergency Medical Services, for information obtained in his EMS Incident Command Course.

;Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME, and EMS Program Coordinator at York County Community College in Wells, ME. He is the author of several EMS textbooks and a nationally recognized lecturer.

Joseph J. Mistovich, MEd, NREMT-P, is a professor and chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, OH, and a nationally recognized lecturer.

Brian K. Bugbee, NREMT-P, is a flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, OH.