Detailed Lesson Plan

Chapter 44

Multiple-Casualty Incidents and Incident Management

100–120 minutes

Chapter 44 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes / Content Outline / Master Teaching Notes
5 / I.Introduction
A.During this lesson, students will learn about the roles and responsibilities of an EMT during a multiple-casualty incident.
B.Case Study
1.Present The Dispatch and Upon Arrival information from the chapter.
2.Discuss with students how they would proceed. / Case Study Discussion
  • What principles guide the management of multiple-casualty incidents?
  • By what criteria are decisions regarding patient care and transportation made?

5 / II.Multiple-Casualty Incidents
A.Definition
  1. Places excessive demands on personnel and equipment
  2. Involves three or more patients
B.Examples
  1. Motor vehicle crashes
  2. Gang-related violence
  3. Apartment fires
  4. Food poisoning
  5. Toxic gas inhalation
  6. Refugee influx
C.Management
  1. Call for enough (or more than enough) help.
  2. Position vehicles properly.
  3. Give appropriate emergency medical care.
  4. Transport patients efficiently.
  5. Provide follow-up care at receiving facilities.
/ Teaching Tip
Discuss events that have led to MCIs in your community and the events that your community includes in its disaster plan.
Discussion Questions
  • What events (local, state, or national) can you recall that would be classified as MCIs?
  • Why is the number of patients that define an MCI different in different locations?
Critical Thinking Discussion
What should you include in a personal disaster preparedness plan for yourself and your family?
Weblink
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource on CDC information about mass-casualties.
20 / III.National Incident Management System—Incident Command System
A.National Incident Management System (NIMS)
  1. Established by federal government in 2003
  2. Provides for consistent approach to managing a disaster
  3. Governs Incident Command System (ICS)
  4. Provides for flexibility and standardization in managing disasters
  5. Compliancy with NIMS required by all EMS agencies in USA by 2006
  6. Special NIMS training ensures that all responders do the following.
  1. Comprehend and employ the same terminology
  2. Have the same knowledge of ICS
  1. Components of preparedness standardization
  1. Planning
  2. Training
  3. Mutual aid agreements
  4. Preparedness exercises involving multiple response agencies
  1. Purposes of preparedness standardization
  1. Lessen confusion as to who is in charge
  2. Foster working interdepartmental relationships
  3. Provide responders with experience in IMS
B.Incident Command System (ICS)
  1. Purposes
  1. Safety of emergency responders and others
  2. Achievement of tactical objectives
  3. Efficient use of resources
  4. Features
  1. Common terminology, standardization of titles, plain English for communications
  2. Common designations for all organizational resources
  3. Manageable spans of control
  4. Common terminology for incident facilities
  5. Distinct titles to designate each person’s position and responsibilities
  6. Action plans that identify objectives to be accomplished
  7. Integrated communications approach
  8. Accountability at all levels; orderly chain of command
  9. Sections
  1. Command
  2. Finance/administration
  3. Logistics
  4. Operations
  5. Planning
  6. EMS responsibilities
  1. Triage unit
  2. Sorts patients by how critical their condition is
  3. Assigns priorities for emergency care and transport
  4. Treatment unit—Provides emergency care to patients
  5. Transport unit
  6. Moves patients to ambulances or helicopters for transport
  7. Notifies receiving medical facilities
  8. Staging unit
  9. Holding area for ambulance, helicopters, additional equipment
  10. May include a supply unit for distribution of supplies and equipment
  11. Morgue unit—Holding and processing area for corpses
/ Teaching Tip
Discuss local ICS configurations.
Discussion Question
What is the purpose of NIMS?
Knowledge Application
Student should be able to apply the principles in this section in order to operate within an ICS.
Critical Thinking Discussion
What is the best way to be prepared to function well in an MCI?
Discussion Questions
  • What is the purpose of ICS?
  • What features are designed to make ICS effective?
Weblink
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a link to the NIMS resource center.
Discussion Question
What responsibilities does each of the typical EMS units in an ICS system carry out?
5 / IV.Triage—Primary and Secondary Triage
A.What triage determines
  1. Who needs immediate emergency care in order to survive
  2. Who will survive if emergency care is delayed
  3. Who will die regardless of emergency care provided
B.Primary triage
  1. Occurs immediately upon arrival of first EMS crew
  2. Conducted at actual site of incident
  3. Patients are tagged with different colors to show priority of care.
  4. Red: immediate care and transport (Priority 1)
  5. Yellow: delayed emergency care and transport (Priority 2)
  6. Green: minor injuries and ambulatory patients (Priority 3)
  7. Black: deceased or fatally injured (Priority 4)
  8. Provides initial report back to EMS command
C.Secondary triage
  1. Conducted in triage unit
  2. Reevaluates patient priority assigned during primary triage
/ Teaching Tips
  • Discuss local triage practices.
  • Discuss the capabilities of local hospitals.
  • Discuss mutual aid agreements in place for cooperation among jurisdictions.
Discussion Question
How do responders use primary and secondary triage?
Knowledge Application
Students should be able to apply the principles of triage while working within an ICS.
Class Activity
Hold an MCI drill or, if this is not feasible, do a tabletop triage exercise with students.
15 / V.Triage—START Triage System
A.START (Simple Triage and Rapid Transport System)—Background
  1. Allows for rapid categorization of patients
  2. Recommended for adult patients
  3. Can be used for child patients over the age of eight who weigh at least 100 pounds
  4. Should not take more than 30 seconds per patient
  5. Three basic categories—RPM
  6. R—respiratory status
  7. P—perfusion status
  8. M—mental status
B.Patients able to walk (ambulatory or “walking wounded”)
  1. Collect ambulatory patients and move to a safe area.
  2. Tag these patients green (low priority for emergency care and transport).
  3. Make sure that patients do not wander but remain in the assigned safe area.
  4. Treat and transport these patients last.
C.Nonambulatory patients—Respirations
  1. Look, listen, and feel for respiratory efforts.
  2. If respiratory rate is greater than 30/minute, tag the patient red and move on to next patient.
  3. If respiratory rate is less than 30/minute, assess perfusion (see below).
  4. If patient is not breathing, open the airway.
  5. If patient begins to breathe at a rate greater than 30/minute, tag red and move on.
  6. If patient begins to breathe at a rate less than 30/minute, assess perfusion.
  7. If respiration is shallow and inadequate and requires assistance, tag red and move on to next patient.
  8. If patient does not breathe after you open airway, tag black (deceased) and move on.
D.Nonambulatory patients—Perfusion
  1. Assess capillary refill and radial pulse.
  2. If capillary refill is greater than two seconds and radial pulse is present, assess mental status.
  3. If capillary refill is greater than two seconds or radial pulse is absent, tag patient red and move on to next patient.
  4. Keep in mind that capillary refill time varies; therefore, radial pulse may be a more accurate indicator of perfusion.
E.Mental status
  1. If patient obeys a command to squeeze your fingers, tag him yellow and move to next patient.
  2. If he is not alert, does not obey command, or is unresponsive, tag red and move on.
/ Discussion Question
How do you perform START triage?
Weblink
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource on START.
15 / VI.Triage—JumpSTART Pediatric Triage System
A.Background of JumpSTART
  1. System developed specifically for pediatric patients
  2. Should be used on any patient who appears to be a child (as opposed to a young adult)
  3. Not designed to be used on infants less than 12 months old
  4. Uses different rules from START because of physiological differences between children and adults
  5. Should take no more than 15 seconds per patient
B.JumpSTART ambulatory
  1. If child can walk, tag him green and escort him to safe area.
  2. If child is developmentally unable to walk but does not meet “immediate” criteria, tag him green and escort him to safe area.
  3. If special-needs child does not meet “immediate” criteria, tag him green and escort to safe area.
C.JumpSTART breathing assessment
  1. If child is breathing between 15 and 45 times per minute, assess the pulse.
  2. If child is breathing fewer than 15/minute, more than 45/minute, or at an irregular rate, tag red and move on.
  3. If child is not breathing or breathing very irregularly, open the airway.
  4. If opening the airway causes child to begin breathing normally, tag red and move on.
  5. If child does not start breathing when you open the airway, check for peripheral pulse.
  6. If there is no peripheral pulse, tag black (deceased) and move on.
  7. If there is a pulse, provide 15 seconds of mouth-to-mask ventilation.
  8. If patient does not begin breathing after ventilation, tag black and move on.
  9. If patient begins breathing after ventilation, tag red and move on.
D.JumpSTART perfusion assessment
  1. If peripheral pulse is palpable, assess mental status.
  2. If no peripheral pulse is present, tag red and move on.
  3. Check pulse in the least-injured extremity.
E.JumpSTART mental status assessment
  1. If child is alert, responds to your voice, or responds to pain by localizing, withdrawing, or pushing away, tag yellow and move on.
  2. If child does not respond to stimuli, or responds inappropriately, tag red and move on.
/ Discussion Question
How is JumpSTART different from START?
5 / VII.Triage—Patient Tagging
A.Highest priority (immediate)
  1. Red tag
  2. Patient with critical injuries who may survive with quick treatment and transport
B.Second priority (delayed)
  1. Yellow tag
  2. Patient suffering severe injuries who will have a good chance of survival with some delay in treatment
C.Lowest priority (minor)
  1. Green tag
  2. Delay in treatment will not reduce patient’s chance of survival.
  3. Examples of green-tag injuries: fractures and soft-tissue injuries
D.Deceased
  1. Black tag
  2. Fatally injured patient (no chance of survival) or dead person
/ Teaching Tip
Show students the triage tags used in your system.
Discussion Question
How can you classify patients according to the red, yellow, green, and black color triage system?
5 / VIII. Triage—Treatment
A.Treatment unit characteristics
  1. Close to the area where ambulances arrive
  2. On high ground
  3. Covered and lit if possible
  4. Safe from falling debris
  5. Safe distance from incident
  6. Clearly marked (with a tall flag if possible)
  7. More than one treatment unit may be needed.
B.Treatment unit procedures
1.Immobilize all patients before moving to treatment unit.
2.Group patients according to triage category.
3.Treat only salvageable patients.
4.Provide only necessary care to manage life-threatening injuries.
5.Treat highest-priority (red-tag) patients first and second priority (yellow-tag) next.
6.Remain in constant touch with triage and transport unit leaders.
5 / IX.Triage—Staging and Transport
A.Staging unit—Monitors, inventories, and directs ambulances to treatment unit as needed at the request of the transport unit leader.
B.Transport unit
  1. Responsibilities
  2. Ensure that ambulances are accessible.
  3. Follow orders from incident commander or operations section chief.
  4. Coordinate patient transportation with triage unit.
  5. Communicate with hospitals involved.
  6. Considerations in making transport decisions
  7. Distribution of patients to each medical facility
  8. Surge capacity of each medical facility
  9. Need for transport to a specialty facility (burn unit, pediatric emergency department)
  10. Need for constant communication and coordination
  11. How to transport efficiently and effectively
  1. Begin to transport highest-priority patients first, as soon as they are stabilized.
  2. Distribute these patients evenly among available hospitals.
  3. Give EMTs specific orders on which route to follow and where to take the patients.
  4. Provide EMTs with maps of the area if necessary.
  5. Radio the hospital that the ambulance is en route; describe the injuries; estimate time of arrival.
  6. Consider loading ambulatory patients onto a bus for transport, with five to ten EMTs and their equipment aboard.
  7. Ambulance can escort bus to hospital.

2 / X.Triage—Communications
A.Be prepared for a variety of communication difficulties.
B.Radio communications may be difficult due to “dead spots,” frequency unavailability, and channel “gridlock.”
C.ICS and mobile command center should help to reduce difficulties.
D.Use plain English for all communications.
3 / XI.Triage—Follow-Through
A.At the scene—Incident manager and assistant supervise clean-up and restoration.
B.At the hospital
  1. Obey instructions of facility’s incident manager.
  2. If your help is not needed
  3. Prepare your vehicle and equipment for the next EMS call.
  4. Update dispatch center about your status and availability.

5 / XII.Triage—Reducing Posttraumatic and Cumulative Stress
  1. Try not to get overwhelmed by the overall picture of the incident; instead, follow the steps outlined in this chapter to gain control and feel that you are making progress.
  2. Instruct each worker to leave the hub of the disaster for rest and food at regular intervals (such as once every one to two hours).
  3. Rotate rest periods so that enough workers are on duty at all times.
  4. Ensure that each worker understands his specific responsibilities.
  5. Monitor workers; if anyone appears to be in trouble, give him a rest period, then assign him a less stressful task.
  6. Assign each worker tasks that are appropriate to his skills and experience.
  7. Provide the staffing area with plenty of nourishing food and beverages for the workers.
  8. Encourage conversation among workers as it helps to relieve stress.
  9. Ensure that workers have the opportunity to talk with counselors after the disaster.
/ Discussion Question
What mechanisms should be in place to monitor for, minimize, and manage rescuer stress reactions?
Critical Thinking Discussion
What should you do if you feel overwhelmed when working at the scene of an MCI?
Weblink
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource for emergency workers.
5 / XIII.Disaster Management—Requirements of Effective Disaster Assistance
  1. Preparation of the entire community: lay persons trained in basic life-supporting first aid and simple rescue procedures
  2. Careful preplanning
  3. The ability to implement a plan quickly
  4. Effective communications among responders
  5. The application of triage skills
  6. The ability to organize quickly and utilize fully all emergency personnel
  7. The ability to adapt the plan to special conditions
  8. A contingency plan for shelter and transportation if an area must be evacuated
  9. Doing the greatest good for the greatest number of people
  10. A plan that avoids simply relocating the disaster to the hospital
/ Teaching Tip
Discuss the response to any disasters that have occurred in your area.
Critical Thinking Discussion
  • How can you promote disaster preparedness in your community?
  • What type of disasters should you anticipate in your community?

5 / XIV.Disaster Management—Warning and Evacuation
  1. Conduct an orderly evacuation if you have advance warning of a disaster (such as a flood).
  2. Keep evacuees in their natural social groupings as much as possible.
  3. Repeat evacuation warnings often and with clarity.
  4. The nature of the disaster
  5. Time that it will impact the area
  6. Description of expected severity
  7. Safe routes to take out of the area
  8. Appropriate destinations for evacuees
  9. Where evacuees can find food and shelter
  10. Use all possible means to spread the warning message.
  1. Radio
  2. Television
  3. Roving police cars with loudspeakers
  4. Public address systems in buildings
  5. Short-wave radios
/ Discussion Question
What types of events can be considered disasters?
5 / XV.Disaster Management—Disaster Communications Systems
  1. Establish details of communications system ahead of time as part of disaster drill.
  2. Appoint one person at scene to be in charge of all communications to the outside.
  3. This person must have appropriate equipment to stay in touch with local hospitals and rescue units.
  4. Area-wide communications are vital to provide warnings and other essential information.
  5. Establish a central registry to record personal information (such as location, health status, and safety).
  6. Monitor and communicate information regarding road conditions, alternate routes, and closed roads.
  7. Monitor and link all hospitals, trauma centers, and clinics in the area.
  8. Do not allow EMTs or drivers to radio hospital en route except in an emergency.
  9. Provide rescue workers with portable radios to use on site.
  10. Record crucial communications for later reassessment.
/ Discussion Question
What principles of communications should you apply in disaster situations?
10 / XVI.Disaster Management—The Psychological Impact of Disasters
  1. Common reactions
  2. Adults
  3. Fear
  4. Shakes
  5. Sweat
  6. Confusion
  7. Irritability
  8. Anxiety
  9. Restlessness
  10. Fatigue, disturbed sleeping patterns, nightmares
  11. Difficulty concentrating
  12. Moodiness and suspicion
  13. Depression
  14. Nausea, vomiting, diarrhea
  15. Reactions to surviving
  16. Fear
  17. Anxiety
  18. Anger
  19. Guilt
  20. Shock
  21. Depression
  22. Denial
  23. Feelings of isolation
  24. Vulnerability
  25. Children and young people
  26. Preschoolers
  27. Crying
  28. Loss of bowel/bladder control
  29. Confusion
  30. Thumb-sucking
  1. Elementary-school age
  1. Extreme fear
  2. Confusion
  3. Depression
  4. Headache
  5. Inability to concentrate
  6. Withdrawal
  7. Poor performance
  8. Aggressiveness against peers
  1. Preteens and adolescents
  1. Same reactions as elementary-school age
  2. Extreme aggression
  3. Severe stress
  1. Helping disaster patients
  2. Disseminate information to patients’ families as soon as possible.
  3. Reunite families as soon as possible.
  4. Group patients with their families and neighbors.
  5. Encourage patients to help with necessary chores when they are able.
  6. Assure the patient that his reactions are normal and that he will probably recover rapidly.
  7. Explain clearly exactly what you expect of a patient (such as “Let’s walk to the treatment unit”).
  8. Encourage patients to talk about the disaster, ideally in groups.
  9. Don’t give anyone any false assurances.
  10. Encourage unwilling patients to accept help; assure them this is not a sign of weakness.
  11. Identify high-risk patients and target for immediate crisis intervention care.
  12. The elderly
  13. Children
  14. The bereaved
  15. Those with prior psychiatric illness
  16. Those with multiple stresses
  17. Those with low or no support systems
  18. Those from low socioeconomic backgrounds
  19. Those with severe injuries
  20. Recruit anyone who is in a unique position to help people in need.
  21. Arrange for all those involved (including rescuers) to get good follow-up care and support.
/ Discussion Question
What is the psychological impact of disasters?
Knowledge Application
Students should be able to apply the information in this chapter to the psychological care of disaster patients.
Video Clip
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a video on children during disasters.
Discussion Question
What can the EMT do to minimize the psychological impact of disasters?
10 / XVII.Follow-Up
A.Answer student questions.
B.Case Study Follow-Up
  1. Review the case study from the beginning of the chapter.
  2. Remind students of some of the answers that were given to the discussion questions.
  3. Ask students if they would respond the same way after discussing the chapter material. Follow up with questions to determine why students would or would not change their answers.
C.Follow-Up Assignments
  1. Review Chapter 44 Summary.
  2. Complete Chapter 44 In Review questions.
  3. Complete Chapter 44 Critical Thinking.
D.Assessments
  1. Handouts
  2. Chapter 44 quiz
/ Case Study Follow-Up Discussion
What principles of incident management and triage were applied in this case study?
Class Activity
Alternatively, assign each question to a group of students and give them several minutes to generate answers to present to the rest of the class for discussion.
Teaching Tips
  • Answers to In Review and Critical Thinking questions are in the appendix to the Instructor’s Wraparound Edition. Advise students to review the questions again as they study the chapter.
  • The Instructor’s Resource Package contains handouts that assess student learning and reinforce important information in each chapter.This can be found under mykit at

PREHOSPITAL EMERGENCY CARE, 9TH EDITION DETAILED LESSON PLAN 44 PAGE1