To protect personnel while accomplishing triage, EMS leaders should consider that large-event supply packs include a box of extra gloves, goggles, gowns and masks, and a box that includes triage cards, MCI vests and signage, and a set of MCI management worksheets.
Responders must be prepared for an event that represents an ongoing threat to them or the public. The recognition of continuing risk is now obvious in events involving explosives. There can be secondary explosive devices. Law enforcement and fire personnel will have to be responsible for identifying areas where those devices may be located, and areas that, at least for a short time, can be used for triage and treatment. EMS personnel may be asked to move patients out of high-risk areas, maybe even using sheets or tarps.
Equally important is identifying risks from ongoing structural instability and moving rescuers and victims away from them. If building parts are still coming down, high winds are still blowing or exhaust is still coming from a defective furnace, the risks are escalating, and the victims and rescuers must be moved. If an event is a result of chemical, biological or radiologic hazards, it will also be necessary to evacuate outside any hot zone.
Proper use of PPE is integral to approaching unsafe scenes. Regardless of the risks, EMS workers should be confident that their lives and the well-being of their families will be protected. That must begin with a day-to-day use of proper turnout gear, personal protective equipment, education, and all tools to mitigate risks for EMS workers.
The most difficult issue in coordinating a major incident response, especially a terrorism incident, is how to establish and maintain effective communications. The first priority is to minimize damage at the original scene, perform a safe operation, involve law enforcement and activate the next level of providers needed.
Communication systems must be established quickly. The first priority is establishment of Incident Command and communication systems that link public-safety providers and the dispatch/9-1-1 center. Some communication will occur face-to-face at the scene. This was facilitated in Boston by the presence of all the providers, in identifying vests, at the scene in a pre-established structure. Those providers changed their roles to respond to the bomb incident, and added the next layers of fire, medical and transportation resources. Hospitals were notified so they could deal with the first-arriving victims, who always arrive by foot or car ahead of the first ambulances.
One important note on communication systems that comes from recent bomb incidents: The EMS plan cannot rely on cellular phones for critical communications. Law enforcement may decide at a bombing incident to shut down the cellular phone network in the immediate area to mitigate the risk of secondary devices activated by cell phones. EMS providers, unless their phones are specifically equipped, will not be able to use their phones in the area.
Quickly following a terrorist incident, prehospital and hospital-based emergency providers must agree on medical management strategies for victims. If it is determined that safe care can be delivered away from the hospital, field treatment without transportation may be instituted. Supplies needed for field care may be delivered to areas near the incident scene or to community collection points where victims are directed to seek care. Transportation to hospitals may be reserved for only those meeting certain triage criteria. Planning activity by hospitals will need to cover the potential to “lock down” and secure a hospital in the event it could become a target, either intentionally or unintentionally. Hospitals need plans to secure themselves with minimal law enforcement assistance, as the community’s initial complement of law enforcement may be committed to scene activity.