ALS Role at MCI in a targeted system

[cprted]

Hi Gang,

Doing a little research project and I'm curious if there are agencies that have specific expectations as to the role ALS providers fulfill during an MCI event.

I'm looking specifically at non-Fire based and targeted or tiered ALS systems.

Does your agency expect ALS to fill a command role? Clinical? Other?

Do you have specific guidelines for such events or is it more of a cultural precedent/expectation within the agency?

Thanks!

T

 

[DrParasite]

treatment area. that's it.

no other roles requires any ALS education; in fact, having a medic doing initial triage (or any higher level medical authority) tends to include less accurate triage results.

You might put an ALS supervisor at the command post (along with every other white shirt that gets represented), but that's more of an operational thing than a clinical thing.

Think of it this way: for what roles in the MCI would you need advanced ALS education? Looking at an ICS chart, what positions would require advanced medical training? Also, why would I want to tie up a valuable resource such as a paramedic, on a role that isn't' going to utilize his or her paramedic skills?

Treatment sector, under operations, and maybe medial unit under logistics.

 

[EpiEMS]

Also, why would I want to tie up a valuable resource such as a paramedic, on a role that isn't' going to utilize his or her paramedic skills?

Agreed.


Just thinking about it, if it's a "real" MCI (really a lot of patients more than resources) or if the incident is CRBN-related, you probably won't have the kind of time or resources to use much in the way of ALS skills.

 

[Tigger]

treatment area. that's it.

no other roles requires any ALS education; in fact, having a medic doing initial triage (or any higher level medical authority) tends to include less accurate triage results.

Citation?

 

[cprted]

Citation?

I can dig up the citation, but in the research that I've done thus far, the studies I've read have found that providers, regardless of license level or previous experience, apply the START triage algorithm equally inaccurately if they haven't had a refresher course in the past 6 months ...

As a tabletop exercise, I agree completely that from an operational perspective, there is no specific need for the highest trained clinician to assume leadership or command positions (outside of people who already work in a supervisory capacity). In the field at the scene of a short-term MCI (something that lasts a few hours, at most) how has that played out in your experiences? Has anyone encountered operational guidelines or policy that specifically address the role of ALS of CCT providers in MCI?

 

[DrParasite]

Citation?

I don't have the citation readily available (and TBH, I am not going to spend time looking for it), but the reasoning is quite simple: the more educated the provided, the more likely they are to use their own judgement and experience, instead of following the basic Triage algorithm.

For example, if you find a patient who is pale, diaphoretic, with blood coming out of an ear, and is in need of walking assistance during an MCI, are you going to be able to turn off your medic brain and give them a green tag, or are you going to recognize him as a sick patient who needs immediate transport and give him a red tag?

In other words, can you follow the simple flowchart (ours used to be printed on the triage tags themselves), or are you going to let your education and experience determine how you triage?

 

[EpiEMS]

the reasoning is quite simple: the more educated the provided, the more likely they are to use their own judgement and experience, instead of following the basic Triage algorithm.

While, intuitively, this sounds about right..., we can't reasonably claim it'll hold in reality in the absence of some sort of evidence.

 

[Flying]

"Based on the post hoc evaluation of triage status, adherence to the triage protocol was 74%. Analysis of patient destinations for protocol non-adherence appears to indicate that paramedic interpretation and discretion played a role in determining hospital choice. There was a marginal time difference between those transported to protocol adherent and non-adherent destinations. Future research needs to determine whether deviations from protocol are associated with differential mortality."

https://www.ncbi.nlm.nih.gov/pubmed/22062495

 

[Tigger]

I don't have the citation readily available (and TBH, I am not going to spend time looking for it), but the reasoning is quite simple: the more educated the provided, the more likely they are to use their own judgement and experience, instead of following the basic Triage algorithm.

For example, if you find a patient who is pale, diaphoretic, with blood coming out of an ear, and is in need of walking assistance during an MCI, are you going to be able to turn off your medic brain and give them a green tag, or are you going to recognize him as a sick patient who needs immediate transport and give him a red tag?

In other words, can you follow the simple flowchart (ours used to be printed on the triage tags themselves), or are you going to let your education and experience determine how you triage?

In the absence of evidence, facts would be better stated as opinions.

While not essential to use place paramedics in many MCI roles, there is nothing that makes it inherently wrong. Paramedics in this area are often the IC, triage leader and, transportation leader. It's not because they're medics, it's because they have generally spent more time developing in the system in therefore know the system better than most of the region's EMTs. I realize there are many places that have lifer (not meant as derogatory) EMTs, and I am sure they would do just fine in these roles. We don't have many of those folks, it's just not how our region works. So in turn, the people with operational knowledge and judgement are often paramedics and somehow despite having a higher level of education, we somehow get by.

 

[Tigger]

While, intuitively, this sounds about right..., we can't reasonably claim it'll hold in reality in the absence of some sort of evidence.

Backboards also made intuitive sense...

 

[DrParasite]

So in turn, the people with operational knowledge and judgement are often paramedics and somehow despite having a higher level of education, we somehow get by.

Sure.... it's just not an ideal way to allocate resources. Can a paramedic be an IC, triage leader, or operations commander? sure. They could also be in the planning department, handle staging, communicate with hospitals, or be responsible for making sure every one has a fresh battery in their portable radio. Nothing is saying a paramedic can't do any of these things; however, most systems don't have a plethora of paramedics just standing around. If you have extra paramedics, feel free to have them doing whatever you want.

The OP asked what roles were ALS expected to fill. I interpreted that to mean what roles should you assign them that will utilize their ALS knowledge, ones that can't be held as well by someone who lacks ALS knowledge. I can take a fire captain (minimal EMS knowledge), and utilize his resource management skills to manage the scene. even have him supervisor the treatment area (give him clipboard, tell him he has 3 paramedic under him, who will tell him if they need more help) if i really needed to. I can also take an EMT who has been around for a bit (doesn't need to be a lifer, but if you have been in the agency for at least 5 years, I'm sure he or she can handle it) and put them in charge of a group, even if it involves supervising paramedics.

If I have an MCI, with multiple DOAs, do I really want paramedics carrying the dead bodies form the scene to the morgue? not really. Can I? well, there is nothing saying they can't, but I'd rather take 4 firefighters and assign them heavy manual tasks, and let my paramedics treat the living, where their additional training and experience can be put to better use.

But you're right, there is no rule that says you couldn't use paramedics for every task at an MCI.

OP, how many paramedics do you have in your system, compared to other providers? how many in the region (meaning available to neighboring agencies)?

 

[VentMonkey]

The fire department in my area is virtually all BLS, the ambulance services are the ALS providers.

The way it is supposed to work is basically fire is in charge of the incident itself, highway patrol, or whatever LEA is superseding has control of the overall scene itself (non-medical), and our paramedics are expected to assume the role of med-group supervisor.

The med-group supervisor is essentially in charge of the medical aspects, and allocation of the right amount of resources. It’s, in reality, extremely inconsistent.

IME with MCI’s I would ask for the (fire) IC and coordinate with them what it is that needs to be done from the medical (i.e., EMS) aspect while going back and forth between the separated sections of patients, communicating with my dispatch, ordering “X” amount of extra units, and/ or canceling the rest.

All of this needs to be funneled back to the IC, as they’re in charge of the overall incident itself, and generally can run an ICS situation in their sleep...because they do it daily here.

In the event that a supervisor shows up, I will gladly relinquish my med-group duties, let them know where I’m at with the incident, and transport the remainder of the patient/s. If it’s done right, I have no patient(s) to transport.

 

[Carlos Danger]

Backboards also made intuitive sense...

As did intra-cardiac epi, MAST pants, and field RSI.

 

[FiremanMike]

Not sure if anyone else here attended Eagles this year, but the first 4 hours of the first day were dedicated to MCI responses. The overwhelming theme of the talks was that everything we thought we knew about MCI planning goes out the window IRL and that triage is incredibly disorganized and triage tags are worthless.

If we're being honest, I think anyone who's truly tried to mentally think through how these events will play out will agree that we've all kinda known this to be true, but we kept plowing forward with the idea that we'll be able to create order out of chaos. As the fine Eagles explained, it's just not realistic at all.

 

[Uclabruin103]

I think it all depends on the situation and your system. How many medics will you have on scene with your initial response? Do you have to pull medics from boxes, or do you have enough on engines? First priority should be treatment and transport, since that's the only place ALS treatments should be rendered (outside of active shooter).

Anyone can fill any rule in the ICS system, well that's the intention behind it anyway. So why would it HAVE to be a medic in a leadership role?

How big of a MCI are we talking? Oklahoma City bombing, train derailment, ten car pileup? While the ICS system is always a good to to utilize, it can also complicate smaller the smaller "MCIs" that might just need one or two ICS positions

 

[RocketMedic]

Type matters too. A mass shooting "needs" ALS a lot less than an organophosphate exposure, etc.

 

[EpiEMS]

Backboards also made intuitive sense...

As did intra-cardiac epi, MAST pants, and field RSI.

I should've been clearer - just because it makes intuitive sense doesn't mean we should do it...and if we are doing something just because it "seems like it makes sense" (without a good RCT), we ought to reconsider...

The overwhelming theme of the talks was that everything we thought we knew about MCI planning goes out the window IRL and that triage is incredibly disorganized and triage tags are worthless.

The slides aren't up yet, any chance you can share them?

 

[FiremanMike]

I should've been clearer - just because it makes intuitive sense doesn't mean we should do it...and if we are doing something just because it "seems like it makes sense" (without a good RCT), we ought to reconsider...



The slides aren't up yet, any chance you can share them?

They didn't distribute them to the group, I'm waiting on them to be posted also..

 

[Bullets]

Not sure if anyone else here attended Eagles this year, but the first 4 hours of the first day were dedicated to MCI responses. The overwhelming theme of the talks was that everything we thought we knew about MCI planning goes out the window IRL and that triage is incredibly disorganized and triage tags are worthless..

One of the reasons why we keep triage tags in the truck in a little used compartment since its a DOH requirement, but our MCI kit has a box of sharpies in them. Screw the tags, know the algorithm, write 1 or 2 on their foreheads and walk all the threes somewhere.

Type matters too. A mass shooting "needs" ALS a lot less than an organophosphate exposure, etc.

How much atropine are you guys carrying?

 

[DrParasite]

Not sure if anyone else here attended Eagles this year, but the first 4 hours of the first day were dedicated to MCI responses. The overwhelming theme of the talks was that everything we thought we knew about MCI planning goes out the window IRL and that triage is incredibly disorganized and triage tags are worthless.

Why? was it because no one was following their MCI plans? did no one know what the MCI plans were? were there issues with the MCI plans? Is triage disorganized because the scene is chaotic, or because everyone is trying to treat and triage, and no one is actually setting up a plan to handle an incident? Was everyone freelancing before an incident commander started to assign tasks to specific people?

If we're being honest, I think anyone who's truly tried to mentally think through how these events will play out will agree that we've all kinda known this to be true, but we kept plowing forward with the idea that we'll be able to create order out of chaos. As the fine Eagles explained, it's just not realistic at all.

So what should we do? just do what the cops did at the aurora shooting, pull up, throw a bunch of people in the back of the car and take them to the local hospital?

There is an old saying: "those who fail to plan, plan to fail." All the experts from the boston bombing said their MCI plan worked pretty well, because it was a planned MCI. Many of the concerts I've worked have been the same. Where we end up with major CF is those unplanned MCIs, normally because we lack sufficient EMS resources to manage the scene, and people don't follow the established plan for how we will handle said MCI.

I'd love to see the presentation to see exactly they said could be done better.

One of the reasons why we keep triage tags in the truck in a little used compartment since its a DOH requirement, but our MCI kit has a box of sharpies in them. Screw the tags, know the algorithm, write 1 or 2 on their foreheads and walk all the threes somewhere.

I am confident that your crews can triage without the tags, but your missing their point (other than proving a cheat sheet for those who forgot the algorithm): numbers, documentation and accountability.

How many patients were on the bus when you arrived? did anyone hop on after the crash? how many reds, yellows and greens do you have? if you have 50 people, and two people doing triage, can you keep track of your numbers? how many reds, yellows, greens? that's where those little tags can help. Ditto the belongings tab, to match up an individual's clothing (based on the serial number of the tag with the serial number of the tear off tab). And the tear off stickers, so you can track where patient A was transported to quickly and easily). And if you need to document a change in triage status (typically happens in the treatment area), you can show a trend.

I've seen red, yellow and green tape used as well. and while I (biasedly) think that NJ's triage tags are better that most (in terms of design and overall system integration, including the barcode scanners and scanning information), we all can always do the cop and firefighter method: if they look sick, they are red, if they can walk, they are a green, everyone else is a yellow, and tell EMS to put a push on it, because we have done all the medical stuff that we want to do.