MODOC OPERATIONAL AREA MULTI-CASUALTY AND MEDICAL EMERGENCY PLAN

Transcription

1 MODOC OPERATIONAL AREA MULTI-CASUALTY AND MEDICAL EMERGENCY PLAN Prepared by E. Dan Bouse and Nancy C. Ballard Modoc County Office of Emergency Services In cooperation with the Modoc County Disaster Council and the Modoc County Emergency Medical Care Committee Adopted, June 2005

2 TABLE OF CONTENTS... I EQUIPMENT AND SUPPLIES... 6 TRAINING & EXERCISES... 6 MUTUAL AID & ASSISTANCE... 6 Table 1. MODOC OA AMBULANCE PROVIDER TRANSPORT EQUIPMENT... 7 FIELD TREATMENT SITES... 7 PATIENT DISPERSAL SYSTEMS... 7 FOCUSED INCIDENTS... 8 Figure 1. MULTI-CASUALTY GROUP/DIVISION RESPONSE... 9 UNFOCUSED INCIDENTS AT SCENE COMMAND AND CONTROL SINGLE COMMAND UNIFIED COMMAND EMS RESOURCE MANAGEMENT...11 Figure 2. MULTI-CASUALTY INCIDENT LAYOUT PROCEDURES FOR EMERGENCY DECLARATIONS MCI DECLARATION DECLARATION OF LOCAL EMERGENCY FOR HEALTH OR MEDICAL REASONS TACTICAL GOALS Table 2. PATIENT PRIORITY DESTINATIONS TRAUMA MEDICAL BURN INJURIES DOC AND EOC ACTIVATION COMMUNICATION Table 3. RADIO FREQUENCY ASSIGNMENTS TRANSPORTATION/ PATIENT DISPERSEMENT Table 4. HEALTH FACILITY DESTINATION LIST DELAYED PATIENTS MINOR PATIENTS Table 5. AERO-MEDICAL RESOURCES Table 6. EMERGENCY NON-MEDICAL TRANSPORTATION RESOURCES FIELD TREATMENT SITES Table 7. FIELD TREATMENT SITES FATALITIES CONTAMINATION...22 DOCUMENTATION TRIAGE TAGS PREHOSPITAL PATIENT CARE REPORTS MULTI-CASUALTY BRANCH WORKSHEET PATIENT TRANSPORTATION SUMMARY WORKSHEET AMBULANCE STAGING RESOURCE STATUS SHEET SUPPLY RECEIPT & INVENTORY FORM... 24

3 POSITION CHECKLISTS MEDICAL GROUP SUPERVISOR TREATMENT UNIT LEADER MEDICAL TRANSPORTATION GROUP SUPERVISOR MEDICAL COMMUNICATIONS COORDINATOR AIR AMBULANCE COORDINATOR MEDICAL STAGING AREA MANAGER MULTI-CASUALTY BRANCH WORKSHEET LOCAL MEDICAL EMERGENCY

4 INTRODUCTION The potential always exists for an event to occur that results in injuries beyond the scope of routine procedures to handle. Bus wrecks, disasters like earthquakes, or even just a large number of victims in a traffic accident can stretch local resources thin. This plan lays out procedures to manage the emergency medical response for such incidents. The plan assumes that all multi-casualty incidents and medical emergencies will also be law enforcement incidents. In a small community, victim s families and friends often arrive at the same time as the first responders. Scene control is always a first priority after scene safety of the first responders. Incidents will be managed under two established systems: 1. The Incident Command System will be used as the organization system in the field. Because of the relative short duration of many medical emergencies, it is possible that Department Operations Centers (DOC) and the Emergency Operations Center (EOC) would not be activated unless the incident would have other lasting residual impacts to the Operational Area (OA). The National Incident Management System (NIMS) and the California Standardized Emergency Management System (SEMS) will be applied as appropriate. 2. START (Simple Triage and Rapid Treatment) will be the triage method used in the OA as a part of the Northern California Medical Emergency Services protocols and Emergency Medical Services Authority (EMSA) Disaster Medical Services Guidelines. The focus of the plan is to do the most good for the most people. NorCal EMS Policy 203 (Appendix D) delegates the Medical Transportation Group Supervisor at scene to arrange transport of patients to the most appropriate available facility. At all times, the most immediate patients should be transported first to the most appropriate available medical facility. It is essential that they be moved as directly as possible to the level of care they require without overwhelming any receiving facility. The OA has two acute care licensed facilities with standby doctors on 30-minute call. In Modoc County, this means that the seriously injured or ill (Immediate Category) casualties will be transported to definitive care outside of the county if at all possible since no trauma centers or intensive care units are located within the OA. The priority for the two local acute care facilities will be the Delayed Category patients to prevent, whenever possible, their deterioration to Immediate Category. Delayed Category patients beyond the capacity of local facilities will be transported to appropriate surrounding hospitals closest to the incident. Minor injuries can be handled within the community health center system within the OA.

5 Two types of scenarios, focused and unfocused, seem likely. This plan primarily addresses focused incidents. The focused incident would be either a trauma scenario such as a bus or plane accident or a chemical/biological scenario with a surge of casualties taxing the medical care system at one time. Examples of the chemical would be chlorine or botulism poisoning. These incidents will generally have casualties at a scene of origin. The second type of scenario, the unfocused incident, would ramp up slowly, possibly even going undetected initially. Bio-terrorism events may take hours to weeks for patients to become symptomatic. Doctors, infection control personnel, or the public health department may be the first to recognize that an emergency exists. The patients will typically self-present to a physician, community health center or emergency room setting with this scenario. Patients may be transported by ambulance to the emergency room when their symptoms become acute, with pre-hospital personnel not detecting what they are dealing with. PREPAREDNESS Preparedness is essential to any kind of effective, coordinated response. The Modoc County Emergency Medical Care Committee (EMCC) will take the lead in preparedness efforts for multi-casualty incidents. Preparedness will focus on six objectives: 1. Procurement and placement of equipment and supplies; 2. Training in ICS and multi-casualty incident management as well as SEMS and NIMS; 3. Mutual aid and cooperative agreements to facilitate implementing the plan, including responsibility for care of the pre-placed multi-casualty caches; and 4. Development of site plans for Field Treatment Sites. 5. Cooperate with Nor Cal EMS in developing a regional patient dispersal system. 6. Develop trigger points for the activation of an Emergency Medical DOC and the Operational Area EOC.

6 EQUIPMENT AND SUPPLIES The first objective will be implemented by the procurement and pre-placement of medical casualty supply caches across the OA. Available personnel will move these caches to the scene. Caches will provide resources for splinting and immobilization, respiratory and airway support, trauma materials, and patient and rescuer protection as well as documentation and incident management equipment and supplies. The caches take two forms, a trailer and drop kits. The trailer, capable of supporting 50 casualties, will be located in an easily accessible location that allows for environmental controls. A minimum of three drop kits will be placed throughout the county. As funds are available and as agencies are willing to take responsibility for inventory and maintenance of them, more drop kits will be added. Designed to handle ten people, the kits will be unitized for transport in an ambulance, on fire apparatus, or by other means as agencies respond from these locations in the OA. The inventories of the caches and trailer are located in Appendix C. TRAINING & EXERCISES The second objective is ICS and multi-casualty incident training for all personnel that might be involved in a multi-casualty incident. The objective of the OA is for all medical, fire, law enforcement and health personnel to be trained to the Basic ICS level. A cadre of personnel will be identified and trained to the Intermediate and Advanced ICS and EMSA MCI course (8 hour course) for personnel that will fill unit leader, group supervisor, or command staff positions in the medical incidents within the OA. Training specific to the contents of this plan and exercises to test this plan are essential to implementation. All potential responders and support personnel at all levels within the OA should be familiar with this and associated plans. MUTUAL AID & ASSISTANCE The OA has three ambulance stations and six ambulances. Table 1 outlines the ground ambulance resources within the OA. Total transport capability is 17 patients. No air ambulance resources are located in the OA. Objective three will be to form a core of mutual aid and other cooperative agreements with various agencies and facilities within and adjoining the OA to implement the Multi-Casualty and Medical Emergency Plan. Mutual Aid agreements are in place on a local and regional level for EMS, Fire, and Law Enforcement. All EMS resources with provider agreements issued by Nor Cal EMS are required, as part of their agreement, to provide mutual aid and disaster assistance. Planning is occurring at the regional and state level for the use of statewide EMS resources during a disaster situation.

7 Table 1. MODOC OA AMBULANCE PROVIDER TRANSPORT EQUIPMENT RESOURCE IDENTIFIER RESOURCE TYPE* PATIENT CAPACITY Surprise Valley Hospital District (STRETCHER) Ambulance Medic 11 Type 2 BLS 3 Medic 12 Type 2 BLS 4 Modoc Medical Center Alturas Medic 21 Type 1 ALS 2 Medic 22 Type 1 ALS 2 Modoc Medical Center Adin Medic 51 Type 1 ALS 4 Medic 52 Type 1 ALS 2 *As outlined in the California Ambulance Strike Team/Medical Taskforce Guidelines. FIELD TREATMENT SITES Agreements should be developed with transportation agencies, community health centers and facilities that would be used for field treatment sites. Agreements should clarify payment arrangement and any other specifics to prevent misunderstandings later. As part of this process, facilities through out the OA should be identified for use as Field Treatment Sites. This needs to be coordinated with the Care and Shelter Plan for general purposes to avoid conflicts. Preplacement of equipment, supplies and other enhancements of these facilities are needed. Alternate sources of power are a major consideration for facilities. Site plans will be developed for each identified field treatment site that is not currently a health care facility. Field treatment sites are discussed further under Operations and in Table 6. PATIENT DISPERSAL SYSTEMS Currently, patient destination decisions are made at the base or receiving hospitals. Base stations for the Modoc Medical Center Ambulance Alturas Station and Adin Station are Modoc Medical Center and Mayers Memorial Hospital respectively. Surprise Valley Ambulance is a basic life support (BLS) service and their receiving hospital is Surprise Valley District Hospital. Surprise Valley Hospital is not an authorized base station hospital at this time. OPERATIONS

8 FOCUSED INCIDENTS Focused incidents involve an event that requires an immediate medical response to care for victims. This type of incident is the emphasis of this plan. When an incident occurs requiring medical response, emergency medical responders are dispatched. One objective of their response is to handle the emergency in the field and not move the disaster to the emergency room. Proper triaging and transporting the patients to a facility that can provide definitive care with the first transport of the patient is a primary objective of this plan. Three classifications of Focused Incidents will be found in the field: Routine: Patients that available resources can manage using routine procedures. Multi-casualty Incident (MCI): More patients than available resources can manage using routine procedures. Declaration of an MCI implements procedures that allow available resources to efficiently handle an increased volume of patients. Consider the following when declaring an MCI, keeping in mind that factors other than patient numbers may justify the declaration. o MCI Trauma: Usually four or more patients with one or more needing transport to a Level 1 or 2 Trauma Center. The intervention of a trauma surgeon is needed. o o MCI Medical: Usually four or more non-trauma patients with one or more requiring transport outside of the OA for appropriate treatment. Examples would be smoke, chlorine gas inhalation, etc. No surgeons or decontamination is needed. MCI Hazmat: Usually four or more patients with decontamination necessary before transport to appropriate facilities and may require secondary decontamination on arrival for definitive treatment. Local Medical Emergency: Requires resources from outside of the OA. (Sometimes called a Mass Casualty Incident) For incidents in the Modoc Operational Area, a Multi-Group/Division response will be dispatched (Figure 1). Patients from a MCI-Hazmat incident may also be either Trauma or Medical; however, the hazardous material contamination must be dealt with first to avoid contaminiation of personnel, ambulances, and medical facilities. The Hazardous Materials Emergency Response Plan will be activated along with this plan when necessary.

9 Figure 1. MULTI-CASUALTY GROUP/DIVISION RESPONSE INCIDENT COMMANDER OPERATIONS CHIEF or BRANCH CHIEF (Lowest filled) MEDICAL GROUP SUPERVISOR Medical Communications Coordinator (if filled) Medical Staging Area Manager (if filled, Air and/or Ground) MEDICAL TRANSPORTATION GROUP SUPERVISOR TRIAGE UNIT LEADER TREATMENT UNIT LEADER Immediate Treatment (Treatment Staff) Triage Personnel Litter Bearers Delayed Treatment (Treatment Staff) Minor Treatment (Treatment Staff) Morgue Manager

10 UNFOCUSED INCIDENTS Unfocused incidents develop slowly and are often undetected initially. If an Unfocused Incident occurs, the Public Health Officer and/or the County Health Department will activate their system. EMS resources often plan a secondary role in these events. Departmental incident management organizations would be set up within the public health department or within multiple health organizations within the OA. The Incident Command System (ICS) will be used to manage the emergency. The Public Health bio-terrorism plan should be referred to when appropriate. AT SCENE COMMAND AND CONTROL Command will be established at the incident scene. The choice of the type of command will usually be made based upon the number of jurisdictions and agencies involved and the size of the incident. SINGLE COMMAND A single command system would be instituted when a single agency clearly has the legal authority and the incident is of a size and scope wherein the highest-ranking official will be able to handle the incident. In some cases, an advisory staff of agency representatives can be established to assist the Incident Commander. A call-out list of agency representatives for EMS needs to be established in the Communications Center to allow rapid notification when needed. These individuals need to be intimately familiar with the Multi- Casualty Medical Organization within ICS and with this plan so that they can assist a non-medical IC in understanding the regulatory requirements and the needs for efficient triage and transportation. UNIFIED COMMAND If the complexity of the incident itself or jurisdictional issues dictate, a Unified Command will be established. This is a system where a group of officials operate together to command the incident. Functions may include fire, law enforcement, public works, EMS, and others. A call-out list of EMS supervisory personnel and their qualifications will be established in the Modoc County Communications Center to allow rapid notification and dispatch to an incident involving a large number of medical casualties.

11 EMS RESOURCE MANAGEMENT EMS resources shall be requested by the Incident Commander or through the Logistics Section, if developed. In a small incident, the Patient Transportation Group Supervisor may be allowed to directly request EMS transportation resources but this should not be assumed. A procedure for requesting resources should be arranged with the Incident Commander. The Medical Group Supervisor will supervise EMS resources. The Incident Commander may assign supervision of a medical staging area to the Patient Transportation Group Supervisor who may assign a Medical Staging Area Manager and Medical Communications Coordinator. All EMS personnel, equipment, and supplies shall be directed to the staging area where they shall remain until relocated or assigned. Figure 2. MULTI-CASUALTY INCIDENT LAYOUT INCIDENT INCIDENT STAGING INCIDENT COMMAND POST MEDICAL SUPPLY CACHE TRIAGE AREA AMBULANCE STAGING PATIENT LOADING TREATMENT AREA Immediate Delayed RECEIVING FACILITIES INCIDENT HELISPOT AND/OR AIRPORT Minor MORGUE AREA PATIENT FLOW PATIENT FLOW PATH IF AIRCRAFT CANNOT ACCESS TO INCIDENT SITE

12 Resources (personnel, equipment, etc.) will be assigned or distributed to specific tasks. They will be assigned by the Medical Staging Area Manager, if assigned, or the Medical or Patient Transportation Group Supervisor. Transport vehicles will maintain a one-way traffic pattern adjacent to the loading area. The Patient Transportation Group Supervisor or Medical Staging Area Manager will be responsible for the ambulance staging area. If possible, keep a driver with each vehicle. If drivers are needed for triage or treatment, KEYS MUST BE LEFT IN VEHICLES and the doors must be left unlocked. Be prepared to remove equipment not necessary for transport. Create a field inventory at the staging area, which can be rapidly moved to treatment areas as needed. PROCEDURES FOR EMERGENCY DECLARATIONS At the local level, there are two levels of declarations. One is the declaration of a Multi-Casualty Incident (MCI). The other is the declaration of a Local Emergency. MCI DECLARATION An MCI may be declared by the Incident Commander in consultation with senior medical personnel at scene. While scene management lies with the agency having jurisdication, the authority for patient health care management is vested in the most medically qualified responder on scene. An MCI is declared when routine procedures prevent available resources from efficiently handling the number and type of casualties. An MCI Declaration releases EMS personnel from certain restrictions allowing: EMS personnel to pass patients off to less qualified care providers for treatment or transportation as appropriate or necessary; ALS personnel on scene to go to standing protocols rather than direct verbal orders from their base hospital; and The Medical Group Supervisor or Triage Unit Leader at scene to declare apparent death.

13 DECLARATION OF LOCAL EMERGENCY FOR HEALTH OR MEDICAL REASONS An incident that exceeds the limits of available OA medical resources, including the normal channels for transport out of county, necessitates the declaration of a local emergency. This opens access to regional and state level assistance. The request for a Local Declaration may be initiated by the IC or by an OA representative in consultation with the IC. A local emergency may be declared by the Board of Supervisors, if in session, or by the Director or Assistant Director of Emergency Services (Modoc County Code ) or by the County Health Officer TACTICAL GOALS The following tactical goals will be established for MCIs in the Modoc Operational Area. As each tactical goal is met, the Incident Commander will be notified and will in turn relay this information to the Communications Center or the Emergency Operations Center. The Medical Transportation Group Supervisor or the Medical Communications Coordinator will notify the Base Hospital of the tactical goals as they are accomplished. 1. Declare an MCI to facilitate efficient handling of patients when necessary based on the number and severity of casualties and other circumstances. 2. Request a declaration of a Local Medical Emergency when normal mutual assistance channels are overwhelmed or inadequate to manage the incident or incidents. 3. Complete Triage and forward results to the IC and the Communication Center (Example: Triage completed: 4 Immediate, 6 Delayed, 5 Minor, 2 Deceased) 4. Extrication Complete - All patients are in the appropriate treatment area and awaiting transport 5. Immediate Category Patients Transported - All Triaged Immediates have been transported from scene 6. Delayed Category Patients Transported - All triaged Delayed patients have been transported from scene 7. Minor Category Patients Transported - All Minor triaged patients have been transported from scene

14 Table 2. PATIENT PRIORITY DESTINATIONS TRAUMA Priority one (immediate) patients Priority two (delayed) patients Priority three (minor) patients Fly directly to trauma centers Ground ambulance to local hospitals Public transportation to local community health centers or treat and release at scene. May require hospital care. MEDICAL Priority one (immediate) patients Priority two (delayed) patients Priority three (minor) patients Fly patients to major medical centers Ground ambulances to local hospitals Public transportation to local community health centers or treat and release at scene. May require hospital care. BURN INJURIES Priority one (immediate) patients Priority two (delayed) patients Priority three (minor) patients Fly patients to trauma/burn centers Ground ambulances to local hospitals Public transportation to local community health centers or treat and release at scene. May require hospital care.

15 DOC AND EOC ACTIVATION If the mutual aid system locally cannot provide enough resources for the incident, a Department Operations Center (DOC) will be activated to coordinate efforts. The EOC will be activated as determined by the Director or Assistant Director of Emergency Services in consultation with the Incident Commander. The Operational Area Ambulance Coordinator will brief the Regional Disaster Medical/Health Coordinator (RDMHC) about the situation and anticipated needs for resources. The OA Ambulance Coordinator will place all orders for medical transport resources, both BLS and ALS, beyond the normal mutual aid system. Contact the RDMHC initially by pager at (530) Once in place at the NorCal EMS Office in Redding, contact can be made by telephone or Med Net Radio. COMMUNICATION With the declaration of an MCI by the incident commander, the Communications Center will assign, as a minimum, a command and tactical frequency to the incident (see Table 3). Green Command will be the assigned command frequency with either Gold or Yellow TAC as the assigned tactical. Grey Net will be assigned to the EOC. Medical Control from the incident will be through the UHF MED NET system. All routine online medical control communications shall be suspended. Communications will occur with hospital(s) only through the Medical Transportation Group Supervisor or the assigned Medical Communications Coordinator. All emergency medical services personnel will carry out patient treatment based on standing orders using NorCal EMS radio failure protocols. Medical units arriving on scene will identify themselves by department name, unit type and number, eg, Lake City IC, this is Surprise Valley Ambulance Medic Eleven. This assists with identification of out-of-oa resources. Medical Personnel will use Med Net Tactical Channel 9A for communication between the Medical Group and Transportation Group Supervisors and the Medical Communications Coordinator. If radio traffic warrants, Med Net 9B will be used for other medical traffic such as between the medical triage unit leader, medical treatment unit leader, treatment managers, ambulance staging, and the morgue manager.

16 Table 3. RADIO FREQUENCY ASSIGNMENTS USE FREQUENCY USER Scene Command and Resource Ordering GREEN COMMAND Incident Command Staff Tactical Operations For Rescue& Fire GOLD TAC Fire and LE, Public Works at scene Tactical Operations, Traffic and Crowd Control YELLOW TAC LE, Fire and Public Works at scene Medical Command MED 3,5,6,7 Medical Destination Control Medical Tactical, Group Level MED 9A Med Grp Sup, Pt Transport Grp Sup, Med Treatment Grp Sup Medical Tactical, Treatment Personnel MED 9B Med Treatment Emergency Ops Center, Center Personnel Interoperability with any Med Net freq. GREY NET MED TONE 8 (All MED NETS) EOC Personnel TRANSPORTATION/ PATIENT DISPERSEMENT Out-of-OA Medical Resources All IMMEDIATE CATEGORY patients will be transported to facilities where definitive care can occur. Specifically, trauma patients go to designated Trauma Centers and other medical patients to facilities with Intensive Care Units. Weather conditions at the time of a multi-casualty incident may radically impact how patient transport can be carried out. If visual flying rules (VFR) are in effect at the time and the disaster site has rotary wing landing zones (LZ) with immediate access to the patients, transportation will obviously be much easier. Alternatives would be to set up an LZ away from the site and commit ground ambulance(s) to transport to the LZ or to the nearest airport where fixed wing aircraft could also be used. Rescue rotary wing aircraft from such agencies as CDF and CHP could be used to shuttle to the nearest airport to enable using fixed wing ambulances to transport IMMEDIATE Category patients out to Trauma Centers without committing air ambulance rotary wing aircraft that should be transporting directly to Trauma Centers. DELAYED CATEGORY patients will be ground transported to the two hospitals in county and surrounding acute care hospitals. MINOR CATEGORY patients will be transported to the nearest available community health care facilities. Consider treatment and release at scene as appropriate. Public and school transportation resources may be called upon to transport these patients. Loading of minor patients should not interfere with the loading of IMMEDIATE or DELAYED patients. If needed and feasible, a separate loading area for MINOR CATEGORY patients can be set up.

17 Vehicle loading should be maximized without jeopardizing patient care. Unless it is the only option, two IMMEDIATE CATEGORY patients should not be transported in the same ambulance. If the destinations coincide, an IMMEDIATE may be transported with one or more DELAYEDS or MINORS to better assure that pre-hospital staff can adequately care for patients during transport. Each patient transported must be registered in the Patient Transportation Summary Worksheet. Once prepared for transportation, the Treatment Unit Leader should notify the Patient Transportation Group Supervisor of the number of patients, their triage categories, and a one-word classification of their injuries, i.e., one IMMEDIATE-HEAD, and IMMEDIATE-CHEST. All IMMEDIATE trauma patients will carry the additional descriptor of head, chest, abdomen or extremity, which will denote the trauma specialty needed for that patient. After receiving direction from the base hospital, the Patient Transportation Group Supervisor will begin the transport of patients beginning with IMMEDIATES to the appropriate definitive care facilities working from closest to most distant. DELAYEDS will be transported in the same sequence with closest facilities taking the first patients and moving out to the more distant facilities, as patient capacities are reached at each hospital. Table 4. HEALTH FACILITY DESTINATION LIST FACILITY PHONE ADDRESS LATITUDE/LONGITUDE FOR LANDING ZONE IMMEDIATE PATIENTS Level 2 Trauma Centers Mercy Medical Center Enloe Medical Center Level 3 Trauma Centers Fairchild Medical Center Rosaline Avenue Redding, CA Esplanade Chico, CA Bruce Street Yreka, CA LAT 40 Deg Sec. N. LONG 122 Deg Sec. W. LAT 41 Deg N. LONG 122 Deg W. Shasta Regional Medical Center St. Elizabeth Community Hospital East Street, Suite A Redding, CA Sister Mary Columbia Drive Red Bluff, CA 96080

18 Mercy Medical Center Pine Street Mt. Shasta, CA 96067

19 FACILITY PHONE ADDRESS LATITUDE/LONGITUDE FOR LANDING ZONE DELAYED PATIENTS Modoc Medical Center W. Mc Dowell St. Alturas LAT 41 Deg Sec N. LONG 120 Deg Sec W. Surprise Valley Community Hospital Main St., Cedarville NO LZ AVAILABLE Mayer Memorial Hospital E, Fall River Mills LAT 41 Deg Sec N. LONG 121 Deg Sec W. Lake District Hospital (541) South J. Street, Lakeview LAT 42 Deg Sec. N. LONG 120 Deg Sec. W. Banner Lassen Community Hospital Spring Ridge Road Susanville, CA LAT 40 Deg Sec. N. LONG 120 Deg Sec. W. Merle West Medical Daggett,Center Klamath Falls, OR LAT 42 Deg Sec. N. LONG 121 Deg Sec. W. MINOR PATIENTS Modoc Medical Center Clinic Surprise Valley Medical Clinic Canby Family Practice Clinic Warner Mtn. Health Center W. Mc Dowell, Alturas Main St., Cedarville Co. Rd. 83, Canby Me-Thee-Uh. Rd Fort Bidwell LAT 41 Deg Sec N. LONG 120 Deg Sec W. NO LZ AVAILABLE LAT 41 Deg Sec. N. LONG 120 Deg Sec. W. LAT 41 Deg Sec. N. LONG120 Deg Sec. W. Big Valley Health Center Medical Center Drive, Bieber Tulelake Health Center Main St., Tulelake LAT 41 Deg Sec. N. LONG 121 Deg W. NO LZ AVAILABLE Table 5. AERO-MEDICAL RESOURCES RESOURCE LOCATION TELEPHONE AIRCRAFT TYPE

20 Mountain Life Susanville Rotary, Fixed Mercy Air Redding Rotary, Fixed Air Med Team Redding Rotary Mercy Flights Medford Rotary, Fixed Care Flight Reno Rotary Medic Air Reno Rotary Enloe Flight Care Chico Fixed

21 Table 6. EMERGENCY NON-MEDICAL TRANSPORTATION RESOURCES SOURCE LOCATION CONTACT NUMBER Sage Stage Alturas Modoc Joint Unified School District Surprise Valley Joint Unified School District Big Valley Joint Unified School District Alturas Cedarville Bieber Pit River Health Alturas Tulelake Basin Joint Unified School District Tulelake FIELD TREATMENT SITES The use of field treatment sites (FTS) may be necessary under some conditions such as flood, fire, and weather that affect the immediate removal and transport of victims. Transportation limitations may cause enough delay that field treatment sites must be activated. Criteria for site selection would include proximity to casualties and access for transport, heat, lights and water, and emergency medical supplies. Emergency power at the sites is essential. Modoc Medical Center and Surprise Valley Hospital will be considered Field Treatment Sites if conditions do not allow for rapid transport of appropriate patients out of the OA. Site plans for each of these locations will be developed. Table 7 displays the preliminary field treatment site selections for the OA. It is not all inclusive and other sites need to be identified. Table 7. FIELD TREATMENT SITES LOCATION OWNER CONTACT Adin Community Center Modoc County Meredith Richno Modoc District Fairgrounds Traci Green Alturas Veterans Hall Modoc County County Public Works Canby Fire Hall Canby Fire Protection District Fire Chief Likely Fire Hall Likely Fire Protection District Fire Chief Davis Creek Fire Hall Davis Creek Fire Protection District Fire Chief

22 FATALITIES Fatalities will not be moved from the positions they are found in unless it hinders on-going operations or the bodies will be further compromised by the incident. The County Coroner will take control of the fatality scene in terms of evidence preservation and the disposition of the decedents bodies. The Medical Transportation Group Supervisor may coordinate transport of deceased victims if asked by the Coroner but this will not be dealt with until all injured are transported from the scene. The single mortuary in the OA can handle three to five victims. If greater numbers are anticipated, the Communications Center will be notified so that arrangements can be made for a refrigeration unit. Consideration should be given to bringing the refrigeration unit to the incident location to use as a mobile morgue. The local mortuary will be contacted immediately if more than three to five deceased are anticipated. This will allow them to staff up for the handling of the casualties anticipated. They would be able to provide staff from other areas that their company serves to respond to the OA. Additional medical examiner support will be requested through the OA law enforcement mutual aid coordinator. CONTAMINATION Pre-hospital personnel must remain alert to the potential for toxic and hazardous materials at the scene of all incidents. Familiarization with the Modoc County Hazardous Materials Emergency Response Plan is essential for all pre-hospital medical personnel. It is critical that decontamination of victims takes place prior to transportation if at all possible and that all receiving facilities be made aware that hazardous materials are involved in the incident. DOCUMENTATION Original ICS-MC and MCM Forms for use with this annex are found in Appendix B. TRIAGE TAGS No triage shall be started without tags. METTAGS will be used throughout the OA. Upon the arrival of the first assigned medical personnel at scene, triage tags will be assigned. Triage personnel will initially tag patients using the START triage method. Tags should be attached loosely around the neck minimizing effort for the triage personnel but avoiding injured areas. Track the numbers of tags utilized so that an estimate of injured can be given to the Medical Group Supervisor. Insure that all walking wounded are tagged as they are assisted from the incident scene and that these patients are kept in the designated minor treatment area for reassessment.

23 When the victims arrive in the treatment areas, indicate the time of triage, and briefly the chief complaint/major injuries. Document vital signs and times obtained on Part I of the tag. List treatment and time administered on Part II of the tag. Reevaluate triage as necessary, preferably every fifteen minutes. Patients can go up in triage category but never down. If the triage category is raised, these patients should be moved to the next higher-level treatment area. If the tags become full of information, DO NOT REMOVE. Attach a second tag and discard all numbers and tabs on the second tag. All tags will remain on patients until received at the appropriate health faculty. Once the destination facility has been determined, it will be written on the tag. The Patient Transportation Group Supervisor will note the tag number on the Patient Transportation Summary Worksheet. Transporting personnel will note the triage tag number on the patient care record/field assessment form. This will enable information to be obtained at a later time and permit a rapid return of the transport vehicles to the incident scene. Hospital admitting personnel will use the triage tag number in the admitting process in such a way that patient information and medical records may be retrieved rapidly by the use of the triage tag number. PREHOSPITAL PATIENT CARE REPORTS These forms should be completed enroute to the hospital by transporting personnel using the Triage tag numbers for identification. MULTI-CASUALTY BRANCH WORKSHEET The Multi-Casualty Branch Worksheet is used by the Medical Group Supervisor as an organizational aid. This worksheet is an abbreviated organization chart that provides space for names of persons filling positions and a checklist for other resources to be considered. PATIENT TRANSPORTATION SUMMARY WORKSHEET This worksheet may be used by the Patient Transportation Group Supervisor, Medical Communications Coordinator, Treatment Unit Leader, and Medical Staging Area Manager to maintain an accurate list of patients as they are moved through the system. It is used by the Medical Communications Coordinator to record information from the Treatment Unit regarding the status of patients ready for transport as well as to record patient destination information as directed by the patient destination control facility. The Patient Transportation Group Supervisor and Medical Staging Area Manager also utilize the worksheet to record the transport of patients from scene.

24 AMBULANCE STAGING RESOURCE STATUS SHEET The Ambulance Staging Resource Status Sheet will be maintained by the Medical Staging Area manager, if filled, or by the Patient Transportation Group Supervisor to track ambulance availability and activities. SUPPLY RECEIPT & INVENTORY FORM The Medical Supply Receipt & Inventory Form is used by the Medical Supply Coordinator, if filled, or the Medical Staging Area Manager to document supplies and equipment obtained from response agency vehicles for allocation to medical group units. INCIDENT REVIEW / QUALITY IMPROVEMENT After the incident, copies of all multi-casualty incident forms will be forwarded to the Modoc County Emergency Medical Care Committee (EMCC) and Nor Cal EMS along with the information required under Nor Cal EMS Policy 204 (Appendix C). The Modoc County EMCC will conduct an all-agency critique of the incident for the purpose of improving the plan, future coordination and performance. Nor Cal EMS will be invited to participate in the critique. The incident critique will be conducted within two weeks of the incident. Critical Incident Stress Debriefing (CISD) should be automatically provided after all multi-casualty events. CISD is an established process for addressing emotional and psychological effects of incidents. Use of CISD should be actively encouraged by all agencies involved in an event.

25 EMERGENCY MEDICAL ICS The National Incident Management System (NIMS) will be used for incidents within Modoc County. The Incident Command System (ICS) is a key component of NIMS. ICS provides common terminology, position descriptions, and structure for incident management. Checklists for those positions unique to emergency medical incidents are included here. Generic ICS checklists can be found in the Modoc Operational Area Emergency Operations Plan and other places. POSITION CHECKLISTS Certain actions are common to all positions and are listed here. COMMON ICS RESPONSIBILITIES- Receive assignment Acquire work materials Maintain accountability of assigned personnel as to exact locations, personnel safety, and welfare at all times Know your assigned frequency(s) and ensure that communications equipment is operating properly Maintain Unit Activity Log (ICS Form 214) Use clear text and ICS terminology (no codes) in all radio communications Complete forms and reports Respond to demobilization orders and brief subordinates regarding demobilization

26 MEDICAL GROUP SUPERVISOR The Medical Group Supervisor will be responsible for the triage and treatment in the multi-casualty incident and should not be directly involved in patient care unless he/she is the only rescuer at the scene for extended lengths of time. He or she reports to the Operations Chief or, if not filled, the IC. The EMS field organization builds from the top down with responsibility and performance placed initially with the Medical Group Supervisor. The specific organizational structure established for any given incident would be based upon the management needs of the incident. If one individual can simultaneously manage all major functional areas, no further staffing is required. If one or more of the areas require independent management, an individual should be named to be responsible for that area. In a small MCI, or in the early phases of a large MCI, the Medical Group Supervisor may also need to serve as Patient Transportation Group Supervisor and coordinate communications with the Communications Center and the nearest medical base station hospital regarding patient dispersement. The Medical Group Supervisor will appoint personnel to positions depending upon the needs of the incident. Personnel can be placed in charge of several areas if this is the best utilization of available resources. Additional personnel may include, but not limited to: Triage Unit Leader, Treatment Unit Leader, and Medical Supply Coordinator. Responsibilities: Review common responsibilities. Receive briefing and ICS designator vest Participate in Multi-Casualty Operations Section planning activities Establish Medical Group/Division with assigned personnel; request additional personnel and resources sufficient to handle the magnitude of the incident. Designate Unit Leaders and Treatment Area locations as appropriate. Request law enforcement/coroner involvement through supervisors as needed. Determine amount and types of additional medical resources and supplies needed to handle the magnitude of the incident (medical caches, cots, backboards, litters, etc.). Establish communication with Patient Transportation Group Supervisor. Direct and/or supervise on-scene personnel from agencies such as Coroner s Office, ambulance companies, county health agencies, and volunteers. Ensure proper security, traffic control, and access for the Medical Group/Division.

27 TRIAGE UNIT LEADER The Triage Unit Leader should be a well-qualified Basic Life Support (BLS) provider who will coordinate the triage of all patients. After all patients have been triaged and tagged, this person will supervise the movement of patients to a treatment area. This person will remain at the triage area and will report to the Medical Group Supervisor, Operations Section Chief, or IC, whichever is the lowest level activated. The Triage Unit Leader may assign as needed: Triage Personnel and Morgue Manager. Responsibilities: Review common responsibilities. Receive briefing and ICS designator vest Assign Triage personnel Communicate with Treatment Areas locations Assign walking-wounded (Minor) patients to a specific treatment area Request Litter Bearer Teams as needed (generally engine companies) Prioritize patient movement from the triage area (Immediate patients first) Report patient triage totals to Medical Group Supervisor Establish a Morgue if needed Reassign Triage Personnel after triage is completed

28 MORGUE MANAGER The Morgue Manager shall be responsible for establishing an on-scene morgue, if not established, and maintaining the integrity, security, and identification of deceased victims. This individual may be a representative from the Coroner s Office. The Morgue Manager reports to the Triage Unit Leader. Responsibilities: Review common responsibilities. Receive briefing and ICS designator vest Assess resource/supply needs and order as needed Coordinate all Morgue Area activities Keep area off limits to all but authorized personnel Coordinate with law enforcement and assist the Coroner s Office as necessary Keep identity of deceased persons confidential Maintain appropriate records

29 TREATMENT UNIT LEADER The Treatment Unit Leader, who reports to the Medical Group Supervisor, is responsible for on scene emergency medical care of victims in the treatment area. This person will be located at the treatment area and may assign Treatment Managers to the Immediate, Delayed, and Minor Treatment Areas as needed. Responsibilities: Review common responsibilities. Receive briefing and ICS designator vest Secure treatment areas contiguous with transportation loading point Ensure secondary triage is performed in designated treatment areas Triage tags updated as patient status changes Paramedics assigned to Immediate and Delayed Treatment Area first Communicate with Medical Division/Group Supervisor and Patient Transportation Group Supervisor Move Patients to ambulance/transportation by triage priority Delayed and Minor patients reassessed regularly

30 MEDICAL TRANSPORTATION GROUP SUPERVISOR This position establishes and maintains communications with the Disaster Control Facility and directs and coordinates patient loading into ambulances as determined by the Treatment Unit Leader. The Medical Group Supervisor may fill this position concurrently in the event there are not enough qualified personnel available. The Medical Transportation Group Supervisor may assign the following personnel as necessary: Medical Communications Coordinator, Air Ambulance Coordinator, and Ground Ambulance Coordinator. The position reports to the Operations Chief or the IC. Responsibilities: Review common responsibilities Receive briefing and ICS designator vest Identify transportation staging areas identify Locate ambulance loading point(s) contiguous with treatment areas Identify ambulance staging manager(s) Equipment needs identified and prioritized Establish and identify ingress and egress routes Coordinate transportation with Treatment Unit Leader Transport patients according to triage priority Transportation personnel reassigned when assignment is completed

31 MEDICAL COMMUNICATIONS COORDINATOR The Medical Communications Coordinator shall establish and maintain medical communications with the designated Hospital Base Station and shall select the mode of transport and patient destination based upon the direction of the Medical Base Station and the treatment bed availability assessment. Once established in this EMS region, the primary contact for patient destination decisions will be the Disaster Control Facility. This position reports to the Medical Transportation Group Supervisor, Medical Branch Chief or Operations Section Chief. Responsibilities: Review common responsibilities Receive briefing and ICS vest Establish communications with Base Hospital or designated patient routing center on appropriate Med Net Channel (Med 3,5,6 or 7) Establish communications for on scene on Med 9A Give an overview of incident to Medical Control with updates on numbers of casualties by triage category when available Relay ambulance patient loading information to Base Hospital or designated control facility. Obtain hospital destination and communicate to Air Ambulance coordinator and Ambulance Staging Area Manager Inform base hospital or designated patient routing center when all patients have been transported

32 AIR AMBULANCE COORDINATOR The Air Ambulance Coordinator shall establish safe landing zones, coordinate operations with the Air Operations Group, if established, and keep the Medical Transportation Group Supervisor advised of air ambulance availability and capability, and complete applicable sections of the Patient Transportation Summary Worksheet. This is an aviation position that need not be filled with medical personnel. The position report to the Medical Transportation Group Supervisor or the Air Operations Group Supervisor, if filled. Responsibilities: Review common responsibilities Obtain briefing and ICS vest Establish helispots safely away from the incident but accessible, if possible, to the treatment area allowing for the flow of patients without having to vehicle transport to the LZ Coordinate the air space over incident if not assigned to other ICS positions such as Air Operations Communicate destination to aircraft as determined from the medical communications coordinator Document information on Patient Transportation Summary Worksheet and ICS-214

33 MEDICAL STAGING AREA MANAGER The Medical Staging Area Manager is responsible for the coordination of incoming personnel and equipment and reports to the Medical Transportation Group Supervisor. The Ambulance Staging Resources Status form shall be used to track ambulance availability and activities. This person will be located at the staging area to organize ambulances or other medical transportation vehicles, medical equipment, and medical personnel and to dispatch them to duties at the request of the Medical Transportation Group Supervisor. Provide information to complete applicable sections of the Patient Transportation Summary Worksheet as requested. Responsibilities: Review common responsibilities Obtain briefing and ICS vest Establish routes of travel for ambulances for incident operations Establish appropriate staging area for ambulances Establish and maintain communications with the Medical Communications Coordinator and Treatment Unit Leader Inventory ambulance resources available Request additional resources needed Provide inventory of medical supplies available at ambulance staging for use at the incident Complete ICS-214 and MCM Form 404

34 APPENDIX A - GLOSSARY ALS (Advanced Life Support)- Allowable procedures and techniques utilized by paramedic and EMT-II personnel to stabilize critically sick and injured patients which exceed Basic Life Support procedures ALS Responder- Licensed Paramedic or Certified EMT II BLS (Basic Life Support) Basic non-invasive first-aid procedures and techniques utilized by PARAMEDIC, EMT-II, EMT-I and First Responder personnel to stabilize critically sick and injured patients DELAYED TREATMENT- Second priority in patient treatment. These people require rapid aid, but injuries are less severe than immediate victims. EMCC Emergency Medical Care Committee is responsible for reviewing ambulance services and emergency medical care in the county. It is defined in California statute (HSC & ). The Board of Supervisors prescribes the membership. EMT I (Emergency Medical Technician) - An individual trained in Basic Life Support according to the standards prescribed by the Health and Safety Code and who has a current and valid EMT-I certificate in the State of California issued pursuant to the Health and Safety Code. EMT II (Emergency Medical Technician II) An individual with additional training in limited Advanced Life Support according to the standards prescribed by the Health and Safety Code and whom has a current and valid certificate issued pursuant to the Health and Safety Code. FOCUSED HEALTH EMERGENCY- A health emergency in which a number of casualties exist in the field or present themselves at one time at a medical facility. Traditionally known as MCIs. HEALTH EMERGENCY ALERT- An alert issued based on information received by the Modoc Communications Center from an Incident Commander, Fire, Police Officer, or County Health Officer. The alert will be issued to Modoc Medical Center, Surprise Valley District Hospital, the County Health Officer, the six ambulance providers that cover Modoc County, the Modoc County Sheriff or his acting, the Deputy OES Director, and the County Fire and Rescue Coordinator. INTERMEDIATE TREATMENT First priority in patient treatment. These people have life threatening injuries with a high probability of survival. MASS CASUALTY- A health emergency of a size or magnitude that over whelms the health care infrastructure within the operational area and requires additional resources to be brought in from outside.

35 MCI TRAUMA- Multiple or mass casualty situation in which multiple patients must be transported to a trauma center. MCI MEDICAL- Usually four or more non-trauma patients with one or more requiring transport outside of the OA for appropriate treatment. MCI HAZMAT- An incident requiring decontamination of victims MEDICAL FIRST RESPONDER- Personnel who have responsibility to initially respond to emergencies such as firefighters, law enforcement officers lifeguards, forestry personnel, and other public service personnel. These personnel meet federal DOT medical first responder requirements and are certified by Nor-Cal EMS. MEDICAL/HEALTH OPERATIONAL AREA COORDINATOR (MHOAC) Ensures establishment and operation of a 24-hour point of contact capable of communication with local, regional, and state government agencies and officials with emergency management responsibilities; hospitals and other healthcare entities; and individuals who are to be notified/mobilized in the event of activation of disaster medical response system. Position filled by the County Health Officer or designee in Modoc County. MINOR TREATMENT 3 rd priority for treatment. These people are ambulatory or walking wounded and require minimal or no medical aid. MULTI-CASUALTY- Incident with more patients than available resources can manage using routine procedures, usually 4 to 25 patients. OPERATIONAL AREA AMBULANCE COORDINATOR Works in the EMS DOC or OA EOC to coordinate requests for ambulances through the mutual aid system. PARAMEDIC- An individual EMT-I or EMT II who has received additional training in Advanced Life Support according to the Health and Safety Code and who has a current and valid State License issued pursuant to the Health and Safety Code. QUALIFIED- a person meeting the certification and/or requirements established by the agency that has jurisdiction for qualifications. START- Acronym for Simple Triage and Rapid Treatment. This is the initial triage system that has been mandated for use by Nor-Cal EMS. STANDING ORDERS- Policies and Procedures approved by Nor-Cal EMS for use by an EMT-II or Paramedics in situations where direct voice contact with a Base Hospital cannot be established or maintained.

36 UNFOCUSED HEALTH EMERGENCY- a health emergency that ramps up with the number of casualties increasing over time. This type of emergency may initially go undetected and the first indication of a health emergency is from the commonalty of the symptoms amongst patients. APPENDIX B FORMS Packets of these forms will be provided in the MCI trailer, in each drop kit, and for all medical response vehicles. Versions of ICS forms are available at many websites on-line but may vary in some details from those presented here. 1. Multi-Casualty Branch Worksheet Form Organizations and assignments 2. Ambulance Staging Resources Status Form resource tracking 3. Patient Transportation Summary Worksheet patient tracking 4. Medical Supply Receipt & Inventory Form

37 ICS-MC Multi-Casualty Branch Worksheet Incident Name Date Time Incident Commander Branch Director Medical Group/Division Supervisor Patient Transportation Group Supervisor Medical Supply Coordinator Treatment Unit Leader Medical Communications Coordinator Triage Unit Leader Immediate Treatment Leader Air Ambulance Coordinator Triage Personnel Delayed Treatment Leader Ground Ambulance Coordinator Minor Treatment Leader Morgue Manager Medical Caches Air Ambulance Law Enforcement Radio Frequencies Coroner Red Cross Chaplain Buses Mental Health Other Other

38 APPENDIX NORCAL EMS POLICY 204 From the Northern California EMS, Inc. Policy & Procedure Manual Miscellaneous Policies Module Policy Effective Date: July 1, 1999 LOCAL MEDICAL EMERGENCY PURPOSE: To provide guidelines to prehospital personnel providers and personnel regarding the treatment and transportation of patients during a Local Medical Emergency (see definition). The individual county s disaster plan will be utilized in conjunction with this policy during a disaster. DEFINITION: Local Medical Emergency - exists when a governing body of a city or a county, or by an official so designated by ordinance has made a proclamation, as termed by Government Code Section POLICY: It will be the policy of prehospital care providers and personnel to follow the procedures and guidelines outlined below with regards to the treatment and transportation of patients during a Local Medical Emergency. BLS/ALS ENACTMENT OF PROTOCOL: 1. A public safety agency of the affected jurisdiction shall notify their communications center of the proclamation of a local emergency, and shall provide information specifying the geographical area where it exists. 2. The communications center shall notify: The County Health Officer or designee. The County Sheriff s Department. Other communications centers in the local area that might be affected by the emergency. Area prehospital providers. Area hospitals. 3. This proclamation will remain in effect for the duration of the Local Medical Emergency or until rescinded by the County Health Officer (Operational Area Medical Coordinator) or his/her designee.

39 MEDICAL CONTROL: 1. ALS and BLS personnel may function within their scope of practice as established in the protocols without base hospital contact. 2. No care will be given unless the scene is secured and safe for EMS personnel. TRANSPORTATION: 1. When possible, patients should be transported to the most appropriate facility (outside the affected area) or staging area. 2. Transporting agencies may utilize BLS units for patient transport as dictated by resources. In cases where ambulances are not available, personnel will utilize the most appropriate method of transportation at their disposal. 3. Patients too unstable to be transported outside the affected area should be transferred to the closest secured appropriate facility. 4. All refusals of care will accompany the run report and signature of the patient as scene safety allows. 5. When possible, receiving facilities should be contacted with the following information: ETA. Number of patients. Patient status: Minor, Immediate, or Delayed. Chief complaint. DOCUMENTATION: Provider and transporting agencies may utilize triage tags as the minimum documentation requirement. The following conditions will apply: A patient transport log will be kept indicating time, incident number, patient number (triage tag), and receiving facility. 1. One corner to be kept by the jurisdictional pubic safety agency. 2. One corner to be retained by the transporting agency 3. Remaining portion of the triage tag is to accompany the patient to the receiving facility, which is to be entered into the patient s medical record. 4. All Radio Communications Failure reports and any other locally required reports will be suspended for the duration of the Local Medical Emergency.

40 BASE HOSPITAL RESPONSIBILITIES: Will conduct a survey of the overall capacity of each hospital to support patients in accordance with immediate and delayed categories. This information will be given to the Medical Unit Leader as requested. RESPONSIBILITIES OF RECEIVING FACILITIES: 1. Upon notification of a Local Medical Emergency by the base hospital, will: Provide hospital bed availability and emergency department capabilities for immediate and delayed patients. Provide the base hospital with hospital status every four hours, upon request, or when capacities are reached. 2. Will not implement Hospital Diversion policy during disaster. 3. Will consider establishing (strongly recommended) a triage area in order to evaluate incoming patients. 4. Will consider implementing its disaster plan (in the event that incoming patients overload the service delivery capacity of the receiving facility). 5. Will evacuate stable patients when facility is saturated. Movement of these patients should be coordinated with the communications center and in accordance with COBRA regulations. POST-INCIDENT MANAGEMENT: Within twenty-four hours (24) of the termination of the incident, the public agency having jurisdiction will notify Nor-Cal EMS of the Local Medical Emergency. The jurisdictional agency will provide the following information to Nor-Cal EMS: 1. Type of incident. 2. Number of patients involved: Delayed Immediate Fatalities 3. Number of patients transported. 4. Number and name of agencies involved. 5. Any rescuers that were injured.