ࡱ> ] էbjbj:/:/ .XEbXEb-j(j(j(j(j(~(~(~(8(B)~(֯******,|-@UWWWWWW$N{j(]-**]-]-{j(j(**000]-j(*j(*U0]-U00ͣ%*60ф."ѧZA0֯+>7.>%>j(%]-]-0]-]-]-]-]-{{0]-]-]-֯]-]-]-]->]-]-]-]-]-]-]-]-]-B 0': Chapter 21 Incident Management Unit Summary After students complete this chapter and the related coursework, they will understand the general approach to hazardous materials (HazMat) incidents, the process of triage at mass-casualty incidents, and the principles of the National Incident Management System (NIMS). They will also have an increased awareness of terrorism and the types of agents that might be used in a terrorist event. The role of EMRs at terrorist incidents is explained and the importance of safety, preparedness, and the use of incident command is stressed. National EMS Education Standard Competencies EMS Operations Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety. Incident Management Establish and work within the incident management system. (pp 439-442) Mass-Casualty Incidents Triage principles (pp 437-440) Resource management (pp 436-437; pp 439-442) Hazardous Materials Awareness Risks and responsibilities of operating in a cold zone at a HazMat or other special incident. (pp 434-435) Mass-Casualty Incidents due to Terrorism and Disaster Risks and responsibilities of operating on the scene of a natural or man-made disaster. (pp 439-443; pp 445-449) Knowledge Objectives 1. State the responsibilities of emergency medical responders (EMRs) in incidents where HazMat are present. (pp 434-435) 2. Describe the actions EMRs should take in HazMat incidents before the arrival of specially trained personnel. (pp 434-435) 3. Discuss the different areas of a HazMat scene. (p 435) 4. Define a mass-casualty incident. (pp 435-436) 5. Describe the role of EMRs in a mass-casualty incident. (pp 435-440) 6. Explain the steps in the START triage system. (pp 438-440) 7. Describe the purpose of the National Incident Management System (NIMS). (p 441) 8. Define terrorism and weapons of mass destruction (WMD). (p 442) 9. Describe potential terrorist targets and risks. (pp 442-443) 10. Explain the risks posed by explosives and incendiary devices. (p 443; p 445) 11. Explain the risks posed by the following chemical agents: Pulmonary agents (p 445) Metabolic agents (p 445) Insecticides (pp 445-446) Nerve agents (p 446) Blister agents (p 446) 12. Explain the risks posed by biologic agents. (pp 446-447) 13. Explain the risks posed by radiologic agents. (p 448) 14. Describe the role of EMRs in a terrorist event. (p 449) Skills Objectives 1. Demonstrate the actions EMRs should take in HazMat incidents before the arrival of specially trained personnel. (pp 434-435) 2. Demonstrate triage of a mass-casualty incident using the START triage system. (pp 437-439) Readings and Preparation Review all instructional materials, including Emergency Medical Responder, Sixth Edition, Chapter 21, and all related presentation support materials. To properly put NIMS in perspective, it is important to understand what drives it and its foundation. The following two sites outline the history behind the Incident Command System (ICS) as well as the executive order that promotes it: US Department of Homeland Security: www.dhs.gov/xabout/laws/gc_1214592333605.shtm National Wildfire Coordinating Group: www.nwcg.gov/pms/forms/compan/history.pdf Review the locally approved ICS and incident management system organization. Review the local multiple-patient/mass-casualty incident protocols and triage system. Support Materials Lecture PowerPoint presentation Locally approved triage tags Locally approved ICS organization charts Current edition of the Emergency Response Guidebook START triage information Enhancements Direct students to visit Navigate 2. The following sites provide examples of ICS charts and best practices: Central Mass Emergency Medical Systems, Incident Command System Charts: www.cmemsc.org/news/mci_orgchart.pdf Kansas Department of Health and Environment, Guidance and Best Practices: www.kdheks.gov/cphp/download/EMS_Planning_Guidance.pdf Independent study courses on terrorism, incident command, and WMD are available from the Federal Emergency Management Agency (FEMA). To learn more, go to the FEMA web site. Teaching Tips Contact local emergency managers to discuss local emergency response plans. If time allows, or if a local disaster drill is scheduled, you should attempt to provide students with the opportunity to practice triage. The use of moulaged volunteers can greatly enhance a students perspective of a triage situation. Unit Activities Writing activities: You may wish to direct your students to the various operations courses offered by FEMA. 1. ICS100A An Introduction to Incident Command System: http://training.fema.gov/EMIWeb/IS/IS100a.asp 2. ICS200 ICS for Single Resources and Initial Action Incidents: http://training.fema.gov/EMIWeb/IS/IS200a.asp 3. ICS700 NIMS, An Introduction: http://training.fema.gov/EMIWeb/IS/IS700a.asp 4. ICS800 National Response Framework, An Introduction: http://training.fema.gov/EMIWeb/IS/is800b.asp Student presentations: Break the class into small groups and provide each group with an index card containing patient scenario information. Ask each group to assign their patient to a triage category (minimal, delayed, immediate, expectant). This category should be based on the START triage method and on the patient information provided on the card. Have the students compare their triage tags with the other groups, and have them justify or explain their rationale. Group activities: Facilitate a group discussion of transportation elements and the various formats of triage. Medical terminology review: Create a matching activity using the Vital Vocabulary terms and definitions at the end of Chapter 21. Ask students to complete the activity alone or in groups of two. Jeopardy templates are available on the Internet. Visual thinking: Bring a copy of the Emergency Response Guidebook (ERG) to class or access it online. The web link is www.phmsa.dot.gov/staticfiles/PHMSA/DownloadableFiles/Files/erg2008_eng.pdf. Introduce students to the ERG, including how it is organized, when it is used, and how it is used. Finally, quiz students on basic information found in the ERG. Pre-Lecture You are the Provider You are the Provider is a progressive case study that encourages critical thinking skills. Instructor Directions 1. Direct students to read the You are the Provider scenario found throughout Chapter 21. 2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions. 3. You may also use this exercise as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. As an EMR, you should be able to identify the signs of a hazardous materials (HazMat) incident and prevent injury to yourself and to others in the first minutes of the incident. B. It is important for you to understand 1. The purpose of an incident management system 2. The framework of the National Incident Management System (NIMS) 3. Basic triage C. You should also increase your awareness of the possibility of terrorism. II. Hazardous Materials Incidents A. Hazardous materials (HazMat) are substances that are toxic, poisonous, radioactive, flammable, or explosive and can cause injury or death with exposure. B. During a HazMat incident, your top priority is to protect yourself and bystanders from exposure and contamination. C. Response to HazMat incidents 1. Identify the substance(s) involved. a. Federal law requires that all vehicles containing certain quantities of hazardous materials display a HazMat placard. b. The placard should include a four-digit identification number, which can be used to identify the substance and to obtain emergency information. 2. The Emergency Response Guidebook lists: a. The most common hazardous materials b. Their four-digit identification numbers c. Proper emergency actions to control the scene when these materials are present d. Emergency care of patients who become ill or injured after exposure to these substances 3. Unless you have received training in handling hazardous materials, keep away from the contaminated area or hot zone. 4. As soon as you recognize that a hazardous materials incident exists, notify the dispatcher so other responders will be aware of the situation. 5. Identify victims who have sustained an acute injury as a result of exposure to hazardous materials. a. Remove them from the contaminated area. b. Have trained personnel decontaminate them. c. Give necessary emergency care. d. Transport them to the hospital. 6. Very few specific antidotes or treatments exist for most HazMat injuries. a. Emergency treatment usually consists of supportive care. b. Constantly reevaluate the patients vital signs, including breathing status. 7. EMRs should receive specific additional training in hazardous waste operations and emergency response (HAZWOPER) to the emergency medical response level. III. Mass-Casualty Incidents A. Mass-casualty incidents (or multiple-casualty incidents) are situations involving more than one sick or injured individual. 1. These situations may range from a serious automobile accident to a building explosion. B. You must first be able to recognize the situation as a mass-casualty incident. 1. These incidents require a very different method of operation from other emergency medical calls. 2. Variables in mass-casualty incidents include a. Severity of the crash b. Access routes c. Available resources d. Response times e. Levels of emergency training f. Overall experience of the emergency medical services (EMS) system 3. Your goal should be to provide the greatest medical benefit for the greatest number of people and to match patients medical needs with appropriate treatment and transportation. C. The visual survey: the eye sees it all 1. As you are on the way to the scene, prepare yourself mentally for what you may find. a. Ask yourself the following questions: i. Where will additional help come from? ii. How long will it take for help to arrive? 2. When you arrive at the scene, force yourself to stay calm. 3. Make a visual assessment of the entire accident scene. a. Number of potential patients b. Severity of their injuries c. How much and what kind of help you will need D. Your initial radio report: creating a verbal image 1. Use clear language, be concise, be calm, and do not shout into the microphone. 2. The key points to communicate include a. Location of the incident b. Type of incident c. Any hazards d. Approximate number of patients e. Type of assistance required 3. Be as specific with your requests as possible. 4. Good rule of thumb: request one ambulance for every five patients. 5. Follow the protocols of your department when calling for additional resources. a. Determine the perimeters for emergency vehicles only and exclude all other vehicles from the area. b. Establish a one-way route for emergency traffic to approach the scene and a separate one-way route for emergency traffic to exit the scene. c. Allow adequate room for emergency vehicles that need to be close to the scene. d. Keep vehicles and personnel who are not needed at the scene at a staging area nearby. E. Casualty sorting (triage): creating order out of chaos 1. Triage, also called casualty sorting, is the sorting of patients into groups according to their need for treatment. a. The purpose of casualty sorting is to determine the order in which patients should be treated so that the most good can be done for the most people. b. The casualty-sorting system should be simple and fast, based on the skills and knowledge you already possess. c. Do not worry about diagnosing patients; categorizing quickly is the basis for a system of rapid, lifesaving actions. d. Do not stop during this assessment, except to correct airway and severe bleeding problems quickly. 2. Many EMS systems rely on the Simple Triage and Rapid Treatment (START) triage system because it is simple and easy to remember and implement. a. START lets EMRs triage each patient in 60 seconds or less, based on three primary observations: i. Breathing ii. Circulation iii. Mental status b. The START triage system is designed to help rescuers find the most seriously injured patients. 3. Triage tagging: telling others what you have found a. Patients are tagged so that other rescuers can easily recognize their triage level. b. Tagging uses colored surveyors tape or colored paper tags, and is based on the method determined by your local EMS system. c. The four colors of triage i. Priority One (red tag): immediate care; injuries are life threatening. ii. Priority Two (yellow tag): urgent care; can delay up to 1 hour. iii. Priority Three (green tag): delayed care, minor care, or hold (walking wounded); can delay up to 3 hours. iv. Priority Four (gray or black tag): patient is dead; no care is required. 4. The first step in START: get up and walk a. Tell all the people who can get up and walk to move to a specific area. b. If patients can get up and walk, they rarely have life-threatening injuries. c. To make the situation more manageable, ask those persons who can walk to move away from the immediate rescue scene to a designated safe area. d. These patients are the walking wounded, designated as Priority Three (green tag/delayed care). 5. The second step in START triage: begin where you stand a. Move in an orderly and systematic manner through the remaining patients. b. Stop at each patient to provide a quick assessment and tagging. i. The stop should never take more than 1 minute. c. Find and tag the Priority One patientsthose requiring immediate attention. d. Examine these patients, correct life-threatening airway and breathing problems, tag the patients with a red tag, and move on. 6. How to evaluate patients using breathing, circulation, and mental status a. The START triage system is based on three observations: breathing, circulation, and mental status. b. Breathing: it all starts here i. Patients with breathing rates greater than 30 breaths/min are tagged as Priority One, Immediate (red tag). ii. If the patient is breathing at a rate less than 30 breaths/min, move on to the circulation and mental status observations. iii. If the patient is not breathing, clear the mouth of any foreign matter, open the airway, position the patient to maintain the airway, andif the patient breathestag the patient as Priority One, immediate (red tag). iv. Patients who need help maintaining an open airway are Priority One (red tags). v. If you are in doubt as to the patients ability to breathe, tag the patient as Priority One (red tag). vi. If the patient is not breathing and does not start breathing with simple airway maneuvers, tag the patient as Priority Four, deceased (gray/black tag). c. Circulation: is oxygen getting around? i. The best field method for checking circulation is the patients carotid pulse. ii. If the carotid pulse is weak or irregular, tag the patient as Priority One, immediate (red tag). iii. If the carotid pulse is strong or if a radial pulse is present, move on to the mental status observation. iv. Treat patients with a weak carotid pulse for shock by elevating the legs to return as much blood as possible to the brain, lungs, and heart. v. Get the patient to assist with controlling the bleeding or ask one of the walking wounded patients to help. vi. If the carotid pulse is absent, tag the patient as Priority Four, deceased (gray/black tag). d. Mental status: open your eyes i. Determine whether the patient responds to verbal stimuli. ii. Patients who can follow simple commands and have adequate breathing and adequate circulation are tagged as Priority Two, delayed (yellow tag). iii. Tag unresponsive patients as Priority One, immediate (red tag). 7. START is just the beginning a. The START triage system is designed to help rescuers find the most seriously injured patients. b. As more rescuers arrive, the patients will be retriaged for further evaluation, treatment, stabilization, and transportation. c. Each mass-casualty scene should have a person designated as the triage officer. d. Injured patients do not always remain in the same condition. i. The process of shock may continue. ii. Some conditions will become more serious as time goes by. iii. If possible, go back and recheck the condition of Priority Two and Priority Three patients. F. Working at a mass-casualty incident 1. If you are not the first person to arrive at the scene of a mass-casualty incident, report to the incident commander before going to work. 2. The incident commander will assign you to an area where your help and skills can best be used. 3. An effective incident command system (ICS) depends on integrated, agreed-upon protocols and procedures involving fire department, law enforcement, and EMS personnel. 4. If you are the first on the scene, you will have to a. Make the initial scene size-up. b. Clearly and accurately report the situation to the dispatcher. c. Conduct the initial START triage. 5. As more highly trained rescue and emergency personnel arrive at the scene, accurately report your findings to the person in charge by noting the following information: a. Approximate number of patients b. Number of patients whom you have triaged into each of the four levels c. Additional assistance required d. Other important information G. National Incident Management System 1. NIMS was developed by the US Department of Homeland Security to provide a consistent and unified approach to handling emergency incidents. 2. NIMS is designed to effectively and efficiently handle the immediate response, mitigation, and long-term recovery of small and massive natural and man-made incidents. 3. NIMS expands on the ICS in your department. 4. Five major areas addressed within the scope of NIMS: a. Preparedness b. Communications and information management c. Resource Management d. Command and Management e. Ongoing Management and Maintenance 5. The ICS consists of six major features. These are a. Standardization b. Command c. Planning/organizational structure d. Facilities and resources e. Communications information management f. Professionalism 6. The EMRs role falls within the command and management component of NIMS. 7. The federal government requires many agencies to utilize NIMS. a. It is recommended that EMRs be certified in the following courses: i. ICS-100: Introduction to ICS ii. FEMA IS-700: NIMS, An Introduction b. Additional information on NIMS is available at the Federal Emergency Management Agency (FEMA) website. IV. Terrorism Awareness A. Terrorism is the systematic use of violence by a group to intimidate a population or government to achieve a goal. B. Terrorist acts may be instigated by a countrys citizens or by people from other countries. C. Terrorists might use a wide variety of methods to incite terror, including the use of 1. Guns 2. Explosives 3. Fire 4. Chemicals 5. Viruses 6. Bacteria 7. Radiation D. The agents used by terrorists are many of the same agents that produce hazards for EMRs in everyday accidents and emergencies. E. Weapons of mass destruction (WMD) 1. Any agent designed to bring about mass death, casualties, and/or massive damage to property and infrastructure 2. Include explosive, chemical, biologic, and nuclear weapons 3. The preferred WMD to date has been explosive devices. a. Truck or car bombs b. Pedestrian suicide bombers 4. Many previous terrorist attempts to use either chemical or biologic weapons to their full capacity have been unsuccessful. F. Potential targets and risks 1. To understand the threat that terrorists pose to people and places, consider the places that terrorists might identify as targets. a. Bridges, tunnels, pipelines, and harbors constitute infrastructure targets. b. National monuments are symbolic targets. c. Housing developments and automobile dealerships have been targeted by ecoterrorists. d. Computer networks and data systems might be targets for cyberterrorists. e. Farms and agricultural installations might be targets for terrorists trying to destroy or taint national food sources. f. Schools, government buildings, churches, and shopping centers represent high-visibility targets. 2. In an open society, a person committed to performing a terrorist act can access most components of the infrastructure. 3. EMRs should always be alert for hazardsthose associated with a terrorist event as well as those connected to any other emergency. G. Agents and devices 1. A wide variety of agents and devices can be used to incite terror, including a. Explosive devices b. Incendiary devices c. Chemical agents d. Biologic agents e. Radiologic agents 2. Explosives and incendiary devices a. Explosives produce a concussion that destroys property and inflicts injury and death. b. Incendiary devices are designed to start fires. c. An explosive device can be hand carried or transported in a heavy truck. d. Often the first indication that an explosive or incendiary device is present is the explosion or fire that results from the deployment of the device. 3. WMD safety considerations a. If you are called to respond to an explosion, be alert for safety hazards that may have been created by the explosion or by a terrorist. b. Do not enter any area that may be unsafe until properly trained personnel assess the risks. c. Be alert for the possibility of a second explosive device that is timed to explode when rescuers are on the scene. d. Use the same safety skills you developed for other types of emergency situations. e. At a WMD scene, you will not be able to enter where the event has occurrednor do you want to. f. Staging should occur upwind and uphill from the incident. 4. Chemical agents a. Industrial-process chemicals can be used to intentionally inflict harm on people. b. Many of the chemical agents that could be used by terrorists are the same chemicals that create HazMat incidents when accidentally released. c. Pulmonary agents i. Pulmonary agents are gases that cause immediate distress and injury. ii. Their primary route of entry into the body is through the airway into the lungs. iii. Once these chemicals are inhaled, they damage lung tissue, which leads to pulmonary edema. iv. Pulmonary agents cause intense coughing, gasping, shortness of breath, and difficulty breathing. v. Phosgene gas is produced by burning Freon, which is found in most air conditioners. vi. The symptoms of phosgene exposure may be delayed for several hours after inhalation of the gas. vii. The safety precautions for an accidental release are the same as the precautions for an intentional release by terrorists: Keep a safe distance away until properly trained HazMat personnel can handle the situation. d. Metabolic agents i. Metabolic agents affect the bodys ability to use oxygen at the cellular level. ii. The most common metabolic agents are cyanides. iii. Cyanides are produced in large quantities and used in gold and silver mining, photography, and plastics processing. iv. Cyanide is also produced by the combustion of plastics and textiles, so there is the potential for cyanide poisoning in any house fire. v. Contact with cyanide produces shortness of breath, flushed skin, rapid heartbeat, seizures, coma, and cardiac arrest. vi. The safety precautions for an accidental release are the same as the precautions for an intentional release by terrorists: Keep a safe distance away until properly trained HazMat personnel can handle the situation. e. Insecticides i. Insecticides are a class of poisonous chemicals that are inhaled or absorbed through the skin. ii. Many insecticides are organophosphates. iii. Absorption of organophosphates produces salivation, sweating, lacrimation (excessive tearing), urination, diarrhea, gastric upset, and emesis (vomiting)known as SLUDGE. iv. Far more emergency providers have experienced accidental contact with insecticides in routine calls than during terrorist-related events. v. In an incident involving an insecticide, keep bystanders far enough away to prevent additional contact with the chemical. vi. In an emergency involving mass people with SLUDGE-like symptoms, assume you are dealing with insecticide poisoning and call for help from a trained HazMat team. vii. Do not make contact with contaminated patients until they have been properly decontaminated by trained personnel. f. Nerve agents i. Nerve agents are among the most deadly chemicals developed. ii. These chemicals can kill large numbers of people with small quantities and cause cardiac arrest within seconds to minutes of exposure. iii. Nerve agents block an essential enzyme in the nervous system and cause SLUDGE-like symptoms. iv. Four of the most commonly mentioned nerve agents are sarin, soman, tabun, and V agent (VX). v. In an emergency situation, your primary responsibility is to keep yourself, other rescuers, and bystanders from becoming contaminated. vi. A well-trained HazMat team in special protective equipment is needed to remove and decontaminate people exposed to these agents. vii. A MARK 1 nerve agent antidote kit and a DuoDote kit contain drugs to counteract the effects of nerve agents. g. Blister agents i. When blister agents come in contact with the skin, they produce burn-like blisters. ii. Inhalation of the vapors of these agents causes burns of the respiratory system. iii. Blister agents produce pain, skin irritation, eye irritation, severe shortness of breath, and severe coughing. iv. Blister agents include sulfur mustard and Lewisite. v. Only well-trained and properly equipped rescuers with self-contained breathing apparatus should approach a scene that might contain these agents. h. Safety considerations when dealing with chemical agents i. If multiple people are experiencing unexplained symptoms, you should suspect a common agent as the cause. ii. Your primary role is to recognize that a problem exists and to avoid contaminating yourself, other rescuers, and bystanders. iii. Stay upwind from any potential source and call for assistance from a properly trained HazMat team. 5. Biologic agents a. Biologic agents are naturally occurring substances that produce diseases. b. They may be bacteria, such as anthrax or the plague, or viruses, such as smallpox or hemorrhagic fever. c. Although biologic agents are hard to disperse so as to contaminate large numbers of people, they could be used as a deadly weapon by terrorists. d. These diseases have an incubation period, which is the time from exposure to the disease organism to the time the person begins to show symptoms of the disease. i. If people were exposed to an infectious organism today, it might be several days before they would show signs of the disease. ii. The first awareness of a biologic terrorist incident would likely come from hospital emergency departments and public health departments. e. Safety considerations when dealing with biologic agents i. Be alert for unusual patterns of diseases with flulike symptoms. ii. Review current information about disease trends provided by your medical director and public health department. iii. Practice appropriate standard precautions. iv. If indications suggest a biologic agent is involved in an incident, call for specially trained assistance and wait in a safe location. v. Patients who have come into direct contact with the agent need to be decontaminated before any EMS contact or treatment is initiated. 6. Radiologic agents a. Ionizing radiation is a kind of energy that is formed by the decay of a naturally occurring or human-made radioactive source. b. Radiation is used in hospitals, research facilities, and nuclear power plants, and for military weapons. i. Exposure to excess amounts can cause delayed illnesses, such as cancer. ii. Exposure to large amounts can cause people to become violently ill within a few hours and may produce death within hours or days. c. Radiation cannot be seen, felt, or detected with any of the normal body senses. i. Special instruments are needed to detect and measure the amount of radiation that is present. d. An explosive device containing a small amount of radioactive material is known as a dirty bomb. i. Such an explosion could contaminate anyone in the vicinity of the blast. e. If the presence of radiation is suspected, stay away from the blast site until specially trained teams check for the presence of radiation with special monitoring devices. H. Your response to terrorist events 1. Emergency response personnel need to develop an all-hazards approach for managing terrorist-related emergencies. 2. In all emergencies, the same safety rules apply a. Good scene safety b. Diligent use of standard precautions 3. Be prepared and know the limits of your training. 4. Many types of terrorist events require you to stay a certain distance away to avoid contaminating additional people. 5. Be alert for secondary devices placed by a terrorist that are set to detonate after emergency responders arrive at the scene. 6. Establish an ICS as soon as possible. a. Know your role in working within the ICS. b. Treat these incidents as mass-casualty situations. c. Establish good working relationships with appropriate local, state, and federal agencies. 7. Always be alert for your safety, the safety of other rescuers, and the safety of patients. V. Summary A. Because you may be the first trained person on the scene of an incident involving hazardous materials, you must be able to identify the potential problem and respond appropriately. B. During a HazMat incident, your top priority is to recognize that a hazard is present and to protect yourself and bystanders from exposure and contamination from the hazardous material. C. You should understand the role of an EMR during the first few minutes of a mass-casualty incident. D. The START system is a simple triage system that you can use at mass-casualty incidents. It sorts patients in groups so that the most seriously injured patients are treated and transported first. E. The National Incident Management System is designed to provide a unified approach to emergency incidents of any size that involve multiple agencies anywhere in the United States. All emergency responders need to have some understanding of this system. F. Terrorist attacks, although rare, are a concern for emergency providers. The goal of terrorists is to intimidate a population or government so as to achieve a goal. Terrorists may use many different approaches to incite terror, including explosives, fire, chemicals, viruses, bacteria, and radiation. G. Chemical agents are man-made substances that can have devastating effects on living organisms. They include pulmonary, metabolic, insecticides, nerve, and blister agents. H. Biologic agents are organisms that cause disease. They are generally found in nature and can be weaponized to maximize the number of people exposed to the germ. I. Radiologic weapons can create a massive amount of destruction. They include radiologic dispersal devices, also known as dirty bombs. J. EMRs need to consider their safety, the safety of other rescuers, and the safety of bystanders whenever dealing with a terrorist-related event. Identifying potential threats, ensuring safety, and calling for specially trained personnel to deal with these threats are the EMRs responsibilities in many of these situations. Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructors presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities. Assessment in Action This activity allows the student an opportunity to analyze an emergency care scenario and develop responses to critical-thinking questions. This scenario is designed to get EMRs to consider the steps they would take if dispatched to a hazardous materials event. Instructor Directions 1. Direct students to read the Assessment in Action scenario located in the Prep Kit at the end of Chapter 21. 2. Direct students to read and individually answer the quiz questions at the end of the scenario. Facilitate a class review and discussion of the answers, allowing students to correct their responses as needed. Use the quiz question answers noted here to assist in building this review. 3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper. Answers to Assessment in Action Questions 1. Answer: C Enter the school building to investigate. 2. Answer: D Highway department 3. Answer: B Pulmonary agent 4. Answer: C Instruct patients who can walk to move to a specified area. 5. Answer: C, D, B, A 6. Answer: The location of the incident, the type of incident, any hazards, the approximate number of patients, and the type of assistance required 7. Answer: Your primary goals when assessing patients in a mass-casualty incident are to provide the greatest medical benefit for the greatest number of patients and to match the patients medical needs with appropriate medical treatment and transportation. To accomplish this you must be able to identify those patients most in need of tratment and those who can wait. 8. Answer: The types of treatment you want to avoid in a mass-casualty incident are those that tie up trained personnel for an extended period of time providing care for a single patient. You want to provide the most good for the greatest number of patients and to arrange for transportation to an appropriate medical facility in the most efficient manner possible. 9. Answer: Because you are at a school and most of these patients are likely minors, the rule of implied consent applies in emergency situations. In some states, teachers and school administrators have the legal right to authorize emergency medical care; however, having a school official contact parents/guardians for consent is always best. For those patients who are legal adults, the rules of informed consent apply. 10. Answer: Until the scene has been assessed and cleared by the HazMat team, there is always a possibility that more people will become symptomatic, including EMS providers. Remember, your safety and the safety of others around you are your primary concern at a HazMat scene. Make sure you account for every person who might have been exposed to the agent, and assess for any signs or symptoms related to the exposure. Also verify all people are out of the building and are at a safe distance away from the scene. If any other patients show signs or symptoms, immediately triage them and assign them to a treatment area. Lesson Review A. In the START triage system, what does the START acronym stand for? (Lecture III-E) B. Place the following steps of the START triage system in the proper order. (Lecture III-E) ____ A. Circulation ____ B. Mental status ____ C. Breathing C. In triage tagging, what are the four levels/colors? (Lecture III-E) D. If you are called to a mass-casualty incident and are not the first to arrive, what are your responsibilities as an EMR? (Lecture III-F) E. What is the purpose of the National Incident Management System (NIMS)? (Lecture III-G) F. Which kinds of places might potentially be targets for terrorist attacks? (Lecture IV-F) G. Name four kinds of agents or devices that may be used to incite terror. (Lecture IV-G) H. What are the SLUDGE-like symptoms? (Lecture IV-G) I. Explain the safety considerations for EMRs when dealing with an attack involving a biologic agent. (Lecture IV-G) Assignments A. Complete all the Student Workbook activities for Chapter 21. B. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by the instructor). Unit Assessment Keyed for Instructors 1. What is another term for the area contaminated by hazardous materials? A. hot zone B. warm zone C. cold zone D. neutral zone Answer: A p 435 2. What is the purpose of triage? A. to ensure that the most critical patients receive treatment first B. to convey to others how many patients require treatment and the severity of their injuries C. to transport patients to the appropriate facility D. all of the above Answer: D p 437 3. The first step in the START system is to A. begin tagging patients. B. walk among the injured patients. C. instruct patients who can walk to move to a specified area. D. ask each patient if he or she can walk to a different area. Answer: C p 438 4. What is a weapon of mass destruction? Answer: Any agent designed to bring about mass death, casualties, and/or massive damage to property and infrastructure p 442 5. A secondary explosive device refers to a device that is intended to A. make the initial explosion more intensive. B. explode when rescuers have arrived on the scene. C. minimize the initial explosion. D. defuse the initial explosive device. Answer: B P 449 6. Pulmonary agents used in weapons of mass destruction tend to cause which sign or symptom? A. shortness of breath B. bleeding in the lungs C. blistering on the skin D. vomiting Answer: A p 445 7. What does each letter in the acronym SLUDGE represent? S __________________________________________________ L __________________________________________________ U __________________________________________________ D __________________________________________________ G __________________________________________________ E __________________________________________________ Answer: Salivation, sweating; lacrimation; urination; defecation, diarrhea; gastric upset; emesis p 446 8. What is the EMRs primary responsibility when responding to a report of a nerve agent release? A. Remove victims from the scene. B. Determine exactly which nerve agent has been released. C. Ensure personal safety so as not to become contaminated. D. Administer Mark 1 kits to the incoming rescuers. Answer: C p 446 9. What is the incubation period for biologic agents? A. the time it takes for the agent to enter a human B. the time it takes for the number of organisms to double C. the time it takes from exposure to showing signs and/or symptoms D. the time it takes for the disease to respond to treatment Answer: C p 447 10. What is a dirty bomb? Answer: An explosive device containing a small amount of radioactive material p 448 Unit Assessment 1. What is another term for the area contaminated by hazardous materials? A. hot zone B. warm zone C. cold zone D. neutral zone 2. What is the purpose of triage? A. to ensure that the most critical patients receive treatment first B. to convey to others how many patients require treatment and the severity of their injuries C. to transport patients to the appropriate facility D. all of the above 3. The first step in the START system is to A. begin tagging patients. B. walk among the injured patients. C. instruct patients who can walk to move to a specified area. D. ask each patient if he or she can walk to a different area. 4. What is a weapon of mass destruction? 5. A secondary explosive device refers to a device that is intended to A. make the initial explosion more intensive. B. explode when rescuers have arrived on the scene. C. minimize the initial explosion. D. defuse the initial explosive device. 6. Pulmonary agents used in weapons of mass destruction tend to cause which sign or symptom? A. shortness of breath B. bleeding in the lungs C. blistering on the skin D. vomiting 7. What does each letter in the acronym SLUDGE represent? S __________________________________________________ L __________________________________________________ U __________________________________________________ D __________________________________________________ G __________________________________________________ E __________________________________________________ 8. What is the EMRs primary responsibility when responding to a report of a nerve agent release? A. Remove victims from the scene. B. Determine exactly which nerve agent has been released. C. Ensure personal safety so as not to become contaminated. D. Administer Mark 1 kits to the incoming rescuers. 9. What is the incubation period for biologic agents? A. the time it takes for the agent to enter a human B. the time it takes for the number of organisms to double C. the time it takes from exposure to showing signs and/or symptoms D. the time it takes for the disease to respond to treatment 10. What is a dirty bomb?     Emergency Medical Responder, Sixth Edition Chapter 21: Incident Management 2018 Jones & Bartlett Learning, LLC, an Ascend Learning Company  PAGE 1 ,fg8 A n } 6 = ? C m v  ) 0 2 h  0 3 5 I O a h !04JSqrwx|&+۳įۯ۫ۯ۫hQhv9Rhfdh v56\]h"h%Shfdh vB*phhBhUH hfdh v hfdh vB*mHnHphuhfdh vmHnHuC ,A n } ? 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