EMS Consequence Management: The ICS Elephant in the Room

As I was looking for ideas for this new EMS Consequence Management column, I ran across an article written by EMS Chief Skip Kirkwood in the February 2008 issue of EMS Magazine entitled: "NIMS and ICS: From Compliance to Competence." In the article, the author challenges us to not only be compliant, but to also be up to speed on how EMS fits into the incident command system (ICS).

Many in EMS feel this ICS animal is only for the fire service. And many are not competent in using this incident organizational method that is not only a presidential directive, but also a proven approach for the tackling domestic all-hazard incidents, both manmade and natural.

Released in 2003, Presidential Directives 5 and 8 address first responders, governmental and private sectors and preparedness as they relate to better management of all-hazard incidents. We have all taken required ICS and NIMS (National Incident Management System) courses via classroom instruction or the Internet, but I wonder how competent we are three years after Chief Kirkwood's article.

Elements to Refresh Your Memory

It's a huge task to understand and utilize the ICS, which was developed in the 1970s to improve scene organization and accountability of wildland fires. To be truthful, the simplicity of ICS is knowing your role in it.

Following are some ICS elements that may refresh your understanding:

• ICS is a standardized on-scene all-hazard management concept.
• ICS is flexible. It can change its size to accommodate the incident.
• ICS has a top-down organizational structure which begins when the first responder on the scene becomes the incident commander. It expands as necessary.
• ICS involves the designation and coordination of elements such as extrication, triage, treatment, transport and staging, which are all EMS-intensive.

Incident command can be singular or unified depending on the incident. With singular command, one person coordinates the incident. It is most useful in smaller, single-jurisdictional incidents. With unified command, officers from different jurisdictions share command. It is used for very large events.

Responsibilities of the incident commander are resource intensive and strategic in nature. Some important aspects related to a successful command and positive patient outcome include:

• Establish communications and request additional resources.
• Stabilize the incident and provide for life safety, accountability and welfare of all personnel, including EMS.
• Ensure all patients are extricated, triaged/treated and transported to medical facilities.

Good incident commanders know that at the end of every successful rescue or operation there are patients. If they don't understand that concept, it's just a body recovery operation.

Break It Down

The ICS management tool breaks things down into pieces. For many EMS systems, ICS will only be utilized during multi-agency responses to mass casualty incidents or mass gatherings and special events. These are huge resource-intensive operations that need to be broken down into manageable bites. We might ask, so how do you eat an elephant? The answer: one bite at a time.

Let's look at the EMS role in a successful ICS operation and our piece of the elephant.

Medical Branch

As Figure 1 depicts, the basic function of the medical branch is to improve medical management of the incident and to properly carry out triage, treatment and transport of patients at the scene. As mentioned previously, these scenes are all-hazard in nature. You may be required to medically monitor other rescuers during hazmat operations in addition to monitoring patients involved in the incident. Your involvement could also include medical expertise in prehospital care with direct patient contact during extrication in a structural collapse or confined-space operation.

The medical branch of ICS falls under the responsibility of operations. Given the top-down organizational structure, the medical branch director is the person responsible to operations. According to ICS, the initial EMS person assigned to the incident is the medical branch director.

As the incident expands, the medical branch director can be turned over to an EMS individual of rank. The medical branch director will exert command and control over all patient care activities and all EMS operations. The director coordinates the medical needs with operations and conducts this strategic position for the duration of the incident. You notice I said strategic. This position is not involved with the hands-on tactical operations or patient care. This position is the ultimate go-to person for EMS resources related to triage, treatment and transport.

Medical Group

The basic function of the medical group or division supervisor is to remain in contact with the medical branch director for the duration of the incident. This person directs EMS operations at the incident site, managing situational issues and resources. Tactical aspects of triage, treatment and transport divisions report to this level. This position within the medical branch is also strategic in nature and coordinates closer to the activity at the incident while the medical branch director is in closer proximity to the incident commander at the command post for quick intervention at a command level.

Groups and Divisions

A group is a functional responsibility. For example, you may be assigned to a triage group or a treatment group.

A division is a geographical location of the group. The incident may be large in scale and need one or more triage or treatment groups functioning at the same time. So according to the incident or location of the patients, there may be a division A treatment group and a division B treatment group. Each group also has a group leader, such as the triage group leader, who sees to the group's efficiency and relays its needs to the medical group supervisor.

Therefore, remember:

• Groups are specific functions or personnel responsible for a task, e.g., a triage group.
• Divisions are geographical locations of functional groups.
• Group leaders are responsible for the functional groups. They report group status to the medical group supervisor, who in turn directs the operations and request needs to the medical branch director, who has direct contact with incident commanders who make it happen.

Triage Group

The triage group, under the direction of the triage group leader, determines the location of triage areas. This group utilizes an approved triage system such as START, SAL or whatever local protocol dictates. The triage group leader communicates resource requirements to the medical group supervisor, who ensures resources through the medical branch director.

Treatment Group

The treatment group determines treatment location and coordinates efforts with the triage group to move patients from the triage division to the treatment division. The treatment group leader maintains communications with the medical group supervisor. This group reassesses patients and conducts secondary triage to match patients with resources in relationship to transportation groups and divisions.

Transportation Group

The transportation group manages patient movement and accountability from the scene to receiving hospitals, or alternative care sites, in disasters where the infrastructure has been incapacitated. The transportation group works with the treatment group to establish adequately sized, easily identifiable patient-loading areas; designates an ambulance staging division; and maintains communication with the medical group supervisor for situation briefings and resource allocation.

Electronic Patient Tracking

Through lessons learned in recent disasters, such as Hurricane Katrina, electronic patient tracking is becoming the tool of choice to account for patients from the prehospital setting to arrival at the hospital or alternative care facility.

Utilizing a bar-coded triage tag and portable electronic scanner, the triage tag is scanned with key patient information in the treatment or transport division. A patient photograph is also captured and stored for identification. Through a server at a remote location, the information can be transmitted to the receiving hospital or alternative care facility while the patient is in transit. Patient information is captured again as he or she arrives at the hospital for further accountability.

Medical Logistics/Staging Division

The medical logistics/staging division is the location designated to collect available resources near the incident area. Several staging divisions may be required. Select a location that is easy for arriving resources to locate. Logistics and staging divisions may need to be relocated as the situation dictates.

The Benefit to EMS?

Why is this ICS business necessary for EMS?

• It allows for better scene management with an organized method.
• It allows for timely patient management.
• It allows EMS to correct deficiencies in response to large-scale events.

Whatever model of EMS service delivery your community utilizes, the day will come when you will interact on a large scale with other agencies. The proven method of working together successfully is NIMS and ICS, which instill a core set of concepts utilizing common principles, common terminology and emerging technologies, and interoperable communication with incorporated information sharing.

So we're back to how you eat an elephant. One bite at a time. The piece we have to chew on and be competent in is the medical branch and its function within ICS. As Chief Kirkwood indicated several years ago, we owe it to our communities. Ask yourself and the service you work for if you're ready for the big one, and if your community can depend on you to work seamlessly with other agencies that will respond to needs during a tornado, flood, hurricane or a terrorist event.

You can find very useful resources at the FEMA Emergency Management Institute website at https://training.fema.gov/EMIWeb/IS/ICSResource/index.htm.

J. Harold "Jim" Logan, BS, EMT-P/IC, is a 27-year veteran of private and fire-based EMS and serves as a lieutenant firefighter/paramedic for the Memphis Fire Department in an EMS administration capacity, specializing in EMS consequence management, quality improvement, and education. He is a nationally known author for several trade journals. He is an EMS instructor coordinator and fire instructor for the Memphis Fire Department and the state of Tennessee. He holds a bachelor's degree in health and safety. For more than a decade, he has also served as a rescue/medical specialist and a medical coordinator for FEMA's Tennessee Task Force One Urban Search and Rescue Team. Contact him at jimlogan1@comcast.net.