NIMS and ICS: From Compliance to Competence

In February 2003, President George W. Bush issued Homeland Security Presidential Directive No. 5 (HSPD-5), which mandated the development of the National Incident Management System (NIMS), including the Incident Command System (ICS). "Compliance" would become an essential element of future life, including eligibility for homeland security grant funding and other federal largesse.

What resulted-to the point of overloading the training and certification infrastructure at the U.S. Fire Administration's online training center-was a frenzy of computer-based training and certification, as providers logged in to complete ICS 100, 200, 700 and 800. Leaders and planners convened to change the terminology of their jurisdictions' emergency-operations plans, making them, too, "NIMS-compliant."

The good news now: Many, if not most, of our agencies are now NIMS-compliant. The bad news: Many of us have the illusion that we are also NIMS-competent. But those who actually manage incidents on the street have, in many jurisdictions, observed that in practice, little has changed. Practitioners have either refused to change the way they've done business for years, or they've continued the same old practices with a different vocabulary. Our colleagues in the fire service continue to be the most proficient users of the Incident Command System, because they use it more than EMS or law enforcement agencies.

WHAT IT TAKES
     To become ICS-competent, an EMS agency must make a concerted effort to develop and improve its competence in the use of the techniques, tools, practices and vocabulary of ICS. There are several components of such an effort:

1. Policy and procedure-The agency will have to develop policies concerning training, implementation and evaluation of ICS.
2. Time and tools-The agency will have to devote staff time to training and provide the tools necessary for on-scene ICS. This means radios, vests and incident management boards for every vehicle. Most agencies will require sessions with outside trainers to build momentum.
3. Walk the talk-Chief officers will need to work hard to develop their own ICS competence. You will be unable to motivate your line staff to utilize good ICS at street level if your command officers are not observed to be ICS-competent at larger incidents.
4. Interagency relations-An EMS agency that has not previously involved itself in ICS, but rather stood back and allowed fire and police to manage incidents no matter the nature will have an awkward time when it begins to "do ICS." There will be reactions ranging from surprise to resistance when, for the first time, an EMS unit arrives on a scene, provides a size-up and assumes command. Leadership needs to deal with interagency friction in advance, and be prepared to deal with whatever may result on a day-to-basis. Remember, we're all required to do ICS in the post-HSPD-5 era.

TRAINING
     Computer-based ICS training does not translate well to implementation in the field. An agency needs to devote some training time to ICS. An orderly process will be needed to move from the awareness provided by computerized ICS courses to proficiency in implementation. We think in terms of "crawl, walk, run," but we may be more successful if we "crawl, crawl a little faster, walk with support," etc. This requires:

1. Training in the practical application of the policy or procedure-Lecture/demonstration will be needed to introduce the new standard to the staff and demonstrate how it should be applied. Creative use of video, incident radio recordings, etc., may make what could be a dry session more interesting.
2. Tabletop or classroom activities with hands-on use of radios, vests and command boards-Facilitators inject scenarios, provide resources, etc. For a first step, try a tabletop that involves managing a three-car crash with four patients. Keep it simple, and don't inject so many confounders that you eliminate the possibility of success.
3. Live scenarios-Again, keep them small and encourage success. To add some realistic interaction, recruit police and fire officers as simulators.
4. Larger scenarios and interagency exercises-These will be important, but don't move to larger problems until you've become good at solving the smaller ones.

THE LINGO COUNTS
     In order for officers and trainers to be aware of current incident management practices they should regularly observe practices at emergency scenes, monitor radio traffic and provide feedback to those engaged in the process.

Successful integration with other services will require demonstration of competence. EMS providers can't expect acceptance by their fire service and law enforcement colleagues in an ICS situation if the EMS personnel can't use ICS terminology correctly. It is an ongoing effort to banish the terms Medical Command and EMS Command from my EMS system's vocabulary, even though everyone demonstrates on ICS tests that they know there's only one Command for each incident.

If you experience larger incidents, conduct formal post-incident analyses or critiques. Get the radio tapes and pictures and video from the media, and walk through the ICS elements. Develop lists of "take away" or learning points that can be shared throughout the agency.

THE WAKE COUNTY EXPERIENCE
     Wake County (NC) EMS Division is an all-paramedic county public safety division with 130 full-time employees operating 15 units 24/7 and three peak-activity units 12 hours a day. The service runs 9-1-1 emergency calls only, and handled about 38,000 requests for service last year in Raleigh (the state capital and county seat), several smaller municipalities and some unincorporated portions of the county. The service area is approximately 340 square miles and home to about 450,000.

Several major events throughout 2005-06 heightened our focus on good incident management skills. A train wreck involving 182 passengers, a large NDMS and evacuee reception operation following hurricanes Katrina and Rita, a large hazardous-materials incident that required evacuation of a nursing home, and several smaller events helped focus our attention on this important subject.

At the same time, Chief John McGrath took the helm of the Raleigh Fire Department, which is our primary medical coresponder. A 30-year veteran of the Philadelphia Fire Department and participant in some of its most notable major emergencies, McGrath is a huge proponent of ICS excellence and responder safety. Wake County EMS and Raleigh Fire enjoy an outstanding working relationship on the street as well as in the administrative suites. Chief McGrath and I agreed that we would work together to enhance our organizations' ICS capability.

One of the first initiatives was a commitment to practice ICS on every incident. This practice, which seems to have originated in Phoenix, calls for providing a size-up and establishing Command on every call. The theory is that you can't get good at ICS for "the big one" unless you use the skills, tools and vocabulary every day. This was initially met with a little resistance and a lot of good-natured teasing, but it continues today.

A second initiative was the development of joint advanced ICS training programs for public-safety supervisors. While ICS 100 and 200 can be taken online, ICS 300 and 400 require classroom participation. Wake County EMS worked with both RFD and the Wake County Fire-Rescue Division (a central service provider for the 20-plus municipal and private volunteer fire departments in the county) to develop and deliver advanced ICS courses for all of the public-safety and other involved disciplines. These occur on an ongoing basis, with initial delivery through 2006-07. Law enforcement, fire and EMS supervisors train with the same officers with whom they will actually manage incidents.

A third initiative involved procuring and providing ICS tools to units that didn't have them. For Wake County EMS, which already provides its staff with head-to-toe NFPA 1999/1951-compliant (EMS and USAR) turnout gear, that meant procuring and using the following items:

1. Helmet shields that reflect unit assignments for all EMS personnel;
2. "Passport" personnel accountability tags for all EMS personnel and vehicles;
3. Initial incident command boards for all EMS units, and larger command boards and accountability boards for EMS supervisor and chief officer units;
4. ICS vest kits for all EMS units (Command, Medical, Triage, Treatment and Transportation), and larger kits for EMS supervisor and chief officer units (the above, plus Operations, Plans, Safety and Logistics).

At the same time, Wake County EMS took delivery of a new major-operations support unit, Truck 1, which has both mass-casualty and responder-rehabilitation capabilities. Truck 1 is dispatched to all incidents with MCI or prolonged-operations potential (including greater alarm fires). In addition to medical care equipment, it carries fans, "cooling chairs," electrolyte drink mix and equipment for medical monitoring, including for carbon monoxide exposure. The capabilities of this unit, and the commitment to our response partners that it represents, have further contributed to improved major emergency operations.

A fourth initiative involves ongoing monitoring, observation, feedback and continuous learning. Senior officers responding to incidents will allow, as resources permit, more junior officers to remain in ICS positions while they assist, observe and coach. This allows line officers to gain valuable experience and confidence as ICS practitioners. Each incident is documented with an after-action report, and major incident highlights are periodically collated and presented to all system members as part of continuing education programs.

The result of these efforts has been an improving incident management climate. EMS officers are integral elements of the command and general staff at major emergencies, and functions and tasks that were often overlooked or addressed late in the game are addressed earlier, to the benefit of citizens and responders alike. This growing comfort with interagency incident management and safety has set the stage for Wake County EMS's latest operational initiative: the high-rise fire scene rehabilitation protocol. Instead of establishing rehab at the lobby level, EMS medics will establish it at the fire service forward operating post, two floors below the fire. This will make prompt medical intervention more readily available to firefighters and reduce firefighter fatigue by limiting the time and climbing necessary to return to work after rehabilitation.

Nursing Home Evac Tests Wake EMS' ICS Initiatives
     On the evening of September 14, 2007, a strong line of thunderstorms and reported funnel cloud passed across southern Wake County. In their path, they left a wide area of storm damage, including fallen trees, a structure fire caused by lightning, and large areas without power. One of the storm's casualties was the Brighton Manor Nursing Home, an older residential facility in the town of Fuquay-Varina. The storm dropped a tree on the building, causing a power outage and roof damage. The initial response to this incident included units from the Fuquay-Varina Fire Department and the Wake County EMS Division.

Attempts to restore power to the building resulted in an electrical fire, and at 2203 hours, Fuquay-Varina Fire Chief Tony Mauldin, the incident commander, declared the building unsafe for habitation. In consultation with the staff of the nursing home, who had an evacuation plan with predetermined destinations already established, the decision was made to begin a complete evacuation of the facility.

EMS District Chief Jason Nienow, the on-duty southern district supervisor, assumed the role of IC from Chief Mauldin. Field Training Paramedic Shannon Glover was assigned the Triage Officer position, and quickly learned there were a total of 63 patients in the facility, in a changing mixture of bed-confined, wheelchair-bound and ambulatory status. Paramedic Rachel Reid was assigned as Transportation Officer, Field Training Paramedic Shawn Mitchell as Treatment Officer, and Paramedic Will Holland as Staging Officer. District Chief Alan Foster, the on-duty central district supervisor, represented EMS at the town's Area Command, established to deal with the widespread public works, utility and traffic problems resulting from the storm.

Unlike previous large incidents, where senior EMS officers responded to the scene and assumed responsibility for incident management, the Wake County EMS command staff assembled at EMS headquarters as an Incident Support Team (IST), but decided early on to leave incident management in the hands of on-scene personnel unless additional assistance was requested.

Division Chief Jon Olson, serving as operator of EMS Truck 1 (the county's mass-casualty and rehabilitation unit), was dispatched to the scene and ultimately assigned as Planning Section Chief for the incident. All other ICS positions continued to be staffed by on-duty line EMS personnel throughout the incident. The IST's involvement was limited to making telephone calls to mutual aid agencies and keeping backup documentation for the incident.

Three hours later, 59 patients had been transported (four had been released to their families). Twenty-two EMS units from eight EMS agencies, as well as two wheelchair buses provided by Harnett County EMS, were used to move the patients to four different destinations. Assisting agencies included Garner EMS, Apex EMS, Harnett County EMS, WakeMed Mobile Critical Care, Johnston Ambulance Service, North State Ambulance Service and First Health of the Carolinas EMS. No patients or EMS personnel were injured.

As always, the incident produced a few lessons, which were identified and discussed at a subsequent staff meeting. These included the need for a formal preplanning process for facility evacuations, as well as a process to better match patients, medical records, assistive devices, oxygen concentrators, etc., many of which cannot be safely transported in an ambulance. Also identified (not for the first time) was the need for a multiple-patient transport vehicle capable of handling both stretcher-bound and wheelchair patients.
-Skip Kirkwood

CONCLUSION
     Although the terms "EMS" and "ambulance service" are often used interchangeably, they are not. An ambulance service runs ambulance calls, and the final product is the transportation of a patient to a hospital for further care. EMS, on the other hand, includes but is not limited to ambulance transportation. EMS includes medical care activities not related to transportation, including mass gatherings, medical support of technical-rescue operations and competent and meaningful participation in management of community incidents. If your organization stands back, waits for someone else to bring you patients and doesn't participate in incident management and other activities that don't directly relate to patient transportation, it is probably an ambulance service. If you are an EMS agency, you must be ICS-competent, engaged in managing your community's major incidents, and a strong partner with your community's law enforcement and fire suppression agencies.

If you call yourself EMS and your community looks to you to be there when there's a crisis, you owe it to them to be ICS competent.

Skip Kirkwood, MS, JD, EMT-P, EFO, is Chief of Emergency Medical Services for the Wake County (NC) Department of Public Safety. Contact him at skip.kirkwood@co.wake.nc.us.