3.5 Illustrative Example

The following example demonstrates how the concepts presented in this chapter may be applied during an actual incident response. The various phases of response (as described in Chapter 1) highlight when critical actions should occur; however, the example extends only as far as incident operations, since this is the focus of the MSCC Management System.

While the following example demonstrates Tier 2 addressing specific activities, it should be noted that in some jurisdictions, many of these activities are addressed by Tier 3.

Background and Incident Description

During MSCC preparedness planning, HCOs in Jurisdiction Y developed a sophisticated healthcare coalition (Tier 2) that is sponsored by the largest hospital in the city with support from the jurisdiction's Department of Health (DoH).
The sponsoring hospital's primary contribution to the Tier 2 coalition is the commitment of its communications center, which during baseline operations coordinates helicopter and ground critical care transports for the hospital. During a major incident, the hospital assigns additional personnel to the communications center to ensure an operational capability for the Tier 2 coalition.
A large incendiary explosion occurs at a subway station during evening rush hour. Calls to 911 report many burned casualties emerging from the underground station, which is on fire. Many victims flee the area before first responders arrive and organize the scene. The number of victims that may be trapped underground is a major concern.

Incident recognition is provided across the Tier 2 coalition by EMS dispatch. Multiple 911 calls describing "a large explosion with casualties" trigger a pre-determined threshold, and the EMS dispatcher notifies coalition hospitals as EMS units are sent to the scene. Almost simultaneously, initial media reports describe an explosion with casualties. Subsequently, the hospital closest to the blast site notifies the Tier 2 coalition that they have already received several walk-in burn patients from the event.

Notification/activation of the Tier 2 coalition occurs immediately and is accomplished by the initial EMS dispatch communication. The initial notification is sketchy and states only that an explosion has occurred at or near Station X, many casualties are expected, and EMS scene officers will call back shortly for an HCO bed availability count. Because of preparedness planning and training, the Tier 2 coalition partners know to immediately survey their HCO's bed availability and categorize additional patient capacity according to a predetermined format.

Mobilization involves the initial staffing of the Tier 2 call center (MACC), as well as the gathering of initial information from the various Tier 1 assets. This includes determining which Tier 1 assets are activating their respective EOPs. In addition, the coalition begins to gather additional incident information from Tier 3 for dissemination to the Tier 1 assets. Participating Tier 1 HCOs appoint a liaison from their organization as their primary contact with the MACC component of the Tier 2, and appoint a senior executive to participate in any potential MAC Group activities in Tier 2.

Incident operations begin within minutes, as initial bed counts are reported by each HCO. The Tier 2 information clearinghouse function collects and aggregates the data, and provides a composite of the data to EMS for use by triage and transport officers, and to the DoH communi-cations officer for jurisdictional (Tier 3) planning. Moreover, the composite is immediately distributed to all coalition HCOs and is used by hospital incident managers to anticipate surge needs for direct patient care or potential support needs for their partner HCOs.

Shortly thereafter, the hospital closest to the blast site reports to the Tier 2 coalition that they are inundated with self-referrals from the scene. The composite hospital-receiving capacity is revised and transmitted to EMS so that triage and transport officers can adjust patient distribution accordingly. The revised composite is also sent to DoH and to all coalition HCOs.

Through the Tier 2 communications mechanism, coalition HCOs (with DoH participating) receive an incident update from an assistant EMS Chief at the blast site. The total number of victims is unclear because underground areas have not been fully accessed by rescuers. The Tier 2 coalition decides to implement a formal reporting mechanism to facilitate distribution of incident information to the HCOs and to jurisdictional health authorities (Tier 3). The Tier 2 clearinghouse function provides an electronic reporting format for hospitals to use and initially requests submission on an hourly basis. Information from the reports is collated by the Tier 2 clearinghouse function and redistributed back to the HCOs to give them a more comprehensive perspective of the response. Essential elements of information in the reports include:

Situation reports at HCOs (counts of victims at each facility)
Resource status updates (e.g., available beds, staff, supplies, pharmaceuticals)
A composite communications plan that describes how jurisdictional authorities (Tier 3) can contact individual HCO's incident management teams (Tier 1).

The Tier 2 coalition coordinates various services among the HCOs. For example, staffing agencies that supply healthcare personnel to more than one HCO are coordinated through the Tier 2 coalition to prevent serious shortages at any one facility. In addition, the coalition sends a liaison to the jurisdiction's EOC to convey the collective issues and concerns of the HCOs to the EOC management team and appropriate Emergency Support Functions (ESFs). For example, the liaison to the EOC informs the jurisdiction that law enforcement activities (e.g., street closures) have hindered the ability of off-duty staff to return to the hospitals to assist with the surge in patient volume. This problem is rapidly addressed.

The blast caused a significant number of eye, burn, and respiratory injuries, which severely challenge the response capability of several HCOs. The Tier 2 coalition assists in coordinating medical mutual aid to these facilities:

Eye injuries: The Tier 2 coalition rapidly locates available ophthalmologic capacity at partner facilities and coordinates the transfer of some victims with eye injuries (who are otherwise stable) to those facilities.
Burn injuries: The one burn center in the area is overwhelmed with victims that have significant burns. The Tier 2 coalition writes guidelines for early inpatient hospital treatment of burn patients, and these are distributed electronically to area hospitals. Burn and trauma experts from an adjoining, unaffected jurisdiction are made available through the hospital radio/conference call system to provide clinical guidance as requested by the non-trauma and non- burn facilities that are receiving burn casualties. This information sharing increases the capability of hospitals to provide adequate initial burn care until out-of-region transfers can be arranged.
Respiratory injuries: One hospital has received a large number of victims that are progressing to respiratory failure due to smoke inhalation. The hospital reports an urgent need for additional critical-care airway management capacity (i.e., ventilators, respiratory therapists, and critical-care staff). Two HCOs farther away from the blast site volunteer their excess capacity, which was generated when the HCOs activated their respective EOPs. Credentialed staff, ventilators, and other supplies are dispatched to the requesting hospital. The jurisdiction's public health authority (Tier 3) is also notified that additional ventilators, supplies, and critical care staff are needed from outside the jurisdiction. Actions are initiated to obtain these resources.

As the blast scene is cleared of victims, the jurisdiction's defined "incident" transitions from focusing on fire/EMS rescue at the site to supporting HCOs as they surge to meet victims' medical needs. Medical representatives from the Tier 2 coalition are appointed as senior advisors to the Tier 3 incident management team. Input from these advisors to jurisdictional incident management will promote optimal support of the local HCOs in their efforts to address evolving surge demands.

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