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Managing a Major Incident


     Disasters come in all shapes and sizes--some with warning, most without. No place can claim to be free from the possibility of having an event that will strain the talents of even its most seasoned EMS veterans. As a supervisor or manager, it may become your responsibility to take care of the EMS crews responding to a mass-casualty incident, natural disaster or terrorist attack. Last issue we focused on preparing for the worst--planning, training and gathering materials and resources ahead of a major incident. This month we will review how to successfully manage such an incident. As the lead EMS representative, how will you direct your resources? The leadership traits you draw on will hopefully ensure not only a successful EMS operation, but a safe working environment as well.

The Plan
     Familiarity with your community (or county/regional/ state) emergency or incident response plan (IRP) is the key to handling any disaster response in your system. An IRP establishes a management blueprint to be used for major incidents at fixed locations or within the community in general. It outlines steps to be taken based upon the size and scope of the event, and identifies any barriers or hazards that may need to be dealt with. Know the plan and share it with those who are expected to play a role: provide copies to all your first-line supervisors; have bound versions in all their response vehicles; include a checklist to be used with the IRP when conducting operations. Remember, there's no shame in using outlines and memory aids during an incident. You cannot and should not memorize an IRP--details change, and a good plan will be revisited often and rewritten as needed.

You're in Charge (But Not Alone)
     If you're the person responsible for EMS operations at a disaster, you will be hit from all sides with questions and expected to have the answers. Making decisions under that kind of pressure is difficult and often leads to mistakes--try to avoid the obvious ones. Don't lose your head in the chaos. Your benchmark for all decisions should be the safety of your crew first and the needs of the incident second. Don't forget to communicate with staff in the trenches. Having the 10,000-foot view is not necessary for the street EMT, but periodically knowing the general direction and progress of the incident management will help keep the troops in the loop and focused on their roles.

     If the incident will be protracted and your agency's assets will be integral to the ongoing response, then a liaison from your organization should have a seat in the Emergency Operations Center. This may be essential in order to facilitate communications between your decision-makers and those at the helm of the overall response. Depending on the structure of your system, the availability of resources, turnaround times for ambulances transporting patients and the general level of EMS capabilities may not be things your EOC can track. Decision-making requires a great deal of distilled information, and it is imperative that the EMS role is not just assumed to function, especially with normal call volume ongoing. There needs to be staff that can give concrete and realistic input related to EMS operations. As the head EMS agent, it is your responsibility to accurately communicate with the Incident Command structure regarding what is realistically available and, likewise, performance expectations for the operations unit. Not having this level of input could lead to misappropriation of assets, failure to meet non-disaster-related responsibilities, inability to properly account for organizational resources (especially when it comes to reimbursement) and a demoralized and overworked operations staff.

Creative Thinking
     The IRP for any disaster incident recognizes the need for certain general resources and specific operational issues that can arise. However, while the IRP is essential for directing initial response, each disaster will have its own unique curveballs. As the response unfolds and more situational analyses can take place, managers will need to make adjustments to the IRP. While high-profile incidents have resulted in the development of generally accepted scenario solution outlines to be taught to emergency managers, your leadership will be distinguished by how your particular event is different and how well you can, in real time, identify solutions for problems the model didn't present. This is where you take the knowledge and experience of your own system and the resources you have on hand and look at things with a fresh perspective. These types of opportunities have been fertile ground for innovative ideas like using airport baggage carts for stretcher patients in New Orleans. When appropriate, take the initiative. If there is a solution that will not endanger lives or make the situation worse, give it a try.

Document Events
     In the heat of a large-scale disaster, it's difficult to accept that you'll ever forget this experience--but you will. After the adrenaline rush has subsided and the sleep deprivation has been corrected, a supervisor can find himself missing the details of decisions he made and why he made them. ICS training stresses the need for adequate event documentation for this exact reason. While you don't necessarily need to use ICS forms, you should have a system of recording your agency's operations and your decisions related to the incident. As you would if you'd just completed a drill or tabletop exercise, your administration should sit down a short time after the incident and hold a critique to review its performance. Just like you conduct QI audits on your providers' patientcare, major-event management should be scrutinized--not to find fault, but to improve future operations. This critical step is often overlooked because the immediate operational needs of an incident tend to overshadow the long-term needs of the organization.

     Even with the best planning, any disaster incident that involves more than one agency, resource or municipality can be described as controlled chaos. Finding the inner calm needed to make good decisions and manage well despite the distractions is both an art and a science. What level of organization you and your incident command staff have over your part of the puzzle will determine your ultimate success. Keep a level head, know what resources are available and make decisions that are consistent with the best possible outcome.

Raphael M. Barishansky, MPH, EMT-B, is executive director of the Hudson Valley Regional EMS Council in Newburgh, NY, and a member of EMS Magazine's editorial advisory board. He can be reached at

Katherine O'Connor, BS, EMT-P/CIC, is an EMS systems specialist for the Westchester County Department of Emergency Services in Valhalla, NY, and the program coordinator for the Westchester Regional EMS Council. She can be reached at

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