 My name is Jeff Dyer, I'm the Emergency Medical Services Program Chair at the National Fire Academy. Join me for the next few minutes in reviewing the Incident Command System and its application at emergency medical services scenes. Let's talk first about the history of the Incident Command System. ICS began as a result of the disastrous fires in Southern California in the fall of 1970. Almost 600,000 acres burned in 13 days, destroying 772 structures and killing 16 people. There were over 100 fire agencies involved along with dozens of law enforcement departments, health services, and many others. During the course of the 13 days, a lot of excellent work was done by all, but a lot of things went wrong as well. In a post-disaster analysis, the fire services involved identified the root causes of the most serious problems. They are the lack of a common organizational structure. The result was a severe loss of effectiveness simply because in many cases, assisting forces did not understand what was happening. Lack of coordinated and co-located planning. As a result, multiple uncoordinated planning and direction occurred. In some cases, two or more agencies staffing the same ground and drastic omissions in other cases. Large areas of unattended fire assumed to be covered by the other guy. Fire ground and inter-agency communications was practically non-existent. Most radio traffic was confined to units within the same agency and any information flow between agencies was limited to verbal or written messages. Sometimes delivered, sometimes not. Existing agency frequencies were overloaded because of all traffic, command logistical and tactical, was being transmitted more or less simultaneously. Lack of valid timely information. This lack was related to the uncoordinated planning but also resulted from traditional neglect of fast, accurate intelligence and planning procedures. As a result of these major wildland fires, Southern California Municipal, County, State and Federal Fire Authorities form an organization known as Firefighting Resources of California Organized for Potential Emergencies or Firescope. Firescope's efforts to address these difficulties resulted in the development of the original incident command system for effective incident management. Although originally developed for wildland settings, the system ultimately evolved into an all-risk system, appropriate for all types of fire and non-fire emergencies. What is the incident command system? There are many systems that are in use throughout the nation for the direction and control of resources and emergency events. The one method, the incident command system, developed by Firescope and adopted by the National Fire Academy has been recognized as the model tool for the command, control and coordination of resources and personnel at the scene of an emergency. The incident command system is based upon basic business management principles. In a business or government environment, managers and leaders perform the basic daily tasks of planning, directing, coordinating, communicating, delegating and evaluating. The same is true for an incident command system when dealing with evolving emergency situations. These tasks or functional areas are performed under the overall direction of the incident commander. A business organization under crisis conditions as resources arrive, an incident command system is a management tool consisting of procedures for organizing personnel, facilities, equipment and communications at the scene of an emergency. Many people who have not studied an incident command system in detail hold a variety of erroneous perceptions on what the system means to them and their agencies. These perceptions may prevent this valuable tool from being fully implemented in a number of communities. To set the record straight, an incident command system is not a way to subvert the normal chain of command within a department or agency. It is not too big and cumbersome to be used in small everyday events such as motor vehicle accidents, multi-agency responses, simple extrication events, as well as many other everyday emergency response events. I would now like to introduce Captain Don Lee. Captain Lee is in charge of EMS training for the city of Los Angeles and is a recognized national expert in the use of the incident command system for emergency medical services. The incident command system has many advantages that address common problems on the emergency incident site. It may be used in a variety of emergency events, including but not limited to fires, mass casualty incidents, hazard specter emergencies, tornadoes, floods, earthquakes, and also non-forcement emergencies. The incident command system has a flexible design. It may be adapted and utilized in a variety of organizational structures, including single jurisdiction, single agency involvement, single jurisdiction with multi-agency involvement, multi-jurisdiction, multi-agency involvement. The incident command system is simple yet effective and causes little disruption to existing systems. When we made the transition to using the incident command system for EMS, we found that it was just a matter of formalizing what we're already doing. One of the biggest concerns in going to an incident command system for EMS was from the potential for losing control. The experience tells us there are very few pure EMS incidents. In fact, most incidents include multiple agencies, such as EMS, Fire, and Police. Even at a two-patient traffic accident, EMS, Fire, and Police units all have a role. Every response, no matter how large or small, is an ICS event. The incident command system has several key elements. The use of common terminology is essential to the effective operation of the incident command system. Common names are established and used for all personnel and resources. A complete ICS glossary is found in the back of your student manual. The incident command system is organized in a modular format. This approach to organizational structure is used for any modules that are organized in a functional basis with five primary functional areas, which we will discuss later. The next key element is integrated communications. This includes communications procedures and protocols, frequency allocations, and the procedures to receive, record, and acknowledge incoming and outgoing communications of any form. The incident command system stresses the use of plain language in all communications. Spent of control is an essential component of the incident command system. This is defined as the number of subordinates one supervisor can effectively manage. End post is a location where all incident operations are directed. The command post may consist of a vehicle designed as a command post, a building, a truck, a squad car, or other vehicle that is identified and known to all participants as the command post. The concept of unified command is employed in multi-agency operations. Unified command is a shared responsibility for the overall management of an incident as a result of multi-jurisdictional or multi-agency operations. Incident commanders are selected on the basis of who has the primary authority for the overall control of the emergency event. In a unified command structure, there will still be one person in charge of the overall event. The incident commander, all involved agencies, will contribute to the command process under the general direction and coordination of the incident commander. The initial incident command system must start with the first responder on scene. The command process may be transferred to higher ranking individuals as more resources arrive on scene. As an example, in an everyday situation when two cars collide and a citizen dials 911, they have assumed incident command for responsibilities. Their role as incident commander transfers to the first arriving unit, whether it be EMS, fire, or police. Every incident commander has certain functions they should include in their role as the incident commander. Assume an announced command and establish an effective operating position, which will be known as the command post. Rapidly evaluate the situation and conduct a size-up. Initiate, maintain, and control the communications process. Identify the overall strategy. Develop an incident action plan. Assign companies and personnel consistent with plans and standing operating procedures. Develop an effective incident management organization. Provide tactical objectives. Review, evaluate, and revise the incident action plan as needed. Provide for the continuity, transfer, and termination of command. As more resources arrive on the scene and the incident continues to escalate, the incident commander builds the command organization by dividing the incident needs and establishing divisions, groups, and sectors. The incident commander's focus should be on the strategic issues, overall strategic planning, and other components of the incident. His focus is to look at the big picture and the impact of the incident from a very broad perspective. The incident commander should provide direction, advice, and guidance to the general staff in directing the tactical aspects of the incident. As previously mentioned, there are five key functional areas in an incident command system. Each function will be present when implementing an ICS, but expanded to differing degrees depending on the size and nature of the incident. In small incidents, the incident commander functions in multiple roles. Some of the roles include operations, planning, and finance and administration. In larger events, like a high-rise fire, these functions are assigned to a command staff. One of the major benefits of the incident command system is its all-risk application to any emergency situation. Many of the principles discussed also apply to mass casualty management. Virtually all medical incidents require the patients to be extricated, triaged, traded, and transported. The incident command system provides many benefits for the incident commander, such as, organizes, controls, and coordinates rescuers towards a common goal. Similar functions are grouped and responsibilities are identified and defined, centralized decision-making but decentralizing tasks and objectives. Lines of authority are established, provides a means to communicate and process information for decision-making, provides predictability of actions and organization design and development, provides for efficient operations. ICS for EMS in very simple terms can be summed up by remembering three Cs and three Ts. The three Cs represent command, control, and communications. Now the three Ts represent triage, treatment, and transportation. A good incident commander uses the three Cs to ensure that the three Ts are efficiently completed. Incident command system for EMS is the effective tool for managing any EMS incident, regardless of the cause, size, or agencies involved. There are 12 victims that are listed in critical conditions, 11 in fair conditions, and 20 were able to walk away from the record. The halfway road is the private road, and the northern end of Pomp's Crane is thought within the jurisdiction of the Pomp's Crane Police Department. The road is the route to the popular Pomp's Crane aerial family, which was a girl's house which we're visiting as part of a two-week California tour. Pomp's Crane police first is counted to the same and determined that all components of the emergency medical services in the area would need to be activated. All the calls were made to the three local hospitals, and the triage team was sent to the same district in the initial treatment of the girl. Numerous ambulancees were used to transport the injured, as well as helicopters. At one point, a new helicopter was tested, recorded, and assisted in transporting injured scouts. The rescue efforts was a combined effort of many different agencies and emergency personnel. It was carried out in a very professional, efficient manner. You told me a bus turned over with kids, and I just drove out here, and my reaction is the worst thing that's ever happened to this town, ever. It's the most heart-wrenching thing I've ever seen in my life. I thought you were working with a lot of the kids that were coming out and they were being transported away. Obviously, you were saying you were very emotional, but you had to seem like you were giving them a lot of support. Yeah, I was thinking if any of them knew who I was, or if I could just spark them at all, or make them feel okay, and just talk to them. How was some of them doing? They were just scared. They're all so scared. They don't know how bad they're hurt. They're afraid of the choppers. They just need some comfort right now. They're just frightened children. Did anything happen? I didn't ask them. I just wanted as much as I could determine if they were okay, and then I would tell them they would be okay, and that they're okay. That's all they wanted to hear is that they're going to be okay. Are they okay? Ask for their friends, obviously, and I would just say, yeah, they're okay. They've got nothing to do with the talking about. No, they're not going to be okay. No, we've got some under there under the bus. Who are you going to follow up with? I don't need to follow up. Yeah, I'll be there. I told them I would be there. I don't want to see the parents. I just can't imagine how somebody can know that we care. Do you think we're together? Everybody? If there wasn't such a disaster, I would say it was wonderful to see how everybody, you know, it's so great to see everybody get rid of the little petty stuff and just go for the survival of others. I don't want to negotiate the terms went off. As of right now, we have six confirmed fatalities, of which one we believe to be the bus driver, and the other five appear to be scouts from the group. They're being transported now by three helicopters to all three local hospitals. We have people here from the county and city and state high of control. We have a team of doctors and nurses that initially see who is the most critical to get those on board first. What is going to be the course of action from here on out for the rest of the evening? This road will remain closed. We're going to try to get the people down from the top of the tram as soon as we get the ambulances out of the way. It'll be closed for many hours. The team is investigating it now, trying to find out what exactly caused it. They're talking to witnesses that may have seen it or have come right under scene afterwards. I try to piece together what caused this. Everybody just came together and everybody did everything they had to do. So that's not a concern. I think what the city can do now is let them know that we're there. I saw the location here and saw the yellow bus sitting down in the ravine over here. That was before anybody else got here. I slowed down, pulled over to the side, saw how much damage was involved, figured that the best thing I could do at that point in time is get back to the valley station and call 911 and that's what I did. And by the time I got back down here with medical supplies and oxygen, everybody else was already here. This was a heck of a response by the city of Palm Springs. One of the leaders said, Christ yourself, I'm having a break. We might crash. Later on, and then I called up, and then I came out and helped me out a little bit. And then I came out and added everything that later on, my body was in shock. And so I had to go to the hospital. So when I got out of the bus, came down, and they were all very calm. They were giving everything they had to matter. This is an initial report. Spring's ambulance, paramedic. I pulled up, I made an assessment of a number of people in the bus. It was stable on some rocks. As you're moving around the valley, there was no fuel leak. The bus was diesel. There was no fire hazard in the media. To my dispatch. They initiated a second alarm. They basically called up all our off-duty personnel. All around Mutual Aid Engines from Riverside County in Kippu City, which was easily blocked at both ends. The scene itself was small. Yet, in spite of the fact that there were three different agencies running different aspects of the rescue, two of them receiving Mutual Aid from surrounding communities, there was no attempt at a unified command. ICS, such as an indie really never unfolded. There was no post-setup. I basically got on scene and started making a triage assessment and assigned people as they arrived on scene to different tasks. Setting up a formal command for the month. The structure should have been established initially. On Spring's police, being such a small community, those folks know each other on site. But for Mutual Aid responders, it may have been a different story. Police Captain Boswell says a command post would have helped them get oriented. Soon after help began to arrive, the narrow tramway road became clogged with traffic. Too many vehicles right now. The lack of a unified command structure also caused problems with communications, both on the ground and... We need different agencies here, all on different radio frequencies. And had we established a regular command post, we probably would have solved some of the problems with communication. But because of the tightness trash scene, I don't think that was a major problem. We had a weak operation with communications to our aircraft and the communications between all the fire units and police and ambulance people. The fire units were all on the same frequency, but we didn't have any established radio communication with police or ambulance. Although the scene commanders differ on whether they need an integrated command system, I'll agree. If they had it to do over again, they'd work more closely together. Well, in review, I think we would probably establish an obvious unified agency's rep. Could get together and coordinate the activities, and I think that would probably eliminate some of the requests for duplicate service and duplicate people. One of the big slices learned was that the ICS system needs to be flexible as far as what it's dealing with. And strictly medical institute needs to be able to shift the command to the appropriate... In spite of the fact that there was no integrated command system, the incident was handled with virtually no lapse in the care or transport of the injured. Even though police, fire, and EMS operated as separate entities, they worked together without conflict. The scene went extremely well. There was a lot of cooperation between the agencies I was seeing. Nobody got involved. Police were carrying backboards. The mayor came down and helped carry backboards. Fire department personnel were assisting in packing the patients and carrying them up the hill. We had to use some of the girl scouts that went on injured from the other bus as far as helping to get the girl's package. We had an out-of-state registered nurse on scene that we utilized for ALS procedures. On the incoming airships, we utilized their personnel. When I arrived on scene and established the command of the fiery units, I did the incident into the two divisions. The remote division was location and triage of the victims. And the other division was stabilization and backboard. As helicopters began to arrive, as fire, medical, and police personnel crowded into the narrow canyon full of school bus wreckage, Mike Allison was hard at work doing triage. Incredibly, it lasted only six minutes. I used what's called a start system and simply triage and rapid transport. It means that you really don't do a whole lot on scene except to stabilize the patients as far as their airway and control in which they're bleeding. You practice a patient and you get them to an appropriate facility, which is basically what we did. We assigned a couple of people, start IVs in patients as many as they could. At the same time, as they were being packaged by the other agencies there, they must seem very quickly to counter 30 minutes to transport 53 patients from scene. There were accelerations, abrasions, long bone fractures, thoracic injuries, abdominal injuries. Initial triage figures showed 13 critically injured, 20. The triage worked so well that the doctors complimented the EMS people because all of the injured were received in the hospitals in their proper order. That means that the minor injuries didn't beat the critically injured. The injured were rushed to three different hospitals. Desert Hospital was only a minute away from the incident site by helicopter, seven to eight minutes away by ambulance. There again, luck was a factor. The hospital put its disaster plan into effect during shift change. Desert State, they would be able to take as many patients as we needed to send them. The hospital's disaster plan had a wealth of results of shift change. The most critically injured were flown or driven to Desert Hospital, the area's only trauma center. Those with moderate or slight injuries were taken to either Eisenhower Medical Center or John F. Kennedy Hospital in Indio, 35 miles away. With only 11 ALS units available and four helicopters, emergency crews used police cars and taxi cabs to transport some of the lesser injuries. Perhaps the hardest part was hitting the injured from the crash site to the road above. The bus was about 30 to 40 feet, but the terrain is extremely rocky, and the victims were, it was difficult. It was obviously difficult footing carrying over large boulders and rocks. While Boswell and his counterparts felt they had control of the situation on the ground, they were all worried about the congestion developing in the air above them. As far as the landing zone, the road was used as a landing zone. The landing zone is a two-lane road, which is fairly narrow. On one side of the road is power lines, and on the other side is rocky terrain. So it was a little tight getting the helicopters in. We had a lot of help from different agencies assess the evaluation. The scene from the air landed and began experiments with their... And as four rescue helicopter pilots jockeyed their ships into that narrow canyon, five more helicopters carrying television crews orbited above. Once we were on scene, I instituted through the Palm Springs Tower an airspace limitation to keep all non-essential helicopters and air traffic out of the area. But there was an apparent difference of opinion over which aircraft were non-essential. Rescuers on the ground didn't think the media choppers needed to be so close to the scene. The noise created by those aircraft made communications on the ground very difficult. In fact, scene commanders do restricting the airspace above them. Federal aviation regulation 91.137A outlines a procedure where you, as scene commander, can contact the FAA for help. The regulation can be put into effect to prevent an unsafe congestion of sightseeing and other aircraft above an incident. There are some important exceptions, however. Notably, an aircraft carrying incident or event personnel, law enforcement, or accredited news media can be allowed over the site. So why bother? Because the pilots of these aircraft must file a flight plan with the proper authorities. Their presence is at the discretion of the FAA with input from the on-scene commander. The aerial umbrella over your scene can be as big as you want it to be. To institute airspace restrictions over your scene, you should act early. Contact the nearest control tower or air traffic control center. Have the following information ready. Your name and agency. Your exact location. If possible, include the exact latitude and longitude of the area you want restricted. The nature of your incident. The size of the area you propose to restrict, both in terms of radius around the incident site and the altitude above your site. And if you have any idea, the amount of time you'd like the restriction enforced. Remember to contact with the same authorities again when the restriction can be lifted. You may not get everything you asked for, so you must be specific in your request. As for the establishment of an integrated command structure, Fire Chief McLean, Police Captain Boswell and Spring's Ambulance Supervisor Jerry Hart, all suggest that you get to know how each cooperating agency works. Practice with the agencies in your area. Agree on a single set of terms to be used in a unified command structure. Agree on who should do what, depending on the emergency. Commanders should plan to work together at a common command post. Face to face if possible. Supervisors should wear vests, hats, or bibs to be easily identifiable to all responders. Agree on common radio frequencies. This should include frequencies for communicating with personnel on the ground and in the air. In Palm Springs, rescuers admit they had no integrated command system. But they did have experience. They had good will and a good measure of luck. Rescue 23 responding. Additional ALS at four additional rescues. Yeah, Rescue 3, Rescue 5, Rescue 11, Rescue 29. Channel 8, balance of the first law of medical. 7th Street and Broadway. Engine 2, Engine 8, Rescue 16, Rescue 3, Rescue 5, Rescue 11, Rescue 29.