Post on 26-Mar-2020
Lawrence-Douglas County Fire Medical Procedure 210.40 Title:
Mass Casualty Response Effective Date: 07/03/2019 Page 1 of 15 Supersedes – SOP II-358 Date(s): 04/02/2018
1 PURPOSE 1
2
This plan establishes structure and guidelines for the management of operations in a multi-3
casualty emergency situation. This plan will integrate into the overall Incident Command 4
System. 5
6
2 SCOPE 7
8
The scope of this procedure applies to department members. 9
10
3 ACCREDITATION REFERENCE 11
12
5G Technical Rescue 13
14
4 PROCEDURE 15
16
INTRODUCTION 17
18
The first arriving unit(s) of a large scale emergency with multiple casualties may well find 19
themselves overwhelmed with minimal resources to act. It is imperative that they utilize 20
strong and effective communication to establish an operational structure to deal with the 21
incident at hand and to bring rapid, effective, and efficient care to the largest number of 22
victims possible. 23
24
MASS CASUALTY INCIDENT (MCI) LEVELS 25
26
MCI Levels are based on the number of estimated patients, and are used by Dispatch centers 27
and area hospitals for coordinating resources. Thus, early determination of the MCI Level is an 28
important part of size-up at an MCI. 29
30
Level V: 5 – 10 patients 31
Level IV: 10 – 25 patients 32
Level III: 25 – 50 patients 33
Level II: 50 – 100 patients 34
Level I: 100+ patients 35
36
FIRST ARRIVING UNIT 37
Establish a strong visible command; 38
- Perform size-up and provide an initial report. 39
- What type of incident (i.e. building collapse, bus accident, tornado, etc.)? 40
- Perform rapid safety assessment. 41
- Estimated number of victims and MCI. 42
- Upgrade alarm and/or request mutual aid. 43
If the incident is a chemical, biological, radiological, nuclear or explosive (CBRNE) mass 44
Lawrence-Douglas County Fire Medical Procedure 210.40 Title:
Mass Casualty Response Effective Date: 07/03/2019 Page 2 of 15 Supersedes – SOP II-358 Date(s): 04/02/2018
casualty event, treat it as a hazmat scene. Immediately request the appropriate hazmat 45
response if not already dispatched. 46
- Time permitting, notify local medical facilities and advise them on potential 47
decontamination needs. 48
Establish access and egress and identify a staging area with easy access for apparatus and 49
resources. 50
Establish a casualty collection area for ambulatory victims. 51
Establish work zones and hazard control zones (if applicable). 52
Initiate triage using START/jumpSTART. 53
Maintain command and control of incident until relieved. 54
55
INCIDENT COMMAND SYSTEM (ICS) FUNCTIONS AT AN MCI 56
57
As additional resources arrive, the Incident Commander will expand the operational structure 58
as needed. 59
60
Most commonly, an MCI will require the Incident Commander to establish a Medical Branch. 61
Under the Medical Branch will be the Triage Group, the Treatment Group, and the Transport 62
Group. Each of the above Groups will have specialized teams working under them. 63
64
Non-medical ICS roles that will frequently be created at an MCI include a Staging Group and a 65
Landing Zone Group (which may be combined into the Logistics Branch at larger incidents). 66
67
Other ICS roles may be created at an MCI to handle specific needs or hazards. A major 68
tornado might require a Rescue Branch with USAR, Structural Collapse, and other technical 69
rescue functions. An incident involving hazardous materials release will likely need a HAZMAT 70
Branch for entry, isolation/containment, and decontamination. 71
72
73
74
75
76
77
Figure 78
1: Sample ICS chart at an MCI 79
80
81
82
83
INCIDENT COMMANDER
RESCUE BRANCH
MEDICAL BRANCH
Triage Group
Triage Team 1
Triage Team 2
Treatment Group
Minor (Green)
Delayed (Yellow)
Immediate (Red)
Uninjured (White)
Transport Group
Medical Control
Transport Teams
Ambulance Coordinator
LOGISTICSBRANCH
Safety Officer
PIO
Lawrence-Douglas County Fire Medical Procedure 210.40 Title:
Mass Casualty Response Effective Date: 07/03/2019 Page 3 of 15 Supersedes – SOP II-358 Date(s): 04/02/2018
ICS POSITION RESPONSIBILITIES 84
85
Incident Commander (IC) 86
Assume command from initial IC. 87
Use the radio designation “COMMAND”. 88
Establish a strong visible command. 89
- Don the appropriate vest, and use green command light on vehicle 90
Perform initial size-up as well as an ongoing evaluation of changing conditions. 91
Establish operational structure and groups to manage resources. 92
- Review available/incoming resources, and request additional as needed. 93
Consider EOC and the Mass Casualty Trailer 94
Consider mutual aid requests 95
- Ensure regional hospitals and Emergency Management Control Centers (EMCC) are 96
notified to initiate their mass casualty plans. 97
This will be the responsibility of the Transport Group, once it is established. 98
Consider need for additional radio channels, request them early. 99
100
Public Information Officer (PIO) 101
Use radio designation “PIO”. 102
- Don appropriate vest. 103
Reports to COMMAND. 104
Monitor situation to be able to answer public questions/concerns. 105
Established designated media briefing areas & times as needed. 106
Craft press releases and social media statements to convey public safety messages. 107
108
Safety Officer 109
Use radio designation “SAFETY”. 110
- Don appropriate vest. 111
Reports to COMMAND. 112
Monitor situation and emergency operations for unsafe practices or plans. 113
Delegate additional safety officers as necessary. 114
- Example: Incident Safety Officer is at Unified Command Post for over-all view of incident 115
operations. If USAR Operations are being conducted in the Hot Zone, the Incident 116
Safety Officer establishes a dedicated USAR Group Safety Officer. 117
118
Medical Branch 119
Use radio designation “MEDICAL BRANCH”. 120
- Don appropriate vest. 121
Reports to COMMAND. 122
Establish/supervise Medical Branch (Triage, Treatment, and Transport Groups). 123
Ensure patient accountability procedures are followed. 124
Coordinate, direct, and request resources as needed for Medical Branch Groups, and make 125
requests via the chain of command. 126
Liaison with other Branches as needed (ex: work with Rescue Branch to ensure coordinated 127
operations during USAR). 128
Lawrence-Douglas County Fire Medical Procedure 210.40 Title:
Mass Casualty Response Effective Date: 07/03/2019 Page 4 of 15 Supersedes – SOP II-358 Date(s): 04/02/2018
129
Triage Group 130
Use radio designation “TRIAGE”. 131
- Don appropriate vest. 132
Reports to MEDICAL BRANCH Director. 133
Supervise one or more Triage Teams. 134
- Consider requesting separate tactical channel. 135
Maintain over-all understanding of conditions in Hot Zone, including: 136
- Total number of patients 137
- Totals in each triage category 138
- Approximate locations of patients 139
- Special hazards or needs 140
- Estimated time to access/remove patients 141
Coordinate Triage Team(s) movement of patients to Treatment Group. 142
- Priority to most critical and easiest removed patients. 143
Collect and retain triage tag slips as patients are moved to Treatment Group. 144
- Track which Triage Team brought which patient out of the “Hot Zone”. 145
Release assigned members for other functions (e.g., Treatment Group) as they become 146
available. 147
148
Triage Team(s) 149
Use radio designation “TRIAGE TEAM 1”, “TRIAGE TEAM 2”, etc. 150
Reports to TRIAGE Group Supervisor. 151
- Number/location/severity of patients 152
- Obstacles/special hazards 153
Typically 2-4 responders per Triage Team. 154
Responsible for medical operations in the “Hot Zone”. This includes: 155
- Patient Triage: Use START Triage, jumpSTART for pediatrics. Initial triage can be 156
indicated with colored ribbon strips. Triage tags should be applied at time patient is 157
being moved to Treatment Group. Save one of the tear-off slips from each triage tag, 158
and provide them to the TRIAGE GROUP Supervisor when possible. 159
- Immediate Treatment: These will be rapid BLS interventions only (airway opening, 160
wound packing, tourniquet application). Use supplies from Mass Casualty/Active 161
Shooter kits. 162
- Victim Removal: Moving patients to Treatment Group. Applies to non-technical removal 163
only (stretchers/backboards) for patients who can be accessed and removed without 164
delay. Operations that involve technical rescue, Hazmat, or other specialized skills will 165
have Groups/Teams from appropriate branches coordinating work with Triage Group 166
Multiple teams at larger incidents should be coordinated. Options include: 167
- Using multiple entry points simultaneously 168
- One team enters, other team(s) move patients to Treatment Group 169
- Two teams “leap-frogging”: 170
Triage Team 1 enters, proceeds to triage/treat until supplies exhausted. 171
Triage Team 2 enters, meets w/Triage Team 1, and continues from where they left 172
off. 173
Lawrence-Douglas County Fire Medical Procedure 210.40 Title:
Mass Casualty Response Effective Date: 07/03/2019 Page 5 of 15 Supersedes – SOP II-358 Date(s): 04/02/2018
Triage Team 1 exits, removing most critical victim(s) to Treatment Group, resupplies, 174
then re-enters to meet with Triage Team 2 and repeat cycle. 175
176
Treatment Group 177
Use radio designation “TREATMENT”. 178
- Don appropriate vest. 179
Reports to MEDICAL BRANCH Director. 180
Supervise Treatment Teams (described below). 181
Establish safe location for treatment area. 182
- Minimize distance to incident scene and to transport area 183
- Outside of Hot Zone 184
Consider requesting tactical channel. 185
Monitor allocated personnel/equipment for each treatment area, redirect as necessary. 186
Maintain awareness of supply levels, request resupplies early through the chain of 187
command. 188
Coordinate patient transport priorities with TRANSPORT GROUP Supervisor. 189
Maintain patient accountability. 190
- Collect triage tag slips as patients are moved to Transport Group. 191
- Utilize the Mass Casualty Patient Accountability equipment provided. 192
193
Treatment Teams 194
Treatment Teams are the personnel assigned to each treatment area. 195
Provide care for the patients in their area until they are transported from the scene. 196
Determine which patients need to be transport priorities. 197
Monitor patients for signs of increasing/decreasing severity. 198
- Move patients to other Treatment Teams as dictated by symptoms. 199
Example: a patient initially placed in Delayed (YELLOW) area who is no longer AxOx4 200
should be moved to Critical (RED) area. 201
- Note any re-triage on the patient’s triage tag. 202
Team size determined by needs – GREEN TEAM may only need 1 person to maintain 203
accountability, while RED TEAM may need a dozen to provide adequate care. 204
205
Critical (RED) Team 206
- Use radio designation “RED TEAM”. 207
Leader should don appropriate vest. 208
- Reports to TREATMENT Group Supervisor. 209
- Provide care for most critical patients: 210
Patients in this area will be breathing spontaneously, but may need airways 211
maintained, and will have one or more of the following: 212
RR>30 213
Absent radial pulse OR cap refill >2 secs 214
Altered LOC 215
- Collect any personal property removed from patients and attach personal property tag. 216
- Patients in this area will require the most attendants and supplies. 217
- Determine which patient(s) is the most critical when transport capabilities are limited. 218
Lawrence-Douglas County Fire Medical Procedure 210.40 Title:
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Consider both severity of injuries and likelihood of expedited transport having a 219
significant impact on patient outcome. 220
Report order in which patients are to be transported to TREATMENT Group 221
Supervisor. 222
223
Delayed (YELLOW) Team 224
- Use radio designation “YELLOW TEAM”. 225
Leader should don appropriate vest. 226
- Reports to TREATMENT Group Supervisor. 227
- Provide care for non-critical patients: 228
Patients in this area will have the widest range of severity in terms of injuries, but 229
common factors will be: 230
Unable to walk 231
AxOx4 232
Pulse, perfusion, and respirations within normal limits 233
- Collect any personal property removed from patients and attach personal property tag. 234
- Patients in this area may require care at scene for prolonged periods before transport, 235
while critical patients are being transported. 236
- Monitor patients for deterioration and re-triage as necessary. 237
238
Minor (GREEN) Team 239
- Use radio designation “GREEN TEAM”. 240
Leader should don appropriate vest. 241
- Reports to TREATMENT Group Supervisor. 242
- Provide care for ambulatory patients. 243
- Monitor patients for deterioration and re-triage as necessary. 244
- Patients in this area may require transport to a hospital via ambulance, but may also be 245
appropriate to transport via passenger vehicle, or be treated and released at scene. 246
Keep ambulatory patients in this area to prevent loss of accountability or 247
overwhelming closest hospitals with patients seeking care in POV. 248
- Alert & oriented patients have the right to decline treatment/transport. 249
If circumstances permit, create an ePCR report for patients to sign refusals. 250
If creating an ePCR is not feasible: 251
Record the patient’s name and other information on their triage tag. 252
Write “refusal” in the comments section of the triage tag. 253
Have the patient write their signature in the comments section. 254
Retain the triage tag for later tracking – patient accountability. 255
256
Uninjured (WHITE) Team 257
- Use radio designation “WHITE TEAM”. 258
Leader should don appropriate vest. 259
- Reports to TREATMENT Group Supervisor. 260
- Act as a collection/accountability area for civilians at an incident who are uninjured or 261
decline further medical care. 262
- Not always established, but a good idea in some circumstances: 263
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Mass Casualty Response Effective Date: 07/03/2019 Page 7 of 15 Supersedes – SOP II-358 Date(s): 04/02/2018
Incidents requiring decontamination or other processing of all people in Hot Zone 264
Incidents with large numbers of uninjured participants 265
- Establish safe exit corridor from scene and release civilians when directed to do so. 266
267
Morgue (BLACK) Team 268
- Use radio designation “BLACK TEAM”. 269
Leader should don appropriate vest. 270
- Reports to TREATMENT Group Supervisor. 271
- Acts as a collection area for the bodies of patients who die after being removed from the 272
Hot Zone. 273
Patients who are Dead On Arrival inside the Hot Zone should NOT be removed from 274
the scene to the morgue, but left in place. 275
- Not always established, but should be created if large numbers of patients in the 276
treatments areas are dead or expected to die prior to transport. 277
- Determine a location for this team that is as isolated from view of other treatment areas 278
and onlookers as is reasonably possible under the circumstances 279
- If staffing permits, at least one person should be assigned to this team, to ensure bodies 280
are undisturbed. 281
- Treat bodies with as much respect and dignity as possible under the circumstances. 282
283
Transport Group 284
Use radio designation “TRANSPORT”. 285
- Don appropriate vest. 286
Reports to MEDICAL BRANCH Director. 287
Supervise Transport Group teams (described below). 288
Consider requesting tactical channel. 289
Maintain patient accountability. 290
Coordinate patient transport priorities with TREATMENT Group using following process: 291
1. TREATMENT Group Supervisor reports a patient is ready for transport and their triage 292
level (most critical first). 293
2. TRANSPORT Group Supervisor requests an ambulance for transport from AMBULANCE 294
COORDINATOR. 295
3. AMBULANCE COORDINATOR notifies TRANSPORT Group Supervisor when ambulance 296
is available for transport. 297
4. TRANSPORT Group Supervisor orders TRANSPORT TEAM to move patient to 298
designated ambulance. 299
5. TRANSPORT TEAM moves patient from Treatment Area to ambulance, as directed by 300
AMBULANCE COORDINATOR. 301
6. TRANSPORT Group Supervisor notifies MEDICAL CONTOL of patient being prepared 302
for departure. 303
7. MEDICAL CONTROL determines patient destination and informs TRANSPORT TEAMS, 304
AMBULANCE COORDINATOR, and TRANSPORT Group Supervisor. 305
8. AMBULANCE COORDINATOR reports when ambulance/patient depart the scene. 306
9. MEDICAL CONTROL updates patient log. 307
10. TRANSPORT TEAM reports to TRANSPORT Group supervisor for next assignment. 308
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309
Ambulance Coordinator 310
Use radio designation “AMBULANCE COORDINATOR”. 311
- Don appropriate vest. 312
Reports to TRANSPORT Group Supervisor. 313
Establish ambulance loading areas & ingress/egress pathways: 314
- Safe locations with controlled site access 315
- Minimize need for backing, if possible. 316
Supervise ambulance arrival, loading, and departure from loading area. 317
- Notified by TRANSPORT Group Supervisor when patients are ready for transport from 318
Treatment Areas. 319
- Request ambulances move into loading area from Staging as space permits. 320
Unlike ground ambulances, helicopters will have an LZ in the Staging area and will 321
not be in the loading zone. Instead, patients will be brought to the LZ by Transport 322
Teams. 323
- Inform TRANSPORT Group Supervisor when ambulances are in place in the loading zone 324
(or helicopters are available in the landing zone) and ready to receive patients. 325
- Direct TRANSPORT TEAM assigned to move patient from Treatment Area to assigned 326
ambulance, supervise patient hand-off. 327
Coordinate ambulance destinations with MEDICAL CONTROL. 328
- Receive patient destination from MEDICAL CONTROL 329
- Inform TRANSPORT TEAM(s) of patient destination 330
- Inform MEDICAL CONTROL once patient is transported, including triage & destination 331
Collect transport receipts from patient triage tags from Transport Teams. 332
- Note patient name (if known), triage, destination, and transporting unit 333
334
Transport Team(s) 335
Use radio designation “TRANSPORT TEAM 1”, “TRANSPORT TEAM 2”, etc. 336
Reports to TRANSPORT Group Supervisor. 337
Responsible for moving patients from Treatment Area to loading zone or landing zone. 338
Patients may be moved by cot, soft-cot, backboard, stretcher, or other device. 339
Activated by TRANSPORT Group Supervisor after the TREATMENT Group Supervisor and 340
the AMBULANCE COORDINATOR report a patient and ambulance are both ready for 341
transport. 342
Take report from Treatment Area, ensure treatments/vitals are documented on triage tag. 343
Move patient to ambulance. 344
- May be with cot, soft cot, stretcher, Gator, or other means. 345
Provide report and transfer patient care to transporting ambulance crew. 346
Collect transport receipt portion of triage tag at time of hand-off. 347
- Should include patient name (if known), triage, destination, and transporting unit. 348
Deliver transport receipt portion of triage tag to AMBULANCE COORDINATOR. 349
Report to TRANSPORT Group Supervisor once ready for next patient. 350
351
Medical Control 352
Use radio designation “MEDICAL CONTROL”. 353
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- Don appropriate vest. 354
Reports to TRANSPORT Group Supervisor. 355
Determine hospital destination(s) for all patients transported from scene: 356
Hospital bed availability is determined in KC Metro Area by EMResource (web-based 357
software), which is accessed by one of three EMResource Control Centers (EMCC): 358
- Johnson County (KS) Dispatch (913) 432-2121 359
- KCMO Fire Dept. (FD) Dispatch (816) 923-3456 360
- Lee’s Summit FD Dispatch (816) 969-7407 361
- Douglas County Emergency Communications Center (785) 843-0250 362
Determine which EMResource Control Center (EMCC) is handling the MCI alert and 363
coordinate with that EMCC to determine bed availability of area hospitals. 364
Cellular networks may be overwhelmed at major incidents. EMCCs may also be 365
contacted by portable radio (mutual aid frequencies). Hospitals in the KC Metro area 366
may also be contacted directly via MARCER radios in ambulance patient compartments. 367
Track the available beds for each triage level (red/yellow/green) at each receiving hospital. 368
- Keep this information updated as patients are transported, and at longer incidents 369
where availability may change. 370
TRANSPORT Group Supervisor will notify MEDICAL CONTROL when a patient is ready to be 371
loaded/transported. 372
MEDICAL CONTROL will use available beds, patient triage, hospital distance, and special 373
needs of the patient to assign a transport destination. 374
Inform AMBULANCE COORDINATOR, TRANSPORT TEAM, and TRANSPORT Group 375
Supervisor of assigned hospital destination. 376
377
Staging Group 378
Uses radio designation “STAGING”. 379
- Don appropriate vest. 380
Supervisor depends on scale of incident – may report directly to COMMAND or may report 381
to LOGISTICS at a larger incident. 382
Establishes a (Level II) staging area for resources to assemble. 383
Ensure that all personnel stay with their vehicles unless otherwise directed. 384
- If personnel are directed to assist in another function, ensure that the keys to the 385
vehicles stay with each vehicle. 386
Maintain a reserve of at least one transport unit. Advise COMMAND when all transport units 387
are depleted. 388
Provide updates on numbers of uncommitted resources via chain of command. 389
May supervise a LANDING ZONE TEAM if air ambulances are in use. 390
391
5 DEPLOYMENT OF REGIONAL MASS CASUALTY INCIDENT CACHES OF SUPPLIES 392
393
The MCI trailer is available for immediate deployment in the Northeast Kansas upon request 394
during a mass casualty or fatality incident. The Incident Commander shall make the request 395
and identify the location the trailer is to be dispatched to. The Douglas County Emergency 396
Communications Center (DGECC) can receive all requests by telephone at 785-843-0250, 397
alternately the Douglas County Emergency Management Agency can be contacted to process 398
Lawrence-Douglas County Fire Medical Procedure 210.40 Title:
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the request through DGECC. There are caches of equipment intended for use during MCI 399
located throughout the KC Metropolitan area. Each cache has a capability to treat 400
approximately 50-100 patients. 401
402
Mass Casualty Incident Caches of Supplies (Appendix F; 2015 MARCER 403
Plan) 404
405
There are caches of equipment intended for MCI use located throughout the metropolitan 406
area. Each cache has a capability to treat approximately 50 to 100 patients. Some of the 407
equipment is ALS capable. 408
Caches include the following: 409
410
Western Missouri Fire Chiefs Association MCI Trailer 411
One trailer available: Located at Central Jackson County Fire Protection District Station #4 412
Contact: Fire Mutual Aid to Central Jackson County Fire Protection District or Call (816) 220-413
4005 414
• Capacity to treat up to 50-100 patients 415
• Carries ALS (IV and intubation equipment) and oxygen 416
417
North Kansas City Fire Department 418
One trailer available: Located at North Kansas City Fire Department Station #2 419
Contact: Call (816) 274-6010 or (816) 274-6013 420
• Capacity to treat up to 50 patients 421
• BLS equipped 422
423
Kansas City, Kansas Fire Department 424
One trailer available: Located at Kansas City, Kansas Fire Department Station #6 425
Contact: Call (913) 596-3050 426
• Capacity to treat up to 50 patients 427
• BLS equipped 428
429
Johnson County MED-ACT 430
Two trailers available: One in Mission and one in Olathe 431
Contact: Johnson County Emergency Communications Center at (913) 432-2121 432
• Each trailer has a capacity to treat up to 50-100 patients 433
• ALS and BLS equipped 434
• Multiple oxygen delivery devices 435
436
Kansas City International Airport 437
Note: This truck cannot leave airport grounds 438
• Capacity to treat up to 100 patients 439
440
441
442
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Mass Casualty Incident Caches of Supplies (Appendix F, 2015 MARCER Plan) 443
Continued 444
445
KCFD 446
One Trailer at the Eastwood Facility 447
Contact: Call (816) 924-0600 448
• Capacity to treat up to 50-100 patients 449
• ALS equipped 450
451
Northland Regional Ambulance District 452
One Trailer at NRAD Headquarters 453
Contact: Call (816) 858-4450 454
• Capacity to treat up to 50-100 patients 455
• ALS equipped 456
457
Belton Fire Department 458
One Trailer at Station #1 459
Contact: Call (816) 331-1500 460
• Capacity to treat up to 50-100 patients 461
• ALS equipped 462
463
Lawrence - Douglas County Fire Medical 464
One Trailer at LDCFM Station #2 465
Contact: Call (785) 843-0250 466
467
There is no cost for the use of the equipment, other than the replacement of expended 468
supplies. To request the cache be deployed to an incident, contact the communications center, 469
or listed contact, for each jurisdiction. 470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
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APPENDIX A 487
Triage Guidelines 488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
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527
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APPENDIX B 528
529
Triage Tag 530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
553
554 Document Initial triage ribbon color here. (applied by Triage Team @ initial contact)
First triage strip (front/back). Triage Team taking patient to
Treatment Area keeps it
Second triage strip (front/back). Removed by Treatment Team once patient is moved to Transport
Group
Transport Receipt (front/back) – removed & retained by Transport Group, to show where patient went & by which ambulance
Ambulance Receipt (front/back) – removed & retained by transporting EMS units for later patient tracking. Remainder of triage tag remains attached to patient for benefit of receiving
hospital
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APPENDIX C 555
556
Mid-America Regional Council Emergency Rescue Committee (MARCER) 557
558
Regional Mass Casualty Incident Plan for Metropolitan Kansas City, June 2011 559
560
Three copies of the document are also provided on the Mass Casualty Trailer. 561