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Foreign Exchange The Twin Cities’ Incident Response Plan Aspects of the Israeli model for responding to large-scale events are reflected in the metrowide incident response plan now used in Minnesota’s Twin Cities area, including the cities of Minneapolis and St. Paul. Here, John Hick, MD, Hennepin County Medical Center’s medical director for bioterrorism and emergency preparedness and assistant medical director for EMS, explains the plan and the 3E post-blast/active-shooter tool used by local responders. Q When was the metro incident response plan developed and why? The plan was adopted in 2005 when we saw a need for a more unified, simple plan for EMS agencies working together. An EMS provider work group through the Metropolitan Emergency Services Board got the agencies together and came up with a NIMS-compliant, very simplified incident response plan. A lot of the principles of the plan were driven by priorities the Israelis have for early or rapid transport and relying on line providers rather than supervisory personnel to become the core of the response. We were fortunate to have a psychologist/hostage negotiator from Israel working with the Minneapolis Police Department who was familiar with their system and helped guide us. Q Q You emphasize rapid transport, as does the Israeli approach. What’s the reasoning? The priority is to get patients to an appropriate-level trauma center or definitive care, especially in a mass- casualty event when you aren’t sure what the scope will be. You want to make sure, as you have patients available and have the transport resources, that you’re clearing the scene of victims as quickly as possible. It’s not appropriate to hold any patients in a casualty collection point. The Israelis feel, as we do, that if you have the resources available, you should be transporting. Your system does decontamination before triage and transport, while Israel does it at the hospital. Why? While we do provide decontamination on scene, we don’t want to delay critically ill or injured patients to do so. If the priority is on patient care, we focus John Hick, MD on clothing control, protect the crew with PPE, then transport and allow the technical decon to happen at the hospital. My concern with providing all decon at the hospital is that you often have “green” patients who are more psychologically impacted and think they need to be decontaminated. Those patients are a major distraction and resource commitment to hospitals when they don’t need to be, so having the availability of on-scene decon for that group is extremely important. Q Q Did you see anything in Israel that could be adapted for what you’re doing? One thing was that all ambulance crews use bulletproof vests and helmets, and that’s something we need to think about for providing appropriate protection for our responders. We also learned that it’s not important to spend a lot of time marking safe corridors at scenes, but rather to just use line of sight to divide the area based on physical features of the scene. What is the 3E post- blast/active-shooter tool, and why was it was developed? We’ve been concerned that in blast and active-shooter incidents, there has not been good coordination between the EMS, police and fire-rescue components. Situational awareness for EMS and fire is often far behind what police know about the perpetrators, so we want to make sure, as soon as the threat is contained or neutralized, EMS and fire-rescue are allowed to establish where safety zones are, where the victims are, and how they can get in to save their lives. The Enter, Evaluate, Evacuate conceptual model was developed to have law enforcement provide a secure environment for EMS and fire to get in and treat victims more quickly and to provide some support for victim evacuation. —Marie Nordberg, Associate Editor EMS WORLD JULY 2011 long anyway, so why don’t we just function that way all the time, whether it’s a great day or bad?” asks DeTienne. “We may have two or three ambulances at a scene and be waiting for more that are 50 miles away, but how quickly can we take any severely injured and get them away from the scene to the hospital? Because that’s where we’re going to save them.” “Treating mass-casualty patients is the same pretty much everywhere,” says McCaughan. “They’re much more expeditious with the entire process because they have to be. But I think if we step back and consider recent events [i.e., the death of Osama bin Laden, his ongoing plans and the possibility of reprisals by his followers], maybe there’s more of a need for us to think in a similar fashion.” Then there’s the issue of hands on scene. A big lesson we took from 9/11 was personnel accountability—knowing exactly who’s on the team and what they’re doing. The Israeli approach is, if not the opposite, at least more fl exible, encouraging the use of bystanders when help is needed. “In a nation that’s prepared, that’s a wise move,” says Wingrove. “Since they start emer- gency preparation with their citizens when they’re young, it’s a good fi t for them. But I don’t think we’re at the same level of preparedness.” Doing decontaminations at hospitals is another difference. Israeli hospitals have the resources to do this and practice it scrupu- lously, which allows EMS teams to merely strip contaminated patients, give them basic cover, and take them away. “That’s a pretty neat concept,” says Schmider. “We could certainly clear a scene more easily that way.” And hospitals need the capability anyway, as contaminated patients could turn up in EDs without calling EMS. On the other hand, not deconning in the fi eld could raise contamination concerns in transport vehicles. “Those ambulances will have to be deconned afterward, and we may be subjecting para- medics and EMTs to contamination,” notes Heilicser. “Our people have the ability to put on personal protective equipment, but they don’t have the sophisticated stuff we saw on those Israeli ambulances.” 11