Fire Department of New York Multiple Casualty Incident Command Structure. Janice Olszewski. Fire Department of New York, Brooklyn, New York

Fire Department of New York 1 Running head: FIRE DEPARTMENT OF NEW YORK Fire Department of New York Multiple Casualty Incident Command Structure Janice Olszewski Fire Department of New York, Brooklyn, New York

Fire Department of New York 2 CERTIFICATION STATEMENT I hereby certify that this paper constitutes my own product, that where the language of others is set forth, quotation marks so indicate, and that appropriate credit is given where I have used the language, ideas, expressions, or writings of another. Signed: Janice Olszewski

Fire Department of New York 3 Abstract The Fire Department of New York (FDNY) does not designate an Emergency Medical Service (EMS) Officer as the Incident Commander (IC) or other high-level position in the Incident Command System (ICS) at any multi-casualty incident (MCI). The problem is that an individual with the highest level of emergency medical management expertise is never in charge of major medical incidents, which may cause compromise to patient care, movement, or transport. The purpose of the research was to assess ICS options to develop the most appropriate command structure model for the FDNY at major incidents when patient care is the active priority. Action research was used to answer the following questions: (a) what organizational structures do other public safety agencies use to manage incidents with multiple casualties, b) what are the advantages, if any, of having an EMS officer in a higher ICS position at multiple casualty incidents, c) what are alternatives to the Incident Command System multiple casualty incident organization chart development? Procedures included interviews with subject matter experts educated and experienced in multiple casualty incidents, issuing a questionnaire to other major city Fire Departments as to how they manage multiple casualty incidents, and developing a work group of ranking Fire Department Officers to address the research problem. A revised Incident Command System organization chart for the FDNY for multiple casualty incidents was developed as a result of the research that recommends an EMS Officer in the ICS Deputy Operations Chief position or higher.

Fire Department of New York 4 Table of Contents Certification Statement... 2 Abstract 3 Table of Contents... 4 Introduction. 5 Background and Significance. 7 Literature Review...13 Procedures..19 Results 23 Discussion.. 27 Recommendations..31 Reference List 33 Appendices Appendix A: Current FDNY ICS Medical Operational System Organization Chart...36 Appendix B: Fire Department of New York Organization Chart.37 Appendix C 1993 World Trade Center Bombing EMS Organization Chart...38 Appendix D: FIRESCOPE Multi Casualty Incident Model Organization Chart.39 Appendix E: Incident Commander and Operations Chief Responsibility Checklists..40 Appendix F: Interview Chief Paul Maniscalco.41 Appendix G: Interview Chief John Peruggia 44 Appendix H: Interview Chief Albert Gehres 47 Appendix I: Major City Fire Department Questionnaire.50 Appendix J: Revised FDNY ICS Medical Operational System Organization Chart...54

Fire Department of New York 5 Fire Department of New York Multiple Casualty Incident Command Structure Introduction The FDNY is currently consistent with the ICS organization model for MCIs recommended by the Field Operations Guide ICS 420-1 (Governor s Office of Emergency Medical Service, 2007) and dictated by the New York City Incident Management System, or CIMS (City of New York Office of Emergency Management, 2006). However, the FDNY places the highest-ranking Fire Department of New York Emergency Medical Service (FDNY-EMS) Officer as a Branch Director, well down the MCI organization chart command structure (See Appendix A for the current FDNY ICS Medical Operational System Application Organization Chart). The current placement level for the EMS Officer in the command structure may be appropriate on MCIs with hazard mitigation ongoing and few patients generated with low potential for casualties. However, on incidents where hazard mitigation is minimal or absent and many patients need to be treated and moved, the EMS Officer is not in a position to manage the incident at a high level of command. Managing care, movement, and transport of hundreds to thousands of patients from an incident is a distinct possibility in New York City due to anticipated natural or human-made disasters striking a densely populated area. New York s status as a terrorism target adds to the potential for large, multiple patient generating scenarios. The highestranking EMS Officer at MCIs in the FDNY is subordinate to Fire Officers with less expertise and education in emergency medical care. The problem was that the individual with the best skill set to manage patients was not in a position to direct staff and resources to affect optimal patient care. The research purpose was to develop an ICS

Fire Department of New York 6 organization model for the FDNY to most appropriately manage MCIs. Action research was used to answer the following questions: (a) what organization structures do other public safety agencies use to manage incidents with multiple casualties, b) what are the advantages, if any, of having an EMS officer in a higher ICS position at multiple casualty incidents, c) what are alternatives to the Incident Command System multiple casualty incident organization chart?

Fire Department of New York 7 Background and Significance New York City is home to 8.2 million residents over 322 square miles. The FDNY serves to protect life and property of New York City residents and visitors, consisting of 11,450 uniformed firefighters and 3,140 uniformed EMS Emergency Medical Technicians (EMTs) and paramedics (Fire Department of New York, 2009). The New York City Emergency Medical Service (NYC-EMS) was developed via the New York State Legislature as an agency within the New York City Health and Hospitals Corporation in 1970. The system provided ambulances staffed with EMTs, later adding paramedics, dispatched to trauma and medical emergencies affecting the citizens and visitors of New York City. In 1977, Mayoral Executive Order #96 was issued, designating the Emergency Medical Service as the coordinating agency for emergency medical care in the City of New York. EMS was charged with establishing an EMS system and coordinating all EMS activities within the city (Fire Department of New York, 2008). The head of EMS was a civilian titled the Executive Director, and the field manager was a uniformed title, Chief of Operations. The Chief of Operations or his designated EMS Officer answered to no one during field operations of MCIs, acting as, and being designated as, the Incident Commander. The FDNY absorbed EMS on March 17, 1996 and NYC-EMS became the FDNY-EMS, a Command within the Department. The EMS lead uniformed manager became the Chief of EMS, and this title answers to the Chief of Department, a Fire Officer, organizationally (See Appendix B for the FDNY Organization Chart).

Fire Department of New York 8 Mayoral Executive Order #27 of 1996 superseded Executive Order #96, designating the FDNY as the coordinating agency for the City of New York for all prehospital services in the event of medical emergencies. The FDNY assumed the resources of NYC-EMS from the Health and Hospitals Corporation (Fire Department of New York, 1996). New York City EMS was no longer a separate agency. Since then, all MCIs currently have a Fire Officer as IC and filling General Staff positions in the ICS; Fire Chiefs with little to no education or training regarding pre-hospital emergency service (Fire Department of New York, 2006). FDNY-EMS members are certified as either EMTs who perform basic life support (BLS), or paramedics who perform advanced life support (ALS). EMS members do not receive any firefighting training and are never expected to participate in hazard mitigation. Firefighters received Certified First Responder (CFR) training at the FDNY Academy as of 1997. CFR is a BLS pre-hospital emergency care level of certification below that of EMT. Most senior Fire Officers, who are the ICs at MCIs, never received CFR training and if they did, did not and do not use it in practice (Regional Emergency Medical Advisory Committee of New York City, 2010). The Regional Emergency Medical Advisory Committee of New York City (2010) defines an MCI as five or more patients regardless of the cause. The FDNY is the designated lead agency for coordination of patient care at MCIs, hazardous material situations, fires/crimes in progress, and unusual public health or safety emergencies; all may be defined as multi-discipline incidents (City of New York Office of Emergency Management, 2006). However, for clarity, an MCI for this paper will mean an incident that produces 10s to 100s of patients or more and patient care and medical management

Fire Department of New York 9 have become or are the priorities of the incident. In addition, the research focuses on internal FDNY coordination, not coordination between FDNY and external agencies. From 1987-1996, EMS used a management system for MCIs entitled the Emergency Medical Action Plan (EMAP). EMAP was developed to provide for efficient use and distribution of EMS resources, as well as those of other agencies in support of the EMS operation. EMAP was divided into seven segments to address an MCI chronologically, from initial notification to termination of the incident (New York City Emergency Medical Service, 1987). EMAP was in keeping with an ICS manual issued by the New York State Department of Health in 1987 (J. Peruggia, personal communication, August 31, 2010). EMS used, and continues to use, a system called START (Simple Triage and Rapid Treatment) to sort patients for priority treatment and transport using tags colored black, red, yellow, and green. A black tagged patient would be deceased, a red critical, yellow stable but cannot walk, and green a walking wounded patient (New York City Emergency Medical Service, 1987). EMS Officers were routinely the IC at major patient producing incidents prior to the merger with the FDNY. On June 5, 1995, two subway trains crashed into each other on the Williamsburg Bridge in Brooklyn, New York City. NYC-EMS responded and an EMS Officer assumed the position of IC of EMS resources as part of a Unified Command operation with inter-agencies the FDNY and New York Police Department (NYPD). No responders suffered serious injuries and communications between agencies was effective. Approximately 200 patients were assessed, treated, packaged, and transported. No single hospital was inundated with patients; they were distributed evenly to 12 hospitals in

Fire Department of New York 10 Brooklyn and nearby Manhattan and Queens. Ambulance access to the crash site was difficult due to approach to the bridge area of the crash, but was accomplished effectively (United States Fire Administration, 1995). On February 26, 1993, a bomb went off in the parking garage of the World Trade Center (WTC) with 50,000 people inside. The blast killed 6 and there were 1,042 recorded injuries (Matthews, 1993). There were more likely approximately 5,500 people treated by EMS resources on the scene, most of whom went undocumented due to mutual aid unit inconsistent reporting, and that many were treated and walked away (P. Maniscalco, personal communication, July 29, 2010). An EMS Chief Officer was the IC for NYC-EMS and initiated the Incident Management System (IMS), assigned roles to EMS Officers, and ensured any victim in need of medical care received it (New York City Emergency Medical Service, 1993). The recorded EMS response that day included 174 ambulances, 48 Officers, and 23 specialty units (New York City Emergency Medical Service, 1993). The EMS Chief had many concerns that day. He had to be involved with securing apparatus access and egress in a congested area, and the patients waiting for transport had to be kept warm due to the cold and snowy February day. He arranged for safe areas for the patients in the lobbies of several buildings ringing the area. The Chief liaised with many New York City agencies in support of the EMS effort including the NYPD, the FDNY, the Red Cross, the Office of Emergency Management, and utility companies. He also had to activate and organize mutual aid hospital, volunteer, and private ambulance units. FDNY staffing was not available for movement and transfer of the patients for several hours due to their own mitigation efforts. (P. Maniscalco, personal communication, July 29, 2010).

Fire Department of New York 11 EMS remained a presence on the scene for 100 days following the bombing in support of recovery operations. The continuing operation required complex EMS leadership and organization to address the multiple tasks and objectives, and an EMS Chief Officer remained the IC for this endeavor (See Appendix C for the 1993 World Trade Center Bombing EMS Organization Chart). Success or failure of an operation may be somewhat subjective in nature though, prone to anecdotal retelling or perception. On March 22, 1992, pre-merger, a plane slid off the runway into freezing water at LaGuardia Airport in New York, killing 27 of the people onboard. The National Transportation Safety Board (NTSB) concluded that the EMS response was effective and contributed to the survivability of the passengers, but that the response was inadequately coordinated and it took too long to transport some people to the hospital (National Transportation Safety Board, 1993). However, the report indicates a key interview was an EMS Lieutenant, not the IC; hardly the most authoritative choice for an accurate overview. In addition, transport times to hospitals are relative due to conditions and available resources. For example, it was snowing and icy, and victims had to be extricated from the damaged plane and freezing, jet fuel-filled water. Current Chief of FDNY-EMS John Peruggia relates that the EMS response went as well as it could possible have under the conditions at the time (J. Peruggia, personal communication, August 31, 2010). Converse to the recorded efficient and effective EMS MCI management prior to the merger, drawbacks currently arise when an EMS Officer is not in one of the lead ICS positions. The Staten Island Ferry crashed into the pier on October 15, 2003. The crash killed 11 people and injured 71, some of them critically (Fire Department of New York,

Fire Department of New York 12 2003). Disorganization reigned from the beginning due to many apparatus and emergency workers converging on a small area. Firefighters began moving patients off the ferry prior to appropriate triage and delivered them to an area where there were not yet available ambulances for transport to the hospital (J. Peruggia, personal communication, August 31, 2010). A commercial airliner had to land in the Hudson River on January 15, 2009 due to engine failure from a bird strike. There were 78 injuries, 5 serious, of the 155 passengers and crew. The Fire Officer IC had no interaction with other responding resources because his Command Post was mobile; it moved up the river, following the rescue boats to their destination. The EMS Command Post was at a fixed location where other city agencies also set up. The result was that EMS was unable to communicate with resources that could bring patients to a central area for triage and treatment. They ended up scattered at multiple boat landing points in both New York and New Jersey, and it was very difficult to account for all the people who were on the flight (J. Peruggia, personal communication, August 31, 2010). Immediate stakeholders concerned with appropriate patient management on the scene of MCIs include the residents, workers, and visitors in New York City. Timely and accurate care of the victims of a disaster depend upon the leaders of the event and that they are the most appropriate people for the tasks at hand. The FDNY is the largest Fire Department in the world and faces the most varied and significant natural or humancaused incidents. The FDNY must remain on the cutting edge and contemporary to continue to meet the challenges it faces by implementing Federal recommendations in context and spirit to maximize incident management.

Fire Department of New York 13 One of the five operational objectives of the United States Fire Administration (USFA) is to respond appropriately in a timely manner to emerging issues (United States Fire Administration, 2009). The research involves a connection with issues such as the current increased threat of terrorism in New York City as well as natural disasters, and that the population is growing and aging. New York City will be relying more and more on the FDNY-EMS and Fire resources to be effectively coordinated during MCIs to meet developing and inevitable patient care scenarios. The Executive Fire Officer Program entitled Executive Analysis of Fire Service Operations in Emergency Management; Unit 2 Sections SM 2.3-SM 2.4 guided the research. The research is a reflection of the described roles and responsibilities of the lead ICS positions and that the individuals with the appropriate qualifications hold those lead positions (National Fire Academy, 2009). The course emphasized that all the ICS positions are integral pieces of the teamwork concept of MCI management operation. But the IC and Operations Chief positions are clearly the most significant regarding direct oversight, authority, and responsibility of an incident. Literature Review A literature review was conducted to determine the most appropriate MCI organization model for optimal FDNY-EMS medical scene management. Active FDNY- EMS Chiefs John Peruggia, Albert Gehres, and retired EMS Chief Paul Maniscalco were interviewed for their expertise in incident management and of the history and evolution of EMS in New York City. The information from the interviews will be presented in the Results section. The results of the literature review and interviews would help determine the most appropriate incident management command model for FDNY MCIs.

Fire Department of New York 14 The National Response Framework (NRF), formerly the National Response Plan (NRP) until 2008, is a guide offered by the Department of Homeland Security (DHS) as to how the Nation conducts responses to all-hazard incidents. The incidents include fires, hazardous materials, terrorism, and natural disasters. It is a flexible plan that defines roles and is scalable for reactions to small incidents as well as major disasters. The NRF enhances the National Incident Management System (NIMS) (Department of Homeland Security, 2008). The National Incident Management System provides an approach to emergency incidents for all levels of government and private organizations. NIMS encompasses all stages of incidents, including prevention, response, mitigation, and recovery. NIMS provides the template for management of an incident, while the NRF provides structure for national-level policy for incident management. NIMS is not an incident management plan, but it offers standards of principals, terminology and organization that enable effective incident management (Federal Emergency Management Agency, 2008). It allows for all resources, fire and EMS included, to speak the same incident management language and it is structured to avoid individual freelancing and conflicting strategies (Coleman, 2008). CIMS is the implementation of NIMS, serving as an incident management document for managing emergencies and planned events in New York City. It establishes roles and designates authority to agencies responding to and managing emergency incidents. CIMS is used to integrate state or federal resources, including private or nonprofit organizations. New York City modified NIMS to suit local emergency expectations. Terminology and organizational structure has been modified in CIMS to

Fire Department of New York 15 meet New York City s specific requirements, authorized by the Mayor of New York City. CIMS delegates command of an incident to an agency based on core competencies, or functional areas of expertise, related specifically to tactical operations that are managed by the Operations Section of the ICS. Agencies have the authority to direct operations related to their core competency. It allows for local policy to dictate who fills ICS positions (City of New York Office of Emergency Management, 2006). The Incident Command System is an integral component of the NRF, including NIMS and CIMS. ICS is an on-scene management approach that is standardized and allows for integration of resources, enables a coordinated response by all agencies and jurisdictions, and establishes a common process for approaching all-hazards incidents. The ICS was developed in the early 1970s by Firefighting Resources of Southern California Organized for Potential Emergencies (FIRESCOPE) to combat major wildfires in California. The ICS was required for use beginning 2003 via Presidential Directive (Governor s Office of Emergency Service, 2007). All levels of government use ICS for all sizes of incident. An advanced incident would include activity by all the functional areas of ICS, which are: Command, Operations, Planning, Logistics, and Finance (Federal Emergency Management Agency, 2007). (See Appendix D for the FIRESCOPE multi casualty incident model organization chart). The ICS functional positions of command most pertinent to scene management include the Command role of Incident Commander, and the General Staff position of Operations Section Chief. The Incident Commander s responsibility is overall management of the scene while others are focused on tasks. The IC may act alone at a Single Command operation, or as a participant in a Unified Command operation. The IC

Fire Department of New York 16 may choose to designate a Deputy Incident Commander or multiple Deputies depending on the size of the incident. The Deputy may be from the same agency or another agency. The assignments are incident specific based on priority tasks and there is flexibility to allow for a transfer of command when situations change, assuming ego and tradition may be set aside to meet the needs of the incident (Coleman, 2008). The Operations Section Chief is responsible for the management of all operations directly related to the primary mission. The Operations Chief activates and supervises organizational elements and directs the execution of the Incident Action Plan. The Operations Chief handles the incident related tasks, for example fire suppression or medical management, and it is recommended that this person should be at the Command Post with the Incident Commander (Coleman, 2008). The Operations Chief may also have as many Deputy Operations Chiefs as necessary (Governor s Office of Emergency Services, 2007). See Appendix E for the IC and Operations Section Chief Responsibility Checklists. The Incident Management Team (IMT) is a group of mirror ICS positions in a rear area in support of the on-scene operation. The on-scene positions communicate with their counterparts for updates and strategies for continuing operations. Emergency service departments nationwide have developed their own IMTs internally and deploy them upon request as aid to states or nations that experience major natural or human-made disasters (Federal Emergency Management Agency, 2007). The FDNY has two IMTs and members on the teams are trained to a particular ICS position with superior expertise in that area. The FDNY IMTs have been deployed on numerous occasions since being developed (Fire Department of New York, 2009). An IMT (not FDNY) was deployed to

Fire Department of New York 17 the British Petroleum (BP) gulf oil spill, which began on April 20, 2010. Media has depicted the team in action in a facility working to resolve the problem (Thompson, 2010). The USFA identified core competencies in 2007 for each of the staffed functional areas and all the other ICS positions branching off of them on the MCI organization chart (See Appendix D for the FIRESCOPE Multi Casualty Incident Model Organization Chart). The USFA does not designate any rank, agency, or discipline to fill the positions; it identifies behaviors and responsibilities to successfully manage stated objectives pertaining to the incident. The USFA recommends that the individual most proficient for the position assume the role, particularly for major positions such as the Incident Commander, Operations Section Chief, and the Planning Section Chief (Federal Emergency Management Agency, 2007). National Fire Protection Administration (NFPA) 1561 titled the Standard on Emergency Services Incident Management System also does not dictate that a particular rank or discipline fill specific positions (National Fire Protection Association, 2002). The McKinsey Report was commissioned at the request of the FDNY for recommendations for changes to enhance the FDNY s preparedness. McKinsey & Company spent five months examining the response of the FDNY to the terrorist attacks on the WTC on September 11, 2001. One of the recommendations was for the FDNY to expand its use of the ICS per NIMS geared toward improving command and control, planning, and logistics when faced with large incidents. Other recommendations included to increase training, and to develop an operations center with infrastructure and communications to support citywide command, control, and planning for routine

Fire Department of New York 18 operations and major incidents. The FDNY was also tasked with implementing a staffing recall system, securing mutual aid, creating a family assistance program, and adopting cutting edge technology (McKinsey & Company, 2002). All of the suggested enhancements were achieved by the FDNY (Strategic Plan Work Group, 2006). Prior to the attacks on New York City on September 11, 2001, FDNY incident command was only loosely based on the current NIMS mandated ICS structured approach. Following publication of the McKinsey Report and Department of Homeland security mandates, the FDNY instituted mass ICS training for all Fire and EMS Officers and developed procedures and documents that followed national guidelines (Fire Department of New York, 2006). It developed that a Fire Officer was and is firmly established as IC at all FDNY MCIs, despite the flexibility allowed by national standards to have the best suited person as IC and filling high ICS positions, not dictated by discipline or rank. However, in 2007, the FDNY appointed an EMS Division Chief to be the IC at the 2007 New York City Marathon and has since then (Fire Department of New York, 2007). The Marathon is not considered an MCI though; it is a planned special event. But it is recognized as an event that is mostly patient producing and that an EMS Officer is the most appropriate person to be the Incident Commander. The Literature Review supports that local MCI management policies may be developed with NIMS as a template, but allow for flexibility regarding who holds specific ICS positions at the wide variety of MCIs. No other publication from national agencies, including the NFPA and USFA, mandate particular individuals or particular disciplines to hold high level ICS positions.

Fire Department of New York 19 Procedures Action research was the method used to develop the most appropriate MCI organization model for optimal FDNY-EMS medical scene management. Interviews were conducted as personal communications with two active FDNY Chief Officers and one retired NYC-EMS and FDNY Chief Officer for their expertise regarding the ICS, IMTs, and EMS scene management structure before and after EMS was a separate agency in New York City. The interview questions for the Chiefs were devised to obtain a perspective on EMS scene management pre and post merger, and to analyze effective methods of EMS scene management for MCIs in cooperation with Fire resources, addressing research questions B and C. A work group was formed consisting of ICS subject matter experts representing EMS and Fire Operations. The group analyzed existing and draft FDNY documents combined with national and local ICS principles to merge scene management perspectives to produce an ideal model for MCI command structure, addressing research question C. A questionnaire was submitted to Fire Department representatives in major cities closest in population to New York City for insight into how other agencies structure their approach to MCIs regarding medical scene management, addressing research questions A and C. Retired NYC-EMS and FDNY-EMS Deputy Chief Paul Maniscalco was interviewed via telephone on July 29, 2010 for 1 ½ hours (P. Maniscalco, personal communication, July 29, 2010). Chief Maniscalco was a member of EMS from 1980 to 2002, hired prior to the merger with the FDNY. Chief Maniscalco was the EMS Incident Commander at the WTC bombing on February 26, 1993. He was interviewed for

Fire Department of New York 20 information and a perspective on pre-merger MCI EMS management and effectiveness at a significant incident that produced multiple casualties and for any advantages of having an EMS Officer in a lead ICS position at an MCI (See Appendix F for the interview with Chief Maniscalco). Current Chief of FDNY-EMS John Peruggia was interviewed in person on August 31, 2010 at FDNY Headquarters in Brooklyn, New York (J. Peruggia, personal communication, August 31, 2010). Chief Peruggia was the lead EMS Officer as Medical Branch Director at the scene of the Staten Island Ferry crash that occurred on October 15, 2003, producing 11 deaths and 71 injuries, and at the emergency landing of a passenger airliner in the Hudson River on January 15, 2009 that produced 78 patients. He was interviewed regarding these incidents for a perspective on post-merger MCI EMS management and effectiveness at significant incidents that produced multiple casualties. Chief Peruggia also gave a perspective on the pre-merger EMS response to a LaGuardia Airport plane crash in 1992 that killed 27 people (See Appendix G for the interview with Chief Peruggia). FDNY-EMS Division Chief Albert Gehres was interviewed in person at EMS Division 5 Headquarters on Staten Island, New York on September 1, 2010 (A. Gehres, personal communication, September 1, 2010). Chief Gehres is a 26 year veteran of EMS and is Commander of EMS Division 5, encompassing Staten Island and Brooklyn South. Chief Gehres is a member of the FDNY IMT, certified in Logistics positions including Medical Unit Leader, Computer Technical Specialist, and Technical Specialist. He is also certified in the Planning positions of Status Check-In, Demobilization Unit Leader, and Resource Unit Leader. Chief Gehres deployed to Hurricane Katrina in 2005 and the

Fire Department of New York 21 Wenatachee National Forest wildland fires in 2007 as a member of the FDNY IMT. Chief Gehres was interviewed for a perspective and effectiveness of the current FDNY MCI command structure and for alternatives to the current structure (See Appendix H for the interview with Chief Gehres). An MCI Medical Management work group was formed consisting of Department ICS subject matter experts with expertise as lead Officers at significant MCIs and as developers of Department procedural documents. The group met to produce a dual document, or an identical FDNY procedural document on a subject distributed to both FDNY Fire Operations and EMS Operations members. The document was meant to update and condense several published and draft documents regarding medical management at MCIs into one concise and comprehensive document. The work group combined the reference document priorities with best practices from IMS and ICS references to produce a revised organization model for medical management and command at MCIs. Members of the group included the author, a 23 year veteran of EMS. The author is trained to the highest level of ICS education and has participated as an Officer at significant patient-producing MCIs, including the terrorist incident at the WTC on September 11, 2001. The author has co-authored Department dual documents, including the FDNY Emergency Response Plan and its addendums, and has completed the National Fire Academy Executive Fire Officers Program third year class entitled Executive Analysis of Fire Service Operations in Emergency Management. The group also included FDNY Captain John Nevins. Capt. Nevins works in the Document Control Unit of the FDNY and has structured and authored Department procedural documents. Also included was Assistant Fire Chief Michael Marrone,

Fire Department of New York 22 Commander of Fire Operations Division 8, EMS Division Chief of EMS Training Ann Fitton, Assistant Fire Chief and Commander of FDNY Fire Safety Education Paul Cresci. The initial group meeting was held on July 23, 2010 to discuss the objectives, goals, and assignments for the group. Individual tasks were distributed and expected deliverables were discussed. The individuals in the group worked independently on their assigned tasks, sharing progress with other group members between meetings. Subsequent group meetings were held in 2010 on August 17, August 31, September 3, September 8, September 10, and September 28. A questionnaire titled Multi Casualty Incident Command was distributed to representatives of Fire Departments of United States cities that provide EMS closest in population to that of New York City. Eight of ten Departments contacted completed the survey. Some large cities were not contacted because their EMS service is a separate agency such as Departments in Boston, Pittsburgh, and Honolulu. The ten questions were either closed-ended or force choice. The purpose of the questionnaire was to determine how other major Fire Departments structure their MCI command regarding medical management. Participants were called or e-mailed for permission for the author to send them the questionnaire, which was available as an Internet link (See Appendix I for the Major City Fire Department Questionnaire). One of the limitations of the study was that an analysis of performances of EMS responses to MCIs was not conducted to determine what criteria establish a response as successful or limited. There are standards for response time to incidents but no known standards regarding, for example, percentage of patients salvaged compared to total victims, transport times to hospitals, coordination of resources, or communication. There

Fire Department of New York 23 are many variables to consider from incident to incident so it may be challenging to set certain expectations. Results The Results section of the study consists of answers to the following research questions: (a) what organizational structures do other public safety agencies use to manage incidents with multiple casualties, b) what are the advantages, if any, of having an EMS Officer as Operations Chief or higher at multiple casualty incidents, c) what are alternatives to the Incident Command System multiple casualty incident organization chart? NIMS is a template for incident management allowing for local policy to fine tune the particulars based on resources and staffing to ensure effective incident command structure (Department of Homeland Security, 2008). CIMS delegates authority to New York City agencies that hold the core competencies to mitigate incident hazards most effectively. The FDNY is the lead agency at MCIs, therefore the FDNY has, to date, assigned an FDNY Officer as the Incident Commander at MCIs regardless of the type. There is no mandate that Fire Officers with minimal to no medical management expertise or education hold the lead ICS positions at medical management MCIs (City of New York Office of Emergency Management, 2006). EMS Officers are trained to a higher emergency medical certification than any Fire Officer in the FDNY. Currently, 27 of 28 EMS Chief Officers hold paramedic certification. All FDNY-EMS Chief Officers have received NIMS, CIMS, and ICS training. All of the FDNY-EMS Chief Officers have held the position of Medical Branch Director at incidents producing significant patients, and 6 of them as Incident

Fire Department of New York 24 Commander at NYC-EMS MCIs prior to 1996. Nine FDNY-EMS Chief Officers hold or held IMT certification and have been deployed to national and international incidents including Hurricane Katrina, the Haiti earthquake, and wildfires (Regional Emergency Medical Advisory Committee of New York City, 2010). There has been precedence in NYC-EMS and the FDNY that EMS Officers have been assigned lead ICS positions for MCIs and that those MCIs have been effectively and appropriately managed. An EMS Officer was the IC at significant patient producing incidents pre-merger including the WTC bombing in 1993 (See Appendix C for the 1993 World Trade Center Bombing EMS Organization Chart) and the Williamsburg Bridge train crash in 1995 (United States Fire Administration, 1995). An EMS Officer has been appointed the IC at the New York City Marathon since 2007, as the Department recognized that the Marathon is primarily a patient-producing event and that an EMS Officer is most appropriate for the position (Fire Department of New York, 2007). The USFA recommends that the individual most suited for an ICS position assume that role (Federal Emergency Management Agency, 2007). In a multi-casualty scenario, the IC and specifically the Operations Chief would be making critical decisions regarding patient care, movement, and transfer. These individuals would be involved with employing the START triage system to decide the best courses of management to allocate resources to do the most good for the highest number of patients. It may mean making the decision to divert the many hands needed for cardiopulmonary resuscitation (CPR) on pulseless, breathless patients to a higher number of critical but likely salvageable patients (Regional Emergency Medical Advisory Committee of New York City, 2010).

Fire Department of New York 25 The lead positions on MCIs must have the expertise to calculate the ratio of resources to patients needed for an incident. Help may be requested in the form of mutual aid to summon regional hospital, volunteer, and private ambulance units. Mutual aid agreement parameters and activation procedures must be immediately available. Hospitals may be asked to provide doctor and nursing resources directly to incident scenes and those hospitals need to be assessed for their ability to handle volumes of patients based on injury type (Governor s Office of Emergency Services, 2007). The questionnaire distributed to large city Fire Departments revealed that all eight of the polled Departments employ ICS at MCIs and all ranked and unranked members receive ICS training. Most Department members in the cities are cross-trained; members are trained in both Fire and EMS strategies, tactics, and procedures. FDNY members are not cross-trained other than the CFR program; no EMS member receives firefighting training. The cross-training in other cities allows for any Department Officer to effectively hold high ICS positions for any type of MCI; the IC, for example, is well-versed in fire tactics and related disciplines as well as pre-hospital emergency medical care. Even so, most Departments place their highest ranking EMS Officer in the Medical Branch Director position. However, 100% of the Departments would consider using an EMS Officer in a higher level ICS position than Medical Branch Director and Philadelphia already appoints an EMS Officer as IC at EMS-based incidents. The interview with Chief Maniscalco offered background on EMS operations at MCIs prior to the merger. He cited the WTC bombing as an example of NYC-EMS as a separate agency successfully handling an intricate acute, then extended medical

Fire Department of New York 26 management operation with an EMS Officer as the IC and EMS Officers filling all other ICS positions. The interview with Chief Peruggia offered background on EMS operations at MCIs after the merger that were not as successful, citing the Staten Island Ferry crash in 2003 and the Hudson River plane ditching in 2009. He also discussed a plane crash handled successfully by NYC-EMS pre-merger in 1992 in spite of NTSB having found flaws in the response. Chief Peruggia stressed that FDNY MCI medical management should be updated to include an EMS Officer in a higher ICS position to achieve increased overview and oversight, up to and including IC. The interview with Chief Gehres focused on explanations and justification for having an EMS Officer in a higher ICS MCI position than Medical Branch Director. Chief Gehres was also able to add insight into the IMT as part of the ICS process and its success nationally when organized as recommended by NIMs. Chief Gehres also feels that the lead EMS Officer should hold a higher ICS position at major patient-producing incidents than Medical Branch Director. Chief Gehres is impressed that when he deploys as a member of an IMT, the NIMS recommendations that the individual with the most expertise maintains the appropriate ICS positions at MCIs. The work group, referencing the research, developed a revised organization chart for the EMS document OGP 112-06 ICS Medical Operational System Description and Multi-Casualty Application. The group also developed strategies and tactics that support the choices made for the organization chart revisions. The chart reflects additional ICS Units and that EMS Officers may be assigned ICS positions of Incident Commander, Deputy Incident Commander, Operations Chief, or Deputy Operations Chief. The

Fire Department of New York 27 document was also converted to a dual document, or one that is identical in the resource books published for both Fire and EMS resources. Discussion The study results suggest that MCIs are rarely single discipline events, that some combination of fire, EMS, hazardous materials, rescue, law enforcement, and public works resource activities are required, therefore an FDNY Fire Officer may be most suited to maintain the position of IC at FDNY designated MCIs. There is no definitive necessitation that an EMS Officer who is not trained in hazard mitigation is assigned initially as the Incident Commander at any MCI where the FDNY is the lead agency, even MCIs that require significant medical management of an influx of patients (City of New York Office of Emergency Management, 2006). However, the research indicates that the Department may maintain the flexibility to transfer the IC position at a large patient producing incident from a Fire Officer to an EMS Officer when the remaining priority is patient care, or place an EMS Officer in the position of Deputy Operations Chief up to Deputy IC. The McKinsey Report recommended that the FDNY increase training and use of the ICS following the terrorist attacks of 9/11 (McKinsey & Company, 2002). That was accomplished (Strategic Plan Work Group, 2006) but there has not been acquiescence to the dynamic nature of MCIs to exchange the IC or other lead ICS position from Fire Officer to EMS Officer when the nature or focus of the situation changes to medical management (A. Gehres, personal communication, September 1, 2010). FDNY members have been deployed as members of an IMT where they have experienced the spirit of NIMS in that ICS positions are not dependent on rank or discipline, but on expertise (Fire

Fire Department of New York 28 Department of New York, 2009). The BP oil rig explosion and subsequent oil leak disaster was resolved using an IMT of members with very specific expertise (Thompson, 2010). It may be argued that an EMS Officer would never be the IC at an MCI that was fire or other hazard based (Fire Department of New York, 2006), so why would a Fire Officer be the IC at an MCI where the major or only priority is EMS triage, treatment, and transport of numerous patients? The role of IC is one of coordination, organization, and management of all resources following a big-picture mentality to ensure and implement the most effective strategies (Coleman, 2008). The National Response Framework and the National Incident Management System are two sets of Federal guidelines that recommend that the ICS be managed as standardized but flexible (Department of Homeland Security, 2008), (Federal Emergency Management Agency, 2008). CIMS is also flexible in that it designates lead agencies for certain types of MCIs consistent with the lead agency core competencies, but recommends that the incident IC have the expertise regarding the particular core competencies required (City of New York Office of Emergency Management, 2006). Large city Fire Departments most comparable to FDNY have progressively crosstrained their members as a means to integrate the resources to increase response capabilities (See Appendix I for the major city Fire Department questionnaire). The cross-training standard makes which individual to choose as the IC obsolete, as all members have fire, hazard, and EMS expertise. The FDNY to date has not cross-trained members to a degree where the IC or other lead ICS position is interchangeable between a Fire and EMS member.

Fire Department of New York 29 The IC position demands the individual who may fill that role with the strongest skills set for those goals (National Fire Protection Agency, 2002). It could be an EMS Officer for an MCI that is multiple patient-producing as IC, but at the least it would be advantageous to have an EMS Officer filling a higher position than Medical Branch Director due to the emergency certification level and expertise in this area, and to allow for broader oversight of EMS incident tactics. Alternative positions for the lead EMS Officer may be Deputy Incident Commander, Operations Chief, or Deputy Operations Chief (Governor s Office of Emergency Services, 2007). The Operations Chief, for example, is more suited to oversee the specific tactics to manage the major issues at hand (Federal Emergency Management Association, 2007). Medical management tactics concerns all phases of patient care; for pre-hospital care it definitely includes the basics of triage, treatment, and transport (Regional Emergency Medical Advisory Committee of New York City, 2010). The lead EMS Officer must also be aware of pre-hospital resources at his or her disposal. MCIs involving many patients may include activating mutual aid from other organizations and geographic areas. The Chief must be familiar with the details of mutual aid agreements in place and the activation procedures. Municipal, volunteer, private, and hospital units may be responding and need to be coordinated. Mutual aid responding units would have to be outfitted with maps, portable radios, and other pertinent equipment for the incident or response area. Familiarization with local hospitals is important for the Operations Chief. Hospitals need to be canvassed for their specialty referral capabilities and capacities to

Fire Department of New York 30 avoid sending too many patients to any one hospital or to hospitals that cannot treat, for example burns or trauma (P. Maniscalco, personal communication, July 29, 2010). Precedence has been set regarding the ability and actuality of an EMS Officer positioned as a successful lead ICS MCI manager at large patient-producing incidents. An EMS Officer successfully led the immense initial response of EMS resources to the WTC bombing in 1993 and the subsequent 100-day ongoing standby at the location (New York City Emergency Medical Service, 1993). The Department has conceded since 2007 that an EMS Officer is most suited to be the IC at the New York City Marathon (Fire Department of New York, 2007). Unexpected findings during the research included the questionnaire result that eight out of eight respondent large city Fire Departments have at least some cross-trained members. It made the questions regarding does or should EMS Officers hold high ICS positions somewhat academic because if all members of the Departments are crosstrained, it is automatic that the IC and immediate subordinates have both Fire and EMS expertise. In addition, the author did not expect to have concluded that an EMS Officer in the FDNY could be recommended to be the IC at any FDNY MCI, including a major medical management scenario. The research supports it as a recommendation, but the author believes not a feasible one presently for the FDNY due to the still-evolving dynamic cooperation between Fire and EMS resources, post-merger. An EMS Officer in a higher ICS position at medical management MCIs may impact the FDNY by advancing the intention of the merger in that it was to be developed as one Department. Members were to be described as being in the FDNY, not in Fire, or EMS. The responsibility that comes with a lead ICS position for an EMS Officer may not

Fire Department of New York 31 be acceptable culturally initially by some Fire Operations members. The needs of the incident should prove to overcome any skepticism or tradition regarding ceding command to an EMS Officer when the situation calls for it. An EMS Officer as IC, for example, lends itself to increasing morale and aspirations for EMS members if they observe a more equal command relationship on incident scenes. Recommendations The Action Research resulted in a revised FDNY ICS Medical Operational System Organization Chart for the multiple casualty incident ICS application (see Appendix J for the Action Research result revised FDNY ICS Medical Operational System Organization Chart). The document should be a dual document meant for joint activity between Fire and EMS resources. The organization chart includes that during a multi-casualty incident, either a Fire or EMS Officer may be assigned the position of Incident Commander, Deputy IC, Operations Chief, Deputy Operations Chief, or Co- Operations Chief. The organization chart also reflects a new Unit named the Patient Transfer Unit that will require a cooperative effort between Fire and EMS resources to most efficiently move many patients around the scene and to waiting transport vehicles. This would entail many task forces consisting of both Fire and EMS members to extricate patients, move them to triage and treatment areas, and package them for transport to hospitals. This operation alone requires oversight by an EMS Officer for appropriate coordination. A second recommendation is that START triage education be enhanced during the CFR certification all newly hired members now receive. This would give the lead EMS Officer, with currently limited Officer and member resources for a catastrophic