HomeMy WebLinkAbout20081647.tiff RESOLUTION
RE: APPROVE NORTHERN COLORADO REGIONAL EMERGENCY MEDICAL AND
TRAUMA SERVICES ADVISORY COUNCIL(RETAC)MASS CASUALTY EMERGENCY
OPERATIONS PLAN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Northern Colorado Regional Emergency Medical and Trauma Services
Advisory Council(RETAC)has presented the Board with a Mass Casualty Emergency Operations
Plan, dated October 13, 2006, with terms and conditions being as stated in said plan, and
WHEREAS, after review, the Board deems it advisable to approve said plan, a copy of
which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Northern Colorado Regional Emergency Medical and Trauma Services
Advisory Council (RETAC) Mass Casualty Emergency Operations Plan, dated October 13, 2006,
be, and hereby is, approved.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 9th day of June, A.D., 2008.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: dandi
vciTY
William H. Jerke, Chair
Weld County Clerk to th- :<-• d
EXCUSED
Robed D_Masdpn, Pro-Tem
BY: /��i�/ /. �i "�+�1.7.1e►ir. f
Deputy Cler o the Board
Will F. Garcia
APP M: '\�\J1 C (
/ ddd
David ZrE A
G '
C n ttorney
s
ugla Rademac er
Date of signature: E1
2008-1647
AM0019
00 '. 41,q.,' Otn-A3- Or(
Northern Colorado RETAC
Mass Casualty
Emergency Operations
Plan
Version 5.0
October 13"', 2006
Page 1 of 36
2008-1647
Table of Contents
Executive Summary 3
Introduction 5
The Incident Command System 5
The Operations Section 5
Major Organizational Elements of Incident Operations 6
Divisions and Groups 6
Functional Groups 6
Resource Organization 6
Medical Division 7
Medical Division Organizational Chart 7
Expanded Medical Organizational Chart 8
Mass Casualty Incident Categories 9
Transport Strategy Notes 9
MCI - 0 9
MCI - I 10
MCI - II 11
MCI - III 11
Multi-Casualty Incident Resource Mobilization 12
Principles of Triage 13
En Route 14
S.T.A.R.T. Triage 15
Start Triage Is Used To Find Patients 15
Working At a Multiple- Or Mass-Casualty Incident 15
Triage 16
S.T.A.R.T Triage Flow Chart 17
JunpSTART Pediatric MCI Triage 18
Safety Considerations at MCI Events 19
Position Checklist 21
Appendices 29
NCRETAC Hospitals 30
NCRETAC Dispatch911 31
NCRETAC Transport Services 32
NCRETAC Non-Transport EMS 33
Page 2 of 36
Northern Colorado PETAL
Mass Casualt Emercenc 0 erations Plan
Executive Summary
The purpose of this Emergency Operations Plan(EOP) is to provide the constituents of
Northeast Colorado Emergency Medical/Trauma Advisory Council (NCRETAC) with an
organized, expandable and practical operational plan to ensure victims of incidents are
cared for appropriately.
Multi-casualty Incidents can include: motor vehicle accidents; aircraft accidents; floods;
tornados; hazardous materials spills; nuclear incidents; fires; explosions; earthquakes;
war-related disasters; acts of terrorism; etc. It is the goal of the NCRETAC to ensure the
preparedness of our providers by providing the training and exercises necessary for
competency. This document also functions as the Standard Operating Procedure(SOP),
which will be made available to all EMS provider agencies within the NCRETAC.
It is the responsibility of the NCRETAC to describe, categorize, inventory and track the
available resources within our region and to assist with prehospital care reimbursement
and cost recovery in the event of a disaster. In all cases of cost recovery, availability of
complete, accurate and timely documentation can help a response organization capture
the compensation it is due.
Most incidents involving between 1 and 5 victims are usually handled by initial
responding units with subsequent requests for additional assistance depending upon the
number of victims involved and the severity of their injuries. Larger multi-casualty
incidents will overwhelm the initial responding resources as well as area hospitals. For
this reason it is important to have a common and useable EOP. A common MCI-EOP
allows multiple agencies to function in an organized and coordinated manner, with all
agencies understanding their roles and the hierarchal structure of the Incident Command
System(ICS). Cooperating agencies should also have mutual aid agreements established
not only to respond to the incident, but also to ensure that communities will have
adequate response to other 911 calls.
This EOP conforms to the standards, terminology and procedures contained in the
National Incident Management System(NIMS)document. This document uses the
Incident Command System(ICS) which is designed to enable efficient and effective
incident management by integrating a variety of responding agencies, communication
centers and receiving hospitals.
In the ICS there can be a single Incident Commander(IC)or a Unified Command(UC).
Both have advantages and disadvantages and depending upon the size and type of
incident, the jurisdiction and the number and type of responding agencies. Regardless the
type of command structure established it must be done early and cooperatively. The IC
will then formulate an Incident Action Plan(IAP) which must take into account the
number of victims, location, potential hazards and any specialized needs such as technical
rescue, HAZMAT etc. It is possible that the first arriving unit may assume the initial IC
role and conduct a size-up and formulate an IAP. It is imperative that Medical Branch
Page 3 of 36
Northern Colorado RETAC
Mass Casualt Emereenc Operations Plan
personnel through their Medical Supervisor are aware of and allowed to provide input to
the IAP. For large disasters with multiple staging areas, then it is possible to have an Area
Commander(AC) with multiple IC under their control.
In the ICS there are 4 sections which include Operations, Planning, Logistics and
Administration. Our duties will fall under the Operations Sections and specifically the
Medical Branch. Other Operational Branches include Fire Suppression, Hazmat, Rescue,
Investigative and Law/Military. Under the Medical Branch there may be up to 5 Medical
Divisions with each Division capable of handling up to 16 patients depending on
criticality, location etc.
The Incident Command Post (ICP) should be located in the immediate vicinity of the
incident. If it is a small incident then the ICP may also function as the Emergency
Operations Center(EOC). In larger incidents requiring multiple agencies and resources,
the EOC may be based at another location.
Effective communications and information management is vital to efficient incident
management. Common operating and communication format as well as data collection
will follow standards as designated by the NIMS Integration Center(see appendix).
Physician Advisory Board
Northeast Colorado RETAC
Page 4 of 36
Northern Colorado RETAC
Mass Casualt Emer enc 0.erations Plan
Introduction
Large multi-casualty incidents will overwhelm the initial responding resources. The
Medical Supervisor must have delineated and expandable operational procedures to
assure that proper emergency pre-hospital care and the prevention of further injury to
victims, the public and public safety personnel will be provided.
This pre-determined EMS Emergency Operations Plan must provide for the effective
treatment and transportation of multiple casualties through the principles of"Triage"
management.
The medical functional group structure is designed to utilize all aspects of Emergency
Medical Service response resources, including on-scene Physician medical direction, if
applicable.
While most incidents are generally handled on a daily basis by a single jurisdiction at the
local level, there are important instances in which successful domestic incident
management operations depend on the involvement of multiple jurisdictions, functional
agencies, and emergency responder disciplines. These instances require effective and
efficient coordination across this broad spectrum of organization and activities.
The National Incident Management System(NIMS) uses a systems approach to integrate
the best of existing processes and methods into a unified national framework for incident
management. This framework forms the basis for interoperability and compatibility that
will, in turn, enable a diverse set of public and private organizations to conduct well-
integrated and effective incident management operations. It does this through a core set
of concepts,principles, procedures, and organizational processes, terminology, and
standards requirements applicable to a broad community of NIMS users.
The Incident Command System
The Incident Command System (ICS) is the combination of facilities, equipment
personnel,procedures, and communications operating within a common organizational
structure, designed to aid in domestic incident management activities. It is used for a
broad spectrum of emergencies, from small to complex incidents.
Command
Operations Planning Logistics Finance/
Administration
Page 5 of 36
Northern Colorado RETAC
Mass Casualt Emersenc Operations Plan
The Operations Section
The Operations Section is responsible for managing tactical operations at the incident site
directed toward reducing the immediate hazard, saving lives and property, establishing
situation control, and restoring normal conditions.
Operations Section
1
fBranches (up to 5)
1
Division or Groups(Up to 25)
1
Resources
Major Organizational Elements of Incident Operations
Divisions and Groups
Divisions and groups are established when the number of resources exceeds the
Operations Section Chief's manageable span of control. Divisions demarcate physical or
geographical areas of operation within the incident area, while Groups demarcate
functional areas of operation for the incident.
Functional Groups
Functional groups can best be used to describe areas of like activity(e.g., rescue,
suppression, medical)
Operations Section
I
Suppression Group Rescue Group Emergency Medical
Service Group
Resource Organization
Initially, in any incident, individual resources that are assigned will report directly to the
IC. As the incident grows in size or complexity, individual resources may be organized
and employed in a number of ways to facilitate management.
Page 6 of 36
Northern Colorado RETAC
Mass Casualt Emersenc Operations Plan
Medical Division
The Medical Division(or Group) organizational structure is designed to provide the
Medical Group Supervisor with the basic expandable system for handling any number of
patients in a multi-casualty incident. A second Medical Division may be established if
geographical or incident conditions warrant.
A minimum structure is required whenever five or more critical patients are being cared
for(see Expanded Medical page 6). When the number of victims reaches 16 or more, one
or more Medical Divisions are required,however, the degree of implementation will
depend upon the number of victims.
Medical Division Organization Chart
Incident
Commander
Staging.
Supplies,
... . .... . .. .. ... Mass Casualty Morgue.
Incident Rehab.
etc.
Medical Division Supervisor
Title:'Mediar
Triage Officer
Title.'Tnage"
Immediate Treatment Delayed Treatment Minor Treatment
Manager Manager Manager
Title:'Red Treatment' Tate 'Yellow Treatnenr Title:'Green Treatment"
Treatment Unit Leader
Title:'Treatment"
Transport Officer Ambulances
Me:'TranspoM
Page 7 of 36
Northern Colorado RETAC
Mass Casualt Emer enc Operations Plan
Expanded Medical Organization Division Chart
(600 PATIENTS)
1 Welt"
IC
corr�nu
I�mmm}i
Stiff
r Smtlea, SI
' Satin j E
J MAT S •
Bratinpoorlit
9imb S �A@BtAKh�
11„„II • t
{ST1 l
TA:acd Soipmt
rat,, • 'r IAW.Vrttt
Di mA Mirror; LDAjdeeC JDMU D ` PM
tut*.
�D1vid� .
nip ice'
lair Valle
r UGmad, 'rnuvwrl � .
yli�n I. r.
1 , , 1- a Laieu
J tWI ♦ tt1• J Yom^ Opidet l IM 1 1 10 ' 4 10p {1 'A► i AND
YEACH ID TREATMENTT
TARP WILL REQUIRE
2 EMT-Ps R4 EMT-Bs
1 30 {t0pmmtJ {'°prtiwt' IIOptimi
l T1sP l ? l Tmi EACH FOR
r TREATMENT TARP Rfl
REQUIRE
( ID 3 (10y�ws (IDpod t iai�omt 5 EMT-B's
AIL VIC1Dt yl TtR_ yl '[LP _tiara...,
THIS STAFFING
LEVELWD.PROVIDE A
i 101 10 1 10 ' inhalants
11(10 RECORDMMON
OR EACH 10 VIC-LMS
J ONE MORGUE
' 10 s IDpumtl I0 is ESTABLISHED OR
X41 100 TAP_J ra LVCIDE\T
Page 8 of 36
Northern Colorado RETAC
Mass Casualt Emer enc ()serrations Plan
Mass Casualty Incident Categories
MCI procedures are tiered into one of FOUR(4) categories:
MCI-0 Mini MCI (2-5 casualties; at least one critical)
MCI-I Expanded Medical Emergency(6-15 casualties)
MCI-II Major Medical Emergency(16-50 casualties)
MCI-III Medical Disaster(51 or more casualties)
Transport Strategy Notes
1-2 critical patients= Split-first arriving crew
3-5 critical patients=First-in-last-out
> 5 critical patients= Full EMS Division(Triage, Treatment and Transport,)
MCI — 0 Mini Mass Casualt Incident, aka Mini MCI
Mini-Mass Casualties(MCI-0) are classified as incidents with 2-5 injured patients with at
least one critical. These occur with greater frequency than other MCI types and can serve
as real-time incidents that utilize the same principles applicable to larger MCI events.
Therefore the Mini-MCI event can be considered the basic Medical Division, which can
be expanded to meet the demands of larger more complex MCI events.
First Arriving Ambulance:
The first arriving ambulance will take charge of and coordinate patient care activities. All
additional responding ambulances will coordinate their efforts with the first arriving fire,
ambulance and law enforcement agencies. Overall Incident Command is typically
assumed by Fire Officers.
First Arriving Ambulance responsibilities are:
1. Announce"Mini-MCI" over the Radio
2. Report to or establish command.
3. Most qualified EMT immediately attends to the most serious patient.
4. EMT performs triage(scene survey; mechanism; number of victims; severity of
injuries) then reports back to paramedic.
5. Triage and tag each patient and prioritize victims for transport.
6. Request additional resources as appropriate through incident command.
7. Rapidly package all patients and assemble them in a central collection point.
8. Most qualified EMT sees all additional critical patients.
Page 9 of 36
Northern Colorado RETAC
Mass Casualt Emer•enc Oserations Plan
When operating in the Mini-MCI mode, all caregivers will provide the following
standard exam and treatment:
1. All"walking wounded" are directed to wait in or near the ambulance.
2. Non-Walking Wounded Exam: Respiration/Perfusion/Mental Status
a. Airway(yes/no)
b. Breathing> 30
c. Pulse (carotid or radial)
d. Cap refill > 2 seconds
e. Skin Color(pale,normal, cyanotic)
f. LOC (follows commands)
g. Chest(look, listen, feel)
3. Treatment:
a. Establish airway
b. Seal chest wounds/treat tension pneumothorax
c. Control Major Hemorrhage
d. Package on Backboard
4. Move to Collection Area
Do not waste time with unnecessary treatment or examinations. All patients should be
rapidly examined and packaged, using a minimum of personnel... further
examination and treatment may take place in the collection area(time permitting).
5. Radio Reports
Use the"command name" in the report.
MCI - I (Involves between 6 to 15 casualties, with at least five considered being
in critical condition
The medical aspects of an incident may be handled by the Medical Division Supervisor
and/or the Medical Division/Treatment Supervisor through direct requests for additional
emergency medical and hospital personnel and equipment, depending upon the number of
victims, severity of injuries and magnitude of the incident.
To determine the amount of additional emergency medical personnel required, the
following is recommended:
1. One ALS EMT and one EMT or First Responder for each critical patient
2. One EMT for every 3-non-critical patient
3. One Senior EMT as Medical Communication, Transportation Leader
4. One Senior EMT as Triage Control Officer
The Medical Incident Commander shall also assure that:
1. Sufficient ambulance and/or appropriate transport vehicles have been requested
2. Sufficient fire suppression support personnel have been requested
3. Activation of Hospital and Mutual Aid Frequencies
Page 10 of 36
Northern Colorado RETAC
Mass Casualt Emersenc Operations Plan
The following line positions are recommended minimums:
1. A Triage Control Officer
2. A Transportation Control Officer
NOTE: Local Mutual Aid will be needed
MCI - II (Involves between 16 and 50 casualties)
The Medical Division Supervisor shall establish a Medical Division, at a level of
support/line personnel as determined by the number of victims and the magnitude of the
incident.
To determine that amount of additional emergency medical personnel required, the
following is recommended:
1. A complete Medical Division appropriately staffed pursuant to the number of
casualties.
2. One ALS EMT per three critical victims. (Note: Patient ratio increased from MCI - I).
3. One EMT per seven minor injuries. (Note: Patient ratio increased from MCI - I).
NOTE Regional Mutual Aid will be needed
MCI - III (51 or more casualties, and the magnitude of the incident can be
handled b the resources available
The Incident Commander(typically assumed by a Fire Service Officer) shall establish
one or more Medical Divisions at a level of support/line personnel as determined by the
number of victims and the magnitude of the incident. To determine the amount of
additional emergency personnel required, the following is recommended:
1. A minimum of one complete Medical Division
2. One ALS EMT per three critical patients
3. One EMT per seven minor injuries
NOTE: County, and/or State assistance will be needed
Page 11 of 36
Northern Colorado RETAC
Mass Casualt Emer.enc O.erations Plan
Multi-Casualty Incident Resource Mobilization
Protocols must be established in advance of Multi-Casualty Incidents with
communications centers for the activation and mobilization of additional patient care and
transport resources. The on scene challenges faced by EMS personnel at these events
require the mobilization of resources be preplanned.
In addition it is an essential element of MCI medical response preparedness that Mutual
Aid Agreements exist between neighboring EMS agencies. A sample EMS mutual aid
agreement is available for review in the Northeast Colorado All-Hazards Region's
"Regional Mass Casualty Incident Plan" (see Appendix).
MCI-I(6-15 patients) (All units report to staging)
1. Full first alarm fire response.
2. Request a total of 5 ambulances.
3. Request 1 helicopter to scene or appropriate Emergency Department(ED) (optional).
4. l bus
5. Notify appropriate emergency department via radio and/or telephone; landline or cell
MCI-II (16-51 patients) (All units report to staging)
1. Full second alarm fire response(ask incident commander).
2. Request an additional 5 ambulances (total of 10)
3. Activate available search and rescue team
4. Request additional helicopter to scene or appropriate ED (total of 2)
5. Request additional bus (total of 2)
MCI-III(51 or more patients) (All units report to staging)
1. Full third alarm fire response
2. LCSO search and rescue
3. Request additional 10 ambulances (total of 20)
4. Request additional helicopter to scene or appropriate ED (total of 3 - optional)
5. Request additional bus (total of 3 - optional)
Page 12 of 36
Northern Colorado RETAC
Mass Casualt Emer.enc 0.erations Plan
Principles of Triage
"Triage" is a word, which originated on World War I battlefields, and comes from the
French word "triage", meaning, "to pick out". Triage was originally applied to the
process of sorting out which casualties could be returned to the front by concentrating the
limited medical resources available to their injuries. Today triage has come to mean the
process whereby patients are sorted according to medical need; the idea being that critical
patients with reversible injuries or illnesses are treated first. Minor,terminal, or fatally
injured patients are consigned to lower priorities for care. This system serves to obtain
maximum salvage rates with medical resources available at the time. The critical feature
of real triage is that it is field oriented. This prevents overloading of pre-hospital
emergency medical providers and allows more efficient use of available resources to save
lives.
Triage is most useful in disaster settings where medical facilities are truly overwhelmed;
as in earthquake, aircraft disaster, high-rise fire, etc. In this setting, persons who would
survive without help are virtually ignored during triage, as are patients who will probably
die despite massive medical intervention. The middle group of patients who will benefit
most are the patients who receive treatment after categorization by the triage teams at the
scene.
There are several principles that must be learned by Paramedics and EMTs to effectively
triage and deliver disaster style medicine.
1. In a large-scale disaster, total patient care is impossible. The slightly injured patient
may receive very little, or no treatment. They may also have to wait considerable
time. Also, the very critically ill patient, with little chance for survival, may receive
little or no care since that would waste resources that could save many other lives if
applied properly.
2. Triage sorts or classifies patients, providing no patient care because the institution of
treatment would slow down the triage capability to an intolerable pace. The
exception to this is airway management and the control of dangerous bleeding. All
emergency medical personnel should deal with these exceptions as quickly as
possible and then go on to the next patient. Routinely, in real disasters, triage can be
effective at a rate of about 30 patients an hour, depending upon the scope of the
disaster and the available resources
3. The Triage Teams must tag the patients, noting their initial assessment, vital signs if
taken, treatment rendered, and the patient's triage classification. It is a time
consuming and often-fatal mistake to triage in the field without tagging the patient,
since he/she requires re-triaging at the medical facility to which he is transported.
By using a casualty sorting system, you are focusing your activities in the middle of a
chaotic and confusing environment. You must identify and separate patients rapidly,
according to the severity of their injuries and their need for treatment.
Page 13 of 36
Northern Colorado RETAC
Mass Casualt Emer•enc O.erations Plan
En route
Even while you are responding to the scene of an incident, you should be preparing
yourself mentally for what you may find. Perhaps you've been to the same location.
Where will help come from? How long will it take to arrive?
Initial Assessment - Stay Calm
The first thing you should do upon arriving at the scene of an incident is to try to stay
calm, look around, and get an overview of the scene. These visual surveys give you an
initial impression of the overall situation, including the potential number of patients
involved, and possibly, even the severity of their injuries. The visual survey should
enable you to estimate initially the amount and type of help needed to handle the
situation.
Your Initial Report - Creating a Verbal Image
The initial report is often the most important message of a disaster because it sets the
emotional and operational stage for everything that follows. As you prepare to give the
first vital report, use clear language(no signals or radio jargon),be concise, be calm, and
do not shout. You are trying to give the communications center a concise verbal picture
of the scene. The key points to communicate are:
• Location of the incident
• Type of incident
• Any hazards
• Approximate number of victims
• Type of assistance required
You might give the following report:
"This is a major accident involving a truck and a commercial bus on Highway 305, about
2 miles east of Route 610. There are approximately 35 victims. There are people trapped.
Repeat: This is a major accident. I am requesting the fire department, rescue squad, and
seven ambulances at this time. Dispatch additional police units to assist."
S.T.A.R.T. Triage
The Colorado Mass Casualty Medical Response System has established a common triage
methodology using the Simple Triage And Rapid Treatment(START)module (see
appendix). Patients will be triaged(or categorized) using the Airport Option METTAG.
Page 14 of 36
Northern Colorado RETAC
Mass Casualt Emereenc Oserations Plan
Start Triage Is Used To Find Patients
This system is designed to assist rescuers to find the most seriously injured patients. As
more rescue personnel arrive on the scene, the patients will be re-triaged for further
evaluation, treatment, stabilization, and transportation. A patient may be re-triaged as
many times and as often as time allows.
Remember that injured patients do not stay in the same condition. The process of shock
may continue and some conditions will become more serious as time goes by. As time
and resources permit, go back and recheck the condition of all patients to catch changes
in condition that may require upgrading to attention.
Working At a Multiple- Or Mass-Casualty Incident
You may or may not be the first person to arrive on the scene of a multiple- or mass-
casualty incident. If other rescuers are already at the scene when you arrive, be sure to
report to the incident commander before going to work. Many events are happening at the
same time and the incident commander will know where your help and skills can best be
used. By virtue of training and local protocols, the incident commander is that person
who is in charge of the rescue operation.
In addition to initially sizing up an incident,clearly and accurately reporting the situation,
and conducting the initial START triage, the first responder will probably also be called
on to participate in many other ways during multiple- and mass-casualty incidents.
As more highly trained rescue and emergency personnel arrive on the scene, accurately
report your findings to the person in charge by using a format similar to that used in the
initial arrival report. Note the following:
• Approximate number of patients
• Numbers that you've triaged into the four levels
• Additional assistance required
• Other important information
After you have reported this information,you may be assigned to use your skills and
knowledge to provide patient care, traffic control, fire protection, or patient movement.
You may also be assigned to provide emergency care to patients, to help move patients,
or to assist with ambulance or helicopter transportation.
In every situation involving casualty sorting, the goal is to find, stabilize and move
Priority One patients first.
Page 15 of 36
Northern Colorado RETAC
Mass Casualt Emer • enc O . erations Plan
Triage
Step 1 - Separation of the walking wounded from the mass casualty site
• Direct all victims able to stand and walk without significant pain to a
predetermined "GREEN" treatment area.
• Select a GREEN treatment area large enough for MCI size and appropriate for
bus ingress and egress.
• Assign first aid personnel, EMTs or Medics, if available to this area.
Step 2 - Triage those remaining by the START Algorithm; respiration, perfusion
and mental status, by using only simple gross intervention skills i.e. airway and
bleeding control only, (please review the START ALGORITHM (adult) and Jump-
Start Algorithm (pediatric) on following pages.
Step 3 -Appropriate category tagging of the victim and the victim's site with the
Triage Tag
• The tear off strip will be removed and retained by the Transportation Supervisor.
• The right corner of the tag is for personal belongings, tag tracking, etc..
• The primary tag (main portion) stays with the patient and both the tag and patient are
delivered to the hospital.
Category 0 - Non-salvageable/ dead
COLOR — BLACK
Last to be transported and by coroner's vehicles.
Do not move bodies unless they are blocking rescuers access to other victims or there are
extenuating circumstances (approaching fire, poss. building collapse, etc.), which may
destroy the body.
Category I - Immediateritical
COLOR - RED
•st to be transported, as soon as possible sin ambulance. Help maintain airway.
status.
Category II: Delayed, Serious
COLOR - Yellow
Can wait a little longer for transport. Respiration's < 30/min., normal perfusion and mental
status clear. Delayed does not mean no serious injury. Injuries may span a wide range and
require frequent reassessment and further prioritization for transport while in the central
treatment area.
Category III: Walking wounded
COLOR - GREEN
Walking wounded, minor injuries: First to lie separated and later to be transported by non-
ambulance transport (first aid.
NOTE: Remember that in a major disaster, it is unlikely that you can save all the
victims. The important thing is to work together with the other rescuers to save
as many patients as you can. START gives you the best chance of doing that
Page 16 of 36
Northern Colorado RETAC
Mass Casualt Emer • enc O . erations Plan
S.T.A.R.T Triage Flow Chart
Priihr1.111-Ul Where You Stana
Aswe t e the Scene
Cal tor Aectatanco
iht2ote MUDD Satrty„sidA
1
Cell Out
1 1
4 *
r Welkin§
Wounded b NonMalking
LInInjurod ,
RESPlRJkTIOt4S
r IIuki in a )4 �1
r I NO
It specific
Loch lion
4
(Position Airway
f Remember to Over AIM E? Under 30c M ln. Look Listen A
Ci. Fun" TRI AGE
Fed
ASAP
I
DIATrj
' f '. I I Ii)N NO
4
I
Racial Pulse Blanch I opt I Repos
ition
t I Airway
I
Absent Pt r-4rri ►t Mule' 1'Sec. Ones 2/Src_ tan
ill
SATE MENTAL 4.4".P
IMMEDIATE
STATUS DEAD
r --
L
4
lows Simple Cult!I
Follow
SimpleCornmende
cuing'tcliKitt
1
INLAYED ill=isiE
Page 17 of 36
Northern Colorado RETAC
Mass Casualt Emer • enc O • erations Plan
JunpSTART Pediatric MCI Triage
Able to ifs
1� walla
f R Evalua4e infants firs in
racondaryt outing
ND 3 the rntft. 4rtfTn
Pe Toon fekEATHIC
Q‘Iroothing' .33 uPPa� o
\ fr
AfTt7C
IPa ND ' DECEASED
t1-s
175
AMA:
5 .°
► DECEASEfl
EfEAI l IING
OM*I itA
f Y
F
{/ \ c15 °R>46 a- AIMEDtATt
Rata >
1646
Montif�l
r PulSe?
TES
plAPR1OPRIATEI 1.1
PIfi571. MB CR V
AVPU
- YtRF
trFRnia
BEIIA'itD
CLAmuAor fikl. 20V
NOTE: Once a patient reaches a triage level indicator in the algorithm (i. e.
IMMEDIATE TAG box), triage of this patient should stop and the patient should
be tagged accordingly
Page 18 of 36
Northern Colorado RETAC
Mass Casualt Emer•enc 0•erations Plan
Safety Considerations at MCI Events
All emergency types are fraught with potential hazards. Safety during any rescue
operation is paramount. Multi-casualty Incidents can include: motor vehicle and aircraft
accidents; natural disasters; nuclear incidents; war-related disasters; acts of terrorism; etc.
Many risks are associated with MCI events, which could involve hazardous materials,
inclement weather, temperature extremes, fire and explosion, toxic gases, unstable
structures and vehicles, heavy equipment, road hazards and sharp edges and fragments
and the potential for hostile situations such as perpetrators and unruly crowds.
Recent terrorism events worldwide emphasize that such attacks, once thought of as only a
remote possibility, are now real-world risks. First responders and emergency medical
personnel cannot afford to be unprepared and all must seriously consider and plan for the
possibility that they may be targets. In any EMS response, hazards that may endanger the
rescuer and/or the patient must be assessed.
If There Is Any Suspicion Of Hazardous Materials: Stay Away!
Unless you have received training in handling hazardous materials and can take the
necessary precautions to protect yourself, you should keep far away from the
contaminated area or"hot zone."
Because the potential for exposure to situations involving hazardous materials is so great,
responders must protect themselves from injury and contamination. Hazardous materials
(Hazmat) incidents involving chemicals occur every day, exposing many people to injury
or contamination. During a hazardous materials incident, responders must protect
themselves from injury and contamination
The single most important step when handling any hazardous materials incident is to
identify the substance(s) involved. Federal law requires hazardous materials placards be
displayed on all vehicles containing large quantities of hazardous materials.
Manufacturers and transporters should display the appropriate placard, along with a four-
digit identification number, for better identification of the hazardous substance.
The US Department of Transportation published the Emergency Response Guidebook,
which lists the most common hazardous materials, their four-digit identification numbers,
and proper emergency actions to control the scene. It also describes the emergency care
of ill or injured patients.
REMEMBER: Contaminated patients will contaminate unprotected rescuers!
These patients should be removed from the contaminated area, decontaminated by trained
personnel (typically Fire Department HazMat Teams), given necessary emergency care,
and transported to a hospital. Because most fatalities and serious injuries sustained in
hazmat incidents result from breathing problems, constant reevaluation of all patients is
Page 19 of 36
Northern Colorado RETAC
Mass Casualt Emersenc Operations Plan
necessary so that a patient whose condition worsens can be identified and moved to a
higher triage level. Once patients are decontaminated triage in hazmat incidents has one
major function; to identify victims who have sustained an acute injury as a result of
exposure to hazardous materials.
Page 20 of 36
Northern Colorado RETAC
Mass Casualt Emer.enc O.erations Plan
Position Checklists
Medical Branch Director
Definition: Most qualified ALS EMT
Commanded by: Incident Commander; Operations Chief
Subordinates: All Medical Groups; All Transportation Groups
Radio Designation: Medical Command
Function: Responsible for the implementation of the Incident Action
Plan within the Medical Branch.
Duties:
I. Review Common Responsibilities (NIMS EMS MCI Plan page 2-3).
2. Review Group Assignments for effectiveness of current operations and modify as
needed.
3. Provide input to Operations Section Chief for the Incident Action Plan.
4. Supervise Branch activities.
5. Report to Operations Section Chief on Branch activities.
6. Maintain Unit/Activity Log (ICS Form 214).
Medical Grou I /Division Su ervisor
Definition: Senior EMT; prefer ALS
(First on scene and independent of jurisdiction.)
Commanded by: Incident Commander, or Branch Director.
Subordinates: Triage; Treatment; Transportation, Medical Supply and
Morgue Supervisors.
Radio Designation: Medical Function: Responsible for the overall management
and delegation of all functions of the Medical Division.
Duties:
1. Establish and supervise a Medical Division. (See Medical Division Matrix)
2. Review Common Responsibilities (NIMS EMS MCI Plan page 2-3).
3. Participate in Medical Branch/Operations Section planning activities.
4. Establish Medical Group with assigned personnel,request additional personnel
and resources sufficient to handle the magnitude of the incident.
5. Designate Unit Leaders and Treatment Area locations as appropriate.
6. Isolate Morgue and Minor Treatment Area from Immediate and Delayed
Treatment Areas.
7. Request law enforcement/coroner involvement as needed.
8. Determine amount and types of additional medical resources and supplies needed
to handle the magnitude of the incident(medical caches, backboards, litters, and
cots).
9. Ensure activation or notification of hospital alert system, local EMS/health
agencies.
Page 21 of 36
Northern Colorado RETAC
Mass Casualt Emer•enc 0•erations Plan
10. Direct and/or supervise on-scene personnel from agencies such as Coroner's
Office, Red Cross, law enforcement, ambulance companies, county health
agencies, and hospital volunteers.
11. Request proper security, traffic control, and access for the Medical Group work
areas.
12. Direct medically trained personnel to the appropriate Unit Leader.
13. Maintain Unit/Activity Log(ICS Form 214).
Tria • e Unit Leader
Definition: Paramedic or EMT
Commanded by: Medical Division Supervisor
Subordinates: Triage personnel
Radio Designation: Triage Leader
Function: Assure responsibility for providing triage.
Duties:
1. Develop organization sufficient to handle assignment.
2. Inform Medical Group Supervisor of resource needs.
3. Implement triage process.
4. Coordinate movement of patients from the Triage Area to the appropriate
Treatment Area.
5. Give periodic status reports to Medical Group Supervisor.
6. Maintain security and control of the Triage Area.
7. Establish Morgue.
8. Maintain Unit/Activity Log(ICS Form 214).
Tria •e Personnel
Definition: Paramedic or EMT
Commanded by: Triage Unit Leader
Subordinates: None
Radio Designation: Triage
Function: Triage patients and assign them to appropriate treatment
areas.
Duties:
1. Report to designated on-scene triage location.
2. Triage and tag injured patients. Classify patients while noting injuries and vital
signs if taken.
3. Direct movement of patients to proper Treatment Areas.
4. Provide appropriate medical treatment to patients prior to movement as incident
conditions dictate.
Page 22 of 36
Northern Colorado RETAC
Mass Casualt Emer.enc Oserations Plan
Mori ue Mana ter
Definition: Personnel designated by Incident Command
Commanded by: Medical Division Supervisor(Coroner's Office)
Subordinates: Aides as required
Radio designation: Morgue
Function: Manage all morgue activities.
Duties:
1. Establish a temporary morgue remote from the patient areas.
2. Secure the area.
3. Maintain records, including victims' identity, location where found.
Treatment Unit Leader
Definition: Paramedic or EMT
Commanded by: Medical Division Supervisor
Subordinates: Treatment Groups
Radio Designation: Treatment
Functions: Responsible for supervision of treatment of victims
assigned to the Treatment Areas.
Duties:
1. Don identifying vest.
2. Establish the Treatment Area. Consider size, safety, space, weather, lighting, and
ease of access and egress for transport vehicles. Arrange Treatment Area in
parallel rows of separate patient groupings IMMEDIATE (RED)/DELAYED
(YELLOW)/MINOR(GREEN). Report location to MEDICAL DIVISION
SUPERVISOR.
3. Prioritize patients arriving in the Treatment Area for treatment.
4. Account for all personnel assigned to TREATMENT.
5. Establish Treatment Area Supervisors.
6. Determine the order of transport of patients and most appropriate transport based
on recommendations from ALS treatment personnel.
7. Maintain communications with TRIAGE and TRANSPORTATION.
8. Provide essential and frequent progress reports to MEDICAL DIVISION
SUPERVISOR.
Page 23 of 36
Northern Colorado RETAC
Mass Casualt Emereenc Oserations Plan
Treatment Dis•atch Mana •er
Definition: Paramedic or EMT
Commanded by: Treatment Unit Leader
Subordinates: Treatment Groups
Radio Designation: ???
Functions: Responsible for coordinating transportation of patients out
of the Treatment Areas with the Patient Transportation Unit
Leader
Duties:
1. Establish communications with the Immediate, Delayed, and Minor Treatment
Managers.
2. Establish communications with the Patient Transportation Unit Leader.
3. Verify that patients are prioritized for transportation.
4. Advise Medical Communications Coordinator of patient readiness and priority for
transport.
5. Coordinate transportation of patients with Medical Communications Coordinator.
6. Assure that appropriate patient tracking information is recorded.
7. Coordinate ambulance loading with the Treatment Managers and ambulance
personnel.
8. Maintain Unit/Activity Log(ICS Form 214)
Immediate Treatment Mana ' er
Definition: Paramedic
Commanded by: Treatment Supervisor
Subordinates: Treatment Area Personnel
Radio Designation: Red Treatment
Function: Responsible for treatment of victims in the Immediate
Treatment Area
Duties:
1. Receive and treat victims assigned to your unit.
2. Assure standing orders for A.L.S. procedures have been obtained.
3. Assure patients are prioritized for transport.
4. Coordinate transportation of victims through "TRANSPORT" Supervisor.
5. Assure that appropriate medical and patient information is recorded.
Page 24 of 36
Northern Colorado RETAC
Mass Casualt Emerpenc Operations Plan
Dela • I. - a ua , . ler
Definition: Paramedic or EMT
Commanded by: Treatment Supervisor
Subordinates: Treatment Area Personnel
Radio Designation: Yellow Treatment
Function: Responsible for treatment of victims in the Delayed
Treatment area
Duties:
I. Receive and treat victims assigned to your unit.
2. Assure standing orders for A.L.S. procedures have been obtained.
3. Assure patients are prioritized for transport.
4. Coordinate transportation of victims through "TRANSPORT" Supervisor.
5. Assure that appropriate medical and patient information is recorded.
Minor . u . uau • 'er
Definition: Paramedic or EMT
Commanded by: Treatment Supervisor
Subordinates: Treatment Area Personnel
Radio Designation: Green Treatment
Function: Responsible for treatment of victims in the Minor
Treatment Area
Duties:
1. Receive and treat victims assigned to your unit.
2. Assure standing orders for A.L.S. procedures have been obtained.
3. Assure patients are prioritized for transport.
4. Coordinate transportation of victims through"TRANSPORT" Supervisor.
5. Assure that appropriate medical and patient information is recorded.
Page 25 of 36
Northern Colorado RETAC
Mass Casualt Emer.enc O.erations Plan
Trans.ortation Su •ervisor
Definition: Senior Paramedic or Paramedic Supervisor
Commanded by: Medical Division Supervisor
Subordinates: Communications, staging, and records personnel.
Radio Designation: Transport
Function: Coordinate patient transportation. Communicate with
receiving facilities. Maintain records.
Duties:
1. Designate a Vehicle Staging Area(within sight of the loading area).
2. Establish an ambulance loading area near the treatment area(within 25 feet).
3. Coordinate patient transportation with "RED, YELLOW, GREEN
TREATMENT" Area Supervisors.
4. Supervise the loading of patients into ambulances.
5. Request additional ambulances through "MEDICAL" division commander.
6. Request additional helicopters through "AIR OPS" if activated.
7. Communicate with receiving hospitals to include: number of victims; their
severity and destination.
8. Obtain bed space information.
9. Assure patient information and destination is recorded.
Medical Communications Coordinator
Definition: Paramedic or EMT
Commanded by: Transportation Unit Leader
Subordinates: Treatment Groups
Radio Designation: ???
Functions: Responsible for continuous communications with the
hospital alert system to maintain status of available hospital
beds to assure proper patient transportation. The Medical
Communication Coordinator assures proper patient
transportation and destination.
Duties:
1. Establish communications with the hospital alert system.
2. Determine and maintain current status of hospitaUmedical facility availability and
capability.
3. Receive basic patient information and condition from Treatment Dispatch
Manager.
4. Coordinate patient destination with the hospital alert system.
5. Communicate patient transportation needs to Ambulance Coordinators based
upon requests from Treatment Dispatch Manager.
Page 26 of 36
Northern Colorado RETAC
Mass Casualt Emer.enc ()aerations Plan
6. Communicate patient air ambulance transportation needs to the Air Operations
Branch Director based on requests from the treatment area managers or Treatment
Dispatch Manager.
7. Maintain appropriate records and Unit/Activity Log(ICS Form 214)
Ground Ambulance Coordinator
Definition: Paramedic or EMT
Commanded by: Transportation Unit Leader
Subordinates: Treatment Groups
Radio Designation: ???
Functions: Manages the Ambulance Staging Area(s), and dispatches
ambulances as requested.
Duties:
1. Establish appropriate staging area for ambulances.
2. Establish routes of travel for ambulances for incident operations.
3. Establish and maintain communications with the Air Operations Branch Director
regarding Air Ambulance Transportation assignments.
Establish and maintain communications with the Medical Communications
Coordinator and Treatment Dispatch Manager.
Provide ambulances upon request from the Medical Communications
Coordinator.
4. Assure that necessary equipment is available in the ambulance for patient needs
during transportation.
5. Establish contact with ambulance providers at the scene.
6. Request additional transportation resources as appropriate.
7. Provide an inventory of medical supplies available at ambulance staging area for
use at the scene.
8. Maintain records as required and Unit/Activity Log(ICS Form 214)
Medical Suppl Coordinator
Definition: Qualified personnel
Commanded by: Medical Division Supervisor
Subordinates: Aides as required.
Radio designation: Supply
Function: Responsible for maintaining required medical supplies for
the division.
Duties:
1. Acquires, distributes, and maintains status of medical equipment and supplies.
2. Requests additional medical equipment and supplies as needed, through
"MEDICAL" division commander.
Page 27 of 36
Northern Colorado RETAC
Mass Casualt Emer•enc Oserations Plan
Strike Teams
Definition: Qualified Personnel/volunteers
Commanded by: Triage or Transport Supervisors
Subordinates: None
Radio Designation: Strike Teaml; Strike Team 2; etc.
Function: Work at assigned tasks
Duties:
1. Evacuate victims to the triage and/or treatment areas.
2. Record and relay the location of all patients found.
3. Transport patients to and from the various patient areas.
4. Load victims into ambulances from the treatment areas.
Page 28 of 36
Northern Colorado RETAC
Mass Casualt Emer•enc 0•erations Plan
Appendices
Page 29 of 36
a N 00 w w
R a0.. e ^ m ,�., en v N- co
R o d
M ,0 an .0 VI
E G iE ,0 yl R V N 0in N 00
03 "O R H V lO in
N M M 00
en 0
L y W
H 8 o 0 0 N o o ,- 0 0
C.) a rn o, a, a; 0, a
L N — N N N N
N — en M N — 0
w co
R M en O O ^ N en N M `0 00 b
R• N N cc d' o b en N b en b d' V
E G C ,0 IA Vl N N N V V 4 O N 00
a o e0 °-, en N R V i/1 N N in M V
R "P t in R l0 in 00 Vl 00 N an M 00
E.1. a a
O o 0 Si 0 O O a O a O
V N N N N N N N N N N N N
D\ D` Q`. D` O, O, 0,, Ol
O Y
G
O .C itl 0 O N y C y O _� v Co
G d E a 9 0 i M v " Z. t E y
E 0 E U v O w
0 ro R a T ° U
�' h.O Z-. T 0 M 'O 0 V 0 g = 0 0 .�
F U G a
° 0 a `�' F �' Q C1
VV Z
W
0
U
Z w Y T " E
dJ N en 0
a e o o in M v en 0 0 0 3 a
IW = m Qe0 000o N ON c IT m C7
V d 0 - d > n m y o O° .C .v N )
H ' 0 . v �i y' OU O 41 =0 c°i OV to
i�`a coo.
hoo �a
YI ¢ a c 0 c s U • U c p� R" c) -0L a e 3 z 4
Z W oN
W o w o 0 « .t W O ., 0 ,,,-., 3 x Grim 00 oo 0OU i0 , a o
C
'6 R
o_ E17
L
C
O
T,
C
C) n1
a y
O0
O Cl«d v v t
U 0 0 a U ,Q 4 V u
• 6' - .� 0 • P.` �0+ .71
'x x gym+ C] a
u O V a C 4, 0
Q• v W v x 0 0 Vrd 0 �E o v C� x
L.1_1
�eN+ E
a Fi ° Y ° F
`id ''� ,4 CC en o O y .Tr a O O
c � O C W T
y ^cci :c id t CO E
- I;
W a.. .4 Ct W U ,4 X lam/°] Z 3 C en
p
0
-4 4 CO V co
- Ul p E E E pp CM a a pap o E E rn W
- L 0 a a a a° a a 0 3 > > a
\
\ \ \ ( / \ \ j
- ` ~ , � } !
� `) (
1- 2 i S . e
) ) ) i ) ) 2 .-
- u - a
U2 4HoCO ) $ } \ / }
o & eRi r-
i u ,....
` ( , \ 0 : \ j
� 1 ( \ k .
\ \ \ \ fl \ 00
/ \ ) \ \ / \ / \ \ / /
•-,j; , \ k , ] \ o
; ; : ; e - -
) : ; li : 9 % \
/ ) ] | | % a
o. -c -o { ) \
\ } ^ , fl 0 U . 0
) 3 en 032 \ ) \ \ /
-
i ( \
} \ ) } \ \ / \ ) ) } \ /
E E
8 8
a s 0 °
5 a m o a
L r 2 m c v
5 9
2 d , — E .E a. e E 8 3 « 8
Cg c 0 `o o, d 9 _ 0 5
'A 8 w e a y 3 K m .E " 0 .E d y -
� � , (g< °f � i = x, f 5
ec °� 8 E '� O E 2 8 8.
Q � 6 m > a a > � = y � 5-,' ❑ a
eTe ern u, m 0 eNn r m rn N N
0a9 o
Jg N en w
N O NO lei y r T < O i" O Y
LL N in o V% N in N N - N '0 `O in V en ey
T N r h w N R v 'o n o
� ,. Se? 0 o . Eoo4.? 0
64 0Q o m °: m S. rn ER m a-
en el in 0 rn
8 V OO INS N in N O b rn O — P N N 0 07
L 4 N Cl 0 N W in V 00 - q '0 '0 N a b
0. N V b % N `} `O N en e'1 N N O M re-
5- N an vel O en en en CNe w .\ V e7n '0 e„et M en
o m O eA O o O a O ON Ore- O O O
E.Q O N S. N U v P O. cr` N N T Si.ca c N N
C Y
8 C m E
N O
go E— .r'- d 0 3 0 .5
o E m 'm n °v3 o N 1 8 a a r .z m` v O
• .e m• at PS v at '�r�' >, et
M g g
❑ F N 4 C7 c 0 m8 'nE' 4 S O ❑ F ❑eg Y ❑
ea een — 0, - in — 0 Al N Al N O 00 .-.
o N b N N en N 0 v h N 0ri en 0 0t N `O N in
V 0▪ 00 0 0 0 0 0 0 00 0 0 0 0 0 0 m 0
yy
a
T
CU
et
Q
O
0
Y
a O
1 0
w g 0
O OV p 0 `O O — V5'
U U N O -. V O O 4'
0 0 .d o o o 0 d 0 . _ V g
v. .8 O § m of « W Q v y a ` z
8 ` .r. L r Q
a, ec ii 5 a' aN o3 O ' 4 o � s°'
y
< N N 2 on > a00 en a oo V' r -,9
� M 0
>, '�' m 4, 0 0 o v W o m o ° 3 E O 0 "••
$ vi - m a m ❑ o m a m m 2. en .. °' 3
N r�
O Q O O Q N Q O en - Q vl
6 a° � o° i in a � O a: � 3 a: en — a: ry
C.
7 8
O v50 v
Yo
0 - O g
v u
2 8 5 g 3 ti 3 .-8,EaE 0 8 0
— 8 8 >. a 0 ca E E 6 2 Q ae 2 v, 8
alu
, § 4 Q w f an c 2 E o' U 3 c °o E
O 0 , E Q
T v �e w O Q Q `A , o E 2 N a c V Q
a V ; Ea
ti, -- a -a y ' w `O '� °v3° o 0 It v E E
w
a Fm ¢ uw9a a. e.0' tig33X
- ' '
xs 0 up
a.
,x W a y F 0 5 '.0i
C 72 a -O `° O`- g m m g "_ N E a O _4 IN3 d 3 r r r 3 r w v
01
a
E
>,
C
m
Q
y T_ N or
N V 0 el
6. M
N N
N in
T or or or
M M N
C O O O
¢y U ONi T
3) t� Cl H1 a - - b a T M h Cl
.D 1- V1 P Cl _ N O a EE N (-- N O Cl Cl b Cl b N N
T V N .� N a N a N V Cl M M N
c Y
O O 0
Q S N0. T P O' O^1 T P T G. O� P P P T
CT Cl fl N M mN - Cl d V M V N N C
6 r
mN co W co co co 0 0 co 0 a 0 W co 0 00
Q
S
U
0
O U > U U 6 6
0 U U U
6 d d
9 _ O O G O O
�. o U U rG U U V. U ffi
€ a _ a a 3 a 3 �o
sjj y '' • = v .o ° a N .4 w a
i o a — _
T - 't0 O a F a , 'r-i O x S. N
a a L V a a U r O a O
O ° E m T O O O V Si Cl O Reg V O
Q N -0 a V1 N a Cl N V1 N W Co V N N
T
U
�. 9 C G C L `� y L
N
A E b V E g 9 03 V .lf •b0 OC u
O N t O` C d U E � O 3 m S N s.' ;
'D
C T 7
In >> µ' ,CO Z' 9 _ L CC lam'. y = YV
p s .3 C E_ O O p 0
C a O.1 ti °' O �°�. a 4 -1 �. .] `.L C7 Q fK a
(U
a_
C
V
a
J H H g w
d d H a
K o o �' a - v vi
O G
T a d v 3 �.
C n m v H a a g 1 m a 0 a g
J O A G' d a g a v v -I > a U
.:f _ a ri " d o a v °o Gv m o O
_ IJ T T L y V. 0 C. 'O W _ y Q 2 O -
¢ x 'x ¢ 3 3 a a 5 a° a 3 •ca a 3 a 6
-1
O .O
C e c
7 h 5c oh O
4' 4 4 a o. EH Ern E.n Ev, Eti Eh Ern SSS5'4 5m V4 ',5 CCC '^
ni
J 0 L L 2 S > > > a> a> a> �> a> �> a> [�. `ra m
U a a a a .-t a .-la a a a a as a .-ta c. 3 3 3 a
n
g o
0 0 0
00 E Y
-
a c ou on a �°a G C0 o 0
E E
v —— o a
n a C @J .0 @ 0 e in
y E .= ''i �u ec x rE 0 y is
a y B $ Z E E E 2 s 8ti
N m 0
0
'Don
terry m en
N N a V toq CA
N N N N
m
O O ^ O N O Ern Not O or O o-
N m 0'1N o. a� �`a Plm °1a@�` a
— rmi Co co C N of on co M „ b co Ni m a O N N P or
or
or
M
O N I e..;1 n M N ebl ^ N 00 cc N or ol, m O N C e\ v O eenn or en ynen
n co or N N N N N N e` h r in W in or M in Cl Cl N N e` b
eel co N tmel VNl �Nn oon on ,nn C' 000000 1/40 m M CO m m N N N N V V
O O O O O O d O O 66O6 O O 000000 O O O O O O
N N N N N N N N N N N N N o 0' r r 0' r r r t' r r C'
0\ C0 Ol Ol Ol Q O1 O� O1 P Ol Q - - - - - -Ol a Ol O� � P - Ol
O N N V on on O een N on N Vol on O 0 0 0 0N ,
. , , , N , ,r N N N r r<36- oo N N v v . . .
0000000 w m 00 . . .0 . 00 m m g
o
o O O
0 U O
o 0 v d d
E 000 A o 3 3 3 u 00 o f
O OV OO N m °••[ m A >' U o E v"i 0 U d
Oc O 'c x OU t oditi v U m U m on a ..1 1 =FF 4
v .fv- 2 6 E — C o C . F . 3 2 ere; N 3 a rn A O 8 J N Vl O o o w o n "A N >' ' M m q
,o U " P. o o p t easel 2 r, en • a t ' `.20-. T4' e o N e a a
on O 'J e' . 8 0, , V ..O N Vl E N
'S x x x ‘1- V 1:4 x '1n 0 x A U E 0 0 >e x 0 0 0 ' 0
51, 4 0 0 0 0 5 o on 0 e o 5 m m N m m m m j z
N O O O g o y 0 - 80 -a o o on O O en a a a a a O
N a a a .1 N a or O a N b a Q. a L 0 a - a
P.. :(6., a
w
o 5 a °yos A NA t
O d „ !n '1'10
�' N o 45 L CO - u
2d
o t Es = E o 2 v = 8 5 2 y S o ooa
'o v a m `c o o '� U] .=1 N S z o v C4 C m v
N 8 , O a m ..1 .. 00 0 0 ` g m Y Y 9 .z.
t� § ,.4. o N V 5 �' V y
rx x O mo ao' m m a v, 'n MO h d' Q CI O c4 a F
n
a
c h c
c v
i v O y'1
Ot02 �F c v
2.` v ( v `.d u_ v a
a Q v a a E v p Y Q O 5 0 •-
N f,) i.:...2 g. -o ._ .c C4 t a
D U Q 'v' Q 5 g VWN.. a .. v E `v V U V G. Q
- c •
.. a e 5 a C 9 a o ¢1 ,c a CL m d s°1 d
o w d u. o, .o 9 `v 00 v, a v ,y u u. en vl 2 ii
�' g —o c nv 'v � .E 0 0 0 0 y g u a d 0 0 0 o `�
3 0 > o i:. a o " > q uo O U -58 °8 .2 an U u° 0 m o
2 E m > c > U - o gA g g g t. °4 . ..., t, 4-:m a [�. o' 0 0 0 m >
.., w 3 o _E }y _ t .5 m >000�om r2 g u J • 1v_
e° uwae 3z° 3 a° r. x 3x Z -i, 3o'
r,
`- o ` V 0
_ ggggggggEv) mmm '0 (0 (0 .q' (0p( o a 0 o � A
A m u a< av m oo ac be 4 `o `o `o E E E E E E �` a
3O 33o333 �� � � >` >` >0 >err " ° n0 '0 -0O, �;, a
E
3
ZH
1.
55 I
A 2 2
y
- r- VD o o '0 M - M '0
CV "4
y b N O in oo °I.` 4N
tin „o
,C V41 Men ,kin M W U W tr m- h
VIM lo 1 O M 00 N N 00 n-
6 en b n 00
V
M 0 M O O O O O co- en
Cr.'C T a O Oer, 0' 0' P 00 0, T en en
O O
00 C1/41 V1 00 yy CA en N N CO N ^ O mei en - ON el Cel V O ^ O en M 10 N M P 0 - N <Vi O - ON d O
N V - 0' N 'o O N V N co N V1 b — a\ r b
en N P o r;' I"' N N V O O 0 O N N e.? 'T Q N N M N M N C
V '0 b a 101/4n O Qen en m m N W N 0' 00 01 en erl M N O W V b m en en W
O o P a, o 0 0 0 0 0 1' f-;' 0 0 o d c' o' o d o 0 0 0 '
q 0' 01 o a 0, a, 01 en 01 O, a a a a a on 0a1 T 0, 0, T a o' en
01 en M M O — J O O — N Vl co .-- V — O0 4 V1 O 0
p — -^ N N N C ? V V V1 n V — N N
N 18 VVI 10 `0 .O b '0 b 10 b '0 '0 '0 b ',2: 'o b 'O VI 10
0. ro 0. 00 0. 00 00 w m 00 m m w 00 CO m 00 00 w 00 00 w 00 00 00
0
N
1/4e1/4
1<
0
m
a
Co 3 0
0 a
0 Do o
E a
i m aG Y t a a `o .. :t1
C
a v N TO C L [ye 0j s y -a .. $g d y U d a C O 2 W
a < o O Q lac � > 44> v a m c m = E n ,y, k (7 3 < m � > Q
> c a o. - LN a. 0 u Z a m d 0 01 c2 fs
h N rn `v N v1 — o N x r b ti .n o.
6 5 .n .7: _ _. F. o. x a o a O m F, -. c
.v. Cj 6: '� !. G a a N V V] V1 r] __,!0.)
o Z o o " M o 0 0 0 0 0 0 0 o x s' -L.P.. o 0 M 0
3 ,n0 O m m o m — m m m m m m m o o m
o ( - M O O N o O -- O O O O O O O o. = -- O O N 0 O -N-,
N - a a N a -- P. 0. O. 0. 0. O. 0. a Cl.. 0. 0. N - 0. -
m Ti CI a a — 4 d L O a
O 0 E V a 9 v S N a to E a " ` ? u x o
G b u m m G
• U B A 4. Na u � 9 „ `zh . m � 0. -0 u. N ; -aN
• v .0 Q .o >>, ,, - - S H ,, .E g y E 00 a y �j-
u a8i T O .V. g 0 0 N O. N L > N 0 0 C ry 2 `5 ^ O "'
0 HQtix , Qa -0c4axa3co ca � ❑ 01z Q ¢
J
hs
o 79 a
s
_ 0. y ¢0
O s
_ O 5 V
T "' Y v°. w Ca a' 4' 0.
co.. E a
r S o a Co hi
u Q w .'= m o Q
1 �+' 0. 0. y, - w = >. N 0. 0. 2 f0.„
61 0 .. 0 m w u, c Q co Q aa.. C7 t -a Q o 0 a' n c
Y u. U u Q Q �` o w E a' a Q > car. 0 1n u v Q Q t g
Li. "a a a.
— o o `v `v_ i w w •0 a' o . a. •i J v m e y - '2 0. -G .°t
G g a n
w -0t, .0 9. g $ r " = 3 n e 0 .9 c m o "
I) mo a m0 6 m` 01 01 I.. w c� x .1 A Z a c. a` K O 3 Q CO` W W a a
m
o
Q m
�o.E a E¢ E¢ a a 00000000000000000000-oat m
'� '� 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3Cn
a
E
0
la 0
0
r
au i
4 _
a 4 @1
4.0 o
w 2 E a
_
Ol- v 'O
o 0
N 0 V N P
rn W m N N
N `° N
O N Orin ci co r O N
tin Q O. T T
~ O O M .O C 8 < O 1N N N ON 0 P U O
'O N N V o] C N N VD O 10 0 ON N N
O V y cO q .O r;' Vi V N N ON b b 0 00 O ,C-21 O
n N 01 C r < b V V w crom N V `r; N N CC W V N N
q 1 b N N V M ' CO V q °° o] OJ vl ON vl N W 00
O 0 0 0 0 0 0 0 0 0 0 0 6 0 o O O O O O
ON en O. ON P N O. O. O. ON P ON O. O. U a N P N N ON
N tn ,L O in en O N N 't N N M 0 O O
CI 40 H U b ir,ON b N in o N N N b Or in ill) in in in in
O V
oo O O00 w m m o m m W W O coon W 0 W 00 W w
0
0
0
Cr
Y
O
O t
o m 0 W
a
0 eo N N b
0 u `a o = z°
00 O O g u E, O o OU > 5 > s
c 3 y d c .c o< o yry. c z g ° a o, O
0 v Cy 3 0 Z 3 ; tn o . E1•1 a O M O`
CC - ^ N < C o m T O M P ^ ^ 2
P .- L
K x LII if x % 4 % x % y m x X 3 i( w K X 0.
O O cs ° O O o o O O O O O 0. O O
CO 0 N W o o m o o U N o o M o o co o 0
a a0. O a a a = °0. a a0. en a a a = a0. a c0. -1 o
v .C w v w
U U c,., r q-. U r - °."
v_ U U
Vi 2
g L o 0 L
5G E -46� el ° C ) U tr ,d, `- ° = N p� j v
:° d to
E1 m a a p ^ ° `� ' > C § E 00[
5 x° �'j a 'X E• ;X, , O Y t v g 0 3 w
O N 2 l' Y o Y T E $ O atl O 0 EO -- t -
CJ oe 3 f] ' m 2 .e m PL a Y o: a '.6 m H 2 o ..
93
J_
CZi
C
o
19
c
> C a g a. " p5
or. E to Q d �3 Ll 0 a
E v 5 g a 0 ° i > >
W a 0 w 0 0 o 6 ❑— O of 3
≥ O P. a A O U C 5
— 'Ji 0 00 Ca C] p p. 4- 6' a .9 p, CJ o g 0 >
Cat 0 e a oo v `2 a• E c E 2. eo a. ° 0 a Z a .
1 `L ,� o f = •I j ° m I f 2 0 ! a z v a, is,
v m
O L aC a 2. 3 w co .S z 3 w W a 0 u] 0 Q a Pl
n m
M
`0
S m g g g gd g g g i3o °o °'o t' o 'o eU M
a a a o v oo ec �o CO �o oh 00 oh m toE - E '- ,E .E- E� .E � w
- 'u o o 8 o ° `o o `o `o `o
33 333 � � 2222222awauaiawa wauaiauai a
Hello