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Chad Garrett: The bottom part of your screen, it looks like a little speech bubble We like to know, where are you joining us from?

And Chris you'll have to read those because I can't see my chat.

Christopher Smith: I'll see them as they pop up, we got Washington State, New Mexico.

Chad Garrett: Nice.

Christopher Smith: I'm in I'm embarrassed to say that I only have one screen at the moment, so Florida, welcome everybody. I apologize in advance, I can't see your chat, so as I'll see it as it pops up, everybody.

Chad Garrett: Well Chris.

Christopher Smith: Yeah, let's go ahead and get started. okay.

Chad Garrett: So folks, as we get started I want to pose a question to you. What kills people faster? An event, the event itself or our inability to organize after it. I want to start with a little story here. It is your first week as associate warden. It's been a great week. You made it to Friday. It's an amazing day. The sun's been shining, the institution has been quiet, and your shift ends in about.

15 min. It is 04:17 in the afternoon on Friday. The executive team has all left for the day leaving you in charge. Beautiful until. Suddenly the radio erupts. Officer down, officer down. Another transmission, but it's a different voice. This is insane, there are multiple inmates fighting.

Then over the radio. There's blood everywhere. Oh my god, they've got weapons. We need help. We need help in the unit. We need medical. And finally you hear, we have a fire. They started a fire at the west entrance.

Welcome to that chaotic chaos. Your first mass casualty event where you're in charge. Now the question is, the question I want you to ponder right this second is, what would be your primary duty? What's your first thoughts that are going through your head? You can put them in chat as we go through here. How would you approach this?

Now see with disaster strikes in the correctional facility, chaos, it just comes, you know, whether it's a riot, a fire, a mass overdose, MCI, corrections demands or response that's not just competent, but, but exceptional. Truly you have to be exceptional. And these.

The ability to sort the salvageable from the unsalvageable to prioritize the bleeding over the breathing and to deliver decisive care and address. It's not just a skill, it is a lifeline that will absolutely make a difference and saved lives. The difference between catastrophic and controlled response lies in one simple truth. And you've heard this from me once or twice. You have to train this relentlessly if you want to perform it flawlessly. Let me go over a couple of housekeeping rules. This event is being recorded and once it's five oh eight compliant and posted.

You should be notified by the NIC that it'll be on our webpage and you can watch it as many times you want or share it. This is a listen only event, but we want your interaction. We need your interaction. This is a very interactive presentation. If you don't interact, it'll be very quiet. So in the chat feature, if you could put what state you're from, the chat feature be in the bottom part of your page there.

Put your state where you're joining us from in that that bottom right. Before we get into the presentation, I want to take just a minute for a public service announcement from one of our amazing librarians, miss Mary Coffman. Mary, you've got the.

Mary Coffman: Thank you Chad. I am one of the four librarians here at NIC and our job is to help you. So if you have a correct corrections related question, please contact the NIC help desk. Oh, you can contact us by emailing us at support@NICIC.gov. I put that into the chat.

We welcome any questions. We're open Monday through Friday and we take about a day to get back to you. But if they have any questions about the industry, please contact us and let us know. On the NIC website, you can also find free trainings and webinars like this one. It's at NICIC.gov.

We also have the learn center where you can take free e courses where you're they're self-paced and you can take them at your leisure. You can get a certificate for taking those courses as well. That's the Learn Center@NICIC.gov. On the website, you can also find free books and webinars from the.

And audio books are through Overdrive and Libby apps. So by all means go to the website and you can find out more about those. The last thing we offer is EBSCO, which is a database for research. You can do the research yourself or you can contact one of us here at the help desk and we'll do it for you. We have a corrections related database that will give you insight into a lot of industry related questions and answers. So that's all for me. I'm gonna hand it over to Chris Smith.

Christopher Smith: Thanks Mary. Appreciate it. Hey everybody Mary and the Information Center do a great job. Please feel free to reach out and check it out, see what kind of service they can be for you. Hey, so now we get to the most exciting part of the webinar. I know everybody looks forward to this every time and that's the legal stuff. I'm gonna go through this just like you would hear the at the bottom of a, of a medication commercial. So this presentation for informational purposes only does not constitute legal medical or even or policy advice. If you use an opinions expressed.

In this presentation are those of the speakers and do not necessarily reflect the official position of the National Institute of Corrections, the Federal Bureau of Prisons, the US Department of justice or any other affiliated government agency. The NIC does not endorse any specific policies, programs, products or commercial entities referencing this presentation while every effort has been made to ensure the accuracy and reliability of the information provided.

The NIC makes no warranties expressed or implied regarding the content attendees and viewers are encouraged to consult with legal medical or subject matter experts before implementing any practices or policies discussed here in. This presentation may also include discussions of legal and regulatory issues. However, it is not intended to substitute for professional legal counsel.

Any reproduction distribution or use of this presentation or its materials without any, without prior authorization from NIC is strictly prohibited. By participating in this presentation, attendees agree to hold the NIC and its affiliated presenters blameless of any claims or liabilities arising for the use of the information provided.

Hi, so we're good.

Chad Garrett: But wait, go ahead.

Christopher Smith: So I want to introduce our speakers real quick. Today we have a lieutenant commander Nicholas Bailey. He's an advanced practice practitioner with the Federal Bureau of Prisons at the FCC complex and Florence where he has served for the past twelve years. His clinical experience spans correctional healthcare emergency medicine, trauma response and management emergency procedures and airway resuscitation and stabilization. Prior to joining the bureau prisons, lieutenant Commander Bailey spent seven years in the emergency medical services.

Providing mutual aid with medic one in Seattle-Tacoma, Washington, metropolitan area, followed with three years of acute emergency department care. We also have with us today Lieutenant Austin Walters-Tracy. He is a Lieutenant with the Federal Bureau of Prisons. It's a Federal Correctional Complex in Florence, Colorado where he served for the past seven years.

He specializes in tactical medical and trauma response before joining the bureau of prisons, he spent five years on active duty in the US Army and three years with the Colorado Army national guard. While on active duty, he was a certified combat lifesaver and completed several tactical combat casualty care courses.

He is also a captain with the local volunteer fire department where he served for eight years. We also have captain Chad Garrett who's been speaking with me so far. He is a calm commander in the chaos of corrections. Captain Chad Garrett is a cool headed clinician with nearly three decades.

Of nursing know how and over 30 or 30 trailblazing years in correctional and operational medicine. From battlefield to cell block, he's brought good medicine to bad places with unshakable precision and purpose. Since co developing the original combat medic curriculum in 2003.

Captain Garrett has worked shoulder to shoulder with the elite tactical teams from sort to DCT to ICE. And of course you have me. I'm a seasoned steward of security with civility at NPA. I bring you over two decades of correctional experience.

15 of those years have been over 15 of those years of federal bureau prisons. I worked for minimum to maximum security inside the bureau and has taken me across five institutions. Excuse me, four institutions and now NIC. So we are your speakers today.

So what we're gonna do is help you prepare, what we're hoping to do today is help you prepare for mass cows of the incident that we hope that you're, that we hope as your speakers, she'll never actually have to implement. But we want you to be prepared anyways. So in order to begin this journey, I'm gonna hand you off to Ad and he will be bringing the next bit of information.

Chad Garrett: So I want to ask you a question, what are the different difficulties that we face in correctional emergencies versus civilian emergencies? That's an interesting question. I have had opportunities to work with a lot of different government agencies and technical teams working on this on both sides of the fence. So in the chat, I want you to think about what are the correctional realities that make it difficult for us?

So I can think of a couple right off the top of my head as you continue to answer. What about security? Staffing, equipment, communication, transportation, command, training, space. So you notice something, most of these problems are not medical. The idea of triage really, and this.

This is the main point we want to get through is to save the largest number of people who are salvageable.

In an incident. So that is kind of the key, is getting our our patients to definitive care. And remember, we've got lock cells, we've got control. We've got inmates that we're dealing with.

So, it's very difficult. Next slide so again triage is is difficult in a high stress environment.

Like a riot lockdowns, you are going to have a huge amount of adrenaline pumping. Just absolutely. One of the things that I recommend to everybody, the first thing you do when you come to one of these is that you take a deep cleansing breath.

And you try to center yourself. Do you think what's going on? Could this event be for something nefarious? It's something we've always got to consider when in corrections. Is there a secondary exploitation of this? We've got to be concerned that again this is different for most, is that this is a distraction.

They're using an emergency to draw staff away from a location. They're trying to use this event as an escape attempt, a medical deception. We see targeted attacks. MCIs are interesting because a lot of times they're a correctional emergency mixed with the medical emergency.

That's why I say there's no such thing as I'm just the medical emergency corrections is always a incident. So this is why medical and corrections must operate as an integrated response, it must practice that rather than a lot of times they operate in two parallel operations.

One team, one fight, and communications is at least as important as a tourniquet. So, correctional medicine is interesting because we're bound by a lot of legal and ethical considerations, consider the 8th amendments which prohibits cruel and.

Unusual punishments. The landmark is Estelle v. Gamble, clarified the deliberate indifference to serious medical needs constitutes a constitutional violation, you may have heard that. So ethical decision making under pressure especially in a triage situation, is.

Very easy to teach, but it's very difficult to do. Triaging with scarce resources, prioritizing cares and determining who the treet first, it's it's not about clinical judgment. It is about an algorithm which we're gonna go over as we're going through it it's.

We're trying to make this a logical, step by step process versus a clinical hoops to jump through. So we've got the constitution 8th amendment. We also have healthcare standards from NCCHC. They have standards for an emergency response plan and emergency care.

The American Correctional Association has standards, which is also access to 24 h emergency, their standards for ALDF-4C 2220 03:24. And the American Jail Association also has guidance. It's not a standard body like the ACA or the NCCHC, but it does have training.

And policy guidance that talk about professional preparedness safety, and liability reduction in the detention environments. But the the key to all of that is that this is not a clinical skill set. It is a legal requirement. It is a standards based mandate, and it is absolutely a professional expectation. And again, we have to train. We have to train so that we can make all of these different.

Rules regulations fit into our framework and ensure that our organization can meet those obligations, meet the liability, but I mean, all of that said, the most important thing is that we train so we can preserve life.

So, I always like to say there's this, this spectrum of care. On one side, you've got people who are gonna survive that pretty much no matter what you do. They're gonna live. Yay! On the other side, you've got people who are gonna die pretty much no matter what you do. And that is how that works. It's these people in the middle.

Right here that that we're working to save as we go through. Got three patients up here. The first patient is walking bleeding from the forehead. He's super angry and super loud demanding medical attention. He maybe like your wardened or your director. He's like, I need to be treated now.

He's got patient B he's lying quietly. He's kind of pale, has a weak pulse, and you can see that he's got this huge amount of blood around his leg. He's just bleeding bleeding bleeding, and you can see that he's bleeding. And you got patient C that's not breathing normally. He's breathing like very irregularly, a deep gasp every.

He wants in a great while, other than that he's not breathing at all. no signs of obvious bleeding. So in your chat, who, who do you think gets the attention first? You have one reminder. Who's gonna get your attention first? Is it gonna be your executive staff with bleeding from the forehead, who's super angry, super loud, and demanding your attention now? Is it the patients lying down with the bleed? Is it the person who is not breathing or breathing very poorly? Who's gonna get your attention first?

Christopher Smith: But you'll be happy to know we're getting a lot of B answers in the chat.

Chad Garrett: okay, okay, very, very cool. So I mean the question in my head is who's gonna die without an inter immediate intervention? And you look at that and you say well patient C, probably patient B So now the question that comes next is who can benefit from the resources we have available?

How many of you guys have CT scans and neurosurgeon on staff 24 h a day? Yeah, exactly. So the person who's not breathing normally is obviously probably needs more attention than we can give him, but we absolutely can save the person with the bleed.

Absolutely can make a difference in that. So that is what we look at and then we ask that really difficult question is who can safely wait? Because triage is not about finding everyone who's sick. It's really about finding the people who can wait.

And the people who cannot wait, and despite the fact that the executive staff is walking around demanding that you treat him with his bleeding from his forehead, that does not make him the highest priority. Next slide.

LCDR Nicholas Bailey: Thank you very much Chad. I'm gonna take over this part right here real quick. So generally in typical situations, most of the time correction officers are responding to any emergency, their available resources for staffing equipment and so on are often far more abundant than the situation demands. That's your.

Typical every day kind of approach to things for the minor things that happen every day. But that paradigm changes when we start to enter into the realm of these mass casualty incidents. So I want to get some feedback from our audience. So let's, let's hear in the chat here, how do you define an emergency at your current location?

What do you feel makes something an emergency at your current institutions? I know while we're waiting for some of those answers, typically for us an emergency is gonna be anything outside of that, that, that normal operations, right? We have a fight that tends to be a potential emergency.

A medical condition going on like a seizure or, you know, chest pain or or some kind of urgent or emergent medical emergency. I see here we've got some, you know, anything that requires multiple resources, time sensitive, ok? We got, you know, a threat to someone's life, definitely an emergency, I agree. I definitely agree. So now let's take that to the next level. How do you define, you know, as opposed to.

To emergency, what's the definition then of a mass casualty at your location? What's the difference between an emergency and this now mass casualty for you? What's your mindset on that? So anything under the normal riots fights, you know, two or more patients, I like that. A whole unit fight.

Very much so.

So something that's definitely a lot more than your standard, you know, two, three on one kind of deal, something that's gotten multiple issues going on, more, more and more people involved. Definitely, definitely. Out in the private sector they use patient resources three or more, right? okay.

So, and then life threatening situations. All those are good responses. I definitely like that. So considering your current locations, let's let's let's kind of go off of this last response here that we have from Brenda and Samson. At your local situations, what number of casualties.

Would be required to outnumber your unit or your institution or your complex resources? Like what, what is too big for what you have? One, it feels like that some days, doesn't it? We work so I got it more than one, so I hired three plus, that's that's often a standard. okay.

okay. It does depend on your facility. That's kind of why I'm we're, we're looking to see where where some of you are coming from. So, two to three events, right? And, and those do happen sometimes just like captain Garrett was talking about is MCIs can be covers for other events to be going on.

So, definitely having something that overwhelms your resources, I know for the complex that I currently am serving at, I mean we have, we have plans in in place to handle large events in series, but when when casualty numbers start breaking into the dozens or or fifties or more, I mean, that's gonna be really pressing our ability to.

Handle that if at all? Yes, so not something that we can just handle on our own. And that's, that's this concept of these mass casualty incidents. They often present a scenario where there's far more casualties than you have resources available. And so what happens when there's a victim to rescue your ratio of maybe three to one, right?

This is what this training is all about, is being able to handle these situations by assessing the patient, beginning life saving interventions, no longer works just like we would train in a standard CPR class. What we have to do is to start to learn how to triage and then manage the situation.

Key takeaway from this, alright, is that treatment is not our first priority in a mass casualty incident. MCIs are all about resource management and efficiency, and more importantly understanding the importance of having the correct resources not only available, but ready.

Alright, so typically an MCI starts off with this huge unbalanced, right? We have all these casualties as you can see on the slide versus our resources. Next slide please. So in order for the rescuers to achieve balance for the incident, triage has proven to be the most effective approach.

And once scene safety has been confirmed and and and we'll come back to that here in a second, but you know I I can't stress it enough, but scene safety is absolutely, you know, important. But once we have that scene safety, we can't do anything for the victims until we go through this triage process.

Once the scene's safe, we start to reflect on back on the incident or I'm sorry. I apologize, you guys, I got lost here. I'd like to reflect back on an incident to kind of show you an example of, of what triage looks like, ok? Several years ago, while I was working at USP Florence, we had an incident.

Where three inmates were involved in a fight, two on one, stabbings were involved. And upon my arrival, the first patient that that I encountered, he was being already treated by correctional staff. Wonderful job by the correctional staff. He had an arterial bleed coming out of his hand from a large open wound. He was spurting blood and they were applying pressure dressings and whatnot. I did a cursory evaluation to determine alright, looks like this guy's getting taken care of fairly ok. Went to go look at second.

Patient. Second patient was a lot quieter than the first one. The first one was howling. He's very verbal about his injuries, you know, you know, making sure that, you know, he was demanding that people stopped the blood, stopped the blood, but second one wasn't making much noise at all. In fact, he said he was fine, and looking at him cur, you know, a cursory overview of him, he didn't have blood pouring out anywhere. He didn't seem to have any significant injuries.

Noted, you know, that were obvious. He was alert, he could answer all my questions. He said he was fine. So I immediately jumped to the conclusion of the one with the arterial bleed was my more serious patient. I was actually wrong, I should have done a more thorough assessment at that time and and checked this inmate over for further injuries. When ends up happening is I'm leaving with the with the patient with the arterial bleed.

My second nurse practitioner arrived and took over for second second patient that I accessed. He started to get weak, couldn't walk, he had to sit down, and that's when the nurse practitioner stripped off his clothes and found an abdominal stab wound just underneath his solar plexus.

And upon further inspection something that wound started gushing blood at a, at a very massive rate. second patient was my more critical patient. second patient you know should have been triaged as the as the more critical one, right? So triage is this whole concept of doing a quick assessment and evaluating and determining alright, who is, who is, you know, more severe and who is less severe, and that's that part of that triage component.

And it's done really quickly and things change as you can see in that experience, that, you know, volume isn't the severity, right? The inmate that was making the most noise, the inmate that seemed to be, you know, you know, that was the loudest. He wasn't the critical patient. He wasn't as critical. His situation was able to be easily managed, whereas the one with the, that was quieter, who wasn't making much.

This noise turned out having the more severe injury, and that's what we need to be finding on those quick assessments. So be mindful, and this is just a caveat for these things. When when when we're in the correctional setting, we, we have other variables that don't come from the outside. We need to be mindful of manipulative inmates, and that's typically those loud ones tend to be ones I I.

I have learned over the years, are the ones that, to have that more manipulative component to them. They want the attention or they want more of the care, but they are not necessarily the ones that are important or the priority. Handling an MCI in the correctional setting adds some unique variables like I was discussing.

Your emergency spots, in the world often doesn't have to deal with security like we have to. Security still has to remain a priority. It needs to be maintained. And while we may have lots of victims during a mass casualty incident, our victim's needs may require for us to take care.

Serve them longer due to delays in transportation due to security reasons. So this again plays into that concept of resource management and hence what makes good triage so important. We're here to do the most good for the most people, but that means we can't save everyone. And I can't stress this enough. Triage is one of the easiest things to teach, but it is one of the hardest things to do, especially if you know the victim or worse if it's one of your fellow officers. But remember, we triage to better understand where our limited resources will be best utilized and most impactful.

Turn that back over to you Chad.

Chad Garrett: Awesome. So clarity's critical, and in order for us to sort of digest this, they have this triage system that we're gonna be using called START triage. The simple triage and rapid treatment. It was developed.

And in 1980s by a fire department in California. And what it really does is that it's gonna help streamline our strategy for quickly categori categorizing patients in a mass casualty event. It's designed to be very swift, very systematic, and it demands that you're spending.

30 to 60 s. I like to see closer to probably 15 s per patient. It's more like a, an event speed dating approach to medicine, where we're gonna be looking at a respiratory rate, the perfusion, their circulation, their mental status, check, check, check check check.

And we're gonna be rapidly evaluating, this helps us starting to sort our staff, to get them off our start the sort the injury, getting them off of the X and putting them in their more definitive care zones going through. So, don't turn triage into some sort of medical exam. Remember the goal is.

A big categorization, not a medical assessment. So on my poll question I want to ask you, and you can answer in chat as I continue to talk is, who do you believe would be the best person at your institution to perform triage? If you could have anyone in your institution, who would you like to be doing the triage? And why you're putting that answer down I'm gonna tell you a quick story. I was training in the army and I had the opportunity to train a multitude of different units as they were preparing to go over to the sandbox. My unit was a training unit and we trained people before they.

There were so many times that we had advanced medical providers that were less professional than at triage, and it seemed to me the more advanced, the less good they performed pre triage, right? The less well they performed triage going through. We always video taped our training and I loved video tape.

Training because then you can have the people do their own after actual reviews. And we had what we called the medical pose and doctors and nurses a lot of times when we had different patients, you would see them step back and do this right here and think about the patient, and you can tell that we've lost them now, they're not in that algorithm anymore. Now they're thinking about the next level, which slows them down, and that's really, really key is that you don't want to overthink.

This process. When you're doing this triage, the answers that you are getting are the right answers. They're the right answers with the information you have at the time, and we move forward from that. It's always evolving process, but you have the right answers as you're moving on.

So it's triage move on triage, move on. Triage, move on. And if it's possible, you can have people falling behind you and they can start beginning treatments and start patient movements. So now we're gonna take a minute and we're gonna walk through the algorithm that will provide you with a.

Very simple toolkit that you can train your staff with and will make a huge difference in a mass casualty event. Chris?

Chris, you're muted muted if you're talking.

Christopher Smith: Well, that sure will make a difference when it's.

All right, hey everybody. As you can see on this slide, we have a simple decision tree there on your right, and it can be something as simple as this. Your institution may want to come up on their own, but something like this is something you can do, and you're literally just going to go down the list.

Can they walk? You can literally have one staff member off to the side saying, if you can hear me and you have no major injuries and you can walk, please come over to me. Well, you've just separated out all the people that are have really minor injuries, so you'll be able to take them and they'll be able to walk themselves out of it. And then you could put minimal supervision one.

Walk them to a separate area where they get their minor injuries treated. The ones who can't walk, ok, well now you're gonna actually start physically checking them. Let's check first they're breathing. Are they not breathing? okay reposition their airway. Are they still not breathing? Well unfortunately that may mean that they're deceased. All right? If they're breathing greater than 30 times in a minute or less than ten.

Well then you're gonna move them over to the immediate treatment area, and we'll discuss here in a minute. We we're using the, the red yellow black, and green. If, if your system has to we'll use different colors for whatever reason, then that's ok too. But it's the same colors every time and you want to make sure everybody is aware of the colors.

okay, so if the person is breathing, then you want to check their pulse. You want to check to see if their circulation if their blood is flowing. You can do two ways capillary refill, which is where you squeeze the fingernail, and if you get a, if you get the color to come back quickly, then you know that they have a pulse, of course.

The problem with that is if they're cold or if there's some other reason why that they're, they're not getting blood fully to their fingers, that maybe the reason a good way to do it is by doing the pulse, you can do the the arm. Remember don't use your thumb, it can create it can create a pulse on its own, and you're just gonna check right on the wrist. You're gonna feel for a pulse.

You can also do the neck, or you're gonna feel for a pulse. Now the challenge with this one is remember, you're gonna be excited, you're gonna be stressed, and there's gonna be a lot of stuff going on. So you may not get a pulse at first, but try again because that's gonna make a big difference.

So ok let's say they have a pulse. Then your next step is going to be checking their mental status. Can they follow simple commands? Can you ask them questions? Now, if you're going to ask them questions to detect their mental status, please maybe don't ask them what the square root of 1416 is, ok? You want to make sure it's a question that the person can ask. What day of the week.

LCDR Nicholas Bailey: What's your name?

Christopher Smith: Where are you at? Questions like that that you feel fairly confident that they're going to be able to answer and that way you're not assigning someone a less than a minute mental status for a question they don't know the answer to. So that's a simple way to do just a basic way to start the triage process. As Chad mentioned earlier, your goals should be especially if you're, if you're a non medical staff member doing this, 30 to 60 s per patient.

If you're a medical or you got more experience, try and keep it at 15. And the reason for that is we keep people moving so that we can get everybody triaged as quickly as we can and get the treatment for them started. The start system is tremendous. And then don't forget that as you're determining what level of of the of that they're hit stopping.

On your decision tree, you need to make sure that you mark them so that it can go on and the next person doesn't have to go through the the question that says the the the decision tree as well. So once you determine what level they are, you've got to mark them. So.

Chad Garrett: And how you can mark them, they have flags that you can use. We'll talk about, they have chem lights and, I mean anything that you can come up with, we've even used sharpie markers before and marked them across their forehead.

Austin Walters-Tracy: Hi, good morning, everybody. We're gonna go over triage coding. So during that triage, we're gonna assign the person a, the patient a specific color, whether that's red, they may survive of given immediate simple life saving measures.

So, you know, the bleeding, we can get that bleeding controlled, massive hemorrhage controlled, done quickly. They're, they're a red. We need to get that done immediately. A yellow, they should survive of getting care within a few hours, so they.

They have some issues, but it's not a immediate issue. We can address that at a later time. Green, the walking wounded, like Chris was talking about minor injuries, they do not require rapid care. They might need a band aid, something like that. Those people.

Sometimes they may end up being a part of helping you move other people bebecause you know they're, they're walking wounded. They're, you know, they've got a little scratch here or something like that. We maybe able to use those people during the rest of our.

Triage just kind of help ushering people and then you're black. They're deceased or severely injured patient unlikely to survive. So that's gonna be priority four. Those are the least priority. I know when I used to teach CPR, when we go over mass casualty situations, I always explained it as.

Black was, they might still be alive, but it's gonna take five of us to save that one person versus those five people can go save five other people that have massive hemorrhage. I'm not gonna waste my resources on saving one person when I can save five.

And that's kind of where we have to be cognizant of that. As Chad was talking about different ways that we can mark people, one thing we want to be mindful of is make sure that whatever we're using to mark the patient.

Is tearproof material and it is waterproof. because you, you know, the weather changes and it starts raining and we use the washable marker to mark somebody's forehead as a color, and now the next group comes through to move triage and now we don't know who's what. Next slide.

LCDR Nicholas Bailey: Alright, so what I'd like to do, oh, there you go, I don't know where, where you've gone here for my, can you back up?

Christopher Smith: Yeah, I'm not sure what happened to the system. Give me 1 s, sorry everybody. There we go.

LCDR Nicholas Bailey: Alright, so we're gonna have a little fun here with you guys. I'm going to share with you the actual testimony from mass casualty incident.

A USP Florence from 2008, and then we're gonna go over cases and we're gonna ask you kind of to to basically color code these, these patients from this incident. All right? So in April of 2008, USP Florence experienced a significant mass casualty event. On the morning of 20 April, officers came to the post and was.

Just like any other day. no indication, no warning or suspicion of the events that were gonna take place later that day. The morning routines went as expected up until about lunchtime. The yard Tower officer began to notice a change in some of the inmates behavior from the white supremacist groups. Instead of eating and going back to the units, 30 to 40 white inmate.

Mates began to gather on the concrete bleachers of the yard, and the tower officer began to radio the compound officers and the special investigative services to start watching the situation. Soon the white inmates began to shout white power and other racial slurs.

The following events that I'm gonna share with you right now are his actual testimony used during this instant instant investigation. So at approximately 12:26 p.m.. I noticed two white and five black inmates in a discussion on the edge of the soccer field. At 12:29 P. M. the white and the black inmates started a fight on the soccer field on the compound.

I initiated the emergency response alarm and fired four blast disturbing blast dispersing rounds into the fight. At this point in time many more inmates joined the fight. The inmates were non compliant to the alarms or the rounds that I, at the time I noticed that the inmates were not being affected by the less-lethal ammunition. The fight escalated into a hundred or more inmates, so I continue to fire gas rounds. I fired a total of nine gas rounds, which the inmates were not respond.

Wanting to nor would they separate from one another. And I'll I'll caveat on here this officer ended up expending all of his less than lethal rounds. At that time I decided that the thread of bodily harm had come to the point where I was to use deadly force. I then grabbed the M 16 rifle and after I acquired an inmate that I was sure had a homemade weapon and was striking another inmate in the head and torso area, I fired center mass.

The inmate separated from one another and appeared to carry their wounded to a safe area, and then they began to fight again. This time their main disturbance was over by the Charlie Bravo unit. I again noticed inmates with weapons striking was one another with homemade weapons around the head and the torso area. So I fired around center mass at an inmate. The round had no effect.

And the inmates continued to fight with weapons, so I fired another round, center mass sent an inmate that was striking another inmate with a weapon. Housing unit officers were making calls on their radio, the inmates were stabbing each other and weapons were everywhere and they needed assistance. You could hear the fear in their voice, that feeling of you know what's going on, but no one can get through the chaos to help. I can't describe it. You can only radio to barricade yourself in your office and defend yourself until help can come. I can't imagine the feeling they had when they realized help wasn't coming. After second shot that I fired in.

So those inmates began to separate. The inmates then began to carry what appeared to be wounded inmates towards staff who were at the bottom of my tower. The staff instructed the inmates to leave the wounded on the ground and back off to the wall, which the inmates complied with and staff carried the wounded to seek medical attention. However, the white and black inmates were continued to argue between, between each other and they approached one another and continued to fight.

I again noticed that that inmates had weapons and began to strike another about the head and the torso. I fired a 4th and final round center mass and an inmate that was striking another with a weapon. This time the inmates began to separate and the white inmates went to the volleyball courts. The black inmates went towards Charlie Bravo. Both sides continued to shout at each other and would.

Start to move towards each other. I then got on the loudspeaker repeatedly ordered the inmates to lie down on the ground. By this time staff had assembled a line across the soccer field and attempted to disperse the inmates and ensure the inmates were were to remain separate. Staff from other institutions began to arrive and provide lateral support to the staff already on the compound. The staff on the compound then.

Began to fire less lethal at the inmates that would not listen to orders to lie down and were approaching one another. This attempts to separate the two opposing factions appeared to work after enough staff had arrived, the lieutenant ordered the white inmates go into the gymnasium so they could be contained. I'm gonna pause here in his testimony for a little bit, but so this is a case of a great example of the kind of chaos that can happen inside our prison systems.

Resulting in a mass casualty incident. The uncertainty and the overwhelming of local resources that can be cons the, that can be experienced here is no laughing matter. And so using this scenario I want you to pick your true yourself as one of the officers on the scene.

And we're gonna move to the next slide here and we're gonna start going through batches of inmates that you're, you first encounter. So using the chat, we're gonna go through and basically what I've got here is I have a patient. We have the scenario. So I'm giving you respirations perfusion, mental status.

And then we wanna know what your start category is. So we have a 30 year old male, he's unconscious, chest impalement, His his breathing isn't happening after he's repositioning. Where are you guys gonna classify this inmate? Number one, where does number one?

Got black from Brenda. Black black, very good, very good. How about number two? We have a 42 year old, well this would be male. I apologize, I didn't catch that one, but abdominal stab wounds, alert.

Radio Pulse is present, obeying commands. What category will we put this one in? I've got some reds. I've got yellow to red, yellow to red, ok? All right, very good. Number three.

Shouting and pain, open femur fracture. capillary refill is good, he's oriented. I got a lot of people calling reds, right? okay, how about number 04:19 year old male, large scalp laceration, walking.

Strong radio pulse. I'm starting to get some greens. Family some greens. Don't throw a red in there. Very good. All right. Patient number 05:53 year old male confused. Bruising the next slow breathing.

He's, you know, he's breathing eight 8 /min, he's got a week pulse. Where are we putting him? Red, very good, very good. And then number 06:22 year old male, open arm fracture, but he's walking around.

Green, seeing a lot of greens. Very good. So for number one, I agree with you black. Number two, it could be a yellow, it could be delayed, but it may turn into a a red, you never know, but his pulse is good and present, so while he's following commands, definitely falls in that yellow, but he could turn into a red.

Number three also is one of those ones where you have a fracture, but they're oriented. They can move. Typically yellow, it's not immediate life threatening, right? Number four was green. You guys got that, number five was red, definitely on, and number six was green. Moving on to the next slide. Here's our next batch of inmates. You've tagged all of those ones. We're moving to.

The next one, and this is the key component about this is you're not stopping to start treating these. You're tagging, you're moving, ok? So now we have a 22 year old male. He's got an open arm fracture walking around. Radio pulse is good, he's alert. What color? Green? Very good, very good. How about number 07:33 year old male unconscious agonal respirations, no radio pulse. Black, black, very good. Very good.

He he is unconscious, he he's definitely one of those ones that's gonna take too much resources. So black. Number 08:45 year old will say male burns to both arms. He's responsive. I think he's too close to those gas rounds that were fired off. What we would do with number eight.

Got a green, yellows yellow, green, very good. That's right in that category, he is responsive, but yes, those burns burns are significant, so definitely I would probably go with yellow more with him. Number nine, the 60 year old male with a chest wound. He's anxious. He's breathing 302a minute. Capri Fill is more than two as.

Seconds. Red, very good. See, you start to see how this starts to come real real quick. You guys didn't need to see this, the, the information for more than a couple seconds and you're tagging and going. Number ten, we've got a 25 year old male bilateral leg fractures, weak radio pulses. He responds to pain only.

Red, very good. And then lastly, the 37 year old male facial trauma. Stridor is heard in his breaths, 36, sorry, 36 breaths a minute, weak radial pulse. He's agitated. All right? You're correct, red. Very good. And last slide, we'll do one more batch. You guys are doing really good at this. So you see how that.

That start method really makes this quick, easy, and you don't have to be a medically trained professional to make this quick orientation. You're looking at how they're breathing, you're looking at what their injuries are, you're looking at their responsiveness, you make a quick judgment, ok?

All right, so we got a 40 year old male walking minor abrasions, 16 breaths a minute, good radio pulse. Beautiful. Stop putting red in there. Who did that Samson? All right. Alright, number 13, we got that 28 year old male. Inhalation injury is suspected. He's coughing, having a tough time breathing capillary refills about two.

Seconds red, red. All right, could be red, could be a yellow, could be red, you're right, it's it he's right on the border, I agree. 14, we have that 50 year old male unresponsive, no respirations after you reposition the airway, no poles. Good job. It's like yep, he's done.

1538 year old male burns over 40 % of his body screaming off the top of his lungs, you're right. And good job on that red. Now this is where we re, you know, this is some medical experience comes in here, Burns that cover a large portion of the body, very, very significant. So this is definitely a red case because of the extent of the.

The burns that he's got. I think the tower officer may have pegged him right with those, those dispersal grenades, so number 16, we got a 21 year old male. He's got a stab to the groin. He's spurting blood. Bleeding, he's breathing about 20 a minute capillary refills. Yep, very good. How about 17? You guys have read on there for 1617. Massive head injury.

He's posturing, alright, you guys are throwing out red, definitely red, right? So you see how quickly this can happen? I mean, you just went through 18 patients, boom, boom boom boom boom with the information presented, and that took only a handful of minutes.

You're the triage person. This is your duty. You're not stopping, you're not treating, you're tagging and going. Tagging back, right? And so I'm gonna pass this off then, here over to Chad.

Chad Garrett: So this kind of leads us to our secondary tria.

For triage and not triaging, it is a continuous process. So it's really gonna be performed on everybody during the treatment phase. So we've already done our primary triage, now we've got them in this other site, they're off the X it's continuous process, and we're gonna go ahead and we're gonna check and recheck people. We're gonna check interventions. We're gonna talk with them. The reason being is that people sometimes get a little better. People sometimes get a little worse as we're going through.

And I want to ask you a question. When we are transporting inmates, do we have to take into consideration anything special or can we put an inmate on an ambulance and ship them over to a hospital?

Kind of a silly question, right? I guess a better question might be is how many staff do I have to send within inmate if I send them to the hospital? Doesn't matter what category they are, does it matter if they are high security inmate? What happens with their maximum security inmate? And we need to send two tenants and four officers and a chase car.

In order to transport that person. Does that change your triage decision on where you can send him if you've got a bunch of other people that you can send with no staff members going through? So this is all part of that secondary triage as you're working through it. And that's why, again, it's so important for corrections and medical to be working together and and.

Solving these little problems and issues as they come up. And it becomes more difficult as we begin to divide the groups in, in corrections. We'll talk about that in a little bit. But again, corrections can't do anything in the easy way. We always make things just slightly slightly more exciting and you have to dig just a little deeper. Next slide.

Austin Walters-Tracy: Alright everybody, gonna go over ICS and the different components of ICS. So, riot breaks out in B blocked 15 inmates are injured. Medical response is overwhelmed. We're gonna activate that ICS.

So commands gonna set the objectives. Some of those objectives might be securing the area. That's our first priority in the correctional setting, right? We want to get the area secured so we can actually get our staff in there to safely do their job. We're gonna triage and treat the wounded, establish a communication plan with the local EMS.

We're gonna track the patient movement and we're gonna prepare for transport. So what is the incident command system? So ICS is a standardized on scene all hazards incident management concept that enables a coordinated response among various jurisdictions and agencies during emergencies, including prisoned riots, medical emergencies, and MCM.

Guys developed by Firescope in the 1970s. ICS is now the national standard for emergency management under Fema's NIMS national incident management system. So the core principles of ICS, Unity of command. Everybody.

Each individual reports to only one designated supervisor. It helps that concept that we see so too often in corrections where we've got too many chiefs and not enough indians, where too many people are trying to give commands to a limited number of people and commands start becoming confused. Common terminology clear consistent behavi.

Language avoids confusion. So we're using clear plain English. We're not using ten codes, nothing like that where no matter who's coming in to assist, we know what the commands being given are. Modular organization, we can scale this to something as little as 15 to.

3000. ICS can fit everywhere in between and we just keep adding resources the higher up we go. Manageable span to control of optimal supervisor to staff ratio is one to five, integrated communications. It allows for secure interoperable channels for all responders.

A comprehensive resource management allows an inventory deploying resources effectively and action planning allows clear objectives with measurable outcomes. So different roles and responsibilities within ICS. You've got command, incident command.

They're the overall commander. They are setting the objectives and the strategies. They are then going to have people that fall underneath them, which include the public affairs officer. Obviously if we have a mass riot at a facility, news media is gonna get a hold of that pretty quickly when they start realizing all the laws.

Local resources are going to this correctional facility. It's important to get that PAO out there to kind of be that bridge between the bureau and the public so that the public is informed of what's going on. The safety officer ensuring the safety responders and inmates, the liaison for us our liaison is gonna be contacting those local.

Agencies and getting us the resources that we need. The operations section chief manages the tactical operations, so that's gonna be if we're sending them special teams to go in and secure the inmates so that we can then get those resources in there covering the triage, the movement and the security, your planning section.

Is going to be doing all the documentation. So like Chad was saying, if we have to start sending inmates out to local hospitals, that planning section is gonna be keeping track of inmate A went to hospital A, inmate B went to hospital A and the staff are with these inmates so that we know when we're all said and done, hey, we sent out 15 inmates to 13 different hospitals.

We know where our inmates are so we can maintain that control. The logistics section chief is gonna be providing the support, so they're gonna be the ones getting us the vehicles, getting us the medical supplies that we need, getting us the comms that we need. And then finally answering the admin chief, they're gonna be tracking all the costs.

Because there's always a cost associated with these mass casualty incidents and it's not always the upfront costs sometimes it's the cost at the end. You know, if they start a riot and they start damaging the building, they're keeping track of those costs as what it costs us.

So when should we activate ICS? ICS should be activated for a minute riots, mass casualty incidents, fires or hazardous material spills, natural disasters that affect the facility. So I know that's all some of you guys have facilities that are right there in tornado alley.

There were some facilities in here from down on the Gulf coast. You know, our hurricane hits a facility, that's a mass casualty incident. Even if it's it can be a mass casualty incident, but it's definitely one to activate ICS. Especially if we're gonna be moving, you know, 1500 inmates from a facility to another facility. That's definitely something to activate ICS on.

And then anything that involves multiple agencies responding to one thing, that is an ICS incident as well. So there's some benefits of ICS and corrections, gives us that clarif it clarifies command and control that reduces confusion and chaotic scenes, it improves communication across teams, it enhances.

Resource coordination and supports better medical outcomes. ICS is not just for fires and floods, it's for any organized medical response. Everyone plays a role whether they are medical, custody or support staff. Remember, in chaos, clarity is leadership. ICF gives structure to your stress.

Next slide. So in this multi tiered levels of triage, so we're gonna have in a correctional scenario, we're gonna have different triage areas and different areas of where we're gonna move the people that we're triaging. We're.

Obviously not going to move staff and inmates into the same triage area. So if we need to like we have a gymnasium, we can move, if there's more staff that need to be triaged and there are inmates, I'm gonna use the gym for the whoever has the most amount of casualties. So if it's the inmates I'm gonna move them in there. Staff, I might take them to the visiting room.

You know, somewhere separate where there's no confusion over, hey, if this person needs to go to the hospital and they're in this room, they're a staff, we can send them with maybe one, you know, send three staff members with one person that's not injured to kind of look out for those versus the inmates where we have to send multiple staff with them.

Staff don't don't always need another staff to go with them. If we're sending a staff member to the hospital, why send more of our resources to the hospital that aren't injured when we can use them to help us triage back at the facility? And I think Bailey had some stuff he wanted to cover on this as well. Bailey, you're muted.

LCDR Nicholas Bailey: Thanks. Sorry about that. So I'd like to cover another variable that you can encounter in when we try to get this balance of these MCIs under, under control. So.

Just because rescuers and responders begin to manage these MCIs and they, you know, it doesn't mean that these mass casualty incidents don't continue to morph or change or even get worse. So I'm gonna go back to that the the USP Florence right in 2008 and kind of pick up a little bit where I left off.

You know, where, where that officer's testimony was. And you're gonna watch how this MCI continued to escalate while officers were beginning to secure the initial scene and triage victims of the initial MCI, here's what the tower officer's testimony continued as. So he states it was at this time a call came across the radio that the white inmates in the gymnasium had begun to fight each other.

We still were trying to keep the races that were still in the yard separate so we couldn't, so we could cuff them and get that area secured. We didn't have the staff and the resources available to go running into the gymnasium. The decision was made to have sort, which is your special operations response team.

Assemble and go into the gymnasium. At that time, the disturbance on the yard appeared to be contained. So since the white and black inmates have been separated, there wasn't much of a fight left by the inmates on the yard. Once the sort team had assembled, and this, this took some time, I'll I'll just throw that caveat in there. It's not like the sort team was just, hey, we're here.

This in, the sort team had to be, you know, organized, put together. Once the sort team went in, calls were coming over the radio from the sort team as they entered the gymnasium and having to pull inmates out that were severely beaten because they didn't want to participate in the continued riot. Do you see how this mass casual incident morphed into two?

second MCI scene couldn't be made safe until further resources became available. And this created an environment that where in essence, two MCIs have now occurred. Each time a division of that incident occurs, it requires in essence, the doubling of your manpower needed. You have, you know, what we have here, your incident.

Command that was managing the first area, they can't be managing the secondary area. This requires a new set of command and a new set of manpower to then go in and start taking care of this specific incident in this scene and triage needs to be done all over again. And, and you see how it can potentially compound this, this issue.

What I really wanna, wanna really point out and I, and I believe this is one of the great successes from this incident is that the scene security for these issues was never attempted until enough resources were made available. This is what made it so staff injuries were at a minimum from this incident. So.

But that means that victims may die due to that delay. It it's just a reality of of of the situation of of your mass casualty incidents because of the delay when we don't have resources, some people will die. And this means that mutual aid might also need.

To be activated. This is where, you know, having to activate other agencies like your local fire department, your police department and others. They need to be called upon because some things can get so far beyond your, your institutional's ability to handle a situation. And so I'd like to give you some of the stats real quick on that actual incident. So there was two deaths.

From that actual incident, that riot, there were five very critically severe patients and well over 50 of your in essence, your yellow and green patients that came out of that incident.

And that's just the reality of the situation. I think it could have been worse, but by responding in, in such a way that in the way that the staff responded, I think there were many lives saved that day because of utilizing both the incident command system and this triage system that was that was put into place.

Back to you Tracing.

Austin Walters-Tracy: Alright, so on this picture here on this slide, on the left hand side, you have what mass casualty incident command can feel like. You know that those cold sweats, chaotic radio traffic, you know, you're gritting your teeth, your heart's racing, and then on the right side is what MCIs command should always look like. Calm cool, and collected. I have.

Fortunately, been fortunate to not be a part of any real life MCIs, but I've done a few training MCIs and my first training MCI, I had just, I was freshly promoted as a lieutenant on the fire department and they said, ok, go. Your first one I'm seen, and I looked like the guy on the left.

But with training and taking time to actually learn the systems, you're able to look like on the right. So in an unpredictable area of operational medicine, particularly within the confines of correctional facilities comm is not just a character trait, it's a clinical tool. When chaos erupts, the responder who remains cool common collected becomes the anchor and mid the storm.

Panic is contagious but so is poised. A steady hand and focused mind can turn confusion into coordination fear into function. Whether you're applying a tourniquet under dress, managing a mass casualty incident in the yard or de-escalating a belligerent inmate with blood pressure to match, composer directly impacts outcomes. Decision making becomes deliberate communication.

Becomes more effective and errors less frequent when the team leader radiates calm confidence. Staying cool isn't about being emotionally detached. It's about being tactically engaged. It's the difference between reacting and responding between escalating and resolving and training hard, trained hard, breathe deep and remember, and high threat environments calm is the silent commander that keeps the mission moving forward.

And the team moving safely. So somebody put in the group chat muscle memory? Yes, this is where this training comes in of training your non custody people and your custody people, your non medical people in these MCIs.

So that when the situation happens, it becomes muscle memory of putting on attorney kit, this isn't the first time they put on a tourniquet in six years. You know, they, they do it all the time, it becomes muscle memory and because everybody knows in chaos, those fine motor skills are gone. You have no fine motor skills anymore. Next slide.

Alright, so on this slide, for anybody that was here for our last Webex series, we kind of went over the tactical medical kits.

And stuff that we carry on us that can help us in those situations. This one we're gonna go moreover the triage equipment and the, stuff for MCIs. So they do make kits as you see here on the slide, for triage that come with, you know, the delay the immediate.

Be it the diseased in the minor. You can also just go to your local hardware store and pick up this flagging or even, you know, some duck tape. You can get some greens, some yellows, some black and some red duck tape and just put a piece of duct tape on their, on their shoulder. As Chad mentioned earlier, sharpies, when I was in the military, we did a mass casualty training and we didn't have.

Don't have any flagging, but we had plenty of sharpies, so we just put a Sharpie mark across our forehead. Easy to use, very difficult to change if their color coding changes and they go from a green to a yellow or yellow to a red, now you've got multiple marks in their forehead.

Another thing you can do is tarps, so we triage them, we move them straight to that tarp, so you can lay those tarps out so when somebody's coming into the casualty collection point, they can immediately see, ok, there's a green tarp, hey, I was marked green, I need to go here or, you know, I'm bringing in a red patient, they need to go to the red tarp, and kind of just.

Helps coordinate everything and keep everything coordinated, and then earlier Chad was saying, you know, if you can't get those colors, come up with a different color scheme that works for your agency to use, just be mindful in passing on that information.

To, you know, your local agencies that maybe coming to your facility to help you. So, you know, if you're, if you've got that good rapport with your local EMS or your local fire, make sure you, you know, you coordinate with them, hey, we're using purple pink.

Blue and green. So then they know when they come in, they see different colors, they know, ok, this is that color. And a lot of times if you talk to those local departments, they'll actually help, they can actually help you out with getting some of these flagging resources as well. Going over some other stuff that's helpful to have in these MCIs.

Making sure we have easy to use, ways to move these patients that can't walk on their own, making sure we know we have those litters available that we can just set it down, move the patient on it and move and we're not, you know, fighting with a gurney, you know, trying to move a gurney that nobody can ever remember how to raise and lower. Sometimes just those simple, breakable, collapsible.

Basket, litters are the best thing to use. Chad, do you have anything to add on this?

Chad Garrett: No, just that the most important thing is, is like you said, is that you've got to practice with the equipment that you're gonna use. You've gotta be proficient. I have seen some of the most unique things ever, with people using litters that haven't been fully extended, are fully put together, so they're kind of saggy in the middle, and it's really hard to hold the, the, the patient that's on there. I have.

I've seen, dressings put on just completely wrong and turnue gets put on wrong. So again, it's it's muscle memory, it's doing this over and over and over again. That's really important. And it's not it's not so important that you use this equipment, but whatever equipment you pick, you need to.

Focus on that and train on that. Next slide Chris. okay, so I want to tell you a story of a person I know. He was in a conflict and he was a Navy corpsman.

And his entire section where it was hit with motor shells. He was hitting the head, had gray matter exposed, lying down, and he could still hear and still remember what the triage folks were saying as they came around. They came around the first time to look at him and they were like, he's a black tag.

And they went on. Helicopter flew off with the people came back, triaged him again. He's a black tag, we got other people we're gonna take. Flew off with some other people and came back again. So this same thing happened several times, and this person remembers it very vividly, that he was black tagged over.

And over and over and a low priority as far as treatment goes, again, he has gray matter showing. Finally, after they've transported almost everybody else, they come to him and they're like, ah, well he's still alive.

okay, let's go ahead and transport him. And that person's my dad. So he ended up going from black tag expectant to, having a real productive life going through. But it just kind of shows you that this is an evolution.

This paradigm is ever changing, and the only real thing that you know you're always gonna have is this move towards entropy, this move towards chaos, and if you can try to control that chaos, it's a.

A much better process. It's, it becomes a little more seamless as you're going through. Next slide. okay, so.

This is not a catchphrase, the start, the salt or whatever you decide to use. This is very usable knowledge as we're going through. You have to train like it's a real crisis every day because, you don't rise to the occasion, you really honestly, you're gonna fall to the level of your training, and that's important to know. You're not gonna magic.

We become better at your job because it's an emergency that doesn't happen. Most people become a little less better at the job. So again, you gotta rise to the occasion. Nope. You're gonna fall to the level of your training. So let's go over just another quick scenario. We're gonna ask about a couple more patients and I want you to put it in chat and we're gonna go relatively quickly, so you're gonna have to keep up as we're going through. So this is a facility, it's the Redstone correctional facility center. It's got.

100 incarcerated folks, 240 staff, it's 02:00, and there's our severe thunderstorms and tornado warnings. There is a EF four tornado approximately half a mile away. Then it strikes the west side of your facility.

The facilities administrated a building, medical clinic food service, and one housing unit sustains significant structural damage. Your fence is down, your outside perimeters down. Windows are blown out throughout the compound. Portions of the roof are missing electric power fails, and it's followed by your emergency generator kicking on sort of.

So the perimeter fence is damaged and down. There are all kinds of people that are trapped beneath the debris. Lots of people have sustained injuries to include staff and inmates.

The medical clinic is damaged, can't function, can't use it. And so now with your initial resources of I'm gonna give you one physician, two nurses.

One pharmacist, two correctional officers to start with. EMS is about 30 min away. Fire and rescue is at least 30 min away. So I want you to triage these patients for me as we're walking through. Put them in chat. Chris, can you rechat for me since I can't pull it up?

Christopher Smith: Absolutely.

Chad Garrett: Awesome sauce. first inmate, 34 walking, superficial facial lacerations. Do I need any more? What do we got?

Christopher Smith: Because a green first one right off the bat, another green.

Chad Garrett: okay, this is quick. Inmate. 52. It's found beneath ceiling debris with an open femur fracture. His bone is sticking out of his leg. His heart rate's a hundred and 32 and his respiration rate is 35. he's pale, diaphoretic, and confused.

Right off the bat. Sweet? Five Nice, another one. You got it. Correctional officer, 41. He's got a severe scalp laceration. You can see that his scalp has been removed and you can see some of his skull underneath. It's a big flap. His heart rate is about a hundred and 18 respiration.

Since are about 24. He's got a lot of bleeding initially because head wounds bleed a lot, but the bleeding has seemed to stop as he puts pressure on it. What is he?

Christopher Smith: We got a number of reds.

Chad Garrett: Number of reds. okay, so red?

Christopher Smith: Alright, if you put red, go ahead and let us know why you think red. no worry, no wrong answer. We got some additional blood loss. There you go.

Chad Garrett: See, and and this is the key to this is there's not really a wrong answer. There's just the best answer you can make with the information you have and right with the heavy bleeding from the scalf, it's kind of an expected thing, but it's also most of the time the thing you could fix with this. Ok, here's the question. Where would I put my tourniquet?

okay, answers in the chat, where do we put you now? Yeah, if it's me right around here and tighten it up a lot. okay.

LCDR Nicholas Bailey: We got a couple of location.

Christopher Smith: The bleeding. I think everybody forgot that it was the scalp that was bleeding.

Chad Garrett: That's ok. This is fast and we're making decisions. Chest trauma, a large piece of concrete flowing on his chest. Heart rates about a hundred and 20 respiration rates are 36. And he appears to be in respiratory distress, he's having difficulty breathing.

Christopher Smith: We got a handful of reds and more reds.

Chad Garrett: Nice. Have mate 61 walking. His ankle is deformed. His foot is sticking at a right angle to his leg. He's got multi multiple little acerations, heart rate, a hundred and ten respiration rate, 20, he's alert.

Christopher Smith: Genuinely Chad, this time we got some mixing, we got some yellow greens and reds.

Chad Garrett: Nice! Nice. I like that. I like that. So I want someone who gave him a green to to to tell me why, why a green? And I don't disagree.

Christopher Smith: Don't be shy folks. Again, there's no wrong answer. This is a quick assessment. All right? Yep. And we're encouraging non medical to make these so got the Brian said oriented and walking.

Chad Garrett: Yep. His injury is not gonna kill him, right? But maybe a yellow because if we don't have his ankle looked at and doesn't have a pulse and all that other stuff, perhaps he would lose his foot. So without going deeper remember, we don't want to go deeper, we want to stick right to the RPM RPM, RPM, RPM. Next one.

Christopher Smith: Elizabeth said there was a distracting ortho injury and maybe that's why people.

Chad Garrett: Right, right. And, and if you've never seen these ortho injuries before, they are amazingly distracting, seeing a bone sticking out of someone's leg or a body part sticking at a right angle or a wrong angle is definitely a high freakout event if you've never seen it before. So we have it inmate 45. Looks like he has a blunt head injury. His heart rate is 40. His respiration rate is eight.

Christopher Smith: Got a couple of reds right off the bat.

Chad Garrett: okay, but more?

Christopher Smith: Elizabeth says almost black.

Chad Garrett: Ah, that is a good answer. I like that Elizabeth. I like that. Yeah. Right. Depending on what my research is like this guy is way bad off and.

I think the commander told us that we've got limited resources and are we gonna spend all of these resources on this one person? So is he red or with our resources, is he gonna be expected like my father was? And eventually.

We may or may not get back to him. See that that's a super hard decision to make. Now make it one step harder. He's not an inmate, now he's an officer. Now how do you triage him? He's an officer. Not only an officer, he's the associate warden. He's the second command of your institution, you know him really well. How do you how do you triage him that? Blood hand injury, heart rate in the fifties, respiration rate.

LCDR Nicholas Bailey: The tenant Brian says it doesn't change. Yep.

Chad Garrett: I love you guys. You guys are brilliant. This is awesome. This one might sound a little familiar. You've got a 48 year old inmate with abdominal trauma. You can see all kinds of bruising. His abdomen is rigid with a ton of pain and he is moaning and groaning his heart rates about a hundred and 26.

Respiration rate is right around 28. He's very pale.

Christopher Smith: We got just a few answers Chad, and they're two yellow one red.

Chad Garrett: okay, okay. I like that. And Bailey, what would you triage that guy out with abdominal trauma, heart rate one twenties, respiration rate in his twenties, pain.

LCDR Nicholas Bailey: Honestly I would say he's more of a red than a yellow only because that's gonna, he's gonna continue to deteriorate based on that presentation, but it's gonna he's gonna continue to need more resources longer than get him to the appropriate help.

Christopher Smith: Yeah, Brenda gave right along an answer with that and she said red depending on numbers, maybe black. If I'm alone he he maybe black.

Chad Garrett: Yeah, you guys are brilliant I mean, you, you absolutely understand this process which Now you've got to take it to your other staff members and you have got to start training it for them. And then you start adding some twists to it as you're going through. We want to add a couple, you know, a little.

Twists to it as you're going through.

And remember, as we're going through this, there's off, also the correctional portion of that. Now, if I had added that inmate one was a max security inmate, does that change? I mean it becomes difficult. Who who can wait? Who requires immediate line.

Life saving interventions.

How do you provide safety and security if your your fence is down? What's your biggest priority? If my perimeter fence is down, what is your biggest priority? okay.

LCDR Nicholas Bailey: Sir? Yeah, there we go.

Christopher Smith: Yeah. Seen security first security first, security defense, the public.

Chad Garrett: The security, always is gonna take precedent over everything else that's going on and that is our mission, number one mission. And I know you guys know that really well. Chris, go ahead and hit our next slide.

Christopher Smith: And as i'm hitting the next slide, let me just remind everybody, the idea, the th this tree, this triage is the epicent or what this whole series is about and that, and that it's every day non medical correctional staff can be vital helpers and with medical and getting through these medical emergencies, so.

Alright, if you guys have any questions, we'll give you a couple of minutes to type questions into your chat. Love to hear questions and then we can answer them.

Yeah ok we got, well everybody else is typing, we got one big one I'll read off real quick, right? As from Dennis and he says what recommendations do you have?

For situations in which medical staff are not providing adequate or appropriate care during an incident. What, if any ramifications could there be for custody staff who step in and provide appropriate emergency medical care? Given my 18 years of experience in the fire service, my.

Continued active status and my experience as a medical and first aid instructor within our department, would I be overstepping my authority if I observed what I believe could be an inadequate medical treatment to intervene to provide appropriate emergency care within my training and scope?

Chad Garrett: Commanda, do you wanna take that first?

LCDR Nicholas Bailey: I was gonna say I might be able to have this one for you if you want.

Chad Garrett: Roger.

LCDR Nicholas Bailey: So I actually have an incident where this really happened with the officers. We had a nurse who, she just wasn't a good nurse. I'll be I'll be flat out. She just was not a competent or good nurse.

She was all by herself on an evening shift and and it mate had a heart attack and she froze. She wasn't giving any instructions or directions to the correctional staff, but the s the staff engaged with her saying, Do you want me to go get the AED?

The staff asked, do you want me to start doing chest compressions? The staff members asked, do you want me to do this? Do you want me to do this? Do you want me to do this? He ended up resuscitating that inmate and saving his life, getting the AED. They got that all done. But it was the correctional staff officers that saved that, that inmate's life.

That the nurse just failed, right? And, and so you can engage with them, you just have to do it in a respectful manner. I I don't know if there's any repercussions that are gonna come, but you know when we're dealing with mass casualty incidents or or things like this on that level, really you have to do what's gonna hold.

Hold up best with with the what's the right thing to do at that moment of time, ok? There's, there's not a board or a standard out there that says, Nope, you should have done this, this, this, and this. You should have known better and and that comes back and and and shoots you in the rear. That's, that's not really a system that works. Although some people, you know, they try. It's just not typically how that works, right? Chad, do you want to add anything on that or?

Chad Garrett: Absolutely. And one of the things that I change all the time is that if you see someone who's making a mistake or not doing something correctly, CPR is a great example. I pull people off of doing chest compressions all the time because they're doing them wrong. I have pulled executive staff and said, that's sir, nope, stop, we're gonna put.

Someone else on the chest for a while. I have been pulled from doing medical things that I wasn't doing correctly at the time and I was a supervisor of the person who told me move out of the way so I can do this. So, again, respectfully, you want to be able to walk in there, you want to work as a team as you're working in there. You want to remember that experience is often the best teacher and how you approach that makes a huge difference. If you were like, oh.

The nurse, you suck, get out of the way. You're terrible. That might not go as well as, hey, let me help with this. Let me move in here. Why don't we suggest, does that help with your question? And are there any other questions?

Austin Walters-Tracy: So add something to to what you just said sometimes the flip side of that, if you are not confident in what you're doing, sometimes the best thing to do is to step back because I've also seen it in my time where you know something happens and we're in medical.

And there's six officers in there trying to help and only two of us know what we're doing or have had that experience without rapport with medical and everybody else is kind of just in the way. So sometimes it's a double-edged sword just kinda, sometimes you do need to take that step back.

Christopher Smith: Yeah, let me add in too that most states have Good Samaritan laws too that would cover you in these situations. So be mindful of that. Those are meant to allow non medical people to assist at medical emergencies to help us save a life. So you got those even though you're in a institution, they still apply to you in the states that have them.

Chad Garrett: The person that wrote the question did say they.

Christopher Smith: Helped.

Chad Garrett: Yeah, I was gonna say, if you're trained and acting within your scope, you should be good to go.

Christopher Smith: Alright, let me see what time it is. We got, this is.

LCDR Nicholas Bailey: Probably not. Here's a harder question to answer, but.

Christopher Smith: And if in your best 3second answer, is it right for administration to prioritize the needs of amount, that's more of a statement. I'm gonna skip over that question. Does anybody else have a question real quick?

LCDR Nicholas Bailey: So there is one up here that about location and medical equipment being or if it's a deciding factor or if the equipment is damaged and far away.

Yeah, that that does play a role in that deciding factor of, of what you, what resources you have available. That's how you in essence, start to also triage, right? If you don't have all the life saving equipment then, then that does affect what level of triage you're giving out to people at that moment of time. When resources change, that's when that's when we do that.

That reassessment.

Christopher Smith: Alright, hey everybody, I appreciate the questions. I hope we answered them. If you have questions you wanted to reach out to us later. We on the screen now is the evaluation tool. If you're in a place where you can use a phone to do the QR code right there, you can.

You can zap it and it will take you directly to the survey. If not, if you don't, you can write down the link at the bottom and you get there that way. Look I don't want to take too much of your time to going over this, but I promise you, everybody looks at these from me all the way up to the director, not just on this, but everything that we do, these surveys.

Help to provide the training that you guys want. These surveys are meant to make sure that you guys, you guys are our customer. We want to make sure that I may think this is a great webinar, but we need to know that you think it's a good webinar and whether or not it will be useful to you. And the way that we're able to do this is by these surveys.

So the survey just takes a few minutes. It is a few questions, it's not too many. But please get in there and and answer the survey that would really help us out. Whether it's you saying how great it is or maybe you said that that Smith guy was horrible. You know, I need to know that. That's how I'm gonna get better at this. So please definitely take a few moments to answer the survey. I'll leave it here for just another second.

Chad Garrett: I was gonna say I just want to say how much I want to thank our speakers from Florence for joining us. I know that they're taking their own time out of their very busy schedule to be here and I'd also like to thank their executive staff for allowing them to be part of this. Their insight is absolutely critical and amazing for the boots underground aspect as we're going through this. And again, I also like to thank everybody who's joining us out there. I know that your time is limited and your time is critical and the fact.

That you chose to come and spend your time with us? Absolutely awesome. If there's ever anything we can do for you, go to NICIC.gov. There is a place to ask your questions or requests, anything you need. And with that.

Thank you guys. I appreciate it.

Christopher Smith: Yes, thank you. Just to echo what Chad said, all those things we really greatly appreciate it. Thank you again to our speakers as well. We got one more session coming up at the end of September for this webinar series, but we also have our other series, everyday correctional emergency management.

We got an episode in, and on 23 September that you can attend on that as well. So, that's kind of a12 punch and thank you again everybody for attending. Greatly appreciate it. Please again, take a moment to answer those surveys.

Chad Garrett: Chris, did you hit the stop recording?