Wilderness EMS Incident Command

David Fifer

INTRODUCTION

Although it is not a clinical discipline, incident command is a crucial component of any wilderness emergency medical services (WEMS) response. The classic definition of incident command revolves around the activities of ordering, directing, and controlling resources (be they logistic or human), but the essence of incident command is actually simpler: Incident command is really about optimizing the potential for your incident to have a good outcome by applying basic principles of organization and management.

This is important because wilderness responses are inherently chaotic. They generally involve many different responders from many different disciplines who are attempting to work together against numerous challenges, potentially including terrain, weather, fatigue, time, limited communications, limited resources, and safety hazards. When used well and applied properly, incident command brings order to this chaos and helps all the pieces of a response fit together.

Much in the same way that certain specific techniques of medicine have been formalized into standardized patient care protocols such as cardiopulmonary resuscitation, Advanced Cardiac Life Support, and others, specific techniques of incident command have been formalized and standardized into the Incident Command System (ICS). First developed in the western United States in the 1970s, ICS is a standardized but flexible methodology for managing incidents of any kind and size. In that sense, it is like a protocol for “treating” the “symptoms” of an emergency response operation. In the United States, it is a core component of the National Incident Management System (NIMS), and its use is mandatory among federal agencies, including the land management agencies responsible for emergency responses in the vast tracts of federal wilderness throughout the country. State and local responders too are generally obligated to use ICS, even if they are not under the direct control of the federal government, because doing so is often a condition for receiving federal funding.

Even if your agency is not obligated to use ICS, choosing not to use it is unwise. Refined since its creation through input from many different disciplines, and through application in countless incidents, ICS is a time-tested set of best practices that is used on a daily basis by public and private organizations throughout the country. Savvy responders know that when used properly, ICS makes the most of the resources assigned to an incident and improves the execution of the mission.

Modern ICS is an “all-hazards” methodology that can be applied to any kind of response, but its history is closely tied to wilderness incidents in particular. ICS was first created under a different name by the U.S. Forest Service in California as a way to manage their response to the large wildland fires that often strike that state. Having seen its effectiveness, the national wildfire community soon adopted it for use wherever wildfires occurred. Its popularity grew throughout the rest of the emergency response community. The U.S. Coast Guard began applying ICS to environmental accidents and collisions at sea, incidents that have many of the same characteristics as wilderness EMS incidents.¹ The U.S. National Park Service mandated the use of ICS for all incidents in 1988.² In the wake of the September 11, 2001 terror attacks, George W. Bush’s Homeland Security Presidential Directive-5 resulted in ICS becoming an official component of NIMS in 2004.³

Even if it were not encouraged to be used by national policies, ICS has several features that make it the ideal system for managing wilderness EMS incidents (Figure 3.1):

Standardization and Common Terminology: ICS works the same way no matter which jurisdiction you are in and no matter what the specific mission is. It has its own universal nomenclature to bridge the differences between agency- and
jurisdiction-specific jargon, ensuring that all the responders on an incident are using common terminology.

FIGURE 3.1. Benefits of using ICS. ICS, Incident Command System.
Scalability and Flexibility: ICS can be applied to the smallest incidents or the biggest incidents; it is simply a matter of how many of its features an incident manager wishes to use. Its principles can be employed if you are functioning as an individual Good Samaritan responder, as a member of a moderately sized response to a backcountry rescue, or as the senior commander on a massive, complex search and rescue operation. As an Incident Commander, you can “right-size” the response structure by selecting the components of ICS that make sense for that incident. You can even modify some of the traditional components of ICS as long as you are staying consistent with the logic of the system.
Unity of Command: As a member of an organized response using ICS, each responder reports to only one individual. They know whom to receive information from, and whom to bring information to. In the challenging environments of wilderness EMS responses, this helps prevent conflicting information, maintains personnel accountability, and enhances safety.
Span of Control: When used properly, ICS assists you in delegating effectively and can help you avoid becoming overwhelmed by limiting the number of subordinates that each supervisor oversees. The limited “span of control” that each supervisor has also helps to improve safety by ensuring that they effectively monitor the small number of people acting under them.
Facilities: ICS recommends the establishment of temporary facilities that can be easily found by all responders, such as an Incident Command Post, equipment staging areas, and helicopter landing zones. It might seem counterintuitive to set up these kinds of facilities in the austere and fluid environment of backcountry responses, but doing so can dramatically improve the effectiveness of a wilderness EMS response by making sure everyone knows where to get needed resources and by minimizing the clutter of vehicles and personnel along narrow fire roads, for example.
Management By Objectives: ICS uses this term to help manage the mission by breaking it down into specific action steps. Ideally, these steps are determined through subject matter expertise. Management By Objectives is about deciding what your immediate goals are; deciding what steps must be taken to achieve those goals; and then measuring your progress by how well you are achieving those goals and adjusting your actions if you are not meeting them.

Over the course of roughly 40 years, ICS has been refined to help make incidents successful. Today, the National Park Service is considered to be a model of how an agency can apply ICS to wilderness incidents of every size and scope.² Likewise, the U.S. Forest Service, Coast Guard, and many large Search and Rescue (SAR) teams have earned reputations for incident management excellence and the use of ICS. They have done so by making ICS a part of their everyday culture. These organizations apply ICS to small, routine incidents, and the comfort level they develop by doing so helps them be successful in managing rare, complex incidents when they occur. Making ICS a part of your agency’s day-to-day operations will help you master incident management, too.

As you read this chapter, keep in mind that wilderness medicine is not confined to the mountains and the woods. Any situation in which resources are limited and the time to definitive care is lengthy could be considered an austere or “wilderness” situation. Although the examples in this chapter do occur in traditional wilderness settings, you can apply them as well to an urban disaster zone, for example, or perhaps a hospital running on generator power that needs to be evacuated.

UNDERSTANDING FIELD INCIDENT MANAGEMENT

With the broad strokes and background of ICS having been laid out, let’s explore the system further and discuss its implementation in the field. As described earlier, ICS has six core features that are helpful in managing wilderness EMS incidents. There are additional core features that are more relevant to other kinds of incidents, but those are best left to the purview of other texts. To manage a wilderness EMS incident well, you must understand these basic characteristics.

Standardization and Common Terminology

It is important to understand that ICS is designed to smooth over the differences in operating procedures and jargon used by various agencies and responders through use of its own standards, terminology, and titles.

When responding to a wilderness EMS incident, it is best to use these terms and titles, rather than those unique to your agency. Wilderness responses almost always involve multiple agencies, and confusion abounds when personnel cling to their own vernacular. For example, the senior ranking officer on duty with Agency A, a rescue squad, might be referred to by that team as their Duty Officer. The senior ranking officer on duty with Agency B, the state land management agency with jurisdiction over the area in which the incident is occurring, might be referred to as the District Ranger. To bridge those differences and maximize clarity, ICS uses the title Incident Commander for the senior ranking official overseeing an incident. The rationale for this approach is that each agency’s personnel are used to referring to their leaders by the titles used in their own systems, and intuitively understand all of the responsibilities and authority that those titles convey in their jurisdictions. But when those agencies come together on a wilderness EMS mission, those titles may not be clear to individuals who do not normally deal with them.

The standardized terminology of ICS largely consists of two categories: Position Titles and Facility names.

Position Titles

For the most part, ICS position titles are intuitive. For example, the ICS titles of Safety Officer, Branch Director, and Unit Leader (as just a few examples) all clearly communicate what those individuals’ responsibilities and scope of authority are, much like Incident Commander.

To highlight this further, let’s explore some of the standard ICS position titles that might be used on a wilderness EMS response:

Incident Commander (IC): As discussed earlier, this position is the senior official overseeing the incident response in the field. These officials are responsible for appointing all the other positions in the ICS organization, or fulfilling those areas of responsibility if they do not. They are also responsible for establishing the mission’s objectives and approving all of the broad activities that occur during an incident. They are accountable for the mission’s overall success or failure.

When an incident involves multiple agencies or jurisdictions that share primary responsibility for the response, it is often wise to use a Unified Command model. In Unified Command, there are multiple ICs, each representing the primary agencies or jurisdiction, who work together as one command team. Often, they will select one individual to serve as the “first among equals” and represent the Unified Command team to the rest of the ICS organization. If a Unified Command model is used, the rest of the ICS structure is still organized as it normally would be under a single IC.

Command Staff: Positions that directly assist the IC in accomplishing organization-wide goals.
- Public Information Officer: The position responsible for providing incident information to the media and general public.
- Liaison Officer: The position responsible for coordinating the involvement of organizations that might wish to help with an incident, but are not part of the official response to the incident. For example, the Liaison Officer might work with local faith-based relief organizations that wish to supply refreshments to the responders.
- Safety Officer: The position responsible for ensuring the overall safety of the incident responders, including ensuring that they are equipped with proper personal protective equipment and physically capable of performing their assignments.

An acronym for remembering the Command Staff positions is IC PLuS, for the IC “plus” the first letters of the three traditional positions that assist them (Figure 3.2).

General Staff: The primary supervisors of each of the standard ICS organizational sections, referred to as Chiefs.
- Finance/Administration Section Chief: The position responsible for tracking the costs related to an incident, as well as handling general administrative tasks such as personnel timekeeping.
  
  FIGURE 3.2. The “IC PLuS” Command Staff Positions.
- Logistics Section Chief: The position responsible for coordinating all of the support functions that keep an incident going smoothly: communications, supplies, utilities, facilities, transportation, nourishment and medical care for responders, and the acquisition of additional equipment.
- Operations Section Chief: The position responsible for coordinating the tactical response to the incident. The Operations Section does the “boots on the ground” fieldwork of search, rescue, patient care, and patient evacuation.
- Planning Section Chief: The position responsible for coordinating the nonlogistic and nonadministrative aspects of an incident, including personnel accountability, anticipation of future incident needs, GIS services, and distribution of important information to incident personnel.

An acronym for remembering these General Staff positions is FLOP, for the first letter of each section’s name (Figure 3.3). As of 2017, the Federal Emergency Management Agency (FEMA) has suggested the addition of an Intelligence & Investigations Section and corresponding Chief to the standard General Staff positions. If formalized, the author proposes the acronym FLOPI to recall this.

As we will discuss later in the chapter, not all of these Command and General Staff positions are needed on every wilderness EMS incident, especially when the incident is of a short duration. In fact, the IC is the only specific position that must be filled on every incident. However, the IC PLuS and FLOP positions are the core ICS positions that you should think about establishing on any mission that is not simple in scope. And recall that the IC is responsible for carrying out the responsibilities of any positions and tasks they do not establish and delegate.

Incident Facilities

ICS also makes use of standard terminology when referring to incident facilities. Although it may at first seem illogical to establish fixed facilities on a wilderness EMS response, doing so will make running a successful mission much easier by providing points from which, and around which, operations can be conducted. In the context of wilderness EMS, a “fixed facility” is simply a known location with some minimal utilities to allow work to be done.

FIGURE 3.3. The “FLOP” General Staff Positions. Because the Operations Section is often the first to be created as an ICS tree expands, it is usually listed first when reading actual ICS trees from left to right. However, the positions in this tree are listed in accordance with the FLOP mnemonic. ICS, Incident Command System.

Standard ICS facilities that might be established on a wilderness EMS incident include:

Incident Command Post: The location from which the IC and his or her staff direct the incident response. This can be a tent, a vehicle, or even just a table. However, not every incident requires an Incident Command Post to be established. On very small incidents, it is often appropriate for the IC and other staff to enter the woods along with rescuers and supervise activities directly.
Staging Area: The location to which responders are directed to report, to organize their equipment, and await mission orders.
Helispot: The location at which helicopters are designated to land. This is the ICS term for a landing zone, as well as the general EMS terminology for an improvised helicopter landing site (with “helipad” being an established site).

Scalability and Flexibility

To manage wilderness EMS incidents well, it is important to understand that ICS is scalable and flexible, and further still to know how to scale it. Its scalability means that if an incident is small, the ICS organization can be small as well; but if an incident is large or complex, the ICS organization can be expanded to reflect that. In other words, not all the features of ICS are needed on every call. Many wilderness EMS incidents can be easily managed through ICS simply by designating an IC, which is the only ICS position that is always required. In fact, 95% of all incidents consist only of an IC and individual responders (referred to as Single Resources in ICS terminology) working under them.³

ICS is modular, and the ICS organization for a given incident is built using a“building block” approach. Starting out, the organizational tree for an incident will need only one block: that of the IC. As an incident grows in complexity, or if its complexity
is understood from the beginning, the IC will add additional blocks by establishing the positions described earlier. There are a few different indications for when the ICS organizational tree should be expanded, and more positions created.

Span of Control

One of the key features of ICS is the principle of “Span of Control.” This principle states that the ideal number of individual responders that a single person can supervise is somewhere between three and seven. Below three, it is inefficient to have a supervisor dedicated to them. Above seven, a supervisor cannot effectively supervise them. With this in mind, maintaining Span of Control is one of the primary reasons to build more blocks onto your ICS organization. A large number of responders will require several supervisors, and an organizational tree will be needed.

Incident Complexity

Most wilderness EMS incidents are complex by their very nature, but only moderately so: They involve a fairly straightforward response to a report of an ill or injured person in a given wilderness location, albeit with many challenges. But some incidents are indeed complex in the truest sense of the word: They involve an unusual number of challenges or exceptional circumstances. If your incident involves factors such as a wide area search for an ill or injured subject, multiple patients, unusually rugged terrain, or unusual aspects such as a plane crash or concurrent natural disaster, consider expanding your ICS organizational tree to ensure that all of your bases are covered.

Incident Duration

Most wilderness EMS incidents are of a relatively short duration, spanning only one Operational Period. Operational Periods, in ICS terminology, are units of time against which the incident’s progress is measured. Normally, operational periods last 12 hours, but they can be shorter or longer at the discretion of the IC. With the standard 12-hour Operational Period in mind, consider expanding your ICS organizational tree if it appears that the incident will last an entire period or span more than one. Fresh personnel and increased amounts of supplies will almost certainly be needed, and more ICS positions will be necessary to manage those resources and the turnover in personnel between periods.

When choosing to expand the ICS organization, you have several options, and they can be used alone or in combination. The determination of which options to use, and in what ways, is often a matter of the IC‘s philosophy and comfort level with different approaches to incident management.

Appoint Command Staff and Establish Sections: One of the easiest ways to scale an ICS organization up to meet the demands of a more complex incident is to appoint the Command Staff described earlier and to create Sections, led by the Chiefs that comprise the General Staff. The Command Staff takes pressure off the IC so that he or she can maintain overall situational awareness and ensure an effective response. The General Staff do the same by taking point on the specific areas they lead.

Not every Command Staff position needs to be filled, nor does every Section/General Staff position need to be. For example, there may be no need to appoint a Liaison Officer if no outside entities are seeking to assist in the response. Moreover, very commonly, the creation of Finance/Administration and Planning Sections is not necessary on incidents of limited scope and duration. It is almost always helpful, given enough personnel with the proper qualifications, to appoint a Public Information Officer, a Safety Officer, and Operations and Logistics Sections led by Chiefs.

Create Divisions, Groups, and Units: Within the Operations Section, Divisions or Groups can be established to further organize the incident response. Divisions are geographic areas, such as Divisions A and B to denote activities occurring on each side of a river. Groups are functional areas of relatively small size, such as a Treatment Group consisting of several patient care providers, or several rope technicians organized into a Rescue Group. Within the Logistics Section, Units coordinate specific areas of support activity. For example, it may become necessary to create a Communications Unit to handle radio systems and traffic, or a Staging Area Unit to manage the area where vehicles and other equipment report for assignments.
Create Branches: Within the Operations and Logistics Sections, Branches can be created to organize major areas of activity that have numerous personnel operating within them. For example, it may become necessary to create a Medical Branch within the Operations Section to coordinate the patient care aspects of a response to a wilderness plane crash that has produced numerous patients.
Create Strike Teams or Task Forces: Strike Teams are small teams of individual rescuers organized around a common skill set, such as a Rope Rescue Strike Team tasked with rigging a particular hazard. A Task Force is a small team of individual rescuers with varying skill sets but a common mission, such as a Medical Task Force consisting of an Emergency Medical Technician (EMT), paramedic, and physician tasked with providing patient care.

If all of these organizational levels are created, they flow in descending order from the IC down to the small group level.
The IC supervises the Section Chiefs, who in turn supervise the Branch Directors, who in turn oversee the Division/Group Supervisors, who in turn oversee the Strike Teams and Task Forces. The Strike Team and Task Force Leaders supervise the individual rescuers assigned to them.

Generally, it is wise to scale your ICS organization by building your Sections from the top down and your Strike Teams, Task Forces, and Groups from the bottom up. Use Branches between those two levels if further organization is needed, and keep the ideal supervisory Span of Control of three to seven subordinates in mind. In other words, begin to scale your ICS organization up by creating some basic Sections and then building small units.

Let’s try a small example. You are the IC organizing a response to a report of a subject who has fallen while rappelling over a cliff, approximately 45 minutes by foot from the nearest trailhead. Twenty rescuers from several agencies with various skill sets and scopes of practice have responded, and are assembled at the trailhead awaiting orders. You decide to establish an Operations Section, led by a Chief, and group the rescuers as follows (Figure 3.4):

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