9 Line Medical Incident Report - Ics 206 Wf
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19 Line Medical Incident Report
Medical Incident Report
FOR ALL MEDICAL EMERGENCIES: IDENTIFY ON SCENE INCIDENT COMMANDER BY NAME AND POSITION AND ANNOUNCE
"MEDICAL EMERGENCY"
TO INITIATE RESPONSE FROM IMT COMMUNICATIONS/DISPATCH.
U s e i t e m s o n e t h r o u g h n i n e t o c o m m u n i c a t e s i t u a t i o n t o c o m m u n i c a t i o n s / d i s p a t c h .
1. CONTACT COMMUNICATIONS/DISPATCH
Ex: "Communications, Div. Alpha. Stand-by for Priority Medical Incident Report." (If life threatening request designated frequency be cleared for emergency traffic.)
2. INCIDENT STATUS: Provide incident summary and command structure.
Describe the injury
Nature of Injury/Illness
(Ex: Broken leg with bleeding)
Geographic Name + "Medical"
Incident Name
(Ex: Trout Meadow Medical)
Incident Commander
Name of IC
Name of Care Provider
Patient Care
(Ex: EMT Smith)
3. INITIAL PATIENT ASSESSMENT:
Complete this section for each patient. This is only a brief, initial assessment. Provide additional patient info after completing this 9 Line Report.
Number of Patients:
Male / Female
Age:
Weight:
☐NO = MEDEVAC!
Conscious? ☐ YES
☐ NO = MEDEVAC!
Breathing? ☐ YES
Mechanism of Injury:
What caused the injury?
Lat/Long (Datum WGS84)
o
o
Ex: N 40
42.45' x W 123
03.24'
4. SEVERITY OF EMERGENCY, TRANSPORT PRIORITY
SEVERITY
TRANSPORT PRIORITY
□ URGENT-RED Life threatening injury or illness.
Ambulance or MEDEVAC helicopter. Evacuation
need is IMMEDIATE.
o
o
– 3
Ex: Unconscious, difficulty breathing, bleeding severely, 2
burns more than 4 palm sizes,
heat stroke, disoriented.
□ PRIORITY-YELLOW Serious Injury or illness.
Ambulance or consider air transport if at remote location.
Evacuation may be DELAYED.
o
o
– 3
Ex: Significant trauma, not able to walk, 2
burns not more than 1-2 palm sizes.
□ ROUTINE-GREEN
Non-Emergency. Evacuation considered
Routine of Convenience.
Not a life threatening injury or illness.
Ex: Sprains, strains, minor heat-related illness.
5. TRANSPORT PLAN:
Air Transport: (Agency Aircraft Preferred)
□ Helispot
□ Short-haul/Hoist
□ Life Flight
□ Other
Ground Transport:
□ Self-Extract
□ Carry-Out
□ Ambulance
□ Other
6. ADDITIONAL RESOURCE/EQUIPMENT NEEDS:
□ Paramedic/EMT(s)
□ Crew(s)
□ SKED/Backboard/C-Collar
□ Burn Sheet(s)
□ Oxygen
□ Trauma Bag
□ Medication(s)
□ Cardiac Monitor/AED
□ IV/Fluid(s)
□ Other (i.e. splints, rope rescue, wheeled litter)
7. COMMUNICATIONS:
Function
Channel Name/Number
Receive (Rx)
Tone/NAC *
Transmit (Tx)
Tone/NAC *
Ex: Command
Forest Rpt, Ch. 2
168.3250
110.9
171.4325
110.9
COMMAND
AIR-TO-GRND
TACTICAL
*(NAC for digital radio system)
8. EVACUATION LOCATION:
Lat/Long (Datum WGS84)
EX: N 40 42.45' x W 123 03.24'
Patient's ETA to Evacuation Location:
Helispot/Extraction Size and Hazards:
9. CONTINGENCY:
Considerations: If primary options fail, what actions can be implemented in
REMEMBER:
Confirm ETA's of resources ordered
Act according to your level of training
conjunction with primary evacuation method? Be thinking ahead...
Be Alert. Keep Calm. Think Clearly. Act Decisively.
ICS 206 WF (1/14)
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Parent category: Medical