Clinical – Core

Sponsored by

Cardiac Assist Devices: What We Have Learned So Far
Stephanie L. Bailey, BSN, CFRN, EMT-P, LifeFlight/Allegheny General Hospital

The field of cardiac assist devices has grown considerably the last several years. These devices are becoming the cornerstone of cardiothoracic care. Recently they have been utilized for more than just cardiac patients. The rise of these transports has expanded and stretched the capacity of the critical care transport industry. This session is a review of the devices, and a discussion of the logistics and troubleshooting required for these transports to be successful.

Patient Advocacy through Documentation: Documenting In a World of Difficult Reimbursement
Bryon Denton, MSN, RN, CFRN, PHRN, Air Methods Corporation

The fastest way to make the news or negative press is through billing issues. This presentation is an in-depth review of the flight crew member’s responsibility to advocate for their patients through documentation. A thorough patient care record is the number one way a crew member can advocate for their patients and reduce or eliminate patient responsibility in the charges. This session discusses the legality of documentation and balancing the issues with reimbursement. This session will provide flight crew members with guidelines for what payers look for to deny claims as well as how to protect themselves legally with documentation, including words/phrases to avoid and better ways to state this information. This session will also detail the four “Golden Rules” for documentation. The “Golden Rules” are four questions that, if answered in every chart, have been proven to decrease denials from the payers by answering their definition of medical necessity for air ambulance transport.

Who’s Behind That Mask? A Real World Application of Sepsis 3.0
Michael Kapas, NRP, FP-C, CCP-C, EMT-P, Joseph Paciello, RN, ADN, EMT-B, CFRN and Christopher F. Galton, MD, NRP, FP-C, Mercy Flight Central

This session will review the case of a 43 year old female patient who was being treated for DKA at a community hospital, when an acute change in mental status followed by hemodynamic collapse led to HEMS transport. Utilizing assessment skills and understanding the importance of obtaining an accurate HPI led this HEMS team to identify, and treat this patient for sepsis utilizing SCCM Sepsis 3.0 guidelines. This session will discuss initial patient management by the community hospital, activation of HEMS, interventions and care provided by the HEMS team both at the sending facility, and en-route to the receiving medical center, as well as the overall outcome. Additionally, it will discuss the current clinical research based best practices for sepsis care in the critical care environment.

Air Goes In, Air Goes Out: Simplifying Complex Mechanical Ventilation
Michael A. Frakes, MSN, APRN, CFRN, CNPT, FACHE, Boston MedFlight

The management of patients on mechanical ventilation is a core skill for critical care transport providers. The language and options on a ventilator can sound like gibberish to some clinicians. As oxygenation and ventilation become more difficult, patient optimization can challenge almost everyone. This presentation will break mechanical ventilation, for all patients, into core concepts and a standardized approach that will take the mystery out of the breathing machine, improving your understanding, your comfort, and the patient’s condition.

Infection Prevention Jeopardy
Karen Swecker, RN, CIC, MedFlight

An interactive game based on the Jeopardy© game show where the audience provides questions for infection prevention answers. The audience is divided into two competing teams. Using a power point presentation each side takes turns choosing a category. Once an answer is revealed, the team has 30 seconds to provide the correct question. If unable to provide the correct question the opposing side gets a chance to respond and earn the points. Both teams are considered winners in Infection Prevention Jeopardy as they will learn valuable infection prevention lessons to protect themselves and their patients while having fun.

Invasive Hemodynamic Monitoring: Do You Know Your Numbers and Lines?
Cindy Goodrich, RN, MSN, CCRN, Airlift Northwest

Critical care transport requires specialized knowledge and skills related to hemodynamic monitoring. Use of these technologies allows for assessment of cardiopulmonary status and responses to therapy. Clinicians must be familiar with hemodynamic monitoring technologies and have the knowledge and skill to provide safe and effective care during transport. The focus of the presentation is to provide the clinician with a brief overview of pressure monitoring and some of the most commonly used invasive hemodynamic technologies in the transport setting. This will include a discussion of arterial lines, central venous catheters and pulmonary artery catheters. Key safety factors and the unique consideration related to transport of patients with invasive hemodynamic monitoring will be emphasized during this presentation.

Labs are Your Friends: Understanding How Lab Work Directs Patient Care
Amy Neglia, RN, MSN, ACNS-BC, CCRN, CFRN, Air St. Luke’s

Do you find lab work confusing? Does a flight crew need to understand serum lab values to take good care of patients? This session helps crews interpret labs on a level that can be integrated into patient care during transport.

Taming the Starfish of Death: Management of Intracranial Hemorrhage
Jacob A. Miller, MSN, FNP, ACNP, CNS, EMT-P, Cleveland Clinic Critical Care Transport

Acute neurologic emergencies are a common reason for critical care transport. This presentation will review flight team management of common neuro-critical care complaints, with a focus on acute intracranial hemorrhage.

Using Music Therapy to Reduce Medical Flight Anxiety
Kevin Gochenour, MD Candidate Class of 2021, EMT-P, University of Arizona, School of Medicine

Many people experience anxiety when traveling by air. In flight anxiety during commercial flights has been well researched and interventions, such as anxiolytic medications, have been recommended. This session will present the results of a research study completed by Guardian Air into music therapies ability to reduce in-flight anxiety. Recommendations for implementation of music therapy as an adjunct intervention into a flight program will be given.

Venomous Snakebites in Transport: What’s New?
Scott D. Hax, FP-C, C-NPT, TriState Careflight, Air Methods Corporation

Venomous snakebite is an uncommon reason for air medical transport. While venomous snake species are not native throughout the North America, providers anywhere can face a patient with a serious envenomation owing to the presence of both legal and clandestine collections. Early management can have a significant impact on patient outcome, and management during scene response and inter-hospital transfer can present special challenges for the transport team. This presentation will review the approach to evaluation and management of envenomation snakebite, including anti-venom administration in transport. We will compare anti-venom products currently available for North American pit viper species, including anti-venom newly-released for marketing in the United States.

Lance Taysom, RN, BSN, CEN, CFRN, EMT-P, Air Idaho Rescue – Air Methods Corporation

A flight request comes in to an avalanche rescue scene. What are the risks? What can we expect when we arrive? Will I be an asset or a liability? In this interactive PowerPoint presentation we will review case studies from actual air medical responses to 2017-2018 avalanche scenes. We will discuss general avalanche awareness and responder safety issues including: preparation, decision making on the scene, what the scenes were like, what the air medical crews did, patient outcomes, and lessons learned.

Bull in a China Shop: The Journey of Transitioning from Adult pre-Hospital to Neonatal Specialty Transport
Sarah Anderson, DNP, CRNP, CFRN, PHRN, MSN, RN, STAT MedEvac

Ever try to put a large wet hand in a small latex glove? That’s exactly what it felt like to reach into an isolette for the first time after caring for adults for over 8 years in the transport environment. Even with pediatric critical care experience, the obstacles faced when transitioning back to small humans after a lengthy time away was a challenge. We will discuss hurdles, struggles, and lessons, in the journey through the transition between patient populations. We’ll discuss common challenges between programs and the biggest difference between knowing a little about a lot (the adult transport role) and knowing a lot about a little (the specialized transport role).

Unintentional Expertise: Redefining Expertise in Specialty Critical Care Transport
Sarah Anderson Senior, CRNP, CFRN, PHRN, Children’s Hospital of Pittsburgh of UPMC and Vahe Ender, NRP, FP-C, C-NPT, Boston MedFlight

Expertise – Noun: ‘Expert skill or knowledge in a particular field” We are taught that in order to develop expertise, one must devote one’s career to a particular clinical domain. What does a transport system do when faced with the task of adopting a new transport specialty; particularly in the unforgiving, high-risk arena of neonatal critical care transport? Can a “generalist” team achieve clinical excellence in the care of the critically ill newborn? In this session we will delve into a single program’s approach to the development of a neonatal transport program and the pursuit towards clinical expertise. We will review the challenges both internal and external encountered in the creation of a robust, high-volume specialty team. Through this we will shift the definition of “Expertise” and consider whether or not it is something solely to be found at dedicated Neonatal/Pediatric programs.

Clinical – Specialty


Intralipid Use in the Pediatric Clonidine Overdose
Kyle Kohls, NRP, CCP, FP-C and Curtis Walker, BSN, RN, CFRN, EMT-B, Gundersen Air

This session will be reviewing a case about the flight of a pediatric patient who had an accidental Clonidine overdose. It will also cover when intralipids may be useful, how it interacts, and suggested administration protocols.

Pediatric Trauma Triage: A Parent and a Providers Perspective
Tyler Weddle, FP-C, NREMT-P, Life Flight Network

‘Life Flight 87, flight request, scene call, trauma.’ It’s not until you arrive on scene that you learn you have 3 pediatric patients who were all buried alive beneath 5 to7 feet of snow. They were all in cardiac arrest when found. Two achieved return of spontaneous circulation (ROSC) with bystander BLS CPR, and one still in cardiac arrest with active BLS CPR. The next closest ALS unit is still 45 minutes away. We will review standard triage guidelines and how to apply them. Next, take a journey through this first hand case review as we apply current PALS and pediatric assessment techniques and explore the complexities of making life altering decisions in the heat of the moment. We will watch as two critical care providers attempt to care for all three patients and see the outcomes. Finally, discuss ways to use personal experiences to relate to family members in a professional way during these life changing events.

Putting all the Pieces Together: Managing and Recognizing Child Maltreatment
Craig S. LaRusso, MA, BSN, RN, C-NPT, Ann and Robert H. Lurie Children’s Hospital of Chicago

The speaker will describe initial presentation of each child including triage information and interventions required to stabilize while on transport. Tools to identify signs of child maltreatment will be discussed as well as the implications of early intervention and recognition. Outcomes for each case will be presented and the goals to decrease child maltreatment nationally will be included. CT scans, photos, and MRI images will be utilized to aid in learning.

When Less is More
Teri Aguiar, RN, BSN, CFRN, C-NPT, ARCH Air Medical

This will be a multi-case presentation of pediatric patients in the transport environment with critical lab values. Cases include 6 day old renal failure, 38 day old transposition of the great vessels, 2 month old water intoxication, 7 year old renal failure, and 15 year old DKA.

ETCO2 On the Go–Use of Nasal Cannula ETCO2 on Pediatric Transport Patients
Justin Parsley, BSN, RN, CCRN, Children’s Hospital and Medical Center

This session takes a look at evidence-based practice regarding nasal cannula capnography. It will also include a review of current literature, and data collected from a pediatric critical care transport program.

Facilitating a NICU Evacuation from a Neonatal Transport Team Perspective
Dennis Swick, RN, CMTE, MTSP-C, Nationwide Children’s Transport Program

An emergent evacuation of a neonatal ICU is a massive undertaking. A transport agency with neonatal capabilities can have a significant role, but not necessarily just by “taking babies out”. Looking at the bigger picture, “out of the box” thinking, and creative utilization of resources are all skills that transport providers can employ to help our NICUs accomplish this efficiently and safely. The session will review how one pediatric/neonatal transport agency participated and assisted several urban level 2 and level 3 NICUs through evacuation planning and drills.

Getting To the Heart of the Matter – Learning From Undiagnosed Congenital Heart Disease Case Reviews
Iain Holmes, MSN, RN, CCRN-K, New York University – Langone

Historically most congenital heart defect education consists of an explanation of a defect followed by clinical considerations. However, this fails to address caring for a young patient who is at the community hospital and has yet to receive an echo and subsequent diagnosis. These case reviews share tools commonly used in neonatal and pediatric cardiovascular intensive care units which apply to the transport environment aiding transport clinicians who find themselves caring for this population.

Sex, Drugs, and Rock N’ Roll: Substance Abuse in Pregnancy
Teri Campbell, RN, BSN, CEN, CFRN, University of Chicago

Substance abuse is epidemic in the United States and unfortunately, the pregnant patient is no exception. Because of fear, guilt, and shame, many pregnant patients with substance abuse often avoid prenatal care. The combination of the substance abuse coupled with little to no prenatal care leads to a very high risk for maternal and fetal complications. Come to this shocking session to get the dope on maternal substance abuse and to learn how factual and non-judgmental care of these patients can greatly improve maternal and fetal outcomes.

Shake, Rattle, and Roll: Pediatric Seizures
Teri Campbell, RN, BSN, CEN, CFRN, University of Chicago

Shake, rattle and roll is great for Elvis but not for our pediatric patients. Pediatric seizures can be a chronic condition for some kids or a marker of a neurologic emergency for others. This up to date session will inform you how to assess, prioritize and manage the pediatric patients with seizures. Ensure that your “status” has nothing to do with seizures!

The Miracle of Life, Gone Wrong: When Obstetric Patients Require Critical Care
Michael A. Frakes, MSN, APRN, CFRN, CNPT, FACHE, EMT-P, Boston MedFlight

Pregnancy and delivery usually go very well. When it doesn’t go well, however, it really doesn’t go well — up to one of every seven OB patients who require critical care dies and about one in seven of the deaths are probably preventable. This is definitely a high-risk and low-frequency population for the critical care transport teams who will be asked to manage these patients safely during transport to a tertiary care facility. This presentation will give an overview of normal physiology of pregnancy, the amazingly dangerous normal physiology of the peripartum period, and review detection and management of the array of critical illnesses that can complicate pregnancy.

Tick Tock Goes the Clock: Neonatal Surgical Emergencies
Michelle Oddi, PhD RN CCRN CFRN C-NPT and Dr. Donald Null, MD, University of California Davis Medical Center Children’s Hospital

The transitional time period following birth can be complicated by the presence of congenital anomalies requiring emergent surgical intervention. Such anomalies require specific key interventions and are associated with specific transport issues. In this session we will discuss malrotation/midgut volvulus, TE fistula, gastroschisis, necrotizing enterocolitis, diaphragmatic hernia, and bowel obstruction. Key information related to the stabilization and treatment during transport will be covered. Multiple case scenarios will also be presented.

How to Build a Neonatal Flight Nurse Transition/Training Program
Scott Beckstead, RN, BSN, CFRN, CEN and Stacy Meredith, RN, MSN, CMTE, CFRN, CCRN, CEN, Guardian Air Transport, Northern Arizona Healthcare

This session will detail how to provide a structured training program for the transition of a current 3 specialty flight nurse team (adult, pediatric, maternal) to a 4 specialty flight nurse team (adult, pediatric, maternal, neonatal), based on a successful model designed and implemented by Guardian Air transport in Arizona. The new program was designed in conjunction with our neonatologist, NNPs, NICU and Guardian Air’s support. We will provide details of the new program along with photos, case scenarios and questions/answer session. Presenters will explain how this program has helped with the relationship between our hospital NICU and Guardian Air. The presenters will discuss how this program addressed employee satisfaction/retention and how the program was essential to meeting the needs for transport of the neonatal population in Northern Arizona to include Native American Reservations.

ECMO: Bringing Lifesaving Therapy to the Bedside
Diane Braxmeyer, RN, BSN, CFRN, Legacy Emanuel Medical Center and Jacob Dalstra, FP-C, NRP, EMT-P, Life Flight Network

What if the therapy that could save your patient’s life is at a facility a 1,000 miles away, yet they are too unstable to transport? Bring the therapy to the patient! Extracorporeal Membrane oxygenation (ECMO) and High Frequency Percussive Ventilation (HFPV) are advanced medical interventions that can be safely delivered to critically ill patients regardless of location. Life Flight Network and Legacy Health’s transport partnership cultivated a program to provide communities access to these life -saving measures. This presentation outlines ECMO and HFPV therapy and transport. Collaborative strategies between both transport teams to provide this specialty transport service are outlined. A detailed review of ECMO and HFPV is explored, transport management, and program development.

Clinical – Advanced

Sponsored by

Critical Care Approach to Mechanical Ventilation Oxygenation & Recruitment Strategies
Jeffrey Simons, FP-C, NR-P, CCEMTP, Air Methods, LifeNet of New York

Dive into the world of critical care ventilator management. This session will discuss monitoring techniques and how to overcome some of common pitfalls and limitations. It will review basic maneuvers that can be applied to most ventilator patients that are minimally invasive. Followed by a review of advanced manipulation of settings and recruitment techniques to help oxygenate and ventilate the critically sick & injured patients.

Advanced EKG Review for the Critical Care Transport Team: Rapid Fire Interpretations
Samuel J. Slimmer, MD, Geisinger Life Flight

While prior lectures at this conference have exclusively looked at dysrhythmias or ischemic changes, the focus of this lecture will be all inclusive. The goal is to visualize as many EKGs as possible during the time given. The medley will include dysrhythmias, conduction aberrancies, findings associated with sudden cardiac death, ischemic changes including what is now considered STEMI equivalent changes and examples where STEMIs were missed due to having only subtle changes. Also, included will be EKG findings due to environmental exposure and due to medication toxicity. Pertinent management of findings will be discussed when applicable. All EKGs in this lecture were not viewed in prior lectures given at this conference.

Attacking ARDS from the Flanks: Using Tandem Chemical and Mechanical Therapies
Charles F. Swearingen, NRP, FP-C, Air Methods Corporation

Acute Respiratory Distress Syndrome or ARDS remains one of the most difficult disease processes to effectively treat in the transport environment. This lecture will take an in depth look at approaching this disease from two separate but complimentary angles. Utilizing both mechanical ventilation and pharmacological therapies in conjunction with each other may reduce mortality by optimizing oxygenation and ventilation while also treating the chemical response within the body. This lecture will use current research and evidence based best practices to highlight therapies and the systematic approach needed to treat these high risk patients.

Charlie Fox Cric: Complications in the Surgical Airway with Front of Neck Access (FONA)
Cynthia Griffin, DO NREMT-P, University of Wisconsin Med Flight

This presentation will get you from cric-disaster-cursed to cric-educationally-versed. It will discuss a real complex inter-facility HEMS transport case of a Can’t Intubate Can’t Oxygenate (CICO) patient requiring another surgical airway after an unrecognized false passage. In this case there were several complications yet these were overcome with various techniques by a group effort of the emergency department team, EMS, respiratory therapists, RN, flight & the critical care crew (flight physician & RN). I will review the pertinent anatomy regarding the surgical airway with front of neck access (FONA), common/uncommon pitfalls, and techniques to overcome these by reviewing up to date literature on this topic. Finally I will discuss what the future holds for this advanced procedure and the implementation of the use of point of care ultrasound to aid in FONA.

Getting the Answers You Want From the Data You Have: How We Can Be Fooled By ‘Evidence’
Charles Sheppard, MD, FACEP, FAAEM, Mercy Life Line and Mercy Kids Transport, Mercy Health System

With today’s emphasis on ‘evidence based medicine’ it is more important than ever that you understand how evidence can be misleading. As more and more of the literature are paid for by people with an agenda, misleading information filters through. This lecture is not a statistics course but rather a look at the “red flags” in articles that should promote a second or third look at the results. This will not make you a statistician, but the goal is to make you a better skeptic of what you read and better able to utilize evidence to help your patients.

On the Bleeding Edge: The Art and Science of Hemorrhage Control in the CCT Environment
Craig Bates, MD, FACEP, Metro Life Flight

Hemorrhage is a substantial source of morbidity and mortality in patients with trauma. The management options for hemorrhage in the critical care transport (CCT) environment are rapidly evolving, making it critical that CCT crewmembers have a strong background in the pathophysiology of hemorrhage and the therapeutic options. In this session there will be a discussion of a wide range of hemorrhage control options from basics like tourniquets and wound packing to more advanced interventions intended to impact a patient’s systemic clotting function.

Serial Inebriates: Healthcare Providers Under the Influence
Jeffrey Bell, BSN, RN, CEN, CFRN, TCRN, NRP, CareFlight Air & Mobile

The prevalence of substance abuse in society is no secret, with 7.5-10% of Americans having a substance use disorder. However, the prevalence of substance abuse in healthcare providers (HCPs), especially nurses and EMS personnel, is estimated by various sources to be 1 to 2.5 times that of the general population. There is a general knowledge deficit among HCPs regarding the disease process of addiction, which can result in increased susceptibility to and inappropriate recognition of a substance use disorder. Education regarding this topic is imperative for appropriate recognition in self and others to promote safety. Everyone, including nurses, EMS personnel and other HCPs, can recover from addiction and should be given a second chance.

The HeART of Critical Care Education
Daniel Davis, MD, Air Methods Corporation

This session will present a novel approach to critical care education using the Helicopter Advanced Resuscitation Training (HeART) model. The use of case-based learning but with a clear scaffolding or paradigm will be offered as the ideal model to engage adult learners but reinforce stable scaffolding that links to performance improvement and educational objectives.

The Top Ten List: Articles from 2017-2018 That May Influence Your Practice
Russell MacDonald, MD, MPH, FCFP, FRCPC, Ornge Transport Medicine / University of Toronto

This presentation provides a summary and critical appraisal of ten articles taken relevant to the prehospital and transport medicine literature in 2017-2018 that may influence your air or land critical care transport practice.

The Young Arrest: A Clinical Review of Sudden Cardiac Arrest in the Young
Vahe Ender, NRP, FP-C, C-NPT, Boston MedFlight

In this session we explore the challenging clinical syndromes which can cause sudden cardiac arrest in the young patient. We review updated epidemiological data for pediatric cardiac arrest including upcoming trends. Beyond that, we delve into syndromes including cardiomyopathies and channelopathies which can lead to sudden arrest. We will review risk factors, physical exam findings and ECG abnormalities which are seen with such disorders with the goal of diagnosis and prevention. This talk aims to guide acute care and transport clinicians in the detection and management of such syndromes before the event, but also reviews acute care management of these challenging cases.

Traumatic Bradycardia: When a Slow Heart is a Fast Death
Bryan Boone, BSN, RN, CEN, CFRN, Michael Boone, BSN, RN, CCRN, CFRN, Indiana University Health LifeLine and Heavy Lies the Helmet

Multi-system trauma patients are often associated with tachycardia due to hypovolemia and the sympathetic nervous system’s compensatory response. However, these patients may present with paradoxical or relative bradycardia a potentially ominous sign of a more serious underlying injury and impending arrest. We will discuss the main differential diagnoses leading to traumatic bradycardia, the limitations of commonly used assessment tools in the pre-hospital environment, and the various treatment options the critical care transport provider should consider outside the realm of ACLS based on their patient’s clinical presentation.

What are Biologics and Biosimilars and Why Should I Care?
Rourke M. Yeakley, MD, Air St. Luke’s

Biologics and biosimilars are the most rapidly increasing class of pharmacologic intervention in the world. In 2017, eight of the top ten selling drugs in the world were biologics. Increasingly, the transport patient is taking one or more biologic or biosimilar. This trend will only increase as their use continues to broaden beyond autoimmune diseases. Acute reactions to biologics and biosimilars can be life-threatening emergencies and present in various ways. These need to be quickly recognized and treated. Their affects can complicate and even predispose to other medical conditions. This lecture will provide an overview of biologics and biosimilars and include an understanding of what they are, why it is important to understand the nomenclature, what conditions they are used for, how they work and how to adjust treatment for those patients taking them.

Airway Management in the Era of Video-Laryngoscopy
Christopher F. Galton, MD, NRP, FP-C, Mercy Flight Central

This session will discuss whether or not our primary airway management algorithms should change, given the recent addition of video-laryngoscopy technology to many air medical service providers. It will start with a review of current practices and go on to discuss how VL fits into many practices now, even without evidence to support broad utilization.

Out of the Woods – Applying Wilderness Medicine to the Transport Setting
Gordon H. Worley, MSN, FNP-C, EMT-P, CFRN, FAWM, VEP Healthcare

Transport medical crews provide patient care in a unique setting, where they are expected to care for complex patients with limited resources. This requires that they be adaptable, self-reliant, and possess a familiarity with a wide range of medical specialty areas. Air medical crews are also often called to transport patients from remote locations, and those who have suffered from environmental exposure. Wilderness medicine is an evolving medical specialty that involves the management of ill or injured patients with limited resources, or under austere conditions when the time to definitive care is prolonged. Both the wilderness setting and transport medical environment require resourcefulness and creativity to be able to manage complex problems with only the items and personnel at hand. This presentation will explore the value of wilderness medicine training, protocols, and practice to transport nurses, paramedics, and other healthcare professionals.

Traps and Tricks of Intra-Aortic Balloon Pump Transport
William Kelly Miller, RN, CFRN, EMT-B, CMTE, Air Methods Corporation

The primary purpose of an Intra-Aortic Balloon Pump (IABP) is to mechanically improve perfusion through counter-pulsation. However, care and management of this specialty population is complicated during transport by altitude, patient movement and complex hemodynamic data. Knowledge of “traps and tricks” is imperative to successful patient outcomes. This lecture will provide the attendee specific case studies and valuable treatment options used to care for this high acuity low volume patient population in transport.

What Actions Do You Take When You Are First on Scene at a Mass Casualty Incident?
Gustav “Bud” Clark, NREMT-P, FP-C, Guardian Air Transport / Tuba City Base

This session prepares all first responders to establish incident command when arriving first on scene at any incident. Further, the session defines the critical command roles which need to be established to manage Mass Casualty Incidents. The attendees will participate in the management of a Mass Casualty Incident (MCI) which will be displayed in the form of a table top exercise. Participants will make critical decisions on triage, patient care, and transport. The incident command skills of scene size up, risk assessment, incident objective creation, and the process of establishing indent command will be practiced during this session. The time frames will be compressed as participants manage the MCI during the session. Prior to the end of the session a debriefing will be conducted, participants will come away with an enhanced understanding of the management skills required to effectively and efficiently mitigate a mass casualty incident.