Mass casualty incidents (MCls) are possibly the most demanding and chaotic events a responder will ever be confronted with. Scene managers must coordinate the patients and emergency personnel in an uncontrolled environment to reach the ultimate goal of every large response: Get the greatest number of survivable patients to treatment facilities in the shortest amount of time.
A scene has to be secured and patients safely extricated before complete treatment and transport can be carried out effectively. A medical branch must be established early to implement specialized triage, treatment, staging and transportation areas. These areas must be ready to receive, treat, process and transport patients in an expeditious and controlled manner as soon as they’re extricated from the scene.
An operational plan and medical branch must be established in the first few minutes and function smoothly throughout the incident. Without preplanning, training, and well-developed operational and equipment checklists, MCI operations can deteriorate rapidly. Having supplies and equipment prepared in advance of a large MCI and ready to deploy will also help operations run smoothly.
This article presents practical and inexpensive approaches to equipment deployment and personnel management at MCIs. Personnel must be routinely familiar-ized with the contents of MCI kits, instructed in their effective deployment and encouraged to utilize MCI principles on a daily basis if they are to be prepared when the Big One hits.
I often compare a successful MCI response to a perfectly conducted orchestra, but an MCI can also be compared to a thought-out and organized customer service plan that has flexibility and coordinated demand response factored into its daily operations. When you attend a wedding reception that goes off without a hitch, watch a kindergarten teacher execute a holiday musical with 35 strong-willed students, or watch 200 hungry emergency personnel move through a cafeteria line in less than an hour, you can appreciate the need for a plan of action to be developed in advance and executed accordingly.
The identification of personnel who will be in charge of key areas should be one of your top priorities at an MCI. Asking someone to report to “the chief in the white helmet” is destined to add to scene confusion and failure when there are five white helmets moving around the scene. The
use of color-coded vests or other identifi-cation greatly adds to scene coordination and control, and will prevent rescuers from freelancing in non-assigned activities at an incident.
You also need to control people, responders and their flow and departure with patients at MCI scenes. Scene tape, traffic cones and cheap orange cones can be used to line a hazard area, establish a defined, restrictive ring around the command area, and create a “cattle-chute” pathway for personnel to follow when moving patients to treatment areas. They can also be used to develop and identify an on-deck area leading from the treatment area to the transportation area.
Colored tarps or salvage covers color-coded to match triage tag priorities will prevent emergency responders from placing victims on moist, debris-covered ground in a haphazard and uncoordinated manner, and discourage personnel from walking on or through the covered areas.
These colored “area designators” must be deployed early into an incident and be large enough to position and treat at least eight supine patients with room for personnel to move around. Also, try to position your covers so there is convenient access to rehab and transportation areas. I recommend that departments carry at least one red, one yellow, and one green 20-foot by 20-foot salvage cover.
Commanders must have a process to log, identify and account for all personnel who arrive on scene without their uniforms or other service designators, but can play a role at the incident. Commercial logging and tagging systems are available, but a simple log-in sheet maintained at the command post is just as effective. The log-in sheet should be used in conjunction with authorization tags or stickers that are assigned to, and worn by, people as they are granted access to the scene (see below).
For example, EMS personnel arriving without protective clothing might be logged in and restricted to the patient treatment area, while members or the news media are restricted to the media area. Everyone who receives an authorization sticker should be required to return it to the command post or other designated area prior to departing the scene so they can be accounted for and logged out.
The minimum elements on an authorization tag or sticker include: name, agency, authorized access areas, ID number, date access is allowed, time admitted to scene, and the signature of authorizing party.
Specially equipped MCI trauma bags should be stocked with large quantities of easy-to-see-and-reach supplies, particularly items that get depleted rapidly or become in short supply at large scenes, such as trauma shears, compression bandages, tourniquets, tape and rescue airways. Don’t store supplies underneath other items; personnel in a hurry won’t look in layers for supplies. Also, remember to prominently label each MCI trauma bag, so your crews will instantly be aware of its purpose and contents at a scene.
All emergency apparatus should carry at least one roll of scene tape so it can be deployed early into an incident. The early use of scene tape will not only restrict and control access at an incident scene, but it will also enable emergency personnel to cordon off the work area, preserve evidence and add definition to the scene.
Moving supplies and patients can require four to six rescuers, but you can avoid committing such valuable resources by establishing a trolley system to carry bulky or heavy equipment and patients. You can obtain the wheeled stretcher from the first-arriving ambulance to move a large amount of equipment to the scene because this ambulance is usually stripped of its personnel and equipment and not used to transport patients. The same stretcher can be used by two people to “shuttle” patients to ambulances.
Proper preplanning, dispatch and deployment of equipment will ensure that adequate supplies are available at a scene. It’s easier for personnel to load and deliver small pods of backboards than to load 50 individual backboards into a vehicle. And don’t rely on a central equipment stockpile for use during an MCI. Instead, consider decentralizing equipment.
By storing pods of backboards at highly populated structures, such as schools, recreational facilities, hospitals, extended care facilities, high-rises, prisons and shopping malls, you can greatly enhance immediate evacuation efforts at those locations and access them as regional supply locations when needed at an MCI incident. Be careful to select structures that guarantee 24-hour access to the equipment by emergency personnel.
Many agencies carry only the bare minimum of 25 triage tags required by state licensure or local protocols. However, at least 100 triage tags should be packaged in groups of 25 and carried on each emergency response vehicle so triage can be started by initial personnel and fanned out into triage zones as additional personnel arrive on scene.
Airway essentials are always in short supply at an MCI. This airway bag can contain essential supplies such as bag-valve masks with oxygen reservoirs and connecting tubing, high-concentration adult- and child-size masks, extra trauma scissors, tape, airways (oral and nasopharyngeal), stethoscopes, convenience bags (vomit and urine), gloves, spare oxygen regulators, 60-cc sterile bulb syringes and six 2-ounce sterile ear syringes for adult and infant suctioning, and resuscitation/ventilation masks.
Not all patients at an MCI need to be packaged and moved on backboards; many could be easily moved on tracked stair chairs, scoop-style stretchers and compact, flexible, multi-handle lifting devices.
Factors that Affect MCI Management
1. Physical location and access/egress complications;
2. Number of access points and distance between exits on a highway;
3. Location, speed and density of traffic;
4. Weather or roadway conditions;
5. Time of day;
6. Staffing levels;
7. Massive debris field;
8. Other simultaneous incident that drain available resources;
9. Location of specialty teams and resources;
10. Ambulances unfamiliar with a district’s MCI operational procedures;
11. Ambulances from another system arriving on scene, or self-dispatching;
12. Hospital backlogs, closures or lack of resources or capabilities;
13. Communication coverage gaps or inability to communicate with mutual response resources;
14. Failure to establish incident command, divisions or group early enough;
15. Lack of scene vests or identification of triage, treatment or transportation areas;
16. Late or improper access directions or staging instruction to incoming units; and
17. Complicating factors, such as ongoing crashes, gunfire or explosions.