Major Incidents, Mass Casualty Incidents, Operations, Trauma

MCI Efficiency: It Takes More than Triage Tags to Run an MCI

Issue 5 and Volume 34.

The Sept. 12, 2008, collision between two trains in a remote area on the outskirts of Los Angeles was an “all-hands” MCI that required significant manpower and resources. This incident presents the opportunity for me to review components of MCI management that are often neglected or omitted from MCI action plans.

Many of these key components were in place at the massive MCI managed by the Los Angeles Fire Department (LAFD) and are detailed in “Trauma at the Tunnel.”

Scene Management

A clear action plan is a top priority. Determine the obstacles confronting your forces in the first five minutes, request resources, and direct incoming units to proper access routes and staging areas or you’ll jam up your scene and lose time for the transport of patients. The designation of a “Staging Officer” is almost as critical as the Triage Officer in the first 10 minutes. The LAFD realized their scene was difficult to access and egress, and they focused on staging incoming vehicles early.


Dedicated frequencies must be obtained early to ensure scene command and control, resource coordination, mutual aid unit coordination, scene-to-hospital communications and incident manager communications. It’s also important to alert hospitals (particularly the closest ones that will receive patients transported by private vehicles before EMS arrival). Determine their capacity to handle patients; keep them updated regularly; and offer them calm, clear patient reports over a secure, dedicated radio frequency. If the scope of the incident is large, hospitals may hold over or call in staff.

The first LAFD ambulance en route to the scene established communications with the L.A. County Medical Alert Center (MAC) before they even arrived on scene to ensure area hospitals were notified of the scope of the incident and polled for their bed and patient capabilities.

Use of Helicopters

Due to the remote location of the incident, LAFD dispatched its three air ambulances early in the incident to transfer Priority 1 patients to the region’s trauma centers. It’s beneficial to place the landing zone (LZ) in a secure area away from the primary scene chaos and designate one or two “helicopter shuttle ambulances” to ensure the continuous and coordinated flow of patients to the LZ.

Forward Triage & Re-Triage

A disorganized or poorly delineated scene could result in unnecessary morbidity and mortality. LAFD established forward triage tarps (color-coded by priority) near the primary impact zone; crews also established well-delineated areas for central collection, treatment and re-triage. Scene tape and colored tarps should be carried on multiple apparatus so they’re readily available for deployment at your MCIs. Scene tape should be positioned at eye or chest level. Color-coded tarps (red, yellow and green) and scene tape must delineate each treatment area to limit non-assigned personnel from entering the areas and to maintain control„of patient placement and movement.

These simple but important techniques were critical at LAFD’s high-impact MCI, because 62 (47%) of the 133 patients were Priority 1s who needed rapid triage, treatment, re-triage and transport.

Staging Vehicles & People

LAFD crews established staging areas not only for incoming ambulances, helicopters and rescue apparatus, but also for personnel. We often forget that “non-assigned” personnel will find a way to get into the action and can overrun a scene like ants at a picnic. Establishing “personnel staging areas” by job classification (ALS, extrication, patient transfer, law enforcement, etc.) allows incident managers to easily assign personnel and teams to necessary tasks. LAFD also established a secure and delineated corridor to allow for easy transfer and loading of patients into ground and air ambulances.

Patient Transfer Teams

LAFD has learned from past incidents the importance of designating personnel as “patient transfer teams” (PTTs). In September, the incident commanders assigned teams of firefighters and law enforcement personnel to move patients from their impact/injury location to the collection and treatment areas, from one priority area to another after being re-triaged, or directly to assigned ambulances.

It makes no sense to pull EMS caregivers from triage or treatment assignments to package, lift and move patients during an MCI. These valuable treatment personnel should be maintained to render rapid patient care and PTTs used to expedite transfer patients.


You can get by at an MCI using the basic principles of MCI management: incident command, triage, treatment and transportation. But if you really want to refine your processes and run a highly efficient MCI, make sure you implement these enhanced techniques for scene delineation, re-triage, communications, and the staging and deployment of vehicles, resources and people. JEMS

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