Mass casualty incidents (MCIs) can be very difficult situations to deal with from both the safety and patient care viewpoints, and in today’s world we can’t rule out the possibility that terrorism was the cause of the incident. EMS practitioners must be vigilant about the safety of all responders as well as the victims and potential victims. The key is to maintain a high level of situational awareness by constantly looking around for anything out of the ordinary. Scene safety and the protection of responders is always the top priority in MCI response.
Of course, our first duty is doing whatever is necessary to access, assess and properly treat the patient. We should exercise that duty with the understanding that the MCI may also be a crime scene where evidence preservation is also a responsibility.
An important aspect of our duty in an MCI response is evidence preservation. This includes not just preserving physical evidence and avoiding its disruption, but also preserving mental evidence: our observations of the scene and what others tell us on scene.
As initial responders, EMS practitioners are often among the first on scene and may be the only ones with access to potential evidence before it’s moved or disrupted. Our actions or inactions can have a significant impact on the outcome of the investigation.
1. Constantly look up, down and side to side. We often convert to tunnel vision when we see potential patients and our peripheral vision shuts down. As you approach the scene, verbally remind yourself and your partner not to let this happen. Good situational awareness for any incident, especially an MCI, means you do a 360-degree assessment of the scene as you approach. Look around carefully and mentally note what you see. Anything out of the ordinary, like a large backpack sitting next to an apparent victim, should activate caution alarms and should be immediately reported. This constant 360-degree approach to working at the scene allows you to observe things that you may not otherwise see.
2. Document what you see. Documentation of an MCI situation must be even more detailed than the typical single patient situation. It should be a standard operating procedure that two sets of documentation be completed: The patient care report (PCR) and the scene observation report (SOR).
The SOR should be a step-by-step account of your movements and observations from start to finish, and should be used to document essential information and preserve potential evidence. Observations that relate to the patient care should also be included in the PCR.
3. Don’t move things unless you must. Remember the fundamental premise of patient care: Do no harm. That premise should also apply to preservation of potential evidence. This means EMS practitioners should approach the scene delicately. Victims who are determined deceased and resuscitation isn’t indicated, shouldn’t be moved, nor should any physical items unless absolutely necessary.
If a victim or object must be moved for safety reasons or for patient care, the original location of the victim or object should be documented in your SOR.
4. Immediately report the unusual. The Department of Homeland Security (DHS) has launched a public relations campaign to help prevent terrorism and it’s founded on the phrase, “See Something, Say Something!” These guidelines for reporting suspicious activity are very applicable to MCI responses that may be the result of terrorism. Always err on the side of promptly reporting suspicious activity to law enforcement on scene. The DHS SALUTE acronym can also be helpful:
S: Size. Note the number of non-responders you observe at the scene, their gender, ages and physical descriptions when possible.
A: Activity. Describe what non-responders are doing as you arrive on scene.
L: Location. Provide the exact location of where non-responders are observed.
U: Uniform. Describe what suspicious individuals are wearing, including type of shoes.
T: Time. Provide duration of the presence of any suspicious individuals and the direction they head if they leave.
E: Equipment. Describe any suspicious vehicles you observe—including make, color, license number or any suspicious looking equipment, tools, weapons or potential weapons observed on scene.
5. Remain calm, use common sense and follow your gut. The key to effective observation is to remain calm, which helps keep the mind clear. We’re much more observant and perceptive when we’re not excited and worked up with adrenaline flowing. When approaching the scene, stop, take a deep breath and let it out slowly. This can clear your mind and heighten your observation skills before you enter into the fray. If things don’t feel right to you, stop what you’re doing and look around. Often our gut instinct can help us do a better job of recognizing a potentially dangerous situation, especially when that danger may be the threat that caused the MCI in the first place.