Major Incidents, Patient Care

Innovative Approaches to Management of Mass Casualty Incidents

Issue 9 and Volume 42.

New approaches to mass casualty care

Emergency responders are trained to recognize disasters, though some are easier to identify than others. Regardless of the cause and scope, medical providers of all types feel the impact when resources are overwhelmed.

This threshold will differ for various agencies and regions, but responders can usually predict when their capabilities will be taxed.

Mass or multiple casualty incidents (MCIs) are among the more common disasters that emergency services will manage. These events are typically related to trauma or hazardous materials, which have an acute onset and relatively short response time. However, MCIs can also result from natural disasters, bioterrorism attacks or even infections and pandemics, which alter the onset and response duration.

Inside a mobile medical unit in Texas.
Photo courtesy Nick Sloan

Consequently, MCIs can challenge providers with an immediate influx of patients or through more prolonged events, some of which may generate a slower onset but continuous stream of patients.

EMS agencies, other emergency responders and hospitals are critical to a community during an MCI and must continue to function and manage daily operations.

Although EMS agencies and emergency responders will be challenged, hospitals are the most likely sites to become overwhelmed with patients seeking care from an MCI. With innovative planning, preparation and collaboration, some of the impact of these mass casualty events may be mitigated.

Regardless of the MCI type (acute or gradual onset), patients can generally be classified as high acuity or low acuity. Keeping these two classes in mind, alternative care options should be considered to help lessen the impact on a community’s emergency services and hospitals.

Ultimately, high-acuity patients are less likely to benefit from alternative care approaches, though in some instances, advanced prehospital care (e.g., surgical field amputations) may be lifesaving.1

The first question that should be asked when considering creative solutions to disaster care is whether a patient can be cared for onsite (low-acuity patients) or whether the patient requires more definitive care and needs to be moved to a facility (high-acuity patients).

Alternative approaches to either option may minimize the impact on hospitals, while onsite care may also serve to lessen the stress on the EMS system by decreasing the number of transports. Further, not all approaches will be practical in every MCI. Short duration events are especially challenging when considering alternative care models. Natural disasters, pandemics and longer-term MCIs allow for more time to implement such programs and processes.

Inside a medical ambulance bus in Charlotte, N.C. Photo courtesy Mecklenburg EMS Agency

On-site Care Options

Perhaps the most obvious way to enhance onsite medical care is to access or enhance resources that aren’t typically optimized, or even readily available, in the local EMS system. Since EMS agencies are the front line in healthcare, it makes sense to strengthen this line as much as possible. This requires proactive management and careful thought.

For example, certified or licensed paramedics functioning as EMTs with BLS agencies could greatly expand ALS care in the event of a disaster. Applicable local and state regulations, licensing issues, oversight, authority, protocols and liability must be thoroughly reviewed in advance.

In addition, maintaining provider competency is critical—functioning in a high-stress environment, such as an MCI, may further challenge providers who haven’t been involved in patient care for an extended period of time. Simple concepts such as this should be anticipated and addressed before a disaster occurs. Mutual aid agreements with other licensed providers can also enhance initial care.

However, interagency cooperation, communications, licensing, reimbursement and other considerations must also be solidified preemptively. Secondly, triage, treatment and transport protocols for MCIs should be carefully planned and developed. Working together with local hospitals, patients less likely to benefit from transport to an ED should be defined and mutually agreed upon. This is where the delineation of high- and low-acuity patients becomes critical.

For example, low-acuity contaminated patients (biological, chemical or radiological) may be best managed away from medical facilities to reduce the risk of spreading contamination. In addition, MCIs due to infectious agents may warrant onsite isolation of low acuity patients. Though this may work for stable patients, those requiring admission or further evaluation and management will still need appropriate decontamination and transport. How such decontamination—both gross and technical—is accomplished, especially in mass numbers, should also be decided well in advance.

A third opportunity is enhancing alternative care options for the non-transported, low-acuity MCI patients. With acute onset incidents, mobile medical teams consisting of practitioners who aren’t typically in the prehospital realm, including physicians, midlevel providers, nurses and other ancillary staff, could be deployed. Mobile medical teams like this already exist at the state and federal levels, but hospitals can also create similar teams.

The advantage of local hospital-based response teams is that they can be operational within hours, while federal and state teams may require a few days to be activated and respond.2

Telemedicine at the Medical University of South Carolina (MUSC).
Photo courtesy MUSC

For planned events, including mass gatherings and natural disasters, many agencies and healthcare institutions already implement this practice. The medical teams staffing the Boston Marathon assisted in providing on-site care after the bomb attacks.3 State and federal disaster medical teams have also proven to be effective models but due to time-constraints tend to be used only with protracted events and a disaster declaration.

Hurricane Katrina was a great example of activating hospital, state and federal mobile teams, who provided several methods of alternative on-site care. These included medical clinics in shelters for evacuees, as well as on-site care clinics in areas most impacted by Katrina, where community infrastructure could no longer function.4,5

Some challenges for these mobile teams include having available staff with appropriate equipment and supplies. In the long run, preventing low-acuity patients from presenting to the local hospitals will allow the medical centers to focus on higher acuity patients.

Equipment is a fourth consideration for emergency responders and hospitals. In 2011, after their community was devastated by a tornado, the Freeman hospital in Joplin, Mo., was inundated with emergency patients and major surgical procedures requiring a tremendous amount of equipment and supplies.6

Plans for restocking and maintaining these supplies are critical. Local or regional disaster caches, including specialty vehicles or trailers, may be useful for durable medical goods, but medications and fluids can be an ongoing challenge.

Rotating stock with a shelf life from disaster cache to daily use is time-consuming, but may allow agencies to maintain additional supplies. Agreements with local hospitals for large volumes of fluids and medications in the event of a disaster can alleviate some of these challenges. Alternatively, agreements with distributors or suppliers can be arranged.

Preselected supplies for an MCI can be organized in pallets in a pre-deployed state, and then the distributor can rotate out supplies as needed in order to avoid expiring materials.

Access to state or federal stockpiles can be considered in some circumstances, though none of these will allow for quick restocking, and a disaster declaration is typically needed before agencies can access these caches.

A fifth consideration for on-site care may prove to be very innovative: telemedicine. Telemedicine is currently being used in more austere environments or locations with limited medical care, such as prisons and oil refineries.7,8 As telemedicine continues to advance, however, it’s also being used for clinic visits, such as psychiatric visits and for hospital-to-hospital consultation.

This advancing technology could also be used at the site of an acute onset MCI to assist with triage or treatment. In prolonged responses, such as a pandemic influenza, electronic visits could assist with evaluation and subsequent management of stable patients in their homes.9,10 This would benefit EMS agencies overwhelmed with transport requests, hospitals inundated with patients seeking care and patients able to avoid unnecessary infectious exposures. Further, hospital-to-hospital consultation could potentially allow community hospitals to manage some patients who would normally be transferred to a higher level of care.

MCI equipment and transportation resources in Charlotte, North Carolina. Photo courtesy Mecklenburg EMS Agency

Definitive Care Options

In most acute onset or traumatic MCIs, the demands of transportation to definitive care sites can overwhelm EMS. Although stable patients will commonly present to EDs by foot or by private vehicle, EMS will transport a significant percentage of
high-acuity patients.11 Limited EMS resources often make this a challenge. Mutual aid from air or ground providers are crucial in MCIs, but such cooperation is routine in EMS.

What’s less common but still an established, viable option is the use of vehicles from public transportation companies or specialty medical ambulance buses (MABs) to transport large numbers of patients.

Using such vehicles can free up ambulances and allow prehospital providers to prioritize care to high-acuity patients.

Regardless of the vehicle, transporting patients doesn’t necessarily require that all of them be treated at a specialty facility or even a dedicated emergency department. Definitive care can be provided in many different ways and locations. The use of alternate care facilities, including preplanned sites, such as jails, schools, stadiums and other public venues, etc. may be options, depending on the amount of time required to equip, staff and operationalize such a site.

Off-site mobile medical units have also been used with great success, especially when a community’s medical infrastructure has been impacted by a large event.

North Carolina’s MED-1 has provided care in environments ranging from hurricanes and flooding to political events and other mass gatherings.5 Tent- and trailer-based systems can accomplish the same thing. Other preexisting locations can also help. Longer transports by air or ground to facilities outside of the region may reduce the impact on local hospitals but present obvious challenges for EMS. Transport to smaller community hospitals, free-standing emergency departments (FSEDs) or even urgent care centers (UCCs) and/or medical clinics may be possible, depending on availability and state and local regulations. Many low-acuity patients could certainly begin their treatment at such facilities with later transfer to more definitive care, if needed.

A variation of this concept has been used effectively during large influenza outbreaks, such as H1N1, where patients were treated in tents or segregated areas of clinics or emergency departments to minimize the likelihood of unnecessarily exposing other providers and patients, while maintaining available beds and infrastructure.12

When using alternate care facilities, it’s important to understand the capabilities of these destination sites to help minimize
triage errors.

In addition, hospitals may be able to expand their ability to handle an increased volume of patients by setting up care sites for low-acuity patients in alternative on-site locations. Converting existing patient care areas, such as dialysis centers, radiology suites, endoscopy units or unused inpatient wards or clinics, may expand capacity.

Using other areas, including cafeterias, waiting rooms, conference rooms, libraries or other gathering spaces may also keep dedicated ED beds available for high-acuity patients. Understanding how such areas will be staffed and equipped quickly is critical to success.

Other ways to help hospitals lessen the impact on any one facility include sharing resources—both equipment and specialty personnel—which can effectively increase total hospital bed capacity, if there’s space available. However, this requires extensive regional planning to make this option feasible and allow EMS to transport more readily to alternative sites.

There are numerous challenges to overcome when hospitals try to share, especially when personnel are involved. Questions of liability, pay and credentialing must all be clarified in advance, so working with local hospitals before an event is crucial for success.

Hospitals are also required to plan for the use of medical volunteers, such as the Medical Reserve Corps (MRC), but again, advanced planning is required to successfully incorporate
these assets.13

In some cases, mobile assessment teams can deploy to smaller facilities to assist with patient triage, instead of presenting to a scene. For example, burn centers—an extremely limited resource in the United States—have sent burn specialty teams (BSTs) to outside facilities and performed on-site assessments to determine the need for transfer to a higher level of care.2

The increasing use of telemedicine has allowed for community hospital-to-tertiary center patient care, such as the use of neurologic specialists to enhance regional stroke care. In this hub-and-spoke model, patients are kept at smaller facilities (i.e., spokes) with select patients requiring more advanced care transported to specialty (i.e., hub) centers.14 Telemedicine could also support clinics, urgent care centers or community hospitals in the ongoing definitive management of traumatic or infectious causes of MCIs, without requiring transfer to more specialized facilities.

In the event that patients need to be transferred to a higher level of care, the use of specialty transport teams may need to be considered. Although some patients may simply require a higher level of critical care, some instances—especially infectious diseases—may necessitate even more specialized management. After the recent Ebola outbreak, regional teams were established to care for patients in isolation during transport.15

Additional Considerations

For more protracted events, especially infectious diseases, public messaging may reduce the impact on EMS, hospitals and emergency departments. Encouraging patients to stay home with symptoms or to seek medical care with their primary care physician or other clinics can reduce the workload on emergency services. Combining this option with home assessment teams or telemedicine may further the effectiveness of such programs.10

Communications are also a critical component of disaster mitigation, both for responding agencies and for information flow between EMS and hospitals. Systems do exist that can help EMS agencies see real-time hospital capacity without having to directly contact each facility by phone or radio to query their ability to care for patients. Maintaining and updating such systems is challenging for hospitals but can save time in a disaster.

Some new web- and app-based prehospital alerting programs may further streamline EMS to hospital communications and allow for more equitable and appropriate distribution of patients, though these programs haven’t implemented MCI-specific modules to date.

Patient tracking needs to be included in EMS–hospital communications, especially if multiple receiving sites or facilities are utilized. Electronic tracking programs do exist to allow for a more seamless flow of information, though careful record keeping may also work. Unfortunately, traditional disaster tag systems may be ineffective during an MCI and of limited use in reunification.3,16

MED-1 operating in Waveland, Mississippi after Hurricane Katrina. Photo courtesy Thomas Blackwell, MD


Although many of these alternative care options have the potential to reduce the local impact of a MCI, most of them require a considerable amount of preplanning and preparation before an incident occurs.

In order to share equipment or use alternate facilities, interagency agreements, infrastructure, equipment, personnel, other resources, etc. must be well planned and practiced
before implementation.

Sharing of personnel and the development of specialty teams also leads to legal, authority, licensing, malpractice, credentialing, reimbursement and other questions, many of which can require months or years to resolve.

Finding the right partners to accomplish these objectives is a critical first step to creating a workable plan. However, partners may not all be local. Understanding resource capabilities at the regional, state and federal level as well as how to access them may also allow for creative solutions to MCI management.

Several of these options may be of limited use in the event of a disaster, even if they have been drilled successfully. It may take several hours to a few days after an incident begins before some teams and processes can be operational. Understanding the limitations of plans and resources is critical to successful implementation. Frequent practice before an incident should reveal deficiencies that can be corrected in advance.


Any time resources are taxed—even if it’s just a busy day on the street or in the ED—it can be stressful. Disasters compound that stress, but advanced planning with consideration of alternative approaches to disaster care may reduce some of the impact on the local healthcare system.

Addressing all aspects of disaster and MCI response can allow for creative uses of
limited resources, including equipment and personnel.

Anticipating these challenges and advanced planning with the right partners may allow for improved onsite care, increased transportation and communications options and access to alternate care facilities that allow the healthcare system to continue to function, even when it’s overwhelmed.


  1. Raines A, Lees J, Fry W, et al. Field amputation: Response planning and legal considerations inspired by three separate amputations. Am J Disaster Med. 2014;9(1):53–58.
  2. Sheridan R, Barillo D, Herndon D, et al. Burn specialty teams. J Burn Care Rehabil. 2005;26(2):170–173.
  3. Gates JD, Arabian S, Biddinger P, et al. The initial response to the Boston Marathon bombing: Lessons learned to prepare for the next disaster. Ann Surg. 2014;260(6):960–966.
  4. Gavagan TF, Smart K, Palcio H, et al. Hurricane Katrina: Medical response at the Houston Astrodome/Reliant Center Complex. South Med J. 2006;99(9):933–939.
  5. Blackwell T, Bosse M. Use of an innovative design mobile hospital in the medical response to Hurricane Katrina. Ann Emerg Med. 2007;49(5):580–588.
  6. Shagets FW. Thoughts on the May 2011 Joplin, Missouri tornado. South Med J. 2013;106(1):113–114.
  7. Nunes Ferreira R, Lopes da Rosa T, Benevenuto de Campos Lima C, et al. The challenge of e-health presence on a petroleum platform: Using telemedicine to make operation of pre-salt wells a reality. Stud Health Technol Inform. 2015;216:937.
  8. Maruschak L, Chari KA, Simon AE, et al. National survey of prison health care: Selected findings. Natl Health Stat Report. 2016;96:1–23.
  9. Hickey S, Gomez J, Meller B, et al. Interactive home telehealth and burns: A pilot study. Burns. June 19, 2017. [Epub ahead of print.]
  10. Hickson R, Talbert J, Thornbury WC, et al. Online medical care: The current state of “eVisits” in acute primary care deliver. Telemed J E Health. 2015; 21(2):90–96.
  11. Auf der Heide E. The importance of evidence-based disaster planning. Ann Emerg Med. 2006;47(1) 34–49.
  12. Pershad J, Waters TM. Use of tent for screening during H1N1 pandemic: Impact on quality and cost of care. Pediatr Emerg Care. 2012;28(3):229–235.
  13. Gist R, Daniel P, Grock A, et al. Use of Medical Reserve Corps volunteers in a hospital-based disaster exercise. Prehosp Disaster Med. 2016;31(3): 259–262.
  14. Wechsler LR, Demaerschalk BM, Schwamm LH, et al. Telemedicine quality and outcomes in stroke: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;48: e3–e25.
  15. Isakov A, Miles W, Gibbs S, et al. Transport and management of patients with confirmed or suspected Ebola virus disease. Ann Emerg Med. 2015;66(3):297–305.
  16. Radestad M, Lennquist Montan K, Ruter A, et al. Attitudes towards and experience of the use of triage tags in major incidents: A mixed method study. Prehosp Disaster Med. 2016; 31(4):376–385.