Columns, Mass Casualty Incidents

Staying Ready for a Fast-Moving MCI

Issue 9 and Volume 42.

Today’s reality of terrorist attacks and fast-moving mass casualty incidents (MCIs) now dictate changes to the way we set up and operate at MCIs because we’re being drawn into scenes under hostile or dangerous circumstances. This quick review highlights some of my observations and recommendations to keep your system up to date with—and ahead of—current MCI trends.

Communications is Still #1

Solid communications yield solid results. You need early scene reports, resources requested and a coordinated and functional work area set up and maintained. (See Photo 1.) The use of multiple radios tuned in on separate frequencies (uninterrupted by a priority scan frequency lock-out) works best to monitor different channels.

You also need to use remote microphones and headsets to be able to hear in a noisy environment. Checklists have been proven to keep scene commanders organized, on track and prevent them from overlooking important areas. (See Photo 2.)

Early Staging & Hospital Notification

Early selection and set-up of ambulance, fire and specialty vehicle staging areas help you begin to load and move patients early and rapidly at active shooter and other fast-moving MCIs with high-acuity patients.

As soon as you go into MCI mode, pick good staging and loading areas, assign a staging officer and work with police command to secure the access and egress routes. (See Photos 3 and 4.)

Side-by-side ambulance staging allows you to load patients faster and transport more patients in less time than a single file staging pattern. (See Photo 5,.)

You also have to realize that patients who’ve been shot or stabbed won’t wait for you to arrive to care for and transport them. They often flee, find transportation on their own and go to the closest hospitals via bystanders, personal vehicles, police vehicles and other means—so it’s important that you alert all nearby hospitals as soon as possible that there’s a fast-moving MCI underway near them. This will allow them to be ready for “early arrivers.”

Color-Coded Vests & Tarps

In the confusion that exists at MCIs, color coding works exceptionally well to identify people, places and functions. (See Photos 6 and 7.)
You should have a complete set of vests and tarps on every piece of apparatus—not just stuffed in a case on a supervisor vehicle, rescue truck or late arriving MCI trailer. If vests and tarps are at another assignment or don’t arrive early in an incident, their advantage in organizing and coordinating an incident from the start is lost.

Scene vests most often forgotten are fire and police command, REHAB, safety officer and individual vests to delineate and identify who’s in charge at each color-coded tarp.

Ballistic tactical vests are a good idea not just because of the protection they offer to a triage officer at a scene, but because some are designed with multiple pockets that can store radios and other essential items. (See Photo 8.)

When you lay down red, yellow and green tarps to establish patient collection and treatment areas, something magical happens: Not only do personnel know where to bring patients, most personnel also know to stay off the tarps unless they’re specifically assigned to work there. (See Photos 9 and 10.)

Patient Tracking

Radioing hospitals and tracking patients who leave are the most demanding tasks at an MCI. These can be made easier by having your radio officer and transportation “charter” sit comfortably together at a makeshift table and chairs (these can be easily constructed with a stretcher, a backboard and two stairchairs).

Comfortable people tend to be more organized and coordinated than those who stand and have to juggle pens, clipboards, radios, transportation stubs and log sheets in an awkward and unnatural manner. (See Photos 11 and 12.)

Specialty Kits & Caches

All kits that you throw down at an MCI should have equipment stored and displayed in a way that enables quick “shopping,” retrieval and use. (See Photos 13 and 14.)

For terrorist and active shooter incidents, forward-thinking agencies like the Service d’Aide Médicale Urgente (SAMU) in Paris now equip all ambulances with large cases containing mutiple individual first aid kits (IFAKs) including tourniquets, chest seals, decompression needles and wound clot dressings that can be handed to rescuers as they fan out to find, triage and treat patients prior to their movement to centralized patient collection points. (See Photo 15.)

Protecting Responders & Patients

Terrorist and active shooter incidents such as those in San Bernardino, Calif; Orlando, Fla.; Paris; Littleton, Colo.; and Little Rock, Ark., have shown us the benefits of practicing close coordination and establishing working relationships with law enforcement.

The fact is that everywhere we operate at an active, hostile scene must be treated as a “hot” or “warm” zone. Terrorists and active shooters will kill EMS responders and patients if they can, so it’s paramount that we have armed officers surround us as we triage, treat and transport patients at hostile scenes. (See Photo 16.)

As detailed in my August 2016 column, “Modifying Our MCI Practices: How EMS and fire processes must change during dynamic and active threat situations,” an engine loaded with water tanks will stop high caliber rounds and protect rescuers working on the opposite side because the density of water stops the forward motion of the bullets within three feet. (See Photo 17.)

Fast Track Priority Patients

Similar to the way hospitals fast track patients, you should set up a fast track lane at a terrorist or active shooter scene so patients who can’t afford to wait on a tarp for care can be loaded and transported on a priority basis. (See Photo 18.) Don’t forget to illuminate all patient treatment and transportation areas. It’s hard to render complete and quality care in the dark. (See Photo 19.)

Use of Drones

Drones can enable you to suvey a scene from a great vantage point, light up a scene from above, use thermal imaging to find warm, living patients and ensure essential areas are funcioning well. (See Photo 20.)


Active shooter incidents and terrorist attacks can occur anywhere and at anytime. Preparing your agency to handle the victims of these fast-moving MCIs and updating your operational strategy is critical to both the successful treatment of patients and the safety of your personnel.