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Home > EMS Products > Incident Management
August 04, 2009
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Insights on Innovation
by Dan White

The Evolution of MCI Management


Modern concepts and methods of triage and mass casualty management have evolved a lot in recent years. What once constituted the simple act of patient sorting is today a refined science. Mathematical analysis of patient outcomes has helped us develop better ways to manage large incidents. Most of this experience was gained in the military theater where these ideas originated. But recent domestic events like Oklahoma City, 9/11, New Orleans, and even the recent H1N1 scare have focused our efforts to develop improvements in disaster preparation and mass casualty management.

Triage originated and was first formalized in WWI by French doctors treating the battlefield wounded. In modern times, the outcome and grading of the victim is frequently the result of physiological and assessment findings. Some models such as the START model are committed to memory, and some like the Sacco Triage System may be algorithm-based. As triage concepts become more sophisticated, triage guidance and technology is also evolving.

Most of my experience with large-scale events was gained long before these ideas became mainstream. I've been to several large fires and building collapse events, one large flood, a building explosion, and innumerable multi-vehicle wrecks. Most were managed poorly in retrospect, but the experience taught me a lot. Here’s what I learned.

We have several competing interests during a Mass Casualty Incident, or MCI. We first have to set up a minimal command structure and organize. Then we need to sort the injured with the goal of moving the worst hurt, most viable patients first. We need to keep track of who goes where, and manage how many are allocated to any one hospital. Lastly, we must match the patient to the best destination to optimize his or her outcome. We have to get the right people to the right place in the right order.

Triage is prioritizing
Concentrate on solving the initial challenges first and the rest will come in due time and order. The management of hospital resources is a system-wide issue. These are challenges which must be confronted in a regional planning context. You simply must involve all the potential partners and stakeholders. As an EMS provider, your primary job is to do two things: identify the most injured patient and get the most viable candidate transported first. If you are still learning the protocol, then that is where initial efforts should be focused. Alaska published a great overview of the basics.

An important concept is the idea of using your MCI tools on micro-incidents. An example of a micro-incident is a nasty three-car accident with four victims. If you practice your MCI techniques on these smaller incidents, you will be much better prepared for a large disaster. Being able to set up a command structure quickly with the first four responders is a mission-critical skill.

If every apparatus has what it needs to identify officers, triage, and initially identify patient-collection areas, then the first four of your people on scene can get started. I’ve found that MCIs tend to be won or lost in the first few minutes. The last thing you want is things spiraling out of control while you are stuck waiting for a MCI trailer to arrive.

Smaller-scale implementation of MCI management gets you used to using your triage tags, forms, and other tools. You will find out quickly if the vests fit, if the collection area markers can be seen at night — more things than you can imagine. Then when a true system challenge occurs, you have already worked the bugs out of your own system.

I was at one big MCI drill where simulated patients were evaluated in a large field. However, this didn’t seem the most realistic; people don't grow in fields, plants do. If you have a nearby freeway, you might be better served by practicing a five-car wreck with 12 patients. If you have a big airport in your area, do a plane down drill.

Mock events are an invaluable tool for MCI preparation. But use scenarios based on practical assumptions of what is most likely to occur or with the greatest historical relevance. Remember that if it happened once, it can happen again. Massachusetts published a wonderful MCI planning guide.

Prepare for the worst
A natural tendency is to prepare for what most recently happened somewhere else. After New Orleans, flood preparation suddenly became a priority. After the Minnesota bridge collapse, every bridge in Missouri was immediately inspected. Today, the hot topic is pandemic flu preparation. Tomorrow it will be big train wrecks. Keep up to date on the latest technologies and training to make your MCI management planning more effective.

FEMA has rolled out of the National Incident Management System (NIMS). It makes perfect sense to teach everyone the same basic planning and management principles. Training opportunities can be resourced at

The one aspect of MCI management rarely discussed is the emotional demands. It seems we plan for recovery afterward with Critical Incident Management (CISM) programs, but don't talk much about the challenge beforehand. What I'm talking about is being emotionally prepared for how different your role will be at a MCI. One of the hardest things I've ever had to do as a paramedic was walk past a women begging for my help because someone else beyond her needed me more. I think we need to have some frank discussions about these feelings before we have to deal with them.

MCI planning and preparation is a young science, founded on the battlefields but carried out today largely in the boardroom. How well we plan and prepare will eventually be tested in every system. It may not be today, this month, or even this decade. But it's far better to plan under the assumption that every single one of us will eventually need these important skills and is completely prepared to execute.

About the author

Dan White, EMT-P works for Intersurgical, Inc. as the National Account Manager for EMS. Immediately prior he ran Arasan, LLC. He served as Sales & Marketing Director for Truphatek, Inc. and before that Director of Corporate Planning & Product Development for AllMed. He has been certified as a paramedic since 1978 and an EMS and ACLS instructor since 1981. Dan has designed many emergency medical products since his first, the White Pulmonary Resuscitator, including the Prolite Speedboad, Cook Needle Decompression Kit and RapTag Triage System. His more recent EMS product designs are the Arasan Ultra EMS Coat and the B2 Paramedic Helmet. To contact Dan, email

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