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Are we more prepared for ‘the big one’?

Have we taken the lessons learned from 9/11 and truly changed our practices?


Does your agency have primary and backup communication systems that can handle having all your units responding to calls in the area at the same time while allowing neighboring mutual aid units to send and receive messages as they respond to assist?


As can everyone that was around on Sept. 11, 2001, I clearly remember getting the news of the World Trade Center attacks. I saw headlines of an airplane flying into the first tower as I was leaving the YMCA after swimming that morning. I saw the second plane strike while watching the news when I got home. The reality of what it all meant took a while to sink in, but my first thoughts were about what a complicated scene this was for New York public safety responders to have in front of them. Next came the realization of just how many lives were lost in each building. We didn’t even know yet the toll it took on the responders. It was like nothing any of us had ever encountered.

That evening, I attended a planning session for an upcoming regional airport mass casualty exercise. Of course, all air traffic across the country was shut down at that point, but we still met. Needless to say, the conversations had little to do with drill planning. We were there to discuss the simulated crash of a 40-passenger commuter jet, but my thoughts turned to how the events unfolding in New York City would change EMS forever and make a 40-patient response something agencies should be able to accomplish without batting an eye.

Was I correct? Are public safety agencies more prepared for “the big one” now? Have we taken the lessons learned from 9/11 and other events since and truly changed our practices? Particularly in the first 10 years after 9/11, tremendous sums of money were dumped into “stuff,” like radios, triage tags, response kits and personal protective equipment. Did we make the same investment in permanently changing our infrastructure and practices?

Take a moment to review the following 10 lessons learned about MCI response and assess the progress your service has made. [At the end of this article, download a list of the questions to ask to gauge your MCI preparedness]

  • Do you really practice the principles, or do you just have a policy that says you do?
  • Do street-level staff know what to do and how to do it?
  • Do they have the authority, training and knowledge to make the switch from daily operations into disaster mode?

While there are many indicators that can be considered, get a sense of your systems’ readiness by answering one question from each of these 10 categories of lessons learned after 9/11 and other recent MCIs.

1. Incident command system

We all know what an incident command system is and how it should work, but there are often real roadblocks in actually implementing it when the time comes. Particularly in EMS, we are so used to running single-patient incidents with single resources, that we rarely practice folding into an event run by an incident commander.

  • Would a BLS ambulance in your service with a rookie crew recognize a call that needs ICS and know how to take the steps needed to activate it?

2. Communications

I doubt there has been an after-action review for a real or training MCI event since 9/11 where communications is not listed as a weakness. Radio frequency congestion, lack of needed frequencies programmed into radios, dead batteries, limited transmission range and overwhelmed communication centers are common challenges faced.

  • Does your agency have primary and backup communication systems that can handle having all your units responding to calls in the area at the same time while allowing neighboring mutual aid units to send and receive messages as they respond to assist?

3. Mutual aid

By definition, mass casualty incidents require requesting resources from neighboring services. Mutual aid plans must realistically address the help your community may need on your worst day, and they should look beyond the daily political rifts and turf battles.

  • Do your dispatch centers have clear instructions for calling mutual aid units that will reliably respond and seamlessly fold into your incident?

4. Hospital communication

The emergency departments are a crucial part of the system that must also ramp up to manage an MCI. Their first notice of an evolving event cannot be the radio report from the first transporting ambulance. They need time to clear beds, call in staff and activate their hospital incident command system. In many regions, hospitals have plans in place to network with other facilities in the area to distribute patients to the most appropriate destinations.

  • Does your multiple-patient or mass casualty plans include sending early notice of an evolving incident to area hospitals?

5. Patient tracking

We will save the topic of triaging and triage tags for another article, but history has shown that it is important to know what happened to all the patients involved in an MCI. Who went to which hospital, by what means, and when did they leave? Technology is available to allow field patient tracking systems to integrate with hospital systems so that each patient can be tracked from beginning to end.

  • Will your transportation section team record basic information about patients transported from the scene?

6. Personnel accountability

Fire departments and law enforcement specialty teams are experts in tracking exactly which personnel and what pieces of equipment are at a scene. Accountability tags and boards communicate to incident commanders the members of each team, their tasks and when they are released from the event.

  • How do your EMS crews check into an incident scene and participate in the incident commander’s accountability system?

7. Self-transporting patients

Particularly now, in the era of cell phones, GPS-powered mapping apps and rideshare services, it is not uncommon for patients to leave scenes of shootings, crashes and fires before EMS can triage them into their transportation system. There have been instances where casualties have arrived at area emergency departments before the alert has been made of an evolving incident. The days of triaging all the green patients into a waiting school bus are over.

  • Have your EMS leaders worked with local taxis or rideshare resources to get their cooperation in distributing patients to appropriate destinations so they do not overwhelm the hospitals closest to the incident?

8. Decontamination

The threat of some form of CBRNE (chemical, biological, radiological, nuclear, high-yield explosives) contamination being a factor in an MCI is apparent. EMS systems must recognize the need for decontamination and work with public safety partners to have patients grossly decontaminated before transport. Hospitals must also have plans in place to decon those patients who arrive at their facilities by means other than EMS.

  • How do your providers arrange for the decontamination of patients that need transportation, particularly when local fire department resources are managing the primary incident?

9. Other calls keep coming in

While many of your resources will be dedicated to the big event, the calls for other emergencies in your community will continue to occur. Understandably, response times will suffer, but these patients still need access to the healthcare system.

  • What arrangements have been made in your system or with neighboring agencies to keep ambulances available for calls outside of the incident?

10. Who do we call next?

At some point in an incident, there may be a need to call for even more help beyond your established mutual-aid resources. There may be regional, state or even federal resources that can be activated.

  • Does your plan list potential resources outside of local mutual-aid agreement and the process for requesting them?

Extra points: Training and practice

Overarching all these 10 categories, of course, is training and practice. Unless the plans and policies are pulled off the shelf, reviewed and put into regular training, there can be no expectation that staff will know them, much less remember to use the resources when the event unfolds.

  • Does your agency conduct regular training and exercises with your plan?
  • Are the exercises realistic and thorough, and do they include other public safety departments, the hospitals and local governmental officials?
  • Are plans updated with the lessons learned during these trainings?

Preparedness for the big events takes a great deal of time and effort, which many EMS leaders are short on these days. Make some time. Include plan improvements in your long-term goals. Let’s not wait another 20 years to be more prepared.

Stay safe.

This article was originally posted Sept. 11, 2021. It has been updated.

Fill out the form below to download your copy of “Gauge your MCI preparedness.”

Michael Fraley has over 30 years of experience in EMS in a wide range of roles, including flight paramedic, EMS coordinator, service director and educator. Fraley began his career in EMS while earning a bachelor’s degree at Texas A&M University. He also earned a BA in business administration from Lakeland College. When not working as a paramedic or the coordinator of a regional trauma advisory council, Michael serves as a public safety diver and SCUBA instructor in northern Wisconsin.