Truth, lies and MCIs

Is it true that for major MCIs, policy goes out the window?

Updated May 7, 2015

I have said repeatedly that I respect and admire EMS providers for willingly inserting themselves smack in the middle of insane situations, placing their livelihoods and lives on the line without question and for complete — and often thankless — strangers.

Perhaps the most chaotic of all situations is the multi-casualty incident (MCI). There's something about debris, bodies, and collective carnage that brings out the best — and sometimes, frankly, the dumbest — in us.

It seems like the myths and realities of managing MCIs are universal. For example, everywhere I go, the triage process is very similar: Green is good, black is dead and everyone in between needs help.

Likewise, no matter how meticulously an agency plans and prepares and rehearses, MCIs never go well. And of course, almost every agency has some set of MCI policies, protocols and procedures in writing.

Yet here's the question that inspired this column: Isn't it true that for major MCIs, policy goes out the window?

Better yet, despite knowing the answer without a doubt, as a paramedic and a lawyer, I actually researched it. My source, a senior prehospital care coordinator at one of LA's busiest trauma centers, thought I was joking.

"I know," I told her. "I just needed to be sure."

I guess when you have been around EMS for so long, sometimes the ridiculous seems plausible. Of course the answer to that question is NO!

Policies exist for a reason 

Policy is policy for a reason.

Like everything else, EMS has matured over the years, evolved after decades of mistakes and misnomers.

Remember the MAST suit? How about sandbags to hold C-spine or hyperventilating head injuries? Those all seemed like good ideas at the time, but we have learned different.

The same is true for MCIs. I do remember a time when MCIs were akin to the Wild West.

"You just do what you gotta do!" is what I was told circa 1987. To a certain degree, that was true.

Fast-forward to 1997, a busload of kids would crash, the scene would be a cluster[mess], everyone would eventually get where they needed to go, and we would spend a few hours on the next shift debriefing to learn from our mistakes.

A couple of months later, a church choir van would roll over, and the process would repeat. The policy never seemed to grow beyond doing the best with what you have.

Skip ahead another 15 years, and things are much different. EMS as we know it is in its early 40s, and much like people the same age, EMS is smarter and far more careful.

Most every metropolitan and peri-rural EMS system has a variety of policies, protocols and procedures related to managing MCIs. Triage methods have improved vastly, and operations plans and communication systems are better than ever before.

If we have come so far, why do people ask me that question so frequently? Governing agencies have protocols, provider agencies have policies, and most of the procedures are right there in black and white for everyone to follow.

Nevertheless, there seems to be a disconnect, and I am not sure where it is.

Maybe EMS is evolving faster than those who provide it. Maybe the training is not as effective as we think, or the plans are too complicated. Maybe command staff members believe they are smarter than the system they are meant to follow. Maybe the rank and file are more interested in getting it done rather than getting it done right.

A solution

Regardless of the reason, I do have the solution: The law expects you to follow the policies, protocols and procedures that govern you. You have to know them, and you have to follow them.

See? Easy.

To make it even easier, I am going to paint a picture for you:

If you decide that you know better or that your emergency is somehow different from all of the others, and you make up your own rules, you could find yourself in a level of hell that Dante never imagined: Bureaucratic-administrative-litigation hell.

It's a level so terrible that few ever emerge. It's a place where they speak a different language and the only friends you have are those for which you pay (Read: Your lawyer).

They use words like "negligent" and "liable" and "defendant," all to refer to you. You will have to repeat your story over and over and over again.

Demons in sharp suits with sharper tongues will ensnare you in webs of words that make you seem incompetent. Those in the same room will refer to you in the third person as if you were invisible, until it's time to eviscerate you with your own words.

When it is over, your license, livelihood and life as you know it may be over.

There's no doubt that EMS providers, perhaps more than any other groups in society, are called upon to improvise, adapt and overcome in some of the most unthinkable situations. However, following policies, protocols and procedures will keep you safe even in the worst of them.

Simply put: No, policy does not go out the window on MCIs. Even for really bad ones.


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