Updated July 14, 2014
What once constituted the simple act of patient sorting is today a refined science as triage and mass casualty management have evolved in recent years. Mathematical analysis of patient outcomes has helped us develop better ways to manage large incidents.
We have several competing interests during a mass casualty incident. 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.
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.
1. Focus on the most injured
Concentrate on solving the initial challenges first, and the rest will come in due time and order.
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.
2. Use micro-incidents to practice
An important concept is the idea of using your MCI tools on micro-incidents, like a nasty three-car accident with four victims.
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.
If you practice your techniques in these smaller settings, 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.
3. The first few minutes matter the most
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 for things to spiral out of control while you are stuck waiting for a MCI trailer to arrive.
4. Train with realistic mock events
I was at one big MCI drill where simulated patients were evaluated in a large field. However, this didn’t seem the most realistic. 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.
5. 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. It makes perfect sense to teach everyone the same basic planning and management principles.
6. Deal with your emotions
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.
