10 tips for ambulance staging at mass casualty incidents

Video from Hoboken commuter train crash showcases best practices for staging ambulances at a mass casualty incident

Ambulance response to staging and egress from a mass casualty incident is critical for an effective EMS response.

Early photos and reports of a commuter train that had crashed into and through a station in Hoboken, N.J. made it clear that there were likely to be lots of patients.

Initial radio calls likely requested all available ambulances and an activation of regional response plans for additional ambulances and mass casualty transport buses.

This short video of the ambulance staging area showcases best practices for ambulance staging at an MCI.

Here is what I saw being done well and additional ideas on how to implement these practices at any MCI response.

1. Keep calm and quiet
It is remarkable how quiet the staging area is. There are no sirens and no one shouting commands.

2. No sirens
It is worth repeating that no vehicles have their sirens activated in the staging area and there are no sirens heard in the distance. Siren noise increases the stress of all responders and complicates communication between responders. Limit siren use to transport of high-priority and critical patients from the incident. Or don't use sirens at all.

3. Red lights optional
Some of the units have their red lights activated in the staging area. During the daytime, running the ambulance lights is fine but likely unnecessary while parked or moving up in the staging area.

At night time, carefully consider the use of rotating lights, especially strobes. The intermittent flashing of lights in a staging area is likely unnecessary and potentially distracting.

4. Stay with your vehicle
In the video, most responders are in or near their vehicles. Orders to move up could come at any time. Don't let an unattended vehicle block other vehicles from egress, which could complicate or compromise the EMS response.

5. Be ready to move
While staging, be attentive to radio, voice and visual commands to move up in line or to exit the staging area. Allowing the engine to idle, especially in a large parking lot, makes sense for easy and rapid ambulance move up.

6. Secure the staging area
Parked ambulances near a major incident are a beacon for the worried well, media and other bystanders. At a known or suspected terrorist incident, ambulances are a potential target. Restrict vehicle and pedestrian access to the staging area, ask non-uniformed people to leave the staging area and if law enforcement resources are available create a secure perimeter around the staging area.

7. One-way and egress
The staging area traffic pattern for ingress or entry into the staging area, as well as parking and egress, needs to be established as soon as possible. It is critical that the earliest arriving units to the staging area be mindful to the traffic pattern and direct later arriving units into the staging area that allows ambulances to continually move up and exit staging to retrieve a patient as quickly and efficiently as possible. Movement in the staging area should be like a smooth flowing river, not like a game of Jenga.

8. Incident safety
Responder adrenaline can be the biggest safety risk during an MCI response. Maintain situational awareness through constant scanning, wearing high-visibility apparel, staying next to or in your ambulance and acting only when ordered to move by a staging officer.

In an unsecured staging area, you are especially likely to encounter bystanders unfamiliar with emergency vehicles. If your ambulance needs to be reversed, make sure to have a spotter in voice and visual contact with the driver.

9. Prepare for patients
Use your time wisely in the staging area. As you become aware of the incident mechanism — train derailment, collapse structure, explosive detonation, or multiple vehicle collision — anticipate patient injuries you are likely to encounter and prepare equipment. For a train versus building, I anticipate blunt trauma injuries, especially to the head, face and chest.

Listen to one of the first responders, Michael Wachs, describe responding to the scene and what he expected to find. 


Patients may require extrication, airway management, spinal motion restriction, pain management and fluids. While waiting in the staging area, prepare a backboard, check airway equipment and spike a bag of saline.

Further into the incident, EMS providers are more likely to care for patients with less severe injuries. Treatment might be limited to reassurance, minor bleeding control and splinting unstable long bone and joint injuries.

Don't relax if your ambulance is at the end of the line. When your turn comes, you might receive the critical patient that took an hour to extricate.

10. Know your resources
The staging officer needs to know the resources that are available. In some jurisdictions, it might make sense to have two staging areas to divide BLS ambulances from ALS ambulances.

The video also shows the County of Hudson EMS Task Force medical ambulance bus. Knowing when to release the bus from staging and how to best use it should be pre-determined based on local protocols, previous incident experiences and MCI training exercises.

Finally, visualize a successful staging area from other types of mass people movement.

At the Las Vegas airport taxi stand, dozens of cabs enter the passenger loading area in a smooth, simultaneous one-way flow. In less than 90 seconds, passengers are loaded and another wave of taxis enter from taxi staging to passenger loading. This is a sharp contrast to the privately owned vehicle loading and unloading area at any major airport. POVs are parked two deep, sharply angling toward the curb and potentially blocking traffic for several minutes.

Watch the N.J. video and share your tips for ambulance staging at an MCI in the comments.

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