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Managing a Mass Casualty Incident: A Military Medic`s Perspective
Thomas Middleton, is the author of Saber's Edge, a firsthand account of the time he served as a combat medic in Ramadi, Iraq. Click here to read an excerpt from his book that details his response to a glass factory explosion that resulted in multiple casualties and deaths. In the article below, he relates some of the lessons he learned about managing mass casualty incidents as a military medic and how they can be applied to civilian EMS operations.
EMS professionals are accustomed to restoring order out of chaos. Every day, we bring multiple rescuers and an array of tools to aid the sick and injured, and we do so at a moment's notice.
There are times, however, when the need for our services far exceeds our capacity to provide them. Thankfully, managing a mass casualty incident is something few of us ever do, but with numerous casualties to care for, the stakes are high.
We cannot totally avoid chaos during an MCI response, but we can try to minimize it. In a perfect system, all the responders would memorize the playbook. We must accept that response to an MCI is going to overwhelm most people and strain us to the limit. Some degree of chaos is almost inevitable. It helps to remember that we didn't cause the event, but we will do the best we can with the cards we are dealt.
PREPARING TO RESPOND
Incident response begins long before disaster strikes. Local EMS systems usually have protocols in place to handle large events, and all of us receive at least rudimentary training in MCI response in basic EMT class. Not all training has to be on a grand scale, however. MCI training may be as simple as a tabletop exercise in the station with your on-duty crew. When was the last time your agency trained on MCI response in the classroom or held a small-scale tabletop exercise? Have your members trained to the point where you are all comfortable assuming various roles in a disaster?
EMS systems typically conduct regional mass casualty incident drills annually, but does every member of your agency participate in the big event? What about members who were off duty that day, or those who were answering 911 calls while everyone else trained?
You can begin with more frequent, realistic training. If only part of your agency trains for an MCI once a year, you can't expect everyone to be proficient when the real thing happens. Consider using a variety of scenarios with varying implications for scene safety. Structure fires and motor vehicle crashes are more familiar, but what about a building collapse or a terrorist attack?
A mass casualty means anything more than your immediate resources can handle. This is typically five or more patients, but your training scenario can be scaled up or down as needed. Don't forget to practice the concepts used in larger scale incidents in everyday motor vehicle crashes. You may only have three to five patients, but you can still practice the roles of incident commander, triage officer, etc. Remember that under the Incident Command System (ICS), all vacant positions remain the responsibility of the incident commander.
Finally, having done everything you can to prepare, the call comes to respond to a mass casualty incident. What can you do while responding? Depending on the dispatch information, you can begin by requesting sufficient resources and alerting receiving hospitals.
In responding to a mass casualty incident, you have to think of the entire incident as your patient. Avoid the trap of latching onto the first patient you see, ignoring the bigger scene and the other hazards all around you. Be alert for hazards to the rescuers and the uninjured, including hazards the patients themselves may pose to others through contamination or secondary violence. Your goal is not necessarily to save every casualty, but to save as many lives as possible.
THE RESPONSE
As you approach the scene, take a moment to do a windshield size-up. This may be the last time you can use your mobile radio for awhile, so make it count. Speak clearly and calmly. Activate your local MCI response plan. Estimate the number of patients, then add more. Try to gauge how serious the injuries are, and request one ambulance for every two patients.
On arrival, be particularly alert to the cause of the incident. Is it likely to continue posing a danger? How can you mitigate this risk? Too often, our training on scene safety begins with "have the police gone in first?" and ends with putting on our latex gloves. We must adjust our thinking to include terrorist attacks where the rescuers might be the intended victims.
Events that do not initially appear to be dangerous can change rapidly, so scene safety is an ongoing concern. Just because the police went ahead into a shooting does not necessarily mean they have all the shooters in custody. Remain alert and watch each other's backs. Look around for hard cover--something that will stop a bullet. Remember this place of refuge if shooting starts.
The first two jobs to be filled are those of incident commander (IC) and triage officer. Disaster plans should include law enforcement supervisors and fire department command staff in a unified command post. In most cases where EMS and fire respond together, the fire department is in charge. In a terrorist incident, the IC may be a law enforcement officer or even military. In any case, close coordination among responders is imperative.
In some systems, the role of triage is split between a primary triage officer who surveys the scene with the primary goal of providing the incident commander with the number and severity of casualties, while the secondary triage officer sorts the casualties according to severity and survivability. Remember that the most severely injured may need to be ignored in order to save the most lives. Some type of tag system is crucial here. There is nothing like spending a lot of time and effort sorting patients, only to turn around and see your efforts ignored or repeated.
The triage officers may apply tourniquets or open airways, but should not get overly involved with any one patient. The primary goal is to sort and tag patients so others may carry them to the appropriate treatment area. Don't forget that your concern is the entire incident, not just the individual in front of you.
Once the IC calls in a size-up and requests needed resources, the next job is to appoint a treatment officer to direct incoming units, and to set up the treatment area and form litter teams. Untrained bystanders may be able to help carry those who cannot walk. It is helpful for each arriving ambulance to drop off jump kits and portable equipment at the treatment area, then park in a transportation area nearby, facing out. There should be enough fixed equipment on the ambulances and enough supplies in the cabinets to sustain patients during transport.
The goal in the treatment section is to effectively stabilize patients. Rapid transport capability is limited and should not begin until the highest priority patients are stabilized. There are generally at least two patients in each ambulance, and perhaps only one basic EMT. Treatment during transport will be limited and transport times may be lengthy, as the closest hospitals tend to become overwhelmed. Once you reach a hospital, it may still take considerable time before your patient receives definitive treatment. Try to stabilize your patients before they leave the scene.
Once treatment is established, the next responsibility is transport officer. If there are sufficient ambulances, load each with one critical and one non-critical patient; if transportation assets are inadequate, it may be necessary to load two critical patients in each ambulance. Consider transporting ambulatory delayed patients in other types of vehicles.
The transport officer also distributes patients among available hospitals according to the hospital's capacity to care for them. Consider the possibility that the hospitals closest to the incident may be overrun by walk-in patients and those transported by private vehicles.
COPING WITH THE AFTERMATH
For many rescuers, a mass casualty incident will present challenges they have never faced before. Most EMS providers develop the ability to cope effectively with severely traumatized patients, but don't usually deal with more than one or two at a time. We often find solace in knowing that we have done everything we can for every patient we meet, but this coping mechanism can be overwhelmed in a mass casualty event, where we may not be able to provide all the care that a patient requires to survive.
While dealing with the psychological after-effects of an MCI response, it is important to remember that we didn't cause the problem. There is frequently a sense of guilt when we couldn’t save everyone. Others may feel guilty for having survived when others died.
Most rescuers successfully deal with the psychological aftermath of serious incidents. Talking things over with one another informally is helpful, and the nightmares, intrusive thoughts and preoccupation usually fade over time. In some cases, however, professional help may be needed. Rescuers should never be ashamed if they need to talk things over with a mental health professional. Critical incident stress debriefing may be helpful in some cases, but rescuers experiencing serious or ongoing symptoms may need individual help from a qualified professional.
MCI TOP TIPS
- One way to sort casualties quickly is to shout to them, asking anyone who can walk to move toward the sound of your voice. The ambulatory are your delayed patients, while the rest are either dead or in need of immediate life-saving treatment. This only works if the patients understand English and can all hear you.
- The triage officer's knees should never touch the ground. Once they do, the tendency is to focus on a single patient and lose sight of the big picture.
- Throughout the incident, patients should be continually re-assessed. A general guideline is that immediate patients should be re-checked every five minutes and delayed patients every 15 minutes.
- In hazardous materials emergencies, the tendency to load and go may be especially deadly. By bringing contaminants into the hospital, patients may take the lives of hospital staff, compounding the incident even further.
- During a mass casualty incident, it is not necessary for each ambulance crew to transmit a full report to the receiving hospital. Doing so may completely tie up limited radio frequencies and prevent critical communications. The transport officer is responsible for providing receiving hospitals with a brief summary of the patients they will receive.
- It helps to remember that MCI response is incredibly challenging, and we do the best we can. This does not mean that we are to blame for the incident. No one ever gets it exactly right, and there will always be room for improvement.
Click here to listen to an interview with Thomas Middleton conducted by EMS Magazine Editorial Advisory Board Member Greg Friese. To read a review by Greg of Saber's Edge, see www.everydayemstips.com.
Thomas A. Middleton is the assistant fire marshal and public information officer for the Burlington (VT) Fire Department, and has been a long-time firefighter and EMT. He served as a combat medic in Iraq as part of Task Force Saber from June 2005-June 2006 and is a member of the Vermont Army National Guard.
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