Mass-Casualty Response: The Vital First Few Minutes

     In a large mass-casualty event, the actions taken by the first-arriving crew in its first five minutes on scene will often mean the difference between a poorly run scene that risks poor patient outcomes and a well-run scene that gives victims their best chance for survival.

     There are many facets to responding to a mass-casualty event. There is the initial scene assessment and setup, triage, movement of patients to casualty collection points, treatment and ultimately transportation for definitive care. A well-designed and well-practiced system will provide for both the safety of the responders and the efficient triage, treatment and transportation of victims. It is important that all EMS responders have a good fundamental understanding of not only the various aspects of triage, treatment and transport, but also principles and concepts pertaining to the management and coordination of MCIs and other large-scale events.

     Most of my staff have only responded to one or two large events in their careers. Though they work in a large, high-volume urban system, most have never been involved in a true MCI or large-scale disaster as a field provider on an ambulance. This is not unusual across the country. But it's concerning, because department heads and chief officers typically don't arrive on scene first at an MCI to run primary operations. Instead, the first-due ambulance crew—which might have less experience in the oversight and coordination of large, complex and chaotic events—will, in nearly every instance, be responsible for the initial assessment, setup and coordination of an MCI response.

     All responders should have a working understanding of the incident command framework and basic ICS concepts. Primary EMS activities typically fit under the Operations Section of the ICS system. This includes medical staging, triage, treatment and transport (see Figure 1).

     The historical expectation within the ICS system is that the senior EMS official serves as the Medical Branch Director. Depending on the circumstances, this could also be the person in charge of the Operations Section, or this person might be the Incident Commander, either as a single commander or as part of a unified command team. It is important to the success of any mass-casualty response to place persons with direct experience in the oversight of such responses in charge. These incidents are as unique in nature as hostage situations for law enforcement or high-rise fires for the fire service.

     Who serves as the Incident Commander of an MCI is often driven by legislation. Legal emergency scene authority can vary from state to state, so it's important for all emergency service providers (EMS, law and fire) to understand current laws and their limitations. In many instances one agency has the legal mandate to be in charge, but this doesn't mean its command officers have the expertise to do it well. Determining an incident manager solely by legislation raises many questions:

1. What about the inexperienced or poorly trained manager? Levels of sophistication vary greatly.
2. What happens when nonmedical managers try to dictate patient treatment?
3. What happens when there are conflicts of authority? You can have a school shooting with many injured where there's also a hazardous material present.

     Coordination of multiple-agency responses must be worked out before they occur. Practically, who's in charge should depend on the circumstances—the primary problems encountered by the responders on scene, not often-outdated and poorly written legislative edicts. The directors and chiefs of the various agencies working these issues out in advance will preclude ineffective and uncoordinated responses by first-due units in the first few minutes after their arrival on scene.

     The National Incident Management System (NIMS) provides all responders a common framework by which to operate. It is important to remember that NIMS is not an operational incident management or resource allocation plan. It does, however, provide all disciplines a common package of terminology, doctrines, concepts and principles that can guide an effective multiagency response. All members of EMS organizations should be educated on and maintain competence with NIMS concepts.

     Underlying any ICS system are certain principles which must be understood by providers in order to work effectively:

     1) Command is established early and includes an incident size-up—Command must be established as one of the first actions at an MCI. Normally, as discussed above, one agency has legal jurisdiction to be in command of the incident. However, nearly all MCIs will involve EMS, law enforcement and fire suppression/rescue services. Following large-scale MCIs and especially medical disasters, unified command provides a much more effective tool for oversight.

     The first-due crew should consider the following:

• Is it safe to be operating in this environment?
• What are we facing?
• What actions will we take?
• What resources do we need?

     2) There is a clear chain and unity of command—This principle entails good information flow up and down the line of command, and that each person operating on scene has just one supervisor to report to. It is important to depict this chain of command visually by utilizing position vests, even on smaller events.

     3) There is an incident action plan emphasizing a management-by-objectives approach—It is the responsibility of the Incident Commander to develop an IAP and communicate it to the responders carrying out the mission. In smaller incidents this is often done verbally. During large events it can be carried out by the ICS Planning Section.

     4) Transfer of command—As a scene evolves or prolongs to multiple operational periods, a transfer of command might be justified. Such transfers are communicated to all responders, so everyone is aware. During this process information about ongoing operations is relayed to the new IC. There should be an accepted process for transfer of command that is done only face to face.

     5) Each supervisor has a manageable span of control—The ideal span of control is a supervisor-to-responder ratio of about 3:7. This can vary based on hazards or other safety concerns. The ICS system should be modularly expanded if this ratio becomes distorted.

     6) All agencies use common terminology—Plain language is the key, both on the radio and in person. Ten-codes have no place during an MCI with multiple agencies involved.

     7) Communications between participating agencies must be integrated—Too many disparate radio frequencies that cannot be tied together is a recipe for failure.

     ICS principles are well-tested and hold up against any type of incident. The mistake many EMS systems make is to only use ICS on large and complex scenes. Like any other EMS skill set, these concepts must be used repetitively so they become second nature when they're needed for that once-in-a-lifetime event. ICS should be incorporated into the daily activities of less complex calls with fewer patients.

     Sedgwick County EMS utilizes the NIMS ICS framework on any call requiring two or more ambulances. This allows first-in crews on smaller scenes, where there may be as few as three patients requiring transport, to routinely utilize ICS terminology, procedures and concepts to organize responses. As part of this philosophy, the department allows the first-in crew to stay in command of the scene even after arrival of field command officers. This way, they can gain the experience of working completely through the phases of a multiple-unit response.

     The EMS Commander chooses to set up as much of the ICS medical response structure as needed, instructs incoming units in staging, and assigns them tasks as they arrive. Additionally, this person is assigned to coordinate and communicate with the fire and law enforcement agencies on scene. The second paramedic on the first-in unit is assigned triage so an accurate count of patients can be quickly determined.

     During these smaller responses, command is only transferred if the paramedic in charge is not meeting scene objectives; a patient's condition warrants that the paramedic in charge must leave with his/her transporting unit; or the situation evolves to a point at which a "fixed command" policy takes effect. At any of these points, the field command officer then takes command of the EMS response.

     Incorporating the use of ICS into the department's normal daily multiple-unit responses has made its use familiar to crews. Now, should a large event occur, there will be a smoother and better-coordinated EMS response that's appropriate to the event at hand.

     On arrival at a large MCI, the key is to immediately begin scene size-up, establishment of command, an initial triage sweep and the coordination and assigning of incoming resources. The speed with which these things are accomplished sets the tone. The initial responding unit's understanding of and adherence to ICS principles will be important to smooth operations.

     During this first few minutes, the IC will have to make key decisions as to how expansive scene operations will need to be. This includes the establishment of a designated command post and a fully employed medical branch operation with designated treatment and transport areas. Much of this decision process will be driven by initial triage counts, matched with availability of transport resources. Smaller multiple-patient incidents with no unusual circumstances usually won't require a fully employed ICS medical system. Larger MCIs often will, especially during extended operations. This decision process may be driven by local protocols defining levels of MCIs and medical disasters.

     The Incident Commander should be prudent in his use of transport crews to staff ICS positions. Using them this way may preclude timely transportation of injured patients. During large-scale events, using unified command to share information and make joint decisions will assist in finding appropriate personnel to staff key positions.

     As a scene evolves, continued communication up and down the chain of command is important. Information about ongoing operations drives decisions to change tactics, if need be, to facilitate good outcomes. Communication failures on MCIs almost always contribute to poor patient outcomes.

     The key to remember as the first-due unit is not to get caught up in performing patient care. Should this occur, an ineffective and disorganized response is all but guaranteed. This is a difficult concept for inexperienced EMS providers to grasp. However, routinely using the principles and concepts described above will help providers make the transition from patient care provider to incident manager when faced with a large-scale disaster.

     All EMS providers should have, at a minimum, basic NIMS certifications. But these alone may not be enough. To become truly proficient with the concepts of ICS, EMS providers must routinely seek out other training opportunities, through both formal certification classes and staged and controlled training scenarios, tabletop and live.

     Tabletop exercises allow providers to think theoretically through situations while getting feedback from instructors. They also allow for "what if?" scenarios to be injected based on responses from attendees. Tabletop exercises can be done frequently as part of recurring training programs for providers.

     Live exercises should be completed at least once a year. These should also present varied situations that fit local circumstances. Training on an airport disaster when you have no airport will not yield true benefit. Live exercise training, while time-consuming to plan and carry out, is invaluable in assuring that EMS providers are exposed to large-scale scenarios with instructor feedback before they're involved in a live situation where safety is at risk.

     Mass-casualty scenes and scenes requiring major medical operations are rare for EMS providers. They require a change in mind-set by first-due EMS crews, from direct patient care to scene coordination and management. First-due crews' understanding of the principles and constructs of NIMS and ICS will help ensure a more effective and coordinated EMS response, and ultimately increase the likelihood of positive outcomes for patients. Remember, the first five minutes of any major scene operation can make all the difference.

     Bledsoe B, Porter RS, Cherry RA. Paramedic Care: Principles & Practice. Upper Saddle River, NJ: Prentice Hall, 2001.

     Chapleau W, Burba A, Pons P, Page D. The Paramedic. New York, NY: McGraw-Hill, 2008.

     Christen H, Maniscalco P. Mass Casualty and High-Impact Incidents. Upper Saddle River, NJ: Prentice Hall, 2002.

     Christen H, Maniscalco P. Understanding Terrorism and Managing the Consequences. Upper Saddle River, NJ: Prentice Hall, 2002.

     National Fire Service Incident Management System Consortium, Model Procedures Committee. Model Procedures Guide for Emergency Medical Incidents. Oklahoma State University, 1996.

     Homeland Security Presidential Directive HSPD-5: Management of Domestic Incidents, www.NIMSonline.com/docs/hspd-5.pdf.

     Steven Cotter, MBA, NREMT-P, is executive director of Sedgwick County EMS in Wichita, KS. He has served for 20 years in both urban and rural EMS systems. Reach him at scotter@sedgwick.gov.

     Common mistakes made by EMS personnel on mass-casualty scenes include:

• Lack of recognizable EMS command in the field
• Failure to provide adequate widespread notification
• Failure to provide proper triage
• Lack of rapid initial stabilization of patients
• Failure to rapidly move, collect and organize patients into a treatment area
• Overly time-consuming patient care on scene
• Premature transportation of patients
• Improper or inefficient use of field personnel
• Improper distribution of patients to medical facilities
• Failure to establish an accurate patient tracking system
• Inability to communicate with on-scene units, regional agencies or other personnel
• Lack of command vests for all ICS officers and supervisors
• Lack of adequate training and/or practice
• Lack of proper community assessment, preplanning and contingency plans.