MCI on the High Seas

Just when you start to get comfortable responding to single-patient emergencies and begin to understand your department's day-to-day operational processes, the inevitable happens: a multiple-casualty incident.

You are dispatched to Cruise Terminal No. 5, where a passenger cruise ship is returning to port because its captain reported a "listing" situation (a sudden tilt to one side). Reports are coming in that numerous passengers sustained injuries when the ship leaned, and some are critical.

Where do you begin? Fortunately, the agencies that managed this real event had an MCI plan and a clear understanding of the Incident Command System. When the ship arrived at the terminal, 102 patients were triaged, treated and transported, five of whom suffered serious injuries. How did all these patients get evaluated and transported while the EMS system maintained control of the situation?

Know Your MCI Plan
As a BLS provider, you might be asked to assist during large-scale events. Are you familiar with your jurisdiction's multiple-casualty incident (MCI) plan?

Upon receiving notification of this incident, the agency having jurisdictional authority activated its county MCI plan. This plan, essentially a template, is designed to help the Incident Commander, first responders and local hospital administrators ensure that all resources necessary to manage large patient events are used when one occurs. It had been reviewed and rehearsed by local agencies, including surrounding hospitals, prior to this event, and was subject to regular ongoing review to ensure its information was accurate and up to date.

The plan required that the Incident Command System (ICS) be used, an Incident Commander be assigned to the incident, and a designated Incident Command Post (ICP) be established. This was all done before the ship returned to port. Command Post personnel then received information from paramedics on board that there were at least five critically injured patients and around 100 with moderate to minor injuries.

What is ICS?
The Incident Command System is an organized, systematic approach to managing large-scale incidents. It is designed to have one primary incident commander and four functional sections--Operations, Planning, Logistics and Finance--below him. Not all of these sections are activated with every incident; some can depend on an incident's size, and each can be further divided if an event dictates as well. Due to the limited space of this article, I recommend visiting www.fema.gov for a more detailed explanation.

For this incident, an Operations Section Chief was assigned to oversee all operational functions. Reporting directly to this person was a Medical Group Supervisor responsible for the triage, treatment and transport teams. Due to the event's magnitude, a Logistics Section Chief was also assigned. This person was responsible for overseeing coordination of all the necessary medical supplies and support for first responders. The extra supplies, food and personnel were all assigned to a staging area. When the ship reached port, triage teams were ready to be deployed inside, treatment teams were ready on the loading dock, and there were 15 ambulances, two city buses and two trauma-center helicopters standing by and available for transport. Being that there was a medical team on board the ship, some of the patients had already been triaged prior to arrival at the terminal. In an attempt to further facilitate patient triage and transport coordination after the ship docked, an EMS medical liaison was assigned to work with the prehospital providers and the ship's medical staff. This proved beneficial.

The critically injured patients (those triaged as Immediate/Red) were transported first. These included a pediatric patient with an arterial hemorrhage, an adult with a possible closed head injury, an OB patient complaining of abdominal pain after suffering a blunt injury to the abdominal region, a patient complaining of chest pain and exhibiting signs of a myocardial infarction, and a patient complaining of shortness of breath secondary to a possible pneumothorax. Those with moderate injuries (Delayed/Yellow) went second, and all walking wounded (Minor/Green) were transported last. These patients primarily suffered long bone and soft tissue injuries. All patients were triaged and transported within two hours of the ship's arrival.

Communication Is Key
As with any incident, communication is a key factor for a successful outcome. The ICS system allows for one single point of command, and with this incident, all communication to and from assisting agencies was handled in an organized manner. In addition, the Incident Command Post provided an area where representatives from each agency could relay information and updates to the Incident Commander. As reports from the ship regarding the injured patients began reaching the ICP, there was no doubt the event would be managed as a large-scale mass-casualty incident. The constant communication between the Command Post and the ship's officers allowed for better preparation before the ship's arrival.

Glossary
Command post--The location where the Incident Commander operates during response operations.

Incident Command System--Set procedures designed to maximize the efficiency of personnel, facilities, equipment and communications during a response to an emergency incident.

Incident Commander--The person in charge, with the authority to make final decisions pertaining to the event.

Multiple-casualty incident--An event with a large number of patients unable to be managed by initial responding units.

Staging area--An area where resources are located before being deployed into specific assignments.

Triage--A system used to sort patients and identify the seriousness of their conditions.

Conclusion
Although most of us will never respond to an MCI the magnitude of a World Trade Center or a Hurricane Katrina, we should never disregard the possibility that our agencies will be taxed to their limits at some point in our careers. A multiple-casualty incident plan, based on the Incident Command System, must be developed and utilized when there are more patients than initial responding units can manage. To be successful, this plan must be trained on and continuously reviewed.

Orlando J. Dominguez, Jr., MBA, FF/EMT-P, is chief of EMS and public information officer for Brevard County Fire Rescue in Rockledge, FL.