Mass Casualty Incident Management: Part 2

In part 1, I defined mass casualty incidents (MCI) and looked at what MCIs mean to different people and different emergency medical systems. In this installment, I will identify the reasons for a first due crew to initiate an MCI response and look at what might discourage them from doing so.

When we refer to “declaring” or “calling” an MCI, using MCI response or entering MCI mode, we’re talking about the same thing. These terms refer to the first due crew recognizing that the number of patients exceeds the threshold of immediate resources. In calling an MCI, the first due crew acknowledges the need for scene management over immediate hands-on patient care and broadcasts this as the “mode” of the incident so that incoming units can coordinate their response.¹ As discussed in part 1, exact thresholds and procedures vary from service to service, while the importance for calling an MCI remains constant.² While many issues may be present at an MCI, the “mass casualty” problem (too many patients) must be dealt with in a unique way in order to provide the level of care expected of any EMS system. By declaring an MCI, we put ourselves and other responding providers into a mode in which scene management is the priority, which both increases incident manageability and improves patient outcomes.³

A fundamental difference between in-hospital and prehospital emergency care is scene management. Hospital staff virtually always know that the “scene” in a patient’s room is fully managed, allowing caregivers to focus on direct clinical care for the patient. However, EMTs and paramedics must always manage the scene to some degree before they can begin care.^2,4,5 Sometimes this is as simple as directing a family pet into another room or moving the victim of an MVA out of the street and into the ambulance. Other incidents are more involved, requiring fire service or law enforcement agencies to help mitigate hazards and secure the scene.

So why do some responders delay or avoid calling an MCI when they should? An informal survey I conducted while teaching at the 2011 EMS World Expo suggests five primary reasons:

1. Peer Pressure: There was a feeling of implied pressure from peers and co-workers that if a responder has to declare an MCI in any but the most extreme circumstances, they are overreacting or could be considered a weak provider. Consequently many “low-impact” MCIs don’t get declared and, as a result, scene management becomes more difficult, impacting patient care.
2. Bystanders: After peer pressure, the most cited reason was public pressure. EMS providers are often pressured to “Do something!” from family and bystanders. Yet because MCIs tend to attract a great deal of attention, they also attract a great deal more pressure on providers to show the public that they are providing immediate and obvious care for patients; however, during an MCI, providers must first perform the scene management that they know will benefit the patients most.
3. Hospital staff/medical control: Some EMS providers described how they might not declare an MCI so they could “scoop and run” to avoid direct or indirect disparaging comments from hospital staff unfamiliar with the MCI tags or process. Crews may also be motivated to avoid a trauma scene time of greater than 10 minutes for fear of hospital or medical control reprisals.
4. Supervisors: EMS providers reported that in many systems supervisors give cues that discourage first due crews from declaring MCIs. These cues vary from putting critical MCI supplies in supervisors’ vehicles and implying that only a supervisor should call an MCI to emphasizing the cost of MCI supplies and discouraging their use in drills and training.
5. Self: Finally, many providers identify internal reasons for not calling an MCI. They cite being unfamiliar with equipment and procedures. While there are many reasons providers may lack information, education and practice, the result is that no one wants to have to figure out an MCI system on the fly and thus, these providers won’t initiate MCI mode unless forced to do so.

Now that we know how to identify an MCI, along with the need for and benefits of calling one, how do we address the reasons providers might avoid initiating an MCI response?

Education, preparation and a culture change are needed to ensure that MCIs (both low-impact and high-impact) get identified and MCI procedures get initiated as early as possible to realize the maximum benefit from the system.

Education includes cognitive factors like understanding the different roles and responsibilities at an MCI (which I’ll address later in this series), affective components so that providers feel comfortable declaring an MCI, and psychomotor hands-on training such as mock-MCI drills and tabletop exercises to practice using service-specific MCI equipment and applying MCI principles discussed in this series.

Next month: MCI Preparedness and Training.

References

1. Kramer WM, Bahme CW. Fire Officer's Guide to Disaster Control. Fire Engineering Books, 1992.

2. Limmer D, O'Keefe MF, Dickinson ET. Emergency Care. Prentice Hall, 2011.

3. Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: Analysis of triage, surge, and resource use after the London bombings on July 7, 2005. The Lancet 368(9554)2219–2225, 2006.

4. AAOS. Emergency Care and Transportation of the Sick and Injured, 10th Edition. Jones & Bartlett Publishers, 2011.

5. Mistovich JJ, Hafen BQ, Karren KJ. Prehospital Emergency Care. Prentice Hall, 2009.

An emergency responder for more than 20 years with career and volunteer fire departments, public and private emergency medical services and hospital-based healthcare, Rom Duckworth is an internationally recognized subject matter expert, fire officer, paramedic and educator. He is currently a career fire lieutenant, EMS coordinator and an American Heart Association national faculty member.