Preparing for the Unthinkable

On any given morning throughout the U.S. and beyond, thousands of paramedics, EMTs, firefighters, and other first responders report for duty and relieve a departing crew. We exchange pleasantries, check equipment, and review memos; nobody anticipates that this is the day that a mass-casualty incident will unfold in their community.

Whether it’s a plane crash, hazmat situation, or structure collapse, our residents look to us not only for treatment and transport but for leadership and stability during these low-frequency, high-acuity scenarios. The situations demand we be at our best as clinicians and critical thinkers, making regular training an absolute necessity. 

Should one of these scenarios unfold in our area, we as EMS professionals will not be operating alone, but rather as part of a team that will unquestionably include fire protection, law enforcement, hospitals, and local emergency management, to name a few. Utility providers may be involved, and depending on the scope of the situation, state departments like highway or natural resources may be represented. 

In short MCIs demand a high degree of collaboration and teamwork. Missouri’s St. Charles County Ambulance District (SCCAD) is taking steps to ensure our training reflects that. 

This year more than 500 county first responders took part in our largest, most immersive MCI training to date: an active-shooter scenario. We’ve tackled this topic before (most recently in 2016), but given the number of high-profile shooter situations throughout the nation in the past three years, we felt revisiting the topic was not only timely but necessary. 

“Since we last trained for these scenarios, our country has unfortunately experienced the two deadliest mass-shooting incidents in its history: the Orlando Pulse nightclub incident, which left 49 dead and more than 50 wounded, and the Las Vegas shooting that killed 58 and wounded more than 800,” says SCCAD Chief Taz Meyer. “These large-scale events, along with dozens of school and workplace shootings, highlight the need to revisit this topic on a regular basis.”

Hands-On Learning

Strategic partnerships developed since the last shooter exercise allowed SCCAD to further enhance the experience for all involved. For the first time this year, St. Charles County Police Department officers trained side-by-side with our paramedics and firefighters from more than a half-dozen county fire agencies.

Officers made entry with paramedics and firefighters, clearing rooms and providing coverage so others could provide patient care in a warm zone. Though law enforcement and EMS/fire have trained on the topic separately numerous times in the past, both sides agreed that collaborative training was the preferred approach.

“The consensus from everyone who participated is that this exercise provided exposure to the needs and objectives of the other disciplines during these scenarios,” says Meyer. 

Our shooter scenario played out at the Health Occupations campus of St. Charles Community College—an institution that wholly embraces cooperative relationships with community partners. In addition to providing a realistic school environment for our scenarios, the facility was ideal in the sense that in some evolutions, it enabled paramedic and fire crews to transport patient volunteers to the college’s eight-bed virtual emergency department, where they gave handoff reports and transitioned care to nursing students.

Leadership at the community college has been enthusiastic about hosting the training, saying it would give their soon-to-graduate students an invaluable firsthand look at care on the front lines. Nursing students were required not only to prioritize patient care among incoming MCI patients but also make decisions regarding whether to move existing ED patients.

The local community college and St. Charles County Police Department are the newest in a growing group of county partners that have joined with SCCAD for MCI training. Some agencies can seem unlikely partners for EMS at first glance but upon further examination hold great potential benefits for both sides.

Two years ago our local Wentzville School District offered up an unused parking lot at its administrative offices for a series of simulated school bus rollover accidents. This exercise provided an opportunity for school district staff to become engaged at their interest point in the scenario: allowing their transportation and communications teams to be in the heart of the action, practicing their chain of command and parent-notification processes. The relationships developed during the coordination process of this scenario led to further collaboration between SCCAD and the school district; we have since provided training for its school nurses and bus drivers, among others. 

Regardless of the scenario selected for annual MCI training, securing role players to serve as patients provides a more realistic, immersive experience for all involved. This year college students and staff took part in the training, as well as volunteers from throughout the community.

Manikins are fine to supplement when there are insufficient live models, but in our experience there is no substitute for live volunteers who can portray any number of variables that would make a difficult situation even more challenging. At our shooter exercises some volunteers were instructed to intentionally disregard crews’ instructions or wander away from the scene; others were told to present as though they were nonverbal, spoke no English, etc. In a region as diverse as St. Louis, these are situations our crews encounter occasionally during regular duties, so we felt it important to incorporate them into our scenario.

Though MCI training exercises give paramedics and firefighters the chance to practice clinical decision-making, triage, and transport skills, they also provide an opportunity to test crews’ situational awareness and ability to operate in a “sensory overload” environment. For the active-shooter scenario, we included numerous variables designed to heighten realism. We used fog machines to simulate a smoke screen the shooter used; a fire alarm blared to create a barrier to communication; and objects of significant importance were positioned throughout the training field (a simulated secondary explosive device, a note from the assailant, etc.). 

Maximizing Learning

Given the scope of the scenario and all the variables competing for responders’ attention, mistakes were inevitable. These are high-acuity, high-stress situations; making errors and learning from them are exactly why we train. Even the most experienced paramedic would be challenged by a scenario such as this. The goal is not perfection but to learn what we’re doing well and where we can improve. 

With these factors in mind, we designed our MCI exercise as a three-hour training. After a welcome and safety check, we provided an overview of the scenario and moved into the first evolution, which unfolded over a 45-minute time frame. Afterward we brought the entire group together to discuss what went well and where they saw opportunities for improvement and address any questions or concerns. 

We then reset the scenario, changed some of our variables within the scene, and completed a second evolution. At the wrap-up we highlighted where improvements were made from one evolution to the next and discussed points that could still be improved. This forum proved particularly beneficial for the law enforcement and EMS sides to get a better understanding of one another’s perspectives. 

With each passing year SCCAD’s MCI training grows in size and scope. Training staff from each of the participating agencies gather nearly six months out to begin discussions on scenarios, training sites, and other details. Though we’re proud of the product we deliver to first responders in our community, we’ll continue to develop strategic partnerships within our service area so we may continue to offer unique, immersive learning opportunities for the professionals we serve.  

Rick Lane is training officer for the St. Charles County Ambulance District in Missouri.