EMS Mass Casualty Management

Dr. Sum Psusma

INTRODUCTION

• A mass casualty incident (MCI) is defined as “an event that overwhelms the local healthcare system, where the
number of casualties vastly exceeds the local resources and capabilities in a short period of time.”
• Any MCI can rapidly exhaust available resources for not only the MCI but the normal day-to-day tasks of the
hospital.
• Each hospital should institute a surge plan in preparation for anticipated, progressive, insidious ("notice" events),
and sudden-onset ("no-notice" events) disasters occurring within the community.
INTRODUCTION
• First and foremost in responding to an MCI is identifying the type of MCI present. Categories include:
1.Planned (sporting event)
2.Conventional, which usually have some level of recurring frequency (transportation incidents, burn, and severe
weather events)
3.Chemical, biological, radiological
4.Nuclear agents from an unintentional or accidental release or act of terrorism
5.Catastrophic health events (nuclear detonation, major explosion, a major hurricane, pandemic influenza, or others).
INTRODUCTION
• The keys in successfully managing the chaos of a fast-paced, moving MCI can be delineated with the organization
of the 5 “S's”:
i. scene safety assessment
ii. scene size-up
iii. send information
iv. scene set-up
v. START.
 Clinical Significance
Activation of an MCI
• Those deemed as having the capacity to declare the activation of an MCI may differ amongst different county and
state protocols within the United States.
• However, it is fairly universal that Incident Command and local hospitals have the authority to declare and MCI.
• Most regions are flexible in this regard, allowing public safety agencies with the jurisdiction of overseeing incident
scene management, emergency management services (EMS) personnel who arrive first on the scene, Central
Medical Emergency Dispatch (CMED), hospitals, and regional council staff to declare MCI to engage immediate,
early action.
Communications and Incident Management

• The ability to successfully allocate resources and organize an effective response to an MCI is centered on flexible,
integrated communication, and information systems.
• A command center should be organized and equipped with multiple radios tuned into separate frequencies that are
“uninterrupted by a priority scan frequency lock-out,” which has shown to be effective.
• Each scene commander should be equipped with headsets, microphones, and clipboards, and checklists to enable
continuous feedback to command regarding scene dynamics.
 ON SCENE CONTROL

• The extent of an MCI is not solely dependent on the total number of created potential patients, but is exacerbated
by other complicating factors coined “MCI Multipliers.”
• MCI Multipliers can range from limited scene accessibility, biohazard contamination, self-deploying responders
not equipped or experienced for the current scenario, lack of on-scene or surrounding hospital resources, etc.
• A.J. Heightman, Editor and Chief of JEMS developed a table of “Multipliers that Affect MCI’s” that should be
identified and managed as early as possible in the course of an MCI, and are listed below:
Multipliers that Affect MCI

1.Physical location and access/egress complications

2.A number of access points and distance between exits on a highway
3.Location, speed, and density of traffic
4.The weather or roadway conditions
5.Time of day
6.Staffing levels
MULTIPLIERS THAT AFFECT MCI

Massive debris field

7. Other simultaneous incidents that drain available resources.
8. Location of specialty teams and resources

9. Ambulances are unfamiliar with a district’s MCI operational

procedures
10. Ambulances from another system arriving on the scene, or self-
dispatching
11.Hospital backlogs, closures, or lack of resources or capabilities
 MULTIPLIERS THAT AFFECT MCI
12. Communication coverage gaps or inability to communicate with mutual
response resources
13. Failure to establish incident command, divisions, or groups early enough
14.Lack of scene vests or identification of triage, treatment, or transportation areas
15.Late or improper access directions or staging instruction to incoming units
16.Complicating factors, such as ongoing crashes, gunfire, or explosions
To combat these roadblocks, early on scene role establishment is essential.
HIERARCHICAL APPROACH

1. Response and management to an MCI are dependent on hierarchy.

2. Operations of the entire MCI are controlled by the Incident Commander of the National Incident Management
System (NIMS) Incident Command System (ICS).
3. an interprofessional Regional Medical Coordinating Systems (RMCSs), where available, meet to coordinate the
transfer of patients during patient surges when the nearest facilities demands exceed their resources.
4. RMCSs coordinate hospital resources based on the amount of emergent and non-emergent patient surges that
each surrounding facility can accommodate.
HIERARCHICAL APPROACH

• Once on the scene, the EMS Branch Director or the Incident Command (IC) is responsible for overseeing all on-
scene operations (safety, scene size-up, communications, and so forth), which should be established early.
• While law enforcement is responsible for maintaining the security of the scene, the Safety Officer is responsible
for assessing current and potential hazards maintaining responding crews’ safety.
• The Radio Officer works directly with incident command in providing frequently updated scene reports and
coordinating communications with the Transportation Officer to local hospitals’ in assessing their ability to
accommodate their ongoing needs. 
HIERARCHICAL APPROACH

• The Medical Supervisor must oversee and coordinate the triage, treatment, and transport sectors of the scene; in
essence, they are responsible for creating patient flow and managing patient resource allocation.
• The Triage Officer coordinates patient flow to the transportation area based on their designated clinical condition
designated by the triage team.
• They are in charge of performing a final scene sweep to ensure no patient that has been rescued has been left
without being triaged.
• The Treatment Officer establishes the treatment zone and allocates supplies.
• They are responsible for anticipating resource needs and updating the Transportation
Officer of the number of “green, yellow, red, and black” triage designations and when
those numbers change based on patients’ worsening clinical condition.
• The Transportation Officer is responsible for patient tracking, transportation assistance
from local responding units, directions, and hospital designations based on resource
availability and needs.
HIERARCHICAL APPROACH

• Mutual aid ambulance services, first responder units, and EMS personnel provide transportation and evacuation of
MCI patients as dispatched per the established regional policy and communications center.
• Individual EMS personnel are prohibited from self-dispatch to the scene.
• The first available responder squad on the scene should be responsible for gauging the extent of the catastrophe,
providing a scene report, and alerting nearby hospitals for the determination of resource and bed availability at
those facilities.
• To quickly and efficiently gauge the extent of the MCI, the Massachusetts Department of Public Health
recommends employing the “METHANE” mnemonic, and is as follows:
• Adapted from the Massachusetts Department of Public Health Emergency
Medical Services (EMS) Mass Casualty Incident (MCI) Plan.
 METHANE

• M: Major incident declaration

• E: Exact location; the precise location of the incident, staging area, if applicable
• Type of incident; the nature of the incident, including how many vehicles, buildings, and so forth are involved
• H: Hazards; both present and potential
• A: Access; best route for emergency services to access the site, or obstructions and bottlenecks to avoid
• N: Numbers; of casualties, dead and injured on the scene
• E: Emergency services; which services are already on scene and which are still required (MCI trailer, Regional
EMS Council staff, Task Force, and so forth)
• Scene identification vests should be distributed to the IC, Safety Officer, Staging Officer,
Medical Supervisor, Radio Officer, Triage Officer, Treatment Officer, Transportation
Officer, and all rescue and responder personnel, branding them in their roles to be easily
identified by the current on-scene personnel, newly incoming crews, and MCI victims.
• In the event of a terrorist-based MCI, ballistic tactical vests should be highly considered
for distribution.
• On the scene, determine safe areas that can serve as a staging area, a specialty vehicle loading zone, a
triage, and a treatment zone that are removed from the scene of the accident or “hot zone,” and secure
these areas with a police command.
• In addition, create a region for a morgue that is out of the way but remains easily accessible for temporary
body disposal and later removal from the scene.
• To continuously direct patient triage without necessitating the designation of a worker to remain in the
staging area, stage the triage zones with color-coded green, yellow and red tarps to delineate minor,
delayed, and immediate care zones, respectively.
• Not only will this tactic free up available first responder resources, but it will also allow the remaining
walking wounded on the scene to locate emergency medical personnel.
• Specifically, with regards to MCIs created by a mass shooting, more than 250 people had
been killed over a 14 year period from 1999 to 2013.
• In response, the American College of Surgeons and the Federal Bureau of Investigation
(FBI) in Hartford, Connecticut, gathered to create an efficient set of critical actions to be
employed on the scene to maximize the survivability of mass shootings.
• These critical actions were summarized within acronym THREAT:
THREAT

• T: Threat suppression
• H: Hemorrhage control
• RE: Rapid Extrication to safety
• A: Assessment by medical providers
• T: Transport to definitive care
Adapted from “Fire/Emergency Medical Services Department Operational Considerations
and Guide for Active Shooter and Mass Casualty Incidents.” FEMA
TRIAGE

• The allocation of resources is based on the difficult decisions of patient triage.

• The START (Simple Triage and Rapid Treatment) adult-algorithm constitutes the basis of MCI triage.
• In total, there are four categories in START: minor (green), delayed (yellow), immediate (red), and expectant
(black).
• All patients should be tracked with START Triage Tags.
• The color designating the patient’s clinical condition is the color remaining after tearing off the other colors that do
not match the patient’s condition.
• Persons that can be tagged green for “Minor” injuries are known as the “walking wounded”: they have relatively
minor injuries, are unlikely to deteriorate over days, and may be able to assist in their own care. 
TRIAGE

• Those triaged to the “Delayed” category are those with potentially serious and life-threatening injuries.
• However, these patients should be able to follow simple commands, have a capillary refill under two seconds, and
the respiratory rate is under 30 breathes per minute.
• Their status is not expected to deteriorate significantly over several hours, and transport can be delayed on this
basis.
• Persons triaged into the “Immediate” category require immediate transportation and requires medical attention
within minutes for survival (up to 60 minutes) for compromised airway, breathing, and circulation.
• These patients meet “Immediate” care criteria if they have respirations over 30 breaths per minute, signs of active
hemorrhage, capillary refill over two seconds, or have altered mental status in which they cannot follow simple
commands.
• Expectants are those who are dead or inevitably dying, and are triaged as “Black.”
• A jaw thrust maneuver may be implemented to determine if spontaneous respirations
resume.
• If not, palliative medications only should be provided.
 Inventory

• Inventory of resources is as paramount as resource allocation.

• Inventory methods should be adaptable and scalable.
• Both on the scene or in the hospital setting, inventory lists can be created on paper or electronic spreadsheet.
• The Incident Resource Inventory System (IRIS) provided by FEMA at no cost is a standards-based information
software tool that “allows users to identify & inventory their resources, consistently with NIMS resource typing
definitions, for mutual aid operations based on mission needs and each resource’s capabilities, availability and
response time, and share information with other agencies.”
 REFERENCES

• 1.
• Lincoln EW, Freeman CL, Strecker-McGraw MK. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Nov 10, 2020. EMS Incident Command. [PubMed]
• 2.
• Wehbi NK, Wani R, Yang Y, Wilson F, Medcalf S, Monaghan B, Adams J, Paulman P. A needs assessment for simulation-based training of emergency medical providers in Nebraska, USA. Adv Simul (Lond). 2018;3:22. [PMC free
article] [PubMed]
• 3.
• Lee HY, Lee JI, Kim OH, Lee KH, Kim HT, Youk H. Assessment of the disaster medical response system through an investigation of a 43-vehicle mass collision on Jung-ang expressway. Accid Anal Prev. 2019 Feb;123:60-68. [PubMed]
• 4.
• Hart A, Nammour E, Mangolds V, Broach J. Intuitive versus Algorithmic Triage. Prehosp Disaster Med. 2018 Aug;33(4):355-361. [PubMed]
• 5.
• Gross IT, Coughlin RF, Cone DC, Bogucki S, Auerbach M, Cicero MX. GPS Devices in a Simulated Mass Casualty Event. Prehosp Emerg Care. 2019 Mar-Apr;23(2):290-295. [PubMed]
• 6.
• Jain T, Sibley A, Stryhn H, Hubloue I. Comparison of Unmanned Aerial Vehicle Technology-Assisted Triage versus Standard Practice in Triaging Casualties by Paramedic Students in a Mass-Casualty Incident Scenario. Prehosp Disaster
Med. 2018 Aug;33(4):375-380. [PubMed]
• 7.
• Hart A, Chai PR, Griswold MK, Lai JT, Boyer EW, Broach J. Acceptability and perceived utility of drone technology among emergency medical service responders and incident commanders for mass casualty incident management. Am J
Disaster Med. 2017 Fall;12(4):261-265. [PubMed]
• 8.
• Yu W, Lv Y, Hu C, Liu X, Chen H, Xue C, Zhang L. Research of an emergency medical system for mass casualty incidents in Shanghai, China: a system dynamics model. Patient Prefer Adherence. 2018;12:207-222. [PMC free article]
[PubMed]
• 9.
• Cummings C, Monti J, Kobayashi L, Potvin J, Williams K, Sullivan F. Ghost Attack: The East Providence Carbon Monoxide Mass Casualty Incident. R I Med J (2013). 2018 Feb 02;101(1):26-27. [PubMed]
• MCI PLAN
LEVELS AND CATEGORIES

•A. MCIs assessed by EMS will be classified by levels.

• Response to an MCI is based on the number of potential victims generated by the incident.
•The following levels indicate the number of potential MCI casualties, should regional EMS providers
require a mutual aid response:
• Level 1:1-10 potential victims
• Level 2:11-30 potential victims
• Level 3:31-50 potential victims
• Level 4:51-200 potential victims
• Level 5: Greater than 200 victims
• Level 6: Long-Term Operational period(s)
 MCI MEDICAL MANAGEMENT
• 
•A. The overall operations on scene shall be managed by the NIMS Incident Command System and shall be under the direction and control
of the Incident Commander (IC) normally from the agency with primary jurisdiction over the incident.
• 
•B. The on-scene medical operations shall be directed by an EMS Branch Director
• 
•C. Coordination of hospital emergency departments and direction of the flow of patients to hospitals shall be done in conjunction with the
CMED in the EMS region in which the event has occurred. If patient direction and flow involves more than one EMS region, the CMED
( Central Medical Emergency Direction) in which the event has occurred shall remain the primary point of contact for patient distribution,
direction and flow from the incident and shall coordinate with CMEDs from other EMS regions.
• 
•D. Regional Medical Coordinating Centers (RMCCs), where available, provide coordination during emergency situations which cause
patient surge. The primary goal of the creation of this entity and associated processes and plans is to provide coordination for and
movement of patients when it appears the needs exceed the present available resources. The Regional Medical Coordination Center is a
multi-discipline organization that will meet in emergency situations to:

 Coordinate in conjunction with CMED the non-emergent patient movement throughout a disaster area and neighboring regions
 Facilitate the coordination of hospital resources
 EMS RESPONSIBLITY

•A. Transportation of patients under the state MCI plan during an incident or evacuation will be overseen by EMS Branch Director or IC for
the incident.
• 
•B. Ambulance services, first responder units and EMS personnel involved in mutual aid response to a regional MCI or evacuation will be
dispatched through the responding services’ or agencies’ applicable communications center according to the established regional policy.
These units will be dispatched only upon IC request. Services not requested will not be allowed access to the site.
• 
•C. Individual EMS personnel shall report to their respective agencies and shall not self-dispatch to the scene of the incident. In the interest
of safety, efficiency and accountability, response to the MCI scene by individual EMS personnel in their privately owned vehicles is
prohibited unless directed by the IC. EMS personnel who respond will be directed to their respective agencies or, at the discretion of the IC
and if they have appropriate EMS identification, may be directed to the incident Staging Area. They will not be allowed direct access to the
MCI site.
• 
•D. All EMS services and/or first responder agencies responding to an MCI site in the Commonwealth must operate in accordance with the
Statewide Treatment Protocols including Section 8.2 Multiple casualty Incidents (MCI Triage).
• 
•E.
EMS RESPONSIBLITY
E. A jurisdiction(s) in which the MCI occurs will be responsible for activating mutual
aid in the region through its own Emergency Communications Center(s).
If local resources and mutual aid are exhausted, a jurisdiction’s Emergency
Communication Center shall request additional EMS resources through it’s region’s
EMS mutual aid plan and if needed, follow appropriate protocol for requesting
activation of Statewide Fire and EMS Mobilization Plan ambulance task forces.
• 
•F. EMS services and/or communities will respond with personnel and equipment
when the state MCI plan is activated. When considering their level of response to
requests for assistance under the state MCI plan, communities and/or individual
EMS services are required to maintain their emergency response capabilities to
meet local needs.
• 
•G. The crews of EMS services responding to an MCI or evacuation will be
required to carry identification and proof of affiliation with their agency.
• 
EMS RESPONSIBLITY

•H. EMS personnel responding to an MCI or evacuation will be responsible for maintaining the
appropriate medical documentation and appropriate ICS documentation, and for making said
documentation available to IC or support staff.
• 
•I. EMS services and their EMS personnel shall use a formal nationally accepted triage system
consistent with Statewide Treatment Protocol Section on Multiple casualty Incidents (MCI Triage)
and that is compatible with the use of Massachusetts SMART Tags.
• 
•J. EMS services should participate in at least annual training exercises of the state and regional
MCI plans.
• 
•K. EMS services shall require their EMS personnel to participate in on-going regional training in
the Incident Command System, Triage System, hazard awareness programs and other related
MCI skills.
8. ACTIVATION

•EMS MCI Activation

•A.Declaration of an MCI: Each of the following individuals or organizations shall have authority for the initiation of declaring an MCI upon making
the determination that the conditions warranting an MCI exist:
• 
• 1. The public safety agency having jurisdiction for overall incident scene management.
• 2. First arriving EMT on site with an emergency response vehicle.
• 3. CMED
• 4. Hospitals
• 5. Regional Council Staff
• 
•B. An MCI declaration signifies that an incident has occurred in which the number of casualties is expected to overwhelm the EMS system.
• 
•C. Request sufficient ambulances within that area to be dispatched to the scene on initial assignment, for triage and other purposes as needed.
• 
•D. Notify the appropriate CMED center to notify the hospitals of type of incident and expected number of patients.
•MCI Operational Procedure
•A.Incident size-up method for the first responding EMS unit using the acronym METHANE:
• M=major incident declaration
• E=exact location; the precise location of the incident, staging area, if applicable
• T=type of incident; the nature of the incident, including how many vehicles, buildings etc. are involved
• H=hazards; both present and potential
• A=access; best route for emergency services to access the site, or obstructions and bottlenecks to avoid
• N=numbers; of casualties, dead and injured on scene
• E=emergency services; which services are already on scene and which are still required (MCI trailer, Regional
EMS Council staff, Task Force, etc.)
• 
•B. Contact the local CMED by radio. The EMS component is responsible for notifying and verifying that an MCI has
been declared and providing the preceeding information via M E T H A N E size up.
•C. When arriving at the scene of a potential MCI, certain additional
steps are necessary to evaluate the situation. Make careful
observations of the scene: the safety of the responders, bystanders
on the scene, objects or people that caused the injury, injured parties,
mechanisms of the injury, any hostile parties involved and their
location, weapons, hazardous materials, etc. and make sure such
information is passed on to responding units and IC.