Mass Casualty Incident

NCM 121 Disaster Nursing

Skills Laboratory level 4
10 Things You Need to Know About
Mass Casualty Incidents to Save Lives

What are the most important things to

remember in order to save lives in a mass
casualty scene? There are a plethora of
wonderful ideas, methods, and memory
aids for staying calm in a crisis, but here are
ten pointers that any level of EMS worker
can employ to help manage mass casualty
crises.
1. START INCIDENT COMMAND EARLY
• The first arriving troops identify the issue and state explicitly that an
incident commander is in charge. If you and your partner are the
only ones arriving on scene, one of you assumes command while the
other does a scene assessment and triage.

• The risk of not starting IC is that vital contact with dispatch and
incoming units will be missed, the overall situation will be
incompletely assessed, and preparation for additional resources will
be delayed. Arriving assistance will not be briefed, and they will
have to find out what is going on and what they should do for
themselves.

• Early on, take authority of the situation and establish command. You
can always pass it on to someone else.
2. CONDUCT A SCENE SURVEY

• For the safety of providers, the care of patients, and the success of
the event action plan, a swift but complete inspection of the scene is
essential.

• Early arriving units must figure out what happened and how it
happened (i.e., the mechanism of injury) and ensure that any safety
problems are addressed. All of the victims involved in the incident
should be identified during the scene investigation.

• The concept of a 360-degree survey is prevalent in the fire service.

Simply put, this is seeing the scene from all sides. It could entail
personally walking around the scene or, at the very least, collecting
reports from people who have checked each location. Remember to
look for patients who have walked away or have been discharged.
3. MAKE THE CALL FOR MORE
RESOURCES EARLY
• Now that you've established incident command and have
a good understanding of the scene and the issue, it's time
to request further assistance. Get them started as soon as
possible. You've heard it before: It's better to get help
going and then cancel it if it turns out you don't need it
than to wait longer for them to respond. This is especially
true for those of us who work in more rural places, when
the nearest source of backup is many miles away.
4. WEAR IDENTIFICATION TO
DELINEATE YOUR ROLE
• It's critical that EMS providers, especially the incident commander,
can be easily identifiable on the scene. Wear some type of clear
identification, whether it's a brightly colored vest, ball cap, helmet,
or glow stick affixed to your shoulder, so that other responders
know you're incident command, operations section chief, EMS
branch director, or one of the group supervisors.

• The fact that ICS is being utilized is established, and others are
reminded to follow it. Visual identification also cuts down on the
time it takes to look for an incident commander on the spot.
Nothing is more infuriating than being on the scene ready to work
and having to question each individual who is in charge who is in
charge.
5. PERFORM PATIENT TRIAGE AND
TAGGING
• Patient triage and the use of triage tags is one of the more
contentious aspects of MCI treatment. It's obvious that we
haven't found out the ideal approach to triage and tag
patients, but that doesn't imply the reasons for doing so aren't
sound.

• Triage is intended to be a quick and easy way to sort the

patients that require assistance. It isn't a comprehensive or
conclusive analysis. That will be provided to patients at a later
time. The initial triage is meant to help you figure out how
many patients you have, what their general conditions are,
and what additional resources you'll need. A good triage
sweep gives crucial information that can help incident
leadership gain better control over the situation.
6. USE CHECKLISTS AND REMINDER CARDS
• MCIs aren't something that most of us deal with on a regular
basis (thank goodness). It could have been months or even
years since your previous mass casualty drill.

• How can we remember the steps we need to follow in these

particular situations with all the other things we have to
remember every day? Checklists and reminder cards are a
simple and effective approach to remain on track, make
decisions, and ensure that nothing is overlooked.

• Basic checklists for each EMS-related job in the ICS are

included in many commercial EMS MCI kits. Many state and
regional MCI template plans also include checklists.
7. KEEP RADIO TRAFFIC BRIEF, CLEAR AND
NECESSARY
• Communication has shown to be one of the most serious flaws in
MCI's response time after time. Responders can strive to
decrease the amount of radio traffic they contribute to aid with
this.

• Think about what you're about to say before pressing the

"speak" button, and be sure it's necessary. It may not be
necessary to take up limited airtime if it does not assist someone
else in doing their work or staying safe.

• If you really must send a message, keep it brief and sweet. If you
are the message's recipient, answer and briefly restate the
message's essential details to ensure that you received it
accurately and understand it.
8. NOTIFY HOSPITALS EARLY AND KEEP
THEM UPDATED
• Not only must the hospitals in the region be prepared to take
patients transported by ambulance from the scene, but they must
also be prepared to receive wounded who self-transport. We've
noticed an increase in the number of patients being brought to
nearby hospitals by law enforcement, taxis, ride-sharing services,
and well-meaning spectators in recent incidents. In rare situations,
badly injured patients have arrived at hospitals before even being
informed of the tragedy.

• Establish a strong communication link with the base hospital,

medical coordination center, or other resource in charge of directing
patient transportation and keep them informed throughout the
incident. Make sure they know when all of the patients have been
transported so that the triage teams may be deactivated.
9. PRESERVE VEHICLE INGRESS AND
EGRESS ROUTES
• Be cautious about where you park when you get at the site.
Aside from safety problems, routes for ambulances and other
emergency service vehicles to enter and exit the area must be
maintained. Randomly parked, driverless equipment cluttering
the only path in and out of a scene would bottleneck it faster
than anything else.

• It will be worth your time to park properly before hurrying to

your patient in order to keep other patient transports going.
Establish one-way traffic lanes in and out of the scene if you're
in an ICS position. Incoming units might be directed to staging
until they are needed, which could help reduce congestion.
10. TRACK PATIENTS TRANSPORTED FROM
THE SCENE
• The tracking of patients transported from the incident area is an often-
overlooked part of MCI management. While patient tracking is unlikely to
affect or improve the patient's care during transportation, it can have a
substantial impact in the long run.

• After an MCI or tragedy, hospitals frequently struggle with identifying victims

and reconciling them with loved ones. This is especially true when juveniles or
patients who are unable to communicate for themselves are involved.

• Information from a patient tracking system may assist law enforcement in their
investigation of the incident, and it will be crucial in documenting the incident
thereafter. Cost recovery and the establishment of after-action reviews will be
aided by patient monitoring data.

• Products and systems are becoming more accessible as technology improves.

THE BOTTOM LINE

• Regardless of how well prepared we are, responding to

mass casualty occurrences and other calamities can be
chaotic and difficult. Response plans, training, and drills
can all help us improve our ability to react fast and save
lives. Participate in your service's preparation efforts and
keep these ten tips in mind to help bring control and
safety to the scene.
MCI LEVELS
• Level A (Minimal to Moderate) MCI
• The vast majority of MCIs in NYC will be classified as a
Level A (Minimal to Moderate MCI). This is a relatively
static incident producing or with the potential to
produce a small number of critical patients. Hospitals
near the MCI (minimum of 2, including the closest Level
1 or 2 Trauma Center) are called by EMD and told to
prepare to accept patients up to the hospital's Level A
fixed allotment.

• Examples of Level A MCIs: motor vehicle accident or

residential fire with small numbers of potential patients
• Level B (Significant) MCI

• This is a relatively static incident producing or with the

potential to produce significant numbers of critical
patients. Hospitals in a broader vicinity of the MCI
(minimum of 3) are called by EMD and told to prepare
to accept patients up to the hospital's Level B fixed
allotment.

• Examples of Level B MCIs: bus accident, small residential building

explosion/collapse.
• Level C (Major) MCI

• This is a dynamic incident producing or with the

potential to produce a substantial number of critical
patients. Hospitals in a still broader vicinity of the MCI
(minimum of 5) are called by EMD and told to prepare
to accept patients up to the hospital's Level C fixed
allotment.

• Examples of Level C MCIs: mass shooting, medium to

large building explosion/collapse.
• Level D (Catastrophic) MCI
• This is a catastrophic event that will likely overwhelm the health
care system. Hospitals are expected to redirect all efforts to
incident response. Rather than rely solely upon a notification call
from EMD for such an event, hospitals should instead rely on
notification sources such as NYCEM Watch Command hospital
radio transmittals, NYCEM All Call email notifications, and
information from credible media outlets. All hospitals should
prepare to receive patients above their Level C fixed allotment.

• Examples of Level D MCIs: World Trade Center attack, intentional

release of poison gas in subway system.
RETURN DEMO
Scenario 1: Bus Accident

• At 5:35 p.m. on Friday of a holiday weekend, 911 receive multiple calls

about a vehicular accident on a nearby roadway. During the holiday
weekend rush hour, a bus crashed into the back of a tractor trailer,
resulting in a four-vehicle pileup, consisting of the bus, tractor trailer, and
two other cars. The bus’s front windshield shattered on impact.
• By 5:50 p.m., fire, EMS, and police begin arriving on the scene. Passengers
of the vehicles involved in the crash have begun evacuating. A number of
other vehicles have stopped, and drivers have tried to help those involved
in the accident.
• By 5:55 p.m., fire and EMS have begun searching the vehicles for any
additional passengers. EMS units are triaging and treating patients on the
street.
• By 6:00 p.m., EMS notifies three nearby hospitals per established protocol.
Each hospital’s ED receives a notification that a Level B MCI has occurred
near the hospital. The nature of the incident is a motor vehicle accident.

• Anticipated injuries: blunt/penetrating trauma, burns, minor injuries

Scenario 2: Park Concert Shooting
• At 7:30 p.m. on a Friday evening, 911 receives several calls about a
shooter in a nearby park during a summer concert. About 300-400
people are believed to be at the concert, including children and teens.
911 continues to receive multiple calls about injured people. Many are
injured and trampled in the process of fleeing the park.
• By 7:35 p.m., fire, EMS, and police are arriving on the scene. However,
they do not have the shooter’s exact location. Fire and police set up
their command posts.
• By 7:40 p.m., EMS units are treating some patients who are outside the
park, but have not yet been able to enter the park area itself to retrieve
victims.
• By 7:45 p.m., based on the number of anticipated victims, EMS notifies
five area hospitals per established protocol. Each hospital ED receives a
notification that a Level C MCI has occurred nearby. The nature of the
incident is an active shooter, and both adult and pediatric victims are
expected.

• Anticipated injuries: blunt/penetrating trauma, crushing, minor injuries

 Scenario 3: Explosion at a Nightclub
• At 2:00 a.m. on a Sunday, 911 receives several calls in rapid succession about an
explosion at a nightclub in proximity to the hospital. It is a large, popular nightclub with
apartment buildings on either side. Routinely, about 1,000 people visit the nightclub on
weekend nights. 911 continues to receive multiple calls for patients injured.
• By 2:05 a.m., fire, EMS, and police are arriving on scene. A second explosion occurs
inside the nightclub. The main entranceway is packed with patrons trying to escape,
with many trampled in the process. The second explosion seems to also impact one of
the adjacent apartment buildings.
• By 2:10 a.m., EMS units are treating approximately 50 patients on the street.
• By 2:15 a.m., based on the number of anticipated victims, EMS begins notifying five
area hospitals per established protocol. The hospital ED receives a notification that a
Level C MCI has occurred near the hospital. The nature of the incident is an explosion,
and there are both adult and pediatric victims.

• Anticipated injuries: blunt/penetrating trauma, burns, crushing respiratory impact