The MCI or mass-casualty incident can perhaps best be described as any incident that results in enough injured or ill victims that it overwhelms the immediate capabilities of the emergency medical services (EMS) staff not only on the scene but also those who could reach the scene in a timely manner. This definition is flexible enough that it applies equally well to the small-town agency with few resources as it does to the larger agency with an abundance of resources. Another important aspect of this definition is that it is cause-neutral – i.e., it applies just as well to a motor vehicle accident as it does to a major fire or a terrorist attack. The role played by EMS personnel also is cause-neutral; the result is that, unlike other responders whose roles change in accordance with the size and nature of the threat, the role of EMS at an MCI is always the same. In theory, the role played by EMS sounds simple: treat and transport the injured and ill from the scene. However, because the basic assumption defining an MCI is that there are not enough resources immediately available to carry out those tasks, changes in the operational specifics have to be made. The familiar components of the incident command system (ICS) are put into play; in the staging phase, resources are provided to permit operations of both the treatment sector and the transportation sector. Because both the function and the form of the components of the ICS system are largely the same, the focus of this discussion will be on operations, since an MCI requires both that additional components be added to the ICS structure and that a deviation from normal procedures is not only permitted but sometimes absolutely necessary. An Assumption of the Unusual The EMS role in the operations area is divided into three major tasks: triage, treatment, and transportation. The important point to understand here, though, is that this is not a business-as-usual situation because, as mentioned earlier, the definition of an MCI starts with an assumption that the event cannot be handled as normal. Unlike “routine” emergencies in which each request for assistance is followed immediately by assignment The important point to understand is that this is not a business-as-usual situation because, the definition of an MCI starts with an assumption that the event cannot be handled as normal of an EMS team, the declaration that an incident is of a mass-casualty nature assumes that such a rapid response is not possible, and therefore requires that specific decisions be made about which victims receive care first, and in what order of priority. During everyday emergencies the sickest patient receives treatment first; but during the triage phase of an MCI situation this rule is modified and those considered unlikely to survive do not receive care first – and also are provided transportation last. Operations in the treatment phase of an MCI are similarly modified in that only life-saving care is administered by EMS staff while on the scene of the MCI. Some injuries, such as small and less serious wounds that are not life-threatening, may not be treated at all. Finally, the transportation phase of the response to an MCI focuses on spreading the load among all available hospitals rather than following the normal procedure –which is simply to provide transportation to the nearest hospital. During an MCI, the travel distance to a hospital matters primarily in how it affects getting the ambulance back in service, and patient preference matters not at all. For planning purposes, it is important that these modifications to normal operations be set forth in writing as part of the treatment protocols or regulations that the EMS units must operate under – for two principal reasons: First, so that legal concerns do not complicate the operational responsibilities of the EMS personnel at the scene of an incident; and second, so that these important changes of policy are made by political decision makers, in a deliberate and well considered manner, before the occurrence of an MCI rather than by the EMS staff on the fly and on the scene. _________________ Links for Additional Information For more about the incident command system http://www.training.fema.gov/EMIWeb/IS/is100.asp http://www.nimsonline.com/ics_training_docs/ICS_glossary.pdf Some helpful ICS tools from OSHA (especially the electronic ICS forms) http://www.osha.gov/SLTC/etools/ics/index.html http://www.citmt.org/start/default.htm http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=137373#B2 REMSCO http://www.nycremsco.org/default.asp Simple triage & rapid transportation (START), appears as Appendix L in the NYC REMSCO Protocol book http://www.nycremsco.org/apendices.asp?intCategoryID=6&intArticleID=62 Triage tags http://www.mettag.com/mt137.php http://www.triagetags.com/ http://www.simplerlife.com/contriagtag.html http://www.simplerlife.com/cersimtriagt1.html
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.