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Mass Casualty Incidents: How To Be Prepared

EMS, fire, and law enforcement are all dispatched to a local interstate for a report of a tour bus explosion with no further information available. You arrive on scene where command has already been established and fire suppression is underway. You are directed to the role of EMS command and are directed to where the patients are on the side of the highway. All 54 passengers escaped the bus before flames engulfed it and are now located roadside. Some are walking and uninjured. Others have critical injuries. You instantly realize there are many more resources needed than what you have, and at the same time, you realize this is the largest incident of your career. This is “the one.” Can you handle it? Do you have the right mass casualty training under your belt?

Preparing And Pre-Planning For Mass Casualty Incidents

When considering mass casualty incidents (MCIs) like major accidents or an active shooter response, often the thought of them seems overwhelming. However, as with any other incidents, pre-planning, practicing, and continuing education for healthcare and first response professionals help MCIs run smoother when they come along.  

The first word says it all–mass. Mass, meaning many patients, a large-scale incident, and a high amount of responding resources, often from multiple different agencies. This is the key reason behind the need for preparing and pre-planning. There are some questions you should be asking during the preparing and pre-planning process:

  • What are the capabilities of your agency?
  • What are the capabilities of the agencies around you?
  • What specialized tools do surrounding agencies have?
  • What are your resources available for mass transit of green patients?
  • What resources are available for field treatment areas?
  • Are there plans in place for long-term scene support, such as food and toilet facilities?

The time for answering these questions is not when the incident happens. Imagine trying to answer these questions with a large, chaotic scene unfolding in front of you. Wouldn’t it be easier to pull up these answers and draw from them when needed?

As with any mass casualty incident plan, they are only good if they work. That is why MCI drills need to happen. Getting agencies together, putting faces to names, and testing communication equipment to ensure interoperability are all items that should be on your checklist for a drill. Ensuring everyone is using the same triage system is paramount as well.  

There are multiple methods to prepare and plan for an MCI, such as hands-on drills or participating in online active shooter training. For additional information on preparing for an MCI as a leader, see CareerCert’s online courses on the topic. These can be things such as table-top exercises, or a functional exercise. These often gather the key players or command staff together, without involving the “ground-pounders” or those “on the street” in the event. Full-scale, real-world type events are the best method to test plans; however, these are often difficult to arrange and execute due to location, logistics, and staffing/coverage concerns.  (You can view an example of a full-scale mass casualty exercise here.)

Triage During Mass Casualty Incidents

Let’s shift our focus to triage for a moment. This is often under practiced and underappreciated in these incidents. One of the initial topics of discussion with neighboring agencies is to make sure everyone is using the same triage system. The very next conversation should be planning to train together on triage. The concept of triage, whatever the system, seems simple—until it must be implemented. 

Remember that those first on scene typically aren’t command staff. They’re the members of the rank and file. When one of them takes the role of triage, they decide the priority of who gets help first. Some may argue that the person in charge of triage determines, to a degree, who lives and who dies.  That’s why it is crucial every member of your department is prepared.

Triage at an MCI can be one of the most traumatic calls of an emergency worker’s career. People who are injured will be reaching out to you for help. You will see critically injured patients, place black tags on them, and move on. You will have to go against every single instinct you have to help. You will label, possibly stabilize, and move on. (For more about how to prepare for and process the trauma of mass casualty incidents, see On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace by Dave Grossman.)

Coupled with performing triage is performing some life-saving measures. If a patient who is encountered is not breathing, simple airway maneuvers can be performed. Depending on local protocol, an OPA may be utilized. A massive hemorrhage from an extremity wound may have tourniquets applied and an open chest wound may have chest seals applied as well. Depending on the system and mass casualty protocol, hemostatic gauze may be used for a non-extremity massive hemorrhage.  

Rom Duckworth identifies a lack in constant training on triage, tourniquet placement, chest seal placement, and hemostatic gauze use. It can be agreed on that all these items are high criticality and low frequency, which highlights the need for continuous MCI triage training. Lt. Col. Dave Grossman, the author of On Combat, outlines the psychological and physiological reasons that practicing these skills are important. In moments of high stress, the body’s heart rate increases, as does peripheral vasoconstriction. This causes a loss in fine motor movement. This leaves us to rely on muscle memory during stressful situations. This alone should be enough reason to not only prepare but train for MCIs. (For an example of a functional training exercise, click here.)

For additional information on preparing for an MCI and other critical education like active shooter response training, see CareerCert’s online courses on the topic.

It’s 05:45 and your shift is over in 15 minutes. You stand at the guardrail on the side of the interstate and look down at your MCI command board and notes. You realize there were 21 EMS agencies, 3 helicopters, 12 fire departments, 3 Offices of Emergency Management, and 4 911 centers involved in the incident, and 46 patients were transported to 7 different area hospitals. Because of MCI training, planning, and knowing your local resources, you did it. You handled “the one.” Because your department took the time to be prepared, you were ready to provide the life-changing and life-saving care necessary.


Caroline NL, Pollak AN, Elling B, Smith M. Nancy Carolines emergency care in the streets. 8th edition. Sudbury, MA: Jones & Bartlett Learning. 2013.

Duckworth R. How to practice the EMS response to an MCI. (2016, June 30). Retrieved January 15, 2020, from https://www.ems1.com/ems-products/wmd-response-supplies/articles/how-to-practice-the-ems-response-to-an-mci-RLbgNGnAqWIs9U50/.

Grossman D., Christensen LW. On combat: the psychology and physiology of deadly conflict in war and in peace. Illinois: Warrior science publ. 2008

Hannagan C. (2011, July 22). Magee Fire Department chief describes scene of fatal tractor-trailer bus crash. Retrieved January 15, 2020, from https://www.syracuse.com/news/2011/07/magee_fire_department_chief_de.html.

Rielage R. When the MCI hits close to home. (2018, January 29). Retrieved January 15, 2020, from https://www.firerescue1.com/mci-mass-casualty-incidents/articles/when-the-mci-hits-close-to-home-Hg84NR6wmuMqPfv4/.

Jason Haag, CCEMT-P, CIC, SFI, is the Quality Assurance Analyst and Clinical Educator for MultiMed Billing in Baldwinsville, NY. He has more than 17 years of fire and EMS experience. He started as an EMT in 2003 and advanced to the Paramedic level in 2006. In 2008, Jason studied at the University of Maryland Baltimore College to obtain a certification in critical care transport. Jason worked as a CCEMT-P since 2008 and has experience transporting critically ill patients utilizing ventilators, IV pumps, advanced pharmacology, and RSI. He was an EMS supervisor from 2010 to 2018. Jason successfully earned his CIC certification and teaches for many agencies across New York. He also speaks at conferences, hosting classes and reviewing texts for Jones and Bartlett Learning. Jason continues his EMS advocacy through his active involvement with Finger Lakes Regional EMS Council, NY SEMSCO, Wayne County ALS, AHA instructing, NASEMSE, and NAEMT. His involvement with Geneva Fire Department, Boy Scouts, Masons, Rotary, and Ducks Unlimited will occupy his days after his daily family time with his wife, Jami, and son, Gavin.

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