2 key MCI strategies for incident commanders

It’s time for ICs to reevaluate the first-arriving transport options and coordination with the facilities that will receive patients


MCIs have become synonymous with incidents involving active shooters. But there are many more incident types – many quite common, in fact – that could strain resources, creating a mass-casualty event. Some examples: vehicle collisions with multiple patients and any hazmat incident, including carbon monoxide (CO) releases.

Firefighters and EMS personnel will immediately go to work at an MCI, doing whatever they can to assist. But let’s pause to consider the role of the incident commander (IC). Specifically, we’ll review two often-overlooked strategies that the IC can implement to achieve a more streamlined and successful patient treatment plan.

1. Keep the first-arriving transport unit focused

By delegating first-arriving units as mobile
By delegating first-arriving units as mobile "field hospitals" as well as notifying ERs and coordinating patient transport, incident commanders can help achieve a more streamlined and successful patient treatment plan. (AP Photo/Julio Cortez)

I was once associated with an agency whose policy concerning MCI triage automatically designated the first-arriving medic unit as the triage group/supervisor. The reasoning was twofold: First, medic units were always staffed with at least one paramedic, permitting the most “medically trained” arriving member to distinguish the priority of injured patients. Second, the medic unit was well stocked with medical supplies in comparison to the first-arriving fire apparatus, and theoretically could serve as a mobile “field hospital” enabling responders to treat multiple patients on the scene.

This approach has some significant shortcomings. Triage is a basic emergency medical skill set. A seasoned EMT could effectively and quickly identify the designation and/or initial treatment of the patients involved. This task includes giving the IC an accurate patient count and advising them of the resources needed to both manage the scene and transport patients to emergency rooms. By limiting an advanced provider’s capability to simply triage, you potentially limit the on-scene emergency care, especially the ALS components of patient management like fluid replacement, airway management (RSI) and analgesic medication administration, depending on the affected agency’s medical protocols. Further, this practice also takes away a paramedic who could be transporting critical patients to the emergency room.

Ambulances are a precious commodity during MCIs. Most departments are not blessed with infinite resources to transport patients. Remember, critical patients need to reach definitive medical care within the “golden hour.” By removing the first-arriving ambulance from the MCIs stream of resources to transport the injured, you are now working against the overall goal of reaching definitive care in a timely manner.

2. Notify ERs and coordinate patient transport

Similar to the issue of transport resources, not all fire and EMS departments have limitless hospital resources within their jurisdictions. More than likely, they may be restricted to one or two regional emergency departments to transport injured patients. As such, the IC must know their local hospitals’ capabilities and resources in order to effectively manage patient transport. This will require immediate notification, coordination and cooperation from both the incident scene liaison and hospital designee.

It’s important that fire personnel understand why this is such a big issue. The bottom line is many of our emergency departments are routinely operating at max capacities in terms of patients. Add staffing shortages, and limits or strain on specialist capabilities, like neurosurgery, and it’s easy to see why ERs won’t be able to handle an immediate influx of patients who are critically injured during an MCI.

For instance, even a well-staffed Level 1 Trauma Center is restricted in terms of simultaneously treating critically injured patients. The ER could have three or four trauma bays and three or four surgery bays, but that doesn’t account for the availability of nurses, doctors, specialists and support personnel. In my jurisdiction, the communicated number of critically injured patients that our primary receiving facility could manage at any given time is four. FOUR. What’s your number?

Taking the step to notify the receiving facilities of the incident, patient count and injuries will assist the hospital with preparing to receive multiple patients. This advanced notice will allow for the ER to begin call-back procedures and moving non-critical patients to other areas of the hospital. Additionally, this heads up will allow the hospital to set up its own triage system before the first patient arrives.

If the IC has multiple hospitals that can receive patients, then on-scene coordination is even more important. Assign a medical branch supervisor who can work with the triage group and relay information to the in-play ERs. This forecasting initiative can help the overall outcome of the patients on the scene, as the coordination may get the transported patient to immediate definitive care faster.

Plan for better outcomes

These two strategic considerations for the IC at an MCI may seem simple, but they could give patients a better chance at a positive outcome. I encourage you to consider reevaluating your MCI plan to account for keeping your transporting units available, plus enhanced coordination with receiving facilities.


‘Utter chaos”: The reality of MCIs

I was not an incident commander, but rather a firefighter-paramedic. It was a busy summer night. I was riding the ambulance that shift when a MVA involving a pedestrian was dispatched out.

As we got into our apparatus, an update was given over the radio advising that multiple people were injured and that police requested EMS to the scene ASAP. I was not the senior person on the ambulance that shift, but I remember my OIC immediately requesting three more ambulances and tried to ascertain a patient count update as we drove the short distance to the incident scene from the firehouse.

The environment was utter chaos, filled with blue flashing lights and indistinguishable noise. A vehicle, in an attempt to flee police, drove up on the busy boulevard’s sidewalk. This resulted in several bystanders being struck by the car until it eventually hit a utility pole and another vehicle at the nearest intersection. Reflecting back, this was probably a fortunate event that probably prevented the carnage from becoming worse.

We arrived and were completely overwhelmed. I remember officers and random bystanders trying to pull us in every direction. Our officer on the fire apparatus assigned us to begin triaging the injured pedestrians, as they assessed the injuries inside the two vehicles that collided. He immediately requested resources equivalent to a structure fire response to the incident scene in order to get enough working hands. The additional request for ambulances climbed from three to five.

We were close to 14 injured patients, with four designated as critical. Our intention was to support the transporting of patients to the emergency room after our initial triage; however, our ambulance was swallowed in a sea full of police cars, fire trucks and the 100 or so bystanders that encircled the scene. I remember that our police officers did a great job controlling the crowd that night, and eventually opened a lane of traffic that could provide the subsequent arriving ambulances a way to access the scene. This is another important tactical issue to address: Remember to keep lanes of travel open as best as you can. We were eventually able to transport, but were the fourth or fifth unit to do so.

Our incident commander did a good job with coordinating the treatment and transport of the injured to the emergency rooms. He was able to do this with an EMS officer from a mutual-aid department, who provided most of the responding ambulances to that event. The key points stressed in the article were established as priorities, and fortunately, all the patients had the best outcome possible.

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