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MCIs are changing: Are you ready?

Our approaches to MCI response and management need to evolve to reflect their increasing complexity and danger


As our society continues to evolve, our conventional approaches to MCI management must evolve to reflect the complexity of communications, self-transport, civilian rendered care, violence and criminal acts associated with modern-day MCIs.

AP Photo/John Minchillo

The escalating level of violence in society, increased incidence of domestic and international terrorism, coupled with the rise of social media use and the realities of generational differences in the population have drastically altered the effectiveness of conventional mass casualty incident (MCI) response paradigms. In more recent MCIs, conventional management strategies and long-taught practices have gone out the window. There is an urgent need for public safety leaders to adopt thinking that reflects current trends in society.

A complex coordinated terrorist attack scenario

It was a typical Tuesday in Saratoga County, New York. The cinema located in a mall approximately 3 miles outside the county’s largest city offered an afternoon matinee that attracted more than usual numbers, owing to it being a school holiday. The timing of the movie corresponded to later arrival of multiple commuter buses carrying parents who worked in state government offices some 35 miles south. About 40 minutes into the matinee, an unknown gas began leaking into the theater through the HVAC system. This resulted in difficulty breathing, coughing and choking symptoms.

Hundreds of panicked theater patrons attempted to exit. Responding firefighters were hampered by the mass exodus, noticing that many of the victims appeared blinded. Social media was flooded with messages from the scene: “A green gas is coming through the vents” and “my boyfriend having a seizure – people crawling, trying to find the exits – I see people on the ground in theater 4, not moving.”

While a unified command post was established outside the mall, buses carrying commuters began arriving at the front of the facility. Without warning, a ferocious explosion destroyed one of the commuter buses as passengers were preparing to exit. The force of the explosion badly damaged other buses, hundreds of cars and buildings, and untold numbers of people in the vicinity. Moments later, automatic gunfire erupted, aimed at the command post and staging areas. Witnesses reported numerous fire, law enforcement and EMS providers down, along with dozens of civilians.

It took only moments for victims from the theater, the explosion and subsequent shooting victims to pour into a freestanding urgent care center located directly across the street from the mall. The urgent care, neighboring medical practices and, ultimately, the closest hospital, a few miles away, were overwhelmed with casualties.

The gas released through the theater HVAC system was chlorine and signified what shortly became evident as a complex coordinated terrorist attack (CCTA).

This event was, fortunately, a tabletop exercise, conducted for Saratoga County leaders by the U.S. Naval Postgraduate School Center for Homeland Defense and Security Mobile Education Team. Many valuable lessons were learned by first responders, critical infrastructure participants and county government leaders.

While there has yet to be such an event in the U.S., experts agree a CCTA will happen.

MCIs are changing; so must our response

The scope of MCIs has changed considerably over time, as has the behavior of citizens involved. Our conventional plans for controlling the chaos at an MCI scene, triaging patients, and then distributing them to hospitals in an organized fashion frequently fall apart, especially at intentionally caused events. Further, citizens have readily available means of communicating, by phone and social media platforms. They often exit the scene well before emergency responders arrive, and are treated and transported by trained and well-intentioned bystanders or others involved in the incident.

Our healthcare system today runs at near capacity, often resulting in additional crises when a devasting event occurs in a community. It may be time to revise our plans to better reflect modern citizen response and actual experiences with recent MCIs.

Social media impact: At the initial notification of a potential MCI, we should expect that citizens will take to social media to describe the situation and alert others. The capacity to monitor social media reports and collect information should be integrated into every 911 center.

Transport: The mobility options available to citizens means that many people will leave the scene prior to our arrival. Shared ride services not only serve as a readily available way to leave an MCI scene, but they have also shifted citizens’ mindset to seeing that any vehicle can be used for transport. Over time, fewer and fewer MCI victims will be transported by EMS. Quick notification of hospitals and medical practices in the community will help them to prepare for surges, even if not from ambulance transport.

Hospitals may also require assistance from public safety agencies as patients arriving by conveyances other than ambulances may need to be moved from these vehicles into the emergency department. Further, huge influxes of families and friends require increased security at healthcare settings so they do not interrupt patient care.

Equipment and supplies: Training that we have provided in the community using courses in bleeding control, airway management and first aid often result in large numbers of trained but unequipped civilians pressing first-arriving responders for equipment and supplies. Every response unit should carry go bags containing the equipment and supplies needed by civilians to render care to others.

Triage: Triage itself seems to break down, often because of complexity of the systems used, plus a lack of familiarity or tendency of responders to render care instead of focusing on triage. Planners should consider more simplified triage systems that account for large numbers of victims of intentional violence rather than natural disasters for which many of our current triage systems were designed.

Patient distribution: Given that many casualties will arrive at hospitals and medical facilities by means other than EMS, our paradigm for distribution needs to shift from one operated out of the scene to one that looks at capabilities, capacity and load across the healthcare system. With the availability of urgent care centers, surgery centers, freestanding emergency departments and other healthcare settings, an MCI should trigger the ability of EMS to deliver patients to non-hospital destinations and become actively involved in redistribution of patients across the healthcare system.


911 and call centers: The proliferation of cell phones results in overwhelmed 911 centers. Not only do calls for assistance come from the scene, but also family and friends of victims who see reports of the incident on social media. Alleviating overwhelmed 911 centers by rapidly standing up call centers or automatic overflow to neighboring 911 centers that are able to stay fully informed on the events in progress are helpful preplanning initiatives.

Mass notifications: Mass notification to all local cell phones using available emergency alerting systems should be used to assure the public aware that responders are aware of the event. These notifications can also identify the locations of family/friend reunification points and facilities for patients with minor injuries so they don’t overwhelm emergency departments.

Multi-agency communications: The fact that MCIs often involve violence or intentionally harmful actions against others requires that all public safety disciplines be able to communicate with one another using multiple platforms as overwhelming communication’s traffic is likely to result in failures of radio systems, cellular service and internet capability. Out-of-area units that may be called to respond also need communications capabilities once they arrive on scene. Face-to-face communication processes and hand signals should also be included in communications plans.

Community communication: Rumor, spread through social media channels, has disrupted hospital operations and patient flow at recent MCIs. Public information officers (PIOs) should be proactive and aggressive in disseminating reliable official reports and quickly countering incorrect information circulated on social media.

Time to evolve

As our society continues to evolve, our conventional approaches to MCI management must evolve to reflect the complexity of communications, self-transport, civilian rendered care, violence and criminal acts associated with modern-day MCIs. We cannot continue to plan and exercise using decades-old MCI management models, many of which were designed for management of accidental or natural disasters.


Hodgson, Luke. “How Violent Attacks Are Changing The Demands of Mass Casualty Incidents: A Review of The Challenges Associated with Intentional Mass Casualty Incidents.” Homeland Security Affairs 17, Article 1 (April, 2021).

Moran M E, Zimmerman J R, Chapman A D, et al. (June 23, 2021) Staff Perspectives of Mass Casualty Incident Preparedness. Cureus 13(6): e15858. doi:10.7759/cureus.15858.

Mike McEvoy, a leader in the EMS world, shares his expertise on issues effecting the jobs and lives of firefighter paramedics. Read, ‘Fire Medicine,’ McEvoy’s FireRescue1 column, to learn about first responder stress, the criminalization of medical errors, current epidemics, and more.