Small-town MCIs: Where to begin?

How small or rural fire departments can plan and train for MCIs


A pool with high chlorine levels. A tornado striking a small town. An active shooter incident. A school bus rollover. What do these situations have in common? They are all potential mass-casualty incidents (MCIs), and they can happen almost anywhere.

An MCI is an incident that overwhelms the local healthcare system. We often think of MCIs as major events happening in a metro area, but MCIs are just as common in suburban and rural areas – and in fact, it may be even more common there. Think about it: It will take fewer patients to overwhelm a small fire department and ambulance service in a rural town than it will to tax the capabilities of a large urban agency. Smaller departments must be prepared to respond to an MCI, as they will find their primary resources expended quickly.

We respond to many types of incidents that Gordan Graham would deem high-risk/high-frequency. These events, like structure fires or traffic accidents, allow us to gain experience and refine our response due to having multiple opportunities to evaluate our performance.

"Smaller departments must be prepared to respond to an MCI, as they will find their primary resources expended quickly," writes Beck. (Photo/Mizzou EMS)

An MCI, on the other hand, is a high-risk/low-frequency event. We may only see a handful of these events in a career, and some firefighters may never respond to one. If we don’t have multiple opportunities to refine our skills in the real world, then we must find another way to gain experience and build reps. This is why training matters so much.

A successful response to an MCI relies primarily on planning and organizing patients and resources, and that requires skilled people, not just a bunch of expensive equipment. Fortunately, training and preparation for an MCI is easily within the grasp of even the smallest agencies. Any agency can develop a plan, and work with their local and regional resources to develop a framework for an MCI response.

First step: Build partnerships

The three main parts of an MCI response are triage, treatment and transport. Use this framework to determine what resources exist in your area and to engage partners helps organize your efforts.

When an MCI occurs, all of these different agencies and partners will be working together, and you dont want people to meet each other for the first time on the scene. Additionally, individual EMS, fire or law enforcement agencies are probably used to running their own incidents. In a large MCI, having a unified incident command system (ICS) structure is essential to ensure that resources are shared and communication occurs across all the response levels. Preplanning and training will help smooth this transition.

1. Patient triage

When you arrive on the scene of an MCI, you will immediately begin patient triage to calm the chaos and ensure that the most critical patients receive the benefits of initial care and treatment supplies.

Training on a triage system can be easily accomplished. START can provide a common operating playbook for everyone involved. So can SALT (Sort, Assess, Lifesaving interventions, Treatment or transport) or other systems that comply with the new MUCC standard.

[Read next: How to standardize mass casualty triage systems]

Write down mock patient info on sheets of paper, and place them throughout a room. Each page should list patient age, vitals, injuries and breathing. You can also include distracting details, like a child who says he needs to find his mother.

After explaining the system to responders, have them practice by walking around the room and categorizing the patients.” You can then, as a group, talk through each patient. Stress how important it is to stick to the plan of the triage system and that there may be uncomfortable decisions, but that is necessary to get the most help to the maximum number of people.

The next step is using real people as mock patients during training. Each real patient can interact and tell the responder pertinent information. A local high school drama club could be a great source for these “actors.” A mock wound or a paper on the patient can tell the story of an unconscious patient.

Follow this training with another evolution using some training smoke, reduced light levels, loud noises, etc., to add another layer of stress. This crawl-walk-run progression will help responders get more repetitions and prepare them to work in a high-stress environment.

2. Patient treatment

When you need to treat many patients at once, you need many first responders. Depending on your surroundings, neighboring agencies may or may not be an option. In rural areas, an adjacent agency can be a long distance away.

You may need to engage with local clinics or nursing homes. Their staff may not have paramedic, EMT or even first responder certifications, but they are skilled medical staff. Can you partner with them and train them on your triage system and basic life support equipment? In an emergency, they could provide critical staffing for less injured patients (think yellow or green in START) and free up EMS staff to manage more critical patients. The facilities where they work may also serve as a destination for patient transport, making it all the more imperative for them to get involved.

Another benefit to engaging medical facilities in the area will be to gauge how much surge capacity they have and how long it may take to access that capacity. At one mock severe storm disaster drill, a hospital emergency coordinator called his facility on a break. At the drill, people had assumed that his facility was a good place to transport up to 20 mock patients. If the incident were real, they would have had four beds immediately available, along with treatment areas in the ER. The hospital would have been able to make surge capacity available, but the coordinator stressed that it would take four to eight hours to make fully functional, and that was if all the staff was able to return to work. It was a sobering reminder that our hospitals are sometimes nearly full – on a good day.

Consider alternatives like a school space or similar large areas until you can transport patients to another location or town. By looking at these locations ahead of time, you can work out how to set them up quickly to accommodate your treatment needs.

3. Patient transport

Remember, an MCI will require treatment and transport for more patients than you are equipped to handle.

  • How will you get patients to the treatment locations?
  • How will you move patients to definitive care if those hospitals are in another community?
  • How will you transport the patients from unrelated EMS calls during the MCI?

Identify resources that can move these patients. School buses or local transit authorities are great options for individuals who can be transported sitting up. This saves ambulance resources for the patients who require more attention. Further, if your state has disaster EMS teams and equipment like additional ambulances or EMS transport buses, find out how to access these resources and how much lead time they need. Disaster resources sometimes require approval for deployment. Find out how this process works and who needs to make the request.

Develop a plan to manage traffic and resources arriving at the scene – an essential part of the incident command system. Make sure your staging area is large enough to park your expected resources, and that you have a way to track resources once they mobilize to the incident location and when they leave to transport patients.

4. MCI training

A fourth T” can be added to the original framework – training. Sending cross-functional groups like hospital staff, EMS staff and law enforcement to MCI training can help build bridges and ensure everyone understands each others job. The National Fire Academy and Emergency Management Institute and the Center for Domestic Preparedness offer ICS and MCI classes for local government agencies.

A tabletop exercise can be a great way to teach key people from the local agencies what the group learned. Learn more about this in Brian Hupp’s article “Training hard and fighting easy: Creative an effective tabletop training exercise for preplanning MCI response.” These exercises can be used to refine plans for an extensive exercise. In addition, many airports are required by the FAA to hold these types of drills periodically.

Once you have connected with your local resources, plan to hold a few large disaster drills to bring all pieces together. Using a crawl-walk-run mentality means that the first drill may be a group walk-through rather than a full-scale response. Make sure you plan tactical pauses to discuss lessons learned and to make sure everyone understands whats going on. Note: It’s important to make sure everyone is keeping up. If one group struggles and essentially gets left by the wayside, they wont learn anything. They also may not be interested in participating in future events.

Once you are confident that you have a solid team and plan, you can pull out all the stops on a full-scale exercise. These exercises should be designed well in advance so hospitals, response agencies and other groups can plan for additional staff and cover shifts. The training should also have clearly defined goals to focus the efforts. It could be as simple as stressing the transport capabilities, practicing triage in a realistic situation, or working out how the hospital or temporary treatment location will function. Make sure the scenario fits this goal and is realistic.

Keep in mind that if you have an emergency manager involved, they may be able to assist with exercise planning and maybe even funding.

Assess your learning

After any training or incident, perform an effective after-action review to learn from the event. This can be as simple as circling up participants and giving each time to answer these questions:

  • What was planned?
  • What actually happened?
  • What went right or wrong?
  • How can we do better next time?

Remember that the facilitator should speak last, giving each person an uninterrupted chance to answer. The key is to capture lessons and to focus on what, not who. We all have room for improvement, and when a mistake is made, it’s typically an issue with the system more than an individual. We want to fix and improve our systems with exercises.

Work together to be ready

Taking the time to invest in an MCI plan and then training on that plan will be well worth the effort when an incident occurs. When you talk to agencies that have been involved in MCIs, the resounding feedback is that the relationships (or lack thereof) among agencies makes or breaks a response. Reach out to your partners; you will all be involved when a disaster hits, so work together to be ready.

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