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‘That won’t happen here’: The MCI mindset that needs to change

An honest and objective community assessment will highlight the many potential MCI events that could occur in any jurisdiction


Have we discussed how to manage a lot of traumatically injured people at once?

Photo/Trevor Frodge

A mass-casualty incident (MCI) will tax any agency regardless of the agency’s size, level of preparation, or available resources. This has been proven time and again by the MCIs that occur every year across the United States.

Unfortunately for many responders, we do not pay enough due diligence or respect to the fact that an MCI can, and likely will, occur in our running districts. Too often we take the approach of “that can’t happen here” or “that is a big city problem.” But it’s not a big city problem; it can happen in any agency, and it is going to be our problem when it occurs on our shift.

Defining MCIs

Any discussion of an MCI will likely first conjure images of an active shooter situation at a school. While the active shooter is an MCI, it is just one of type of event that can occur in our districts.

An MCI is defined an incident that places great demand on the EMS system and has the potential to produce multiple casualties. Some texts will place a specific number of patients as well, which can lead to confusion as to what constitutes an MCI. For instance, the American Academy of Orthopaedic Surgeons (AAOS) text for EMS defines an MCI as three or more patients, whereas my local protocol is 10 patients. We must look beyond static patient numbers and focus more broadly on our EMS capabilities within and outside of our organization. What can we effectively manage?

Let’s consider some types of MCIs and where they commonly occur to start brainstorming our planning needs.

Active shooter events: Looking at active shooter situations or violent incidents is a good starting point. Does your agency have schools in its running area? Within those schools, is there the potential for conflict from bullying, parental issues at home, relationships, or other factors? Of course there is; this could happen anywhere, meaning there is the potential for a violent incident. How many students attend that school? What is the building layout? What is the plan for evacuation or shelter in place? Is there a school resource officer?

All of these questions help first responders plan for the ingress and egress of EMS resources, the assembly of rescue task forces for entry, and to build a unified command post to manage the overall incident.

Places of worship: Does your running district have a worship center? Are there multiple worship centers with multiple religions? Within a mile in my area, there is an Islamic Mosque, Catholic church, Presbyterian church, Baptist ministry and Lutheran church. What are the peak times for worship? Is access an issue? Does the worship center have a safety team or police presence? Are there events during the week? We don’t want to think of violent incidents occurring in a worship center, but the fact is that they have occurred and will continue to occur, so we must be prepared.


Interstates and highways have the potential to create an MCI with every crash due to the high speeds and number of vehicles involved.

Photo/Trevor Frodge

Roadways: Does your agency cover a highway, or rather any roadways? Are there busses for school or general public transportation? What about passenger rail systems, airports, ferries or other modes of travel? Interstates and highways have the potential to create an MCI with every crash due to the high speeds and number of vehicles involved. Don’t be fooled or lulled into a sense of complacency, though. Even smaller roads or main thoroughfares can also produce an MCI from a crash. Consider a simple two-vehicle crash, but both vehicles are minivans full of kids. What if we have a crash with four or five vehicles involved? Do we have a plan or have we discussed how to manage a lot of traumatically injured people at once?

Structure fires: Another shift in MCI thinking is the “bread and butter” structure fire. At a recent fire alarm activation at one of our apartment complexes, I asked my probationary firefighter how many units were in the building. This particular apartment building has 36 individual units, all non-sprinklered and not monitored by a central alarm system. At the minimum, if that building has a significant fire, there are 36 potential victims although we know the number is substantially higher. Some units are single occupancy, while others have been found to have six to eight people occupying a single unit. While we mount an aggressive fire attack, there also must be an aggressive command and control to manage myriad people flooding out of the building with various injuries and respiratory issues.

Natural disasters and beyond: Is a nuclear bomb likely to go off in my suburban fire department in the Midwest? Likely no, but there are so many other issues that can occur. Natural disasters such as tornadoes, hurricanes and earthquakes will devastate the local population and overrun the EMS and healthcare system in many cases. Hazardous materials releases can wipe out a neighborhood. The point is, it can happen, and it will happen, so we must prepare.

MCI assessment and planning

So how do we plan for MCIs? Begin by surveying honestly and objectively what your agency can handle. My agency is a fire-based EMS system with three ALS ambulances. As such, we can transport three people. We can treat several more in the field, but we need more resources.


For rural and volunteer companies, the need for resources is even more pressing due to diminishing volunteerism in the fire service, unavailability during daytime hours, and long drive times as communities are more spaced apart. What can your neighbors provide without sacrificing their own coverage needs?

Perform a community risk assessment on what is most likely to occur. Consider roadways, schools, churches, railways as well as the possibility of terrorism, even if it seems remote.

Finally, form an aggressive incident management system with clear roles, responsibilities and expectations for triage, treatment and transport. The MCI is an incident that cannot be approached like our typical calls; we must be flexible and fluid with the circumstances that are provided. Ensure that mutual-aid partners and chiefs are involved in the planning and incident command response.

MCI inevitability

MCIs are an inevitability in our jobs, and we must plan and prepare for them. MCIs include far more incident types than a chemical attack or terrorist bomb; they include any event that has the potential to overwhelm resources during our everyday incident responses. With some simple preplanning and teamwork, we can build a robust plan of attack with our agencies and neighbors. This will best position us to take the actions that may ultimately save lives – our primary mission.

Trevor Frodge is a fire lieutenant with the West Chester Fire Department in suburban Cincinnati, Ohio, currently assigned to one of two rescue engines. He is a nationally registered paramedic, fire and EMS instructor, and fire inspector. Frodge is a member of the Butler County Technical Rescue Team, as well as a Hazardous Materials Specialist for Ohio Task Force 1.