Your MCI playbook: Simple tools to prepare for the big day

The best way to avoid analysis-paralysis during an MCI is to ‘get some of your thinking out of the way’ beforehand


Most textbooks and policy manuals define a mass-casualty incident (MCI) as any event in which the medical resources are inadequate for the number or severity of injuries that have occurred.

"A solid game plan, a playbook, and some practice allow the players to know their assignments well before the snap count," writes Knollman.
"A solid game plan, a playbook, and some practice allow the players to know their assignments well before the snap count," writes Knollman. (Photo/South Lake Tahoe Fire Rescue)

With such a broad definition, what constitutes an MCI differs greatly from place to place but can result from myriad incident types:

  • Serious or large motor vehicle collisions
  • Transit accidents (plane, train or bus crash)
  • Large fires or those in buildings with significant life hazards
  • Crowd surges
  • Acts of terror or bombings
  • Active shooter events
  • Civil unrest
  • Weather events
  • Structural collapse
  • Hazmat release
  • Nuclear fallout
  • Pandemics
  • And many other types

This list looks like a greatest hits album for chaos.

When faced with such contrasting emergencies ranging wildly in cause and outcome, first responders can easily be led to a sense of feebleness in our capacity to respond. The feeling of powerlessness combined with these incidents representing the ultimate high-risk/low-frequency response, can bring any department or agency to its knees.

MCIs will happen in your area

As a member of a relatively small suburban fire department, I have felt the urge to write off these events as something that “just can’t happen here.” This rationalization, if embraced as a defense mechanism, may allow us to sleep a little easier now, but on a long enough timeline can lead to an impotent response, heartache and loss.

Our little suburb has already experienced small plane crashes, a transit bus rollover, hazmat incidents, large multi-vehicle collisions, tornado damage and, like everyone else – COVID. Clearly these incidents CAN – and HAVE – happened here, and some combination of the above list will happen again in the future.

The reality we all must accept is that MCIs can and will happen wherever you are in this moment.

Developing a playbook

As a youth football coach, I would often tell my players that they needed to get all their thinking out of the way before the ball was snapped. If a lineman is still pondering his blocking assignment or a quarterback his pass progressions when the play starts, reaction time is slowed to a crawl – and “analysis paralysis” leads to lying flat on your back wondering what the heck just happened. On the other hand, a solid gameplan, a playbook, and some practice allow the players to know their assignments well before the snap count. It allows them to react to changes on the field in a fluid way and troubleshoot rapidly changing situations with limited information and no discretionary time. Sound familiar?

As the fire service has embraced our role as all-hazards response agencies, our mission as well as our responsibilities and roles have grown – but not in a linear way. The expectation placed upon us by those we serve is that we are physically and mentally prepared to handle incidents as they start, grow and evolve. The people in the township I serve may not expect our little suburban department to handle a bus rollover on our own, but they rightfully expect us to be able to recognize the situation and begin executing a plan to bring this emergency under control and get initial treatment and delivery to definitive care to those who need it.

Like those youth football players, we need to get some of our thinking out of the way. We need a playbook, a solid gameplan and some practice. For us these things can come in many forms:

  • Policies
  • Standard operating guidelines and procedures (SOGs and SOPs)
  • Preplans
  • Tabletop exercises
  • Triage methods training (START, SALT, etc.)
  • Communications/plans with local and state EMA
  • Communications/plans with area hospitals
  • Mutual-aid agreements
  • Access and participation in regional to federally typed teams

And there are certainly many other tools at our disposal.

Triage bags assist the first-due units' ability to respond to an MCI. 
Triage bags assist the first-due units' ability to respond to an MCI.  (Photo/Matt Knollman)

Easy planning wins

There are so many simple things we can do to make a difference:

  • Triage bags: Training on and implementing triage bags can greatly improve a first-due units’ ability to respond to an MCI. Locally, our triage bags were supplied by our county EMA but augmented with additional equipment by our own members.
  • COOP: Consider writing and implementing a continuation of operations plan (COOP). Our assistant chief recognized the significance of COVID-19 early in the pandemic and wrote a COOP that has served us well and remained flexible through the pandemic.
  • Regional/federal teams: Join or support larger regional or even federal teams to give you and your members exposure to larger multi-jurisdictional incidents and training. Our local regional technical rescue team partnered with the regional health collaborative to deliver and deploy large, climate-controlled field treatment shelters for triage and patient care. This type of simple interagency cooperation builds the relationships and greases the wheels before the system is strained by an MCI.
  • EMA: Learn about your county emergency management agency (EMA) services, and see where you, your crew or your department can get involved. Does your county have an MCI response plan? Have you read it recently? Where does your department fit into it?

All departments or agencies will certainly have blind spots and will always have work to do – but starting with events that are either the most likely to occur or the most impactful should they occur can help a department start to take bites out of that MCI preparation apple.

Look within your role

This type of preparation and relationship building may not be what most firefighters signed up for when they started out in this career. I know when I joined the fire service, it was not to write or even read policy manuals, train in START triage, or take part in the meetings and communications necessary to facilitate a multi-jurisdiction response. But as current and future leaders in this service, that is exactly what is required of us. From firefighter to fire chief, it is incumbent upon us to ask: What have I done this year, this month, this week, this shift to make sure that my crew, my unit day, my department, and myself are preparing for whatever emergency may come our way?

Look within your role and level of influence to see what you can do. If you work on a company, ask your company officer, battalion or training bureau about your department’s emergency plans. Read and have a working knowledge of your department’s SOGs. Write a crew training about triage at a large MVC on a busy street in your district. Some of the best preparation for large incidents that actually benefits firefighters and EMS providers happens at the crew level where patient care and triage actually take place.

Ben Franklin is often credited with the adage “failing to prepare is preparing to fail.” Sometimes things are trite because they are true.

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