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Responding to an MCI of 9/11’s proportions, with today’s limitations

We must not only “never forget” those who died, but also never forget to stay safe, plan for the worst and to make swift decisions despite challenging parameters


Medical and emergency workers, who are standing in front of the Millenium Hilton, look towards where the World Trade Center towers used to be, after the terrorist attack.

AP Photo/Mark Lennihan

What happened on 9/11 was beyond fathoming for responders of the time ... now add-on today’s limitations of COVID precautions and we’re dealing with a whole different element of MCI response ... but it may not actually change much of “how things get done” when we get right down to the point.

Imagine the task – the challenge – of having to transport 10, 25, 100 or 1,000 patients to surrounding hospitals in the wake of a mass casualty incident (MCI).

Now, add on the already crammed emergency departments, and a national shortage (or allocation issue) of EMS providers, and you’ve got one heck of an equation for a disaster waiting to happen ... no pun intended!

This is our reality, today.

As the somber anniversary of the 9/11 terrorist attacks in New York, Pennsylvania and Virginia nears, we still owe it to our industry to reflect on the lessons learned – the post-incident analysis takeaways – from these MCI events. How has your EMS agency, fire department, rescue squad or emergency management agency increased its front-end training, peri-incident resources, and post-incident analysis practices to be ready for incidents of this magnitude?

How is Pulaski, Wisconsin, prepared to handle an active shooter event at its annual Polka Days festival, with COVID restrictions in place? What about a more populous Castle Rock, Colorado, during a freeway-closing ice storm? Or, a mega-metropolis as it begins to plan for the Superbowl? What would your EMS agency do differently, today, compared to then?

It’s one thing for us talk about crowded emergency departments in today’s context, but it’s another to add-in an MCI event where there’s an all-at-once need for care right now. So, how would we respond to an MCI of 9/11’s magnitude given today’s environment?

Rip the cover off of the flight plan

“What’s this?”

“That’s what they gotta make.”

Those are the beginning lines of the duct tape scene in “Apollo 13”. There was a growing problem onboard the spacecraft that needed some immediate attention. Step one of the procedures to remedy this was to “rip the cover off” of the flight plan.

In the event of an MCI of 9/11’s magnitude, my gut feeling is that that’s what has to happen.

Now, by no means am I advocating for freelancing, self-dispatching, sneaking onto the scene to help ... no! What I mean, instead, is that all the plans in the world cannot surmise to an event of that scale, not without the calm voice, steady hand and the cool intellect of someone orchestrating its response, and that someone might just be you.

Unified command – yes – but, once the phones begin to ring and the first tone drops, someone has to begin the incident command process. I certainly hope by now that your EMS agency has had some sort of discussion, tabletop exercise or planning roundtable with its dispatch, law enforcement and fire service colleagues related to incidents that require this command structure. And, I hope that your last time reviewing any such plans or partaking in any such discussions wasn’t back in 2002, either.

MCI planning and preparedness – for all size incidents – requires ongoing planning and preparedness. Even reflecting upon the magnitude of 9/11, there’s likely a large force of new hires within your agency that have no recollection of “that day,” or the tabletops, MCI trailer purchases or planning that followed after it, so you owe it to them to make sure they’re up-to-speed (from day 1 and annually) on what to do if “it” happens. After all, we can’t expect a new EMT or paramedic – or a tenured one, for that matter – to know what it means to “rip the cover off” if they’re never even seen the movie.

PPE, precautions and doing something, now

Do what you can, what you think is best, with what you have.

That’s pretty much all that you can do (and then document it!).

On any other day of the week or call, yes, please follow your agency’s PPE and precautions guidelines/policies. Even in the event of an MCI of 9/11’s magnitude, do the best that you can ... but I’m sure that we would all understand that dire constraints require swift decisions to be made to care for and transport multiple patients.

Off the wall

Emergency departments are often full because the “house” is often full. Throughput issues are nothing new to many EDs. While I don’t condone the freelance decision to simply drop off your patient and assertively assign them to the ED nursing staff, an instance involving an MCI just might be the time where you have a frank (one-way) conversation with the ED staff right now (and deal with the consequences later). I think that most would understand that you don’t belong “on the wall” during these moments ... you belong on the other side of it so that more patients can be cared for and transported.

Be safe

Jazz-hands up, recite after me: “BSI, scene safe.”

OK, now that we got that over with, it seems only fair to recap what that actually means in the event of an MCI.

Down power lines might be of legitimate concern; barking dogs likely aren’t. Leaking gas lines, falling and unstable debris, secondary explosions (both intentional and incidental), weather hazards, respiratory/dust concerns ... this is what “scene safety” equates to in MCI events.

How is your EMS agency prepared to protect its employees for such responses? Do you have helmets on your ambulances? Ballistic vests? Have you trained on the safety concerns for any of these low-frequency, high-acuity (and high-consequence) incidents?

I hope so; after all, your new-hire onboarding process should be the place to get them prepared for the different types of responses that your agency might encounter ... right?

For those of us who were around during 9/11 – whether as an active responder in our own community or a new/future service member that was involved in the subsequent training that followed this event – we owe it to the future (and new, current) generations within our field to not only “never forget” those who died, but to also never forget to stay safe, plan for the worst, and to make swift decisions despite the parameters that might otherwise be imposed on us on a daily basis.

This article was originally posted Sept. 10, 2021. It has been updated.


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Tim is the founder and CEO of Emergency Medical Solutions, LLC, an EMS training and consulting company that he developed in 2010. He has nearly two decades of experience in the emergency services industry, having worked as a career firefighter, paramedic and critical care paramedic in a variety of urban, suburban, rural and in-hospital environments. His background includes nearly a decade of company officer and chief officer level experience, in addition to training content delivery and program development spanning his entire career. He is experienced in EMS operations, community paramedicine, quality assurance, data management, training, special operations and administration disciplines, and holds credentials as both a supervising and managing paramedic officer.

Tim also has active experience as a columnist and content developer with over 200 published works and over 100 hours of education content available online, and is a social media influencer on LinkedIn within the EMS industry. Connect with him on LinkedIn or at