Managing a Mass Casualty Incident: A Military Medic's Perspective

Thomas Middleton, is the author of Saber's Edge, a firsthand account of the time he served as a combat medic in Ramadi, Iraq. Click here to read an excerpt from his book that details his response to a glass factory explosion that resulted in multiple casualties and deaths. In the article below, he relates some of the lessons he learned about managing mass casualty incidents as a military medic and how they can be applied to civilian EMS operations.

EMS professionals are accustomed to restoring order out of chaos. Every day, we bring multiple rescuers and an array of tools to aid the sick and injured, and we do so at a moment's notice.

There are times, however, when the need for our services far exceeds our capacity to provide them. Thankfully, managing a mass casualty incident is something few of us ever do, but with numerous casualties to care for, the stakes are high.

We cannot totally avoid chaos during an MCI response, but we can try to minimize it. In a perfect system, all the responders would memorize the playbook. We must accept that response to an MCI is going to overwhelm most people and strain us to the limit. Some degree of chaos is almost inevitable. It helps to remember that we didn't cause the event, but we will do the best we can with the cards we are dealt.

PREPARING TO RESPOND

Incident response begins long before disaster strikes. Local EMS systems usually have protocols in place to handle large events, and all of us receive at least rudimentary training in MCI response in basic EMT class. Not all training has to be on a grand scale, however. MCI training may be as simple as a tabletop exercise in the station with your on-duty crew. When was the last time your agency trained on MCI response in the classroom or held a small-scale tabletop exercise? Have your members trained to the point where you are all comfortable assuming various roles in a disaster?

EMS systems typically conduct regional mass casualty incident drills annually, but does every member of your agency participate in the big event? What about members who were off duty that day, or those who were answering 911 calls while everyone else trained?

You can begin with more frequent, realistic training. If only part of your agency trains for an MCI once a year, you can't expect everyone to be proficient when the real thing happens. Consider using a variety of scenarios with varying implications for scene safety. Structure fires and motor vehicle crashes are more familiar, but what about a building collapse or a terrorist attack?

A mass casualty means anything more than your immediate resources can handle. This is typically five or more patients, but your training scenario can be scaled up or down as needed. Don't forget to practice the concepts used in larger scale incidents in everyday motor vehicle crashes. You may only have three to five patients, but you can still practice the roles of incident commander, triage officer, etc. Remember that under the Incident Command System (ICS), all vacant positions remain the responsibility of the incident commander.

Finally, having done everything you can to prepare, the call comes to respond to a mass casualty incident. What can you do while responding? Depending on the dispatch information, you can begin by requesting sufficient resources and alerting receiving hospitals.

In responding to a mass casualty incident, you have to think of the entire incident as your patient. Avoid the trap of latching onto the first patient you see, ignoring the bigger scene and the other hazards all around you. Be alert for hazards to the rescuers and the uninjured, including hazards the patients themselves may pose to others through contamination or secondary violence. Your goal is not necessarily to save every casualty, but to save as many lives as possible.

THE RESPONSE