In a large mass-casualty event, the actions taken by the first-arriving crew in its first five minutes on scene will often mean the difference between a poorly run scene that risks poor patient outcomes and a well-run scene that gives victims their best chance for survival.
There are many facets to responding to a mass-casualty event. There is the initial scene assessment and setup, triage, movement of patients to casualty collection points, treatment and ultimately transportation for definitive care. A well-designed and well-practiced system will provide for both the safety of the responders and the efficient triage, treatment and transportation of victims. It is important that all EMS responders have a good fundamental understanding of not only the various aspects of triage, treatment and transport, but also principles and concepts pertaining to the management and coordination of MCIs and other large-scale events.
Most of my staff have only responded to one or two large events in their careers. Though they work in a large, high-volume urban system, most have never been involved in a true MCI or large-scale disaster as a field provider on an ambulance. This is not unusual across the country. But it's concerning, because department heads and chief officers typically don't arrive on scene first at an MCI to run primary operations. Instead, the first-due ambulance crew—which might have less experience in the oversight and coordination of large, complex and chaotic events—will, in nearly every instance, be responsible for the initial assessment, setup and coordination of an MCI response.INCIDENT COMMAND
All responders should have a working understanding of the incident command framework and basic ICS concepts. Primary EMS activities typically fit under the Operations Section of the ICS system. This includes medical staging, triage, treatment and transport (see Figure 1).
The historical expectation within the ICS system is that the senior EMS official serves as the Medical Branch Director. Depending on the circumstances, this could also be the person in charge of the Operations Section, or this person might be the Incident Commander, either as a single commander or as part of a unified command team. It is important to the success of any mass-casualty response to place persons with direct experience in the oversight of such responses in charge. These incidents are as unique in nature as hostage situations for law enforcement or high-rise fires for the fire service.
Who serves as the Incident Commander of an MCI is often driven by legislation. Legal emergency scene authority can vary from state to state, so it's important for all emergency service providers (EMS, law and fire) to understand current laws and their limitations. In many instances one agency has the legal mandate to be in charge, but this doesn't mean its command officers have the expertise to do it well. Determining an incident manager solely by legislation raises many questions:
- What about the inexperienced or poorly trained manager? Levels of sophistication vary greatly.
- What happens when nonmedical managers try to dictate patient treatment?
- What happens when there are conflicts of authority? You can have a school shooting with many injured where there's also a hazardous material present.
Coordination of multiple-agency responses must be worked out before they occur. Practically, who's in charge should depend on the circumstances—the primary problems encountered by the responders on scene, not often-outdated and poorly written legislative edicts. The directors and chiefs of the various agencies working these issues out in advance will preclude ineffective and uncoordinated responses by first-due units in the first few minutes after their arrival on scene.NIMS/ICS PRINCIPLES