Mass-Casualty Response: The Vital First Few Minutes

     During these smaller responses, command is only transferred if the paramedic in charge is not meeting scene objectives; a patient's condition warrants that the paramedic in charge must leave with his/her transporting unit; or the situation evolves to a point at which a "fixed command" policy takes effect. At any of these points, the field command officer then takes command of the EMS response.

     Incorporating the use of ICS into the department's normal daily multiple-unit responses has made its use familiar to crews. Now, should a large event occur, there will be a smoother and better-coordinated EMS response that's appropriate to the event at hand.

     On arrival at a large MCI, the key is to immediately begin scene size-up, establishment of command, an initial triage sweep and the coordination and assigning of incoming resources. The speed with which these things are accomplished sets the tone. The initial responding unit's understanding of and adherence to ICS principles will be important to smooth operations.

     During this first few minutes, the IC will have to make key decisions as to how expansive scene operations will need to be. This includes the establishment of a designated command post and a fully employed medical branch operation with designated treatment and transport areas. Much of this decision process will be driven by initial triage counts, matched with availability of transport resources. Smaller multiple-patient incidents with no unusual circumstances usually won't require a fully employed ICS medical system. Larger MCIs often will, especially during extended operations. This decision process may be driven by local protocols defining levels of MCIs and medical disasters.

     The Incident Commander should be prudent in his use of transport crews to staff ICS positions. Using them this way may preclude timely transportation of injured patients. During large-scale events, using unified command to share information and make joint decisions will assist in finding appropriate personnel to staff key positions.

     As a scene evolves, continued communication up and down the chain of command is important. Information about ongoing operations drives decisions to change tactics, if need be, to facilitate good outcomes. Communication failures on MCIs almost always contribute to poor patient outcomes.

     The key to remember as the first-due unit is not to get caught up in performing patient care. Should this occur, an ineffective and disorganized response is all but guaranteed. This is a difficult concept for inexperienced EMS providers to grasp. However, routinely using the principles and concepts described above will help providers make the transition from patient care provider to incident manager when faced with a large-scale disaster.

     All EMS providers should have, at a minimum, basic NIMS certifications. But these alone may not be enough. To become truly proficient with the concepts of ICS, EMS providers must routinely seek out other training opportunities, through both formal certification classes and staged and controlled training scenarios, tabletop and live.

     Tabletop exercises allow providers to think theoretically through situations while getting feedback from instructors. They also allow for "what if?" scenarios to be injected based on responses from attendees. Tabletop exercises can be done frequently as part of recurring training programs for providers.

     Live exercises should be completed at least once a year. These should also present varied situations that fit local circumstances. Training on an airport disaster when you have no airport will not yield true benefit. Live exercise training, while time-consuming to plan and carry out, is invaluable in assuring that EMS providers are exposed to large-scale scenarios with instructor feedback before they're involved in a live situation where safety is at risk.

     Mass-casualty scenes and scenes requiring major medical operations are rare for EMS providers. They require a change in mind-set by first-due EMS crews, from direct patient care to scene coordination and management. First-due crews' understanding of the principles and constructs of NIMS and ICS will help ensure a more effective and coordinated EMS response, and ultimately increase the likelihood of positive outcomes for patients. Remember, the first five minutes of any major scene operation can make all the difference.