A mass-casualty incident (MCI) is defined as an event that “overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time.”1 Just reading this definition explains the inherent challenges of such an event: Terms like overwhelm and exceeds are scary and require a concerted effort from multiple agencies working cohesively and fluently in response. Consider these aspects now to be better prepared when it happens to you.
Communication failures remain chief among contributing factors to the complexity behind MCI responses. Since MCIs inevitably involve multiple agencies that often use different frequencies, a lack of communication is a danger to both the initial MCI victims as well as the responders.
To examine the issue more deeply, we can use the findings from the 2018 After-Action Review of the Orlando Fire Department Response to the Attack at Pulse Nightclub, developed by the National Police Foundation and solicited by the Orlando Fire Department (OFD). The issue of poor communications is in no way confined only to the OFD, and it should be commended for funding such a document.
With regard to intra-agency communications, the report found OFD executive leadership did not arrive on the scene until several hours into the event. Anyone in EMS knows that if these officers were aware of the incident, they would have responded. The report indicates that “due to failures in communication technology, some OFD executive staff did not receive the message on their pagers and were unaware of the ongoing incident.”2
Regarding interagency communication, the delayed response by OFD executive leadership delayed establishment of a unified command. The report found “the lack of unified command and inadequate communication between police, fire, and EMS resources reduced OFD’s situational awareness and exacerbated communication and coordination among first responders.” The National Incident Management System, among other doctrines of MCI response, emphasizes the importance of having a single command post where stakeholders from each responding agency can communicate directly.
Further, “The lack of coordination regarding radio channels among public safety, first responders created challenges in integration and communication.” In the Pulse event this led to OPD not knowing where and how to access OFD transport assets and therefore transporting patients outside the EMS triage and treatment structure.
There is a critical period from the time an incident begins until professional medical help arrives and engages in which lives are lost. It is during this period that bystanders alone will be able to save lives.
In a paper published in Prehospital Emergency Care,3 emergency physician E. Reed Smith, MD, et al., studied the autopsies of the Pulse shooting victims. Smith and colleagues found that 16 patients (32%) had potentially survivable wounds—four had extremity injuries, two involved femoral vessels, and two involved the axilla. With regard to on-scene treatment, “No patients had documented tourniquets or wound packing prior to arrival to the hospital.” The article’s conclusions include: “A comprehensive strategy starting with civilian providers to provide care at the point of wounding, along with a coordinated public safety approach to rapidly evacuate the wounded, may increase survival in future events.”
This suggests a rethinking of how we plan for treatment of patients involved in an MCI—especially those in which perpetrators are involved. There are opportunities to shave time from the incident to treatment by both the lay public and EMS. To address the latter, the rescue task force (RTF) concept has been developed. The RTF consists of medical teams that have trained with law enforcement teams to enter an incident alongside law enforcement during the operation, rather than after a scene has been secured. The RTF EMS team can reach victims more quickly than when EMS waited on the sidelines.
Bystanders need to be empowered to act as well. This is why the U.S. federal government and public safety agencies have embarked upon public education initiatives such as the Stop the Bleed campaign and development of courses such as FEMA’s IS-360: Preparing for Mass Casualty Incidents: A Guide for Schools, Higher Education, and Houses of Worship.
How do we train first responders to achieve the objective of saving more lives? How do we improve communications within and between our agencies? How do we train bystanders to bridge gaps in patient care? How can we help law enforcement and EMS RTF members collaborate effectively?
The answer is ongoing and realistic training. The most authentic training available includes using various types of simulation.
This is just one reason why the medical simulation industry is booming. According to Grand View Research, healthcare/medical simulation was valued at $1.36 billion in 2017.4 The industry is anticipated to expand to a compound annual gross rate of 16.3%. Many diverse specialties, from orthopedics to cardiology, are incorporating simulation into their practices. EMS is doing the same.
We know simulation training is a core strategy to facilitate flawless execution. There is not yet, though, a tremendous amount of research published on EMS simulation training. According to an article in Prehospital Disaster Medicine by UCLA’s Samuel Stratton, MD, “Simulation-based research represented a minimal fraction (4%) of original research submissions to a dedicated disaster medicine journal in the period June 2013 to May 2014, compared to survey-based research (64%) and descriptive case series (23%).”5
Technology and Disasters
Whether in emergency response for a few months or a few decades, you’ve likely seen rapidly changing technology affect the way our jobs are done. Technological improvements are a part of life in any profession, and finding balance, value, and need are critically important in providing the highest-quality service possible, no matter your discipline. Some of these novel technologies may help us do our jobs better.
Unmanned aerial vehicles (UAVs) or drones—Photographers and videographers may have toyed with purchasing one of those really nice action-camera drones to add to their weekend hobby (or perhaps already own one) and may have even used one to capture scene pictures or video. The reality is these drones can be reasonably affordable to most departments, offer real-time images of large-scale incident scenes, and be deployed in minutes. The integration of this technology into your department’s workflow can offer a number of possibilities.
Wearables—A few years ago we were lucky enough to trial Google Glass, a pair of smart glasses that basically offered a wearable heads-up display and computer at eye’s reach. The technology was far ahead of the rest of the options out there, and application availability was quite limited, but the future of this type of device was constrained only by the imagination.
While the Google Glass project has since taken on different forms, other companies are introducing similar solutions for a variety of purposes. What kind of wearables would we like to see for emergency and disaster response? Smart glasses for scene triage tracking, barcoding, patient data, scene information, clinical guidance and telehealth, and CAD integration. Compact, affordable, and connected vital signs monitors. Proximity sensors that can connect via wi-fi, cellular, Bluetooth, or other deployable independent network to track resources, supplies, personnel, victims, and casualties. Finally, a health data wearable for our first responders would present tremendous value in any mass-casualty or high-impact operation; monitoring real-time heart rate, pulse oximetry, ECGs, temperature, location, and level of activity can mitigate provider overexertion and allow for appropriate rehabilitation.
Cloud-based data systems—As cloud-based data systems grow and become even more integrated into our operational flow, we should consider the ways this type of technology can impact coordination. Along with a dependable network, cloud-based solutions can serve as a first responder’s hub for all things data, with information that is accessible and sharable.
Social media—In an age when so many share real-time information through social media, it would be negligent to ignore the data that’s shared. Crowdsourced intelligence through social media can help communications centers, emergency managers, and other first responders predict or mitigate the evolution of an incident. Integration of crowdsourced data can aid incident mapping, responder accountability, compilation of survivor data, and family reunification.
Point-of-care ultrasound (POCUS)—Recent literature has confirmed the applicability of ultrasound in austere environments as well as mass-casualty incidents. In a 2017 study POCUS was found to be a reliable and valuable tool in the context of disasters, one that could assist in triage, clinical resource allocation, and injury prediction.6 POCUS can be looked at as a reasonable way to improve our clinical decision-making in high-stress situations. Ultrasound technology is advancing rapidly, and devices have become small, portable, and reasonably priced.
Over the last few years, events have taught us much about how we’re never fully ready for the stuff of nightmares that may one day appear during our shift, and how we can always learn from our performance. It is in our knowledge, skill, and humility that we understand the need to keep working to make ourselves better as individuals and as a community of responders.
1. DeNolf RL, Kahwaji CI. EMS, Mass Casualty Management. Treasure Island, Fla.: StatPearls Publishing, 2019.
2. National Police Foundation. After-Action Review of the Orlando Fire Department Response to the Attack at Pulse Nightclub, www.policefoundation.org/wp-content/uploads/2018/11/OFD-After-Action-Review-Final.pdf.
3. Smith ER, Shapiro G, Sarani B. Fatal wounding pattern and causes of potentially preventable death following the Pulse night club shooting event. Prehosp Emerg Care, 2018; 22(6): 662–8.
4. Grand View Research. Healthcare/Medical Simulation Market Size, Share & Trends Analysis Report By End Use, By Products & Services (Anatomical Models, Web-based Simulators, Simulation Software), and Segment Forecasts, 2018–2026, www.grandviewresearch.com/industry-analysis/medical-healthcare-simulation-market.
5. Stratton SJ. Is there a scientific basis for disaster health and medicine? Prehosp Disaster Med, 2014 Jun; 29(3): 221–2.
6. Gharahbaghian L, Anderson KL, Lobo V, et al. Point-of-care ultrasound in austere environments: A complete review of its utilization, pitfalls, and technique for common applications in austere settings. Emerg Med Clin North Am, 2017 May; 35(2): 409–41.
Sidebar: Planning for Disaster—The Essentials
Disasters are an inescapable reality we must face as first responders. These disasters can encompass a wide range of challenges, including triage, command structure, scene access, resource allocation and tracking, logistics, and communications. While we may not be able to predict all disasters, it is our collective responsibility to plan for every scenario we can think of.
One aspect of disaster response should remain constant—how we approach the planning process. How we deal with the operational period of disasters may evolve over time, but some key concepts should sit at the forefront of our minds as we prepare:
The lives of our responders and the public come first, everything else second. If there is any aspect of our planning process that comes at the risk of life safety, we’ve failed ourselves. Go back to the drawing board and try again.
Become intimately familiar with your area of operation (and areas neighboring you). Understand the risks, challenges, and threats to your environment. Know your roadways, secondary (and tertiary, quaternary, etc.) routes of travel, air-resource access and flight paths, communications dead zones (radio and cellular), and fire-service resources.
Build relationships with business owners and residents within your community. Who can help you in a time of crisis? Spend time training with other first responders from your community and surrounding areas. Understand each other’s modus operandis; train to each other’s standards. Social meetings and collaboration opportunities are good for us—use them to forge bonds, improve morale, and build trust. And build relationships with responders we may also depend on during disaster operations, such as public works, utility companies, medical-supply distributors, fuel suppliers, and the like.
Exercise due diligence in performing a complete hazard identification and risk assessment. Anything and everything is free game.
Collectively create your plans. Involve your first-response organizations, community leaders, local businesses, and anyone else who can inform your processes. This isn’t about politics; it’s about saving lives. Check your agendas at the door and work together.
Train, drill, train, drill. Ensure everyone is trained on your disaster plans and then drill like it’s the real thing. Make every effort to not skimp on education, drilling, and simulation. It could mean the difference between a well-prepared department or one that just wants to feel good about its plans.
After drilling go back to the drawing board and edit your plans—there will definitely be lessons learned. Train and drill some more. There is never a time to be done with this cycle. This should be the lifeblood of your first-response career, no matter your field.
Kevin L. Pohlman, MEd, NRP, FACHE, CCEMT-P, EMT-T, CHSE, CHSOS, NHDP-BC, is assistant professor of public health and assistant director of the Center for Disaster Medicine at New York Medical College.
Joshua D. Hartman, MBA, NRP, is senior vice president of the Cardiovascular and Public Safety divisions at HMP, the parent company of EMS World.