By Justin Schorr
When you think of mass casualty incident (MCI) training, chances are that your mind wanders off to chief officers donning reflective vests and carrying multiple radios. Visions of triage tarps and cones cloud your mind while dozens of high school kids laugh while they’re supposed to be seriously injured, funneling through an elaborate treatment area, tags in place. Many departments plan for large-scale events with large-scale interventions in mind. Command vans, tarps, flags, and tags seem to dominate the discussion while initial actions are taken as a side topic.
When the shift starts, you should be given a very clear assignment and set of expectations on the engine. “You’re on the pipe” means I need to be first out, first on air, and ready to go to work at a fire since I’m on the nozzle. It also means that I grab the bundle on a building alarm. Because emergency medical services (EMS) is such a large part of what we do, I also know that the nozzle position performs compressions at a cardiopulmonary resuscitation (CPR) case and the layout position is in charge of the airway. We assign these positions to enhance our ability to accomplish known tasks on the fireground and at the scene of a medical emergency. Multiple casualty response should be no different.
The American fire engine has become a tool capable of amazing things. Long gone are the days of serving as a manifold to supply water down the block. It is now a rolling tool box filled with all manner of devices to aid citizens in their time of need. Included in that vehicle are the most important and valuable tools: the firefighters.
An MCI evolves quickly and amid chaos, the place where a well-trained engine company thrives. We are trained to size up a situation clearly, anticipate hazards, adapt quickly to changing conditions, and position ourselves and our apparatus in a manner to not only facilitate initial attack but also not be a hindrance to the companies coming in behind us to aid in the efforts. These tasks are often forgotten at an MCI as we fall out of our comfort zone and into the unfamiliar. Fire in a building is predictable, whereas victims fleeing an explosion, an active shooter, a burning aircraft, or some other danger will be erratic and move in many directions quickly.
The engine company often will arrive first–our one-stop shop for all-hazards initial response. Apply what you have learned from the fireground at your MCI to maximize your team’s effectiveness, and make sure the next few hours go smoothly to help the most people.
Size-Up
When turning the corner and seeing that orange glow, we know we’re about to go to work, but what do we know about the building? We give a uniform size-up: size, occupancy type, conditions, and hazards. Then we state our objectives and pass along critical information to incoming units. An MCI should be no different. Clear communications from the beginning can save time when additional resources have to be redirected, redeployed, or asked to respond too late.
Engine 33 has been dispatched to a smoke investigation. “Engine 33 is on the scene of a single-story residence. Fire showing from the A/B corner. Engine 33 will be assuming Spring Street Command. Extending a line for primary search and fire attack. Second-in engine, approach from the west with a supply; the east is blocked by a downed tree.”
Each unit on the air responding to this fire has all it needs to make access and get to work when it arrives. An MCI report should be no different. Engine 33 has been dispatched to a reported explosion. As it turns the corner, the street is full of people. They are unable to pass.
“Engine 33 is on scene one-half block west of the theater. We have multiple persons in the street restricting access. Engine 33 is establishing Spring Street command. Declaring an MCI, approximately 30 traumatic injuries. Triage unit will be deploying from Spring Street east toward the theater. Request law enforcement to secure the area and funnel walking wounded toward Engine 33.”
Engine 33 has given responding units the clearest picture of the situation it can from its location. It has established a command rally point for initial units, stated its tasks, and requested additional units to assist in the early collection of information and wounded.
Quick Attack
Stretching a 1¾-inch line to a room-and-contents fire has a specific set of steps to accomplish successfully. Rapid triage at an MCI is no different. Triage tags are clumsy and take too long to fill out at this stage. Use flagging or other simple marking techniques to define patient condition. There are three categories of patients to be concerned about, even though there are four categories of patients total. Patients tagged black do not meet minimum life sign requirements to have care administered. They should be tagged, counted, and their location noted for later reporting. Red patients are those requiring immediate care. They are usually unconscious, unable to breathe effectively, or have decreased pulse or capillary refill. Green patients do not qualify for medical care in the immediate or even delayed areas and are able to walk. Yellow patients do not meet immediate (red) treatment criteria but are unable to walk. In short, they are stationary greens.
The goal of the first-in engine company is to gather intelligence regarding the initial event, count the number and severity of injuries, and request additional support based on those findings. Triage must be swift and accurate if additional responding units are to adequately begin treating the wounded. The same is true at a fire.
The company officer must immediately begin gathering information from the firefighters performing triage and determine the location of the immediate (red) treatment area. The first responding medical unit will need directions to this location, which should be as close as possible to ambulance ingress and egress. This area will very quickly begin to fill up with seriously injured people. There is no need for tarps, vests, or signage at this point; there isn’t time. When the incident command structure (ICS) begins to be built behind you, it will be based on your actions now.
Identify the red treatment area, and relay this location to the triage team. It can often be done from the cab as you complete your scene size-up. It can be as simple as “Red treatment on that corner near the café.” This area needs to be established immediately because your triage team will be directing that people be moved there as soon as they can.
Using walking wounded to move critical patients can be essential if the initial response is unable to handle a large event. Instead of making a blanket statement over the public address system and clearing the area of able-bodied help, consider enlisting the assistance of some of the witnesses and walking wounded. When a critical patient is identified, flagged, and counted, green patients and witnesses can be directed to move that person to the red treatment area and out of harm’s way.
Knockdown
As the supporting units arrive on scene, triage teams should have a good idea of the scope of the event. That information, just as at a fire, is passed back to the company officer, who notifies dispatch. As the initial chaos is controlled, or at least contained, the initial engine may be completing triage and moving into treatment or will be augmented by additional triage teams. Transitioning from counting to treating is as simple as returning to the red treatment area with all the red patients identified in the primary search.
This is the point where the initial attack transitions to a support role. The engine will now be assigned a role in the established ICS structure and be redeployed as necessary with vests, radios, and a greater view of the incident they helped to stabilize.
Overhaul
Initial patient conditions and locations may be vital to law enforcement in the investigation of the incident. Details such as debris removed to allow rescue, discoloration of clothing, or the need to move a deceased person to ensure the survival of others, all need to be thoroughly documented individually and as a company following the incident. Immediately following the conclusion of initial actions, it may be necessary to regroup and evaluate the situation and how it is unfolding. Safety concerns, means of egress, or suspected travel paths for potential victims should all be reported each time the company comes back together or when the information is deemed necessary for treatment of victims in need.
Evaluation
After an MCI, there will be media and industry scrutiny. Folks you’ve never met will suddenly have a better idea on how to handle the initial response than your company did in the heat of the moment. Learn from their suggestions, and possibly apply those techniques in the future. Each MCI is unique in the presentation, hazards, victims, and resources available, but every community in America has a time-tested workhorse ready to take any challenge with confidence and professionalism–the engine company. Will you be ready?
BIO
Justin Schorr is a 20-year veteran of the fire service and a second-generation firefighter with experience in rural, suburban, and urban firefighting and paramedicine. He is a speaker on numerous EMS topics ranging from quality management and oversight to sharing media and all points in between. He is assigned to a large urban department in the San Francisco Bay area and has been active in the online fire and EMS community since 2008; he is the editor of Happy Medic.com.
