The Evolution of MCI Management

Modern concepts and methods of Triage and Mass Casualty Management have evolved a lot
in recent years. What was once the simple act of patient sorting is today a refined science. Recent domestic events like Oklahoma City, 911, New Orleans, and the H1N1 scare have focused our efforts to develop improvements in disaster preparation and mass casualty management.

Most of my experience with large-scale events was gained long before these ideas got
mainstream. I’ve been to several large fires and building collapse events, one
large flood, a building explosion and enumerable multi-vehicle wrecks. Most
were managed pretty poorly on retrospect, but the experience taught me a lot. Here’s
what I learned.

We first have to set up a minimal command structure or organize. Then we sort the injured with the goal of moving the worst hurt viable first. We have to keep track of who goes where, and manage how many go to any one hospital. Last, we have to match the patient to the best destination to optimize their outcome. We have to get the right people to the right place
in the right order.

As an EMS Provider your primary job is to do two things; Identify who is the most injured
and get the most viable of the injured transported first. If you are not very good at that yet, then that is where your initial efforts should be focused. Alaska published a great over-view of the basics.

An important concept is the idea of using your MCI tools on micro-incidents. An
example of a micro-incident is a nasty 3-car accident with 4 victims. If you
practice your MCI techniques on these smaller incidents, you will be much
better prepared for a large disaster. Being able to set up a command structure
fast with the first four responders is a mission-critical skill.

I’ve found that MCI’s tend to be won or lost in the first few minutes. The last thing you want is things spiraling out of control while you are stuck waiting for an MCI trailer to arrive. Smaller
scale implementation of MCI management gets you used to using your triage tags,
forms, and other tools. You will find out quickly if the vests fit, if the collection area markers can be seen at night, and many more things than you can imagine. Then when a true system challenge occurs you have already worked the bugs out of your system.

Mock events are an invaluable tool for MCI preparation. But use scenarios based on practical assumptions of what is most likely to occur or with the greatest historical relevance. Remember that if it happened once, it can happen again. Massachusetts published a wonderful MCI planning guide.

A natural tendency is to prepare for what most recently happened somewhere else. After New Orleans people got real about flood preparation. After the Minnesota bridge collapse, every bridge in Missouri got inspected immediately. Today the hot topic is pandemic flu preparation. Tomorrow it will be big train wrecks.

The one aspect of MCI management rarely discussed is the emotional demands. It seems we plan for recovery afterward with Critical Incident Management (CISM) programs, but
don’t talk much about the challenge beforehand. What I’m talking about is being emotionally prepared for how different your role will be at an MCI.

One of the hardest things I’ve ever had to do as a Paramedic was walk past a women
begging for my help, because someone else beyond her needed me more. I think we need to have some frank discussions about these feelings before we have to deal with them.

MCI Planning and Preparation is a young science, founded on the battlefields but carried out today largely in the boardroom. How well we plan and prepare will eventually be
tested in every system. It may not be today, this month, or even this decade. But it’s far better to plan under the assumption that every single one of us will eventually need these important skills and is completely prepared to execute.


About Dan White

I'm a retired Paramedic and EMS Instructor with 35 years EMS and emergency medical product experience. I love canoes, cars and EMS. I have written a lot about EMS Technology on the Paramedic Blog, the Insights on Innovation column for, on and I can be reached directly at 573-240-0002.
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