MCIs–When You’re First on Scene

A bus crash, train wreck, deck collapse, fire in a nursing home or school or, as we have seen with the tragedy in Aurora, Colo., a mass shooting all present first responders with the opportunity to respond to and manage a mass casualty situation.

In incidents like this, there is an expectation that the fire department will work with police and EMS, and perhaps lead the effort to ensure that scene hazards are secured and patients are cared for and transported to the hospital. Even still, this type of incident can give even the most seasoned firefighters or rescue workers a case of butterflies in the stomach. Just because you might not ride an ambulance doesn’t mean that you won’t be the first one to show up at an incident like this. What is done by the initial responders will not only set the tone for the incident, but may make the difference in the effort being successful or not. What do you do when you are the first on the scene?

Size-Up
The initial step needed for successful scene management is a size-up. What hazards are present, and what group can properly manage them? Can victims be removed to safety while minimizing risks to responders?
    
To get the proper resources, a primary evaluation of the number/severity of injuries and victims trapped is needed. Just by looking at the size and type of vehicle (minivan, bus, train) or structure (multi-family dwelling, theater, school) should provide an initial approximation as to the potential number of patients that may be involved. This can allow the first responders enough general information to make an initial request for additional resources, such as EMS or fire/rescue task forces to at least be dispatched to a staging area.

A rapid triage of the incident is crucial; select your best crewmember for this job. Don’t underestimate the criticality of this function. Be aware of regional resources, such as MCI units and “ambulance buses” or similar units that should be requested early into the incident. The “walking wounded” can be directed to get themselves to an area where they can be monitored by one or two responders, while the more serious injuries can be handled by additional responders elsewhere. Someone needs to be designated to make this happen. Once this triage is complete, more detailed resource requests can be made. Further, it should be obvious that a clear incident command system must be established to ensure proper resource requests and directions are provided.

Scene Safety & Control
So much must be done at once. While the size-up and triage is beginning, the scene must be made safe for rescue personnel. Unsafe conditions (fire, gas release, collapse, active shooter) must be stabilized and contained, and responders must do what they can within their limitations to prevent further losses. The scene is likely to be fluid early on, with circumstances and hazard zones changing rapidly. Good communication must be established between police, fire, EMS and hazmat responders so that the size-up is as accurate as possible.

Responders must also be protected against bodily fluids and other, similar hazards. Are gloves and other personal protective equipment (PPE) readily available for all personnel who could respond to this type of situation? Can key positions be readily identified in the chaos?

At the same time, perimeters must be established, and access to the scene for non-essential personnel must be denied. This is another crucial job, as many individuals who are not emergency responders will likely converge on the scene, some to assist while others, such as media or onlookers, may only obstruct response efforts. A simple task that will assist in this effort is to send a less-experienced responder to set up barricade tape around the incident. While this will not necessarily prevent all onlookers from entering the incident scene, it will provide a starting perimeter for additional responders to reinforce.

Remember that ambulances and other transport vehicles operate differently than fire or law enforcement units. They need to not only get rapid access into the scene and the victims, but then leave the scene to transport victims to more advanced care. At the same time, it may be decided to bring the first ambulance or two into the scene and keep them there as both an equipment cache and/or treatment area that can be used during the entire incident. This must be made clear to those on the scene. Fire apparatus laying hoselines at the incident must keep in mind the issue of access for EMS vehicles. Set up the scene in a way that minimizes the need for EMS units to back up or turn around. It is easiest and safest for ambulances to pick up their patients, then leave the scene in the same direction that they were initially headed.

While attempting to keep onlookers away, figure out how to best initiate care for the victims. Don’t hesitate to use individuals who are already on the scene, although some caution is needed. Nurses or other paramedical personnel often stop to render assistance at situations like this. You will need to make split-second decisions as to whether you can put them to work; they may at least be able to maintain stabilization of some victims. It may be difficult to determine whether they can be effective, but it may be equally as difficult to turn down their assistance. Less serious injuries may only require the comfort/care of family members or friends already be with them. During the triage phase of the incident, recognize this and give them brief instructions to keep the patients safe and to continue reassurance. Let them know that more help is on the way and will be there soon to relieve/assist them.

Triage
As already mentioned, this is the most important job at this scene. During efforts to triage patients, utilize colored tarps or flags to demarcate each treatment area. Green areas are for lesser injuries/walking wounded, and this group can even be put into a separate room/store or a bus or other area. The bus may even be able to transport these victims to a hospital; however, be sure to coordinate any transport of these patients with the transportation officer to avoid overloading any one hospital. Yellow areas are for more serious injuries, although not immediately life-threatening. Red areas are for immediately life-threatening situations. As quickly as possible, designate a responder to initiate communications with local medical facilities that will be utilized for the incident for both transport and medical command. Give them a heads up as to what is going on, so that they can get their disaster plans in motion.

Logistics
As more assistance arrives, begin logistics efforts. Obtain some of the resources already mentioned, places to temporarily house victims and response personnel as needed, and manpower needed to move patients and materials and to secure the incident perimeter. This manpower does not necessarily need to be EMS-certified, although it would be quite useful if they have performed some basic patient movement skills in advance.

As transport is being planned, it is tempting to direct many patients and ambulances to the nearest hospital. In some cases, there may be no choice and it is natural for some victims to be placed in police or other official vehicles, or private vehicles and taken off site to that hospital. It may seem counter-intuitive, but when more than one hospital is available, the lesser injuries (green or “walking wounded”) can be sent off to more distant hospitals. As previously discussed, buses or other non-traditional transport vehicles may be used for this. While it seems harsh, leave the deceased where they lie. Establish a clear branch of the incident command system to deal with fatalities and the investigation portion of the situation.

Medical evacuation helicopters may also be utilized to transport the most serious victims the tertiary care facilities. Often these may be at a distance, again relieving some of the burden on the closest hospital(s). Command will need to quickly designate and secure a helicopter landing zone (LZ) near the incident site. One or more personnel, or an engine company if available, will need to be sent to that area to secure the area, and coordinate landing the helicopters, being fully cognizant that several may be coming in. Be sure to clearly identify the hazards around the LZ and communicate that to the helicopter(s). Taking time to pre-select these around major hazards in your coverage area will help. We have a fairgrounds in our coverage area and have pre-designated a horse ring on the property as the primary helicopter landing zone. It is fenced in with white plastic fencing that’s easily visible from the air, and only has two gates as entrance points, which allows the LZ to be easily secured by a minimal number of personnel.

Final Thoughts
Being dispatched to the scene of a MCI may be enough to make many responders take pause. Most will rise mightily to the challenges these types of incidents present. Preplanning and training for these kinds of incidents will make dealing with them a bit easier. Determine in advance the necessary roles to fill, and where you would get the people to fill those roles and the equipment needed to be most effective. Make sure your people can step in and fill those roles and be the best they can be. No one wants a mass tragedy to occur in their community, but the possibilities exist. Be ready when the call comes.