Mass-casualty incident
Encyclopedia
A mass casualty incident (often shortened to MCI and sometimes called a multiple-casualty incident or multiple-casualty situation) is any incident in which emergency medical services
resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties. For example, an incident where a two-person crew is responding to a motor vehicle collision with three severely injured people could be considered a mass casualty incident. The general public more commonly recognizes events such as building collapses, train
and bus
collisions, earthquakes and other large-scale emergencies as mass casualty incidents. Events such as the Oklahoma City bombing
in 1995 and the September 11 attacks in 2001 are well publicized examples of mass casualty incidents.
in the US, about the incident. A formal declaration of an MCI is usually made by an officer or chief of the agency in charge. Initially, the senior paramedic
at the scene will be in charge of the incident, but as additional resources arrive, a senior officer or chief will take command, usually using an incident command system
structure to form a unified command to run all aspects of the incident. In the United States
, the Incident Command System is known as the National Incident Management System
(NIMS), and according to the Federal Emergency Management Agency
, "NIMS provides the template for the management of incidents."
This is not an exhaustive list, and many other agencies and groups of people could be involved in a mass casualty incident.
. Pre-hospital emergency triage generally consists of a check for immediate life-threatening concerns, usually lasting no more than one minute per patient. In North America, the START system (Simple Triage and Rapid Treatment)
is the most common and considered the easiest to use. This system checks three things: breathing, circulation, and consciousness and, based upon the medical responder's findings, assigns each casualty to one of four colour-coded triage levels. "Walking Wounded" or "Green Tagged" is the second-lowest level of triage, and is assigned to those with minor injuries who can get out of the incident area and to a treatment area under their own power. "Delayed Treatment" or "Yellow Tagged" is the next highest level of triage, and is assigned to those who have non-life threatening injuries, but cannot get to a treatment area under their own power. "Immediate Treatment" or "Red Tagged" is the highest level of triage, and is assigned to those with major life-threatening injuries who are salvageable. That is to say people who need immediate advanced care, but can wait until additional crews arrive. The lowest level of triage is called "Dead/Non-Salvageable" or "Black Tagged" and is assigned to those who are obviously deceased, or whose injuries are so severe that care rendered to them would require more effort than is practical. For example, a patient who needed cardiopulmonary resuscitation
(CPR) or artificial respiration
would be classified as "Dead/Non-Salvageable" because their care would mean that at least one responder would have to treat them and not be able to assist other people. This obviously poses some serious moral and ethical issues for emergency responders who respond to mass casualty incidents as they must make a determination as to who does and does not receive treatment. While treatment is not the priority during this phase, when triaging, responders will attempt to ensure a patent airway, and provide short-term interventions for injuries such as a major bleed. Triage can usually be accomplished by a small group of responders, usually the first two or three crews on-scene.
bearers will have to transport patients from the incident scene to more secure and safe treatment areas located nearby. These treatment areas will always be within walking distance and will be staffed by appropriate numbers of properly certified medical personnel and support people. The litter bearers do not have to be advanced medical personnel; their role is to simply place casualties onto carrying devices such as a portable stretcher (such as a Ferno #9), wheeled stretcher (such as a Ferno 35X or Stryker MXPRO), emergency litter (such as a pole stretcher), or other carrying device (such as a scoop stretcher or backboard for patients with spinal injuries) and carry them to the appropriate treatment area. Casualties should be transported in order of treatment priority, with Red Tagged patients being transported first, followed by Yellow-Tagged, Green-Tagged, and finally Black-Tagged. Treatment areas are often defined by coloured tarpaulin
s, flagging tape, signs, or tents, and each level of care receives its own treatment area (i.e. Red Tagged patients are not treated in the Green Tagged treatment area). Upon arrival in the treatment area, the casualties are re-assessed and their injuries are given initial treatment to stabilize them until they can be released (in the case of green-tagged casualties), transported for further treatment (in the case of red and yellow tagged casualties), or transported to the morgue or medical examiner's facility (in the case of black tagged casualties). Treatment areas can be staffed by any combination of First Responders, Emergency Medical Technicians, Paramedics, Nurses, Doctors, and Firefighters; depending on the area, available personnel on-scene and the training/experience of those available.
to handle the bodies of the deceased persons at the scene while awaiting transfer to a permanent morgue, or when the deceased persons have to be removed in order to access those who are injured. When this is used, care and consideration is given to respect for the deceased, family members, the public at the scene, and the responders at the scene. Most often, this is set up on the far side of the incident, away from public sight, and is in an enclosed area such as a temporary tent, or nearby building.
, firetruck, or civilian vehicles such as personal vehicles or transit buses. As with treatment, transport priority is decided based on the severity of the patient's injuries. Usually, the most seriously injured are transported first, with the least serious transported only after all the serious patients have been transported. However, in an effort to remove as many lightly injured civilians as possible, an incident commander
may choose to have those least seriously injured transported to local hospitals or interim-care centres in order to provide more room for emergency personnel to work. It is also possible that lightly injured casualties will be transported first when access to those who are more severely injured will be delayed due to heavy or difficult rescue efforts.
set-up. Permanent buildings are preferred to tents as they provide shelter, power, and running water, but many governments maintain complete field hospital setups that can be deployed anywhere within their jurisdiction within 12–24 hours. While full field hospitals require a significant amount of time to deploy (in relation to the length of most incidents), temporary interim-care centres can be set up by emergency services fairly quickly if needed using the personnel and resources they have on-hand. These centres are usually staffed by a combination of doctors, nurses, paramedics/emergency medical technicians, first responders, and social workers such as those from the Red Cross who work to get families reunited after a disaster.
Emergency medical services
Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties. For example, an incident where a two-person crew is responding to a motor vehicle collision with three severely injured people could be considered a mass casualty incident. The general public more commonly recognizes events such as building collapses, train
Train
A train is a connected series of vehicles for rail transport that move along a track to transport cargo or passengers from one place to another place. The track usually consists of two rails, but might also be a monorail or maglev guideway.Propulsion for the train is provided by a separate...
and bus
Bus
A bus is a road vehicle designed to carry passengers. Buses can have a capacity as high as 300 passengers. The most common type of bus is the single-decker bus, with larger loads carried by double-decker buses and articulated buses, and smaller loads carried by midibuses and minibuses; coaches are...
collisions, earthquakes and other large-scale emergencies as mass casualty incidents. Events such as the Oklahoma City bombing
Oklahoma City bombing
The Oklahoma City bombing was a terrorist bomb attack on the Alfred P. Murrah Federal Building in downtown Oklahoma City on April 19, 1995. It was the most destructive act of terrorism on American soil until the September 11, 2001 attacks. The Oklahoma blast claimed 168 lives, including 19...
in 1995 and the September 11 attacks in 2001 are well publicized examples of mass casualty incidents.
Declaration of an MCI
A mass casualty incident will usually be declared by the first arriving unit at the scene of the incident, though it can be declared by a dispatcher based on the information available from people who call an emergency number, such as 9-1-19-1-1
9-1-1 is the emergency telephone number for the North American Numbering Plan .It is one of eight N11 codes.The use of this number is for emergency circumstances only, and to use it for any other purpose can be a crime.-History:In the earliest days of telephone technology, prior to the...
in the US, about the incident. A formal declaration of an MCI is usually made by an officer or chief of the agency in charge. Initially, the senior paramedic
Paramedic
A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
at the scene will be in charge of the incident, but as additional resources arrive, a senior officer or chief will take command, usually using an incident command system
Incident Command System
The Incident Command System is "a systematic tool used for the command, control, and coordination of emergency response" according to the United States Federal Highway Administration...
structure to form a unified command to run all aspects of the incident. In the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, the Incident Command System is known as the National Incident Management System
National Incident Management System
The National Incident Management System is emergency management doctrine used nationwide to coordinate emergency preparedness and incident management and response among the public and private sectors.NIMS is a comprehensive, national approach to incident management that is applicable at all...
(NIMS), and according to the Federal Emergency Management Agency
Federal Emergency Management Agency
The Federal Emergency Management Agency is an agency of the United States Department of Homeland Security, initially created by Presidential Reorganization Plan No. 1 of 1978 and implemented by two Executive Orders...
, "NIMS provides the template for the management of incidents."
Agencies and responders
A mass casualty incident can involve many and varied types of responders and agencies, including (but not limited to) the ones listed here:- Certified first responderCertified first responderA certified first responder is a person who has completed a course and received certification in providing pre-hospital care for medical emergencies. They have more skill than someone who is trained in basic first aid but they are not a substitute for advanced medical care rendered by emergency...
s may be part of local emergency medical servicesEmergency medical servicesEmergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
or may arrive on their own. They will assist with all aspects of patient care, including triage and treatment at the scene, and transport from the scene to the hospitalHospitalA hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
. - ParamedicParamedicA paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
and emergency medical technicianEmergency medical technicianEmergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
(EMT) personnel may arrive in ambulances, in their personal vehicles, or from another agency. They will have the lead in all aspects of patient care as assigned by the medical officer or incident commanderIncident CommanderThe incident commander is the person responsible for all aspects of an emergency response; including quickly developing incident objectives, managing all incident operations, application of resources as well as responsibility for all persons involved. The incident commander sets priorities and...
. - Land ambulanceAmbulanceAn ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
s will be assigned to the transport sector to transport patients and personnel to and from the incident scene, emergency departments of hospitals, and a designated helipadHelipadHelipad is a common abbreviation for helicopter landing pad, a landing area for helicopters. While helicopters are able to operate on a variety of relatively flat surfaces, a fabricated helipad provides a clearly marked hard surface away from obstacles where a helicopter can safely...
. These may be municipal services, volunteer services or from private corporations. - Air ambulanceAmbulanceAn ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
s will transport patients from the scene or from designated helipads to receiving hospitals. - FirefighterFirefighterFirefighters are rescuers extensively trained primarily to put out hazardous fires that threaten civilian populations and property, to rescue people from car incidents, collapsed and burning buildings and other such situations...
s will perform all initial rescue related operations, as well as fire suppression and prevention. They may also provide medical care if they are trained and assigned to do so. They may arrive on a fire truck, in their personal vehicles, or from another agency. Many areas near airportAirportAn airport is a location where aircraft such as fixed-wing aircraft, helicopters, and blimps take off and land. Aircraft may be stored or maintained at an airport...
s will have automatic mutual aidMutual aid (emergency services)In emergency services, mutual aid is an agreement among emergency responders to lend assistance across jurisdictional boundaries. This may occur due to an emergency response that exceeds local resources, such as a disaster or a multiple-alarm fire. Mutual aid may be ad hoc, requested only when...
agreements with airport fire departments in the event of a plane crash outside of the airport boundaries. - Police officerPolice officerA police officer is a warranted employee of a police force...
s will secure the scene to ensure that only properly authorized people are present to ensure safety and smooth operation. - Specialized rescue teams may be part of the local fire departmentFire departmentA fire department or fire brigade is a public or private organization that provides fire protection for a certain jurisdiction, which typically is a municipality, county, or fire protection district...
; they may be dispatched and associated with the state, provincial, or federal governmentGovernmentGovernment refers to the legislators, administrators, and arbitrators in the administrative bureaucracy who control a state at a given time, and to the system of government by which they are organized...
s; or they may be privately operated teams. These teams are specialists in specific types of rescue, such as Urban search and rescueUrban search and rescueUrban search and rescue involves the location, extrication, and initial medical stabilization of victims trapped in confined spaces due to natural disasters, structural collapse, transportation accidents, mines and collapsed trenches.USAR teams in different countries may be organised in a...
(USAR) or Confined Space RescueConfined space rescueConfined space rescue is a subset of technical rescue operations that involves the rescue and recovery of victims trapped in a confined space or in a place only accessible through confined spaces, such as underground vaults, storage silos, storage tanks, or sewers.Confined space rescues can be...
. - Utility Services are responsible for ensuring that utilities to the area are turned off as necessary in order to prevent further injury or damage at the scene.
- HazMatHazmatHazmat, HazMat and similar terms can refer to:* Hazardous materials and items—see Dangerous goods** Hazchem—a system of hazardous chemical classification and firefighting modes** A hazmat suit is a type of protective clothing...
teams are responsible for cleaning up and neutralizing any hazardous materials at the scene. Sometimes these will be specialized CBRNE (chemical, biological, radiological, nuclear and high-yield explosives) teams. - HospitalHospitalA hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
s with emergency departmentEmergency departmentAn emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
s will have a mass casualty incident protocol which they initiate as soon as they are notified of a mass casualty incident in their community. They will receive all of the injured and have preparations in place to do so, including calling in more staff, pulling extra and spare equipment out of storage, and clearing non-acute patients out of the hospital. Some hospitals will send doctorPhysicianA physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s to the scene of the incident to assist with triage, treatment, and transport of injured persons to the hospital. - Railways and transportation agencies will be notified if an incident involves their tracks or right-of-way, or if they are required to cease operations in and through affected areas. Transportation agencies will provide buses for transportation of lightly injured people to the hospital, as well as to provide shelter at the scene if required.
- The mediaNews mediaThe news media are those elements of the mass media that focus on delivering news to the general public or a target public.These include print media , broadcast news , and more recently the Internet .-Etymology:A medium is a carrier of something...
play an important role in keeping the general public informed about the incident and in keeping them away from the incident area. - Non-governmental organizationNon-governmental organizationA non-governmental organization is a legally constituted organization created by natural or legal persons that operates independently from any government. The term originated from the United Nations , and is normally used to refer to organizations that do not form part of the government and are...
s such as St. John AmbulanceSt. John AmbulanceSt John Ambulance, branded as St John in some territories, is a common name used by a number of affiliated organisations in different countries dedicated to the teaching and practice of medical first aid and the provision of ambulance services, all of which derive their origins from the St John...
, the Red Cross, the Red Crescent and the Salvation ArmySalvation ArmyThe Salvation Army is a Protestant Christian church known for its thrift stores and charity work. It is an international movement that currently works in over a hundred countries....
will provide valuable assistance with all aspects of a mass casualty incident including trained medical staff, vehicles, individual registration and tracking, temporary shelter, food service, and many other important services.
This is not an exhaustive list, and many other agencies and groups of people could be involved in a mass casualty incident.
Flow of an MCI
Once an MCI has been declared, a definite and well co-ordinated flow of events will occur, using three separate phases: triage, treatment, and transportation.Triage
As soon as additional crews are en-route to the emergency, the first-arriving crew will conduct triageTriage
Triage or ) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate,...
. Pre-hospital emergency triage generally consists of a check for immediate life-threatening concerns, usually lasting no more than one minute per patient. In North America, the START system (Simple Triage and Rapid Treatment)
Simple triage and rapid treatment
Simple triage and rapid treatment is a method used by first responders to effectively and efficiently evaluate all of the victims during a mass casualty incident . The first-arriving medical personnel will use a triage tool called a triage tag to categorize the victims by the severity of their...
is the most common and considered the easiest to use. This system checks three things: breathing, circulation, and consciousness and, based upon the medical responder's findings, assigns each casualty to one of four colour-coded triage levels. "Walking Wounded" or "Green Tagged" is the second-lowest level of triage, and is assigned to those with minor injuries who can get out of the incident area and to a treatment area under their own power. "Delayed Treatment" or "Yellow Tagged" is the next highest level of triage, and is assigned to those who have non-life threatening injuries, but cannot get to a treatment area under their own power. "Immediate Treatment" or "Red Tagged" is the highest level of triage, and is assigned to those with major life-threatening injuries who are salvageable. That is to say people who need immediate advanced care, but can wait until additional crews arrive. The lowest level of triage is called "Dead/Non-Salvageable" or "Black Tagged" and is assigned to those who are obviously deceased, or whose injuries are so severe that care rendered to them would require more effort than is practical. For example, a patient who needed cardiopulmonary resuscitation
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...
(CPR) or artificial respiration
Artificial respiration
Artificial respiration is the act of assisting or stimulating respiration, a metabolic process referring to the overall exchange of gases in the body by pulmonary ventilation, external respiration, and internal respiration...
would be classified as "Dead/Non-Salvageable" because their care would mean that at least one responder would have to treat them and not be able to assist other people. This obviously poses some serious moral and ethical issues for emergency responders who respond to mass casualty incidents as they must make a determination as to who does and does not receive treatment. While treatment is not the priority during this phase, when triaging, responders will attempt to ensure a patent airway, and provide short-term interventions for injuries such as a major bleed. Triage can usually be accomplished by a small group of responders, usually the first two or three crews on-scene.
Treatment
Once casualties have been triaged, they can then be moved on to their appropriate treatment areas. Unless a patient is Green Tagged, litterStretcher
A stretcher is a medical device used to carry casualties or an incapacitated person from one place to another. It is a simple type of litter, and still called by that name in some cases....
bearers will have to transport patients from the incident scene to more secure and safe treatment areas located nearby. These treatment areas will always be within walking distance and will be staffed by appropriate numbers of properly certified medical personnel and support people. The litter bearers do not have to be advanced medical personnel; their role is to simply place casualties onto carrying devices such as a portable stretcher (such as a Ferno #9), wheeled stretcher (such as a Ferno 35X or Stryker MXPRO), emergency litter (such as a pole stretcher), or other carrying device (such as a scoop stretcher or backboard for patients with spinal injuries) and carry them to the appropriate treatment area. Casualties should be transported in order of treatment priority, with Red Tagged patients being transported first, followed by Yellow-Tagged, Green-Tagged, and finally Black-Tagged. Treatment areas are often defined by coloured tarpaulin
Tarpaulin
A tarpaulin, colloquially tarp, is a large sheet of strong, flexible, water-resistant or waterproof material, often cloth such as canvas or polyester coated with urethane, or made of plastics such as polyethylene. In some places such as Australia, and in military slang, a tarp may be known as a...
s, flagging tape, signs, or tents, and each level of care receives its own treatment area (i.e. Red Tagged patients are not treated in the Green Tagged treatment area). Upon arrival in the treatment area, the casualties are re-assessed and their injuries are given initial treatment to stabilize them until they can be released (in the case of green-tagged casualties), transported for further treatment (in the case of red and yellow tagged casualties), or transported to the morgue or medical examiner's facility (in the case of black tagged casualties). Treatment areas can be staffed by any combination of First Responders, Emergency Medical Technicians, Paramedics, Nurses, Doctors, and Firefighters; depending on the area, available personnel on-scene and the training/experience of those available.
On-site morgue
In some mass casualty incidents, it is necessary to have an on-site morgueMorgue
A morgue or mortuary is used for the storage of human corpses awaiting identification, or removal for autopsy or disposal by burial, cremation or otherwise...
to handle the bodies of the deceased persons at the scene while awaiting transfer to a permanent morgue, or when the deceased persons have to be removed in order to access those who are injured. When this is used, care and consideration is given to respect for the deceased, family members, the public at the scene, and the responders at the scene. Most often, this is set up on the far side of the incident, away from public sight, and is in an enclosed area such as a temporary tent, or nearby building.
Transport
After triage and treatment have been accomplished, the final stage in the pre-hospital management of a mass casualty incident is the transport of the injured and ill to a hospital for more definitive care. This is usually accomplished using ambulances, but can also be accomplished using other emergency vehicles such as a police carPolice car
A police car is a ground vehicle used by police, to assist with their duties in patrolling and responding to incidents. Typical uses of a police car include transportation for officers to reach the scene of an incident quickly, to transport criminal suspects, or to patrol an area, while providing a...
, firetruck, or civilian vehicles such as personal vehicles or transit buses. As with treatment, transport priority is decided based on the severity of the patient's injuries. Usually, the most seriously injured are transported first, with the least serious transported only after all the serious patients have been transported. However, in an effort to remove as many lightly injured civilians as possible, an incident commander
Incident Commander
The incident commander is the person responsible for all aspects of an emergency response; including quickly developing incident objectives, managing all incident operations, application of resources as well as responsibility for all persons involved. The incident commander sets priorities and...
may choose to have those least seriously injured transported to local hospitals or interim-care centres in order to provide more room for emergency personnel to work. It is also possible that lightly injured casualties will be transported first when access to those who are more severely injured will be delayed due to heavy or difficult rescue efforts.
Definitive Care
The care that is rendered at the scene of an MCI is usually only temporary and designed to stabilize the casualties until they can receive more definitive care at a hospital or an interim-care centre.Interim-care centre
An interim-care centre is a temporary treatment centre which allows for the assessment and treatment of patients until they can either be discharged or transported to a hospital. These are often placed in gymnasiums, schools, arenas, community centres, hotels, and anywhere else that can support a field hospitalField hospital
A field hospital is a large mobile medical unit that temporarily takes care of casualties on-site before they can be safely transported to more permanent hospital facilities...
set-up. Permanent buildings are preferred to tents as they provide shelter, power, and running water, but many governments maintain complete field hospital setups that can be deployed anywhere within their jurisdiction within 12–24 hours. While full field hospitals require a significant amount of time to deploy (in relation to the length of most incidents), temporary interim-care centres can be set up by emergency services fairly quickly if needed using the personnel and resources they have on-hand. These centres are usually staffed by a combination of doctors, nurses, paramedics/emergency medical technicians, first responders, and social workers such as those from the Red Cross who work to get families reunited after a disaster.