The first thing about mass-casualty incidents (MCIs) that comes to my mind is tabletop training. Time and time again, we all sat around and talked about triage, transport, red/yellow/green, staging, blah, blah, blah. However, how relevant are these things when an MCI happens? Well, obviously, all of them are relevant, but how do you bite off each chunk in an efficient manner? Of course, it isn’t as easy as tabletop training because of the amount of stress that inherently is induced.
The initial on-scene aspects of an MCI are some of the most difficult to battle for EMTs/paramedics, particularly us rural folks, who don’t encounter such significant events often and likely will be the only two responders on scene for a while.
You’re in charge
Consider this scenario: When you show up with your partner, you see an accident that involves three automobiles. Traffic is backed up. People are walking around everywhere. What’s worse, there are bodies and screaming. In other words, hell has broken loose. I wouldn’t be surprised that “bodies and screaming” made a few of your hairs rise, particularly if you had it happen to you previously.
The view through the windshield presents the total crap show that’s in front of you. You take a deep breath, because it’s time to make something happen, and you unbuckle your seat belt with just a few things in mind at this point.
You are the senior person, the paramedic, the experienced one. Guess what? You’re in charge. Here’s the kicker: You aren’t the one who’s providing any medicine. You don’t have enough people to make this happen. Your job as of right now is to coordinate all of the forces that you have and request all of the forces that you will need. It’s a lot to manage. Write it down, stand back and keep an open view of the accident scene—but don’t get tunnel vision on what you see on the inside or try to handle incident command and patient care at the same time. This is, hands down, the most difficult thing to do as a paramedic. I absolutely can’t stand watching someone I can’t help, because I will devote my all to that person, that child, that individual, who is screaming.
You are in charge, and you stand back until other people arrive who can handle the incident commander position.
Triage
The next step, which is best completed by a fully capable EMT, is triage. Triage is meant to be swift and efficient. I don’t care whether you use Sort/Assess/Life-saving Interventions/Treatment/Transport (SALT), Simple Triage and Rapid Treatment (START), Rapid Assessment of Mentation and Pulse (RAMP) or whatever your agency or medical program director chooses, but it must be easy and fast.
Having been involved with numerous MCIs, I honestly can say that I never actually counted a patient’s respirations to determine whether the individual was red or yellow. My mind was too stressed, and thinking, in general, was difficult enough. I use my good ol’ experience and “sick/not sick” to make a lot of the decisions.
Of the aforementioned triage variations, I like SALT and RAMP but prefer RAMP because of its extreme simplicity for when you are in the middle of mayhem.
Save lives
At this point, one more task must be added—lifesaving interventions, but nothing more. If you dig down into the weeds too far, patients could be neglected and, potentially, die. Keep it simple and fast. That’s what this is all about.
I like to use the “MAR” portion of the MARCH treatment (massive hemorrhage, airway, respirations, circulation, head injury/hypothermia) for treating during the triage portion of an MCI: massive hemorrhage by applying a tourniquet; adjust an airway and, maybe, place an oropharyngeal airway (OPA); and respiratory (needle chest decompression/chest seal for a tension hemopneumothorax).
Little elapsed time
Wow. That was a lot in the first 2–20 minutes of an MCI, but it’s a good start for the field provider who doesn’t get to run a big event very frequently. It’s scary and undeniably something that you never will forget, but, if anything, it adds to your toolbox for when it happens all over again.
Keep it simple. Keep it fast. Don’t fall down the traumatic rabbit hole.
Brandon Heggie
Brandon Heggie is a lieutenant firefighter/paramedic who has worked in fire and EMS for more than a decade. He served as a tactical medic on a SWAT team and is involved in high-angle rope rescue. Heggie provides in-depth knowledge in aggressive, simplistic medical assessment and care. He obtained an associate degree in emergency medicine and health services. As an instructor, Heggie provides a high-energy educational approach to maximize the learning experience and taught at Firehouse World and Firehouse Expo.
