Much of the recent emphasis in the United States on bleeding control and tourniquet use for the public is because of events like the Boston Marathon bombing, the Orlando Pulse shooting and the Las Vegas shooting. Events like these have not been isolated to the United States either. Sadly, many events have resulted in situations where there are critically injured patients who all need care at what feels like at once. An event of any size that stresses responding resources is called a mass casualty or multi casualty incident or MCI. The resources we refer to can be either personnel, equipment, or both. For this reason, what is considered an MCI can be different based on where you are and where your local resources are. Obviously, at some scale, an event would be considered an MCI anywhere, or a disaster. If you work in a rural location and only have one ambulance for a large area, an accident that results in three patients even if they aren't critically injured, but all need to go to the hospital, could be an MCI. It overwhelms the resources, specifically, the equipment. When most people think of an MCI, they think of sick trauma patients like a bus crash, a multiple car pile-up, active shooter situations for example. Certainly, triage principles have their roots in trauma care. It's why we have included it in this course on trauma. However, MCIs don't have to be a large amount of critical patients. A bunch of patients that have minor injuries can still be an MCI as they are all patients and you will have to figure out what to do with them. It's also possible to have an MCI with medical patients, for example, let's say a chemical exposure, or food poisoning at a homeless shelter or dorm. A poorly organized MCI regardless of the type of patients can quickly lead to more chaos and poor patient care. At worst, it results in delay of care for those that need it emergently. MCI does not only overwhelm your resources but they can be actually overwhelming to you, the provider. To help pre-hospital providers manage MCIs, we teach a few simple but critical steps to build a framework around. As an EMT, you will not usually be in a position to assume final control of a scene. However, understanding the basic principles can be really helpful as you might be the first one on the scene of an MCI or need to manage one for a period of time until more resources arrive. We will not spend much time here talking about the Incident Command System, but you should be aware of it. If you go on to work in an EMS system, you will likely be required to take ICS 100 at a minimum. This introductory ICS class is offered for free online through FEMA. The Incident Command System, or ICS, is based on the national incident management system that is the gold standard for Incident Management at the federal level. This system provides a scalable structure to manage any type of MCI or disaster. As you can see in this diagram, it has branches to account for the finances of an incident, supplies needed for an incident, and broader planning. EMS falls under the operation section and can be further scaled. Step one of an MCI might sound obvious but it's surprising how many times it is actually the first error that is made; you need to recognize that you have an MCI. It is pretty easy to get tunnel vision and find one patient that is sick and forget to take a step back and recognize there might be many patients who are sick. This is especially common when patients present one at a time, let's say, coming out of a building or you find them one at a time. Before long, if you don't think about it early, you'll have multiple patients in front of you that need care and you haven't taken any steps to ask more resources to come. Step two is to ask for more resources. Once you identify the call is going to need more resources, you need to ask for them. How many should you ask for? Well, that will vary from call to call of course, but as the EMT, you will certainly be asking for advanced providers. You'll make an estimate based on the size of the call, a rough estimate on the patients, and what resources you may need. When in doubt, ask for more than you think you will need so you can scale back later. Step three is to establish communications. Chances are that multiple resources like a fire department and police department will have all been dispatched to the scene that you are also dispatched to. As you learned in EMT foundations, communication is really important with patients, hospitals, and each other. If you do not get on a radio channel where you can all communicate about what is going on, as well as communicate with the extra resources that you will be needing, you will then have a much more complex situation. In one event we had a situation where the different teams didn't establish a common communication channel. The result was that the EMS crews didn't know what the police were doing and the police didn't know what the fire departments were doing. Obviously, it took a high-stress and chaotic situation and made it more disorganized. You may simply need to go find other responders and stand next to them to make sure that you're all on the same page. Step four is to consider where your closest hospitals are and what their capacities are. Defer to your local protocols or procedures for establishing how many patients your nearest facilities can take. Don't assume that if you only have one hospital nearby that you'll be taking all of your patients there. Figure out how many patients they can safely handle and then consider what other local or even regional options there are. Depending on the type of MCI, your closest hospital may be overwhelmed with people taking themselves to that hospital and they may be already overwhelmed when you get there. Regardless, don't just displace the disaster from the scene to the nearest hospital only because they're the closest. Very early in your scene management, you will need to establish how ambulances will get into the scene and out of the scene, this is step five. There needs to be a clear path for getting into and out of the scene. If you do not establish this early, then you will have police vehicles scattered all over like a maze and the fire trucks blocking the only driveway, or maybe your ambulance is blocking the only way. It doesn't matter how well you run your scene. If you can't get to the patients from the scene to the hospital, then you have failed at your primary objective. Finally, in step six, you will assign people to jobs since hopefully you will have or expecting more resources to come. Tasks that will need people assigned to them are triage, transport, treatment, and staging. Let's discuss an overview of some of these roles on an MCI. For triage, you will need people identifying and sorting the patients. For transport, you will need people moving the patient from the site of triage to where they will get treatment and transported. Treatment officers provide initial care and interventions to the triage patients as well as perform ongoing evaluations for changes in patient condition. Lastly, staging people helps stage or organize the ambulance flow for patient movement. That covers the initial steps of maximizing your success managing an MCI. These can be really challenging scenes. When somebody with more experience arrives, you can and should turn the management over to them. But don't use that as an excuse to do nothing until then. In the next videos, you will learn the details of different types of triage systems as well as how we communicate about patients during an MCI.
