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Multiple Casualty Incident Plans by Paul E. Pepe, MD, Civilian government and military authorities continually are compelled to develop, revise, and update disaster plans in order to demonstrate that they are prepared to manage any major incident occurring within their jurisdiction. Likewise, the medical community, including hospitals, health departments, and medical societies, develops its own plans, particularly today with the growing threat of terrorism, whether it relates to threats of bombs, lethal chemicals, fatal biologicals, or other hazardous materials. Such plans may have value because they often contain lists of key people and agencies to contact in the event of a major incident, or because they prospectively document local policies of operation and communication when actions taken during the incident are subsequently critiqued by second-guessers. However, elaborate plans, while more useful for secondary and tertiary phases of a significant incident, generally are forgotten, inapplicable, or initially disregarded at the immediate scene of a major emergency. From various collective experiences, it has been recommended over the years that an emergency medical services system develop a simple, easy-to-remember list of basic axioms to be used in planning, training, and implementing actual field operations for an urban multiple casualty incident. In view of the recent terrorist attacks in US urban settings, such a list for MCI management is more than timely. To that end, we present "10 Golden Rules for Dealing with Multiple Casualty Incidents." Our hope is to provide a better understanding of the simple strategic plans that EMS systems can use to optimize outcomes in an MCI. Multiple Casualty Incidents For addressing medical resource needs, the MCI will be considered as a situation in which the local system transiently is under-resourced at the scene or at the hospital(s), but eventually can be managed by the local system. For example, in urban EMS settings, this might be the relatively small-scale incident in which suddenly there are a dozen or more seriously injured patients (bus collision, factory explosion, structural collapse). Although the first-arriving EMS units might be overwhelmed, the scene eventually is managed by the local system and patients are efficiently evacuated to appropriate facilities for definitive medical care, without the need for external support or mutual aid relief. An MCI also can be defined in terms of a larger incident in which hundreds of people are injured and evacuated to area hospitals over several hours. The hospitals may be overwhelmed initially, but eventually catch up with the load and are able to cope with the situation locally. The New York City incident involving the destruction of the World Trade Center is a good example. On Sept 11, nearly 1500 people were taken to nearby hospitals within the first few hours after the attack. Although transiently pressed, the hospital teams handled the patient loads and adapted accordingly. It was unnecessary to set up temporary military-type mobile facilities or evacuate patients to distant sites. In distinct contrast, for purposes of this discussion, a MASSCAL event will be defined as one in which the local system is fully overwhelmed and outside jurisdictions are called for assistance. This situation may occur when no local resources remain (eg, the hospitals toppling in the Armenian earthquake of 1988) to handle the thousands of victims or when the injured people number in the tens of thousands or hundreds of thousands (eg, the Bhopal, India, chemical leak in the mid-1980s). In Dallas, activation of the mass casualty plan does not imply that a MASSCAL event is occurring; it simply is a plan that covers both MCI and MASSCAL situations in the initial response to the event. In urban areas, a MASSCAL situation probably would involve tens, or even hundreds, of thousands of seriously injured people-a scenario in which local receiving facilities would be overwhelmed because of problems, such as not enough medical personnel, operating rooms, or intensive care beds to handle the load locally. It implies a situation in which field hospitals need to be set up or hundreds or thousands of people need to be transported to other facilities. As such, we have not had such an incident in the United States in modern times. Although it was initially feared that the World Trade Center attack might have been the first such event, as horrific as it was in terms of deaths, it remained an MCI event for the medical community as the system rapidly adapted and prevailed. While calling the New York City event an MCI, we are focusing only on the medical care aspects of the event. We are referring to potentially treatable injury cases, not the casualties in terms of the immediate deaths at the scene. Deaths must be distinguished from the patients needing treatment. In that respect, most EMS-managed MCIs generally involve an "all or none" phenomenon in which the victims are either killed outright or have relatively minor or insignificant physical injuries, such as minor fractures, abrasions, small burns, and lacerations. Usually, only a few have immediate life-threatening injuries. We have seen such a phenomenon with the crash of Delta Flight 191 at Dallas-Fort Worth Airport in 1984 and the Phillips Petroleum explosion in the Houston ship channel in 1989. Victims were either dead-on-scene fatalities or so-called "walking wounded." Only a small percentage (10% at most) make up the group that needs immediate critical care. Similarly, in the recent WTC event, fewer than 100 people (< 10% of those treated in the first few hours) were classified as critical. However, as we consider events involving larger numbers of people, this perspective may change. Even in terms of conventional disasters, 5% of 10,000 injuries can be overwhelming, not only for the rescue crews, but also for hospitals. In addition, with nuclear, biological, and other atypical weapons of mass effect, simplistic classifications of event magnitudes (MCI vs MASSCAL) also may need to be modified, particularly when considering the potential numbers of victims and the delayed onset of some of the sequelae that would result from these unconventional vectors of injury. In addition, although these definitions generally apply to the immediate incident injuries, post-traumatic stress syndromes may affect survivors, rescuers, and their families. In terms of major incidents such as the WTC attack, the psychological ramifications, both short-term and long-term, probably are impossible to quantify. Even for those not directly involved-other New Yorkers, travelling coworkers, hospital workers, or the accountable intelligence/investigatory communities-significant psychological stressors will be subtle but widespread. In addition, the economic and societal sequelae of such events may affect tens of millions of people. In this discussion, we will focus on the early management of the more probable local MCI which can be handled within the local urban EMS system. 10 Axioms for MCI Management For example, the local police may use the term "Priority 1" for the most critical situations, "Priority 2" for the less urgent situations, and "Priority 3" for the least urgent. At the same time, the local EMS crews may use the term "Code 3" for the most critical patients, "Code 2" for the less serious cases, and "Code 1" for stable people. Other agencies providing mutual aid may use an entirely different nomenclature, confusing things even more. For the sake of coordination among interacting agencies, a county or municipal disaster plan may state that each patient's condition should be classified by color to indicate severity. Typically, as in the military, this might be classified as "red" for critical patients, "yellow" for patients whose care can be somewhat delayed, and "green" for patients with minimal, non-life-threatening, insignificant injuries. If color designations were used in an MCI, then they should be incorporated into the routine operations of that jurisdiction, including the EMS, law enforcement, and mutual aid agencies. This avoids a confusing situation in the heat of the MCI, which, in turn, allows rescuers to better concentrate on their functions during that MCI. Likewise, if interagency liaisons are to be set up at an MCI, such interactions should be part of the routine, even at motor vehicle collisions or domestic violence scenes. People who normally function inside a hospital can best serve the patients in that setting and not at the scene of an MCI. Therefore, physicians planning to participate in the out-of-hospital setting at an MCI should be those who are part of the routine EMS system and who respond routinely to EMS scenes. 2. Do What Will Save More Lives in the Long-term. If hazards still exist-fumes, weapon-fire, secondary explosion-rescuers first should protect themselves and the minimally injured victims, and they should warn incoming rescuers and bystanders. These unharmed victims and rescuers theoretically have a much better chance of long-term survival than the severely injured victims. Rescuers cannot help anyone if they themselves are harmed. Therefore, instead of directly implementing standard triage priorities, unharmed victims should be removed and incoming rescuers should be detoured from existing hazards so they can avoid injury. In evaluating the existence of hazards, the possibility of a "second-pass phenomenon" should be considered. For example, rescuers always should consider the possibility of a second explosion, a major aftershock, a second or third tornado, or a second terrorist bomb detonation planned for the incoming rescuers. It was not a total surprise to those familiar with terroristic incidents that a second aircraft might ram into the WTC or that a secondary bomb (or bombs) might have detonated when rescuers arrived. After initial protective actions are taken to protect the healthy and unharmed, and the hazards removed, then standard triage and evacuation can be implemented. This second axiom also follows traditional triage procedures-the triage officer evaluating two victims who are critically injured should give priority to the one who has greater chance of long-term survival. For example, with a trauma center nearby, a person with a severe head injury would not be prioritized over a hemodynamically unstable person with a penetrating abdominal injury who is still conscious. The probability of long-term, neurologically intact survival determines the decision. 3. Establish a Centralized, Easily Identifiable Incident Command Post and Incident Commander. An MCI generates enough confusion without rescuers being unable to find out easily where they should report for instructions. It is suggested that representatives or liaisons from the involved agencies-police, power companies, rescue crews, mutual aid departments, Red Cross, media crews, supplemental medical volunteers-be stationed at or near the command post to facilitate communications to and from the incident commander. It is better to establish liaisons rather than put everyone on the same radio channel. Each sector or involved agency can communicate independently with its own sector liaison, as is done daily. In turn, the liaison at the command post can directly communicate as needed with the incident commander or staff. Specific tasks should be assigned to specific people. Avoid commands such as, "Somebody get me an ax." Also, each person should be told which supervisor he will be assigned to follow. In general, the chain of command should not be broken in either direction. Depending on the sector, a group leader should be assigned for every three to 10 people or, on a hierarchical basis, a senior command officer should oversee four or five groups. For example, a fire engine crew may have an officer and three firefighters, while an EMS lieutenant may have four or five ambulance crews, or a battalion chief might have four or five apparatus under his or her command. At each level of hierarchy, such ratios generally should be implemented. This tactic follows the routines for most fire, police, or EMS departments. 4. Communicate Succinctly in a Clear Zone, Clear of Surrounding Noise, That Allows a Strong Signal and Redundancy. Transmission clarity should be kept in mind when establishing a command post or a sector chief's position. Noisy apparatus or certain electromagnetic interference can disturb radio or cellular messages. Sometimes something as simple as getting inside a car may allow for clear transmission with diminished ambient noise. Although radio traffic should be kept at a minimum, regular updates on the situation should be provided to dispatchers, as well as to those assigned to notify auxiliary support agencies and potential receiving facilities. An important strategic plan for any disaster is provision of redundancy and back-up systems. This can be stressed in terms of potential loss of incident or medical leadership (in case of absence or actual on-scene casualty involvement). It can also apply to having special caches of drug supplies or extra equipment in case of inaccessibility or destruction. It can apply to medical facilities in case certain lead hospitals are destroyed or become inaccessible. Most importantly, redundancy needs to be built into communications. Back-up communication centers for dispatches, medical base stations, and emergency operation centers should be established ahead of time and be familiar to potential users. At the scene, multiple options for communicating (radios, phones) should be available as well. 5. Fewer Knowledgeable, Designated Rescuers Perform Better than Many Volunteers. Inexperienced volunteers, although well-intentioned, usually add to the confusion, or even can inhibit the routine. They should be staged in a holding area where they can be accessed readily and hailed in, if needed. For example, physicians unfamiliar with the prehospital environment and the usual operations of civil authorities are best used at the usual receiving facilities. Even if it is determined that physicians are needed at the scene (such as for amputation or assistance with a military-type mobile field hospital), they are easier to locate if they report to their usual medical facility. Again, this is a corollary of axiom No. 1, follow day-to-day routines as closely as possible. This phenomenon occurred at the WTC attack in which many people wanted to volunteer, but truly were not needed. Despite the magnitude of the incident, little outside medical support was required. Typically, certain specialized teams could be called in to such events (such as urban search and rescue teams) or patients might be transported out of the area. Therefore, those would-be volunteers are best used when they stand by ready to respond as requested, or, more likely, when they stand by ready to receive evacuated patients. Well-intentioned people wanting to volunteer often are a liability to the ongoing rescue effort because they will need food and shelter themselves. They also are at risk for injury. Likewise, rescuer injuries may exceed the number of survivors with injuries. At the US Air snowstorm crash at New York La Guardia airport in March 1992, about 25 people were killed outright, and another 25 survived. A few of the survivors had critical injuries, but the majority were "walking wounded." Over the next several hours, however, more than 80 rescuers, mostly rescue divers, were treated for hypothermia, eye burns from jet fuel, lacerations, and orthopaedic injuries. Likewise, at the WTC incident, many people treated in the initial hours were rescue personnel and several hundred more received medical attention over the next few days. Another consideration is the number of people exposed directly to the reality of the scene and its horrors. Even experienced, jaded rescuers will have some degree of post-traumatic stress syndrome when exposed to the atrocity. These concerns do not even address the technical issues, such as license to practice medicine or credentialing issues. Often, American physicians want to help at a foreign disaster site, but they don't know the language and don't have the proper tools (diagnostic or interventional), and may cause more problems for officials than help. Unless physicians practice tactical medicine on a daily basis, such as certain military physicians or certain EMS physicians who routinely respond to major incidents, the risks outweigh the potential benefit. Although this discussion seems to dissuade the concept of volunteerism, the heartfelt need to help is important to recognize. In times of great tragedy, good human beings want to be involved, even at risk to themselves. This is true for several reasons. When tragedies occur, the emotion of guilt creeps in and can be manifested in many ways. The guilt may arise from a sense of feeling responsible for an event, whether directly involved or not. This sense of responsibility may be related to one's deep-seated self-image as a "lifesaver," particularly in someone who rarely gets a chance to do such "heroics." Regardless of the motivation, however, the desire to help should be seen as well-intentioned and should not be dismissed or patronized. In planning for such incidents, a rescue agency should expect contact from such volunteers and plan ways to put this volunteerism to good use. At the least, appreciation for this spirit of good citizenship should be made clear, even if the help is unneeded. 6. Emphasize Centralized Control of Evacuation. In general, basic life support providers should be dedicated to search and rescue efforts, and should be used to move patients to the evacuation point. Therefore, most rescue personnel should receive some form of BLS training. Advanced life support providers (paramedics, physicians, nurses), if present, should render secondary triage and accompany critical patients. In circumstances such as entrapments, ALS personnel could be called in to assess or provide care. Thus, certain ALS personnel can be staged to stand by for such circumstances. The concept of controlled evacuation is key, preferably through one or two people who communicate closely and know where everyone should go. In disasters, walking wounded and minor injury victims often are taken in private automobiles or in facility vehicles to sites away from the disaster or to nearby area hospitals before EMS arrives. Therefore, it is important for the on-scene officer responsible for tracking the evacuation to be in contact with area facilities. Preferably, this activity is mediated through a communications center with direct ring-down capabilities, such as a dispatch office or an EMS base station, which routinely handles hospital transport communications and diversion issues. This communications center can keep track of the census at each hospital and its ability to handle more patients, particularly when it is ready to accept more patients after being overwhelmed initially. This feedback is invaluable to the on-scene evacuation officers who have no idea how many patients were transported out of the area before EMS arrival and who need to monitor ongoing treatment and disposition at the hospital. This concept is important particularly with respect to chemical threats. In such situations, decontamination may need to be completed prior to transport to avoid further exposure to hospital personnel. Likewise, on-scene officers identifying such problems can notify hospitals of this threat in case victims leave the scene prior to hazard identification and/or EMS arrival. 7. In the Initial Phases, Triage and Evacuate Patients to the Usual Receiving Facilities. Triage (evacuation) officers should direct transportation of the critically ill and injured to the usual trauma centers/burn centers/tertiary care centers if that is the routine, even if the number of victims appears to be large. Often, such centers can adapt to such loads, particularly because all of the patients do not arrive at once. Patient arrivals at the major emergency departments usually are staggered because patients cannot be evacuated from the scene simultaneously. In addition, triage officers may allocate minor injury patients to smaller EDs while alternating transport of the more critical patients to trauma centers in large urban areas. This gives trauma centers time to assess, stabilize, and achieve dispositions on the critically injured, and allows time to notify back-up medical personnel and back-up facilities. Under these circumstances, capable medical assistance (extra ED physicians, surgeons, critical care and ED nursing, anesthesiologists, and other emergency/critical care personnel) can arrive by the time they are needed. In the interim, medical evacuation officers should continue to get feedback from receiving facilities before modifying these routines. Again, the facilities can let the EMS providers know whether they can safely accommodate more patients and what kind of patients they can receive and manage. Even when a facility is at capacity at one moment, it may be open again for new cases a short time after assessments and dispositions are made. 8. Log Events Chronologically and Centralize the Media as much as Possible. In the United States, the media often can be helpful in chronicling events so lessons can be better learned, retrospectively. Usually, they are supportive and subsequently paint a favorable picture of MCI management when they collaborate in the incident themselves. Media also can be useful in notifying the public about hazards or even dispelling unnecessary fears, thereby avoiding public panic. For example, they can ask potential victims' relatives and friends not to go to the scene (and either become a victim themselves or be lost to contact), but rather to stay in their homes (or workplaces) so they can be contacted more readily. Alternatively, the media can advise such people to call certain phone numbers or go to a safe checkpoint. Also, the media can ask the public for help, such as for blood, money, food supplies, or to sign an organ donor card. This is most important today when the "scene"may be the community as a whole in the event of natural (eg influenza) or intentional outbreaks of communicable biological illnesses where treatment instructions may best be provided through mass media. In such situations, a public health model may be used (ie stay in place or quarantine) and paramedics may be used for immunizations or antibiotic administration. The best way to handle media is to work with them on a daily basis and to have a plan to centralize them. In a major incident, one or two camera people can be selected (or chosen among themselves) to go into closer areas under escort. They then share their video with other media. This approach may help with the logging of events and quality assurance reviews, and it helps establish better rapport and a sense of public responsibility with the media. 9. Always Prepare to Provide Post-incident Care for Rescuers and Victims, Family Members, and Friends. Immediate and subsequent communication, comfort, care, and formal debriefings should be provided to rescuers, family members, survivors, and other bystanders. Comfort and care includes the provision of food, shelter, and medical management for all those at the site, and those who will arrive later. In addition, one must prepare to protect rescuers and victims alike from legal and journalistic opportunists. Also, the post-traumatic stresses on all members of the rescue team as well as the victims, families, friends, and coworkers usually are enormous, often denied, and can go unrecognized. Major events also cause moderate to extreme effects on society as a whole, and it is important for governmental leaders to provide leadership and follow their normal routines as soon as possible to help establish a sense of stability. 10. Train and Test all Potential Rescuers. All designated rescuers and auxiliary agencies (including media) should meet regularly to establish what each will do in the event of a major incident. Even education of the public on its role in the event of a major incident is important. Although disaster drills often are seen as unrealistic, unemotional, and time-wasting exercises, they provide at least one important advantage-they bring the players together so they can get to know each other before an event. Knowing the various personalities in leadership positions and their potential contributions is of enormous benefit. Sometimes, just seeing a familiar face at a major event allows more effective communications, teamwork, and concentration on the job at hand. Acknowledgments Dr Pepe, medical director of the Dallas Area EMS and the Dallas Metropolitan Medical Response System, has co-authored multiple scientific publications regarding medical management and public information aspects of multiple casualty incidents and disasters. These publications largely are based on his experiences at major incidents including large-scale petroleum refinery explosions (eg, the Houston Ship Channel Phillips Petroleum disaster), aircraft crashes (eg, New York City and Houston) and multiple hazardous-material incidents. He also has reviewed disaster incidents for foreign governments and made recommendations accordingly. Domestically, Dr Pepe has served as the emergency medicine and trauma consultant to such diverse entities as the White House Medical Unit, ABC News, and the National Institutes of Health. Eric Anderson is a paramedic officer and a 20-year veteran
of Dallas Fire Rescue. As EMS shift captain, he is the lead officer
for one of the three DFR field shifts. He recently developed
a specialized training program for all DFR personnel that organizes
medical care scenes in a manner akin to fire incident command
systems.
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