Mass Casualty Incident!!

Responding to a Mass Casualty Incident

Awhile back, we had the massive explosion in Lebanon. More recently, we had the horrific explosion in Kabul that claimed the lives of 13 Americans and over 100 Afghans. 

The first few moments after the explosion are surreal. You don't necessarily know exactly what happened, but you know it's not good. Your brain is in a temporary fog and having difficulty understanding the magnitude of what you witnessed. Your ears are ringing. You check yourself to see if you're injured, and then know you need to help others. Casualties are everywhere. It's initially calm, but then people start screaming for help.  Your brain is having a million thoughts a second trying to assess, plan, process and help all at once. Everyone seems to be moving around, but no one is quite sure how to help. These are the realities of the moments after an IED blast. We know. We've been there before. This post will hopefully help those who have never experienced an incident like this gain a fundamental understanding of what to do should they encounter one (God forbid). 

We tend to think of Mass Casualty Incidents (MCI) as being due mainly to crazed shooters in the civilian sector and IED’s in the military sectors, and you'd be mostly correct. However, MCIs can also occur for a number of reasons, such as earthquakes, tornados, car accidents, and yes, industrial accidents.

The rules for military MCI/CCP’s and civilian CCP’s are inherently different, yet they share many of the same principles of care. Staying safe, rapid evaluation and prioritization of patients, and subsequent stabilization and evacuation.

This post is to help expand the understanding of EMS and First Responders, those with medical knowledge who are witness to MCI, and military medics who need refreshers on helpful tips and techniques.

What makes an MCI an MCI? By military definition, an MCI is when you have more casualties than you do medical resources to support their care.

In a civilian setting, this can also mean a resource constrained environment due to time, availability of services, or lack of nearby medical personnel.

A perfect example of this recently is the explosion in Kabul. The hospitals and EMS in the city were immediately overwhelmed, and hundreds of casualties wandered aimlessly seeking care. 

Rarely will a solitary medic/EMS response team have enough supplies to adequately care for large numbers of wounded simultaneously. We know that even a small delay in resources can have a major impact on the immediate need for care. Therefore, prioritization's must be made.

Step 1: Size the Scene Up

- Is what caused the incident under control? Are you at risk of becoming a casualty yourself? Taking the time to read this and wanting to help means you aren’t a coward. Scene Size Up means you being smart and taking a tactical pause to assess the situation to ensure you do not become another casualty before you’re able to help.

- Begin to assess what type of resources you’ll need. For example, in an explosion may see lots of amputations, burn injuries, head injuries, cuts from shrapnel etc., a shooting—puncture wounds, and in a car accident—blunt force trauma. Thinking about what injuries will most likely accompany an event will help you to immediately plan your response.

- Identify any onlookers who have medical training and /or are willing to help. Remember, people are more willing to help when directed. Saying “I need you to help me get this patient moved over here” is more effective than saying “who will help me?”.

If you are the bystander with no medical knowledge, take direction. Use available resources, and be proactive about reporting back to the medic with what you see. 

Step 2:  Identify a Casualty Collection Point (CCP)

- You’ve taken a second to recognize there will be multiple casualties requiring medical care. Rather than continuously running between each casualty over the entire casualty scene, it is necessary to get them all in the same area to render effective care. Identify a casualty collection point (CCP), preferably close to the patients but out of harm’s way. Must be accessible to emergency vehicles to begin accepting and transporting patients when they arrive. 

Remember! AS A MEDIC IN A MASS CASUALTY INCIDENT, YOUR JOB IS NOT TO TREAT EVERY SINGLE PATIENT YOURSELF. YOUR JOB IS TO DIRECT THE TREATMENT OF THOSE PATIENTS.

Step 3: Begin Initial Triage of Patients

  - A good way to begin is to yell out “If you are wounded and can walk, walk to the sound of my voice”. Those who may be less seriously injured and still conscious can identify themselves and begin assembling towards you. This will reduce your need to visit every patient and assess.

- Begin a systematic but expedient walk-through of patients. Identify injuries that need to be handled immediately, such as massive bleeding.

- Once you have identified a patient who needs immediate intervention, direct others to apply a tourniquet if they know how. If no one else knows how, apply a tourniquet, direct someone to hold pressure, or pack the wound yourself as quickly as possible. Have someone else hold packing in place once complete and move on to next patient. Remember, in this step, you are doing only immediate and life-threatening interventions only and moving on to more patients.

- Continue identifying all patients by order of seriousness of injury and have them moved to CCP and arranged accordingly.

Step 4: Take charge of Casualty Collection Point

The CCP is meant to assemble, continue triaging, stabilize and subsequently evacuate your casualties.

How you set up your CCP matters.

1) Organize patients by severity of wounds. Keep patients who will need greater attention together allows more rapid assessment, treatment and attention.  Try and keep the more severely wounded patients closest to where you expect them to be picked up by transport.

2) Economy of movement means being able to treat, direct treatment and move between patients as quickly and efficiently as possible. We recommend setting up your patients in the following ways to maximize efficiency. The lead medic establishing a presence in the center of the wounded allows for rapid evaluation and easy to direct patient care. 

Color BLACK: Expectant—Do not waste supplies on those who are dead or who would take up a sizable amount of resources with a small amount of survival.

-- Examples of Expectant injuries include: Exposed brain matter, agonal respirations, severe polytrauma.

-- A good rule of thumb is to separate the dead and expectant from the rest of those in your CCP, both for the sake of the living patients and to minimize confusion in a chaotic situation.  

Step 5: Begin systematically treating patients

As the lead medic, you will be responsible for directing care. As you move from patient to patient, assess rapidly through the MARCH algorithm.

1) Is the massive bleeding under control?

2) Is their airway open and patent?

3) Are their breathing/respirations adequate?

4) Is perfusion/circulation adequate?

5) Is this patient covered properly to prevent hypothermia?

Above diagram courtesy of @the_resusitationist
 - What we found to be effective was assigning a helper when available to each patient. The lead medic would rapidly assess MARCH for each patient. The helper would then be given instructions like “I need you to place your hand here and hold pressure, and don’t move until I get back” or “Keep the patient covered, and every 2 minutes I want you to count their respirations and pulse”. 

- If you were to work through the full MARCH algorithm yourself on each patient, it would delay vital assessments on other patients. Quickly understand what is happening to each patient, direct a helper to fix the issue, and move onto the next patient.

- We cannot stress this enough; In a mass casualty incident where you are responsible for multiple patients, your job is to DIRECT CARE as much as possible. You can direct others to place/check tourniquets, hold pressure on wounds, position people, cover them, etc.

- In a resource constrained environment, placing a hand on a chest wound may have to suffice instead of a chest seal. Putting pressure on a heavy bleeder with a shirt may have to take the place of a proper bandage. You as the medic know what supplies you have and which ones you do not. You must be smart about how and when you use them.

- If complicated procedures must take place, such as cricothyroidotomy, the medic would still be responsible for that.

Step 6: Continuously work to upgrade the status of your patients.

You’ve gone through your initial assessments. Starting with the most severely wounded, begin using what limited resources you have to upgrade when possible. Have an idea of who you want EMS or higher-level medical authorities to pick up first, and be prepared to give them proper vitals, treatments etc. when they arrive.

Final Thoughts

MCI’s and establishment of CCP’s are rare, but must be practiced. You can expect chaos, confusion, and a high-pressure environment. Don’t let the first time you experience it be a real-life event. 

If you are a medic, LEO, First Responder, etc. Please work an MCI, CCP etc. into your training. Even practicing it one time can have a significant impact on your ability to understand what is expected of you. It will also demonstrate how rapidly supplies are used, and can help you better assess and treat patients with alternative methods.

If you have experienced a Mass Casualty Incident, and want to share some feedback, please do so in the comments to continue the learning points!

If you want to help, but aren’t sure how, please check out our First on Scene Guides HERE. It will help walk you through the SMARCH algorithm of care, as well as how and where to place tourniquets, how to pack wounds, where to place chest seals, how to perform CPR, and more!

For military medics, we have an excellent guide for you HERE.

If you have or want to purchase a medical kit, but aren’t entirely sure how to use the contents within it, we have you covered with our Medical Kit Quick Reference Guide HERE. 

For all other medics…we have a full assortment of guides for you as well!

Visit us at www.readywarriorllc.com !!!