Mass casualty incidents: 5 things emergency medicine doctors need to know

In the Federal Emergency Management Agency (FEMA) After Action report from the Las Vegas mass shooting in 2017, responders cited training and exercises as being responsible for their ability to mount an effective response.

The American College of Osteopathic Emergency Physicians coordinated its first-ever mass casualty incident simulation in conjunction with the city of Chicago at this year’s ACOEP Scientific Assembly.

Immersive hands-on training

This immersive hands-on training taught physicians how to respond to a mass casualty incident (MCI) and how to take this specific training back to their facilities to help implement an emergency hospital plan in their own emergency departments (EDs).

As emergency physicians, we are expected to perform expertly in the worst of situations, and MCIs create such an environment. Hospitals, staff and supplies can quickly become overwhelmed following an MCI. Extensive and frequent training for physicians is necessary to prepare for an MCI.

A pre-planned, integrated response by all health care facilities (HCF) is the best option to maximize effectiveness and improve the survivability of those injured in such attacks.

In preparing for a MCI, here are 5 things to keep in mind.

1. Plan to assess victims using the START method.

Triage is a key aspect of an MCI.  Depending on the number of casualties, officials at some hospitals may set up small tents outside their facility’s entrance to quickly evaluate which patients need immediate assistance.

Assigning a doctor exclusively to triage duty is extremely useful in responding to mass casualties. START triage, which stands for: “simple, triage, and rapid treatment,” is commonly used by hospital officials when they’re responding to an MCI.

This is a shift from the standard triage process. Patients are normally triaged based on their chief complaint or the possibility of having a severe injury or illness. However, in the START triage system during an MCI, patients are triaged based on their ability to walk, if they are breathing and how well they’re breathing, and their mental status. That is, if they are alert and answering questions.

There are four categories:

1. Has injuries incompatible with life

2. Requires immediate life-saving interventions

3. Has injuries that are not immediately life-threatening

4. Has minor injuries

2. How will you expand the capacity of the ED?

Typically, first responders notify hospital officials when they’re transporting victims, providing some notice about the flow of incoming patients, but in a mass shooting, many victims will get to the hospital in Ubers, taxis, in the back of a truck, etc.

Expanding the capacity of the ED is a key concept in an MCI due to the sheer number of victims that inundate the emergency room at one time. We must think outside of the four walls of the hospital.

The first step is to set up triage outside of the ED to immediately assist in controlling the flow of patients and resources in the emergency room. This immediately allows patients with minor injuries to be directed to other areas of the hospital to await treatment.

The most gravely injured patients, according to START triage, are brought into the ED for life-saving procedures, interventions and/or possible transfer to the OR for surgical intervention.

Moderately injured patients may be taken into the ER if space allows, or other predetermined patient care areas. Often, having a plan for a second area in the hospital for these patients allows for maximum use of ED space.

The final key step in expanding the capacity of the ER is to determine the disposition of patients already in the ER and to determine the length of time to expedite transfer of those patients out of the ER.

3. Approach with an “all hands on deck” attitude

With an overwhelming number of patients, a communication plan to notify hospital staff, including physicians, trauma surgeons, surgeons, hospitalists, etc. is key and helps expedite assistance.

There are three key aspects to this approach:

1. Designate an area where staff and physicians will report to obtain assignments. This allows for not only designation of roles but also decreases the chaos of everyone descending on the already overwhelmed ED.

2. Plan for a delayed response from staff members. Although the initial incident is overwhelming, it may take hours or even a couple of days to recover from such an incident. Having everyone respond does not allow for relief of those staff members currently working.

3. Any non-emergency, and not surgically trained physicians can be utilized to care for patients, including non-emergent patients.

4. Stop the bleeding!

Bleeding from even a seemingly moderate wound or injury can cause someone to die within minutes. Nurses, support staff, and even civilian bystanders can save lives by using tourniquets, applying direct pressure, or packing. Medical personnel can quickly teach civilians how to help treat a patient’s bleeding.

5. Supplies, supplies, supplies.

From almost every mass casualty incident that we have seen, one major limitation has been supplies. In the FEMA After Action Report for the Las Vegas Shooting, EMS and first responders stated the lack of supplies on site was a major hindrance.

If they had them, officers and medical personnel could have distributed simple supplies such as pressure bandages and throw kits to victims, but instead civilians had to use their own belts and shirts as makeshift tourniquets.

Physicians at the facilities affected stated that limited supplies, including chest tubes and ventilators, adversely affected patient treatment in the aftermath of the Las Vegas shooting. Making sure EDs and medical personnel are stocked with proper equipment ahead of time is key.

Further reading:

25 years after the Waco massacre, a DO remembers the fire and the victims

West, Texas, fertilizer explosion: DO first responder reflects on recovery, 5 years later

Disaster Response 101: 5 top tips on being ready for the unthinkable