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Category: EMS Operations

Topic: Multiple Casualty Incidents

Level: EMT

26 minute read

Risks and Responsibilities of Operating at a Natural or Man-Made Disaster.

If confronted with a natural or man-made disaster, EMS professionals will encounter the greatest challenges of their careers. Rarely will many EMS professionals encounter one that is significant in scale. However, it is important for EMS professionals to study and be prepared for their occurrence because the sheer magnitude and complexity of these events can be overwhelming.


Role of EMS

There are four major roles that emergency providers play in a Mass Casualty Incident:

  1. Ensuring the personal safety of responders at the incident.
  2. Providing patient care.
  3. Initiating and operating within the incident command system (ICS).
  4. Assisting with operations.

NOTE: ICS is under the National Incident Management System (NIMS), a part of FEMA (which is part of Homeland Security). 


Personal Safety

First Priority to Responder Safety: Just like any other incident, the safety of responders is of the utmost importance when responding to natural or man-made disasters.

Before responding to any suspected terrorist incident, responders should position themselves uphill, upwind, and upstream of the incident to perform surveillance. If PD and FD have secured the scene, the ambulance should be parked at least 100 ft past the scene, uphill and upwind to secure the safety of ambulance personnel. In this position, the ambulance deflects and diverts other vehicles away from the scene, preventing them from striking the ambulance or the providers.

From a position of safety, responders can establish the incident command system, size up the scene, develop an incident action plan, and request additional resources.

Personal Protective Equipment: If responding to a mass casualty incident involving possible "B-NICE" exposure:

  • Biological,
  • Nuclear,
  • Incendiary,
  • Chemical or
  • Explosive agents

It is likely that ordinary personal protective equipment will not provide enough protection to responders.

For most of the agents encountered, the use of specialized protective equipment will be required to protect responders, to include the use of a self-contained breathing apparatus (SCBA).

Time, Distance, and Shielding for Nuclear Agents: If responders encounter nuclear agents, time, distance, and shielding should be employed.

That is, the less time exposed to a nuclear agent the less likely damage to tissue will occur; the further a responder is from a nuclear agent the less damage to tissue will occur; and the thicker or denser the objects that are placed or located between responders and a nuclear agent, the less likely tissue damage will occur.

Inverse-square law: Move a little, protect a lot! Remember that in many situations (such as radiation) the lessening of damage is inversely proportional to the squaring of the distance. In other words, protection with distance is exponential, not just arithmetic: moving twice as far away will reduce your exposure by four times. Therefore, moving just a little bit farther away can make a BIG difference in your risk--even an extra inch! 

Emergency Responders and Secondary Attacks: When responding to deliberate attacks, it is important to stay vigilant because responders will generally be targets for terrorists at mass casualty incidents. Additionally, responders should be aware of the potential for secondary devices or attacks. Secondary devices are those devices that are designed to be delayed in their activation to target unsuspecting responders and others rushing in to assist or "sight-see."


Patient Safety

Making Patient Contact: When making patient contact, inform the patient of your actions and develop a plan to protect them from further harm.

This may include sheltering a patient in place or moving them to a position of additional safety.

Responders should be alert to the signs of B-NICE substances when making patient contact. If B-NICE substances are suspected, responders will need to take immediate precautions.

Greater Good: When interacting with patients involved in terrorist incidents, the concept of "greater good" should resonate with responders. This concept may lead to the delay or even the death of patients involved in terrorist incidents to protect a greater population or community. 

If presented with treating a potential terrorist or criminal involved in the incident, it is incumbent on responders to put personal feelings aside and treat them as any other patient encountered.


Scene Assessment and Size-up

Outward Signs of Terrorist Incidents, WMDs, and B-NICE: Response to a suspected terrorist event requires first responders to actively consider safety factors, observe the scene for hazards or attackers, and be efficient in treating patients.

During these incidents, the scene must be continually evaluated to detect developing threats or unforeseen challenges. Moreover, responders should be aware of the potential risks for terrorism at specific locations within their community.

Locations that present potential risks for terrorism include:

  • nuclear plants,
  • chemical or bio labs,
  • government offices,
  • military bases,
  • transportation depots,
  • dams,
  • water treatment facilities,
  • petroleum storage areas,
  • hospitals,
  • large churches, and
  • festivals and rallies.

Additionally, be alert to the signs or symptoms of terrorist incidents, weapons of mass destruction, and biological, nuclear, incendiary, chemical, or explosive substances. These signs may present in two ways,

  1. environmentally or
  2. physically.

The following are examples of environmental indicators:

  • Sick or dead animals, fish, or birds - Wildlife are often more sensitive to chemical or biological agents than humans.

Animals, fish, or birds that are sick, dying, or dead may indicate the presence of a biological or chemical attack.

  • Unscheduled spraying or abandoned spray devices - Several September 11 terrorists are known to have made inquiries into purchasing and learning to fly crop dusters. Many other types of agricultural sprayers can be used to disperse biological and (more likely) chemical agents.
  • Vapor clouds or mists that are unusual for the area or for the time of day.

Although many biological and chemical agents cannot be seen with the naked eye, the substances in which they are suspended when dispersed may be visible for some time after an attack.

  • The absence of crops, wildlife, or insects that are common for the area, time of day, or time of year.

Being aware of what is not in the environment that should be is as important as being aware of what is in the environment but is out of place.

  • Out of place and unattended packages, boxes, or vehicles - Terrorists have a long history of hiding explosive devices in packages, boxes, or vehicles. Items that are out of place and unattended could signal a possible terrorist attack.
  • Packages that are leaking may be harmless—but they may also signal a terrorist incident.

The terrorists who released Sarin in the Tokyo subway system (Aum Shinrikyo) merely poked holes in bags containing Sarin, then left the area as the poison leaked out.

  • Materials or equipment that are unusual for the area.

Dispersal devices, lab equipment, or quantities of hazardous materials that are not typically located in the area may indicate that a terrorist attack is occurring or is about to occur.

  • Small explosions that disperse liquids, mists, or gases are an obvious sign that something is wrong.
  • Unusual odors or tastes.

Additionally, be alert to physical indications, for example:

  • Multiple casualties without obvious signs of trauma.

This may indicate a biological or chemical attack.

  • Multiple victims who are exhibiting similar symptoms.

Symptoms may range from difficulty breathing to skin necrosis to uncontrolled salivating, uncontrolled muscle twitching, or convulsions. All of these symptoms indicate that a chemical attack may have taken place.

  • Large numbers of persons seeking medical attention with similar symptoms that are not characteristic of the season.

The symptoms of many biological agents mimic the flu or other common illnesses. An unusually large number of persons seeking medical attention for the flu in July could indicate that a biological attack has taken place.

Determining Patients, Implementing MCI Protocols, and Evaluating Resources

During mass casualty incidents (MCI), responders will need to recognize and identify the sick and injured, take an accounting of those patients, and evaluate available resources. If B-NICE substances are present, responders will need to request military resources to identify and handle many of those substances.

Responders should have mass casualty protocols in place for handling such situations. These protocols should be enacted to provide a guideline for responders to follow in handling these incidents.


Operations During Terrorist, WMD, of Disaster Events

INCIDENT COMMAND SYSTEM: If confronted with an MCI event, responders will need to establish the incident command system and scale it as needed.

Position themselves a safe distance away from the incident uphill, upwind, and upstream and perform surveillance and reconnaissance to determine the nature of the event.

Additionally, if B-NICE substances are suspected, responders will have to request additional resources, establish hot, warm, and cold zones for the incident, and provide protections for responders. An event of this complexity will be protracted and may take many hours if not days to resolve.

ALL-HAZARDS: MCI events should be approached with an all-hazards methodology. That is, responders should expect every potential hazard to be present at the incident and prepare accordingly.

Responders must provide a continual assessment of the incident and situation for the potential of secondary events or other hazards that may present themselves.

In general, events involving terrorists will require the establishment of a Unified Incident Command System to include fire, EMS, law enforcement, and other important stakeholders in the command decisions of the incident.

PERIMETERS: Perimeters should be established to contain the incident, protect rescuers, patients, and the public from the expansion of the incident or the spread of any agents that may be a part of the initial incident.

Additionally, responders should establish escape plans and mobilization points to protect them from additional threats and create centralized locations for additional resources to meet.


Care of Emergency Responders

In the event of a B-NICE incident, responders should be provided and trained in the use of auto-injectors for chemical agents. Additionally, responders should be trained in the disposal of these devices after activation.