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Everyday EMS Tips

Focus on Mass Casualty Incidents


Products, Training, and Response

March 2010

Greg Friese, MS, NREMT-P

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DISCLAIMER AND/OR LEGAL NOTICES:


The information presented herein represents the views of the author as of the date of publication.
Because of the rate with which conditions change, the author reserves the right to alter and
update this information based on the new conditions. The publication is for informational
purposes only. While every attempt has been made to verify the information provided in this
publication, neither the author nor its affiliates/partners assume any responsibility for errors,
inaccuracies or omissions. Any slights of people or organizations are unintentional. If advice
concerning medical, legal or related matters is needed, the services of a fully qualified
professional should be sought. You should be aware of any laws/practices or local policies which
govern emergency care or other pre hospital care practices in your country and state. Any
reference to any person or business whether living or dead is purely coincidental.

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Introduction 
This ebook is a compilation of articles by Greg Friese, MS, NREMT-P that relate to MCI
response, preparation, products, and training. Greg is a paramedic, presenter, author, blogger,
podcaster, and elearning designer. To read more tips visit everydayemstips.com.

Reader tips are being compiled for future ebooks. Please submit your tips and suggestions by
email to greg.friese@everydayemstips.com.

Table of Contents 
Introduction ..................................................................................................................................... 3 
Mass Casualty Supply Kits ............................................................................................................. 4 
MCI Response Tips......................................................................................................................... 5 
Mass Casualty Trailers .................................................................................................................... 6 
MCI Training .................................................................................................................................. 7 
Debriefing Patient Assessment Scenarios ....................................................................................... 8 
How to Buy: Communications........................................................................................................ 9 
Emergency Response Guidebook Training .................................................................................. 10 
About Everyday EMS Tips ........................................................................................................... 11 
About the Author .......................................................................................................................... 11 

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Mass Casualty Supply Kits 
Where are the mass casualty supplies in your ambulance or first response vehicles? I am
guessing they are tucked in a cabinet behind the back-up airway kit or obstetrics kit, like most
infrequently used items. Am I right? With space at a premium inside the ambulance, these are
important items for your mass casualty supply kit.

The first step in any mass casualty situation is declaring an MCI and initiating the incident
command system (ICS). As this is done, the ICS personnel should don vests that are labeled with
their position. Vests should be highly visible with reflective marking. Since many MCIs occur on
roadways make sure vests meet current ANSI guidelines for visibility. Some vest collections
color code the vests by the function area in the EMS branch. For example, the transportation
group supervisor might be assigned a green vest and triage group supervisor a yellow vest.

The next step for any ICS member is to review and understand the immediate responsibilities of
their position. A job action sheet is a quick reference of the position’s immediate and long-term
tasks, span of control, and reporting responsibilities. For example, the triage group supervisor
leads triage teams and reports the number of patients to the EMS Branch Director (or Operations
Section Chief or Incident Commander depending on the size of the incident). A job action sheet
is not the full mass casualty response plan for the agency. Instead it is focused on the
accomplishment of specific tasks. Job action sheets can be laminated or in a clear plastic folder
for durability and protection. Include a pen, grease marker, or a marker with the job action sheet
depending on its format.

Depending on the size and duration of the incident, EMS professionals may need to deploy other
incident management supplies. Colored flags, scene lights, cones, tarps, and tape can be used to
designate different locations at the incidents. Two
important areas to clearly designate are the incident Having a designated
command post and the patient treatment areas. Having a incident command post
designated incident command post helps keep the
helps keep the incident
incident commander stationary.
commander stationary.
There are a variety of products for patient triage. Tags,
wrist bands, and even different colors of surveyor’s tape can be used to designate patient’s triage
category. A triage product should be durable, have a number or bar code system for patient
tracking, and allow recording of basic patient demographic or assessment data. Additional triage
tag features to consider include tear-off portions to designate a patient’s contamination status and
a tag patient’s belongings like clothing, bags, and other potential contaminated evidence. Also
evaluate the current or future ability of the triage tag to integrate with an electronic record
keeping system.

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Pre-packaged or made-to-order Mass Casualty Supply kits are available for purchase. Another
option is to make your own kit with a small or medium size duffle bag and then pack it with
vests, scene supplies, job action sheets, and triage tags. Which do you use – pre-packaged or
build-your-own?

What are supplies are essential for incident management? Share your experiences and ideas by
sending an email to greg.friese@everydayemstips.com with your feedback.

MCI Response Tips 
What does a MCI look like for your agency? Is it five patients? Or ten? Or more than twenty?
MCI is defined by responder capabilities, not patient numbers. To better understand what would
or would not be an MCI for your service talk through past or potential scenarios with your co-
workers to better understand what an MCI would look, sound, and feel like.

When responding to an MCI remember these Everyday EMS Tips:

1. Plan and prepare using an all hazards approach versus a specific plan for all potential
incidents.
2. MCI response is not all or nothing. Use plan components, equipment, and ICS positions
appropriate for the actual incident.
3. Communicate with receiving hospitals early and often about the number and severity of
patients.
4. The first emergency responder(s) on scene need to identify and confirm the MCI, initiate
the MCI plan, and initiate command. Next complete a scene size-up of hazards before
starting triage or treatment.
5. Establish functional areas like staging, command post, and treatment areas early. Mark
functional areas with flags, signs, tape, and lights.

Finally, make sure the Incident Commander stays put in an incident command post which could
be a vehicle, trailer, or specific area.

To learn more about MCI Concepts for EMS browse the


www.EMSBootCamp.com archives for an online training session I
delivered on the topic. The session is a compilation of sessions I have
presented at numerous EMS training sessions and includes the
materials for a twenty patient tabletop triage exercise you could
facilitate for your service.

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Mass Casualty Trailers 
Mass casualty supply trailers are mobile caches of equipment for rapid response to mass casualty
incident (MCI) scenes. During an MCI, supplies on responding ambulances may not be adequate
for on-scene treatment. Unless those ambulances are unloaded before they initiate transport,
many of the extra supplies they contain will not be available for the remainder of the incident.

The primary purpose of an MCI trailer is rapid delivery of supplies for decontamination and
personal protection, treatment of life threats, and incident management supplies like tarps,
lighting, and long-term patient care supplies like cots and blankets. Secondary purposes might
include the delivery of supplies for EMS professional sustenance like water, food, and clothing –
or treatment of patients with minor injuries like small wounds.

Because of the high cost for the trailer or trailers, as well as the initial equipment, a needs
analysis should be conducted to confirm the need for a mass casualty trailer, the size of the
trailer, and the contents for the trailer. If the need for a trailer is confirmed, do these things
before actually purchasing the trailer and stocking it with supplies:

1. Create a protocol or adapt the existing MCI plan to specify the type and size of the
incident that would trigger deployment of the trailer.
2. Identify locations where the trailer or trailers will be stored and, if needed, agree to
mutual aid response agreements for transport of MCI trailers to the incident scene.
3. Ensure that the public safety answering point understands the protocol and has the
capability to dispatch an MCI trailer and track its times like any other response resource.
4. Prepare an equipment specifications list that can be submitted to vendors.

Most MCI trailers are provisioned for multiple patients that have a trauma mechanism, including
patients from a multiple vehicle collision, building collapse, or mass shooting. Work with local
and regional emergency responder groups to conduct a hazard analysis for the trailer’s response
area. Other mechanisms, like chemical exposures, influenza pandemic, or foodborne illnesses -
may be higher risk and higher probability. The supplies of the trailer should reflect the local
hazard analysis.

You can either determine what you want and find a trailer to
hold those contents or pick a trailer and then fill it with contents. The amount of
The amount of supplies will expand to fit the trailer. While supplies will expand
having lots of supplies may seem advantageous, make sure to
to fit the trailer.
consider the cost of restocking outdated supplies or rotating
unused inventory off the trailer and into ambulances to use it
before it expires.

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When a trailer is used during an MCI there will probably be little thought to tracking the
equipment used. A plan needs to be in place before deployment for tracking and replacing
inventory from the MCI trailer. Also consideration should be given as to how supplies from the
trailer will be billed.

Finally, educate EMS professionals and other emergency responders about the availability of
MCI trailers and their contents. Include deployment of the trailers in all functional and full-scale
exercises. After the initial purchase make sure to orient new personnel to the trailers.

What is in your agency’s MCI trailer? What advice would you give to an agency considering an
MCI trailer? Share your ideas by sending an email to greg.friese@everydayemstips.com with
your feedback.

MCI Training 
Since mass casualty events are infrequent for most EMS professionals we have limited
opportunities to practice and improve our incident management skills. Didactic training can help
us become familiar with concepts, but regular hands on practice through table top exercises,
functional drills, and full-scale simulations is needed to achieve incident management
competency. Here are some tips for MCI training:

1. Scenario planning. A scenario is a story that needs to have a beginning, middle, and end.
The beginning is usually what happened before EMS arrives. The middle is the actual
EMS response including triage, patient assessment, treatment, and transport. The end is
the resolution of the MCI and the demobilization of EMS.
2. Identify clear training objectives. What do you want personnel to accomplish during
the training program? Create objectives that are specific, attainable, and measurable.
3. Document the training for analysis and debrief. Use a digital camera and/or handheld
camcorder to record the training program. I usually record short bursts of action, such as
quick moments of triage, extrication, and treatment. Video and photos allow personnel to
see other parts of the scene that they could not see during the actual training.
4. Debrief what went well. Most debrief sessions quickly devolve into discussion about the
short comings of the training plan and the negative performance actions. Focus the
debrief on positive lessons learned and how to apply those lessons to future trainings and
actual incidents.

Finally, make incident management roles and responsibilities part of your routine. Some services
conduct Triage Tuesday and use triage tags on every patient one Tuesday a month.

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Debriefing Patient Assessment Scenarios 
Patient assessment scenarios are great opportunities for students to see injuries and illness within
the context of the assessment. They also allow students to practice applying treatments. The final
phase of any patient assessment scenario is debriefing. During this phase, the instructor’s role is
to review what happened and begin the process of transferring the lessons learned from the
performance phase to future training activities or real incidents. If you are instructor or
facilitator, follow these general guidelines for debriefing:
1) Don’t attempt to debrief every component of the scenario. Focus discussion on the
components most important to the objectives of the scenario.
2) Ask questions to stimulate discussion about the scenario objectives while avoiding
statements that judge performance.
3) Make sure to ask what went well. It is often more difficult for instructors and students to
talk about successes.
4) Ask specific questions to specific people. All students need to be ready for giving hand-
off reports. Specific questions – i.e. “What was your first set of vital signs for this
patient?” -- prepares the student for the work environment.
5) Use a question that teaches and elicits new information. If every group assessed a chest
pain patient, each student reporting during the debriefing should add new information to
the discussion.

As you near the conclusion of the debriefing ask, “What questions do you have?” Instead of
asking “do you have any questions?” A ‘yes’ or ‘no’ question almost always results in a ‘yes’ or
‘no’ answer. Asking, “What questions do you have?” almost always leads to a question.

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How to Buy: Communications 
Guidelines for purchasing Communications products

The after action report for every major incident or training exercise invariably includes
“Improve Communications” as one of the top three lessons learned. I am confident we could
review decades of after action reports and find recommendations to improve communications by
purchasing new radios, better radios, more radios, fancier radios, programmable radios, digital
radios, stronger radios, encrypted radios, and lots of other assorted radio infrastructure.

Despite purchasing billions of dollars of radio equipment, clear communication continues to be a


problem and a lesson learned at major incidents and training exercises for all emergency
responders. It has become apparent to me that the solution – buying radios – is not fixing the
problem.

As you review your department’s needs to improve internal and external communication, make
sure you correctly understand the problem and then pick the appropriate solution.
Communications hardware is just part of the problem and likely a much smaller part than we
realize. When improving communications, make sure you also address the teamwork, trust, and
knowledge issues that are at the core of solving communication problems.

Here are three things to consider when making a communications purchase:

1. Clearly understand the problem you are solving. New radios will not resolve distrust
among mutual aid partners.
2. Stay true to an accountability system on every incident. New radios will not prevent
freelancing.
3. Improve and monitor listening skills. Radio batteries last a lot longer in the receive
mode than they do in the transmit mode.
4. Focus on completing the task you are assigned. Radios that scan multiple frequencies
don’t improve our ability to multi-task.

In the 7 Habits of Highly Effective People, author Steven Covey teaches, “Seek first to
understand, then to be understood.” Focus communications training, purchases, and solutions on
first listening to solve the underlying communications problem and to appropriately distribute
scarce purchasing resources to the areas of greatest need.

How would you improve communications without purchasing communications equipment? Any
other suggestions? Anything we missed in the list above? Send an email to me at
greg.friese@everydayemstips.com with your feedback.

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Emergency Response Guidebook Training  
Where is the Emergency Response Guidebook (ERG) in your ambulance, rescue vehicle, fire
truck or personal scene response vehicle? The Department of Transportation’s stated goal is to
make sure there is an ERG in every emergency response vehicle.

Before you do anything, go out to your vehicle and make sure you have the most up-to-date copy
of the ERG. If you need more free copies, contact your state coordinator.

How do you deliver ERG training to EMT students and new members? The U.S. DOT Pipeline
and Hazardous Materials Safety Administration has an excellent video available that you can
view online or download. The video is designed for new emergency responders that are
unfamiliar with the ERG. However, I have received numerous classroom lectures and refreshers
on the ERG, and even I have learned several new things from watching this video.

Remember that any ERG training program should include hands-on opportunities to look up
information in the ERG and discuss how it applies to different scenarios described by the trainer.

Visit the U.S. DOT PHMSA website to download a PDF of the ERG. There are also versions
available for PDAs and in Spanish.

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About Everyday EMS Tips 
EverydayEMSTips.com and Every Day EMS Tips are brands developed by Emergency
Preparedness Systems LLC. (http://eps411.com). EverydayEMSTips.com provides tips,
resources, study guides, and ebooks for students, EMTs, Paramedics, and EMS managers.

About the Author 
Greg Friese, Plover, Wisconsin, is the founder and president of Emergency Preparedness
Systems LLC. He founded EPS to deliver innovative and efficient emergency preparedness
solutions. Greg helps clients create, design, distribute and facilitate rapid e-learning for
emergency responders. Greg is a paramedic, EMS instructor, conference speaker, EMS author,
and a Wilderness Medical Associates Lead Instructor.

Greg is the Everyday EMS tips columnist at EMS1.com. His tips are featured on the EMS1.com
homepage and EMS1.com subscriber newsletter. Greg has recently written for JEMS.com,
Wilderness Medical Associates, JEMS Magazine, EMSResponder.com and EMS Magazine, the
NAEMSE Educator Newsletter, and EMSLive.com.

Connect with Greg at http://gregfriese.com

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