Mass Casualty Incident Reality

I’ve been to a few mass casualty incidents over the years. They have ranged in severity and acuity from a large group of bored teenagers with chemical eye irritation to an active shooter in a crowded school. One lesson I’ve learned is that the real events never look or feel anything like the mock training scenarios that we often create for training purposes. Real disasters tend to present challenges that we just can’t account for in mock scenarios.

This makes the lessons learned at real MCI scenes incredibly valuable.

Recently, I was able to listen to Dr. Jonathan Apfelbaum MD, one of our local ER physicians, talk about his experiences at the Reno Air Race crash. Dr Apfelbaum was photographing the event when one of the aircraft lost control and crashed at the front of the grandstands. I loved Dr. Apfelbaum’s class on this subject. I think real, first hand accounts of actual MCI events, (and the specific challenges encountered) are far more productive and educational than most of the fictional MCI scenarios that we frequently create.

Here is a list of some of my “take home” lessons from listening to Dr. Apfelbaum. Please note than none of these are specific learning points from the doctors lecture. These are simply my personal interpretation of his experiences.

  • Nothing beats a solid preplan. As a physician who had seen multiple similar events (He was also present at the Charlotte Indy race crash when three fans were killed by debris.) Dr. Apfelbaum has seen a vast difference between the responses of crews who had a plan in place prior to the event and those who did not. While you can’t always preplan every venue where an MCI might occur, when things do go sideways, an emergency medical action plan is golden.
  • Train for events where the resources are truly overwhelmed. The Reno EMS system was well prepared for this event. They had done multiple mock disaster drills in the lead up to this event. Create realistic scenarios and let them play out in real time. Afterwards, don’t just pat everyone on the back and say good job. Really discuss what you learn about your system. Ask good questions and attempt to answer them.
  • Consider the worst case scenario and start your planning and training from that model. Work backward from the most significant event you can reasonably envision. During the Reno Air Show morning EMS briefing, one of the events EMS planners mentioned that the worst case scenario that they could reasonably envision was a plane striking the grandstands. They had already considered this possibility and planned for it.
  • While training helps us to understand what we should do, you can’t overestimate how difficult it is to detach emotionally from the process of triage. As caregivers, we are trained to care for the injured. Triaging a real human being and moving on to the next patient is incredibly hard.
  • Consider peoples mindset and ability to function when assigning them tasks. Bystanders with medical training will offer to help, but their training and experience will vary. Medical personnel with EMS experience will be the most calm, but everyone will have an emotional response that will affect their ability to be affective. Peoples prior training is a consideration when assigning them tasks, but so is their mindset. People who can’t cope with the magnitude of what’s happening can still carry backboards and evacuate minor wounds.
  • In today’s world of instant social media, your MCI will likely be posted on YouTube before you clear the scene. This will help with pulling-in off duty resources to assist and bolster the system. It will also increase the number of on-lookers exponentially.
  • On many large and chaotic scenes, you may have to make peace with the idea that many victims will go directly from where they lay to a transport ambulance. (This has been true on every MCI scene that I have experienced. It’s also the primary method used in Israel and many parts of the middle east.)
  • Convincing bystanders / responders to cease resuscitation efforts when the patient is no longer viable is a remarkably difficult task. Especially when the responders know the patient.
  • Kids will most likely be over-triaged. If they have an injury, they will invariably end up in the red category. Be wary of overloading your red triage category. Knowing the difference between true yellows and true reds can be one of the more challenging aspects of triage.
  • For ambulance ingress, consider shutting down a major road and having resources respond in the opposite direction of the normal traffic flow.
  • People will still have car accidents, heart attacks, strokes and cut fingers. Consider that you may be able to respond every single EMS resource in a 15 mile square radius, but someone will still need to take care of the normal 911 traffic for that region as well. You can’t plan to exhaust the resources of an entire system without planning how you will back-fill the system.

There you have it. This is, by no means, a complete list of real MCI considerations, but it is a powerful one. These lessons come from the real experiences of medical personnel responding to an extremely challenging MCI event. That makes each of them golden.

And what about you? Do you have any helpful learning experiences from MCI scenes where you have been a responder? What could you add to the list?


  1. I’ve listened to radio traffic after various events (typically when it gets posted to and am usually disappointed that I don’t hear keywords like “MCI”, “Triage”, “Disaster Plan” early in the incident, and especially not from law enforcement. Hopefully there is some level of pre-planning in every community. It seems to me that a little time training local law enforcement to declare an MCI when some threshold is met would be useful to get more resources mobilized sooner. For example the theater shooting in Aurora would have run better if 5-10 minutes in a cop had said “Activate our Jumbo MCI Plan” rather than “send lots of ambulances”. If the bulk of the transport ambulances are coming from a distance it might be nice to have them sitting in a staging area sooner rather than on the road or back at their station.

  2. And if FIRE/EMS know they are rolling up on a MCI they might be able to assign some duties on the way and plan on stepping out with triage tags in hand.

  3. One thing to add, beware of the freelancing. I know they mean well but it does add to the chaos.

  4. Andrew Przepioski says:

    I haven’t responded to an MCI before, but the county I work in, which I think you used to work in too, Santa Clara County, CA, does a mock MCI a couple of times a year. Although a mock is probably nothing like the real thing, I wish we did them more frequently to become a little more fluent with things our multiple patient management plan (MPMP), how to use the radios, etc. It seems like we practice only 1-2 a year (the county, not individual companies), and we are still pretty weak with what’s suppose to go on. At least that’s how I feel.

    We are required to get a bunch of FEMA certs too: ICS 100, NIMS 700, AWR 160, IS 3, IS 704, and some other certs like First Responder Operational. A lot of us do them once and then we forget. I take some of the take home points like use plain English, be dynamic, etc., but I don’t feel like they are useful either unless we regularly review over them.

    Overall, I don’t feel prepared for an MCI. :[

  5. Alex Thomas says:

    Just a thought. You have some typos at the beginning that really take away from the article. can instead of can’t and ever instead of never. Could get confusing. 🙂

  6. Jami Blackwell says:

    Typo’s….really! Get a life. If that is all you can think of to comment after this article, keep your “thoughts” to yourself.

    Person took the time to share a lot of great info and thats all you have….