Stephanie Davis, DO, FACOEP

Recent catastrophic events remind us all too often of the threat of mass casualty incidents (MCIs). For decades, hospital officials have conducted drills to prepare for mass casualty natural disaster events, but as mass shootings are unfortunately becoming more prevalent, many hospitals and health care systems are conducting drills to prepare for these instances as well. When these tragic and traumatizing large-scale events occur, the public expects emergency medical care to be available quickly – to save lives, to treat pain and to lessen the fear of those involved by letting them know help is available and ready.

In the Federal Emergency Management Agency (FEMA) After Action report from the Las Vegas Shooting, responders cited training and exercises as being responsible for their ability to mount an effective response. On October 20th, the American College of Osteopathic Emergency Physicians is proudly coordinating its first-ever Mass Casualty Incident Simulation in conjunction with the city of Chicago. This immersive hands-on training will not only teach physicians how to respond to an MCI, but also how to take this specific training back to their facilities to help implement an Emergency Hospital Plan in their own emergency department.

As emergency physicians we are expected to perform expertly in the worst of situations, and MCIs create such an environment. Working in a high intensity environment, with the facility, staff, and supplies quickly becoming overwhelmed, these types of events demand far more extensive and frequent training for physicians. It’s no longer a question of “if” but “when” it is going to happen, and we must prepare for that. A pre-planned, integrated response by all health care facilities (HCF) is required to maximize effectiveness and improve the survivability of those injured in such attacks. An intra-network plan must be in place to increase survivability when supplies, including things as simple as blood products, chest tubes, and ventilators are exhausted.

In preparing for a Mass Casualty Incident there are 5 key components.

Quickly expand the capacity of the emergency department.

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.  A report by FEMA found that local civilians assisted greatly in transporting victims out of the shooting area in the recent tragic Las Vegas Shooting. Some victims had been shot and wounded; others had been knocked down and trampled as terrified concert-goers tried to escape the gunfire. Expanding the capacity of the emergency department is a key concept in an MCI due to the sheer number of victims that inundate the ER 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 emergency department to immediately assist in controlling the flow of patients and resources in the ER. This immediately allows the less injured patients 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 ER department 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 maximal use of Emergency Department space. This may include utilizing outpatient surgery, PACU, or other designated areas depending on the facility and proximity to the Emergency Department. 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.

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 however to an “all hands-on deck” approach.

First, 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 emergency department.

Second, 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.

Finally, any non-emergency, and not surgically trained physicians can be utilized to care for not only medical patients but also non-emergent patients. Whether it is suturing lacerations or treating minor extremity fractures, their assistance can help alleviate the burden on emergency medicine physicians to care for the critically injured.

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 a mass casualty incident. 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:

  • Has injuries incompatible with life
  • Requires immediate life-saving interventions
  • Has injuries that are not immediately life threatening
  • Has minor injuries

With the START approach, a medical provider would assess patients based on the severity and location of his or her wounds and assign a color to each victim: black for someone who is deceased, red for those patients in critical condition who need immediate attention, yellow for victims with moderate injuries and green for those patients with less severe wounds. START triage also allows and frankly demands reassessment as a patient’s status can deteriorate quickly.

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. Such on-the-fly training is common during mass casualty incidents, and ACOEP is ensuring it becomes a routine part of medical providers’ responses.

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 hinderance. If prepared, 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 were limiting factors in patient treatment in the Las Vegas shooting aftermath. Making sure emergency departments are stocked with proper equipment ahead of time is key. At some facilities, such as St. Luke’s of Kansas City, they have prepared for such events by having portable carts with supplies to be taken out of the emergency department to provide care. St. Luke’s has also purchased several extra portable battery-operated ventilators in the event of an MCI.

Mass casualty incidents have become common phrase and place unfortunately; however, that should not cause physicians to become numb or complacent. Focused training and preparation are key for any physician and facility to be prepared. We hope you will join us on Saturday, October 20th in Chicago, IL and learn how to prepare if disaster ever strikes your community and emergency department.

Please visit to learn more and register today!