From Crisis to Coordination: Preparing Emergency Medicine for Mass Casualty Incidents

Mohammad Abuakar, M4, CCEMT-P, Idaho College of Osteopathic Medicine
EMRA MSC Midwest Coordinator

Thomas Johnston, MBA, M4, Southern Illinois University School of Medicine
EMRA MSC Great Plains Regional Representative

Payton Wolbert, BS, M3, Central Michigan University College of Medicine
EMRA MSC Great Lakes Regional Representative

Given the approximate 240% increase in mass shootings across the country from 2014-2023, it is no wonder that these tragic events are at the forefront of the collective consciousness when considering mass casualty incidents (MCI).¹ However, the United States and the rest of the world have been staggering through the repercussions of a different type of mass casualty incident for the last few years — a global pandemic. According to the National Institute of Health (NIH), COVID-19 “warrants consideration as a mass casualty incident of the highest nature” as it caused the entire healthcare system worldwide to be overwhelmed. Simply put, an MCI is any event that results in more patients than can be managed with the available resources.²

Who’s Involved?

Effective management of a mass casualty incident requires the coordinated efforts of a broad array of emergency and healthcare professionals, each playing a crucial role in the response. Emergency Medical Services (EMS) are often the first on the scene, providing critical prehospital care and triage. They work closely with police and fire departments, who secure the area, manage public safety, and assist in the initial response. 9-1-1 dispatch centers are the nerve centers, ensuring that the appropriate resources are deployed swiftly and efficiently. Federal agencies like the Federal Emergency Management Agency (FEMA) provide overarching support, coordination, and resources, especially for large-scale incidents that overwhelm local capabilities. Regional networks and hospital systems are essential in managing patient flow, ensuring that those in need of care are directed to facilities with the capacity to treat them. Subspecialties within hospital systems, including trauma surgeons, critical care specialists, and infectious disease experts, provide the specialized care necessary to address the varied needs of patients in an MCI. The collaboration among these diverse groups is vital to minimizing casualties and maximizing the effectiveness of the response.

FEMA was established in 1978 under the Department of Homeland Security due to the significant level of coordination needed in crises. FEMA instituted an Incident Command Systems (ICS) response standard to outline how prehospital professionals will respond to an MCI and ensure inter-organizational collaboration. Many disaster response teams use this, along with the two generally accepted triage methods, START (Simple Triage and Rapid Treatment) and SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport), to make objective decisions on how to allocate resources to patients in an MCI. One of the most important resources to be allocated are ambulances that can transport ill and injured patients to definite care. This process, from response to triage, to transport, to hospital transfer, requires collaboration between many agencies. 

While prehospital operations are arguably one of the most vital components of an MCI response, hospital operations are equally as important. Hospital systems often have an integrated disaster response team, many of which use a modified ICS standard called Hospital Emergency Incident Command Systems (HEICS). Nonetheless, emergency department physicians, nurses, and staff often bear the brunt of the chaos.

What Emergency Medicine Can Do to Prepare Their Residents

Given the crucial role that emergency medicine professionals play during MCIs, residency programs must equip their residents with the necessary skills and knowledge to manage these challenging situations effectively. Mass casualty incidents, which are increasing in frequency and complexity, highlight the critical need for robust disaster preparedness training within emergency medicine residency programs. Integrating MCI training into residency curricula is essential for developing competent physicians and enhancing the healthcare system's overall resilience.³

Emergency medicine residents are often on the front lines during disasters, making swift decisions that can significantly impact patient outcomes. By incorporating MCI training, residents gain proficiency in triage protocols, efficiently applying methods like START and SALT to sort patients based on severity. They also become familiar with ICS and HEICS structures, allowing residents to integrate seamlessly into coordinated response efforts, improving communication and resource management. Additionally, MCI training enhances crisis management skills, preparing residents to handle the stress and unpredictability of such incidents and enabling them to make critical decisions under pressure.

Program Specifics

Many residency programs have adopted several strategies to enhance MCI preparedness.⁴ Incorporating didactic education through lectures and workshops focused on disaster medicine principles, such as disaster epidemiology, surge capacity planning, and ethical considerations during resource scarcity, provides foundational knowledge. Simulation exercises that utilize high-fidelity simulations and drills replicating real-world MCI scenarios promote hands-on experience in a controlled environment, fostering teamwork and problem-solving skills. Interdisciplinary training by collaborating with other specialties like trauma surgery, critical care, and public health offers a multidisciplinary approach to disaster response. Furthermore, encouraging community engagement by participating in local disaster preparedness initiatives and partnering with EMS, fire departments, and law enforcement agencies helps residents understand the broader context of emergency response.

Disaster Medicine Fellowships

For residents seeking specialized expertise, Disaster Medicine Fellowships offer advanced training in several key areas. Fellows learn about disaster preparedness and response by developing and implementing emergency response plans, conducting hazard vulnerability analyses, and coordinating with governmental and non-governmental organizations.⁵ They have opportunities for research and policy development, engaging in studies that inform best practices and contribute to policy-making at both institutional and governmental levels. Additionally, these fellowships provide global health perspectives by exposing fellows to international disaster response efforts, including humanitarian missions and global health security initiatives.

References

1. Las Vegas shooting: At least 59 dead in Mandalay Bay Hotel attack. BBC News. Published October 3, 2017. Accessed September 22, 2024. https://www.bbc.com/news/world-us-canada-41488081
2. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Medical and Public Health Preparedness for Catastrophic Events. Regional Disaster Response Coordination to Support Health Outcomes: Summary of a Workshop Series. National Academies Press (US); 2018. Accessed September 22, 2024. https://www.ncbi.nlm.nih.gov/books/NBK459369/
3. American College of Emergency Physicians (ACEP). Disaster Medical Services. ACEP. Accessed September 22, 2024. https://www.acep.org/patient-care/policy-statements/disaster-medical-services
4. Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. Updated July 1, 2023. Accessed September 22, 2024. https://www.acgme.org/globalassets/pfassets/programrequirements/110_emergencymedicine_2023.pdf
5. American College of Emergency Physicians (ACEP). Disaster Medicine Fellowships and Other Training Programs. ACEP. Accessed September 22, 2024. https://www.acep.org/disastermedicine/resources/disaster-medicine-fellowships-and-other-training-programs