First in on an MCI

MCIs are among the most common of unusual calls.  I mean unusual in that a single ambulance can run the vast majority of EMS calls.  It is kind of unusual to need additional busses.  But not all that unusual, right?  It is something you can expect to do in your first month on the job, and continue to run for the rest of your career.

Most places define an MCI as an incident that requires more resources than can be provided at once.  In a vernacular sense, though, a paramedic referring to “an MCI” is probably talking about a multiple patient scene.  In my jurisdiction, we begin referring to incidents as MCIs when it requires a three-ambulance response to deal with the sick and injured.  So in this post, when I am talking about an MCI, I’m talking about a scene like that.  I know that a five-victim grinder with three ambulances isn’t overwhelming to an EMS system and doesn’t represent mass casualties, but the principles are the same.

Think of how easy it is to get to a three-unit response.  It is a really common situation.  Car crashes do it all the time.  A decent fight can do it.  Shootings.  Carbon monoxide.  Weddings.  Structure fires.  Hell, most special events like NFL games are really just preplanned MCIs that develop slowly.  I’ve even run MCIs caused by spilled cleaning supplies.  Every crazy situation you can think of has been run by some poor sucker paramedic somewhere.  

Let me let you in on a secret: How well you run an MCI will make or break your reputation.

Whether the MCI is run well or poorly, it will affect how your coworkers perceive you from then on.  Even your first one.  Even if it falls on your first day.  An MCI must be run well.  And the secret to a smooth MCI lies on the shoulders of the first arriving crew.

The first crew has five actions to perform.  Taking care of these actions means the call is likely to go well, from an EMS point of view.  The five actions constitute 90% of the success of the whole scene.  Not performing the five critical actions usually means that the call becomes irrecoverable – any supervisor or later crew will have a very hard time getting the call back on the tracks.

The actions are simple: 1. Identify the call as a big deal, 2. Request more help, 3. Get onto an MCI channel, 4. Start getting bed counts, and 5. Set up the scene. 

That's it.  If you do this, the call is much more likely to run smoothly.  Like 90% likely.  And these are tasks you can do on your first day on the street. 

Identify the call as a big deal: You arrive on scene to find a three-vehicle highway accident.  One of the vehicles is a fully occupied school bus that rolled.  You have a high likelihood of ending up with more patients than you can transport by yourself, right?  If there is someone who is critically injured, you can’t just ignore them until you check out everyone on the bus, right?  You need more help.  Let people know that you are on a big-deal call: “Dispatch, this is a three-vehicle accident that involves a rolled over school bus.  Show me as ‘Highway Operations.’” 

Don’t forget your Chuck Yeager voice.

One of the biggest problems can arise when you are slow to identify your call as a big deal.  Listen, I get it.  We all want to be badasses who can handle anything the EMS Gods throw our way.  Or patients trickle in one at a time until you notice that there are too many for you to handle.  Whatever.  The earlier you identify your call as a big deal with more patients than you can comfortably transport, kick into MCI mode and identify the call as a big deal.

Probably a big deal.  I'm no expert, but it looks like more than two people may have been hurt. BA38 crash, Heathrow, London, UK.  (By Marc-Antony Payne [CC-BY-3.0], via Wikimedia Commons)

Request more help: Do this early.  I find that paramedics are more likely to try to handle the call too long by themselves.  Request what you need and do it early.  Be specific in describing what you want.  If you end up cancelling some units, that is fine.  Start getting help to your scene: “I will need five ambulances to this scene to start, and you will want to start preparing to send me more…”

Get on an MCI channel:  My jurisdiction has radio channels set up to facilitate mutual aid communication between different jurisdictions.  The police have four channels, fire departments have four channels, and there are even command channels for people to talk to one another.  If I am on an MCI, I know that the more ambulances I use, the higher chance of another agency responding to my scene.  They deserve to be communicated with, as well.  In addition, an MCI can clog up a radio channel and there are other calls going on in the system.  So switch everyone involved to a tactical channel that most agencies possess: “Switch all units assigned to this call to Green1…”

Request a bed count: This step is needed more as transport numbers increase.  Three patients being transported in three ambulances probably don’t actually need a bed count.  But as the number of transports increases, hospital systems will become more stressed.  Requesting a bed count early is important for a few reasons.  First, it tells hospitals that you have a big deal call going on.  They should get ready.  Second, it tells you that Hospital A just got slammed from a different big deal call and has no trauma ORs readily available.  Good to know.  Finally, it gives receiving facilities the chance to make whatever adjustments they need to make.  Bed counts in my system can be a simple call to medical control asking where to take five patients, or it can involve dispatchers getting onto web-based MCI resources that contact hospitals region-wide.  This is a system-dependent task, so make sure you know what needs done in your system.

Set up your scene and tell people your plan: There are a few sub-tasks with this one.  We’ve all had the MCI management lecture in school with ICS jobs like staging, triage, communications, and transport.  Each call is different in how you will set it up.  A compact scene with straightforward patients is easier to handle, for example, so you may handle all of the ICS roles yourself.  Alternatively, you may decide that you will be best served by backing off and setting up the whole enchilada.  I say it depends on your call.  But every MCI needs to have this decision be an actual conscious decision.  Make the choice of how you want to run this call.

The tasks are dependent on what kind of scene you have going on, what resources you need, and that kind of thing.  You need to tell people where to go.  This is when you set up a staging area, decide on triage and treatment areas, and that kind of thing.  On any MCI, though, it is important to set up ingress and egress routes.  Be specific as to how you want people to approach your scene – it will cut down on freelancers.  For example: “Have the first two units come to me at mile marker 123.  Have units after that stage on the northbound highway at mile marker 122.  I will want cars to enter from the south and exit northbound…”

So how does this all sound?  “Dispatch, I have multiple victims at this fire with minor burns and smoke inhalation.  I’m going to need two more units, nonemergent.  Have them approach from the Main Street side and stop at First to avoid fire trucks.  Let’s move this scene to the Green1 channel, and call Burn Center Hospital to make sure they can handle six patients with minor burns, please.  I will be Southern Operations for the duration.” 

How about a bigger deal?  “Dispatch, Ambulance Six on scene.  This looks like a gas explosion and building collapse with more than fifty casualties.  Show me as Downtown Operations.  Send me three ambulances to my location at the south parking lot to set up triage.  Stage all other ambulances at First Avenue until we call them in.  I’m going to need at least twenty ambulances before this is all done.  Switch to Green1 for this scene and start getting bed counts for me.” 

One final point – this has to be practiced all the time.   The way to get good practice is to implement a plan like this on every call where you need two more ambulances.  I despise disaster drills.  I hate tabletop MCIs.  Whatever the emergency managers, chiefs, and administrators have in mind doesn't matter because it is the first medic on scene who sets these calls up for success or failure.  Don’t wait for a school shooting to try to remember all of this.  Your whole system should have this as second nature, based on running dozens of car crashes and fights that result in multiple responses.  That way, when the big one does drop, it is run using your normal practice.