2 Incident Management and Mass-Casualty Response

Purpose and priorities

A Mass-casualty incident (MCI) occurs when the number or needs of patients exceed the resources immediately available. The threshold is operational rather than a fixed patient count: it depends on local capacity and response plans.

Response priorities are to protect responders and the public, establish coordinated command, identify and treat life threats, and move patients to appropriate care. Follow local protocols and the incident’s command structure.

Establishing command

The Incident Command System (ICS) provides a common structure and terminology for agencies working together. The Incident Commander (IC) establishes incident objectives, organizes resources, and maintains overall responsibility for incident management. When multiple agencies or jurisdictions share authority, Unified Command sets common objectives while each agency retains its responsibilities.

The organization expands as needed. Smaller incidents may require only an IC; larger incidents may use Operations, Planning, Logistics, and Finance/Administration sections. At an EMS-heavy incident, command may assign an EMS or Medical Branch Director to coordinate medical operations. Functional assignments can include triage, treatment, and transport, with a staging manager controlling incoming resources.

Personnel should report through their assigned supervisors rather than self-deploying or bypassing the chain of command. An incident action plan communicates objectives, assignments, safety concerns, and resource needs. When necessary, the initial plan may be a brief verbal plan; plans and assignments should be updated as conditions change.

Sizing up the scene

Before committing personnel, gather information from dispatch and observe conditions on approach. Assess safety and hazards, including traffic, fire, structural instability, violence, weather, electrical hazards, and hazardous materials. Choose safe access and egress routes. Do not enter an unsafe or contaminated area without appropriate training, authorization, and protective equipment; coordinate with the responsible hazard-response team.

Determine the incident’s exact location, type and mechanism, visible hazards, likely number of patients, and whether the scene or casualty count may expand. Consider the best approach, staging location, safe work areas, and possible locations for triage, treatment, and transport functions.

Identify resource needs, which may include additional EMS units, fire or law-enforcement support, specialized teams, equipment, transport assets, and coordination with receiving facilities. Identify or establish command, announce the incident and any MCI declaration according to local procedure, and use assigned radio channels and plain language.

Give dispatch and command an early, concise report containing the location, hazards, estimated number of patients, immediate needs, command designation, and access instructions. Request resources early when circumstances indicate they will be needed. Keep responders accounted for, route incoming units to staging, and reassess the scene as new information arrives.

Coordinating resources and patient movement

Command matches resources to priorities, gives them specific roles, and tracks their status and location. Staging prevents congestion at the scene and allows resources to be sent where they are needed. Supervisors should give clear assignments, maintain manageable spans of control, and report changing needs through the chain of command.

Request mutual aid through established channels. Record arrivals, assignments, patient counts, and departures according to local procedures. Incident-management tools include forms for briefings, resource check-in, communications, medical planning, and resource status.

Coordinate patient flow as well as treatment. Keep triage, treatment, and loading areas organized and accessible to transport vehicles. Track each patient’s triage priority, destination, and departing unit. In coordination with medical control and local plans, distribute patients among appropriate receiving facilities; avoid sending every patient to the nearest hospital if that could overwhelm it. Maintain patient identification and destination records, including when a patient’s identity is initially unknown.

Applying triage

Triage is a rapid, repeated process for prioritizing care when resources are limited, not a definitive diagnosis. Use the system adopted by the jurisdiction and incident plan. SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) is one recognized all-hazards approach.

SALT first sorts patients globally. Patients who are still or have an obvious life threat are assessed first; those who can wave or make purposeful movement are assessed next; walking patients are assessed later in a safe area.

During individual SALT assessment, providers may perform brief lifesaving interventions within their training and authorization. Examples include controlling major bleeding, opening an airway, giving an indicated antidote, or performing chest decompression if qualified and permitted. Patients are then categorized according to their condition and the resources available:

• Immediate (red): Needs time-critical intervention or transport.

• Delayed (yellow): Has a significant injury, but care can be delayed temporarily.

• Minimal (green): Has minor injuries and may be able to wait in a designated area.

• Expectant (gray): Is unlikely to survive given the injuries and resources available; provide appropriate comfort and supportive care under the incident plan.

• Dead (black): Is dead or has injuries incompatible with life, as defined by the triage protocol.

Triage tags and categories support communication and prioritization; they do not replace clinical care. Reassess patients because both their conditions and available resources can change. Triage criteria, labels, and scope of practice may vary by jurisdiction, so use the local protocol.

Adapting as the incident evolves

As operations continue, command should review patient counts, hazards, resource availability, transport capacity, and hospital status. Adjust objectives and assignments when conditions change. Brief incoming personnel, document key decisions and resource movements, and plan for relief and demobilization.

Effective mass-casualty management depends on disciplined command, clear communication, responder safety, coordinated patient flow, and repeated reassessment—not simply on the number of units dispatched. Keep safety, accountability, and information sharing central throughout the response.