When the unthinkable happens
Real challenges of an MCI from a metropolitan city’s perspective
Whether your municipal area is in a major metropolitan urban setting or in a rural environment, mass casualty incident (MCI) responses can wreak havoc on first responders as well as others within the impacted area.
The impetus for an MCI can be accidental in nature, human-influenced turmoil or unpredictable natural disasters. Each situation can yield a different impact, depending on the community in which it occurs. Regardless of the cause, the first-arriving responders are likely to be inundated with mass chaos.
Most will agree that no community is immune or invulnerable to an MCI. In fact, MCIs are notorious for making appearances in such a wide variety of types and circumstances that it is pragmatically impossible to be totally prepared for everything. And generally, such preparation falls primarily to public safety, as these agencies hold the initial burden of mammoth incidents that are eventually shared with partnering agencies as additional resources are needed and requested.
Over the years, we have witnessed many of these events. Most of us in public safety immediately try to make an evaluation of how that particular event would play out in our towns, districts, cities, counties, states or countries. “Are we prepared for that?” is a frequent question we ask ourselves. While we can never be fully prepared, we can still examine the challenges experienced by others in order to learn from them and enhance our preparedness.
Here we’ll highlight a few of these challenges, in no special order, that may surface. And I’ll share my perspective on a real-world experience faced with my metropolitan city fire department.
Challenge #1: Obtaining accurate information
Early information about MCIs can come from anywhere. Although first responders have traditionally received our initial information from 911/Dispatch, this information can also come directly from the public by way of station walk-ins, TV breaking news or social media.
Even with the latest and greatest technology, information is only as accurate as the witness’ account of what is happening. Interpreting and deciphering what has been communicated can be a major feat that is hit or miss for the initial-arriving units.
Incidents with multiple patients add a considerable amount of stress to the caller and the recipient of the information. Psychology and mental health professionals have long posited that varying situations will require different levels of cognitive or analytical processing. Perhaps this is the primary element of one’s ability to clearly scrutinize, interpret and communicate an accurate assessment of an acute MCI.
Regardless of the reliability of a calm or panic-stricken person, our duty is to get to the scene, identify the reality, and begin to work toward incident mitigation.
Real-world incident: On July 27, 1996, as the City of Atlanta hosted the Summer Olympic Games, our 911 center received a call advising, “There is a bomb in Centennial Park … you have 30 minutes.” This terrifying 8-second call was real and, for the most part, very accurate.
With no additional details, multiple law-enforcement agencies and officers who were already present in great numbers had the daunting task to search a crowded 22-acre urban park filled with visitors and concert attendees.
I recently spoke with a career-long friend and coworker, Captain Keith Schumacher (retired) about this event. He, along with a few other members from Atlanta Fire, represented the first AFRD units to arrive on scene. He recalled feeling and hearing an explosion as they were located approximately a block away from the perimeter of Centennial Olympic Park. He and the group witnessed military police (in formation) rushing toward the park. They followed the soldiers and were met with thousands of people rushing from the park.
The team requested a full assignment with a barrage of specialty units but were still not clear of what was beyond the massive crowd being moved away from the park’s footprint. Screaming, running and chaotic visitors informed them “People are injured,” but details were minimal.
As the initial team pushed forward through the crowd and began encountering injuries, they saw firsthand that it was more than an explosion from something like a malfunctioned piece of equipment.
Additional fire/EMS units in the immediate area converged on the scene while additional units were dispatched to the park with barely any specific information. Multiple ambulatory and immobile patients with a variety of penetrating injuries quickly overwhelmed our initial resources. Many of our team members began to recognize the injuries and were able to relay accurate information to other responding units about what they believed we were facing.
Lesson learned: An unyielding fact of any MCI is that the early-arriving units will receive the least amount of information. However, once on the scene, these units can confirm and offer more accurate information for other responding units. This MUST be a priority as soon as the information is available to allow the other responders to prepare themselves with knowledge about the best routes, impedances, estimated number of patients, area involved, types of injuries, etc.
Challenge #2: Traffic/access
Atlanta is known for her traffic, and MCIs do not get a pass.
After a couple years of planning for the Olympics, detailed emergency routes leading to, through and from the Olympic venues were identified, but the plans may have missed the ingredients of frantic chaos and mass-exiting of thousands of persons.
Although there were multiple fire/EMS/law enforcement personnel within the footprint of Centennial Park, more resources were needed on scene to assess, treat, transport and secure the area. Many of our first- and second-alarm units had to walk several blocks away, as the streets were full as a result of soft foot-traffic barriers being moved and disassembled to effect a faster means of egress. Further, after attempting to begin treating nearly 100 patients scattered across a rather large area, traffic/access issues caused some firefighters and EMS workers to become separated from their vehicles, which held supplemental first aid equipment and supplies.
Access issues created numerous challenges. The earlier-arriving units had no idea how many injuries they were about to face, and the later-arriving units were quickly overwhelmed even though they had the opportunity to prepare by bringing more supplies than just a jump-bag and oxygen caddy.
Lesson learned: It is imperative that the initial incident commander (IC) considers apparatus and ambulance ingress and egress early in the MCI. Take into consideration that people will initially run away, but as the chaos settles, they will begin to roam back into the environment out of curiosity or the desire to assist in whatever method they are able.
The streets will rarely be clear during an active MCI. Ambulances can quickly become blocked inside and around an incident by emergency responder vehicles and other specialty equipment. The initial IC must work closely with a law enforcement representative (preferably the law enforcement IC) to ensure that fire/EMS/law enforcement are all on the same page as it relates to ingress and egress routes.
Challenge #3: Executing the plan
Many of us find it difficult to execute “The Plan” when the big MCI happens. Although we prepare for anything, it can feel as though everything happens and works against the plan. The plan usually calls for unified command, triage tarps, tags, thorough communications, staging officers, transport officers, treating and handing patients off in accordance to acuity level priority, logging information, contacting area hospitals, etc. When the stuff hits the fan, with an onslaught of distractions that emerge, it’s very difficult to fully execute any semblance of a plan. Although not impossible, it must be acknowledged that it will be difficult.
During the 1996 Olympics, our fire/EMS units were waiting on or missing vital pieces of the puzzle that were needed to fulfill the MCI plan. Resources were either en route to the area by foot, delayed from treating walk-ups patients who were seriously injured and could not be bypassed, or never made it to the requested location(s).
This impacted the outcome of other teams within the hot zone who were waiting on resources or assistance. The reality of people limping in your direction with shrapnel lodged in their legs, chest, back and face diverted the attention of would-be resources. While some patients were non-ambulatory, others were walking in every direction seeking help.
Being a metropolitan fire department, with multiple mutual-aid relationships, we had the ability to dispatch a tremendous number of resources and personnel to the incident and maintain coverage within the city. Although many of our units were familiar with the plan, several responded from territories well beyond the expanded footprint of the incident and were not as familiar. The usage of Incident Command was an asset, but at times, it seemed as though we were the only ones using it. Remember, this was in 1996. With multiple units, agencies, personnel and guests who had a variety of training levels, it became impossible to know who was doing what in the surrounding streets or across the entire 22-acre park. Radio traffic was constant, and everyone needed something. Honestly, it is difficult to say if we ever had control of the environment as all who were involved went from zero to 100 instantly.
Lesson learned: We must accept the reality that things will rarely go as planned, especially early in these types of events. However, with thorough planning that accounts for a level of chaos, agencies can be assured that as the dust starts to settle, so will the plan.
Remember this saying: “Get additional resources started early; we can always send them home if we don’t need them.” Medical ambulance buses are always a plus. QR code readers and driver’s license barcode scanners would have been helpful in 1996. These devices are becoming more common practice today. Our crews were overwhelmed by patients as well as people who wanted to help but had nothing to help with.
Today, many agencies create multiple trauma kits or throw bags to address the need for basic first aid supplies. Other municipalities place hard barriers to ensure emergency vehicle routes are maintained. This requires significant coordination among multiple agencies, as even these well-established routes can be clogged with units that stop to assist patients or colleagues. Additionally, I will offer that as soon as the opportunity arises, the IC should work to rein in everyone to focus on plan execution.
Learning from our challenges
We must keep in mind there are other challenges to address as well – mental health, fatigue, managing the involved families, facilitating intra-agency coordinated communications, and hospital capacity and capabilities.
It is our nature to do the absolute best that we can when disaster strikes. Whether five or 117 patients, our charge to action for scene mitigation can be fulfilled. It requires laser focus on your agency’s plan. Will plans have gaps and unforeseen situations? Of course they will. But this is where professionalism and dedication to do the right thing comes into play. Preparation is mandatory, and if we fall short, we learn from it and push ahead toward even more preparation.
The horrible events of the 1996 Centennial Olympic Park bombing produced many challenges from which we learned – both the department and the collective industry. Unfortunately, instances of MCIs will never go away; fortunately, nor will our profession.