Mass Casualty Incident
Dear Brown EMS Volunteers:
This manual serves as a brief introduction to the complicated world of the Incident Command
System, START Triage, and Mass Casualty Incident operations. The goal of these systems is to
provide an established framework for large-scale emergency response and operations.
We highly recommend that you read this manual carefully, and commit some structures and
flow charts to memory. Regardless of your overall position in MCI operations, it is important to
have a good understanding of the “big picture”. So read through this guide, come to a training
session, and above all, HAVE FUN!
Thank you for your willingness to learn and participate. We appreciate it immensely.
Brown EMS Senior EMTs, 2007-2008
Basic MCI Guidelines
First, we must lay out some operational guidelines. Despite the fact that we are coming together
on a beautiful May afternoon, we must remember that this is a training exercise. We are all
representatives of Brown University EMS, and we must all remember to act in the professional,
compassionate, and knowledgeable manner for which we are known and respected within the
Please examine the following basic guidelines:
SAFETY is our primary concern.
1. The safety word is “BANANA.” If a patient says this stop what you are doing immediately.
2. Report all unsafe conditions to an overseer immediately.
3. Call for additional units to help lift and extricate patients as necessary.
4. If anyone actually becomes injured or has any kind of medical problem, inform the
Operations officer by radio or tell one of the overseers. Some of the overseers are designated
as a medical response team, and they will provide medical care.
PATIENT ASSESSMENT will be as realistic as possible.
1. It is your responsibility to perform a thorough patient assessment.
2. To take vitals, actually do so and say the values aloud. The patient will then tell you his or
her “simulated” vitals.
3. Do a rapid trauma exam or focused physical exam as you actually would. Do NOT cut or
TREATMENT should proceed as in real life. Evaluators will be observing your
skills and treatment procedures. DO NOT CUT CORNERS!
1. Splint extremities as you actually would.
2. Apply Hare Traction, MAST, c-collars, KEDs, and spineboards as you actually would. Do
not apply mechanical traction using the Hare Traction splint, or inflate the MAST trousers.
3. Simulate administering oxygen by applying a NRB mask and stating the flow rate. Make
sure the valves are removed from the NRB mask.
4. To establish an IV, spike a bag of NS or LR solution with the appropriate drip set. Flush the
line as you actually would. Tape the end to the site on the patient where you wish to a start
the IV and tape the catheter you wish to use next to the site. Do not remove the catheter from
the packaging. DO NOT OPEN ANY SHARPS. This is now considered a patent line.
5. To administer enteral/parenteral medications, show one of the overseers the desired
medication box or vial and indicate the dosage and route of administration.
6. To perform an EKG, apply the electrodes in the correct locations and take a real EKG.
Afterwards, one of the overseers will show you with a rhythm generator what the patient’s
“simulated” EKG is.
7. To intubate, assemble the necessary equipment. Indicate to an overseer that you are
attempting intubation. The overseer will tell you if you succeed.
FOLLOW THE CHAIN OF COMMAND! The Incident Command System breaks
down if all components do not operate within the confines of the determined
FREELANCING IS NOT AN OPTION! Once you are assigned to an ICS section
or division, THAT is your assignment until you receive other orders from an
officer. Even if you see a purple elephant running through the incident area,
trumpeting loudly and blowing bubbles, DO NOT LEAVE YOUR POST OR
ASSIGNMENT! It is important for those in a command position to know your
location and assignment at all times.
Incident Command System
The Incident Command System (ICS) was developed to ensure:
1. An established chain of command.
2. A scalable response structure that is adaptable to the specific needs required by an
incident or organization.
3. Adequate flow of information for decision-making.
4. Adequate and structured communications.
5. Coordinated planning and execution of emergency plans.
6. A systematic approach to incidents that stress a response organization beyond its capacity
Different types of incidents and different response organizations require different ICS structures.
The following image shows the full Incident Command System. Some portions are eliminated for
The Brown EMS 2008 version of the ICS structure, shown here, is much smaller and less-
complicated than the larger chart shown above.
The following has been adapted from the Incident Command System National Training
Curriculum and the Seattle Fire Department’s Training Division:
The Incident Commander (IC) is responsible for the overall incident management, including
developing incident objectives and managing all incident operations. Responsibilities include:
• Establish immediate priorities, including the safety everyone involved.
• Establish an Incident Command post and appropriate organization.
• Determine incident objectives and strategy to achieve the objectives.
• Coordinate activity for all Command Staff.
• Approve the implementation of the written or oral Incident Action Plan.
The Safety Officer’s role is to develop and recommend measures to the IC for assuring
personnel health and safety, and to assess/anticipate hazardous situations. The Safety Officer
also develops the Site Safety Plan, reviews the Incident Action Plan (IAP) for safety
implications, and provides timely, complete and accurate assessment of hazards and required
The Operations Section Chief (OPS) is responsible for the management of all operations
directly applicable to the primary mission. The OPS assists in developing the operations portion
of the Incident Action Plan and supervises its execution for operations. Responsibilities include:
• Maintain close communication with IC.
• Develop and execute operations portion of IAP.
• Brief and assign Operations Section personnel in accordance with the IAP.
• Supervise Operations Section.
• Determine need and request additional resources.
• Make expedient changes to the IAP as necessary and report information about special
activities, events, and occurrences to the IC.
• Maintain Unit/Activity Log.
The Communications Officer is responsible for managing all communications at the incident
location. S/he must facilitate communication among command units, provide communication
support for transport units, and provide maintenance facilities for all communication devices.
The Triage Officer is responsible for the rapid evaluation and cataloging of all MCI patients.
S/he must maintain full records of all patients. S/he works closely with other units to extricate
patients to the proper color-coded treatment areas. The triage officer reports the status of
patient triage and extrication to OPS.
The Treatment Officer is responsible for the emergency medical treatment of all patients. S/he
must ensure that patients are properly categorized into treatment areas, and that providers (ALS
and BLS) and equipment are used to their maximum capacity. The treatment officer reports to
START Triage System
Triage is a method to rapidly categorize patients for priorities of treatment. The process has two
phases: primary triage (occurs on site) AND secondary triage (occurs in treatment area). One
common technique for primary triage is START (Simple Triage And Rapid Treatment).
Triage should take no more than 60 seconds per patient. Triage units use color coded tags to
differentiate patients of various treatment priority levels. The levels are as follows: BLACK
(Deceased); RED (Immediate); YELLOW (Delayed); GREEN (Minor)
All triage tags are kept, and patients are directed to the appropriate treatment area. The
following flow chart summarizes the START process:
The following is an example of a triage tag:
The tag must be affixed on the patient in secure manner. The lower portion of the tag (indicating
treatment priority) is torn on scene. The removed portion goes to the Triage Officer. The
upper left portion is torn at the treatment area, and handed to the Treatment Officer. The
upper right portion of the form is torn upon transport, and is filed by the Transport Officer.