An MCI “just won’t happen to me”

How can we practice for a mass casualty incident (MCI) if we believe “it couldn’t happen to me”?

While in San Francisco I had the chance to speak with Dr. Jacob Or, the president of the Israeli Association of Emergency Medicine, on a couple of occasions. He also happens to be an emergency physician at the largest trauma center in the Middle East. During a presentation he gave on the state of emergency medicine in Israel, Dr. Or couldn’t help but comment on how excellently well-prepared his men and women were for a mass casualty incident. Their surge capacity, apparently, is the stuff of legend, and it’s all been tested and proven. There was an upspoken current that the U.S. had a lot to learn from this small nation in this regard. Undoubtedly.

But I had a question, so I met up with Dr. Or after the talk over a beer. What about the docs in Iowa? In Peoria? What about the docs who want to improve surge capacity and disaster preparedness, but for whom an MCI simply isn’t a daily reality? How can we make disaster preparedness a reality for the EPs in the States who don’t see an impending threat of any kind?

“That’s the million dollar question” another doc chimed in.

The response I heard from Dr. Or and others was this: Focus on legitimate regional threats. If your town is near an oil refinery, base your mass casualty drill on a disaster at the plant, not a bomb at the mall. If you practice in Florida, your MCI should involve a hurricane rather than a terrorist attack.

Makes sense and it’s good logic, but it only partially satisfied me, so I want to know what people think. Have you experienced a mass casualty drill that was either particularly effective or ineffective? In your experience, what efforts were taken to get participants mentally invested in the drill? How can we make mass casualty drills more meaningful, and more effective in the long term?

-Logan Plaster

Emergency Physicians Monthly




  1. First of all Lorne, I love you’re blogs. For some reason they resonate with me. I’ve been involved in many MCI drills and a couple of minor MCI’s. We’ve done burnt 737’s with the cities resources at Toronto Pearson Airport >200 casulaties, simulated helicopter and bus crashes with 50 or so casualties and the Caribana Parade in Toronto with >100 calls/casualties in several hours (real MCI – but well planned out).

    I think the MCI drills need to be divided into seperate categories. Overwhelming casualties from an immediate event (tornado/bus/bomb) vs overwhelming casualties from long term event (high humidity at rock concert/hurricane). Also practice in a stable and unstable situation. In the unstable situation (riot/fire/flood or other disaster that puts staff at risk) triage is supposed to reverse and it calls for a different set of priorities.

    I don’t think it has to be anything near and dear to the staff’s heart, in fact it’s more fun when it’s more fanciful. But I think you need to practice all four types of disaster (short term/long term/stable/unstable) on small and large scale. The clinical staff need only be involved in the small scale while the organization staff only the large scale (e.g. the large scale will learn just as much with computer/written simuations). If you can do one coordinated drill per year that is large that’s great but I think you’re better doing many smaller ones. Finally, you have to break out all of the actual equipment and simulate in failed/missing equipment. From the organization end, all of the disasters I’ve seen on the management side have been due to missing/lost communication (can’t hear radio due to noise, jammed cell phone lines, dead batteries in radios & cells). It’s part of MCI’s.

    If you do 8 simulations per year (4 with clinical staff and 4 with coordinators) where actual equipment and communications (and failures) are used I think you’ll be more than prepared.

  2. Ubergeek says:

    I’m a 3rd year medical student in Israel, and I’ve seen the drills they do here. I have to say, it’s amazing to watch. Part of why I think it’s so effective is that if you’re not currently attending a critically ill patient, you participate in the drill. Everyone here knows, accepts, and encourages the drills, so patients are more than willing to wait an extra hour if it means better service in an emergency. In a lot of cases, patients themselves are part of the drills. What do you do with your patients if there is a bomb threat in the hospital? (It’s happened here, so it’s not so far off of reality) You figure it out in the drill by actually moving the patients. It’s by actually doing it that you figure out which route has too many doors and takes too long.

    Another thing that is particularly effective is that everyone has a color-coded jacket that says what they are and what they are doing. They have, for example, transporter, triage nurse, med nurse, etc. This way it’s clear who does what. During a drill everyone is required to actually find their vests and put them on. In the case of an emergency, all the little logistical problems of “hey wait, someone blocked our boxes of vests” are sorted out and everyone knows exactly where to go.

    Since I’m just a student I didn’t get the chance to participate, but it was a thrill to see everyone get out of their departments and actually hosing off fake patients. I’ve only been in one drill in the States, and the only reason I knew it was going on is because of the announcement… one moved from their departments.

    That mentality of “it won’t happen here” is strong in the States. Israeli’s tolerate these sorts of drills precisely because they know it can and will happen, so they’d better be prepared. I’m not sure how to rouse people into action, or make them tolerate such a diversion from their care, but it is fun to take an hour or two off and run around like a crazy person.

    I hope my two cents helped.

  3. I mostly work on a med/surg floor, and when there have been drills like this at my hospital, the most involved we are upstairs is peering out the windows at the mess in the parking lot. I think any realistic drill would need to include the rest of the hospital; in a real situation, I’m sure that we would be needed for something.

  4. Jim in Texas says:

    “Focus on legitimate regional threats”

    So,GD, you practicing for stampedes in Ft. Worth?