By Abdolghader Pakniyat, Reviewed by DR. Sabrina Berdouk

The Scenario: The “City Center Collapse”

14:00: You are the attending physician on duty. Dispatch reports a partial collapse of a stadium during a high-profile event. Expected casualties: 150+. Your hospital is 4 kilometers from the scene.

In this moment, the standard of care shifts. You are no longer just a clinician; you are a tactical leader. An MCI is defined by one rule: Patients > Available Resources. For your ED, this means you are now operating at 20% above your licensed bed capacity. Chaos is coming—your only defense is a realistic, practiced protocol.

Phase 1: Activation and The “15 ’til 50”

Before the first patient arrives, you have a 15-minute window. This is the “15 ’til 50” framework—the critical steps to prepare for 50 patients in 15 minutes.

• Activation: Declare a “Code Triage.” In a small hospital, you (the EM attending) are the Disaster Medical Officer until the Hospital Incident Command Center (HCC) is staffed.
• Predicting the Surge: Expect the Dual Wave Phenomenon.
  • Wave 1 (15–30 mins): The “Walking Wounded” (Green). They arrive via taxi, private car, or on foot.
  • Wave 2 (1–2 hours): The critically injured (Red/Yellow) arriving via EMS.
• The Math: Total expected casualties ≈ (Patients in the first hour) × 2. Roughly 50% of your total load will arrive within 60 minutes.
• Leadership: Coordinate with EMS immediately. Note that EMS transport patterns change; they may bypass trauma centers with stable patients to avoid clogging specialty resources.

Phase 2: The 10-Step Immediate Action Checklist

Do not rely on memory. Locate your Disaster Binder and execute these 10 steps:

1. Assign Roles: Use Job Action Sheets. (See Section 3 for roles).
2. ED Huddle: Brief the team. Distribute vests, walkie-talkies, and triage tags.
3. Reverse Triage: Identify every current ED patient who can be safely discharged or moved to a non-clinical area.
4. Clear the Floor: Move stable admissions to a “Launch Pad” (hallway or cafeteria).
5. Stop Routine Triage: Announce to the waiting room that routine care is suspended. Clear the parking lot for ambulances.
6. Deploy External Triage: Move teams and supplies (tarps, kits) outside the main entrance.
7. Lockdown: Security must secure all but one ingress/egress point.
8. Downtime Tracking: Switch to paper. Use a whiteboard to track Red, Yellow, and Green counts.
9. Staff Recall: Activate the “Fan-out” system for off-duty personnel.
10. Logistics Call: Request 20–40 cots, wheelchairs, and extra oxygen tanks.

Phase 3: Personnel and Role Assignments

Roles must be clearly defined by vests and Job Action Sheets:

• MCI Triage MD: Stands at a single entry point. Does not treat. Only sorts and tags.
• Charge RN: Coordinates beds and communicates with the Command Center.
• Disposition RN: Manages the “Launch Pad” and executes rapid discharges.
• Flow RN: The traffic controller, ensuring “Red” patients go straight to the OR or ICU.

Phase 4: Logistics, Equipment, and Meds

Store equipment on-site; off-site storage is often inaccessible in real disasters.

• Hardware: 20–40 cots, ~100 tourniquets, and hemostatic dressings.
• Pharmacy Carts: Standardized packs including RSI medications, analgesics, antibiotics, and anticonvulsants. Pharmacy must rotate these regularly to prevent expiration.

Phase 5: Triage Mastery—SALT vs. START

Triage must be fast (<1 minute). While START (Respiration, Perfusion, Mental Status) is common, SALT is the current gold standard.

• SALT (Sort, Assess, Lifesaving Interventions, Treatment):
  • Step 1 (Sort): “Everyone who can walk, move to that area.” (Green). “Everyone else, wave a hand.” (Yellow/Red).
  • Step 2 (Assess): Prioritize those who didn’t wave.
  • Step 3 (LSIs): Perform Immediate Lifesaving Interventions during assessment: tourniquets, needle decompression, or 2 pediatric rescue breaths.
  • Step 4 (Tag): Red (Immediate), Yellow (Delayed), Green (Minor), Black (Deceased), or Grey (Expectant—unlikely to survive).

Phase 6: Zone Management and Tracking

Once tagged, move patients to colored treatment zones.

• Reassessment: Conditions change. A Yellow patient with an occult internal bleed will become Red. Update the tag immediately.
• Diagnostics: Revert to paper orders. Use runners to carry samples to the lab and bring results back to the zones.
• Reunification: Use a patient ID number and link it to the EMS tag number to help families find their loved ones via the Red Cross or HICS.

Phase 7: Special Considerations—CBRNE and Tactical

If the collapse involved a chemical agent or explosion:

• CBRNE Zones: Hot (Contaminated), Warm (Decontamination), Cold (Treatment).
• Decon: Dry Decon (removing clothes) removes 80% of contaminants. Wet Decon (warm water shower) follows.
• Tactical: If the threat is active (e.g., active shooter), divide the scene into Hot (Threat present), Warm (Police-secured, limited LSIs), and Cold (Safe staging).

Phase 8: Resource Scarcity and Ethics

As resources dwindle, care shifts on a spectrum:

• Contingency Care: You are still providing standard care but with adaptations (e.g., 2 patients per room, nurse-to-patient ratios of 1:8).
• Crisis Care: Resources are depleted. You must make agonizing decisions, potentially using age or comorbidities to allocate ventilators or medications. Proactive ethical planning with diverse stakeholders is required to ensure equity.

Phase 9: System-Wide Integration

The ED cannot survive alone.

• Inpatient Support: Medicine and Surgery must “census share,” absorbing admissions rapidly.
• HICS: The ED is the Casualty Care Unit within the Medical Branch.
• Maintenance: Practice makes perfect. The Joint Commission requires annual exercises. Use tabletop drills for policy and functional drills (moulage) for workflow.

Strategic Mentorship: Identifying Blind Spots

When planning for your facility, consider these operational risks:

1. The Communication Blackout: If the EMR goes down and the hospital Wi-Fi is overwhelmed, how do you track patients? You must have a physical whiteboard and runners (staff members) ready to carry paper orders.
2. The “Fixation” Trap: Triage physicians often get “bogged down” performing a procedure on one patient while 20 others wait to be sorted. Operational discipline is key: Tag first, treat only if it takes <15 seconds.
3. Reverse Triage Pushback: Inpatient teams often resist taking patients who haven’t been “fully worked up.” You must have a pre-signed mandate from hospital leadership that authorizes these transfers during an MCI.

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The Mass Casualty Incident” (Roberts & Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, Chapter 75)