Emergency Volunteer Training for Mass Casualty Incidents

Moulage (fake injury) for mass casualty training. Photo by ER24 EMS (Pty) Ltd.

Moulage (fake injury) for mass casualty training. Photo by ER24 EMS (Pty) Ltd.

Authorities spend significant effort on teaching Community Emergency Response Teams (CERT) and Medical Reserve Corps (MRC) units about incident command, triage, and emergency medical care in the field. We train in first aid, or take basic and advanced disaster life support classes (BDLS and ADLS). We practice START triage (Simple Triage and Rapid Treatment). Emergency volunteers regularly observe and take part in mass casualty exercises. Although I find the topics fascinating, I’ve always wondered whether this is the best use of training time. After all, when a mass casualty event occurs, our volunteers are definitely not the “go-to” group. We’re not quick response. By the time we’re deployed, hopefully the event will be over.

What if trained emergency volunteers are randomly at a mass-casualty scene as citizens?  Would we be a help to official responders or just a hindrance? I suspect responders have more important things to do than decide if people are qualified to help just because they wave a CERT or MRC badge. In the overwhelming majority of cases, I expect spontaneous emergency volunteers are rounded up and escorted from the scene, just like the general public. Only if official resources are truly limited,  might we actually play a role – at least for a while. The odds of that happening spontaneously seem slim – probably even less than the odds of a true disaster!

If we are primarily disaster volunteers, perhaps our training needs to better designed for disaster situations. If official emergency response is not just delayed, but completely absent for hours or days, we may need a different skill set. START triage and first aid assumes transport and “non-rapid” treatment will be quickly available. How much time do we spend training on what to do when it’s not? It’s difficult to find courses applicable to that situation.

Large Public Events – A Potential Niche?

Aftermath of the Boston Marathon Bombing. Note how the public has been cleared from the scene. Photo by Rebecca Hildreth.

Aftermath of the Boston Marathon Bombing. Note how the public has been cleared from the scene. Photo by Rebecca Hildreth.

Boston MRC members actually played a role in the Boston Marathon bombing, providing emergency treatment, helping move injured, and assisting the official response as needed. It turns out that Boston routinely includes emergency volunteers in large events, meaning training, coordination, and plans were already in place before the bomb exploded. After this successful event response, some have suggested that local MRC (and maybe CERT) units play a regular role in large public events – but what exactly should that role be? How big is large? Is it worth the effort and volunteer time “just in case”?

First aid is necessary, or even required, at public events. Clearly emergency volunteers could help, but so can other healthcare volunteers without emergency training. I used to volunteer regularly at my daughter’s horse shows long before my involvement in emergency preparedness. Research on first aid at large public gatherings shows about 1 in 1,000 attendees require basic first aid, with only 3% of this already small group needing hospital transport.

It obviously depends on the event. Heat, humidity, crowd mobility , and alcohol use all increase first aid use. Sporting and music events routinely keep first aid providers busier (of interest –  they’re also the events at greatest risk for crowd crush). Overall, medical issues outnumber trauma two to one, although when I did horse shows, I took care of several fractures, an impressively broken nose, mild shock, and a 3 inch laceration. There’s a reason why horse back riding is considered a dangerous sport. It rates right up there with things like bull running and base jumping!

In Pain? Photo by Mike Renlund.

In Pain? Photo by Mike Renlund.

If a public event requires only one or two first aid workers, CERT or MRC involvement may be overkill. You’ll either have a lot of volunteers standing around doing nothing, or you’ll have too few volunteers to make a difference when a true emergency occurs.

Advance cooperation with local official emergency responders might help decide whether staffing  trained emergency volunteers is a worthwhile exercise. Will official responders utilize CERT and MRC units if a major incident occurs, or will we be grouped with the public? If not part of the official incident response plan, I question the value of “official” emergency volunteer presence. On the other hand, if official responders and emergency volunteer groups agree in advance to work together, this could truly be a win-win.

An Opportunity To Test My Theory

Key up The Great Oregon Steam-Up – an upcoming two weekend event near Salem, drawing about 25,000 people and specializing in firing up antique steam equipment. Marion County Fire asked if our MRC would run first aid for this event – a role traditionally provided by the fire department. With our presence, the fire department won’t tie up an ambulance at the event. After saying yes – mostly to improve our working relationship with the fire department –  belated realization hit. We will be the only on-scene “officials” with medical or emergency training during a large rural public event with a real risk of something blowing up.

My reaction – excitement! This is not a high risk – they do this event every year with good safety precautions. But the risk is there, and should be addressed. Not that I want an explosion, but here’s an opportunity to turn training into real-life incident planning. And I get to do it in advance, in coordination with official responders, and with a reasonably narrow focus so I don’t drive myself crazy from “what-ifs”. Let me share some ideas, realizing this is a work in progress.

Identifying Goals in an Explosion Incident

In an incident plan, always identify goals first.  Limited resources (staff in our case) are wasted by trying to do too many things. Goals encourage focus on the most important areas. Our first goal must be volunteer safety, followed immediately by getting Emergency Medical Services (EMS) to the scene as quickly as possible. EMS has the equipment, transport, and most importantly, the experience. MRC volunteers are just place holders until real first responders arrive. Our next goal is saving lives – quickly identifying the most urgent victims, providing quick life-saving interventions and directing EMS to the highest needs when they arrive.

With enough staff, we might help with crowd control– calming panic, corralling people, and keeping walking wounded from flooding local emergency rooms even before the severe traumas arrive. And finally, once EMS assumes command, we help however requested – walking wounded treatment, psychological first aid, or nothing at all. Once in command, EMS gets to decide what, if anything, we do.

The Explosion

Photo by gynti_46

Photo by gynti_46

Not all explosions are created equal. It matters whether your explosion occurs in a closed space or outside. An explosive blast bounces off walls, literally getting victims coming and going. A corner is the worst possible place in an explosion – forces hit from all sides. Structures may collapse, adding entrapment and crush to your problem list.Projectiles (flying fragments) come from both the explosion source and the environment. (Terrorists commonly add random bits of metal to bombs just to increase injuries.) Explosions break windows blocks away from the source – just ask the Russians. The sonic blast from a crashing meteorite 4 months ago broke more than 1 million square feet of glass, injuring 1,100 people who flocked to windows to see the bright light. Explosions might be multiple. Perhaps the primary source isn’t “dead yet”! There could be a secondary device (security lingo for another bomb), or someone mishandling a chemical. Boom again! And don’t forget thermal (a fancy word for fire or burn) factors. Is the explosion a “fireball”? Are there flammable structures? Is there an ongoing fuel source?

We have the luxury of planning for a specific type of explosion in advance, making this a great MRC exercise. Most emergency responders don’t get that luxury. Our steam engine explosion scenario will likely be outside – a major plus. Steam burns and machine fragments would be our major source of injury. Some buildings on the grounds might be affected in an adjacent blast, with glass as the biggest concern.  Chemicals shouldn’t be a problem, and the odds of a large fuel source are low. Despite large numbers, people are rarely packed together at this event, which should help keep major injuries low.

The Event Grounds

Map importance becomes glaringly obvious– both for command and for every volunteer. How else will we communicate about locations? It’s not like there are street signs. We need quick ways to get from Point A and Point B. Entrances and roads on the event grounds are limited. Maps will help us expedite getting EMS from the entrance through the crowds to their staging area, and then to the scene. We can pre-identify open areas for public grouping after an incident, including a area for walking wounded. And of course there are the basics, like locations of water and fire equipment.

Keeping Volunteers Safe

Safety means preventing injury, adequate equipment, and good planning and training. The first question is always whether the scene is safe. “Our” explosion (steam engine) will probably happen outside, so structural stability worries should be low. With few structures, hopefully fires would also be small and localized. Our explosion scenario is mechanical, without chemical hazards and decontamination worries. I suppose we should add the risk of a terrorist bombing masquerading as a steam engine explosion – after all, this is a public event. However, we’ll let observation at the scene guide our level of concern. My biggest worry is ensuring that further explosions are unlikely, without delaying medical response unnecessarily. Any ideas?

Dust Mask. Photo by Pacific Northwest Safety and Health Center University of Washington

Dust Mask. Photo by Pacific Northwest Safety and Health Center University of Washington

In an explosion, dust and airborne toxins cause respiratory illness in responders.  Avoid shouting if possible – you breathe in more junk. We’ll finally use the ubiquitous whistle in every emergency kit, plus we’re adding a bullhorn to our mobile unit. Each volunteer will carry a fanny pack with a mask to protect their airway, work gloves for moving debris, and medical gloves to protect against blood and body fluids.

Event Communications

Cell phones are our primary communication method at the event, but we’ll carry two-way radios for back-up (I’m a redundancy freak, plus we can practice with two-ways when things are slow). Immediately after an incident, all MRC volunteers on the grounds first call incident command before responding. After ensuring all volunteers are safe, incident command can quickly gather available information from each volunteer before determining the next steps. Our MRC trailer has a county radio capable of talking to EMS directly. 100 simultaneous bystander calls may go to 911, but our MRC incident command can give situation reports and plan directly with EMS control while in transit.

Event Staffing – A Balancing Act

This feels a little like the Bible story of the fishes and the loaves. We plan 6 volunteers  for each four-hour shift, including two healthcare providers. With twelve shifts, this still means 72 volunteers (not including set-up) – a lot for our “young” unit. During normal operations, we’ll have both a mobile first aid unit (using a Gator utility cart) and a first aid tent, each staffed with a medical person (MD, NP, PA, RN, EMT, etc) and a non-medical “first-aid assistant”. The shift commander and communications officer will hang out at our trailer.

Medical Volunteers at a Marathon. Photo by Christiana Care.

Medical Volunteers at a Marathon. Photo by Christiana Care.

But things change if a mass casualty incident occurs. After reporting in, our mobile unit will head for the scene, joined shortly by the “tent team” – using our second motorized cart, saved for emergencies.  These four will assess the situation, perform triage, and provide life-saving interventions. They can direct willing bystanders in basic hemorrhage control and first aid (and maybe keep them from doing unintentional harm). Hopefully, event volunteers (not our group) can handle crowd control, and help the MRC with supervising walking wounded. Command for the MRC will run from our trailer. Our communications officer will be left with the task of physically meeting EMS when they arrive, clearing their way, and directing them to the staging area and scene.

Explosion Incident Timing

How long will we be on our own? EMS response should begin arriving within 5-10 minutes, with additional units called in as needed. After arrival at a mass casualty incident, EMS first establishes a command center, assesses scene safety, and develops their response plan, adding potentially another 15-20 minutes before assuming care. Although I don’t want an actual incident to occur, it would be interesting to see if this transition process could be hastened by MRC intervention and coordination before EMS arrival.

Will This Work?

I haven’t actually discussed the medical issues associated with explosion yet – that’s my next post (of course). But what do you think? Is this a viable role for a MRC unit? Are my thoughts regarding our incident plan heading in the right direction? I’d love feedback.

I hope to get a draft prepared this week, and then share it for discussion with everyone involved locally. A plan prepared in isolation isn’t really a plan. In fact, an incident plan is really just a thought exercise. Once an event actually occurs, plans may quickly go out the window in the face of reality. However, if participants understand the thinking behind the plan, hopefully they adapt. We will have a training session 2 weeks before the event, plus “just-in-time” training when MRC volunteers arrive at the event.

Stay tuned for progress, and of course an after-action report after the Steam-Up. Add a comment to let me know your thoughts and questions!

Stay safe,

Sheila Sund, M.D.

  1. […] Mass Casualty Incident Plans – Do Volunteers Have A Role? […]

    • Barb Chrisman, former RN says:

      Hoping no major incident happens, but interesting that the fire department is placing us (MRC) in position to be the first to respond if a big emergency did happen.

      • disasterdoc says:

        Perhaps neither fire or MRC thought it through fully at first, but now that we have, it still makes reasonable sense. MRC can probably have more people on site at all times than fire could, so providing we have a good plan including rapid EMS response, we might actually be able to accomplish more in the first few minutes.

    • Noel Coates says:

      Hey Doc, I’m a member of the local CERT here in Penetang, ON. Canada. Our role here is mostly first aid support at large public events in the area. Everything from the local hockey game (100 to 200 spectators) to the various rural fairs where the number of visitors can range into the thousands. I’m actually working the roller derby this weekend 🙂 I do believe that CERT and MRC etc do play an important role in Mass Casualty Plans, especially in rural area’s when EMT’s are in short supply and can be 15 min to an hour away. Really like your posts, keep them coming!

      • disasterdoc says:

        Providing first aid at events is a great way to practice disaster healthcare skills. Unfortunately, there are malpractice liability issues that need to be addressed before healthcare professionals can safely help in these settings – at least in the United States 😦

        Good Samaritan laws only protect medical providers from malpractice liability in true emergencies (the majority of first aid at events does not count), and only when care is outside a hospital, clinic, or place where “medical equipment” is available. An event first aid station could be arguably be considered a place with medical equipment.

        The bottom line is that for a true emergency like a cardiac arrest or a mass casualty, I would probably be safe from liability – at least until EMTs arrive. But bandaging a laceration or making a recommendation for heat exposure symptoms at a first aid station would probably leave me vulnerable to malpractice claims. A non-professional CERT volunteer with official first aid training is safer treating those things than I am!

        Of course, if the event organizer or governmental agency that supports the CERT/MRC provides malpractice coverage, I could play a full role. However, this is rarely the case. They may say they provide liability coverage, but the fine print usually excludes professional malpractice. It’s sad, as my personal suggests professionals could really use the practice in these settings.

  2. Kevin Coughlin says:

    I see that hope was part of your planning. Your leadership (incident command) needs to coordinate with the event staff yo make sure those small issues are resolved well before the event. Planning involves not only talking through the plan but committing it to paper. That way you have something to deviate from if necessary (AKA “plan B”). using other volunteers (CERT members) can be useful to clear emergency access for arriving outside response (never leave to chance what you can control). Establish liaisons with all the other response groups that will be present, including the fire department ( just because they gave you the lead doesn’t mean they won’t be involved) You should follow the ICS format including all the paperwork. It will make the after action report easier to start.

    • disasterdoc says:

      Thanks for the feedback. We should have everything in writing long enough in advance to review and revise with all involved, including fire and event staff (it’s part of the “exercise” component). Your comment does emphasize a need to coordinate better with the actual event staff and organizers – something we probably haven’t done adequately yet. They would be the ideal choice to handle crowd control and clear emergency access if they are prepared in advance to do so.

      We have a defined incident commander, operations chief, and communications officer on site at all times. Given limited staff, we will probably have to double up on some other positions, but at least duties for each person will be defined by the ICS model.

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