Leadership at the Scene of a Mass-Casualty Incident

There are many “how to” books and manuals about how Emergency Medical Services (EMS) command structures should function during a mass-casualty incident (MCI), but relatively few policy guidelines related to day-to-day operations are available. There should be, though, because developing an effective EMS supervision program is much more than merely issuing orders to the staff. Supervision must meet a number of important goals.

The first and most obvious task of the EMS supervisor, as with any other organization and/or business, is the general supervision of the EMS staff both initially and during operational situations. General supervision necessarily includes paying proper attention to such mundane details as ensuring that: (a) staff show up for work on time, and fully prepared to carry out their individual and team responsibilities; (b) equipment is properly signed out; and (c) overtime is authorized if and when necessary to fill vacancies. The important thing to remember here is that all tasks related to keeping units “rolling out” and carrying out their responsibilities are central to the work of the EMS supervisor. For that reason, each properly organized EMS system has at least one leader, designated by name, fulfilling that goal.

The second goal of the EMS supervisor should be troubleshooting. EMS productivity is usually calculated, logically enough, by the number of responses the system can handle and the speed at which the specific EMS unit can respond. However, incoming requests often have to compete for resources. If an EMS unit is immediately available, the emergency call does not have to wait for a unit to be dispatched. If there are several units available, the likelihood increases that a particular unit is closest to the incident scene. Swift troubleshooting translates directly into faster response times and, in many situations, more lives saved.

Time, Technology, and a Clear Chain of Command 

The quality and operational effectiveness of the response team of any EMS unit are determined by many factors – several of them, unfortunately, outside the control of the EMS system. The time needed for medical care, for example, varies for each case. However, there may be technological solutions to eliminate or at least reduce certain problems to manageable size. The use of Global Positioning Satellite (GPS) tracking – to cite but one recent technological advance – can significantly decrease travel time to the incident scene. And it will, but only if the dispatcher uses the information available to him or her to locate and dispatch the EMS unit closest to the incident scene.

Some situations tie up EMS crews indefinitely, though, and hold the EMS resource in place. Among the most frequent scenarios involved are an overwhelmed emergency room with no stretcher available for another patient, a sick prisoner with no police officer available to escort him or her to the hospital, or a patient who will neither refuse care nor consent to transportation.

In these and most other situations where EMS resources are stalled, the role of the supervisor varies. However, regardless of the situation, the focus must still be on expediting release of the unit – but without jeopardizing the patient’s wellbeing. Supervisors can and, in such situations, should focus their efforts on resolving the problem. Unlike the other crew members, supervisors usually do not have to focus primarily and/or exclusively on the care and monitoring of the patient.

In addition, the EMS system itself may in certain specific situations empower the supervisor to “break the rules” – if and when necessary, of course. This is where the organizational rank and position of supervisors enables them to resolve most if not quite all operational issues without having to navigate the chain of command; they can simply speak to one another “boss to boss,” as it were.

The “Added Value” Provided by Medical Training 

With a little troubleshooting, some delays can be minimized or ameliorated in other ways. In the case of the hospital without a stretcher, there may be stretchers available in other areas or departments of the same hospital – in those circumstances, a quick call to the hospital administrator may be all it takes to authorize a hospital staff member to get the stretcher.

Similarly, when a sick prisoner is not critically ill – and seems unlikely to become so – the EMS supervisor may: (a) authorize a crew to leave the police station and go back into service; and (b) at or about the same time, direct the police to call back when an escorting officer becomes available. (In at least some situations, though, the supervisor may also decide to remain at the police station to monitor the patient’s condition.)

Medical training for EMS supervisors is also important. If the supervisor is called on to take medical action, he or she must be medically trained. Also, medical training experience creates credibility and respect with the staff. Without proper training, the supervisor cannot perform the task of medically monitoring the patient at the police station, cannot pitch in and help either at the scene of an incident or when a vacancy must be filled on short or no notice, and cannot reasonably be allowed to participate in medical decisions.

The bottom line is that having proper EMS supervision available at the scene of an incident – particularly a mass-casualty incident – is an extremely valuable “bonus asset” in itself. EMS supervisors are by definition the best and most qualified to coordinate and organize the operations on the scene – and, if they have received the medical training required, they also represent an extra pair of hands if and when needed.

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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