You pause with your morning cup of coffee. The tones never seem to stop reverberating from the overhead speaker. It pauses, then: “Engine 4, Engine 3, Truck 1, Rescue 7, Medic 12, Medic 8, Medic 11, Battalion 2, Chief 1 — respond to Southbound Highway 88 at Miller's Crossing for a report of an overturned tour bus with multiple victims.” Given the size and scope of this type of incident compared with the available resources in your department, these words can skyrocket your level of anxiety to a near panic. Or these words can cause you to respond in your command vehicle with the confidence that your personnel will be able to handle this type of emergency well.

Effective emergency services leaders have learned that one of the key elements of successfully handling a potential large-scale mass-casualty incident is the preparedness phase. With a nod to the obvious need for MCI response training at all levels, providing the necessary materials and supplies for the emergency responders is paramount for overall success at the event. Months or perhaps years before the event occurs, the amount and type of materials to handle a MCI event must be part of the disaster planning.

Failing to prepare for disaster is in itself a disaster waiting to happen. Whether a jurisdiction is large or small, there is the increasing potential for natural and manmade disasters to occur. There also is a high potential that agencies perceived to have been ill prepared will be held liable.

However, the days of the blank-check mentality are gone. Many times in the past, incident command staff would order great quantities of goods in anticipation of a rapidly developing need only to later find large piles of rotting, wasted or unaccounted supplies. Now, almost without exception, in every public or private agency, budget issues are of greater concern for emergency managers. While it is important to adequately prepare for all types of MCIs, one must make a reasonable effort to provide what might be needed without unreasonable costs. Too much and funds are wasted, too little and victims suffer needlessly. It may seem unfortunate to have to consider these issues, but to ignore them would be politically irresponsible. This can be a delicate process but with some forethought and willingness to consider other non-traditional options, it can be done.

One concept that has been used is stockpiling a large amount of litters, blankets and bandage materials in a storage building or a trailer. While this seems like the obvious solution, it has its problems. Storage is one of these problem. Large stockpiles take up space and have to be in an environment that will preserve the goods until they are needed. Clean, dry, and rodent- and bug-free storage space is not only costly but frequently unavailable or inconvenient. If the supplies go unused, they may become outdated and obsolete.

Many articles and books have been written over the past few decades regarding systems of providing MCI equipment and supplies in the time of disaster. For example, Hank Christen and Paul Maniscalco describe a push-pull system in The EMS Management System: EMS Operations for Mass Casualty and High-Impact Incidents. They define the pull system as ordering supplies as needed. The push system is having predetermined and pre-positioned materials, in small quantities that are moved automatically to an MCI incident. Then larger quantities are moved by vehicles or trailers to augment the initial response. These caches of non-perishable supplies are stored in public facilities spread throughout the operational jurisdiction. Perishable medical supplies such as intravenous fluids are stored in hospitals where they can be rotated with the normal stock. The authors recommend that these materials be stored in inexpensive plastic bins, labeled and color coded as to the type of treatment priority. One of the advantages is that these caches can serve as self-sufficient emergency treatment centers in time of disaster.

Another system involves moving excess supplies from arriving ambulances and other emergency response vehicles to an impromptu onsite supply pool. This is gives the incident responders rapid availability of supplies. However, it does not provide for efficient inventory tracking and may become problematic during the early recovery phase of the incident when attempting to return units back to routine availability. For this system to function, it is vital that non-disposable equipment be marked with the agency name and perhaps unit number so that it can be returned to the proper vehicle.

There are many design configurations of MCI supply response vehicles; some are better than others. Depending on a department's budget and logistical needs, it will need to decide on whether to use some form of trailer or a powered vehicle. Trailers cost less to own and maintain than a truck chassis vehicle. Because these trailers are packed full, it is important to remember check its weight. Some agencies have used grant money to purchase large trailers packed with enormous amounts of supplies and equipment only to find the axles bowed and that the vehicle is grossly overweight at the local highway patrol scales. The trailer will require towing that is always available.

A powered vehicle typically can handle more weight and provide for a more rapid response. But the issue is the cost and responsibility of maintaining the mechanical systems. Depending on the potential for deployment, it may be necessary for whichever vehicle is chosen to be transported great distances by aircraft. Thus, overall size and weight is an added concern.

When developing the details of a MCI supply system, a lot will depend on the needs assessment for the operational area. The potential for large MCI in rural and remote areas may be small, but the distance from available mutual aid resources could dictate a need for a medium to large cache of supplies. Suburban and metropolitan areas have a much higher potential for very large MCI numbers, however, they can look at just-in-time delivery. This is a philosophy to deliver products at the right place, in the right quantity, and at the right time. In a major metropolitan area, it may be more feasible and cost-effective to develop relationships with commercial suppliers that have warehouses located nearby. This should involve written memorandums of understanding or blanket purchase orders in place to facilitate the logistical needs of the emergency response agency. Frequently these district or regional supply warehouse operations also have a ready supply of vehicles to transport materials to the incident site or staging area. Not only can they provide large amounts of supplies, they are most likely to have recently manufactured goods due to their system of rotating stock.

Departments still must decide on how much and what type, size, brand of supplies to purchase or plan for. There is no easy answer. It takes a serious assessment of needs and thoughtful planning to develop a customized ready supply of materials to support local response teams. The assessment should include working with vendors, experienced operational personnel and neighboring jurisdictions. It is also crucial to assess regional, state and national resources. There are enormous amounts of supplies available outside the normal operational area. Find out what works and what has failed in the past.

Because the size and scope of a future MCI is largely unknown, consider a multi-tiered plan for supply logistics. Tier one would be the supplies readily available on the initial response vehicles. Engine and truck companies can be stocked with a minimum cache of MCI supplies such as extra backboards, bandages and triage tags. Rescue and ambulance units can be stocked with enough supplies for a moderate amount of patients. This should give the initial responders sufficient materials to initiate triage and basic patient care until the next level of support arrives. Tier-two resources would involve the movement of local caches, either by truck or trailer, from strategically staged storage areas to the site of the MCI. If the MCI is large enough to deplete those resources, then the ICS logistics staff would request the tier-three MCI response. This would engage the use of nearby medical supply warehouses, if available, and mutual aid with neighboring departments. Finally, grand-scale MCI would require implementation of tier four. This would secure supplies from out of the immediate area, such as state or federal government resources.

Having the proper plan in place will make disaster management and the drive to the scene a much smoother ride.

Mike McDonough has worked in the emergency response service for 25 years as a full-time paramedic, a volunteer firefighter, and an emergency medical services manager. He has associate's degrees in fire technology and emergency medical services. He is an associate faculty member in the Public Safety Education & Training department at Allen Hancock College. He is also an adjunct faculty member at the EMS program at the Emergency Services Training Institute's Texas Engineering Extension Services in College Station, Texas.