The call for multi-casualty or mass-casualty incidents is one of the most prevalent challenges an incident commander or company officer is likely to face in the future. Often a tremendous amount of stress is created because of the lack of resources to mitigate such an incident. The customer or patient doesn't benefit from the improper request for ambulance resources. Fire chiefs don't always take the initiative to educate and organize their regional ambulance resources, which would ensure an efficient response of transportation and advanced life support resources.

What is most damaging about the delivery of patient care during a multi-vehicle collision or multi-casualty incident is the inability to provide immediate transportation. Often company officers or incident commanders piecemeal a request for ambulance or ALS resources to an incident. This results in delays as the time lag for the next ambulance requested is compounded by the travel time of an ambulance coming from the next-due district or neighboring jurisdiction. Superimpose a delay of 10 or 15 minutes in the request for resources, combine it with travel-time delays, and the result is that the golden hour for a trauma patient is nearly consumed.

In many large-scale incidents a good number of incident commanders express frustration regarding control of ambulance resources responding to the scene. As is often the case, the private ambulance industry does not train their personnel to understand or function within the ICS. This in turn leads to freelancing by ambulance crews, which often places them in a risky environment. If ambulance resources don't check in with the incident commander or the staging area officer, critical ALS resources could be deployed to the wrong location. For the incident commander, the concept of managing the supervisor of a response team is preferred to tracking several incoming single resources.

Even more varied are the definitions that define a mass-casualty, multi-casualty or EMS disaster. The number of patients that qualifies each of these events still is undefined in the medical hierarchy. A standard among local, state and federal resources has not been established.

The Arizona state system has defined a multiple-patient incident as up to 25 patients. If the incident is between 25 and 100 patients, the term mass-casualty incident is used. An incident with more than 100 patients is considered a medical disaster scenario. While these numbers reflect the Arizona system, most multi-casualty incident plans simply state the Department of Transportation's definition of this kind of incident, which in most disaster plans means any event resulting from man-made or natural causes resulting in illness and/or injuries that exceed the EMS capabilities of a hospital, locality, jurisdiction and/or region.

The incident commander has the responsibility to ensure that each patient receives treatment and transport and that the crews working on a scene are safe. The fire service has seen several incidents in which firefighters and EMS personnel sustain injuries or medical emergencies during a call and no immediate transportation is available. EMS incidents tend to move very quickly, and command officers should not be caught without additional resources to use when time is critical for a patient. Additional resources in staging have saved the day many times over when circumstances changed for the worst.

One way to assist in combating the delay in adequate resources arriving at the scene is to develop a predefined response matrix for medical incidents. The idea is to have enough resources and a cushion to handle unexpected emergencies. For several years the fire service has sent a first-alarm fire assignment or box alarm to a structure fire. However, few departments have dispatch policies that send first-alarm medical assignments or a standard set of resources to an incident that appears likely to generate several transports or require more ALS resources.

The Phoenix Fire Department has been at the forefront of sending a given number of resources to EMS calls. Phoenix has a first-alarm medical response that brings four engines, two ladders, two chief officers, three ambulances, a rehab truck, a command post vehicle, light unit and an EMS supervisor to significant EMS events. For smaller incidents that generate five or fewer patients, or collisions involving multiple patients, PFD has a two-and-one medical response that brings two ambulances, two ALS engines, a ladder truck and a command officer.

The Phoenix approach requires well-rehearsed incident management procedures. The department makes use of two levels of staging. Level I staging occurs when the originally dispatched unit arrives at the address. In a very systematic fashion, other arriving units stage a block away from the scene and report their location. Level II staging identifies an area to marshal equipment and sends all of the resources to a specific location. This allows the incident commander and company officer to have a more fluid resource. Consider the Feb. 28, 1997, shooting that took place at Bank of America in North Hollywood, Calif. This incident moved through several blocks before coming to an end. The use of staging kept fire department units out of harm's way and allowed for resources to be deployed parallel to the moving incident.

Another common way to organize resources is with task forces and strike teams. A task force is composed of five different types of EMS resources with a common radio frequency and a leader. A strike team is composed of five of the same types of resources with a common leader and common radio frequency. This is commonplace within the ranks of wildland firefighting agencies, yet task force and strike team concepts have not been applied routinely to EMS.

There are two notable attempts to develop strategies to use the wildland model for EMS. California Fire Chiefs, the Emergency Medical Services Administrators of California and the California Ambulance Association are working on a joint document to align ambulance resources in strike teams. This effort has been fueled by recent events in which self-dispatched EMS units responded to a disaster without coordination, leaving primary service areas uncovered. This document will specify the minimum training for ambulance strike teams and EMS managers in the private ambulance industry that would be assigned to supervise ambulance strike teams.

The California initiative requires ICS 100 and prefers ICS 200 plus one year of EMS experience in order to participate on a team. The work group's document is available online at www.calchiefs.org/index.cfm?HeadNum=17&PageNum=357, and it specifies the equipment and necessary supplies an ambulance strike team will require for a 72-hour period. Two types of ambulance strike teams are defined. The Type I ALS team requires five ALS ambulances, one supervisor vehicle and one disaster support vehicle. The Type II BLS team requires five BLS ambulances, one supervisory vehicle and one disaster support vehicle.

In Virginia, the state department of health has set the pace by establishing 14 regional EMS disaster task forces. The real success in this program is the teamwork between several rural and volunteer providers. When the governor declares a state of emergency, EMS task forces are mobilized from other unaffected regions of the state. In Virginia an EMS task force is composed of a BLS ambulance, an ALS ambulance, a rescue truck, a quick-response vehicle or command vehicle and a disaster trailer or truck.

Multiple-casualty incidents will continue to appear in our jurisdictions, and increasingly we will have to rely on our neighbor to help in managing the efforts to save lives and move patients to the hospital or to safety. We owe it to the fire and EMS workers on the front line to support their efforts in an organized and efficient way.

Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has a master's degree in public administration and an associate's degree in fire management.