One of the most difficult types of incidents to gain control of and organize is the multiple casualty incident. At a bus crash, for example, controlling the hazards may be simple, and gaining access may not be too difficult. But what about managing 40 patients with varying degrees of injuries in the confines of a wrecked bus? What about the bleacher collapse at the high school football game, where access for ambulances is limited? Or a 50-car pileup on a foggy highway, stretching one-quarter mile from front to back? Or the train derailment, where groups of injured persons are in separate areas, with no access between these areas? Or the tornado that rips through a trailer park, injuring dozens of people?

Successful management of a multiple casualty incident absolutely depends on delegating the primary incident objectives–rescue/extrication, medical control, and patient transportation–to competent personnel. Knowing how to do this, the components into which the incident should be broken, and the responsibilities of the various supervisory personnel will help make multiple casualty incident operations run more smoothly and safely.


Although the incident commander (IC) has ultimate responsibility for all activities at an incident, the use of an incident management system enables him to delegate tactical objectives to functional area officers. The modular design of an incident management system allows the IC to establish supervisory positions on an as-needed or projected-need basis. Organizational development, therefore, will vary from incident to incident. Expansion of the incident management system should center on maintaining an effective span of control to meet incident objectives.


The IC normally establishes the Rescue/Extrication Group position early in the incident. It often is assigned to the first engine or rescue at the scene. Additional positions follow as additional resources arrive on the scene. Personnel operating within the extrication area generally do primary care on the patients and then coordinate the transport of patients to the triage areas. Often, the Rescue/Extrication Group is operating within the hazard zone–a potential risk for personnel and patients; appropriate personal protective equipment should be worn and safe practices observed.

Where possible, extricate, triage, and deliver critical patients to the treatment area ahead of more stable patients. Doing so involves some interface with the Triage Unit leader. This may not always be possible, since first you must extricate some stable patients to reach the more critical patients.

The Rescue/Extrication Group supervisor is responsible for managing the rescue of entrapped victims. This requires him to do the following:

Determine the resources needed to extricate patients, such as rescue tools, backboards, personnel, and relief personnel.

Communicate resource requirements to the IC as necessary.

Provide tactical direction and supervision to assigned resources.

Ensure the safety of members operating in the area.

Coordinate with the treatment unit for patient care during the rescue operation.

Coordinate patient transportation to the triage area.

Provide the IC with frequent and timely progress reports.

Maintain incident documentation.


The Medical Group supervisor usually reports directly to the IC and supervises the Triage Unit leader, Treatment Unit leader, and medical supply coordinator. The Medical Group supervisor controls the activities within a Medical Group/Division to ensure the best possible emergency medical care to patients during a multiple casualty incident. The Medical Group supervisor does the following:

Participates in Incident Action Plan/ Operations Section planning activities.

Establishes the Medical Group with assigned personnel; requests additional personnel and resources sufficient to handle the magnitude of the incident.

Designates unit leaders and treatment area locations as appropriate.

Isolates the morgue and minor treatment area from immediate and delayed treatment areas.

Determines amount and types of additional medical resources and the supplies needed to handle the magnitude of the incident (medical caches, backboards, litters, and cots, for example).

Establishes communications and coordination with the Patient Transportation Group supervisor.

Ensures activation of the hospital alert system and local EMS/health agencies.

Ensures proper security, traffic control, and access for the triage and treatment areas.

Directs medically trained personnel to the appropriate unit leader.

Maintains incident documentation.


The Triage Unit leader is responsible for the triage and tagging of all patients at major incidents. These functions may be done in the extrication area or at the entry to the treatment area. In either case, close coordination must be maintained with the Treatment Unit and Extrication Group. Personnel assigned to triage must have the basic medical skills to make appropriate triage decisions.

The Triage Unit leader does the following:

Determines the location of triage areas.

Ensures that all patients are assessed and sorted in accordance with appropriate triage protocols.

Determines the resources required to conduct triage operations, such as communications, personnel, equipment and supplies, and relief units.

Communicates resource requirements to the Medical Group supervisor as required.

Develops triage organization sufficient to handle the assignment.

Ensures the safety and security of all members operating in the triage area.

Provides frequent progress reports to the Medical Group supervisor. Establishes initial morgue operations (as needed).

Coordinates the movement of patients from the triage area to the treatment area.

Maintains incident documentation.


The Treatment Unit leader position typically is established next. The leader establishes an area where patients can be collected and treated. Central treatment areas maximize the limited resources of rescuers in incidents that involve large numbers of patients. Extensive treatment and advanced life support care are conducted in the treatment area.

The Treatment Unit leader is responsible for the overall management of patient care delivery in the treatment area. He does the following:

Identifies and establishes a suitable area for treatment operations, communicating that location to the Medical Group supervisor and the Triage Unit leader. The area should be upwind and uphill and have sufficient space for operations (think BIG!); unimpeded access and egress for units; and separate areas for patients classified as immediate, delayed, and minor.

Identifies and requests additional resources as needed, such as communications, personnel, equipment and supplies, and relief or other support units.

Coordinates with the Triage Unit leader the movement of patients from the triage area to treatment areas.

Ensures the patients received in the treatment area(s) are separated by triage category, are reassessed and retriaged as appropriate (continual), and receive prompt and efficient treatment in accordance with established ALS/BLS protocols.

Establishes communication and coordination with the Patient Transportation Group supervisor.

Assigns, supervises, and coordinates personnel within area(s).

Ensures the safety of all members operating in the treatment area.

Directs the movement of patients to the ambulance loading area.

Provides frequent progress reports to the Medical Group supervisor.

Maintains incident documentation.


The Patient Transportation Group supervisor has a substantial challenge: to obtain all required transportation and have the patients transported to the appropriate hospitals. Hospitals will need to be notified. There will be an almost continuous flow of radio communication between the group and the receiving hospitals (either direct radio communications from the scene to the hospital or relayed through a dispatch center).

The Patient Transportation Group supervisor is responsible for the overall management of patient movement from the scene to the receiving hospitals. Special attention must be given to the patient`s needs and to whether transport to a specialty center is required. In addition to patient condition, the receiving hospital`s ability to handle additional patients and the overall impact on the EMS system must be part of the decision-making process on patient destinations.

To accomplish this, the Patient Transportation Group supervisor must do the following:

Establish an adequately sized, easily identifiable patient loading area in coordination with the Treatment Unit leader.

Establish communication with area hospitals and maintain a list of capacities.

Designate an ambulance staging area (if needed).

Identify and request additional resources as required, such as communications and personnel.

Direct the transportation of patients in coordination with the Treatment Unit leader.

Request air and ground ambulances as needed.

Coordinate air ambulance transportation.

Establish an air ambulance landing zone as needed.

Maintain patient tracking records and other incident documents.

When helicopter transportation is needed, a Landing Zone (L/Z) officer will be required. Responsibilities of this position include the following:

Locating a safe and adequately sized L/Z.

Advising operations and the Patient Transportation Group supervisor of the L/Z location.

Ensuring L/Z site safety.

Maintaining communications with helicopters.

Securing safe routes for ground ambulances entering and exiting the L/Z.

Requesting and supervising resources as needed.

Maintaining incident documentation.

If the incident involves multiple aircraft, an Air Operations Branch may be established. The Air Operations Branch director is to serve as an “air traffic control” and to ensure safe operations of all inbound, exiting, and overhead aircraft.

Other subordinates may be needed in the Patient Transportation Group. These include a medical communications coordinator (hospital communications), an air ambulance coordinator, and a ground ambulance coordinator. n

(Top) The Medical Group supervisor oversees the triage and treatment operations. It is important that this officer not get involved in direct patient care. (Bottom) The morgue area should be separated from treatment areas and have appropriate security throughout the incident. (Photos by author.)

(Top) Ambulances should be staged away from the incident scene but close enough to move in when called for by the Patient Transportation Group supervisor. (Photo by author.) (Right) This patient tracking board uses magnetic tags and/or markers so the Transportation Group supervisor can keep track of which unit takes which patient to what hospital. Communications with each hospital are accomplished by radio or cell phone from wherever the detachable board is set up. [Photo courtesy of Lieutenant John Spicuzzo, Lee Co. (FL) EMS.]

GORDON M. SACHS is chief of training and safety with the Marion County (FL) Fire-Rescue Department. He has more than 19 years of fire and EMS experience in both the career and volunteer services. In addition to many journal articles and U.S. Fire Administration publications, Sachs wrote the EMS chapter in The Fire Chief`s Handbook, Fifth Edition (Fire Engineering Books, 1995). He is a National Fire Academy instructor in EMS management and health and safety. Sachs currently chairs the Florida State Fire College EMS Management Curriculum Advisory Committee and is a member of the Fire Engineering editorial advisory board.

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