MCI & incident command.
A mass-casualty incident flips your normal mindset. You stop treating one patient and start sorting many. Incident command and triage are the tools that make that shift possible.
The first 60 seconds
- Scene size-up: hazards, number of patients, resources needed.
- Establish Incident Command and a staging area.
- Declare the MCI and request additional units.
- Designate triage, treatment, and transport sectors.
- Begin triage; do not stop to treat until command structure is set.
START triage for adults
Step 1: ask anyone who can walk to move to a designated area. These are GREEN — walking wounded. Then assess the remaining patients with RPM.
R — Respirations
No respirations after airway repositioned → BLACK. RR > 30 → RED.
P — Perfusion
Cap refill > 2 sec or no radial pulse → RED.
M — Mental status
Unable to follow simple commands → RED.
If a patient passes all three RPM checks, they are YELLOW (delayed). If they fail any one, they are RED (immediate).
JumpSTART triage for pediatrics
JumpSTART follows the same principle but adds a pediatric rescue-breath step. Apneic children with a pulse get 5 breaths — if they breathe on their own, they are RED. If not, they are BLACK. This acknowledges that pediatric cardiac arrest is often caused by respiratory failure.
Incident command structure
- Incident Commander: Overall strategy, safety, resource requests, and communication.
- Triage Officer: Sorts patients by priority and assigns tags.
- Treatment Officer: Manages the treatment area and delegates care.
- Transport Officer: Coordinates destinations, patient distribution, and tracking.
- Staging Officer: Holds incoming units and equipment until assigned.
Transport priorities
- RED patients go first to the closest appropriate trauma center.
- Distribute YELLOW and GREEN patients across multiple hospitals to avoid overwhelming one ED.
- BLACK tags remain on scene until the incident is controlled and resources allow reassessment.
- Track every patient destination for reunification and family notification.
NREMT tip
On the NREMT, the MCI answer is almost always about triage and command before treatment. The correct first action is establishing command and triage, not beginning CPR on the first patient you see.
FAQ
What is the first arriving unit's responsibility at an MCI?
The first unit on scene becomes Incident Command until relieved by a higher-ranking officer. They give a size-up, establish safety zones, and begin triage. Do not commit to patient care until command is established.
What does START stand for in triage?
START stands for Simple Triage and Rapid Treatment. It uses RPM: Respirations, Perfusion, and Mental status. Ambulatory patients are tagged GREEN first, then the remaining patients are assessed with RPM.
How does JumpSTART differ for children?
JumpSTART gives apneic pediatric patients with a pulse 5 rescue breaths. If they resume spontaneous breathing, they are RED. If they remain apneic, they are BLACK. This reflects that pediatric arrests are often respiratory.
What are the four main MCI sectors?
Triage, Treatment, Transport, and Staging. Some scenes also add a Morgue or Medical branch. Each sector has a unit leader who reports to Incident Command.
How long should each triage assessment take?
About 30 seconds per patient. Triage is not treatment — reposition the airway, control obvious bleeding, and move on. Detailed care happens in the treatment sector.
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