Introduction
Mass-casualty incidents (MCIs) are characterized by a large number of victims in need of immediate and definitive medical care that exceeds local capacity. 1 Such events are also described as major incidents or disasters. They are diverse and unpredictable and include accidents, fires, mass shootings, and terrorist attacks. They may result in severe injuries and fatalities, and sometimes devastate communities. Reference Gabbe, Veitch and Mather2 Mass-casualty management refers to a coherent and interrelated set of procedures, policies, and plans that contribute to optimizing health care services capacity to respond to the incident and to efficiently increasing capacity throughout the response. 1 Emergency Medical Services (EMS) are often the first point of contact between health care systems and MCI victims; they therefore play a critical role in determining the event’s outcome. Reference Cimino and Braun3 Effective mass casualty or major incident response systems rely on, among other things, a well-functioning communication system, adequately trained human resources, command-and-control systems and structures, adequate medical protocols, leadership, governance, and surge capacity. Reference Gabbe, Veitch and Mather2,Reference Usoro, Mehmood and Rapaport4 Previous studies have presented challenges for the overall health care system. Reference Hugelius, Becker and Adolfsson5 However, the prehospital context presents specific challenges. From a global perspective, EMS staffing and organization differs significantly between countries. 6 Command-and-control structures and judicial aspects of prehospital MCI response likewise vary. Prehospital MCI response is managed and led according to several concepts, such as the Major Incident Medical Management and Support concept. 7 Such concepts often focus on safety, command-and-control structures, and structured reports from the scene to the hospital; they are also sometimes used to introduce mass-casualty triage systems. Some of these concepts have been developed for specific events, such as terrorist or active shooter events, Reference Berben, Vloet and Lischer8 while others are more general. Reference Tiyawat, Liu, Huabbangyang, Roza-Alonso and Castro-Delgado9
Prehospital MCI management has been identified as an essential area of future research, Reference Castro Delgado, Alvarez Gonzalez and Cernuda Martinez10 and prehospital guidelines of MCI management still fail to rely on evidence-based recommendations. Reference Martin-Gill, Panchal and Cash11 Therefore, a systematic synthesis of real MCI experiences is strongly needed.
This study aimed to analyze common challenges in prehospital MCI management.
Methods
Design
A systematic integrative literature review Reference Whittemore and Knafl12 was conducted on case studies or reports describing specific MCIs.
Terminology Used
This paper uses the term Emergency Medical Services to describe responses by ambulances (both airborne and land-borne), emergency physicians’ units, or specific prehospital medical teams. The term EMS personnel is used to describe medical prehospital responders, regardless of formal education or training. The term prehospital medical incident commander is used to refer to the individual of being in charge of the prehospital medical response on an operational level. All affected people, both injured and uninjured, are called victims.
Literature Search
On April 2, 2024, with assistance from an academic librarian, the first author conducted systematic searches in PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); CINAHL Plus with Full Text (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Clarivate Analytics; London, United Kingdom); and Scopus (Elsevier; Amsterdam, Netherlands). The search included Medical Subject Headings (MeSH) terms, subject headings, and free-text searches (Table 1).
Table 1. Systematic Search
Abbreviation: MeSH, Medical Subject Headings.
The following eligibility criteria were used to select studies: (1) papers describing prehospital management of specific events referred to by the authors as mass-casualty situations, major incidents, or disasters; and (2) case reports, field reports, or other types of academic papers published in English from year 2015 through 2024. Studies were excluded if they: (1) were published as editorials or similar texts; (2) were reviews or studies summarizing data from several incidents; (3) reported on the response solely from the emergency department or hospital perspective; (4) reported on the prevalence of specific injures or medical conditions following an MCI; (5) reported specifically on the effects of COVID-19; or (6) relied on simulations or exercises. Studies were selected using the Covidence systematic review software (Veritas Health Innovation; Melbourne, Australia).
Data Evaluation
A quality appraisal was conducted by using a modified version of the Joanna Briggs Institute (JBI; Adelaide, Australia) critical appraisal checklist for case reports. 13 The checklist was modified by the authors such that it was adopted to assess reports of events rather than on individual patients (Table 2). The authors conducted the quality appraisal together. Each report was comprehensively valuated and received a final grade of “medium” or “high” quality.
Table 2. Quality Appraisal, Based on a Modified Critical Appraisal Checklist for Case Reports
Note: Modified checklist based on JBI (2020). Checklist for case reports. Critical Appraisal tools for use in JBI Systematic Reviews.
Abbreviation: JBI, Joanna Briggs Institute.
Analysis
Data were synthesized by integrative analysis. Reference Whittemore and Knafl12 First, relevant data were extracted from the reports’ results, discussion, or conclusion sections. Thereafter, they were sorted and integrated thematically. Finally, they were comprehensively analyzed, resulting in themes representing common challenges in prehospital MCI management.
Results
Four hundred and twenty-five papers were retrieved from PubMed (n = 113), Web of Science (n = 213), and Scopus (n = 99). After duplicates were removed, 374 papers remained and were screened by title and abstract. Of these, 342 were excluded. A full-text review of 33 articles was conducted, resulting in the exclusion of 19 papers. A manual search in Google Scholar (Google Inc.; Mountain View, California USA) added three papers, resulting in the inclusion of 17 papers in the analysis (PRISMA flowchart shown in Figure 1).
Figure 1. PRISMA Flowchart.
The 17 reviewed papers covered 15 different events including terrorist attacks, chemical incidents, traffic accidents, a storm, and fires. The events had occurred in Denmark, France, Israel, Italy, Iran, Japan, Lebanon, Malaysia, South Korea, Switzerland, the Netherlands, the United Kingdom, and the United States. The number of victims injured ranged from 15 to 6,000 (Table 3). Most (13) events occurred during the daytime or in the evening.
Table 3. Overview of Papers Included in the Review
Abbreviation: EMS, Emergency Medical Services.
The analysis identified several common themes and challenges in prehospital MCI management, of which Table 4 presents an overview.
Table 4. Overview of Themes and Subthemes
Safe Access to the Scene and Victims
Several challenges were related to physical access and security issues for both victims and EMS personnel.
Assessing Security and Defining Adequately Safe Zones
Assessing the security situation and determining adequately safe zones required the close cooperation of the prehospital incident commander, the police, and rescue services. Reference Hansen, Mikkelsen and Alstrøm14–Reference Idrose, Abu-Zidan and Roslan16 Sometimes, a joint command team was established, wherein minute-to-minute information sharing enabled informed decisions. Reference Hansen, Mikkelsen and Alstrøm14,Reference Zhang, Wang and Fan17–Reference Hardy19 A common strategy for handling security threats was to divide the scene into different zones described by the level of danger, such as “dangerous” (“red”), “relatively safe” (“orange”), and “safe” (“green”) areas. Reference Carli15,Reference Idrose, Abu-Zidan and Roslan16 In most events, the security situation developed over time, requiring constant evaluation. Security threats included secondary attacks directed at EMS Reference Hansen, Mikkelsen and Alstrøm14 and the possibility of chemicals or explosives causing serial explosions. Reference Zhang, Wang and Fan17 The presence of upset or aggressive civilians also posed security risks. Reference Safi Keykaleh and Sohrabizadeh18 Failing to continuously assess the security situation could result in fatalities among primary victims and EMS personnel, in the latter case reducing EMS’s ability to respond to the event.
Physically Accessing Victims
In many events, the location of the scene, most often combined with damaged infrastructure, adverse weather conditions, or security issues, made it difficult for EMS to physically access victims. Obstacles included narrow spaces, Reference Idrose, Abu-Zidan and Roslan16 roadblocks, Reference Hansen, Jepsen and Mikkelsen20 power lines crossing the scene, Reference Hansen, Jepsen and Mikkelsen20 or strong winds. Reference Hansen, Jepsen and Mikkelsen20 In some cases, access was hindered by security threats such as active shooting. Reference Hansen, Mikkelsen and Alstrøm14,Reference Jaffe, Wacht and Davidovitch21,Reference Carli, Pons and Levraut22 A strategy for enabling the provision of medical care was to establish medical posts in “safe enough” zones and move victims to these zones. Reference Carli15
Developing and Communicating Situational Awareness
Several challenges were related to prehospital situational awareness, analysis of the situation, and the sharing of the results of analysis with the strategic command level or the hospital.
Understanding the Situation and its Consequences
In some cases, the first indication of an MCI was a flux of emergency calls overwhelming the dispatch center. In one example, approximately 550 calls were recorded within a few minutes, Reference Hansen, Mikkelsen and Alstrøm14 and in another example, the emergency calls increased by 400% during the first hour. Reference Carli15 In other cases, the first indication of an MCI was when EMS met with a crowd fleeing the scene as they approached it. Reference Hansen, Mikkelsen and Alstrøm14,Reference Hardy19 Determining the exact or potential number of victims was challenging. Wide-spread scenes, spontaneous evacuations, the movement of people at the scene, and insecure environments often make it hard to make good estimations of numbers of injured. Reference Hansen, Mikkelsen and Alstrøm14–Reference Idrose, Abu-Zidan and Roslan16,Reference Hansen, Jepsen and Mikkelsen20,Reference Maruhashi, Takeuchi and Hattori23 Sometimes, the prehospital incident commander estimated the number of victims based on location, event type, and a “gut feeling.” Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15
Lack of a physical overview of the scene, Reference Hansen, Mikkelsen and Alstrøm14–Reference Idrose, Abu-Zidan and Roslan16,Reference Hansen, Jepsen and Mikkelsen20,Reference Koning, Ellerbroek and Leenen24 uncertainty and rumours, Reference Hansen, Mikkelsen and Alstrøm14 and challenges to obtaining information from the victims Reference Maruhashi, Takeuchi and Hattori23 made it difficult to gain situational awareness and to analyze its medical consequences. The incident commander had to consider not only obvious injuries, but also pre-event conditions Reference Choi, Lim and Cha25 and secondary medical effects such as contamination of victims, Reference Zhang, Wang and Fan17 cardiac infarction or other acute medical conditions, Reference Hirsch, Carli and Nizard26 secondary injuries from falling debris, Reference Gamberini, Imbriaco and Flauto27 hypothermia risks, Reference Koning, Ellerbroek and Leenen24 or dehydration. Reference Hardy19 The ability to foresee such needs was limited and required medical knowledge and experience. Reference Idrose, Abu-Zidan and Roslan16,Reference Hirsch, Carli and Nizard26
Communicating Situational Awareness
It was emphasized that the prehospital response had to be integrated into the overall medical response. One of the greatest challenges to enable that was the sharing of information between the prehospital scene and the hospital, as well as other strategic levels within the crisis management system. Where information sharing failed, hospitals and strategic EMS management could not adapt their responses. Reference Hardy19,Reference Koning, Ellerbroek and Leenen24,Reference Choi, Lim and Cha25 Communication technologies affected information sharing. Not all prehospital responders deployed units had the possibility or were familiar with the radio communication systems used. Reference Hansen, Mikkelsen and Alstrøm14,Reference Idrose, Abu-Zidan and Roslan16,Reference Safi Keykaleh and Sohrabizadeh18 Where many units were deployed, it was necessary to default to a “listen only, do not answer” basis to ensure radio discipline and clear communication channels, Reference Hansen, Mikkelsen and Alstrøm14 and it was a common problem that much of the information shared through technical systems was not perceived by its intended recipients. Reference Hansen, Mikkelsen and Alstrøm14,Reference Idrose, Abu-Zidan and Roslan16,Reference Zhang, Wang and Fan17,Reference Hansen, Jepsen and Mikkelsen20,Reference Maruhashi, Takeuchi and Hattori23
Determining and Adjusting a Prehospital Management Strategy
In all events, a prehospital strategy had to be developed to ensure effective management of the situation. This strategy most often relied on general guidelines and principles but had to be adapted to the situation.
Adapting the Standardized Plan to the Event
Successful prehospital MCI management required the determination of a clear prehospital strategy and its communication to all actors. Reference Hansen, Mikkelsen and Alstrøm14–Reference Idrose, Abu-Zidan and Roslan16 As situations developed over time, these strategies had to be regularly adjusted. Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15 Factors influencing the prehospital strategy included the estimated number of victims and their conditions, the location of the scene and of hospitals, logistical matters and the available resources, including staff and means of transportation. Several decisions had to be made based on these factors. A core component of the strategy was to get an effective flow of patients from the scene to the hospital, or designated points such as medical posts, for which there were several options. If the turnaround time for available ambulances was short, weather conditions were severe, or the scene was presumed too dangerous for on-site medical care, a strategy relying on the “load and go” principle was chosen. In such cases, medical treatment was not provided at the scene, but rather, in transit to the hospital, regardless of the standard plan or guidelines. Reference Hansen, Mikkelsen and Alstrøm14,Reference Jaffe, Wacht and Davidovitch21,Reference Maruhashi, Takeuchi and Hattori23 In other situations, the strategy was to gather victims for triage and care at the scene or at medical posts in safe areas before transferring them to hospitals. Reference Carli15,Reference Koning, Ellerbroek and Leenen24 Sometimes, it was necessary to keep ambulances on standby at short distances from the scene due to security risks or to avoid crowding at the scene. Reference Hansen, Mikkelsen and Alstrøm14 In other situations, infrastructural damage or adverse weather conditions forced the flow in certain unplanned directions, despite the original plan and most suitable hospitals. Reference Hansen, Jepsen and Mikkelsen20
Improvising
Even where general prehospital MCI management principles and guidelines existed, the complexity of the events and the presence of severe security issues required medical commanders’ quick decision making and improvisation. Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15,Reference Pasquier, Dami and Carron28 Some such decisions were to transport several patients in one ambulance Reference Hansen, Mikkelsen and Alstrøm14,Reference Jaffe, Wacht and Davidovitch21 or to use other means of transportation. Reference Hansen, Mikkelsen and Alstrøm14,Reference Pasquier, Dami and Carron28 Others involved abandoning the plan to use triage areas or medical posts due to security risks. Reference Carli15,Reference Idrose, Abu-Zidan and Roslan16 If the strategy was to immediately transport all patients to the hospital, the use of pre-planned key functions such as ambulance loading officers or triage officers could be omitted to reallocate manpower to increasing transport capacity. Reference Hansen, Mikkelsen and Alstrøm14
Efficiently Distributing the Injured
A question raised across events was how to best distribute the injured, considering both the prehospital and hospital situations. In most events, both uninjured and injured victims went from the scene to nearby hospitals without assistance from EMS. Such spontaneous evacuation started before the arrival of EMS. Reference Hansen, Mikkelsen and Alstrøm14–Reference Zhang, Wang and Fan17,Reference Hardy19,Reference Hansen, Jepsen and Mikkelsen20,Reference Hirsch, Carli and Nizard26,Reference Pasquier, Dami and Carron28,Reference Helou, El-Hussein and Aciksari29 In dangerous situations, such behaviors could be seen as a way of both saving oneself from the scene seeking medical care and were sometimes life-saving. Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15
Overall, EMS distributed patients in two main ways. The first was to transfer them to the nearest hospital, resulting in short ambulance turnaround times; however, this risked crowding in emergency rooms, especially if many victims had spontaneously evacuated there. Reference Jaffe, Wacht and Davidovitch21,Reference Choi, Lim and Cha25,Reference Gamberini, Imbriaco and Flauto27,Reference Helou, El-Hussein and Aciksari29 The other option was to transfer to hospitals farther from the scene. This required more ambulances due to the longer turnaround time, but gave the receiving hospitals more preparation time and allowed for fewer secondary transports. Reference Jaffe, Wacht and Davidovitch21,Reference Alpert, Assaf and Nama30 Regardless of the strategy, it was important to register and track where each patient had been sent. Reference Koning, Ellerbroek and Leenen24
Providing Prehospital Medical Care Beyond Everyday Routines
The studied MCIs required medical care somewhat different from routine care.
Extracting Victims and Providing Care Under Severe Threats
Some of the events required civilian EMS not only to provide medical care but also to safely extract victims from danger zones. This necessitated close cooperation with the police and military; one strategy was to form a secure corridor, protected by armed police or soldiers, from the scene of the event to an ambulance collecting point. Reference Hansen, Mikkelsen and Alstrøm14 In other situations, injured persons were sheltered in places protected by the police, unable to move. Reference Carli15 These cases illustrate that EMS personnel sometimes have to assist in both dangerous extractions and provide care under fire. Reference Carli15,Reference Jaffe, Wacht and Davidovitch21,Reference Alpert, Assaf and Nama30
Providing Services Beyond Traditional Prehospital Medical Care
In most events, natural triage (ie, the on-scene death of victims with severe injuries) was high, and medical interventions were limited to clinical assessment, triage (often “eyeballing triage”), and treatment of minor injuries. Reference Carli15,Reference Idrose, Abu-Zidan and Roslan16,Reference Hardy19,Reference Hansen, Jepsen and Mikkelsen20,Reference Maruhashi, Takeuchi and Hattori23,Reference Gamberini, Imbriaco and Flauto27 However, in some, interventions were performed to stop severe hemorrhaging (eg, tourniquets or wound packing) or to provide intravenous analgesics. Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15,Reference Maruhashi, Takeuchi and Hattori23,Reference Hirsch, Carli and Nizard26 Some events required the use of “ad-hoc” triage systems or treatment guidelines due to the nature of the medical conditions. Reference Pasquier, Dami and Carron28 An important aspect of prehospital medical care was to ensure the maintenance of ethical principles and to provide quality care for all victims, including suspected perpetrators, even under severe circumstances. Reference Carli15
Following an event, prehospital EMS also involved providing victims and their relatives with care and services other than life-saving aid (eg, treating minor injuries or assisting with psychological support). Reference Hansen, Mikkelsen and Alstrøm14,Reference Idrose, Abu-Zidan and Roslan16,Reference Hansen, Jepsen and Mikkelsen20 Victims who had received medical care at the scene but were directly discharged therefrom required information about their clinical conditions and more extensive advice about self-care in everyday situations. Reference Pasquier, Dami and Carron28 Where victims had to remain at the scene or in collecting areas for extended periods of time, EMS personnel, with the help of local authorities, had to provide food, water, and shelter. Reference Hardy19 They were also required to orient family members who arrived at the scene looking for their loved ones. Reference Koning, Ellerbroek and Leenen24 They thus had to prepare for such duties, most often in close collaboration with the police and local authorities.
Ensuring Endurance and Resilience
Strategic EMS management was the main challenge to ensuring an enduring and resilient response. Constant strategic revision of the situation was essential to making adequate operational decisions. It was important for the prehospital incident commander and the strategic commander to be aware that their situations most likely differed due to their different perspectives and information sources, and therefore to prioritize regular information sharing. Reference Hansen, Mikkelsen and Alstrøm14
Planning for a Long-Lasting Prehospital Response
Most events required the presence of EMS for hours after the initial alarm. In the reviewed events, EMS presence ranged from four-and-a-half Reference Maruhashi, Takeuchi and Hattori23 to five, Reference Koning, Ellerbroek and Leenen24 eight, Reference Zhang, Wang and Fan17 or ten hours. Reference Hardy19 It was important not to withdraw prehospital resources too soon, as victims could be found during repeat sweeps of the scene. Reference Hansen, Mikkelsen and Alstrøm14 Since most events lasted several hours, the need for food and refreshments for both victims and EMS personnel had to be addressed within a few hours of the start of the event. Reference Hansen, Mikkelsen and Alstrøm14,Reference Hardy19 Even where emergency care was completed, response activities such as victim identification were on-going, sometimes requiring medical backup. Reference Jaffe, Wacht and Davidovitch21
Balancing Resources
Everyday emergencies do not cease when MCIs occur. In one case, only 40% of the day’s EMS calls were related to the MCI. Reference Jaffe, Wacht and Davidovitch21 Therefore, strategic prioritization of how to use the available EMS resources to increase the response capacity was challenging. It likewise had to be decided early whether to assign all available ambulances to the incident or to hold some back in case of multiple-site or time-staggered incidents. Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15 A common strategy was to request additional EMS resources from other parts of the country as backup or in response to unrelated emergency calls. Reference Hansen, Mikkelsen and Alstrøm14,Reference Carli15,Reference Clancy, Christensen and Cortacans31 In foreseeable events, such as weather-related events, such preparations were possible to do before the event. Reference Clancy, Christensen and Cortacans31 The need for secondary transport, which could emerge during or after the event and last for several days, Reference Alpert, Assaf and Nama30 also had to be weighed against regular emergency calls.
Promoting Resilience among Prehospital Responders
Since the reviewed MCIs required unusual and demanding effort from all EMS personnel involved and lasted several hours or days, actions to promote resilience among EMS personnel were important. Reference Hansen, Mikkelsen and Alstrøm14,Reference Hansen, Jepsen and Mikkelsen20,Reference Jaffe, Wacht and Davidovitch21,Reference Alpert, Assaf and Nama30,Reference Clancy, Christensen and Cortacans31 Examples of such actions included pre-deployment briefings for incoming personnel, Reference Carli15,Reference Clancy, Christensen and Cortacans31 the provision of food and water during deployment, Reference Hansen, Mikkelsen and Alstrøm14,Reference Hardy19 and the implementation of clear stand-down strategies for EMS personnel at the end of their shifts and beyond. Reference Hansen, Mikkelsen and Alstrøm14,Reference Clancy, Christensen and Cortacans31 Such strategies included short, technical post-action reviews, the monitoring of EMS personnel’s well-being over a period of three weeks to three months after the event, and the provision of professional individual psychosocial support. Reference Hansen, Mikkelsen and Alstrøm14,Reference Hansen, Jepsen and Mikkelsen20,Reference Jaffe, Wacht and Davidovitch21
Discussion
This review demonstrates that common challenges in prehospital MCI management include issues related to the safety and security of both victims and responders; the development and communication of situational awareness; the application of a prehospital response strategy; the delivery of care under severe circumstances; and the need for extended strategic EMS management.
Several of the reviewed events entailed security issues for both victims and responders. Previous studies have shown a need for better mental and educational preparation for EMS personnel to act in insecure environments. Reference Stendahl, Rollgard and Behm32 Some of the reports also suggested adapting a tactical medicine mindset within civilian EMS. Reference Jaffe, Wacht and Davidovitch21,Reference Carli, Pons and Levraut22,Reference Hirsch, Carli and Nizard26 Such suggestions, along with the fact that EMS sometimes have to face severe security issues, might engender ethical dilemmas concerning the balancing of personal risks against professional responsibilities and what “acceptable risks” really means. Reference Egodage, Doucet and Patel33 These matters deserve both scientific and clinical attention. Future research and clinical discussions should therefore focus on the matters of training prehospital incident commanders and strategic EMS officers to assess security risks and use strategies to reduce them; mentally preparing responders for these situations; and discussing what, from a clinical and ethical perspective, “safe enough” means in the context of an MCI.
Creating and communicating accurate situational awareness was another common challenge. The ability to maintain appropriate situational awareness has been identified as an essential competence for incident manager. Reference Hayes, Bearman, Butler and Owen34 A core component of the Endsley situational awareness theory is to comprehensively interpret the meaning of the event and try to project its consequences onto a near future. Reference Endsley35 The present review supports this idea, also reported in other studies on crisis incident management, Reference Hayes, Bearman, Butler and Owen34 and emphasizes that the prehospital incident commander must be able to analyze longer timeframes and think ahead of the current situation. This requires both a broad medical knowledge and analysis skills. A central part of the situational awareness is the estimation of numbers of victims and injures. Reports on casualty counts have traditionally been essential to information sharing between prehospital scenes, hospitals, and strategical management levels. However, determining the exact number of victims, considering, in particular, spontaneous evacuation, has proven difficult or even impossible in an MCI’s early stages. The incident commander’s immediate impression and “gut feeling” may therefore be more efficient than exact numbers, especially in the first stage of the event management. Reference Rimstad and Sollid36 Technical solutions such as drones or artificial decision-making tools were not mentioned in any of the cases. Such solutions may be supportive, but their potential contributions to establishing situational awareness cannot be determined in this study and is a question requiring scientific attention. Also, it is well-known that communication failure is common in the prehospital response to terrorist attacks, with regards to technical systems, overwhelmed communication services, failure due to damaged infrastructure, and by lack of training. Reference De Cauwer, Barten, Willems, Van der Mieren and Somville37 This should also be taken into consideration when planning for information flow and information needs in other types of MCI.
A question raised by the present study is what kind of training should be required for EMS personnel and prehospital incident commanders. The infrequency with which MCIs occur makes it difficult for EMS personnel in general, and prehospital medical incident in particular, to improve their management skills in real-life situations. Therefore, learning from others’ experiences may be a successful alternative. Reference Rimstad and Sollid36 Challenges related to communications, leadership, logistics, and resource management are frequently reported in “lessons learned” MCI reports. Reference Donahue and Tuohy38 In this study, most of the reported challenges were related to management skills, such as improvisation and situational analyses, rather than to the medical treatment of individual victims. This underscores the need to integrate medical mass-casualty knowledge with common, general incident management skills to improve the effectiveness of prehospital MCI management. The gap between the training and real events is also considerable Reference Hugelius, Edelbring and Blomberg39 and it is essential that MCI training relies on real-life experiences and evidence rather than on exercises or simulations. Reference Westman, Kurland and Hugelius40 Further studies on how to prepare EMS personnel and prehospital medical incident commanders for the dynamics and the complexity of real prehospital MCIs is therefore needed.
Limitations
There is a general need for evidence- and experience-based information on prehospital MCI management. Reference Turner, Lockey and Rehn41 Using case reports to build such evidence is a method accepted within evidence-based medicine. Reference Murad, Sultan and Haffar42 The systematic integrative review method enables systematic synthesis of both qualitative and quantitative data. Reference Whittemore and Knafl12 It was therefore considered suitable to the present study. Despite a structured search across four databases, it cannot be excluded that other or more reports were available. Also, the reports’ formats varied widely. It has been suggested that uniform MCI reporting and population-based studies would facilitate progress in research. Reference Turner, Lockey and Rehn41,Reference Castro Delgado, Naves Gómez, Cuartas Álvarez and Arcos González43 Many reports focus solely on describing injuries or medical conditions, and few report on prehospital management as such. Since medical outcomes are closely related to incident management, it is important to build further evidence incorporating both medical and management science. Reference Tranfield and Smart44 This review was not pre-registered, since the study participants were not human.
Conclusion
Resilient prehospital MCI response demands both a clear strategy and improvisation and should be integrated into the overall medical response strategy. Responders must understand the main concepts of prehospital MCI management, have a situational awareness that foresees the event’s medical consequences, and have the experience required to interpret the situation in both a short-term and a longer perspective. Emergency Medical Services personnel and medical incident commanders require specific training and mental preparation to be able to provide care under severe security threats, to improvise beyond routines and guidelines, and to provide care in ways different from their everyday work.
Author Contributions
KH: Conceptualization and design; literature search; quality appraisal; analysis; writing and editing of manuscript. JB: Quality appraisal; analysis; writing and editing of manuscript. Both authors approved the final manuscript.
Conflicts of interest
The authors declare none.
