As we discussed in part 1, the ICS is a standardized approach to the command, control, and coordination of on-scene crisis management ( This approach provides a common hierarchy where personnel can be integrated across health care systems (Mayo Clin Proc 2020;95:S3-S7).

The following characteristics are the foundation of ICS and contribute to the reproducibility and efficiency of the approach (

  • Common terminology: The National Incident Management System establishes common terminology to support cooperation and ensure understanding between various agencies.
  • Modular organization: ICS’ organizational structures develop in a modular fashion based on an incident’s size and complexity.
  • Manageable span of control: Efficient operations maintain an appropriate span of control. One supervisor to five subordinates defines the optimal span of control; however, this ratio may vary depending on the circumstances of the crisis.
  • Establishment and transfer of command: The incident commander should be established at the start of an incident. Command transfer must include a situation briefing that captures essential information for continuing safe and effective operations.
  • Unified Command: Unified Command may be established when no one jurisdiction, organization, or agency has the primary authority or the resources to manage an incident completely independently. There is no one “commander” in Unified Command. Instead, Unified Command manages the incident by jointly approved objectives.
  • Chain of command and unity of command: Chain of command refers to the hierarchical ranks of the incident management organization. Unity of command means that each individual reports to only one person. This clarifies the reporting relationships and reduces confusion caused by multiple, conflicting directives.
  • Accountability: Incident personnel should not waiver from principles of accountability. These include incident action planning, unity of command, personal responsibility, span of control, check-in/check-out, and resource tracking.

Buffalo General Medical Center is one of western New York’s major hospitals. Buffalo General shares an emergency department designed to accommodate more than 60,000 patient visits each year, a helipad, 610 beds, 28 ORs, 17 interventional procedure labs, four CT scanners, and four MRI machines with the adjacent Gates Vascular Institute. Given the proximity to Buffalo’s major traffic thoroughfares and high-capacity downtown venues, including a convention center and two high-volume sports venues, Buffalo General would be a major health care access point for a mass casualty event.

We have created an anesthesia organizational structure for Buffalo General, in line with ICS principles, during a mass casualty event (Figure). Under a hospital incident commander, an anesthesia chief would establish control of four anesthesia divisions: preoperative, postoperative, Buffalo General ORs, and Gates Vascular ORs. The preoperative division will consist of an ER liaison to coordinate patient flow into surgery, a holding area for an anesthesiologist to care for patients awaiting surgery, and an anesthesiologist to provide anesthesia outside of the ORs. The postoperative division will consist of a postanesthetic care unit (PACU) anesthesiologist and an ICU attending. The Buffalo General OR and Gates Vascular OR divisions will delegate OR anesthesia care into manageable teams.

It’s a snowy Thursday in Buffalo, with lake effect snow conditions worsening throughout the day. You are the anesthesia coordinator at Buffalo General. The day has been fairly light with many elective surgery cases canceled due to patients avoiding travel. You anticipate the overnight call to continue to be quiet enough to watch the Bills game.

At 4:35 p.m., you receive a frantic phone call from the ER notifying you of the activation of the mass causality protocol. Poor road conditions and low visibility have resulted in a massive multi-car pileup involving as many as 50 vehicles, including two buses. The hospital is expecting 30-45 patients by ambulance in the next two hours. Following established protocols, a command center is established with the hospital’s emergency coordinator becoming hospital incident command. The senior anesthesiologist is appointed anesthesia chief to oversee all anesthesia and perioperative care during the mass casualty event and report directly to hospital incident command. You are asked by the anesthesia chief to lead the Buffalo General OR Division.

As Buffalo General OR Division Lead, the first step is to report the needs and abilities of your team to the anesthesia chief. A quick assessment of the current OR status shows four out of 16 ORs in use. All rooms are staffed with either an anesthesiology resident or CRNA with five anesthesiologists in-house. There are two add-on cases scheduled; neither are emergent or urgent. The anesthesia chief states there are available staff to operate an additional two ORs at this time and on-call staff available within 30 minutes.

Patients begin arriving by both ambulances and private vehicles. Ground ambulance units are unavailable for interhospital transfers due to a surge in 911 calls compounded by weather conditions prolonging transport times. Helicopter ambulance units are grounded due to difficult flying conditions. After selecting an anesthesia team member to serve as the liason between the emergency department and the surgical teams in assessing surgical needs, you are informed of two patients needing emergent surgery; one with a subdural hematoma and the other with abdominal bleeding.

With the arrival of on-call staff and coordination with the OR charge nurse, you now have enough resources to open four ORs. You designate a cluster of four ORs in close proximity to one another for the first wave of patients requiring surgery. You assign an anesthesia extender (fellow, resident, or CRNA) to each room. You call this “Buffalo General Team A.” You also appoint an anesthesiologist as “Buffalo General Team A Lead.” Anesthesia providers within these ORs will make their needs known to Team A Lead, and Team A Lead will relay any necessary information directly to you. The two emergent cases are taken back for surgery, and the remaining two ORs are reserved for future emergent use.

As enough staff arrives for an additional four ORs, seven patients arrive requiring emergent surgery. The two most urgent patients are sent to Team A. You assign anesthesia providers to another cluster of four ORs, label them “Buffalo General Team B,” and appoint a Team B Lead. The next four most emergent cases are taken back for surgery, while the ER staff work to stabilize the final emergent case until an OR becomes available. As seen, the command structure can be expanded to meet the needs of the crisis. This structure will allow you to maintain a manageable span of control by having only one direct report for every four ORs.

Two additional anesthesiologists arrive at the hospital. The first anesthesiologist will lead the four ORs in use before the mass casualty activation, titled “Buffalo General Team C Lead.” Similar to the other leads, this lead will be kept apprised of case updates and OR availability. The other arriving anesthesiologist will serve as a Postoperative Division Lead. This individual will work with PACU, ICU, and surgical floor staff to streamline the outflow of patients to their appropriate location.

At 7 p.m., the last patient from the accident arrives in the ER, but you will be working well into the night. You eventually expand to four OR teams and have a maximum of 16 ORs in simultaneous use. At midnight, you scale down to eight ORs in use and you begin to release staff. At 4:30 a.m., the last case finishes. In total, you have managed to provide operative care for 21 emergent trauma patients. Although the initial surge is finished, more work is required. Non-urgent cases from the crisis are scheduled in the OR starting first thing tomorrow.

A version of the above-described events can happen in any hospital. If you replace the snowstorm with a flash flood, earthquake, or tornado, you still have an emergency mass casualty event that needs a rapid, systematic response to save lives. I encourage every reader to sit down with their teams and brainstorm how they will respond to emergency events within their hospital. The time to construct a plan is not at the moment disaster strikes. Be prepared, save lives, and ensure your response to a mass casualty is something to write about!