– Voltaire

For years, wildfires along the west coast of the United States have threatened public safety and led to loss of life, property, and natural resources. From these disasters, the U.S. Forest Service formed fire suppression crews to combat the infernos. An early example of these crews was the El Cariso Hotshots, formed in 1947 (USDA Forest Service Fire Management 1974;35:14-7) and known for their speed and skill under austere conditions. Despite their tenacity and skill, however, 12 of their team members were lost in the 1966 Loop Fires (asamonitor.pub/3Bnbkxq). By 1970, the destruction of the California wildfires had reached its peak and overwhelmed all efforts. Following a disastrous wildfire season, after-action review uncovered glaring issues. Individuals involved on the ground voiced confusion around the organizational structure, terminology, resource allocation, and the operating procedure that was utilized at the time of the crisis.

The U.S. Forest Service underwent a candid self-assessment and reached the conclusion that poor communication and organization had a far greater impact on the outcome than insufficient resources. Congress responded by funding the development of an improved system for wildland firefighting. In 1972, FIRESCOPE Task Force was formed with the primary goal of ensuring seamless coordination between different agencies responding from multiple jurisdictions (asamonitor.pub/3BkO5El). However, shortly after its roll out, it became apparent that strong central coordinating for their tactical field operations and incident management was lacking.

From the ashes arose the incident command system (ICS), which became the gold standard in the management of occurrences such as a mass casualty event. ICS was developed to manage the chaos of emergency incidents, provide effective communication, ensure accountability, and optimize available resources. FEMA defines ICS as: “a standardized approach to the command, control, and coordination of on-scene incident management that provides a common hierarchy within which personnel from multiple organizations can be effective” (asamonitor.pub/3HRxkD2).

ICS uses a modular organization that permits a flexible response to a wide variety of mass casualty events. It is not a rigid blueprint, but an organizational system designed to expand or contract with changes in size or complexity of a mass casualty event. As the number of patients and complexity of the response grows, the incident commander expands the system to accomplish the challenges they encounter.

“As physicians accustomed to dealing with emergency situations and adept at making quick treatment decisions, we possess the knowledge and skills necessary to lead in a crisis situation. We are also the critical interface between our partners in nursing and surgery, uniquely able to understand the strengths and weaknesses of our teams and the system overall.”

A mass casualty event can be large or small, urban, suburban, or rural. The ICS offers a coordinated response that integrates resources within a common organizational structure. ICS clarifies chain of command. It provides plain and common language to improve communications and fosters cooperation between diverse disciplines and agencies (asamonitor.pub/34GTrxL).

So why should we care? In a 2017 multicenter survey of anesthesiologists and anesthesia residents, the majority reported inadequate education and training in a mass casualty event (Anesth Analg 2017;124:1662-9). This defect highlights the need for further education. In an effort to address this gap in knowledge, The ASA Committee on Trauma and Emergency Preparedness published an OR Mass Casualty Checklist (asamonitor.pub/3JuYFeF). While this document lists many objectives that need completion, it does not provide an organizational framework to accomplish these goals in the perioperative setting. The more important reason we need to care about ICS is for our patients. When crisis situations arise, we are often at the epicenter of the event. We can have a profound impact on stabilizing a volatile situation and save lives.

In an event such as a mass casualty, our primary impact can be the decompression of the emergency department and providing a smooth pathway into the operating suites. In utilizing ICS, we can provide an organizational structure to expedite surgical interventions and save lives. Stated simply, ICS works. Over 30 years, ICS has been successfully deployed by professionals across a range of incident types. It is an effective management strategy that is scalable and adaptable for emergencies of almost any size. You can manage a blizzard in Buffalo, a mass shooting in Las Vegas, a Category 5 hurricane in Houston, or an industrial explosion in Beirut. An opportunity exists for anesthesiologists to become proficient in this life-saving operational strategy.

The need to become proficient at this operational strategy does not only result from our desire to care for patients, it comes from regulatory requirements. Congress empowers the Centers for Medicare & Medicaid Services (CMS) to regulate health care. CMS relies on the Federal Emergency Management Agency (FEMA). And FEMA relies on ICS. In 2017, CMS made enforceable their final Emergency Preparedness Rule. This rule empowers entities like The Joint Commission to audit hospitals for compliance, offer incentives, or impose penalties. If hospitals do not follow regulations, they can expect to lose their funding. The loss of this critical financial support could spell the end of health care systems in an already stressed environment.

The necessity to care for patients in a crisis, regulatory requirements, and the skill set unique to anesthesiologists has placed our specialty in a position to lead change in this critical arena. As physicians accustomed to dealing with emergency situations and adept at making quick treatment decisions, we possess the knowledge and skills necessary to lead in a crisis situation. We are also the critical interface between our partners in nursing and surgery, uniquely able to understand the strengths and weaknesses of our teams and the system overall.

Our current operative model is geared toward optimizing system resources. Our anesthesiology coordinators must offer scheduling flexibility for surgeon convenience but be available to answer any emergency case that presents to the OR. This routine model for OR “stretch” can be quickly over-burdened. Imagine you are coordinating the OR schedule when a mass casualty event occurs. In facing the crisis, you must not only manage the cases within your ORs, but you must determine which resources you have and will need to successfully manage the crisis you are facing. If you take this a step further, imagine the event happens at a time when you have minimal staffing, such as on evenings, weekends, or holidays. How many emergent surgical patients would it take to overwhelm your immediate staffing resources? How will you mobilize, organize, direct, and communicate during these critical situations? ICS is the answer.

ICS is the gold standard used by all emergency medical service, law enforcement, and fire agencies in the US as mandated by FEMA to receive federal funding (asamonitor.pub/34GTrxL). CMS requires all hospitals to develop an emergency plan that is coordinated with those agencies (asamonitor.pub/3gPJReg). However, current plans are limited in their scope to pre-hospital and emergency room management. OR management of these incidents is often only briefly mentioned. This provides a unique opportunity to expand our scope of practice as anesthesiologists and learn from the experts in emergency preparedness. ICS can optimize OR efficiency and resource utility during a mass casualty event and be easily integrated into the systems currently in place. It is time for anesthesiologists to embrace the battle-proven incident management system developed by the U.S. Forest Service and take our rightful place as leaders in mass casualty event management.