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Emergency Preparedness and Response for Mass Casualty Incidents

A mass casualty incident is defined as “an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time.”

Mass casualty incidents can occur from causes such as:

  • Violence, such as mass shootings
  • Chemical, biological, or radiological events
  • Extreme weather or natural disasters, such as tornadoes, floods, and wildfires
  • Transportation incidents, such as multi-vehicle car crashes and train collisions

Mass casualty incidents can be referred to as conventional or catastrophic. Conventional mass casualty incidents occur with somewhat regular frequency, such as large vehicular crashes or severe weather events. Catastrophic mass casualty events are less common. These include incidents and health events from a major explosion, natural disaster, or nuclear detonation.

Mass casualty incidents in rural areas often occur without warning, garnering the name “no notice” events or incidents. In any community, but particularly in rural communities, mass casualty incidents have the potential to quickly exhaust the resources available for a response. The Administration for Strategic Preparedness and Response (ASPR), Technical Resources, Assistance Center, and Information Exchange (TRACIE) has developed a series of tip sheets to support no-notice incident planning and response.

Planning for Mass Casualty Incidents

There are several key considerations for healthcare providers and emergency medical services (EMS) in rural areas related to planning and preparing for mass casualty incidents. Although mass casualty incidents are often unpredictable, emergency preparedness efforts can help mitigate injury, death, and trauma resulting from the event.


Ongoing training for mass casualty incidents and regular practice drills can help prepare first responders and hospital personnel for the “chaotic atmosphere” of a mass casualty incident. Public education, such as the Stop the Bleed Program, provides opportunities for physicians and first responders to teach the public how to assist in a bleeding emergency before first responders arrive at the scene. Staff and personnel should be pre-trained to deliver “just-in-time training” to bystanders and spontaneous volunteers who may arrive at the scene of a mass casualty incident.


In case of a mass casualty incident, communities should ensure access to necessary equipment and supplies. EMS and other first responders should be properly stocked with trauma bags, tourniquets, tarps, triage tags, boundary tape, and medical supplies. In addition to medical equipment and depending on the type of mass casualty incident, first responders will likely need personal protective equipment (PPE). Other types of equipment to consider include technology and communication equipment, such as internet-connected devices and radios; physical space and equipment for triage and emergency operations centers, such as desks and lighting; and backup equipment and infrastructure, such as generators.

Triage System

Rural EMS and hospital systems, especially emergency departments, should develop a triage system to ensure that in the event of a mass casualty incident the most severely injured victims can be identified and transported to the appropriate facility in a timely manner. As part of triage planning, rural communities may consider establishing fully staffed mobile triage centers. Mass casualty preparedness should also include the development of a patient tracking system and protocols for communicating between the accident scene and nearby hospitals.


In rural communities, response may be delayed following a mass casualty incident due to long transportation times for first responders, challenges with communication and access, and limited resources such as ambulances and personnel. Establishing regional partnerships prior to an incident is key to a successful response and helpful for ensuring coverage across the region. Partner organizations can provide support to the local response team by setting up command tents, transporting the deceased from the scene, bringing in support staff, or supplying temporary cellular infrastructure. For more information on partnerships, see Partners and Collaborators for Emergency Preparedness and Response.

Case Study

AUGMENT Tele-ED/EMS Supporting Rural Emergency Rooms and Emergency Medical Services in Vermont
This project uses a telehealth hub-and-spoke model to create capacity and access to healthcare services in rural Vermont, with the ultimate goal of being able to assist in a mass casualty incident. It facilitates communication among emergency management physicians within emergency departments, along with EMS agencies in the field.

Responding to and Recovering from Mass Casualty Incidents

Surge Capacity

During a mass casualty incident, rural health systems can quickly exceed capacity. Clinicians must quickly shift into a disaster mindset to “do the most good for the greatest number of patients.” Within healthcare facilities, staff and specialty healthcare providers may take on non-traditional roles to support patient surge. For more information on surge capacity, see The Role of Public Health and Health Systems, Facilities, and Providers in Emergency Preparedness and Response.


During a mass casualty response, there are many key players and partners that need to stay aware of the situation as it develops. Community leaders and partners such as EMS, healthcare personnel, public health officials, law enforcement, and government agencies must be in regular communication. Hospitals may use mass notification systems to communicate within the hospital system. In addition, interfacility communication is critical for coordinating across healthcare facilities. Community leaders should establish plans for alternative means of communication, like walkie talkies or pagers, in case cellphone coverage is unreliable. For more information on crisis communications, see Public Safety and Crisis Communication in an Emergency or Disaster.

Following a mass casualty incident, local and regional media services can be especially useful for keeping the public informed and preventing the spread of misinformation. However, it is possible that the high volume of media activity may overwhelm cellular communications in a rural area. It is also possible that the mass casualty incident results in communications infrastructure failure. In these situations, communities should be prepared to set up temporary infrastructure to maintain cellular communication. Portable cell towers, called cells on wheels (COWs), can be rented or purchased to make up for a lack of signal.

Mental Health, Social Services, and Family Support

In the aftermath of a mass casualty incident, healthcare facilities might establish Family Assistance Centers (FACs) to support survivors and their families. A hospital, in partnership with the jurisdiction, may establish a temporary Family Reception Center (FRC) within hours of the incident, which will be transitioned into a more established FAC within a couple days. FACs provide a “one-stop shop” for mental health support, spiritual care, law enforcement, and information on victims' rights. FACs can offer support from social workers, counselors, and support groups as well as food and water for families and victims while they wait for updated information about their loved ones.

Mass casualty incidents can also take an emotional toll on hospital staff and first responders. Hospitals should develop recovery assistance plans to ensure that staff have the support they need after a mass casualty incident. Psychological First Aid is a strategy for reducing distress and supporting long-term coping after a traumatic event. For more information, see Mental and Behavioral Health Considerations in Emergency Preparedness and Response.

Relevant Case Studies

A Mass Shooting in a Small Texas Town Shows the Importance of a Coordinated, Team-Based Response
In November 2017, a man entered a small Baptist church in Sutherland Springs, Texas, and opened fire on the congregants inside, killing 26 people and wounding at least 20 more. In response, the District 1 Fire and Rescue — a member of Wilson County's emergency services system — along with its volunteer emergency medical service (EMS) partner were paged for a possible shooting at first dispatch, which was soon updated to a mass shooting. All other emergency services in the county were soon dispatched to assist. By operating as a team with other responders, District 1 Fire and Rescue was able to adequately respond to the needs of the community in the moments following this disaster.

First Responders to a Hot Air Balloon Crash in Caldwell County, Texas, Use All-Hazards Response Framework for Mass Fatality Event
In July 2016, a hot air balloon crashed in rural Maxwell, Texas. This tragic mass fatality event killed all 16 people aboard, including the captain. When first responders arrived, the scene was in flames. The Caldwell County Office of Homeland Security and Emergency Management initiated a coordinated, all-hazards response in collaboration with outside agencies to manage the scene and recover the victims' remains. The Caldwell County community was significantly impacted by this event, prompting local emergency management leaders to delegate special attention to the mental health needs of the first responders and the victims' families.

Passenger Train Derailment in a Remote Area of Montana Leaves 3 Dead and Scores Injured: Liberty Medical Center in Chester, MT, Coordinates Triage and Treatment in a Regional Response
When a passenger train derailed in a remote section of north-central Montana, resulting in 3 deaths and many injuries, the nearby rural communities leapt into action. Liberty Medical Center and its community, Chester, Montana, acted as command central for triage and treatment, including coordinating the transfer of some patients to higher levels of care throughout the region. Although they incurred barriers such as mobile victims, a large crash area, and some communication hitches, they also were reminded of what they already knew: that when they are called to action, rural people show up and find a way.

Mass Casualty Incident Occurs when Duck Boat Sinks in Rural Missouri – Local Fire Protection Districts Lead Response and Recovery
In July 2018, during a severe thunderstorm, a duck boat capsized and sank in Table Rock Lake in rural Missouri. The boat was at capacity with 31 passengers; 17 people lost their lives. The Southern Stone County Fire Protection District (SSCFPD) led response efforts and received support from the Western Taney County Fire Protection District and other organizations through mutual-aid agreements and cooperation. Notably, SSCFPD learned the importance of securing the scene, holding a Critical Incident Stress Debriefing (CISD) within the appropriate timeframe, and striking the balance between being transparent with the public and being careful about communicating sensitive information internally.

Tour Bus Carrying 30 Chinese Nationals Crashes Near Bryce Canyon, Utah – Local Critical Access Hospital Helps Lead Response to Mass Casualty Incident
In September 2019, the driver of a tour bus heading to Bryce Canyon National Park in Utah lost control of the vehicle, causing a rollover crash in a remote area several miles from the park entrance. The bus was carrying 30 Chinese nationals at the time. Four passengers were killed in the crash, and all the surviving passengers sustained injuries, most of them severe. First responders were on the scene within minutes to triage victims and transport them by ambulance or by air to medical facilities for treatment. As the nearest medical provider, Garfield Memorial Hospital (GMH) in rural Panguitch, Utah, played a pivotal role in the emergency response. GMH, a 25-bed Critical Access Hospital, treated 19 of the crash victims. While the emergency stretched the hospital's capacity and presented multiple challenges, including the significant language barrier between patients and staff, the hospital provided an organized and coordinated response that contributed to successfully treating the patients and limiting loss of life.

Resources to Learn More

Mass Fatalities Planning and Response for Rural Communities: Participant Guide
Offers an awareness-level training course for rural communities planning for and responding to mass fatalities on topics including roles and responsibilities, asset management, diversity issues, and developing a mass fatality plan.
Organization(s): Federal Emergency Management Agency (FEMA)
Date: 8/2012

Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary
Provides case studies and lessons learned from historical mass casualty incidents in rural areas.
Organization(s): Institute of Medicine
Date: 2011