Civil Unrest

Background Information


*If staff is limited, a single hospital administrator can fill all three roles. 

Incident Commander- If available, a hospital administrator would ideally assume the role of the Incident Commander. Depending on ED/Hospital staffing, the ED medical director or lead attending physician could fill this role. Additionally, this person could be the same person as the Operations Section Chief. This person should delegate responsibilities to Section Chiefs and disseminate information obtained by the EMS liaison. They should also coordinate call-in of off-duty healthcare providers and providers from other areas of the hospital, as needed.

EMS Liaison- The EMS Liaison should relay information from in-bound ambulance and area 911 dispatch centers to the incident command and operation section. In times of limited staffing, this role could be also filled by the Operations Section Chief.

Operations Section Chief- This position would ideally be filled by a lead RN or attending physician. This person should coordinate the management of patients entering the emergency department by delegating tasks of Triage, Decontamination and Treatment to respective Group Supervisors. Healthcare providers should report directly to this person to receive their tasks. 

Triage Group Supervisor- This person, ideally the most senior physician, should triage incoming patients and place them into appropriate areas of the ED based upon their condition. They should delegate a transport team to help bring patients to the correct area designated for different level of injuries. 

Transport Team- A group of providers or other ED staff (who need not be healthcare workers) who can help move patients to areas based upon their injury severity. 

Treatment Group Supervisor- This person, ideally a physician, should coordinate the medical management of triaged patients, in the order of their severity. They should group providers into small teams to manage patients geographically.

            Non-ER providers- This group of physicians can be any available off duty non-ER trained providers that the operations chief can call on during an MCI. This group should be assigned to treat patients with less to moderate injuries. Auxiliary spaces such as parking lots and in-patient units can be utilized. 

            Trained ER providers- This group of physicians should be assigned to treat patients with severe and life threatening injuries directly in the ED. 

**If staff is limited residents and interns should tend to the less and moderate injuries. More experienced providers and residents should be assigned to the more life-threatening and severe injuries. 

Decontamination Group Supervisor- This person, who should be trained in hospital chemical decontamination techniques, should lead the decontamination of patients who require it, prior to entering the ED.

Logistics Section Chief- The role should be filled by a person in a role consistent with managing the logistics of the ED (such as hospital supply, facilities or support leadership). If needed, this role could also be staffed by the Operations Section Chief or other available personnel. They should coordinate the acquisition of appropriate supplies and equipment needed. Non-healthcare workers should report directly to this person to receive their tasks.

Security Group Supervisor- This person, from security leadership ideally, should coordinate the placement of security to both externally and internally protect the hospital. 

Hospital Staffing Considerations:

  • Perform early trauma team notification, and notify on-call staff as situation requires.
  • Consider notification of vascular surgery and interventional radiology if not already included in trauma team activation.
  • Consider notification of transport services for emergent transfers, if at non-trauma facility.
  • Increase security staffing
  • Consider utilizing non-security personal for some security tasks such as traffic direction and supervision of hospital entrances.
  • Consider requesting local law enforcement for hospital security, however, do not rely on these personnel, as they may be preoccupied with management of the civil unrest in the community.

EMS Staffing Considerations:

  • Perform early up-staffing of additional ambulances 
  • Consider utilization of mutual aid resources
  • In the event of a mass casualty event, consider dispatching of buses or other means of transporting large numbers of patients.



  • Protection of the hospital staff and property from violent agitators is of upmost importance.
    • Be prepared for external and internal protection as well as total facility lock down.
  • Security and crowd control are specifically important in triage, decontamination and treatment areas.
    • Consider separate treatment areas for the public and for those involved in the civil unrest.
  • Be prepared to manage large numbers of visitors, injured protestors, and their personal effects.
    • Also be prepared to handle increased numbers of persons in police custody.


  • Don appropriate PPE, including APR/PAPR with riot agent canisters, or customary PPE used by receiving healthcare workers.
  • Focus on preventing further contamination of the patient and secondary contamination of healthcare workers.
  • Perform decontamination prior to entering the main Emergency Department.
    • e.g. in the field (by EMS), or in designated hospital decontamination areas.


Identify areas for:

  1. Triage
    • Set up triage outside of the ED (such as the parking lot) to immediately assist in controlling the flow of patients and resources in the ED 
      • Assign a senior doctor exclusively to triage duty 
  2. Decontamination
    • Designate area for clothing removal and proper disposal
    • Occur on site of incident or outside of emergency department/hospital
  3. Treatment
    • Most severely injured patients are brought into the ED to start treatment immediately. 
    • The less injured victims should be directed to other areas of the hospital
  • Another area of the hospital should be sectioned off to increase capacity such as outpatient surgery units and PACU.
  • Canceling elective surgeries promptly 

Consider separate treatment areas for the public and for those involved in the civil unrest.