1. An Overview in Mass Casualty Incident (MCI) Operations and Triage
MASCAL
An Overview in Mass Casualty Incident (MCI) Operations and Triage

2. Purpose To familiarize personnel with: the triage process
the organization and conduct of MASCAL Operations
Purpose

3. MASS-CASUALTY SITUATION: used to describe a situation in which the number of casualties exceeds the hospital's capabilities to provide medical care.
Maybe one patient maybe 20…question is have we exceeded our ability to provide medical care
MASCAL

5. Possible Scenarios Accident War Terrorism Epidemic Toxin
Environmental Extremes
Possible Scenarios

6. Situational Factors Numbers of Casualties Location of Casualties Time
of day
to medical facility (Distance)
Transportation
Vehicles
Lines of Communication
Medical Resources
Personnel
Facilities
Distance
Situational Factors

7. Hospital Disaster Plan Considerations
Alert Process
Activation Levels
Notification Procedures
Emergency Privileging Process
Operations
Triage Areas
Marking Techniques
Standing Orders
Layout/Patient Flow at Medical Facility
Supplies
Backup Transportation
Organization of Health Care Providers
Echelons of Providers
Ancillary Personnel
Litter Bearers
Drivers
Traffic controllers
Security
Chaplains
Red Cross
Housekeeping
Runners/Messengers
Patient Administrators
Communications
Command and Control
Medical Resources
Hospital Disaster Plan Considerations

8. Conduct of MASCAL Initial Response
Notification/Alert
First Response
On-Site Activities
Safety
Security
Traffic Management
Communications
Personnel Management
Triage
Medical Care
Medical Facility Preparation
Transportation
Conduct of MASCAL Initial Response

9. Notification (Example)
MCI (Mass Casualty Incident) reporting form located on 121st website.
The IC (Incident Commander, the Hospital Commander) is notified and initiates the MASCAL plan.
The Deputy Commander for Administration (DCA) activates the EOC (Emergency Operations Center (S3) ). There is a 24 hour on-call NCO for this center. Cell #
Units/departments alert personnel via own department policies (alert rosters).
Notification (Example)

10. Incident Commander (Example)
Is the Hospital Commander
Initiates and terminates the MASCAL Plan.
Designates the Level of Response to the MASCAL
Notifies higher headquarters and keeps higher headquarters informed of MASCAL status.
Prioritizes utilization of all assets.
Determines patient holding and evacuation criteria.
Incident Commander (Example)

11. Deputy Commander for Administration (DCA) (Example)
Coordinates administrative staff support to manpower pool operations
Activates the USAMEDDAC-Korea EOC
Acting IC in the absence of the Commander
Observes MASCAL response
Deputy Commander for Administration (DCA) (Example)

12. Deputy Commander for Clinical Services (DCCS) (Example)
Designates surgeons for triage and other duties.
Reviews MASCAL triage decisions with Chief Nurse
Assists training of EMT personnel in triage.
Assigns physicians to duty positions.
Deputy Commander for Clinical Services (DCCS) (Example)

13. Deputy Commander for Nursing (DCN) (Example)
Controls nurse corps workforce.
Observes MASCAL response; initiates on-the-spot correction of the patient care process not foreseen in planning and rehearsal.
Monitors patient flow and assigns nurses to appropriate sections as required.
Deputy Commander for Nursing (DCN) (Example)

14. Command Sergeant Major (CSM) (Example)
In conjunction with the Chief Nurse, and the DCCS, determines treatment areas and patient flow
Designates NCO to act as MASCAL site manager
Command Sergeant Major (CSM) (Example)

15. Chief Ward Master (Example)
Reviews MASCAL procedures for adjustments
Briefs hospital staff on MASCAL procedures
Chief Ward Master (Example)

16. Manpower Pool NCOIC (non-clinical)
Directs all personnel reporting to the Manpower Pool.
Reports directly to the Command Sergeant Major (CSM).
Organizes personnel into litter teams.
As needed, assigns personnel to act as:
Runners
Vehicle and personnel guides
Security teams
Manpower Pool NCOIC (non-clinical)

17. Hospital Non-Clinical Staff
Personnel Officer (S1): Manages Personnel/Manpower pool
Intelligence Officer (S2): Identifies possible Nuclear, Biological, Radiological, and Chemical (CBRN) threats and briefs hospital staff
Plans and Operations Officer (S3): Serves in the Emergency Operations Center (EOC) as required by the Incident Commander (IC)
Logistics Officer (S4): Anticipates supply requirements and notifies command of critical supply state
Communications Officer (S6): Establishes and Monitors Communications
Hospital Non-Clinical Staff

18. Patient Administrative Division (PAD)
Establishes the Patient Identification process outside the Emergency Department.
Processes casualties for admission; collects patients' funds and valuables at the Triage Point.
Discharges those current in-patients selected by ward doctors to make additional beds available; transfers patients as required.
Provides bed and patient status reports to the EOC every thirty minutes.
Provides updated patient rosters to the command
Provide staffing to the Emergency Operations Center (as required or as per Standard Operating Procedure)
Patient Administrative Division (PAD)

19. Provides augmentation personnel to the Emergency Department as required.
Department of Surgery

20. Department of Medicine
Receives and treats casualties in the Acute Care Clinic (ACC) requiring MINIMAL treatment; obtains personnel support for the ACC from the Mass Casualty Manpower Center, should the workload indicate.
Provides augmentation personnel to the Emergency Department as required.
Department of Medicine

21. Lab Services and Pathology
Provides emergency laboratory services for the treatment of casualties, as requested.
Expands emergency blood bank services, if required.
Implements emergency procedures for handling remains.
Provide one staff pathologist to the Emergency Department, if required.
Lab Services and Pathology

22. Department of Pharmacy
As required delivers drugs and supplies to the Emergency Department.
As required issues required drugs and supplies to inpatient wards.
Provide staffing to Emergency Operations Center (EOC) as required.
Department of Pharmacy

23. Department of Radiology
Positions one mobile X-ray unit in the Emergency Department immediately upon announcement of a MASCAL.
Determines, with the Chief of Emergency Medicine Service, the requirement for additional mobile X-ray units in the Emergency Department to support mass casualty operations.
Provides staff radiologist to the Emergency Department.
Implements procedures to provide wet readings, if required.
Department of Radiology

24. Supervises the reception and treatment of casualties.
Uses augmenting personnel provided by other departments, services and divisions and activates and manages the expanded Emergency Department.
Provide staffing to EOC as required.
Emergency Department

26. Emergency Department (ED) Considerations after Notification
Alert the on-call team
Analyze incoming reports
Rapid brief of team
Organize available personnel
Triage
Treatment teams
Position personnel
Check communications
Check readiness of ancillary staff
EKG, X-Ray, Lab, Blood Bank, etc.
Check emergency equipment and supplies
Check readiness of OR/surgeons
Review SOP's
Safety, safety, safety INCLUDING BLOOD AND BODY FLUID PRECAUTIONS
Emergency Department (ED) Considerations after Notification

27. DO THE MOST FOR THE MOST
Triage

28. Principles of Triage Rapid assessment of every patient Safety
Experienced Triage Officer
Triage "Captains" do not give medical care
Speed, with Thoroughness
Impassionate
Use simple criteria, without need for equipment
Return the Most to Duty
Principles of Triage

29. Problems Humbling Second-Guessing Errors Imprecise Process
Scoring Systems not any better than Experience, Knowledge, Instinct
Triage is at multiple levels-- everyone needs training
Problems

30. I-immediate: This group includes those soldiers requiring life -saving surgery.
Procedure should not be time consuming
Casualties should have high chance of survival
D-delayed: those wounded who are badly in need of time consuming surgery but whose general condition permits delay in intervention without unduly endangering life.
Will require sustaining treatment 
IDME or DIME

31. M-minimal or “walking wounded”: These casualties have minor injuries and can usually care for themselves with self-aid or “buddy aid”. 
These casualties should still be employed for mission requirements (litter bearers runners, scene security).
E-expectant: those whose wounds are so extensive that even if they were the sole casualty and had the benefit of optimal medical resource application, their survival would be unlikely
IDME or DIME

32. Examples Immediate: Delayed: Respiratory obstruction
Unstable casualties with chest or abdominal injuries
Emergency amputation
Delayed:
Large muscle wounds
Fractures of major bones
Intra-abdominal and or thoracic wounds
Burns < 50 % Total body surface area ( TBSA)
Examples

33. Examples Minimal: Expectant: Minor lacerations and or abrasion
Minor fractures of small bones
Minor burns
Expectant:
Unresponsive patients with penetrating head wounds
High spinal cord injuries
Mutilating explosive wounds
Partial and full thickness burns > 60% TBSA
Profound shock
Exhibiting agonal respirations
Examples

34. What is the Category?

35. RPG to R Knee

37. Triage Officer Should be experienced Leader
Not involved in patient care
"Chance favors the prepared mind." Louis Pasteur
Triage Officer

38. Remember Triage is: Continuous (for each victim)
Repeated (for groups of victims at each site)
MASCAL Site
Treatment Areas
Entry
Exit/Evacuation
Remember

39. Organization of the Staging/Triage Area
Primary Rescuers
Triage Officer (Senior Medical Officer on scene)
Communications Liaison
Traffic Control
Personnel Control
Security Officer
Site Manager
Organization of the Staging/Triage Area

43. Arrival of Patients Check your pulse Exhibit calm demeanor
Control the flow of communication
Control the flow of people
Assess number of casualties
Arrival of Patients

44. Preparation and Training
Develop Triage System
Analyze patient Flow
Analyze communication flow
Train Staff
in triage
monitoring
treatment
Reporting/communication/documentation
Analyze/Train pre-hospital team
Talk thru
Walk Thru
Drill, Drill, Drill
Feedback/After Action Discussions
Study Trauma
Medical Threat Intelligence
Endemic Diseases
Enemy Weapons
Preparation and Training

45. Preparation and Training
Clinical Knowledge
Trauma assessment and treatment
Triage Skills
MASCAL Process
Organization
Command, Control, Communications
Logistics
Exercises
Partial
Complete
Mental/Spiritual Preparedness
Preparation and Training

46. Debriefing and After Action Review
To analyze the good and the bad
Emotional venting & support
Make immediate reports
Make corrections quickly
Debriefing and After Action Review

47. "To improve is to change; to be perfect is to change often."
--Winston Churchill

48. Questions?