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

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

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

Possible Scenarios Accident War Terrorism Epidemic Toxin Environmental Extremes Possible Scenarios

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

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

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

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 # 010-9101-4032 Units/departments alert personnel via own department policies (alert rosters). Notification (Example)

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)

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)

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)

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)

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)

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

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)

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

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)

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

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

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

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

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

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

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

DO THE MOST FOR THE MOST Triage

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

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

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

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

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

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

What is the Category?

RPG to R Knee

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

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

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

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

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

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

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

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

Questions?