MASCAL
An Overview in Mass Casualty Incident
(MCI) Operations and Triage
• 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.
MASCAL
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Accident
War
Terrorism
Epidemic
Toxin
Environmental Extremes
Possible Scenarios
• Numbers of Casualties
• Location of Casualties
• Time
• of day
• to medical facility (Distance)
• Transportation
• Vehicles
• Lines of Communication
• Medical Resources
• Personnel
• Facilities
• Transportation
• Distance
Situational Factors
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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
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Drivers
Traffic controllers
Security
Chaplains
Red Cross
Housekeeping
Runners/Messengers
Patient Administrators
Communications
Command and Control
Medical Resources
Hospital Disaster Plan
Considerations
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Notification/Alert
First Response
On-Site Activities
Safety
Security
Traffic Management
Communications
Personnel Management
Triage
Medical Care
Medical Facility Preparation
Communications
Transportation
Conduct of MASCAL
Initial Response
• 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)
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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)
• 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)
• 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)
• 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)
• 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)
• Reviews MASCAL procedures for adjustments
• Briefs hospital staff on MASCAL procedures
Chief Ward Master
(Example)
• 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)
• 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
• 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
• 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
• 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
• 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
• 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
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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
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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
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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
• Immediate:
• Respiratory obstruction
• Unstable casualties with chest or abdominal injuries
• Emergency amputation
• Delayed:
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Large muscle wounds
Fractures of major bones
Intra-abdominal and or thoracic wounds
Burns < 50 % Total body surface area ( TBSA)
Examples
• Minimal:
• Minor lacerations and or abrasion
• Minor fractures of small bones
• Minor burns
• Expectant:
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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?
• Should be experienced
• Leader
• Not involved in patient care
"Chance favors the prepared mind." Louis Pasteur
Triage Officer
Triage is:
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Continuous (for each victim)
Repeated (for groups of victims at each site)
MASCAL Site
Treatment Areas
Entry
Exit/Evacuation
Remember
• 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
BAACH/121 CSH SEPT 2010 MASCAL
MCU
“Delayed”
ER
“Immediate”
Triage
DFAC
Manpower
Pool
PT Clinic
“Expectant”
“CODE
GREY!!”
ACC
“Minimal”
CCR
EOC
BAACH/121 CSH SEPT 2010 MASCAL
MCU
“Delayed”
MASCAL PATIENT FLOW
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Check your pulse
Exhibit calm demeanor
Control the flow of communication
Control the flow of people
Assess number of casualties
Arrival of Patients
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Develop Triage System
Analyze patient Flow
Analyze communication flow
Train Staff
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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
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Clinical Knowledge
Trauma assessment and treatment
Triage Skills
MASCAL Process
Organization
Command, Control, Communications
Logistics
Exercises
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• Complete
• Mental/Spiritual Preparedness
Preparation and Training
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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?