MASCALAn Overview in Mass Casualty Incident (MCI) Operations and Triage

Purpose

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

Operations

MASCAL

• MASS-CASUALTY SITUATION: used to describe a situation in which the number of casualties exceeds the hospital's capabilities to provide medical care.

Possible Scenarios

• Accident • War • Terrorism • Epidemic • Toxin • Environmental Extremes

Situational Factors

• Numbers of Casualties • Location of Casualties • Time

• of day • to medical facility (Distance)

• Transportation • Vehicles • Lines of Communication

• Medical Resources • Personnel • Facilities • Transportation • Distance

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

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• Communications• Transportation

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).

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.  

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 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 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.

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

Chief Ward Master (Example)

• Reviews MASCAL procedures for adjustments • Briefs hospital staff on MASCAL procedures

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

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

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)

Department of Surgery

• Provides augmentation personnel to the Emergency Department as required.

 

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.

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.

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 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. 

Emergency Department

• 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 (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

Triage

• DO THE MOST FOR THE MOST

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

Problems

• Humbling • Second-Guessing • Errors • Imprecise Process • Scoring Systems not any better than Experience,

Knowledge, Instinct • Triage is at multiple levels-- everyone needs training

IDME or DIME

•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

Examples

• Immediate:• 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

• Minimal:• 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

•What is the Category?

Triage Officer

• Should be experienced• Leader• Not involved in patient care

"Chance favors the prepared mind." Louis Pasteur

Remember

Triage is:• Continuous (for each victim)

• Repeated (for groups of victims at each site)

• MASCAL Site

• Treatment Areas

• Entry

• Exit/Evacuation

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

Triage

“CODE GREY!!”

ACC“Minimal”

ER “Immediate”

MCU“Delayed”

PT Clinic“Expectant”

CCREOC

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AC

Man

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BAACH/121 CSH SEPT 2010 MASCAL

MASCAL PATIENT FLOW

MCU“Delayed”

BAACH/121 CSH SEPT 2010 MASCAL

Arrival of Patients

• Check your pulse • Exhibit calm demeanor • Control the flow of communication • Control the flow of people • Assess number of casualties

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

• Clinical Knowledge • Trauma assessment and treatment • Triage Skills • MASCAL Process • Organization • Command, Control, Communications • Logistics • Exercises

• Partial • Complete

• Mental/Spiritual Preparedness

Debriefing and After Action Review

• To analyze the good and the bad • Emotional venting & support • Make immediate reports • Make corrections quickly

"To improve is to change; to be perfect is to change

often."

--Winston Churchill

Questions?