Top Ten Mass Casualty (MASCAL) Lessons Learned

Educational Objectives

The goal of this program is to improve the preparedness of hospital systems in managing mass casualty (MASCAL) events. After hearing and assimilating this program, the clinician will be better able to:

1. Identify the key components of an effective MASCAL response plan.
2. Implement a triage system that prioritizes patients with exsanguinating hemorrhage during MASCAL events.
3. Apply the principles of scene safety and security in the context of a MASCAL event.

Summary

Introduction: despite the unique nature of each mass casualty (MASCAL) event, the challenges encountered are consistently similar; trauma systems are important; MASCAL incidents are unpredictable and can occur at any facility, not just at level 1 trauma centers, eg, active shooter incidents, terrorist attacks, natural disasters, cyberattacks; clinicians must quickly assess the situation and make critical decisions

MASCAL events: multiple casualty incidents may have adequate resources; in true MASCAL events, resources are overwhelmed; the key to effective management is converting a MASCAL event into multiple manageable incidents through efficient patient distribution, eg, Boston marathon bombing; a defining characteristic of a MASCAL is the implementation of crisis standards of care, which involve significant deviations from normal medical practices; the COVID-19 pandemic led to the repurposing of intensive care units (ICUs), staffing changes, and expedited credentialing

Communication: effective communication is paramount; this may necessitate backup systems, eg, pagers because of potential disruptions in cell phone networks; clear communication with disaster management teams is important; social media and communication applications can facilitate rapid information sharing; activating the incident command system is important for a sustained response; it may not provide immediate assistance during the initial chaotic hours

Capacity management: hospitals must prioritize immediate resource management, including clearing space in the emergency department (ED), operating rooms (ORs), ICUs, and inpatient wards; decompressing the wards is a prerequisite for decompressing the OR; strategic patient diversion and effective hospital capacity management are important; understanding the existing patient population, eg, patients with psychiatric disorders during the Boston Marathon bombing, is important for efficient resource allocation; prompt decision-making by attending physicians is essential to expedite patient disposition

Triage: prioritizes maximizing benefits for the greatest number of patients; effective triage is paramount for successful MASCAL management and should be conducted by experienced, trusted individuals rather than by physicians with the least clinical experience; effective triage requires a simple system, eg, the DIME (delayed, immediate, minimal, expectant) system; expectant patients may require pain management and nursing care; dedicated areas for “expectant” and “dead on arrival” patients must be allocated; many hospital plans lack adequate protocols for these patient categories; before implementing any triage protocol, a “zero survey” is conducted, ie, assessment of the situation, available personnel, supplies, and capabilities; this initial assessment dictates triage priorities; the availability of specialized personnel, eg, neurosurgeons, influences the urgency of specific injuries; shifting of patients may commence only after the zero survey is completed; triage strategies must be adaptable based on the scale of the event and available resources; a small influx of casualties may be managed within larger events that necessitate external triage points; there is a need for well-equipped external triage sites, including adequate heating and supplies, especially in adverse weather conditions

Overtriage in MASCAL events: leads to increased mortality by consuming critical resources needed for severely injured patients; managing patient volume is important to avoid overwhelming the hospital’s surge capacity; preparations must be made to extend the facility’s ability to provide effective care; patient arrival patterns are unpredictable; minimally injured patients may arrive first because of their mobility; robust security measures are necessary; to prevent overtriage, the speaker advocates for “right-turn” triage, diverting minimally injured “walking wounded” directly to designated areas outside the ED, eg, clinic areas, outpatient facilities; hospitals should avoid using large, ill-equipped spaces, eg, auditoriums, for patient care because they may not be conducive to providing the necessary medical attention; outpatient clinics are the most suitable locations for triaging minimally injured patients because of their existing staff, supplies, and electronic medical records (EMRs); in case of overflow, alternative spaces (eg, auditoriums, gymnasiums) may be used, but these should be considered a last resort

Trauma care: prioritization of interventions must be based on the leading causes of death; Martin et al (2009) suggested that hemorrhage is the primary cause of death in prehospital and in-hospital settings; this prompts a shift from the traditional airway-breathing-circulation (ABCs) approach to one that first addresses exsanguinating hemorrhage; tourniquets and hemostatic dressings are effective in controlling life-threatening bleeding, making it important to have these supplies readily available; hospital personnel must be trained in their proper application; health care providers should avoid distractions during patient care; once hemorrhage control is achieved, the focus shifts to a systematic approach, following the ABCs; covering dramatic injuries may help clinicians concentrate on the patient’s overall condition

Prioritization: in a MASCAL event, a critical shift in approach is needed, moving beyond standard medical protocols to prioritize lifesaving interventions; diagnostic procedures, while important, must be streamlined; the focus should be on essential laboratory testing, primarily type and screen, crossmatch, and critical imaging, with chest radiography taking precedence; “compulsive pessimism” is advised, ie, anticipating rapid deterioration and prioritizing actions that address immediate threats; unnecessary investigations (eg, routine computed tomography [CT], nonessential radiography) should be avoided; the use of ultrasonography should be maximized to expedite assessments and potentially bypass some imaging needs

Patient flow: during a MASCAL incident, patient flow is inherently chaotic, contrasting sharply with the orderly diagrams found in planning documents; in reality, hospitals face a surge of patients arriving through all available entrances, along with potential security threats from media and unauthorized individuals; to manage this, a secure single-entry point must be established, creating a controlled bottleneck; this allows for effective triage and a one-way patient flow throughout the facility; identifying and mitigating potential internal bottlenecks is important; security must be involved in MASCAL drills; common obstacles include excessive radiography and CT, and limited blood product availability; restricting imaging to essential chest radiography, prioritizing critical CT, and implementing immediate massive transfusion protocols with universal donor blood products are essential strategies; logistically, using low-titer whole blood when available is a superior method for MASCAL

Command, control, and communications: effective leadership and communication are important; a centralized command area, staffed by key personnel (triage officer, OR chief, nursing supervisor, patient admin) ensures efficient information flow; utilizing a visible status board to track patient flow, especially for critical resources (eg, CT, ORs), streamlines operations; communication failures with external agencies, eg, scene commanders, may severely hinder patient distribution and resource allocation

Security: measures are not solely focused on external threats; they are also vital for managing the influx of well-meaning but potentially disruptive individuals (friends, family, media, volunteers); controlled access helps prevent overcrowding and ensures patient safety; simulated disruptive patients during drills can help highlight security vulnerabilities

Documentation and records: relying on EMRs can create an issue during MASCAL events; EMRs may crash or operate too slowly; preprepared MASCAL charts might not be available; paper-based systems, including premade packets and bedside recording, often prove more efficient; clear naming conventions, sequential numbering, and direct documentation on scrubs or patients are practical solutions; clipboard-based bedside recording can also be helpful; time-stamp dressings is important for ensuring continuity of care during transfers

After action review (AAR): postincident analysis is vital for improvement; this involves a thorough review of every patient, radiograph, and procedure to identify missed injuries or errors; an effective AAR focuses on identifying areas for improvement, with a higher number of identified issues indicating a more thorough and beneficial review; recouping, recovering, and resupplying are essential components of postincident procedures

Readings

Bazyar J, Farrokhi M, Salari A, et al. Accuracy of triage systems in disasters and mass casualty incidents; a systematic review. Arch Acad Emerg Med. 2022;10(1):e32. doi:10.22037/aaem.v10i1.1526; Gabbe BJ, Veitch W, Mather A, et al. Review of the requirements for effective mass casualty preparedness for trauma systems. A disaster waiting to happen?. Br J Anaesth. 2022;128(2):e158-e167. doi:10.1016/j.bja.2021.10.038; Martin M, Oh J, Currier H, et al. An analysis of in-hospital deaths at a modern combat support hospital. J Trauma. 2009;66(4 Suppl):S51-S61. doi:10.1097/TA.0b013e31819d86ad; Stubbs JR, Jenkins DH. Blood transfusion preparedness for mass casualty incidents: are we truly ready? Am J Disaster Med. 2019;14(3):201-18. doi:10.5055/ajdm.2019.0332; Suda AJ, Franke A, Hertwig M, et al. Management of mass casualty incidents: a systematic review and clinical practice guideline update. Eur J Trauma Emerg Surg. 2025;51(1):5. doi:10.1007/s00068-024-02727-0.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Martin was recorded at the 72nd Annual Detroit Trauma Symposium, held November 7-8, 2024, in Detroit, MI, and presented by Detroit Trauma. For information on upcoming CME activities from this presenter, please visit DetroitTrauma.org. Audio Digest thanks the speakers and Detroit Trauma for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

GS720802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.