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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.

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


  • To familiarize personnel with:

    • the triage process

    • the organization and conduct of MASCAL Operations



  • 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

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

    • Transportation

    • Distance

Situational Factors

Hospital disaster plan considerations


Traffic controllers



Red Cross



Patient Administrators


Command and Control

Medical Resources

  • 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

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

  • Communications

  • 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)

Department of surgery

  • 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

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

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


Emergency Department (ED) Considerations after Notification




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


  • 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 dime1

  • 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



  • 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)



  • 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

Triage Officer


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

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 training1

  • 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



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