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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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Mascal

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


Mascal1

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

    • Transportation

    • Distance

Situational Factors


Hospital disaster plan considerations

Drivers

Traffic controllers

Security

Chaplains

Red Cross

Housekeeping

Runners/Messengers

Patient Administrators

Communications

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

  • Safety, safety, safety INCLUDING BLOOD AND BODY FLUID PRECAUTIONS

Emergency Department (ED) Considerations after Notification


Triage

  • 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


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


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

IDME or DIME


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


Examples1

  • 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

Examples


Mascal

  • What is the Category?


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 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


Mascal

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

--Winston Churchill


Questions

Questions?


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