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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


  • 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


  • 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)
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 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


  • 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


    • 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)


    • 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
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