MASCAL SOP

***DRAFT***

14th Field Hospital

10 April 1997

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PURPOSE:

To guide hospital personnel in the preparations for, and conduct of a mass casualty situation.

REFERENCES:

AR 40-2, FM 16-5

DEFINITIONS:

MASCAL- Old Definition"A situation in which the number of casualties exceeds the hospital's capabilities to provide medical care."

MASCAL- Revised Definition-Any situation in which the number and severity of casualties exceeds the capabilities of the EMT Section to treat immediately casualties in the triage categories "Immediate" and "Delayed."

Triage-Process of prioritizing victims based upon:

• Immediacy
• Salvageability
  • In order to do the most for the most.

Triage Categories:

• Immediate- casualties requiring immediate treatment to save life, limb, or sight.
• Delayed- casualties requiring treatment within a short period of time to save life, limb, or sight, but can wait for the more seriously injured to be treated, without jeopardy to their general condition.
• Minimal- casualties who can be treated as outpatients and returned to duty or the labor pool.
• Expectant- casualties who will die in the existing field medical care support system, or would require exhaustive efforts to temporarily extend their life.
• Neuropsychiatric- casualties incapacitated from combat stress, psychosis, or other psychiatric conditions.

RESPONSIBILITIES:

• The Chief Nurse will supervise revision of this SOP with staff input from the Chief of Emergency Medical Services, Chief of Surgical Services,Chief of Medical Services, Command Sergeant Major, Executive Officer, and Chief Wardmaster.
• The Chief of Emergency Medical Services will develop a hospital MASCAL training program.
• The Chief of Medical Services will ensure during deployment the MASCAL Plan is exercised on a monthly basis or as directed by the Hospital Commander.

GENERAL:

• Treatment Areas Layout (see Annex___) At each new field hospital location, the Chief Nurse, Chief of EMT, Chief Wardmaster, and CSM will specify the locations of the following areas:
• Triage Tent: The Chief, EMT will designate a site in front of the EMT tent for a covered area (GP Large, hard shelter, or building) for triage. Wheeled litter carriers will be stored under this shelter, and moved out by the Labor Pool at the start of a MASCAL.
• Immediate Treatment Area: The EMT section will be the site of Immediate Care; if additional space is needed, the Dispensary, Dental Section, and Triage Tent will be added in sequence.
• Delayed Treatment Area: The Dispensary will be used unless needed for Immediate casualties. The alternate site will be the ICW nearest to the external casualty route.
• Minimal Treatment Area: The Minimal Care Ward.
• Expectant Treatment Area: The Dental Section; alternate site is one of the MCW tents. Minimally injured casualties can be moved to the Labor pool, or an ICW.
• Morgue: A GP Medium, or other covered area adjacent to Supply.
• Neuropsychiatric Treatment Area: The Neuropsychiatric Ward.

Levels of Response:

• The field hospital commander may approve varying levels of response based on MASCAL information, and existing hospital staffing and workload. See Annex __.

Sequence of Events:

MASCAL Layout and Marking:

The Chief Wardmaster will supervise marking of all areas and routes (see Annex__), and retrieve all signs and marking materials upon site disestablishment.

Notification and Verification:

• The first warning of a MASCAL situation can come from a variety of sources:

• Incoming phone call
• Incoming radio message
• Radio intercept
• Passersby
• Sudden arrival of casualties
• Sound or Visual evidence of an explosion
• Military Police

• Whoever receives information about a potential MASCAL event will immediately notify the Hospital Operations Center (HOC) and give all available information.
• The HOC (S-3) will verify the information, and notify the Hospital Commander.

Initiation:

• The Hospital Commander will determine the level of MASCAL response needed, and initiate the MASCAL.
• If the Hospital Commander is not available, the MASCAL SOP will be initiated according to the following order of succession:

• Chief of Medical Services
• Chief Nurse
• Hospital Executive Officer
• Senior Physician on Duty in the EMT Section

• Upon initiating the MASCAL plan, the Commander (or designated representative) will notify the switchboard and radio operators who will begin alert procedures.

Alert Procedures:

(see Annex_____)

Mobilization and Assembly:

(see Annex_____)

• Stable hospitalized patients: ICW staff will relocate them to a site designated by the Chief Wardmaster.
• Physicians:
• General surgeons will report to the EMT Tent.
• Other surgeons will report to Preop.
• Other physiciansWill report to the EMT Section.
• Anesthetists:

• Will report to Pre-op, and be on call to move to the EMT Tent if needed.

• Ward ANC:

• On duty personnel will report to their work areas.

• Off duty personnel:

• ICU and ICW staff will report to their work areas; and await further instructions from the Chief Nurse and Chief Wardmaster.
• EMT Personnel will report to the EMT tent.

Other Specific Instructions:

• One 66E ANC will report to the triage area to assess surgical requirements. The NCOIC of the OR will prepare the OR IAW with the 66E's direction.
• Two 66F ANC anesthetists will report to the EMT tent to assist with resuscitation
• PT/OT Section
• Field Sanitation Unit
• Minimal Care Ward Staff
• Neuropsychiatric Ward Staff
• Dental Section
  • Will report to the Dispensary. The Dental Section OIC will report to the senior physician in the EMT tent for further instructions.
• MFFS Section
• Maintenance Platool
• Motor Pool
• _________
• _________
• _________
• _________

Control of Incoming Casualties:

• Vehicle Control Points/Ground Guides
• The CSM/Site Manager will designate personnel to guide vehicles to the casualty off loading area adjacent to the Triage Tent.

Casualty Off loading:

• The Labor Pool Leader will provide litter bearers to the Triage Tent for use by the Triage Team to assist in off loading casualties from vehicles and aircraft. Litter bearers will carry casualties to the Triage area, then to the treatment areas as directed by the Triage team. Litter bearers will then return to the Labor Pool Assembly Area.

Triage:

• EMT personnel will organize to triage casualties: The Chief of EMT will designate a "Triage Captain." If more than one ambulance, medevac helicopter, or more than 4 casualties arrive at one time, then the Chief of EMT will also designate at least one "Triage Lieutenant" to assist in triage, and report directly to the Triage Captain.
• If existing hospital workload permits, then the Chief of Surgical Services, or other general surgeon will act as Triage Captain for the initial casualties, and accompany those that need immediate surgical intervention to the EMT area, and through to the Operating Room. The Chief, EMT or his designee will assume the Triage Captain role as soon as the Surgeon departs the Triage Area.

Patient Treatment Sequence by Triage Category:

• Immediate:

• EMT--->Pre-op--->OR--->ICU

• Delayed

• Dispensary--->(EMT)--->OR or Ward
• or
• ICW--->EMT or Dispensary--->OR or Ward

• Minimal

• MCW--->Dispensary--->MCW
• or
• Labor Pool--->Dispensary--->MCW

• Expectant

• Dental--->Morgue

• Neuropsychiatric
• NP Ward

The Chief Nurse will determine based on numbers of casualties and staffing if continuity of nursing care can be provided by assigning a medic to each casualty. The medic will assist treatment, monitor clinical status, document patient care, and remain with the patient until relieved of attendant duty by an ANC officer responsible for the final treatment area for the patient. when relieved of this duty the medic will return to the labor pool.

Casualty Holding:

Casualty Evacuation:

Reconstitution:

Debriefing and After Action Reports:

EPW Handling:

C3: (see Annex__)

• Locations of Key Personnel
• Radios, hand-held
• Field Telephones
• Signs & Chemlights
• Guides
• Road Guard Vests
• Flashlights
• Tape

Hospital Personnel Management

Locations of Key Personnel

• Commander
• HQ Section
• Nursing
• PAD
• Labor Pool
• Physicians

Staging Areas

• Labor Pool-

• non-medical
• medical

• Visible Identifiers

Ambulance Traffic Flow:

Supply:

Hospital Commander

• Initiates and terminates the MASCAL Plan.
• Designates the Level of Response to the MASCAL
• Notifies higher headquarters and keeps higher HQ informed of MASCAL status.
• Only indivudual authorized to discuss the MASCAL situation with the press.
• Prioritizes utilization of all assets.
• Determines patient holding and evacuation criteria.

Chief, Surgical Services

• Designates surgeons for triage and other duties.
• Reviews MASCAL triage decisions with Chief, EMT.
• Assists training of EMT personnel in triage.

Chief, Medical Services

• Assigns physicians to duty positions.
• Reviews MASCAL SOP with hospital staff prior to hospital establishment to ensure all personnel understand their duties and responsibilities.
• In conjunction with the Chief Nurse, Chief of EMT, and CSM, determines treatment areas and patient flow.

Chief Nurse

• In conjunction with the Chief of Medical Services, Chief of EMT, and CSM, determines treatment areas and patient flow.
• Controls ANC workforce.
• Observes MASCAL response; initiates on-the-spot correctiosn of the patietn care process not foreseen in planning and rehearsal.
• Monitors patient flow and assigns ANC's to appropriate sections as required.

Executive Officer

• Observes MASCAL response.
• Maintains communication with, and assists in coordination between the field hospital and outside activities/commands as necessary to execute hospital operations.
• Acts as Medical Regulating Officer.
• Supervises logistical support of the MASCAL operation.

Command Sergeant Major

• In conjunction with the Chief Nurse, Chief of EMT, and Chief of Medical Services, determines treatment areas and patient flow.
• Designates NCO to act as MASCAL Site Manager.

MASCAL Site Manager- supervises:

• marking of areas and routes
• the labor pool NCOIC
• security teams
• vehicle and personnel guides
• Selects and briefs the Labor Pool NCOIC

Chief, Emergency Medical Treatment

• In conjunction with the Chief Nurse, Chief of Medical services, and CSM, determines treatment areas and patient flow.
• Selects Triage Captains and Lieutenants.
• Reviews MASCAL triage results with the Chief of Surgical Services.
• Reviews MASCAL procedures for adjustments.
• Briefs hospital staff on MASCAL procedures.

Chief Wardmaster

• Determines nursing staffing needs, and reports to the Chief Nurse.
• Supervises the marking of all areas and routes; collects signs and marking material upon site disestablishment.

Labor Pool NCOIC

• Directs all personnel reporting to the Labor Pool.
• Reports directly to the CSM.
• Organizes personnel into litter teams.
• As needed, assigns personnel to act as:

• runners
• vehicle and personnel guides
• security teams

S-1

• Assigns personnel to patient admission and disposition duties.
• Releases available S-1 personnel to the labor pool.

S-2

• Identifies NBC threats and briefs hospital staff.
• Supervises handling of EPWs.
• Releases available S-2 personnel to the labor pool.

S-3

• Installs telephone lines IAW Annex__.
• Establishes radio net for hand-held radios, IAW Annex__.
• Provides the Mobile Triage Team with a radio and operator.
• Manages ambulance traffic to and from the hospital
• Releases available S-3 personnel to the labor pool.

S-4

• Anticipates supply requirements, initiates communication with the EMT, OR, and ICU sections to obtain requests.
• Details personnel to take custody of US Government property at the Triage Tent.
• Ensures all weapons are cleared of ammunition, and are on SAFE.
• Prepares morgue area and supervises graves registration.
• Initiates hospital resupply actions.
• Notifies Hospital Commander of critical supply status.
• Issues unifors to Return to Duty soldiers.
• Releases available personnle to the labor pool.

PAD OIC/NCOIC

• Establishes inpatient treatment records.
• Assigns MASCAL patients with a number and inpatient record.
• Supervises patient tracking.
• Supervises the securing of personal property of MASCAL casualties.
• Inventories personal property of the dead.
• Maintains bed status records, and reports to the Hospital Commander.
• Prepares for increased evacuation workload.

Communications Section

• Establishes the radio nets.
• Supplies radio and CEOI for the MTT.
• Establishes and staffs the switchboard.

Motor Pool

Maintenance Section

Supply

Pharmacy

• The Pharmacy OIC will detail one pharmacy tech to:

• EMT and Dispensary
• OR and Post-op ICU's
• Other Wards
  • Monitor medication usage in a MASCAL for restocking and planning of future needs.

Food Service

• Off duty personnel will report to the labor pool.
• On duty personnel will ensure that hospital staff receive rations during MASCAL operations.

Laboratory and Blood Bank

• Will report to their duty areas.
• The Lab OIC/NCOIC will assign one 92B to EMT for blood drawing duties.
• Will prioritize lab procedures as follows:

• emergency transfusion requests
• type and crossmatch
• Hct
• urinalysis
• sodium and potassium
• HCG

Radiology

• Will assign personnel to portable X-ray apparatus for reporting to EMT and Pre-op.

Laundry and Bath Section

• Report to the labor pool.

Chaplain

• Provides support to the following areas by priority:

• Expectant
• Triage
• Inpatients
• Hospital Staff
• Combat Stress Casualties

PT/OT

• Reports to the labor pool.

Ortho Section

• Reports to their duty area

Psychiatry

• Reports to the Neuropsych Ward
• Releases available personnle to the labor pool.

Hospital Unit, Holding

• Physicians report to the Dispensary for assignmnets.
• Nursing personnel to the labor pool

ANNEX:

• LEVELS OF MASCAL RESPONSE
• ALERT PROCEDURES
• MOBILIZATION AND ASSEMBLY PROCEDURES
• LABORATORY AND BLOOD BANK
• CHEMICAL CASUALTY DECON AND TREATMENT
• EPW
• SAFETY (Weapons and Ordnance Handling)
• REMOTE TRIAGE
• PACKING LISTS AND SUPPLY
• MASCAL-Specific Items
• AEROMEDICAL EVACUATION
• PATIENT FLOW DIAGRAMS
• COMMUNICATIONS

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