Page 27 - JSOM Fall 2024

MASCAL response from different perspectives, contributing as time evolves and any threats on the scene decrease, medical
new data, and identifying critical limitations and challenges of care advances with the transition to a three-category system
various triage systems and event management. termed “USA” triage—Unstable, Stable, and Ambulatory—for
live casualties.
Most of the authorship (across all services) have real-world
experience managing MASCALs at the point of injury (POI) Kamler et al. reviewed the civilian literature on the use and ac-
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or a military treatment facility (MTF), as well as organizing curacy of formal triage systems. The accuracy of many com-
and executing numerous large-scale MASCAL exercises in monly used systems was approximately 50%. There was also
military and civilian settings. It is important to note that the wide variation in rates of over-triage noted across systems, of-
recommendations put forth by the authors are not based on ten above 50%, which opens susceptibility to the overuse or
hypothetical responses to MASCALs but on issues identified in misallocation of critical event resources. Notable real-world
real-world events, including the Khobar Towers bombing, the over-triage rates included the following: Beirut (1983) at 80%,
Battle of Takur Ghar (also known as Robert’s Ridge), the Bos- Buenos Aires (1994) at 56%, Oklahoma City (1995) at 37%,
ton Marathon bombings, the Ghazni offensive, a Syrian nerve New York City (2001) at 70%, Madrid (2004) at 89%, Lon-
gas attack, and numerous smaller-scale operations, to name don (2005) at 64%, Virginia Tech (2007) at 69%, and Amster-
a few. This information was analyzed and organized over dam (2009) at 80%. Finally, reports of real-world use of these
many iterations to create a novel MASCAL response system. systems in civilian events revealed they were only used 16% of
This work is the product of collaboration between medical the time. Since formal triage systems tend to be inaccurate and
responders (Medics, Corpsmen, and Pararescuemen) and phy- rarely used in actual MASCALs, the value of time spent train-
sicians from multiple services and organizations to ensure that ing and memorizing perishable, infrequently used information
the principles were established in good medicine, practical, is in question. 8–9
and written appropriately for teaching prehospital clinicians.
Based on these three manuscripts, real-world experience, and Finally, Rush et al. reported the first combat series of 29
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consensus among medical responders and physicians, we rec- MASCALs. An overarching theme was a comprehensive ap-
ommend a system called “Move, Treat, and Transport,” which proach to security, communication, and movement of casual-
we describe in detail, along with other recommendations for ties. Formal triage was used in only one event. Twenty-eight
medical responders relevant to MASCAL response. of 29 events utilized a basic, binary category system for live
casualties, reflecting the need for either immediate or delayed
intervention (“dying now” versus “dying later”). There were
Summary of the Literature
no events utilizing colored marking systems for triage catego-
Shackelford et al. wrote on the impact of time on triage, intro- rization. Considerations for time and tactics were paramount,
ducing several essential concepts, including defining the scale with LSIs performed as able. Emphasis was placed on casualty
of the MASCAL (e.g., dozens vs. thousands), establishing a movement to a safe and secure casualty collection point (CCP)
timeline for life-saving interventions (LSIs), and simplifying or directly to an MTF.
triage decisions. The authors provided a new framework for
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classifying events:
Discussion
• Multiple casualties: resources stretched but not exceeded, MASCAL Management vs. Triage System
with initial response within minutes to an hour. Our findings in reviewing different aspects of MASCAL re-
• MASCAL: resources exceeded, but traditional approaches sponse demonstrate the need for prioritizing overall incident
to response can be executed, with initial response often de- management rather than adhering to formal triage systems
layed a half-hour to many hours. (i.e., algorithms, 3–4 live categories, colored tags), which over-
• Ultra-MASCAL: an overwhelming event where the response emphasize focus on individual casualties. Currently, MASCAL
may be delayed many hours to days, and medical interven- training includes nuanced algorithms that focus on individual
tions primarily include basic survival and comfort measures, patient physiologic parameters assessed in a linear fashion. Triage
and wound and fracture care. exercises tend to incorporate evaluation of the accurate applica-
tion of these algorithms rather than emphasizing overall inci-
Considering the difference between a dozen casualties man- dent management. The triage algorithm known as SALT (Sort/
aged by a pair of experienced medical responders available Assess/Life-saving Interventions/Triage & Treatment) offers
immediately and hundreds to thousands of casualties receiv- a more comprehensive but non-validated approach to mass
ing delayed bystander care, it is clear that both cases require casualty response by including early casualty sorting and as-
a planning framework that incorporates the necessary time- sessment, LSIs, and organizing casualties into respective triage
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sensitive interventions and available resources. priorities. Despite these improvements, SALT offers no guid-
ance for patient flow or incident management.
To establish realistic expectations for medical care from the
time of injury and to improve survival, the following clinical Current algorithms fall short in their ability to guide first re-
interventions were recommended as defined by prior casualty sponders in managing the MASCAL event, focusing instead on
care research: control of massive external hemorrhage within vital sign–based triage. Training medical responders to rigidly
5 minutes, blood transfusion for shock within 36 minutes, apply triage algorithms delays all other aspects of MASCAL
and handoff to a surgical team for advanced resuscitation and management, including movement away from a life- threatening
control of non-compressible hemorrhage within 60 minutes. situation and transport to surgical and resuscitation teams.
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Finally, the authors introduced a more straightforward triage Furthermore, it is unrealistic to expect medical responders to
strategy for live casualties. At the POI, the initial focus is on execute these protocols proficiently during real-world events
determining an “unstable” versus “stable” casualty. However, that are chaotic, dynamic, disorganized, and often dangerous.

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