Page 28 - JSOM Fall 2024

The MASCAL response must be intuitive and practical across Assessment of Mentation and Pulse) and Vayer and colleagues’
a broad range of medical responder training levels, while uti- recommendation for “geographical triage.” 1,12 This new ap-
lizing common principles and terminology. proach is based on real-world responses and avoids the tradi-
tional acronym systems in the literature, which are inaccurate
“Stable” and “unstable” are standard terms used to describe and infrequently implemented. Using an organic and intuitive
live patients; most medical responders understand these, and response during chaos and danger provides a more realistic
they serve to streamline the triage and transport process. The framework for training medical responders. While “save and
designation “expectant” may require nuanced decision- making run” gets directly to the heart of the matter, our proposal is
beyond a medical responder’s experience and is replaced by meant to provide a broader framework for training, organiz-
the designation “unstable” if alive and “dead” if vital signs are ing, and equipping medical responders.
absent. An experienced prehospital clinician may choose to
categorize an unsalvageable casualty as “expectant,” but this is A New Prehospital MASCAL System Proposal
beyond the scope of new medical responders and may contrib- Based on our findings and input from experienced military
ute to adverse psychological impact. In fact, we have received medical responders, operational prehospital physicians, and
feedback from combat zones that many medical responders trauma surgeons, we propose an intuitive, simplified, and
will not use “expectant.” easy-to-recall process for combat medical responder initial on-
scene MASCAL action: Move, Treat, and Transport (Figure 1).
“Ambulatory” is a sub-category of “stable” and may be useful in
large MASCALs. In practical application, many of these casual- • MOVE: Move live casualties to a safe CCP, treat with LSIs,
ties self-evacuate (civilian event) or remain in the fight (military if able, and use best judgment to find and identify unstable
event). Medical responder experience and gestalt help supple- patients for early transport to an MTF. If able to immediately
ment the usual definitions of unstable based on abnormal vital transport casualties to an MTF, the CCP can be bypassed.
signs, mental status, and evidence of degraded end-organ perfu- • TREAT: Generally, limit LSIs to external hemorrhage con-
sion. At a minimum, mental status (alert or not) is an acceptable trol, airway management, chemical, biological, radiological,
1
tool for initial assessment. Using pulse and respiratory status and nuclear (CBRN) countermeasures, and the judicious use
is also valuable based on the number of casualties and provider of blood products if available.
experience. Ultimately, “unstable” refers to a casualty in need of • TRANSPORT: Transport to an MTF as soon as able if a
immediate blood transfusion and/or life-saving surgery. 7 higher level of care is needed.

Others have advocated for the simplification of the MASCAL The following principles should also be incorporated:
response. Migration to a system with fewer categories and an
emphasis on speed of action is consistent with the “save and 1. Early designation of an event as multiple casualties, MAS-
run” approach in Israel. These qualities are seen with some CAL, or ultra-MASCAL. Consider scene safety (environ-
other triage systems, such as the RAMP Triage Model (Rapid mental threats, smoke, fire, etc.) and security (enemy threat),

FIGURE 1 Proposed “Move, Treat, and Transport” approach to MASCAL management.

TCCC = tactical combat casualty care; LSI = life-saving intervention; CCP = casualty collection point; CASEVAC = casualty evacuation on a
vehicle of opportunity; MASCAL = mass casualty event; MEDEVAC = medical evacuation on the designated medical platform.

26 | JSOM Volume 24, Edition 3 / Fall 2024