Page 29 - JSOM Fall 2024

the number of casualties, and the adequacy of resources. fracture care. This includes eye injuries in the wound cat-
Estimate the time needed for medical personnel and evac- egory, though specific care is required for these.
uation transport to arrive at the scene. Estimate whether 12. Incorporating non-medical responder assistance during
evacuation will be rapid or lengthy and anticipate the a MASCALs is often overlooked in planning. In civilian
modes used (e.g., buses to local hospitals vs. air assets to settings, people trained in first aid or “Stop the Bleed”
a remote location with limited space). This will dictate the can assist in providing potentially life-saving treatment.
type and extent of medical treatment and consideration for The Department of Defense has incorporated various lev-
other basic needs. els of Tactical Combat Casualty Care (TCCC) training
2. Move live casualties as they are identified, if the scene is across all services. These personnel should be enabled to
not safe and secure. Do not classify (“tag”) and assess perform basic care and free up the medical responders to
casualties before movement. If the scene is safe and tactics organize, allocate assets and resources, and perform more
permit, work to find unstable casualties, perform LSIs, advanced LSIs. This extra layer of resiliency in MASCAL
and move the unstable casualties as they are identified, response should be incorporated into MASCAL training
before moving stable casualties. Move casualties to a CCP and doctrine.
or transport directly from the POI to an MTF if transpor- 13. Have a plan for the deceased. Location may be near or
tation is immediately available. Move deceased casualties away from CCP based on preference and impact on sur-
last. vivors. If the number of dead exceeds the number of body
3. Perform LSIs based on the capability and experience of bags, consider improvised covering of the torso, head, and
the medical responder or first aid provider and gener- mutilated remains with space blankets and duct tape.
ally limit care to external hemorrhage control and air-
way interventions. Needle or finger thoracostomy, blood MASCAL Planning Considerations
transfusions, and CBRN antidotes may also be considered Planning for MASCAL response includes a global approach
based on scale, time, and tactics. 7 to command and control, communications, and logistics. No
4. Triage and sort by stable, unstable, and dead. If there are matter how well trained or functional the on-scene medical
an overwhelming number of casualties, consider sorting by responders are, they will be limited to only basic life support
mental status (alert or not) only. As soon as possible, per- care if there is no equipment. Logistics includes personnel,
form a secondary triage to better define and prioritize un- gear, and plans for follow-on care. This can be approached
stable patients for evacuation and on-scene interventions. through the broad framework of multiple casualties versus
5. Perform treatment (e.g., MARCHPAWS: massive hemor- MASCAL versus ultra-MASCAL. Rather than a traditional,
rhage, airway, respiration, circulation, hypothermia/head single-algorithm approach to MASCAL, event management
injury, pain, antibiotics, wounds, splinting) in the CCP if can be tailored to one of these three categories. For multiple
time, tactics, and resources permit. 13 casualties, such as a squad or any small combat element with
6. Basic survival needs will become a priority depending an indigenous partner force, planning should include medical
on time and scale (hours to days and/or MASCAL vs. and non-medical roles, limited clinical interventions based on
ultra-MASCAL). This will include considerations for shel- casualty numbers, and consideration of immediately available
ter from the environment, warmth, water, and some form blood products. Consider surgical case capacity and contin-
of nutrition. gency plans for a walking blood bank if surgery is available.
7. Organize patients in the CCP so they are prioritized in an For a civilian setting, such as an active shooter, plans for LSIs,
appropriate order for evacuation, either inline or grouped rapid casualty movement, and evacuation should be detailed.
by who is leaving first (so-called geographic triage).
8. Evacuate unstable patients first, followed by stable pa- For MASCAL events, command and control leadership is crit-
tients with significant injuries, and then patients with ical, and timely access to blood products and surgical teams
minor injuries. Load patterns may include stable casual- will determine the limits of definitive care for unstable pa-
ties in advance of additional unstable patients because of tients. A relatively minimal number of these casualties will
litter and ambulatory configurations on evacuation plat- make it to surgery in less than an hour because of the logistics
forms to move more casualties faster. Triage should be of responders arriving from afar. Therefore, most survivors
continuous with interval reevaluation of stable patients. will benefit from wound and fracture care planning, including
9. Mastery of casualty movement using various techniques analgesia and antibiotics. Critical to this point in military set-
of carries and drags, as well as webbing, litters, stretchers, tings is the creation of MASCAL kits, which will be detailed in
and improvising with available items, is fundamental to the next section. As casualty numbers increase, mental status
carrying out a MASCAL response and may impact time and pulse will guide basic triage.
to transfusion and surgery.
10. It is critical to consider the principles of time and triage. For an ultra-MASCAL, it is expected that, owing to the scope
Casualties with massive external hemorrhage or airway and time of the response, there will be almost no role for LSIs
compromise will likely die if responders are not available in the first 30–60 minutes, unless performed by those on the
to intervene within minutes, essentially on scene during scene who survive and have gear. Treatment priorities move
the event. The same concept applies to blood transfusion into primarily wound and fracture care, but survival needs
for shock within 36 minutes and delivery to surgical ca- are equally, if not more critically, dependent on the environ-
pability within 60 minutes. This should guide responders, ment. One of the authors is a retired senior Pararescueman in
along with the scale of the event, as to what is appropriate Alaska who has responded to numerous remote plane crashes.
to focus on at various time intervals after the injuries were Typically, the survivors are reached after several hours, and
sustained. 7 having passed the “test of time” (no massive hemorrhage,
11. Large MASCAL or ultra-MASCAL planning should fo- airway obstruction, or severe brain injury), these patients do
cus on survival needs, logistics, analgesia, and wound and not require LSIs for traumatic life threats. The focus shifts to

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