Authors: Rachel Steffes OMS-II, Megan Unrath OMS-II, Andres Toledo OMS-II, Alissa Leyman OMS-II

Location/School Affiliation: Kansas City University College of Osteopathic Medicine – Kansas City Campus

Keywords (3): Emergency Preparedness, Mass Casualty Training Simulation, Medical Education

Short Author Bio: Co-authors and second-year medical students Rachel Steffes, Megan Unrath, Andres Toledo, and Alissa Leyman served on KCU’s SAMOPS chapter inaugural executive board and created the first annual Mass Casualty Incident Simulation with assistance from Emergency Medicine, Wilderness Medicine, and Simulation Clubs at KCU-KC.

Social Media Handles:

• Twitter: @rachsteffes, @adtoledo23
• LinkedIn: Megan Unrath, Andrés D. Toledo, Rachel Steffes, Alissa Leyman

INTRODUCTION

A mass casualty incident (MCI) can be defined as “an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time.”¹ The goal of a mass casualty incident simulation (MCIS) is to practice executing a response plan to a catastrophe and to anticipate the needs of patients in a limited resource environment. These simulations are important to fully prepare every aspect of the community – from the hospital facilities to healthcare personnel and first responders – for the needs required to overcome an actual incident.

A recent study suggested that Emergency Medical Service (EMS) providers had high rates of self-assessed MCI preparedness but had low rates of MCI training.² It was reported that 27% of respondents felt that they needed more preparation for the COVID-19 pandemic,²  thus overestimating their level of preparedness to respond to a MCI appropriately. This mentality can be dangerous, as it  could result in medical providers “freezing up,” or the feeling of being unsure of what to do next, during an actual event. Another publication reviewed 21 MCI studies to determine the effectiveness of MCI training methods.³ It found that hospital disaster drills effectively allowed healthcare personnel to become familiarize with disaster procedures, to identify weak areas, and to provide an opportunity for lessons learned, without the risk of an actual disaster.³ Overall, research has shown that more practice and simulations increases preparation for MCI events.

Kansas City University (KCU) College of Osteopathic Medicine’s chapter of Student Association of Military Osteopathic Physicians and Surgeons (SAMOPS) held its first annual MCIS in April 2023. Inspired by other medical schools that have held similar simulations, we believe that MCIS should be strongly encouraged and widely available for medical students. As we will be at the forefront of healthcare in just a few years, we should have the greatest preparedness in emergency situations. Prior to beginning clinical clerkship experiences, many medical students are required to become BLS- and/or ACLS-certified through the American Heart Association, allowing them to provide basic care skills to those in need. Providing access to an MCIS may engage students in critical thinking skills not otherwise tested or taught during the preclinical years, and build care skills. We will explore the background of MCI and MCIS, provide an overview of our MCIS event, showcase survey results from participants, and engage in a discussion regarding the importance and practicality of MCIS for medical students.

BACKGROUND

General Information on MCI and MCIS

There are specific guidelines to successfully manage an MCI or MCIS and its chaotic environment. First, establishing communications and assigning an Incident Commander is crucial for effective delivery of information and efficient use of resources.¹ The role of the incident commander is to ensure scene safety, to delegate tasks to personnel facilitating care on scene, and to communicate between designated hospital facilities and staff.⁴ Additionally, three physical areas are designated as sectors on the incident site to treat, stage, and transport patients – this allows for organized flow of patients and resources. In the treatment sector, patients are provided appropriate medical care to based on what is available, re-triaged, and tagged to show treatment priorities; the latter step will identify which location the patient should go next.⁴ The staging sector is typically located within a walking time of three minutes of the incident scene, where personnel and equipment can be stored and secured.⁴ The transportation sector works with the treatment team and local hospitals to coordinate the transport of patients.⁴ Once these three areas are established, patients can be sorted based on their need and severity of injuries using the Simple Triage And Rapid Treatment (START) method.^1,4

The START method triages and tags patients using four distinct colors – green, yellow, red, and black – that identify the severity of injuries.⁴ A green tag is used if patients can walk; they are typically less ill. Black is used to identify those who are deceased or patients whose injuries are severe enough to consume most resources available and immediate care may not help them. Red identifies patients that are significantly injured but may be able to be saved with immediate care. Everyone else who does not fall into these parameters is classified as yellow or delayed. As soon as the initial triage is completed, the patients are moved to their respective sectors to receive additional treatment or transported out of the area. Triage tags need to be continuously re-evaluated, as patient’s initial triage status may change depending on their presentation.⁴

Once all of the patients are discharged and cleared from their respective sectors, concluding the MCI becomes the new priority. As many personnel and equipment are borrowed from surrounding facilities, returning responders and gear to respective locations is vital for continued care, as patients still need to be treated at their destination locations. The incident commander writes a report of the incident and offers a Critical Incident Stress Debriefing (CISD) for those who experienced the event.⁴ Most importantly, beginning to prepare for the next potential MCI is imperative to preventing casualties. With all this in mind, providing an MCIS is crucial for preparedness for any catastrophic event, as any disaster can become the groundwork for an MCIS.

KCU-KC Campus’ MCIS Logistics

To prepare for KCU’s first MCIS on the Kansas City campus, a preparatory 36 minute lecture and one mandatory two hour skills lab was provided about two weeks prior to the MCIS.⁴ The recorded lecture was taught by a KCU emergency medicine faculty physician on how to properly triage victims and how to prioritize patients for the treatment and transportation.⁴ The MCIS skills lab taught fundamental triage and medical care skills including internal hemorrhage with FAST ultrasounding, splinting and pelvic immobilization, intubating and ventilatory management, and external hemorrhage with tourniquet techniques. Each section of the lab was led by one of the SAMOPS executive board second-year students; we taught the same skills from our KCU Military Medicine Specialty Track and had two faculty physicians overseeing the skills lab to help supplement our knowledge.

All participants invited to take part in the MCIS were first- and second-year students in the College of Osteopathic Medicine (COM). There were 24 first-year COM students that signed up as MCIS victims/patients and 28 second-year students were the healthcare providers. The student healthcare providers had the option to sign up for one of three sections: Preclinical (triage), Emergency Department (ED), or Intensive Care Unit (ICU) Stations. Preclinical tested the eight students’ knowledge of first responder skills and their ability to triage, based on the SMART system. Once the victims were properly identified and tagged, they were transported from the primary disaster site to the secondary triage site, still within the Preclinical Station. At the secondary triage site, while waiting for EMS transportation to the ED Station, the healthcare providers obtained detailed histories, focusing on the red-tagged victims first, followed by yellow- and green-tagged patients. With limited supplies and a chaotic environment, this gave the providers the opportunity to make decisions on who was the most critical and needed to get to the hospital first. The EMS transportation consisted of two students who had the capacity to each transport two victims to the ED Station at a time. To simulate a delay as would be common in a real MCI, EMS transportation could only take four victims every five minutes. At the ED Station, twelve student healthcare providers used their skills to properly present SOAP notes, interpret labs and imaging, receive “consults” from orthopedics and vascular “surgeons”, perform FAST ultrasounding, suture wounds, intubate manikins, and obtain IV access. Students had to present their patients prior to allowing for admission or discharge of the victim. Four of the victims in the MCIS were critical and quickly deteriorating, which required them to be transported to the ICU Station. In the ICU Station, eight students were tested on their CPR skills, obtaining IV access, properly identifying and administering medications, reading electrocardiograms, and intubating if necessary. Overall there were 52 student participants, nine students overseeing the event, six student volunteers, and four physicians. Of the total participation, there were two military physician veterans, two student veterans, and eight currently commissioned Health Professions Scholarship Program (HPSP) students.

RESULTS

After immediate completion of the MCIS, there was a collaborative and constructive one-hour discussion regarding each station of the event and areas to improve. In the hope for more honest feedback from all participants, we distributed two surveys linked by QR codes for individuals to complete. Participants were alerted in writing that their responses would be used for publication and/or media with either KCU or National SAMOPS. The surveys were distinguishable by class year, with first-year students completing a patient-focused survey and second-year students completing a provider-focused survey.  As this is an opinion piece written post-MCIS, data was collected without IRB-approval and serves merely as a tool to help prompt discussion on the importance of MCIS. It will be used to help guide our SAMOPS chapter and future MCIS events, and we hope that its use will help inspire other medical schools to establish MCIS events of their own.  No major data analysis was performed outside of calculating the average and range. Any individual student testimonial used as qualitative data expression was reviewed with the participant directly for approval of use in this opinion article.

There were 24 first-year medical students involved in the event, with 21 respondents to the survey; this represents an 87.5% participation in the poll. A total of 100% of participants responded with “Yes” when prompted with the question “Has being a simulated patient in this year’s MCI made you want to return next year as a second-year provider?” A total of 18 respondents agreed an MCIS should be a required aspect of the curriculum when asked “Do you think the Mass Casualty Incident should be a required part of KCU’s curriculum for COM students before they begin their clinical rotations?” This correlates to 85.7% of first-year respondents.

There were 28 second-year medical students involved in the event, with 24 respondents to the survey; this represents a 85.71% participation in the poll. Of the respondents, there were 5 from the Preclinical Station (62.5% response rate), 12 from the ED Station (100% response rate), and 7 from the ICU Station (87.5% response rate). When prompted with the following statement, “Rate your confidence in an emergency situation PRIOR TO the Mass Casualty Training Simulation on a scale of 1 to 10, with 1 being ‘not prepared at all,’ and 10 being ‘extremely prepared’,” there was an overall average confidence rating of 3.79, with a range of 1 to 8. The Preclinical Station rated their confidence prior to the MCIS at an average of 4.4; the ED Station rated their confidence prior to the MCIS at an average of 3.5; and the ICU Station rated their confidence prior to the MCIS at an average of 4. When prompted with the following statement, “Rate your confidence in an emergency situation AFTER the Mass Casualty Training Simulation on a scale of 1 to 10, with 1 being ‘not prepared at all,’ and 10 being ‘extremely prepared’,” there was an overall average confidence rating of 6.13, with a range of 3 to 9. The Preclinical Station rated their confidence after the MCIS at an average of 6.0; the ED Station rated their confidence after the MCIS at an average of 6.08; and the ICU Station rated their confidence after the MCIS at an average of 6. Overall, across all stations, the confidence prior to the MCIS compared to the confidence after the MCIS increased 2.25 increments on average. A total of 19 respondents agreed an MCIS should be a requirement in the curriculum when asked the question: “Do you think the Mass Casualty Incident should be a required part of KCU’s curriculum for COM students before they begin their clinical rotations?” This correlates to 79.16% of all respondents.

Along with gathering quantitative information, we also offered second-year medical students the opportunity to share their thoughts with two separate prompts: “As a second-year provider, how do you feel like this event prepared you moving forward into the rest of your medical school education?” and “Describe the most valuable aspect of the Mass Casualty Training Simulation. This could be a specific moment for you, or a skill you learned at the mandatory training lab that you felt empowered you.” The following responses were approved for public use by the participants:

Without a doubt, the most exciting extracurricular activity I’ve participated in during my first two years at KCU. From the adrenaline and chaos to the one-on-one guidance from the clinical faculty and the excellent acting from the first-year students, the MCIS will absolutely stand out as one of my favorite med school memories. The energy all around was very positive. Everybody wanted to be there and do their part, whether it was learning, teaching, or acting. Hard to believe this was the first time this event was held because it was run very smoothly. – Jason-Flor Sisante OMS-II, Triage Station

The different situations were creative and stimulating. Coming up with the right plan for the patients actually made me nervous, and I gained experience on how to keep going in a situation like that. [One of the physicians] talked with me during a pinky fracture, but went through every step of a physical exam and why we do each step was very helpful in making that connection of practical exam skills to a real life stressful setting. This was an incredible experience! – John Dunton OMS-II, ED Station

It was good to make us uncomfortable before we go into clinicals next year. This is a no risk situation so it was a safe place to make mistakes and keep working. – Brit Belme OMS-II, ED Station

I felt the thought process of how to triage patients that we learned in the training was valuable and became extra solidified at the actual event. And the importance of the ABCDE steps became extra clear with our basilar skull fracture case, which I hadn’t formerly used in an [Manikin Based Experience] MBE before. We also had a chance after the encounter to run through the case again after our patient expired and we had been debriefed, which seemed like an impromptu decision by the [Standardized Patient] SP, but it was appreciated since we at least knew some steps to take to improve the patient’s condition, even though we were told beforehand that our patient would have died no matter what we did. I feel more confident in the ABCDE thought process, even though that is the literal basics. It was a much more high energy/intense environment than we get in MBEs, and even more so than I was expecting. Learning that feeling of being comfortable with being uncomfortable is invaluable, and I’m happy to get some extra training with that. – Griffin Dufek OMS-II, ICU Station

There were some limitations in this data: our team only conducted a post-survey to assess both the confidence rates prior to and after the MCIS; the sample size was small; and the pre-MCIS Skills Lab and MCIS were held over two weeks apart due to scheduling conflicts amongst both student bodies and physicians.

DISCUSSION

MCIS are important for clinical rotation preparation, as well as our careers as future physicians, and should be considered integral to the medical education of students, as well as be a potentially required event before beginning clerkships. As we have learned from the survey responses, the MCIS was a successful learning event for KCU’s first- and second-year medical students. KCU’s SAMOPS chapter was the main sponsor of the event, with assistance from Emergency Medicine Club, Wilderness Medicine Club, and Simulation Club. We would be remiss without mentioning the vital life experience and hands-on assistance from faculty mentors. In addition to leading our SAMOPS’ chapter as the executive board, we are also HPSP recipients within the U.S. Army and Air Force. KCU is unique in that it has a Military Medicine Specialty Track (MMST) for HPSP students, where we learn additional material with labs and lectures outside of the general curriculum throughout first- and second-year; much of our knowledge culminated into what we taught in the MCIS.

The necessity of preparing future physicians in proper response to a mass casualty event is of paramount importance. In 2022 alone, there were 18 natural disaster events that caused at least 474 direct or indirect fatalities,⁵ as well as 648 mass shootings with 21 involving five or more fatalities.⁶ Emergency preparedness is critical for civilian and military personnel alike, as a mass casualty situation can occur at any time. As future physicians who are developing crucial critical thinking skills in caring for patients and assessing situations, we believe that being able to use and apply knowledge in a practical setting was incredibly pivotal for participants, based on their responses to the polls and personal feedback. The MCIS lessened some of the unknowns, such as approaching a situation with multiple casualties, triaging and treating efficiently and effectively, and managing multiple patient cases and staff in a high stress environment. The MCIS placed each student in a stressful situation early in their healthcare career,  thus giving them the tools they need to further develop their ability to be the best leaders and providers, regardless of the supplies, situation, or demands.

While KCU’s MCIS was seen as a success to many, some participants voiced their worries about making it a required event, as it could possibly lead to negative experiences from those who do not want to participate. A possible solution to this could be creating an interactive lab (much like the required skills lab prior to the MCIS) where students can practice FAST ultrasound scans, intubation, tourniquet placement, splinting, and other hands-on emergent skills; this would allow students to become proficient in those skills required in a mass casualty response situation without having to host a required MCIS for hundreds of students, especially if funding or resources are limited. This could also be an introduction to starting an MCIS, and could be an initial starting point for future discussions of making it an university-required event.

In regards to other universities that hold training exercises, Rocky Vista University, in partnership with Touro University Nevada, AT Still University of Health Sciences, and Western University of Health Sciences, collaboratively hosts a “Cut Suit Week,” an annual mass casualty event as a part of the intensive surgical and trauma skills course, hosted by Strategic Operations, Inc (STOP). This “large-scale, health care simulation event takes place every year at STOP’s facility in San Diego, California, where first responders, medical students, and other emergency personnel come together to practice complex procedures in a controlled environment.”⁷ This event is for military medicine track students at these universities only, and also highly regarded for its empowering training amongst their military students. Other medical schools that have integrated an MCIS include University of Texas Health’s Center for Interprofessional Collaboration in Houston,⁸ the Zucker School of Medicine at Hofstra/Northwell,⁹ AT Still University School of Osteopathic Medicine in Arizona (ATSU-SOMA)/Arizona School of Health Sciences (ATSU-ASHS),¹⁰ East Carolina University Brody School of Medicine,¹¹ Mayo Clinic Florida Campus,¹² and KCU-Joplin Campus.¹³ Additionally, the University of Michigan conducted a study on preparedness of students after a one-day didactic training and scenario-based mass casualty simulation, citing improved preparedness and the importance of interprofessional collaboration.¹⁴ Since KCU did not have anything similar to “Cut Suit Week” or other simulation trainings in place, the goal of our MCIS was to integrate the MMST students and their curriculum with KCU first- and second-year medical students, creating a collaborative and high-yield skill experience, as emergency preparedness is critical for all future healthcare providers. Furthermore, MCIS should be considered integral to the education of all medical students before they begin clinical rotations, and should be strongly encouraged and widely available at all medical schools as proper training in emergency preparedness can save lives.

REFERENCES

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[10] Atsu News. A.T. Still University. https://www.atsu.edu/news/atsu-soma-and-ashs-students-participate-in-mass-casualty-simulation. Accessed April 13, 2023.

[11] News.ecu.edu. https://news.ecu.edu/2022/11/28/emergency-training/. Accessed April 14, 2023.

[12] Mayo Clinic College of Medicine and Science. Fully immersed in the simulation center: Mass casualty exercise at Mayo Clinic in Florida – News Archive – Mayo Clinic College of Medicine & Science. Mayo Clinic College of Medicine and Science. https://college.mayo.edu/about/news/news-archive/fully-immersed-in-the-simulation-center-mass-casualty-exercise-at-mayo-clinic-in-florida/. Published December 6, 2021. Accessed April 13, 2023.

[13] Louque A. KCU Joplin medical students participate in mass casualty simulation. KOAM News Now. https://www.koamnewsnow.com/lifestyle/kcu-joplin-medical-students-participate-in-mass-casualty-simulation/article_1f532762-cb17-11ed-9f85-db5315343c6b.html. Published March 26, 2023. Accessed April 13, 2023.

[14] Saunders M N, Iyer N, Lucas-Roberts C, He K. A Simplified Mass Casualty Incident Training for Medical Students. J Med Edu. 2018;17(2):e105610. doi: 10.22037/jme.v17i2.22210