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. 2020 Oct 15;5(4):SG1-SG231.
doi: 10.21980/J82H1R. eCollection 2020 Oct.

Simulated Mass Casualty Incident Triage Exercise for Training Medical Personnel

Alaina Brinley Rajagopal  1 , Nathan Jasperse  1 , Megan Boysen Osborn  1
Affiliations

Simulated Mass Casualty Incident Triage Exercise for Training Medical Personnel

Alaina Brinley Rajagopal et al. J Educ Teach Emerg Med. .

Abstract

Audience: The target audience is any medical professional who requires training in mass casualty incident (MCI) triage. This could apply to pre-hospital specialists, nurses, medical students, residents, and physicians.

Introduction: Emergency medicine specialists must be able to triage patients quickly, especially in an MCI scenario. The simple triage and rapid treatment (START) system allows providers to categorize patients according to the urgency with which patients must access limited resources. Providers should be comfortable utilizing the START triage system before an MCI or disaster so that they can be prepared to implement it if necessary. This exercise uses simulation and gamification as instructional strategies to encourage knowledge of and comfort with the START triage system for emergency providers.

Educational objectives: By the end of this exercise, learners should be able to (1) recite the basic START patient categories (2) discuss the physical exam signs associated with each START category, (3) assign roles to medical providers in a mass casualty scenario, (4) accurately categorize patients into triage categories: green, yellow, red, and black, and (5) manage limited resources when demand exceeds availability.

Educational methods: Gamification is the use of elements of game design in non-game contexts.1 Gamification was implemented in this scenario by assigning participants to roles and teams, while creating an engaging, fun, and competitive environment. The exercise also uses low fidelity simulation (without simulation equipment) to encourage learners to practice using the START triage system in a low stakes environment.2 It is possible for the learners to be divided into two groups that each have the same patients, resources, and objectives. The team that finishes triaging all patients first would be declared the winner. However, in our implementation, we completed the exercise as a single group of learners and patients.

Research methods: Learners were given a survey at the end of implementation and also given the opportunity to discuss feedback with the instructors in a group discussion after completing the exercise. There was no formal assessment completed after the exercise.

Results: Informal feedback was collected at the end of the exercise. Residents and medical students all enjoyed the experience. The feedback was overwhelmingly positive. All participants providing feedback stated they would enjoy participating in the exercise again and suggested that it is implemented annually for review of triage topics. We also received informal feedback for suggested changes which we will discuss in this article. An optional, anonymous survey was given to participants at the end of the exercise. There were six responses. Of those surveyed, 100% of participants stated the effectiveness and value of the exercise was outstanding (a rating of five on a scale of one to five). Regarding the quality of the exercise, and whether the participants felt engaged, 100% of responses gave a rating of five. When asked to consider the relevance of the session, 100% of participants selected a score of five ("I loved this session"). Regarding whether the content was applicable to practice of emergency medicine, 80% of respondents stated the session was highly relevant and 20% of responses selected a score of mostly relevant. One question asked for points of improvement for the session to which there were no responses.

Discussion: Learners were assigned roles in the exercise by the incident commander, fulfilling objective three. The START categories were discussed at the beginning of the exercise by the lead proctor (using PowerPoint) and then utilized throughout the exercise, thus accomplishing objectives one and two. The residents/students filling the triage roles were primarily responsible for fulfilling objective four; however, all participants assisted in categorization of patients throughout the exercise. Finally, objective five was addressed through the various social situations and complications that can be implemented during the exercise. We chose not to implement the additional "radiation contamination" scenario (details available in the article text) due to time constraints; however, this is an additional option to address objective five. The implementation was effective based on informal feedback from participants and proctors as well as evidenced by the responses to the anonymous survey. Learners found the aspects of resource management, review of START triage, repetition of the START triage system, and medical management of various types of trauma informative and meaningful. We received valuable feedback from both learners and proctors, which we will discuss in this article.

Topics: Mass casualty incident, disaster, START, gamification, simulation, emergency medicine, triage, triage category, contamination, teamwork, trauma, projectile trauma, penetrating injury, blunt trauma, intracranial hemorrhage, fracture, trauma in pregnancy, active shooter, radiation, radio communication.

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Figures

None
Please see associated PowerPoint file
Figure 1
Figure 1
START triage handout. To be distributed to learners prior to start of exercise
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Cheng, J. Bilateral hand amputation. Radiopaedia.org. rID: 53544. https://radiopaedia.org/cases/bilateral-hand-amputation?lang=us. Published 2020. Accessed June 3, 2020. CC BY-NC-SA 3.0.
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Puyo D. Subarachnoid hemorrhage. Radiopaedia.org. rID: 22377. https://radiopaedia.org/cases/subarachnoid-haemorrhage-4. Published 2019. Accessed August 28, 2019. CC BY-NC-SA 3.0.
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Samir, B. Femoral shaft fracture. Radiopaedia.org. rID: 22120. https://radiopaedia.org/cases/femoral-shaft-fracture-2?lang=us. Published 2020. Accessed June 3, 2020. CC BY-NC-SA 3.0.
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Burns E. Lateral STEMI ECG changes. Life in the Fast Lane. https://litfl.com/lateral-stemi-ecg-library/. Published 2019. Accessed August 28, 2019. CC BY-NC-SA 4.0
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Harvey H. Pelvic fractures. Radiopaedia.org. rID: 6611. https://radiopaedia.org/articles/pelvic-fractures. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
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Jones J. Normal pelvis x-ray AP. Radiopaedia.org. rID: 36147. https://radiopaedia.org/cases/normal-pelvis-x-ray-ap. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Maled I, Velez R, Lopez R, Batalla L. Pseudoaneurysm of the superior gluteal artery during iliosacral screw fixation. Acta Orthopaedica Belgica. 2007;73(4):544–547.
None
Pinotti E, Santurro L, Famularo S, Uggeri F. Surgical removal of radiolucent lodged bullet fragment 5 years after a shotgun injury. Open Journal of Clinical and Medical Case Reports. 2017;3. CC BY 4.0.
None
Venkatesh M.. Extension teardrop fracture. Radiopaedia.org. rID: 26327. https://radiopaedia.org/articles/extension-teardrop-fracture-1?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Smith D. Normal CT head (3 years old). Radiopaedia.org. rID: 53696. https://radiopaedia.org/cases/normal-ct-head-3-years-old?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Brick C. Clinical Ultrasonography 101: Where Right Upper Quadrant Scans Go Wrong - CanadiEM. [online] CanadiEM. Available at: https://canadiem.org/right-upper-quadrant-scans-go-wrong/. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 4.0.
None
Jerome JTJ, MNAMS, Varghese M, Sankaran B, Thirumagal K. Lateral subtalar dislocation of the foot: a case report. The Foot and Ankle Journal. 2008;12(2). doi: 10.3827/faoj.2008.0112.0002. CC BY.
None
Agrawal AC, Raza HK, Haq RU. Closed posterior dislocation of the ankle without fracture. Indian J Orthop. 2008;42(3):360–362. doi:10.4103/0019-5413.41864. CC-BY.
None
Smith D. Normal CT head (3 years old). Radiopaedia.org. rID: 53696. https://radiopaedia.org/cases/normal-ct-head-3-years-old?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Kwon DH, Moon JD, Park WJ, et al. Case series of keratitis in poultry abattoir workers induced by exposure to the ultraviolet disinfection lamp. Ann Occup Environ Med. 2016; 28:3. Published 2016 Jan 15. doi:10.1186/s40557-015-0087-7. CC BY 4.0.
None
Salam, H. Pulmonary contusion. Radiopaedia.org. rID: 13270. https://radiopaedia.org/cases/pulmonary-contusion-2?lang=us. Published 2020. Accessed June 4, 2020. CC BY-NC-SA 3.0.
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Gaillard F. Lung hyperinflation. Radiopaedia.org. rID: 10550. https://radiopaedia.org/articles/lung-hyperinflation-1?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Brick C. Clinical Ultrasonography 101: Where Right Upper Quadrant Scans Go Wrong - CanadiEM. [online] CanadiEM. Available at: https://canadiem.org/right-upper-quadrant-scans-go-wrong/. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 4.0.
None
Gundlapalli VS. Recurrent evisceration from Mcburney’s incision. International Journal of Case Reports and Images 2012;3(6):54–56. CC BY 4.0.
None
Gołofit P. Normal ://radiopaedia.org/cases/normal-femur-radiographs-2?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Samir B. Humeral shaft fracture. Radiopaedia.org. rID: 22063. https://radiopaedia.org/articles/humeral-shaft-fracture-1?lang=us#image_list_item_3012469. Published 2020. Accessed June 3, 2020. CC BY-NC-SA 3.0.
None
Cuete D. Epidural hematoma.Radiopaedia.org. Radiopaedia.org. rID: 29440. https://radiopaedia.org/cases/epidural-haematoma-4. Published 2019. Accessed August 28, 2019. CC BY-NC-SA 3.0.
None
Orapin J, Sa-ngasoongsong P, Thamyongkit S. Case Report: Closed Posteromedial Dislocation of the Ankle without Medial Malleolar Fracture. Clinical Research on Foot & Ankle. 2016;4(3). doi:10.4172/2329-910x.1000197. Open access creative commons license.
None
Cheng, J. Bilateral hand amputation. Radiopaedia.org. rID: 53544. https://radiopaedia.org/cases/bilateral-hand-amputation?lang=us. Published 2020. Accessed June 3, 2020. CC BY-NC-SA 3.0.
None
Jones J. Middle finger tuft fracture. Radiopaedia.org, rID: 6429. https://radiopaedia.org/cases/middle-finger-tuft-fracture. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Jones J. Odontoid fracture. Radiopaedia.org. rID: 9137. https://radiopaedia.org/articles/odontoid-fracture. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Burns E. Atrial Fibrillation. Life in the Fast Lane. https://litfl.com/atrial-fibrillation-ecg-library/. Published 2019. Accessed August 28, 2019. CC BY-NC-SA 4.0.
None
Smith D. Normal CT head (3 years old). Radiopaedia.org. rID: 53696. https://radiopaedia.org/cases/normal-ct-head-3-years-old?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Puyo D. Subarachnoid hemorrhage. Radiopaedia.org. rID: 22377. https://radiopaedia.org/cases/subarachnoid-haemorrhage-4. Published 2019. Accessed August 28, 2019. CC BY-NC-SA 3.0.
None
Samir, B. Femoral shaft fracture. Radiopaedia.org. rID: 22120. https://radiopaedia.org/cases/femoral-shaft-fracture-2?lang=us. Published 2020. Accessed June 3, 2020. CC BY-NC-SA 3.0.
None
Burns E. Lateral STEMI ECG changes. Life in the Fast Lane. https://litfl.com/lateral-stemi-ecg-library/. Published 2019. Accessed August 28, 2019. CC BY-NC-SA 4.0
None
Harvey H. Pelvic fractures. Radiopaedia.org. rID: 6611. https://radiopaedia.org/articles/pelvic-fractures. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Jones J. Normal pelvis x-ray AP. Radiopaedia.org. rID: 36147. https://radiopaedia.org/cases/normal-pelvis-x-ray-ap. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Maled I, Velez R, Lopez R, Batalla L. Pseudoaneurysm of the superior gluteal artery during iliosacral screw fixation. Acta Orthopaedica Belgica. 2007;73(4):544–547.
None
Pinotti E, Santurro L, Famularo S, Uggeri F. Surgical removal of radiolucent lodged bullet fragment 5 years after a shotgun injury. Open Journal of Clinical and Medical Case Reports. 2017;3. CC BY 4.0.
None
Venkatesh M.. Extension teardrop fracture. Radiopaedia.org. rID: 26327. https://radiopaedia.org/articles/extension-teardrop-fracture-1?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Smith D. Normal CT head (3 years old). Radiopaedia.org. rID: 53696. https://radiopaedia.org/cases/normal-ct-head-3-years-old?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Brick C. Clinical Ultrasonography 101: Where Right Upper Quadrant Scans Go Wrong - CanadiEM. [online] CanadiEM. Available at: https://canadiem.org/right-upper-quadrant-scans-go-wrong/. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 4.0.
None
Jerome JTJ, MNAMS, Varghese M, Sankaran B, Thirumagal K. Lateral subtalar dislocation of the foot: a case report. The Foot and Ankle Journal. 2008;12(2). doi:10.3827/faoj.2008.0112.0002.CCBY.
None
Agrawal AC, Raza HK, Haq RU. Closed posterior dislocation of the ankle without fracture. Indian J Orthop. 2008;42(3):360–362. doi:10.4103/0019-5413.41864.CC-BY.
None
Smith D. Normal CT head (3 years old). Radiopaedia.org. rID: 53696. https://radiopaedia.org/cases/normal-ct-head-3-years-old?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Kwon DH, Moon JD, Park WJ, et al. Case series of keratitis in poultry abattoir workers induced by exposure to the ultraviolet disinfection lamp. Ann Occup Environ Med. 2016; 28:3. Published 2016 Jan 15. doi:10.1186/s40557-015-0087-7. CC BY 4.0.
None
Salam, H. Pulmonary contusion. Radiopaedia.org. rID: 13270. https://radiopaedia.org/cases/pulmonary-contusion-2?lang=us. Published 2020. Accessed June 4, 2020. CC BY-NC-SA 3.0.
None
Gaillard F. Lung hyperinflation. Radiopaedia.org. rID: 10550. https://radiopaedia.org/articles/lung-hyperinflation-1?lang=us. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 3.0.
None
Brick C. Clinical Ultrasonography 101: Where Right Upper Quadrant Scans Go Wrong - CanadiEM. [online] CanadiEM. Available at: https://canadiem.org/right-upper-quadrant-scans-go-wrong/. Published 2019. Accessed August 13, 2019. CC BY-NC-SA 4.0.
None
Gundlapalli VS. Recurrent evisceration from Mcburney’s incision. International Journal of Case Reports and Images 2012;3(6):54–56. CC BY 4.0.
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