Michelle Claypool, Sheryl Pfeil and Lisa Mayhugh describe the steps taken, cost allocated and groups involved in developing a mass casualty drill at Ohio State’s CSEAC.

Training for mass casualty events across the nation has become an unfortunate necessity. In order to make individuals more comfortable to responding in these types of situations the Clinical Skills Education and Assessment Center (CSEAC) at The Ohio State University College of Medicine created an “active shooter” immersive mass casualty simulation that was used for first-responder training sessions. The CSEAC transformed a lab space within the simulation center into two movie theaters complete with a lobby containing movie posters, a ticket counter, and popcorn to add situational realism. This movie theater shooting simulation was created to provide medical students, residents, nurses, and social workers with the skills they would need to work as a team and assign responsibilities amid a chaotic and disorganized setting.

 A debrief of a mass casualty drill. All images: CSEAC, Ohio State University.
A debrief of a mass casualty drill. All images: CSEAC, Ohio State University.

Hands-On Skill Stations

Prior to participating in the movie theater simulation, learners participated in a tourniquet skills session and received a presentation on triage. These two stations allowed students to learn and practice the skills that would be necessary in the simulation scenario. Tourniquet placement and use, wound care for bleeding, airway placement, IV placement, and needle decompression were some of the procedures that the participants learned and then applied during the simulation.

Purchases and Budget

The CSEAC had a target budget of $2,000 for the materials and construction and came in under budget. Some major purchases for this event were a 360° camera that was situated inside one of the movie theaters so the simulation could be live-streamed to another simulation lab for viewing, EMS vests for the first responders, and piping and drapes for the actual movie theater setup. Although staff work hours were not accounted for in the costs, the simulation staff allocated approximately 150 hours to the scenario design, meetings with faculty leaders, training sessions for the standardized patient participants, construction, setup, moulage for standardized patients (movie theater victims), actual scenario run through, and cleanup.


Two theaters were created side-by-side in the simulation lab space. The large movie theater where the “shooting” occurred had about forty-five chairs that the learners needed to work around, twelve standardized patients/actors portrayed movie viewers, and eventually, victims of the simulated shooting and six moulaged manikins were strategically placed around the movie theater as victims. The smaller theater displayed a different movie, contained 15 chairs, and housed the “movie goer” group until the shooting began.

Objectives of Participants

The session was repeated three times over a two day period which allowed learners from four different disciplines to participate. All of the learners in the simulation had three main objectives: 1) Execute a mass casualty triage using the SALT (sort, assess, lifesaving interventions, treatment/transport) algorithm for multiple victims of an active shooter event; 2) Demonstrate relevant lifesaving interventions, including the use of a tourniquet, and 3) Provide advanced trauma life support to multiple victims of a mass casualty incident in an Emergency Department setting. In order to accomplish these objectives the participants were divided into three groups: movie goers, first responders, and Emergency Department personnel. The group division allowed all learners to have hands on training at different parts in the simulation.

Group One-Movie Theater Participants

The first group of movie goers was in the small theater when the initial simulated shots were fired. The CSEAC had a movie playing and about three to five minutes into the movie the simulated shots (a soundtrack created by the CSEAC staff) were fired in the large theater. The participants had to respond using the “Run, Hide, Fight” response for active shooter situations. Once the shooter was confirmed “down,” and the scene declared safe, the movie goers were allowed into the theater to assess the situation.

Group Two-EMS

The next group of learners were the first responders/EMS group. This group had EMS vests on and a “first-in” bag that they brought into the movie theater, along with a few gurneys. Before the EMS group started their participation in the scenario, the movie goers provided a hand-off to them regarding what happened and what was completed with the patients. Then the movie goers were excused to go to the “live-streaming” room, where they viewed the remainder of the simulation. The EMS group used their SALT triage training to assess the victims. They color tagged all of the victims, placed tourniquets that had not been done, and placed the patients who required immediate care onto gurneys for transport to the Emergency Department.

Group 3-Emergency Department

The final group of learners was in the simulated Emergency Department located in one of the simulation bays in the CSEAC. This group had been watching the live stream from the cameras during the entire scenario, so they knew they were receiving shooting victims. The scenario involved three patients being simultaneously sent to the Emergency Department which required the learners to “divide and conquer.” In addition, a few “family members” played by standardized patients (confederates) arrived at the ED looking for their loved ones throughout the scenario. Not only did the learners have to treat the patients, but they also had to engage the family members and determine how to properly communicate with them.

A mannequin which sustained injuries during a mass casualty scenario.
A mannequin which sustained injuries during a mass casualty scenario.

Assessment Possibilities

Although the CSEAC was not responsible for participant assessment, opportunities did exist. For example, facilitators could evaluate video recordings of the event to assess learner knowledge in the use of Run Hide Fight®, tourniquets, and SALT triage. Additionally, these skills could be re-evaluated during future simulation sessions in order to explore knowledge retention.


From an operations and engagement perspective, CSEAC reached out to many departments and faculty to accommodate as many leaner groups as possible in the two day period. This mass casualty training simulation allowed the learners to experience and respond to a shooting incident in a variety of roles. A similar training construct, could be applied to many other scenarios, such as multiple car accidents, a bus or subway disaster, bombings, or weather emergencies like a hurricane, tornado, or fire. Feedback from participants alluded to an improvement in their preparation for such an event, including their knowledge of important behavioral steps, the skills required of them, and the critical communication steps in these types of scenarios. The more learners are able to train, practice and debrief in these simulated situations, the more experience they will have with the critical skills necessary to respond safely and effectively in a disaster situation.

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About the Authors

Michelle Claypool is an Education Resource Specialist at The Ohio State University Clinical Skills Education and Assessment Center and has been involved with simulation for the past 3 years. In addition, she serves on the SimGHOSTS National Research Committee.

Sheryl Pfeil, MD, FACP, CHSE, is the Medical Director of The Ohio State University Clinical Skills Education and Assessment Center. She oversees center operations and educational activities involving technical simulation and the standardized patient program.

Lisa Mayhugh is the Associate Director of the Clinical Skills Education and Assessment Center and has professional experience in the areas of student services, program management, and educational administration.

Special acknowledgement to Scott Winfield, Jessica Tindall, Todd Lash, Dr. Daniel Bachman, Dr. Nicholas Kman, and the entire Ohio State University Wexner Medical Center Emergency Department for their role in the design, implementation, and success of this simulation program.

Originally published in Issue 4, 2018 of MTM Magazine.