Mass Casualty Training

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 acrossthe nation has become an unfortunate necessity. In order to make individualsmore comfortable to responding in these types of situations the Clinical SkillsEducation and Assessment Center (CSEAC) at The Ohio State University College ofMedicine created an “active shooter” immersive mass casualty simulation thatwas used for first-responder training sessions. The CSEAC transformed a labspace within the simulation center into two movie theaters complete with alobby containing movie posters, a ticket counter, and popcorn to addsituational realism. This movie theater shooting simulation was created toprovide medical students, residents, nurses, and social workers with the skillsthey would need to work as a team and assign responsibilities amid a chaoticand disorganized setting.

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

Hands-On Skill Stations

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

Purchases and Budget

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

Setup

Two theaters were created side-by-side inthe simulation lab space. The large movie theater where the “shooting” occurredhad about forty-five chairs that the learners needed to work around, twelvestandardized patients/actors portrayed movie viewers, and eventually, victimsof the simulated shooting and six moulaged manikins were strategically placedaround the movie theater as victims. The smaller theater displayed a differentmovie, contained 15 chairs, and housed the “movie goer” group until theshooting began.

Objectives of Participants

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

Group One-Movie Theater Participants

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

Group Two-EMS

The next group of learners were the firstresponders/EMS group. This group had EMS vests on and a “first-in” bag thatthey brought into the movie theater, along with a few gurneys. Before the EMSgroup started their participation in the scenario, the movie goers provided ahand-off to them regarding what happened and what was completed with thepatients. 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 theirSALT triage training to assess the victims. They color tagged all of thevictims, placed tourniquets that had not been done, and placed the patients whorequired immediate care onto gurneys for transport to the Emergency Department.

Group 3-Emergency Department

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

A mannequin which sustained injuries during a mass casualty scenario.

Assessment Possibilities

Although the CSEAC was not responsible forparticipant assessment, opportunities did exist. For example, facilitatorscould evaluate video recordings of the event to assess learner knowledge in theuse of Run Hide Fight®, tourniquets, and SALT triage. Additionally, theseskills could be re-evaluated during future simulation sessions in order toexplore knowledge retention.

Summary

From an operations and engagementperspective, CSEAC reached out to many departments and faculty to accommodateas many leaner groups as possible in the two day period. This mass casualtytraining simulation allowed the learners to experience and respond to ashooting incident in a variety of roles. A similar training construct, could beapplied to many other scenarios, such as multiple car accidents, a bus orsubway disaster, bombings, or weather emergencies like a hurricane, tornado, orfire. Feedback from participants alluded to an improvement in their preparationfor such an event, including their knowledge of important behavioral steps, theskills required of them, and the critical communication steps in these types ofscenarios. The more learners are able to train, practice and debrief in thesesimulated situations, the more experience they will have with the criticalskills necessary to respond safely and effectively in a disaster situation.

Run, Hide, Fight® is a registered trademark of the City of Houston

About the Authors

Michelle Claypool is an Education ResourceSpecialist at The Ohio State University Clinical Skills Education andAssessment 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 theMedical Director of The Ohio State University Clinical Skills Education andAssessment Center. She oversees center operations and educational activitiesinvolving technical simulation and the standardized patient program.

Lisa Mayhugh is the Associate Director ofthe Clinical Skills Education and Assessment Center and has professionalexperience in the areas of student services, program management, andeducational 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.