by Preethi.K & Santhiya.E, Final Year Healthcare, TIPS Global, Coimbatore


A hospital is a place where people get diagnosed, cured physically as well as mentally. Most of them are scared to hear the sound of an ambulance on the roads. During these days due to large population and heavy traffic with no patience and no fear for life, lot of road accidents happen. We would realize how life is important when we enter into casualty/emergency department, where medical professional’s daily fight for several lives to save them and their delay for a minute would kill a patient. So this article provides you the information on various aspects of casualty management.

Why do we think it is important?

“An accident won’t arrive with a bell on its neck”

In the last decades more than 2.6 billion people have become casualties of natural disasters. Acute events such as natural disaster earthquakes, landslides and cyclones and rising tide events such as floods or severe cold weather can result in significant number of casualties.

Mass Casualty Incident can be classified as

  • Natural
  • Accidental or
  • Intentional event

As mentioned in above figure, an estimated 1.2 million people are killed and as many as 50 million people are injured each year in road crashes, of which large number are mass casualty incidents. Projections indicate that this will increase by about 65% over the next 20 years. Conflict and civil unrest also contributes to trauma cases.


Whenever there is an accident on a road we used to dial for an ambulance on the spot and when ambulance arrives as quick as possible, the first aid and CPR required will be given in ambulance and will be taken to the hospital straight away. Most of them know by the name emergency department in hospital and it is termed as causality department, where the attention and treatment is given immediately for the patients who need prompt medical attention, then it is called emergency.

The causalities are patients who come for emergency care, they may be from

  • Road accidents
  • Fire accidents
  • Air craft accidents
  • Building collapses
  • Explosions
  • War
  • Natural disaster
  • Due to stroke or heart attack

Mass causality management:

Think of a situation where you prepare food for standard number of people basically family members but when you see your relative’s arrival; there will be shortage for food. Likewise, hospitals have allotted standard resources for emergency care, when the numbers of casualty patients are more than the available resources of the emergency department; then it is a mass casualty management. When there are emergency patients more than 1 and should be at least three, it is called as multi casualty management.

Principles of disaster plan:

  • There should be a plan for the hospital to manage the causalities from mass incidents.
  • Plan the emergency department for receiving 100-200 patients.
  • Use colour code for triage system
  • Should get collectors permission for sample post mortem
  • Set teams, so that they readily receive the patients without confusions
  • Use triage system for all the available resources to use wisely.
  • Implement the plan.

“A good process produces good results”

As the saying goes with, each and everything has a process on its own, likewise this Para explains on the process of casualty management.






At this first stage of the process, hospital will get a call from the incident site regarding the emergency care need. Each and every hospital has disaster plan made prior for implementing immediately for managing minimal and mass casualties. The superior medical superintendent will collect information regarding the place, time and type of incident and type of casualties expected and every medical professional will be intimated for the preparedness. When the alert is made by the public or non-qualified person should reconfirm the incident once.

After the alert and response step, safety and security will be implemented by restricting the flow of visitors and other external factors from the point of care given to the casualties. The hospital securities will be assisted with the police personnel for controlling the traffic inside the hospital.

When there are mass casualties, there is a need for expansion of emergency area with the expansion of wards, seminar halls and operation theatres should be fully functional. Even when hospital space is not adequate to accommodate the patients, nearby halls, colleges and other institutes can be accommodated.


You may wonder what triage system is…..

Triage system is effective and efficient process to easily sort out the patients who need medical care immediately; prioritize the patients who are more injured according to the urgent need of medical care and distribute the available medical resources to the patients accordingly by medical professionals.

Who are all involved in triage process?

1) General Surgeon-1

2) Orthopaedic Surgeon-1

3) Physician-1

4) Anesthetist-1

5) Staff Nurses-2

6) Nursing Attendants

7) Sweeper-1

8) Two teams of stretcher-bearers, each having a stretcher.


This stage involves two procedures; first procedure is resuscitation, and second is treatment of specific illness.


This is done only if needed when there is lack of breathing or when there is no heartbeat for the patient. This procedure acts as a first aid action to save lives before the treatment, to revive the heart beat or breathing. This becomes difficult at time of mass casualty management. When there are more casualties greater than the medical professionals and resources, it is hard to perform. So that’s why triage system is used to sort and prioritize the patients need resuscitation where they are given severe treatment and care but they are not responding to the treatment, Even though every attempt should be made to save the life.


After the triage process the patients with the major injuries should be taken to the respective area of medicine for treatment, diagnosis and if surgery needed and the minimal wounded patients can be wound dressed by nurses with the consult of doctors and if needed TT injections and painkiller should be provided. When patients come from disaster incidents they may have dislocated bones and internal injuries which have to be immediately taken care.


This documentation process should work simultaneously along with the first step, identifying the patients, collecting details, giving them unique hospital identification number and labelling.

Casualties of rapid onset disaster are:

  • Blunt trauma
  • Crush related injuries
  • Drowning and
  • Mental health issues


Pressure cooker bomb blast In Boston during marathon on 2013

During this marathon the pressure cooker bomb blast was last about 13 seconds. There were 264 people injured and 3 are died. The people are placed in the Boylston Street. This blast blew out windows of buildings nearby and doesn’t cause any structural damage. Rescue workers and medical professionals came there to assist the people. The 264 people injured were treated in local hospitals. 14 people lost their organs as a result of bomb blast.

                     Boston Marathon Bombing: Smoke from the explosion

Communication Limitation

The Massachusetts Emergency Management Agency says people are trying to contact nearby by text messages rather than using voice calls as cell phone service is congested. At the same time cell phone services were shutdown to control the blast.

Assisting family and friends

The American Red Cross assisted concerned friends and family to receive information about casualties. Boston police department also formed a helpline for people worried about relative and friends.

Activation of treatments

Brigham and Women’s Hospital, received 31 patients 28 of them are significantly injured came at 3:08pm. Seven of them are severely injured who needed emergency surgery. First surgery was done with patients in shock, hemorrhaging, inadequate breathing were revived at 3:23 pm. All these are managed using smart (Simple triage and rapid treatment) tag triage system.

Strategies For Hospitals During Casualty Management

Nowadays the number of casualty incidents are higher as number of accidents are increasing. The mass casualty incidents occurring all over the world says the sudden surge in MCI, was unable to manage.

To overcome this, proper planning is needed. “Failing to plan is planning to fail.” Due to overwhelming of MCI, the health care system and government is forming steps to manage mass casualties. A survey conducted by American college of Emergency physician (ACEP), most of the participants said “Emergency departments are not fully prepared for managing patient surge due to natural or man-made incidents.

MCI management principles are given below, which can be updated to manage mass casualties.

The three main phases of MCI plan

  • Pre-MCI phase
  • Response to MCI
  • Post MCI phase

1) Pre MCI phase

A) Forming a Plan

Planning for MCI is needed by all hospitals to ensure that goals are set and formatted to successful implementation during sudden emergency circumstances. In this plan the participation of Pre hospital team (EMS) and hospital management includes both clinical and non-clinical are important. This plan should emphasis the roles and responsibilities of each professional. MCI plan should detail about the process, policies and plan.

B) Vulnerability & Capacity

This is to identify hazards or threats in the community and the ability to prevent and respond for Mass Casualty Management (MCI). It is important that hospitals identify such threats nearby. However it is not always possible to know all the hazards in the community.

C) Training and Education

Forming a policies and action plan is not only enough. Proper training and education for professionals in MCI team is important. Training and education can be done through self-learning, Seminars, lectures, Conferences, Workshops and exercises.

D) Monitoring and Evaluation

Once the planning stage is completed, the next step is to invent MCI simulation exercise. It is an instrument to train, assess and improve the performance in protection, response and recovery potential in risk free environment. MCI simulation exercises not only validate plans, policies and interagency agreements, it also improves communication, clarifying roles and identifying mistakes in the preparation. In developed countries there is regular usage MCI simulation exercise. Most commonly they have agencies to execute and evaluate the MCI simulation exercise. There should be clear objective for hospitals for proper MCI preparedness. These agencies provide an evaluation report which gives suggestion to improve the process.

2) Response to MCI

The live action takes place based on the policies and guidelines provided in the planning stage.

A) Notification

The hospital will be informed by agencies or police about the incident.

B) Activation of MCI plan

Once the incident is informed, the allocation of individual who assess the information and have authority to activate the MCI incidents is made. This process continues till deactivation of triage management.   

C) Patient Triage and Management

During MCI, too many critical patients are there for limited resources. So a senior emergency physician is important for proper guidance and treatment. Primary triage is performed once the arrivals of patients, in a particular area larger than usual triage system. The patients then go through secondary triage once the interventions are made and there is availability of resources. Tertiary triage is performed for patients who received ongoing intervention. Resuscitation and stabilizing the patient is done in emergency room. If patient becomes stable, they moved from emergency based on the availability of resources.

D) Hospital Security

After MCI plan activation the security is increased, it not only stops the staff, patient and public movement but also provides protection to staff. These security arrangements are key in biological, infectious and radiological emergencies. Inside the hospital, there need to be control over entrance electronically and outside the hospital, can get help from security agency or police.

E) Communication

For a smooth running of MCI plan communication is important. A control and command system should be there. If needed the relevant additional staffs should be called for help. Different resources can be used by the organization to communicate with public.

F) Deactivation of MCI plan

During an MCI a person should be allotted, who starts to plan for the recovery phase. This planning consists of staff support, re-supply, discharge planning, patient transfers and returning the surplus staffs to daily operations once the MCI plan is deactivated.

3. Post MCI 

A) MCI Response Review

Hospital has a main role in MCI response. Once MCI and simulation exercise is over it is important to analyze. Working during MCI differs from the regular routine work environment, because it gives more pressure to the frontline workers. After every such event a review is needed, which analyzes the strength and weakness. This assists to learn and enhance the resilience and sensitivity of an organization.

B) Longer Term Demands

During acute MCI, care is given for damage control and resuscitation. Once acute patient influx is over it takes time for organization to return to normal level. Admitted patient needed further treatments which impacts daily operation in the hospital. Hospital opens operating rooms and ICU beds for acute influx patients. After MCI, rehabilitation starts which include doctors, Nurses, physiotherapist and occupational therapist. Traumatic experience can lead to mental health issues for patient and families; hence support is required to identify the risk.

C) Staff Support

The effect of traumatic events can affect the physical and mental health of medical professionals. The organization should be ready to deal with such events. The medical staffs response differ, some may recover quick while others take some time and some have profound effect on their life. Staff support is critical for medium and long term post MCI planning.

Advantages of Mass Casualty Management

  • Focus on unpredictable MCI, and act as an alert mechanism
  • Early organized medical professionals
  • Prioritized and organized transportation
  • Alleviated bottlenecks in emergency rooms
  • Strong interagency co-operation
  • Early organized process
  • Early arrangements of facilities
  • Strong communication
  • Selection of appropriate location to victims
  • Continuous revision of patient status

Challenges of Mass Casualty Management System

  • Cost of training and re-training
  • Arranging equipment and supplies
  • Storage place needed for supplies
  • Dependency on inter agency cooperation
  • Delayed patient transport to hospital
  • Allocation of communication equipment


For managing the unexpected causalities, the only mantra each and every hospital should have is plan and prepare. Without proper planning, the real time execution will be difficult and brings in more confusions and errors. Hospital should prepare the personnel’s with training and education to act immediately. There are several technologies have come up for reducing the time and increasing efficiency. Technology should be used accordingly to save the lives by not letting them die by minutes. At last great salute to the medical professional who takes risk to save the lives with no proper sleep and food by controlling all their emotions. Professionals who are involved in emergency care tend to have post traumatic disorder, which severely affects their work life balance. So we will help them and respect them!



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