Uttarakhand is an Indian state in the Himalayan foothills, a favored adventure destination in the country due to abundant natural beauty. However, the terrain has also conferred an increased risk of earthquakes, flash floods, and major road tragedies, resulting in as many as 8 major natural disasters in the state in the preceding 20 years. AIIMS Rishikesh, an autonomous central institute, has been entrusted to build a Level 1 Trauma Center in Uttarakhand, which would help improve the response, coordination, and hence outcome in mass casualty scenarios (MCSs).

As a step toward the achievement of this larger goal, a workshop on MCS and management was conducted by the Department of Trauma Surgery in collaboration with Rambam Hospital, Haifa. We hereby present our template for conducting MCS drills in low resource settings like ours and the lessons learnt.

Process, logistics, limitations, workforce, scheduling, overview, and report of the MCS drill conducted are discussed hereafter.

This template may be replicated by hospitals that intend to conduct similar MCS drills in low resource settings, realizing the real threat of MCS occurrence in our country at anytime.

Mock Code Training is an exercise designed to develop competency in emergency responsiveness. The objectives for this educational intervention were: (1) demonstrate basic airway maneuvers (2) demonstrate basic life support-cardiopulmonary resuscitation (BLS-CPR); (3) demonstrate when and how to call a Code; (4) recognize life-threatening cardiac arrhythmias; (5) initiate relevant cardiac monitoring; and (6) initiate relevant resuscitation based on algorithms.

Drills were conducted monthly on various inpa-tient and outpatient nursing units at the University of Wisconsin Hospital and Clinics. The following data was collected: (1) chime sounded; (2) basic patient assessment; (3) universal precautions; (4) compressions; (5) automated external defibrillator (AED) arrival; (6) unit emergency cart arrival; (7) oxygen administration; (8) code team arrival; (9) Advanced Cardiac Life Support (ACLS) Guidelines; (10) presence of recorder; (11) monitor initiation; (12) advanced airway; (13) intravenous (IV) access; (14) medications; (15) and time resuscitation ended.

The mean results were: (1) action for delivery of compressions = 1 minute, 10 seconds; (2) unit emergency cart arrival = 2 minutes, 15 seconds; (3) oxygen-bag valve mask = 3 minutes, 10 seconds; (4) defibrillation = 7 minutes; (5) code team arrival = 3 minutes, 33 seconds; (6) ACLS Guidelines Initiated = 6 minutes, 13 seconds; (7) monitor initiation = 5 minutes, 33 seconds; (8) advanced airway = 6 minutes; (9) IV access = 3 minutes, 15 seconds; and (10) medication administration = 6 minutes, 30 seconds.

The objective of this study was to determine providers' opinions of SALT Triage after receiving training and using it during a simulated mass-casualty incident.

A survey was conducted of trainees in a disaster course. Trainees were given a-30 minute lecture on SALT (sort, assess, life-saving interventions, treatment and/or transport) Triage and then used it during a drill. After the drill, trainees were asked to complete the survey. Results were analyzed using descriptive statistics.

Thirty trainees (11 medical doctors (MDs), six registered nurses (RNs), eight emergency medical technicians (EMTs), one RN/EMTs, four other) participated in the course. Of these participants, 67% had prior drill experience (mean: 10 drills) and 37% had prior mass-casualty incident experience (mean: four experiences). Prior to the drill: 7% reported that they felt very confident using SALT Triage, 33% were confident, 30% were somewhat confident, and 30% were not confident. After the drill: none reported not feeling confident using SALT Triage, 27% were at the same level of confidence, 73% felt more confident, and none felt less confident. Before the drill: 52% of respondents felt SALT Triage was easier to use than their current disaster triage protocol, 44% felt it was similar, and 4% felt it was more difficult. After the drill: 67% did not change how easy they felt SALT Triage was to use, 26% thought it was easier to use, and 3% thought it was similar.

Providers felt confident using SALT triage after a 30-minute training session and found it was similar or easier to use than their current triage protocol. Using SALT Triage during a drill improved confidence.

A mass toxicological event (MTE) caused by an act of terrorism or an industrial incident can create large numbers of ambulatory casualties suffering from mild intoxication, acute stress reaction (ASR), and exacerbation of chronic diseases or iatrogenic insult (such as atropine overdose). The logistical and medical management of this population may present a challenge insuch a scenario. The aim of this article is to describe the concept of the Israeli Home Front Command (HFC) of a “Mild Casualties Center” (MCC) for a chemical scenario, and to analyze the results of two large-scale drills that have been used to evaluate this concept.

Two large-scale drills were conducted. One MCC drill was located in a school building and the second MCC drill was located in a basketball stadium. These medical centers were staffed by physicians, nurses, and medics, both military (reservists) and civilian (community, non-hospital teams). Two hundred simulated patients entered the MCC during each of the drills, and drill observers assessed how these patients were managed for two hours.

Of the casualties, 28 were treated in the “medical treatment site”, 10 of which were relocated to a nearby hospital. Only four casualties were treated in the large “mental care site”, planned for a much higher burden of “worried well” patients. Documentation of patient data and medical care was sub-optimal.

A MCC is a logistically suitable solution for the challenge of managing thousands of ambulatory casualties. The knowledge of the medical team must be bolstered, as most are unfamiliar with both nerve gas poisoning and with ASR. Mild casualties centers should not be located within hospitals and must be staffed by non-hospital, medical personnel to achieve the main task of allowing hospital teams to focus on providing medical care to the moderate and severe nerve gas casualties, without the extra burden of caring for thousands of mild casualties.

No universally accepted methods for objective evaluation of the function of the Incident Command System (ICS) in disaster exercises currently exist. An ICS evaluation method for disaster simulations was derived and piloted.

A comprehensive variable list for ICS function was created and four distinct ICS evaluation methods (quantitative and qualitative) were derived and piloted prospectively during an exercise. Delay times for key provider-victim interactions were recorded through a system of data collection using participant and observer-based instruments. Two different post exercise surveys (commanders, other participants) were used to assess knowledge and perceptions of assigned roles, organization, and communications. Direct observation by trained observers and a structured debriefing session also were employed.

A total of 45 volunteers participated in the exercise that included 20 mock victims. First, mean, and last victim delay times (from exercise initiation) were 2.1, 4.0, and 9.3 minutes (min) until triage, and 5.2, 11.9, and 22.0 min for scene evacuation, respectively. First, mean, and last victim delay times to definitive treatment were 6.0, 14.5, and 25.0 min. Mean time to triage (and range) for scene Zones I (nearest entrance), II (intermediate) and III (ground zero) were 2.9 (2.0–4.0), 4.1 (3.0–5.0) and 5.2 (3.0–9.0) min, respectively. The lowest acuity level (Green) victims had the shortest mean times for triage (3.5 min), evacuation (4.0 min), and treatment (10.0 min) while the highest acuity level (Red) victims had the longest mean times for all measures; patterns consistent with independent rather than ICS-directed rescuer activities. Specific ICS problem areas were identified.

A structured, objective, quantitative evaluation of ICS function can identify deficiencies that can become the focus for subsequent improvement efforts.

Recently, mass-casualty incident (MCI) preparedness and training has received increasing attention at the hospital level.

To review the existing evidence on the effectiveness of disaster drills, technology-based interventions and tabletop exercises in training hospital staff to respond to an MCI.

A systematic, evidence-based process was conducted incorporating expert panel input and a literature review with the key terms: “mass casualty”, “disaster”, “disaster planning”, and “drill”. Paired investigators reviewed citation abstracts to identify articles that included evaluation of disaster training for hospital staff. Data were abstracted from the studies (e.g., MCI type, training intervention, staff targeted, objectives, evaluation methods, and results). Study quality was reviewed using standardized criteria.

Of 243 potentially relevant citations, twenty-one met the defined criteria. Studies varied in terms of targeted staff, learning objectives, outcomes, and evaluation methods. Most were characterized by significant limitations in design and evaluation methods. Seventeen addressed the effectiveness of disaster drills in training hospital staff in responding to an MCI, four addressed technology-based interventions, and none addressed tabletop exercises. The existing evidence suggests that hospital disaster drills are effective in allowing hospital employees to become familiar with disaster procedures, identify problems in different components of response (e.g., incident command, communications, triage, patient flow, materials and resources, and security) and provide the opportunity to apply lessons learned to disaster response. The strength of evidence on other training methods is insufficient to draw valid recommendations.

Current evidence on the effectiveness of MCI training for hospital staff is limited. A number of studies suggest that disaster drills can be effective in training hospital staff. However, more attention should be directed to evaluating the effectiveness of disaster training activities in a scientifically rigorous manner.