While security may not seem to be a direct medical responsibility, it is always your concern, since the current asymmetric battlefield entails risk at all echelons of care, from aid station to theater hospital. Ongoing enemy action at the scene will force limited “care under fire” response. Fire superiority can be the “best medicine” until the site is secure, but medical personnel pull triggers only if security elements cannot meet the demands. Avoidable injuries to the medical team can doom its mission. Security forces should quickly assess for catastrophic secondary attacks and establish a safe perimeter for the treatment facility or triage site. If chemical contamination is a risk, a sweep of incoming casualties may be required, but available chemical detectors will slow your triage and treatment process.

Your MASCAL plan should incorporate a thorough plan for providing safety and security to the patients and facility staff. The priorities should be on securing the area, controlling vehicular access, controlling pedestrian access, and assisting with the management of enemy or suspected enemy casualties. Although hospital units have traditionally been off-limits during conventional warfare, they are seen as a high-value target by enemy forces in current combat operations. All unknown vehicles or persons must be verified and searched prior to allowing them access to the facility. Enemy casualties should be searched and secured, even if it does delay care. Controlling access then becomes the most important security function, as people will naturally gravitate to the hospital area when there is a MASCAL situation. Although most are well intentioned, if you allow access to bystanders and nonessential personnel, you will only make an already chaotic situation worse.

The current military casualty triage and evacuation system uses a model of echelons of care with progressively increasing capabilities, from point of injury (Level 1) to Level 5 hospitals in the USA (Table 2.1). Your unit’s role in the casualty care continuum in both military and civil contexts will shape its trauma response, whether it is Level 1 unit point of injury care on the forward battlefield, Level 2 lifesaving damage control surgery, or Level 3 vascular reconstruction. While not ironclad, Level 1 units are often first responders to civil and military events, with “on-scene care” and care under fire. Level 2 units frequently receive ground- and air-transported casualties, and Level 3 facilities are geared to receive air-evacuated casualties as “fresh trauma” from point of injury and Level 1 units and as stabilized casualties from Level 2 units which have already performed initial lifesaving surgical management. Local host nation hospitals may be able to receive and manage wounded national patients in order to augment a unit’s MASCAL response.

Medical personnel will benefit from trauma care experience prior to deployment. Advanced trauma life support (ATLS) training is a must but should be supplemented with additional combat and service-specific courses. Since units are often built with personnel who have minimal time together before deployment, common training can accelerate cohesive unit response in theater. Be sure to survey personnel in your unit and on the base to find capable people “hidden” in other units or in command and staff billets. You can often identify individuals with medical skills beyond their duty titles that can be helpful in MASCAL scenarios. Since many units receive and treat more civilian than military casualties, specialty skill sets such as pediatrics, obstetrics, or burn care can be invaluable.

Competent cultural assistance is vital in international trauma response. Medically seasoned interpreters are essential team members at the bedside throughout the triage and treatment process. They play a huge role in shaping culturally sensitive care. Unit members who learn basic local language greetings and health questions can enhance trust and effectiveness in the care of wounded nationals. A capable bicultural or host nation medical officer or authority can “sweep” the injured to identify family groupings or key individuals such as high-ranking government officials or celebrities. The same liaison can help disposition injured host nationals to national medical providers and facilities if medical personnel have cultivated relationships with them. In Afghanistan, tea with the local hospital director resulted in over 20 rapid patient transfers to his facility during a busy summer month, allowing quicker facility recovery and better support of coalition operations. In Baghdad, the combat support hospital (CSH) hosted shared continuing medical education (CME) for local physicians to build trust in sessions orchestrated by a contracted Iraqi-born civil medical liaison physician. US Marine Forces operating in Al Anbar routinely augmented medical missions in support of local Iraqi physicians and provided resources, medical supplies, and logistics that their healthcare infrastructure lacked, building trust bonds.

Casualty care can consume large volumes of supplies, and resupply will be a major determinant of unit casualty response. Many units develop lists of trauma response supplies and cache them in strategic locations. Be sure to note expiration dates prominently if IV fluids or meds are part of these contingency stores. Define transportation and evacuation resources and routes. Transport options are exquisitely sensitive to tactical situation, terrain, and weather. A dust storm can eliminate rotary wing evacuation of casualties. Stabilization and rapid transport to a higher level of care are the main mission for Level 1 and nonsurgical Level 2 units without patient hold capability or resources to “sit on” casualties. If you depend on rotary wing evacuation, prepare ground evacuation or patient hold contingency plans in case aircraft are grounded.

Analyze and plan for the mission, engaging all stakeholders to choreograph a shared response that remains flexible enough to match unique events. (See Fig. 2.1 for simple plan template.) The MASCAL mnemonic (minimize chaos, assess, safety, communication, alert, and lost) is a great starting point and guide (Fig. 2.2). Key considerations include security and protection needs, command and control, communication means and frequencies, casualty collection points (CCPs) , medical resupply, litters and straps, and personal protective equipment posture. Landing zones need to be defined with marking devices at the ready, and lights are needed for outdoor night operations. Safe transportation routes into and out of the area must be clearly defined, with special attention not to endanger casualties and treatment areas on the ground. Casualties will need to be disarmed, and suspected enemy combatants will need to be appropriately monitored. Many sites modify the Incident Command structure employed in emergency response at many US hospitals, where an overall incident commander directs coordinators with specific responsibilities such as triage, treatment teams, security, logistics, public affairs, manpower pool, security, transportation, and evacuation.

Trauma readiness is a daily preoccupation, particularly tough for units with infrequent trauma and rare opportunities to put plans into practice. Rehearsal of the MASCAL plan with real people in litters or beds during exercises will identify vulnerabilities better than by brainstorm or tabletop drills. Practice with both continuous patient loads and sudden surges, as the demands are different. Nearly all exercise after-action reviews identify breaks in command, control, coordination, and communication as the major “opportunities to improve” these MASCAL plans.

Successful trauma response hinges on effective communication and use of available resources. Employ elements of your MASCAL plan with every injured patient to exercise procedures and to develop “muscle memory” for bigger events. Since the formal MASCAL plan is initiated only when the top medical official decides that resources cannot keep up with medical demands, many units never need to launch the full plan. But the overload may be hard to recognize if a “slow burn” continuous stream of casualties, no one by itself too much for the facility, steadily depletes resources (a particular risk for Level 1 and 2 units). Sudden “flood” MASCALs are usually easily recognized, even before the wounded arrive at the facility.

If advance warning is received, preposition personnel in accordance with your MASCAL plan and anticipated needs. Notify all on-duty personnel and make sure you have reliable methods in place (pagers, runners, public address system) to activate a full recall of all key off-duty personnel. Close proximity of living areas for personnel can minimize notification and response times. MASCALs rarely happen when your hospital is empty, so you must incorporate a plan for expanding bed capacity as well as relocation or discharge of current inpatients. Security forces can be deployed, and the manpower pool can be mobilized in advance to be ready as runners, litter bearers, blood donors, and other non-provider responders.

While any unit can quickly find itself in a “casualty scene” response, such as when local blast casualties flood its gates, Level 1 units may be more frequently called to initiate hasty on-scene triage and response near hostile fire. A quick survey of the scene will define security issues, as well as the number and nature of injuries. An effective tool in outdoor response is the triage triangle (Fig. 2.3), allowing the triage officer to move around the center to quickly assess each patient and to direct interventions as needed to “treat and transport.”