The journey of every medical deployment is paved with massive amounts standard operating procedures, training, lessons learned, down time, assigned additional duties, and satisfying endless spreadsheets. In the end, the real evaluation that matters is how a hospital performs under pressure when its capabilities, personnel and resources are stretched beyond its known capable limits. The results of a hospital’s report card that really matter is how they respond in a mass casualty event, more commonly known as a MASCAL. A MASCAL is a when the hospital takes on more patients than it can handle and is usually the result of some kind attack or large-scale accident. All hands-on deck is required, and every Soldier in the Role III gets to work. Non-medical personnel convert into transport teams and medical personnel from outside units fall in on the hospital where needed.

“MASCALs really start with good triage,” said Maj. Matthew Ramey, Joint Task Force Med 374 Chief Nurse, who is also oversees clinical operations on site.

Triage is the process of the sorting patients according to their medical categories which determines the priority care for a patient. Patients at risk of losing life limb or eyesight are assigned a higher triage category then a Soldier who has sustained lesser injuries and does not have to be seen right away.

“Triage is one of the big areas that we train in. If patients are not properly triaged and given the proper categories, it can cause patient flow issues throughout the different sections of the hospital,” said Ramey. “It really comes down to good group of people conducting triage when patients arrive and funneling the right patients in.”

The overall goal of battlefield triaging is using what supplies and resources that are available that can benefit the most Soldiers. In some situations, depending on the location and resources on ground, tough decision might have to be considered for a Soldier with fatal injuries and low chance of survival, in order to give other Soldiers the chance to life.

“This is just the tough side of triage and why it is so important that it is done right,” said Ramey. “No one wants to say a patient is expectant (expected to die). We know that Soldier might be a father and a mother, but we are not able to treat other Soldiers if we use all our resources on one Soldier.”

To help make the MASCAL scenarios as realistic as possible, the Task Force has been fortunate enough to have its own group of Hollywood aspiring makeup artists. These Soldiers, commonly referred to as the moulage team, help prepare simulated patient wounds to make treatment for the medical staff as realistic as possible. In their spare time, they have done their own moulage experiments to improve their craft.

Capt. David Kyrie, RN is the OIC for the group and has been impressed by the groups level of motivation, curiosity and creativity.

“The moulage team is made up all volunteers, requiring each of them to show up two hours before. Sometimes that meant getting up really early and they always showed with a great attitude and I never heard them complain once,” said Kyrie.

Another key component of MASCAL training is communication within the hospital as well as the battle space. Senior hospital staff and providers must know what kind of patient are coming in, where they are coming from, when they could be arriving, what kind of care will be required, as well as considerations of how a patients will get to the next level of care. To do all this requires efficient communications networks and a team that monitors patient movements every step of the way. This is the primary task of the PAD (patient administrative) team, keeping track of all patient movement inside and outside the hospital.

“It gets pretty chaotic,” said Schopper, assigned JTF MED 374 PAD NCO. “The first ten minutes of a MASCAL is pretty crazy and they dump a lot of patients on you all the once. It is important to stay calm and stay in constant communication the entire time.”

To monitor incoming and outgoing patients, the PAD team relies on the radio communication within the team as well as communication with higher. PAD members are strategically positioned throughout the hospital and then use voice radios and runners to keep the patient tracking board up to date. All patients are given pseudo socials and arm bands to assist in the tracking process.

After the hustle and bustle of the MASCAL calms down, the PAD team’s responsibilities does not slow. Now that patients have been assessed, treated, stabilized, with all related documentation, the real wok begins of getting them to the next level of care. Real world, this takes a high level of coordination by the PAD team coordinating all movement of patients within the middle east and beyond. While the main purpose of the Role III Hospital is to care for U.S. Soldiers, this same level of responsibility and quality of care is extended to foreign and domestic contractors, as well as the other NATO Coalition Forces to include 77 other nations.

“Each of the different countries and Soldiers has their own insurance plans and ways they bill for care,” said Schopper. “Most of the time we send our Soldier to Germany, but for these other countries we have to find out a way to get them back to their own country and how that country is going to pay. Sometimes the insurance companies will not approve for a procedure, or the type of transportation we have available. There is so much behind the scenes stuff that we have to do to move patients. There is a lot of phone calls that have to happen. I have learned a lot on patient movements.”

In addition to the MASCAL drills and the key involvement of PAD, key persons in the Task Force and surrounding units hold regular meetings to discuss and make improvement to their processes. Key medical personnel visit outlying sites to participate in the collaborative training with other Role I, and Role II facilities as well all nearby air medical units commonly referred to as “Dust Off.’

“Complacency can kill,” said Ramey. “That’s why we do these MASCAL drills and work regularly with our other units. Its really easy to get into a rut. These training exercises are an attempt to stay out of these ruts and keep making improvements. When we look back on the trainings we are able to look at where our issues are and this helps us prepare for next one. Everyone brings ideas to the table, and this helps us test out our protocols which have the potential to be used elsewhere. Our lessons learned have the potential to be used by other agencies like the Department of State, Department of defense and even FEMA.”