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”Organization before care!” - Mass casualty incident training in Stockholm

The triage team arrives at the scene of the bomb blast. Students from Karolinska play the victims of the attack.
Foto: Sonja Leister / Läkare Utan Gränser
Two participants of the training transport a girl with a leg injruy to the hospital.
Foto: Sonja Leister / Läkare Utan Gränser
The training is in full, physical motion: The team takes care of the patients that urgently need surgery in the red area of the hospital.
Foto: Sonja Leister / Läkare Utan Gränser
The team is examining a patient that was marked as "yellow" by the triage team which means they need surgery but are not the most urgent cases.
Foto: Sonja Leister / Läkare Utan Gränser
A gynceologist takes care of a pregnant women who broke her leg. The patient next to her does not get too much attention since the woman is continously shouting for help.
Foto: Sonja Leister / Läkare Utan Gränser
Before the training started a nurse prepared all the students and did their make-up to fake the injuries.
Foto: Sonja Leister / Läkare Utan Gränser
Sonia Peyrassol briefed the participating students before the training and gave them more instructins.
Foto: Sonja Leister / Läkare Utan Gränser

A bomb has exploded on a market close to an MSF project, approximately 20 people are injured or dead. The capacity of the hospital is overwhelmed by the medical needs. Organize and prioritize! - This was the focus of the recent Mass Casualty Incident Training for MSF field doctors and nurses working with gynecology, anesthesiology and surgery. The training was held during the GAS Week at Karolinska University Hospital in Stockholm in early March.

A man is sitting in the corner and seems apathetic, a pregnant woman is shouting for help, another woman, lying on the ground seems to be bleeding from her forehead. Fear and panic is in the air when the triage team arrives at the scene just minutes after what looks to have been a bomb blast. The team is checking the patients one by one.

Mass casualty incident training at Karolinska University Hospital

The victims are not real patients; they are 20 students from Karolinska University Hospital who have been briefed on their injuries and how to behave convincingly. All students wear make-up to fake injuries and a card around the neck presenting their vital signs. The triage team has to decide who is going to make it and who needs help first. Accordingly, they put cards of green, yellow or red around the patients’ wrists. Red indicates the most urgently needed surgery, yellow indicates required surgery that can wait, and green indicates only minor wounds. Dead and dying patients are assigned a black card.

The 20 participating field workers had half an hour to prepare. Each participant had a role in the exercise from stretcher bearer, to OT nurse, to coordinator – regardless of their actual professions. The field workers divided themselves into teams responsible for each group of patients, and then organized a functioning circuit for the patients at the hospital.

Everybody has to be a team player

The psychologist Sonia Peyrassol is responsible for emergency preparedness at MSF´s operational center in Brussels and has been arranging this training for many years.

“The motto in a mass casualty is: Organization before care! It´s a pitfall for the participants to focus too much on the medical activities, especially for the doctors who usually find it challenging to organize. But it is of the utmost importance that doctors also understand this and become team players.”

Mass casualty incident training at Karolinska University Hospital

The training proceeds in full, physical motion. Stretcher bearers carry the severely injured to the hospital; the others walk themselves. When the patients arrive at the pretend hospital in the exercise, the teams must work quickly, making important decisions under great stress. Some patients are crying, others are shouting for help. A confused women rushes around yelling at the staff, accusing them of hurting the other patients.

"They ignored me"

The training lasts 60 minutes. Sonia Peyrassol then gathers the field workers and the student victims. Victims discuss their injuries and their health condition in greater depth and talk about how they were treated. One student was playing a 17-year old boy with an unidentified object in his abdomen. He was put in the green category because he could walk. But when he arrived at the hospital green zone, they discovered the mistake and upgraded him to red.

“Unfortunately I was asked to wait next to the pregnant patient who was shouting a lot and got a lot of attention. The team ignored me and I guess I would have bled to death.”

Other victims added that they also ended up in the wrong triage category; some “changed color” several times. A girl complains that the doctors and nurses in the role play mostly talked about her rather than with her. They even dropped the distressing comment: “There is not much we can do for her.” “That was maybe not the nicest thing to hear people saying about you”, she laughs. The patients in the green zone of the hospital felt abandoned because all medical staff left them after a while. They became worried and were starting to look for a doctor in other parts of the hospital, which resulted in a bit of a chaos.

All patients need attention

Sonia Peyrassol and some other MSF colleagues gave feedback to the field workers, explaining how to avoid common mistakes: “Talk to the patients directly, try to calm them down. Tell them you will take care of them all.” She underlines how important it is to pay attention to all patients including those with minor wounds. “There should always be a doctor to help them as well. Those with minor wounds can cause the most problems because they understand what is going on around them and can be quite demanding”, Sonia explains.

One of the participants, Troels Vedel, a surgeon from Denmark, gives his perspective on the training:

“The biggest challenge was to organize ourselves as a team, where everybody knows what to do. We did many things wrong during the training. But you learn more from making mistakes than from doing everything perfectly correctly.”

He has worked for MSF in Afghanistan and experienced four mass casualty incidents with a very skilled and well trained team. He remembers that everything worked much better in reality than during the training. “Everybody knew exactly what to do.”

Obstetrician became a midwife in the training

Another participant, the gynecologist and obstetrician Rudolpho Truffa Kleine from Brazil, really liked the training although it was tough: “Many doctor cannot act, they just react. For me that was the biggest challenge. You had to suddenly transform yourself into a character with a different profession. I became a midwife in the green team, maybe not my best performance.”

I know you will all do much better in reality, Sonia Peyrassol

Sonia Peyrassol is aware that the training can be more difficult than a real situation. “I know you will all do much better in reality!” But she is still convinced that the trainings are very important, because MSF staff has to face mass casualties regularly for example in Irak or Afghanistan.

“Some field workers are not prepared at all and then everything becomes a big chaos. That makes it very difficult to take good care of the patients.”

The idea of training is not only for the specific practice, but also to learn how to train others. Field workers can then train colleagues coming into a project. In this way, they can contribute to the disaster plan and encourage the team to practice so that everybody is prepared in the event of a real bomb when real patients need real lifesaving health care.