Management of Mass Casualty 
Mike M. Mallah, David R. Mann, Richard Davis and Peter Bird 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction 
Natural disasters, war and conflict, terrorist 
attacks and transportation injuries have led to 
increased civilian injuries and casualties over the 
past several decades. Hospitals in resource- limited 
settings have a great challenge responding to these 
issues. To achieve the best possible outcomes, it is 
paramount to consider management of mass casualty 
incidents in advance and to be prepared for them long 
before they occur.  
Management of mass casualty is a broad 
subject including several perspectives: a centralized 
government perspective, a pre-hospital, emergency 
medical services perspective, and a hospital 
perspective. In the hopes of being most beneficial to 
the reader, this chapter is written from a hospital 
perspective. It is understood that in most resource-
limited settings, pre-hospital care, and even pre-
hospital coordination and allocation of patients, is 
non-existent. Patients often arrive at your facility 
with little or no warning, in excess of what you can 
safely handle, with no option to transfer elsewhere.  
While there is no consensus definition for a 
“mass casualty,” we will adopt the World Health 
Organization definition: A mass casualty incident is 
an event which generates more patients at one 
time than locally available resources can manage 
using routine procedures. It requires exceptional 
emergency arrangements and additional or 
extraordinary assistance. 
Notably, what qualifies as a mass casualty 
incident will be very specific to the practice setting. 
For example, two or three patients arriving 
simultaneously in a more rural hospital with only one 
available provider may overwhelm that specific 
system, particularly in the low resource setting. 
However, even in limited resource urban centers, the 
same volume of patients may be appropriately 
managed. In order to adequately handle each 
situation, it is crucial to be critically honest about a 
facility's capabilities. 
 
In this chapter, we discuss the Mass Casualty 
in three phases: Before, During, and After the event. 
 
A mass casualty event at a large hospital. Facilities with 
training programs can call on multiple workers quickly to deal 
with a rapid influx of patients.  
 
Before 
 
Anticipation of and preparation for a mass 
casualty incident will lead to improved outcomes 
Specifically, it will be vital to understand the 
landscape of resources available at your current 
facility. 
Below, 
we 
discuss 
Personnel, 
Equipment/Supplies, Medicines, Space, and Medical 
Records. We follow with a brief discussion on 
planning, that coordinates all these resources. 
 
Personnel: 
Identifying the number of people available to 
an organization is the first step in evaluating your 
resources. This will allow you to ensure that supplies 
and other resources can be well utilized by the 
personnel. Additionally, if there are training or skill 
deficiencies identified prior to a Mass Casualty, 
personnel can be recruited and trained.  
It would be ideal to have a full complement 
of operating theater, laboratory, x-ray and central 
supply technicians on duty 24-hours per day; the 
hospital leadership needs to decide whether they are 
busy enough to justify this expense. A small rural 
hospital that is unstaffed on evenings and weekends 
should encourage injured patients to be sent 
elsewhere, 
providing 
basic 
resuscitation 
and 
stabilization prior to transfer.  
 
Ancillary Staff 
 
Small hospitals face the disadvantage that 
many of these skilled workers are not in the hospital 
24 hours per day. But mass casualties can and do 
arrive at all hours of the day and night. You should 
Management of Mass Casualty 
Mike M. Mallah, David R. Mann, Richard Davis and Peter Bird 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
advocate to Administration for the full-time 
immediate availability of the following people: 
● Radiographic technologists 
● Operating Theatre technicians 
● Central Supply technicians 
● Representatives of Finance and Management 
● Information Technology 
● Security  
 
Nursing 
 
Similarly, nurses are crucial for conducting a 
mass casualty well, especially in the Emergency 
Department. Nurses play the following roles:  
● Nurse-in-Charge: This valuable person manages 
all 
the 
logistics 
of 
the 
mass 
casualty, 
coordinating the team of nurses and ancillary 
staff. Most large hospitals have a senior nurse on 
duty full time- usually this person takes on this 
role. Likely they were also the one who decided 
that criteria for mass casualty were met and 
activated the team, as described further below. 
The Nurse-in-Charge will be the key point of 
contact for the Physician-in-Charge. 
● Casualty nurses: These nurses have experience 
caring for injured patients. Usually, they cannot 
stay with one patient, but will assist multiple 
clinicians 
caring 
for 
multiple 
patients 
simultaneously.  
● Operating Theatre nurses: These nurses can 
assist anesthetists, prepare the room, and care for 
patients in the Recovery suite.  
● Ward and Intensive Care nurses: In addition to 
their regular duties, these nurses can help 
mobilize patients and create more bed space, 
allocating more critical patients to beds near the 
nursing 
station, 
recognizing 
deteriorating 
patients, and making other critical decisions.  
 
Clinicians 
 
Clinicians, whether physicians or others such 
as Clinical Officers, must be able to work closely as 
a team. The team’s leader must be aware of the 
strengths and weaknesses of every member of the 
team, and must assign patient care duties 
accordingly. Communication is essential: in order for 
the leader to make effective decisions, they must 
receive timely feedback from each clinician on the 
condition of the patient under that clinician’s care.  
● Physician-in-Charge: This is the team leader; 
they must be a senior clinician with intimate 
knowledge and understanding of the hospital and 
its people. This physician’s role is most 
analogous to “orchestra conductor” or “traffic 
police,” watching out over all the patients and 
deciding simultaneously on the care of all of 
them, in light of a detailed understanding of the 
hospital’s and the team’s strengths, weaknesses, 
and other characteristics. The Physician- in-
Charge will be the key point of contact for the 
Nurse-in-Charge. The Physician-in-Charge need 
not automatically be a surgeon; a non-surgeon 
physician with experience in the Casualty 
Department, such as a specialist Emergency 
Medicine Physician, can do this job quite well. 
● Other specialist physicians: These should be 
surgeons 
or 
other 
specialists 
with 
an 
understanding of trauma resuscitation steps. 
Some of these may be able to step in as 
Physician-in-Charge. Each one will be assigned 
to one patient only, providing feedback to the 
Physician-in-Charge.  
● Clinical and Medical Officers: These are 
generalist clinicians who play a similar role as the 
physicians above, caring for only one patient, 
doing interventions as needed, and giving 
feedback to the Physician-in-Charge.  
● Trainees: Residents and interns will have a range 
of 
skills. 
The 
Physician-in-Charge 
must 
understand each one’s capabilities and assign 
them accordingly. A very junior trainee may be 
most helpful as an assistant to one of the other 
clinicians above in caring for one complex 
patient. A junior or mid-level trainee may care 
for a patient alone. A senior surgical trainee may 
take a patient to the Operating Theater alone. In 
all cases, the Physician-in-Charge must assign 
them duties that fall within their skillset and 
watch them as closely as possible.  
 
All clinicians caring for patients will have 
some degree of independence and must know the 
principles of initial management of the injured 
patient. These can be taught and then reinforced 
during care for individual patients, according to the 
Advanced Trauma Life Support (ATLS) course or 
Management of Mass Casualty 
Mike M. Mallah, David R. Mann, Richard Davis and Peter Bird 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
other courses. You may also design an “in house” 
course of your own.  
In a city or on a Mission Station it may be 
easy to mobilize personnel, whereas rural hospitals’ 
staff may live quite a distance away and be 
functionally 
unavailable. 
Depending 
on 
the 
frequency of mass casualty incidents, personnel may 
be offered a “retainer” or salary bonus in return for 
being available on short notice for emergencies.  
An adjacent or nearby nursing school can be 
an excellent source of workers: senior students can 
act as nurses (under the watchful eye of other nurses.) 
Junior students can help with transport or other 
logistical issues.  
 
Equipment 
 
Commonly used equipment such as plain 
gloves, gowns, chest tubes and chest tube bottles, 
dressings and splints, plaster and suture will be 
needed in large quantities. There are two strategies to 
assure availability:  
● Casualty Store: A room, adjacent to the casualty, 
staffed by a clerk, where such equipment is 
always stored and disbursed for patient care 
during all hours. By design, there is enough 
equipment available for surges such as a mass 
casualty even though these happen rarely. The 
advantage of this system is that it allows 
equipment to be rapidly available, and some 
measure of inventory and cost allocation is 
available even during a mass casualty event. 
Also, the equipment can be easily located, since 
the clerk knows quite well where everything is. 
The disadvantage is that it requires a full-time 
employee staffing the store; if a hospital’s 
Emergency Department is not very busy, 
maintaining this employee may not be a justified 
expense.  
 
This “ministore” serves the adjacent outpatient and casualty 
departments. It is staffed full-time and contains enough 
emergency supplies for a mass casualty, rapidly available. The 
clerk knows every piece of equipment and can access it rapidly. 
The Central store is elsewhere in the hospital and can replenish 
the ministore in real time if needed.  
 
● Mass Casualty Carts: Rapidly accessible carts are 
created with essential consumables (e.g. gauze, 
bandages, IVs, chest tubes) and medications (e.g. 
fluids, pain medications, sedatives, antibiotics).  
Once prepared these should be stored near the 
designated triage center. The cart should only be 
accessible by the lead nurse in the event of a mass 
casualty event to prevent depletion of the 
supplies 
and 
to 
ensure 
their 
immediate 
availability. The advantages of this system 
include immediate availability; the cart can be 
rolled directly to an unstable patient’s bedside. 
The disadvantages are mostly related to its 
designation for use in mass casualties only: 
Personnel will be unfamiliar with its contents 
when these are needed in an emergency. If the 
cart is unlocked, staff will “pilfer” it for supplies 
during 
normal 
patient 
care 
because 
of 
convenience. If it is locked, it may be difficult to 
locate the key when it is needed, and it may be 
ignored or not stocked properly after the previous 
mass casualty event.  
Management of Mass Casualty 
Mike M. Mallah, David R. Mann, Richard Davis and Peter Bird 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
A Mass Casualty Cart in a resource-rich hospital, containing 
portable suction and oxygen, a defibrillator, and a separate 
“toolbox” (Orange) with medications that might be needed, 
which can be carried with the patient during transport.  
 
You should develop surge distribution plans 
to provide expedited delivery during mass casualty 
events, should more supplies be needed. In the case 
of the Casualty Store, this is backed up by a larger 
Central Supply elsewhere in the hospital that can 
replenish it if needed. In the case of the Mass 
Casualty Carts, these can be replenished by other 
carts that have been created for this purpose and 
stored elsewhere.  
 
Space 
When planning for mass casualty events, you 
should be aware of the total number of beds/spaces 
available to accommodate patients. Are there 
additional spaces that could be converted to 
accommodate patients if needed? For example, how 
many patients could be accommodated into hallway 
spaces? How many beds could be converted to 
provide ICU level care? Can beds near the nursing 
station be used as a “surrogate” for critical care beds, 
where patient deterioration would be noted sooner? 
Can beds, rooms, or spaces typically designed for 
one or few patients be “surged” up to house more 
than 
the 
designated 
number 
during 
routine 
operating? Understanding the space available will 
allow you to utilize your decreased resources more 
efficiently.  
 
Medical Records 
 
In order to keep track of multiple patients’ 
diagnoses and treatment plans, you must be able to 
generate medical records quickly. Your Medical 
Records department may not be able to create enough 
new files at once by the usual process. If you use an 
electronic medical record, access to multiple 
computers simultaneously can be another choke-
point. But even if your hospital’s medical record 
system is only a small notebook carried by the patient 
themselves, we recommend using a worksheet like 
the one below.  
 
A well-designed worksheet encourages the 
clinician to follow a standardized approach. It is 
structured to be systematic, including the Glasgow 
Coma Scale, and priorities for assessment such as 
airway, breathing, circulation, etc.  
 
The worksheet accompanies the patient 
during the mass casualty event, and the Plan section 
can record orders (“X-ray of Chest, Pelvis, Lateral C-
spine.”) Eventually the worksheet is added to the 
patient’s medical record, usually at the time of 
admission. We include a copy of this worksheet for 
download here.  
 
A worksheet that helps clinicians evaluate the patient according 
to typical trauma priorities.  
 
Planning 
Once all of the above are understood, all that 
remains is to “put it all together” into a cohesive 
system that can respond as needed.  
Management of Mass Casualty 
Mike M. Mallah, David R. Mann, Richard Davis and Peter Bird 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
First, a clear trigger should be outlined to 
"activate the system."  This will be different for every 
institution given the resources available. For 
example, a specific hospital might designate the 
arrival of three simultaneous trauma patients as a 
mass casualty event.  If so, this criterion should be 
clearly outlined and staff informed that if the criteria 
is met, the system can be activated.  
You may choose to have a certain number of 
patients be the trigger. But we also recommend 
allowing senior clinicians and nurses to use their 
discretion in activating the system. If your hospital’s 
trigger is four patients, and three critically ill patients 
arrive with survivable injuries requiring immediate 
treatment, it is quite reasonable to activate the 
system.  
Secondly, a clear communication strategy 
should be outlined. If a "mass casualty incident" is 
activated, who initiates that activation? Is the 
activation decided on by an individual or a group? 
Often this is the senior nurse on duty in the hospital 
(variably called the House Supervisor or the 
Coverage Nurse.) This person activates a central 
communication method in order to connect the 
involved parties. The communication platform 
WhatsApp has been used frequently given its 
accessibility and end-to-end encryption. Often the 
Nurse-in-Charge or Physician-in-Charge will need to 
make phone calls directly to other personnel to 
decide on activating the system; this is another 
reason why such roles should be filled by people who 
are quite familiar with the hospital and its resources.  
 
The roles of the Physician-in-Charge and 
Nurse-in-Charge are the most important in a mass 
casualty event. Nurses who can take this role should 
be among the most experienced and should 
understand the hospital well. Specifically, knowing 
who plays what role, and who else could play it if the 
right person isn’t available, is the kind of knowledge 
that only comes with experience.  
 
The 
Physician-in-Charge 
faces 
similar 
demands. As described further below, this person 
must be able to coordinate multiple complex 
activities at the same time. There is no substitute for 
experience with the facility and knowledge of its 
working parts here. Therefore, the most senior 
physician in the hospital is usually the one who plays 
this role. In these days of “Global Surgery,” visiting 
surgeons who are on-call must be properly prepared 
if they are to play this role. For example, a visiting 
trauma surgeon with extensive patient care 
experience who does not know your hospital well 
would be better suited performing direct patient care, 
rather than being the Physician-in-Charge. 
 
During 
 
The Nurse-in-Charge and Physician- in-
Charge work closely together. Neither takes care of 
an individual patient.  They conduct the mass 
casualty event itself and should be not distracted by 
the needs of a singular patient.  During the event, 
these two “in-Charge” leaders coordinate the entire 
team’s roles, ensure proper management and triage, 
and monitor crowd control.  
 
A Yellow vest allows the Physician-in-Charge to be easily 
identified even in a chaotic environment. The Nurse-in-Charge 
wears one as well.  
 
Roles 
A highly experienced physician should be the 
Physician-in-Charge, ideally with training in 
emergency medicine or trauma. As stated above, a 
thorough understanding of the hospital is the most 
important attribute. In the absence of a physician, an 
individual with the most medical training may serve 
in this position.  
If there are additional clinicians, the 
Physician-in-Charge 
will 
coordinate 
physician 
efforts. These include other physicians, specialists, 
resident physicians/house officers and other trainees 
present. The Physician-in-Charge must delegate 
responsibilities appropriate for other personnel at 
their level of training. As patients and clinicians 
Management of Mass Casualty 
Mike M. Mallah, David R. Mann, Richard Davis and Peter Bird 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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arrive, try to “match” the level of the clinician to the 
perceived injury burden of the patient.  
The Physician-in-Charge will decide which 
patient receives which treatment and will prioritize 
patients based on their needs. This includes deciding 
the disposition of the patients, whether to the x-ray 
department, the Operating Theater, the ward, or the 
critical care unit. In order to do this, the Physician-
in-Charge must have a general idea of the condition 
and injury burden of every patient. This information 
is relayed by the individual clinician caring for the 
patient. 
The Nurse-in-Charge manages logistics, 
coordinates nursing efforts, and ensures that triaged 
patients receive the care indicated by the Physician-
in-Charge. 
Nurses 
should 
be 
proportionally 
distributed to ensure that triaged patients receive the 
adequate level of care based on the acuity of their 
injuries. The Nurse-in-Charge also ensures that 
patients are transported efficiently and prevents 
bottlenecks of patients which may obstruct halls or 
overwhelm services. Specifically, we attempt to send 
only one patient at a time to the x-ray department, to 
avoid patients waiting unsupervised in the hallway 
where their deterioration might not be noticed.  
 
Management 
 
Patients are triaged according to their 
condition, as below:  
Designation 
Condition 
Red 
Critical condition but salvageable 
with 
immediate 
intervention: 
airway, breathing, or circulation 
problem. 
Yellow 
Possibly in critical condition or 
may deteriorate soon, but does not 
require immediate intervention. 
Green 
Injuries sustained but not in critical 
condition. Has the potential to 
deteriorate in the future but does 
not require immediate intervention. 
Black 
Survival is not likely with any 
intervention: caring for this patient 
would 
divert 
resources 
from 
patients who otherwise have a 
reasonable chance of survival. 
Table showing one technique for triaging patients during a 
mass casualty event. Note that patients designated “Black” 
may, under other circumstances, get a full effort at 
resuscitation. During a mass casualty event, we recognize that 
resources are limited and best directed to other patients with a 
better chance of survival.  
 
Below we delineate the duties of the 
Physician-in-Charge: These points can be distributed 
beforehand to potential Physicians-in-Charge, and 
posted in a prominent place: 
● Don’t personally manage any patient! 
● Delegate tasks: Have someone by your side if 
possible as a scribe / runner / phone caller. 
● Liaise closely with the Nursing team and the 
Nurse-in-Charge, especially to mobilize ancillary 
staff. 
● Find out the details of the incident: Mechanism, 
how long ago, any more patients at the scene?  
● Triage casualties and assign staff as appropriate, 
ideally one clinician and one nurse per patient. 
● Move “Walking Wounded” to the Outpatient 
Department or elsewhere outside of the 
Emergency Department.  
● Assure ATLS protocols are being followed. 
● Consider moving unstable patients directly to the 
operating theater to be resuscitated and treated 
there. 
● Assign 
FAST 
Ultrasound 
scan 
to 
one 
experienced person with a portable machine. 
● Alert anesthesia. If during a normal business day, 
do not start any elective cases in the operating 
theater until you can estimate how many patients 
will need urgent operations.  
● Control the flow of patients to x-ray and other 
patient care areas outside of the Emergency 
Department. Try not to have any patients waiting 
in unsupervised areas. 
 
Management of Mass Casualty 
Mike M. Mallah, David R. Mann, Richard Davis and Peter Bird 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
If you have a portable ultrasound machine, assign one person 
to perform bedside Focused Abdominal Ultrasonography for 
Trauma examinations on patients, beginning with the most 
critical, as assigned by you.  
 
Patients will generally leave the Emergency 
Department to go to: 
● Admission: the ward or a critical care unit after 
full evaluation. In general, needed treatment is 
done first in the Emergency Department, 
including cleaning and suturing lacerations, 
splinting fractures or placing traction pins, and 
other interventions.  
● Operating Theater: you must make sure the one 
doing the operation is qualified to do so. If you 
are the Physician-in-Charge and the patient needs 
an operation, you may send another qualified 
surgeon, or you may choose to hand over the “in-
Charge” role to someone else who is capable of 
doing the job.  
● Discharge: After evaluation and treatment, they 
do not meet the criteria for admission. 
 
Crowd Control 
 
Security is very important here: Hospital 
Security Guards must gently but firmly cause all non-
medical 
personnel 
to 
leave 
the 
Emergency 
Department. This will be difficult, as emotions are 
high and family members are concerned. They may 
insist that their family member receives precedence, 
and this could become an unnecessary distraction at 
a time when attention is most needed. “Walking 
wounded” should be monitored closely for 
deterioration, but otherwise they should stay 
elsewhere, in a place such as the Outpatient 
Department, waiting their turn to be evaluated. 
Police officers and soldiers will enter the Emergency 
Department 
and 
display 
varying 
levels 
of 
professionalism as they watch the proceedings; 
sometimes these can be “redirected” with a request 
to help with crowd control.  
 
After 
In resource-rich settings, there is heavy 
emphasis on practice and “drills” of mass casualty 
events. However, full scale practice of plans within 
resource-limited settings may not be feasible due to 
limited resources and the impact on everyday 
operations. Despite this fact, limited practice 
sessions can decrease the confusion and delays of 
poorly coordinated efforts. Once your institution is 
initially prepared and a plan is set, practice it.  
While practice and simulation are reasonable 
surrogates prior to a mass casualty, the events 
themselves are often the most informative. Conduct 
an audit, formal or informal, and ask the following 
questions:  
● What worked well?  
● What do we need to adjust?  
● How is our plan vulnerable and how can we 
mitigate those weaknesses in future events? 
● Were there any clinical competence issues, or 
need for additional training, exposed?  
 
Many issues that are exposed by an audit 
cannot be addressed very well: a mass casualty is a 
chaotic and brutal event and mistakes will be made. 
The most likely weakness to be exposed will be the 
competence of your team in initial management of 
the injured patient. Fortunately, this problem is the 
one that you can control best, through better 
preparation. If more teaching sessions are needed, 
organize them without delay. In general, an official 
ATLS course will be expensive and difficult to 
access in a low-resource setting. But its principles are 
the most applicable here, and your clinicians should 
be very familiar with the priority-focused approach 
that it teaches. Consider organizing your own “in-
house” courses that teach the same principles.  
The answers to the questions highlighted 
above are critical in the aftermath of an actual mass 
casualty event and can also shed light on weaknesses 
Management of Mass Casualty 
Mike M. Mallah, David R. Mann, Richard Davis and Peter Bird 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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within local, regional, and country level disaster 
responses. Debriefing after these events will allow 
teams on every level to go back to the drawing board 
and optimize their plans. Incremental improvements 
can then be made and thus hopefully increase your 
capability to provide quality care in the face of mass 
casualties. 
 
 
 
The authors acknowledge the work of Doug 
Norcross, MD FACS and Ben Cassidy. 
 
 
Mike M. Mallah MD 
Medical University of South Carolina 
USA 
 
David R. Mann DO MS 
Medical University of South Carolina 
USA 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Peter Bird MBBS FRACS 
AIC Kijabe Hospital 
Kenya 
 
June 2023 
Resource-Rich Settings 
Industrialized countries are usually divided geographically into 
“catchment areas” with a robust emergency service 
infrastructure: 
• 
Prehospital services such as ambulances, helicopters, and 
fixed-wing aircraft, staffed with skilled practitioners up to 
and including specialist Emergency Medicine physicians. 
• 
One hospital designated as the area’s “Trauma Center.” At 
this Center, skilled personnel and facilities can be rapidly 
mobilized. Within the area, there may be other hospitals 
that can also care for less injured patients as well. 
• 
Coordinated communication services including all of the 
above resources, allowing rapid decisions such as 
mobilizing personnel and equipment, and sending injured 
patients to several hospitals so that one hospital is not 
overwhelmed. Trauma Centers serving other catchment 
areas may receive patients from the one where the accident 
occurred if needed. 
• 
Trauma practitioners frequently conduct mock exercises at 
all levels to ensure preparedness.  
 
Because of these advantages, a true “mass casualty” which 
suddenly overwhelms an individual hospital’s resources, is 
relatively rare in resource-rich settings. Large-scale terrorist 
attacks, train derailments, or natural disasters would be dealt 
with in the above framework.  
