Trauma

June 21, 2025

The American College of Surgeons Committee on Trauma (COT) wants every trauma center — not just Level 1 trauma centers — to prepare for regional mass casualties, says Denise B. Klinkner, M.D., M.Ed., pediatric trauma medical director at Mayo Clinic's campus in Rochester, Minnesota. Dr. Klinkner also previously served as the Minnesota chair for the COT.

"We all need to be educated and ready to handle situations that overwhelm our practices," Dr. Klinkner says.

The COT encourages regionalization of the process of mass casualty preparation, including establishment of centralized incident care locations.

"Any emergency care professional can declare a mass casualty," says Daniel Stephens, M.D., adult medical director and mass casualty incident command chair at Mayo Clinic in Minnesota. "Allowing any one of multiple individuals to declare a mass casualty is intentional so it's not dependent on any one person."

The mass casualty threshold varies by facility, using a patient-to-local-population ratio. For example, 10 individuals with traumatic injuries arriving simultaneously might overwhelm a larger medical center, but three injured patients might overwhelm a smaller center's resources.

Becoming mass casualty ready: Preparation steps

Drs. Klinkner and Stephens outline some scenarios all trauma centers must prepare for in a mass casualty, such as a tornado, plane crash or gun violence. They say these two steps are crucial:

• Establish mass casualty leadership. Each center must determine incident command leadership for any mass casualty affecting the facility.
• Define a staff emergency communication plan. This might involve an app or tools such as call trees.

Trauma centers also must be ready to:

• Handle multiple patient entry points. Patients may arrive by ground or air ambulance. They also may enter on foot through a facility's front door if transported by private vehicle, a mode Dr. Stephens says is common in mass casualties.
• Keep patients the center would typically transfer. Any center may need to continue supporting and stabilizing patients who cannot be moved due to lack of capacity at higher level trauma centers. Referral trauma centers will coordinate triage processes with smaller centers, including which patients require immediate transfer. In a burn surge, any trauma center may need to retain patients with burns while awaiting transfer to a burn center.
• Function despite facility destruction. In a mass casualty event involving a natural disaster, a trauma center's own facility or trauma centers to which the center would typically transfer patients may be destroyed. Yet, care must continue.
• Manage triage outside the typical care realm. Trauma staff should familiarize themselves with simple triage and rapid treatment (START) patient status color coding. Additionally, the team must prepare to provide care in situations without the capacity to treat everyone who may benefit from care.
• Negotiate atypical language barriers. Mass casualties can prompt more language barriers to arise than day-to-day trauma center encounters due to unique populations entering the facility.

Each trauma center must ensure its mass casualty readiness.

"You cannot assume another, larger healthcare facility will take care of everything in a mass casualty," says Dr. Klinkner. "Smaller sites would be asked to help recover patients."

Dr. Stephens encourages every trauma center to conduct mass casualty practice exercises. Facilities with smaller staffs may not have time for full exercises. However, even an hourlong tabletop exercise can be valuable.

"If you don't practice, you won't have any preparation," Dr. Stephens says.

He also encourages trauma centers to consider what types of mass casualty incidents might occur locally. For thorough preparation, he encourages trauma centers to consider the three S's:

• Staff.
• Stuff.
• Space.

The three S's may include items such as obtaining more blood and blood products or calling in more staff.

A key resource: Facility mass casualty preparation course

Dr. Klinkner strongly recommends that all personnel at any trauma center level take the American College of Surgeons Disaster Management and Emergency Preparedness online course. While the course is designed for Level 1 and 2 trauma centers, Dr. Klinkner considers it an invaluable resource for all facilities to prepare for emergencies and handle disasters. Dr. Stephens echoes this sentiment.

The course lasts one day and covers preparedness concepts and system approaches. The curriculum is sensitive to the differences among trauma facilities, says Dr. Stephens. If it is not feasible for all staff to complete the course, he suggests appointing one staff member to attend, such as the individual responsible for facility emergency management.

A case example: MCI preparedness at Mayo Clinic's campus in Rochester

Emily K. Sohm, mass casualty incident (MCI) program coordinator at Mayo Clinic Trauma Center, in Rochester, Minnesota, offers examples of how Mayo Clinic has prepared for a local or regional mass casualty:

• Exercises. Conducting exercises is a critical mass casualty response preparedness tool for incidents such as a nearby bus accident, apartment building collapse or a hazardous material encounter. Mayo Clinic conducts up to four exercises annually.
• Mass notification system. This system ensures staff are notified quickly about critical emergency or crisis information through desktop alerts, emails, text messages, overhead announcements and phone calls, plus contact with staff personal devices. Mayo Clinic asks that all staff sign up for this system, which notifies supervisors across the hospital, who then notify their staff.
• Incident command. Mayo Clinic created a hospital incident command system, a group deployed as needed to lead and make decisions for incidents impacting the facility.
• Decontamination area. In case of an MCI involving hazardous materials, Mayo Clinic created a decontamination area in the ground ambulance garage that staff can use before entering the hospital.
• Backup emergency transport. Through an arrangement with Olmsted County, where Mayo Clinic in Rochester resides, 911 dispatch can use other emergency vehicles, such as police cars or fire trucks, to transport injured patients in case there are not enough ambulances for injured patient volume.
• Internal personnel coordination. Sohm coordinates all groups responding to Mayo Clinic's Emergency Department in a mass casualty. This may include physicians, nurses, respiratory therapists, chaplaincy and housekeeping, among others. The Mayo Clinic MCI subcommittee includes personnel in 48 departments. Once alerted to an MCI, each department has a designated physical role to play in an incident response. Each department also has designated equipment to bring to the Emergency Department and an assigned location to line up for service.

"For instance, extra cots, wheelchairs, MCI carts and extra linens would be brought down to the Emergency Department," says Sohm.

Other Mayo Clinic personnel oversee moving nonacute patients out of the facility to make room for patients potentially affected by the mass casualty event.

Sohm says the MCI planning process has educated staff about managing an influx of patients, which she says is helpful as the Emergency Department typically may not see the patient volume arriving after the incident.

"Mayo Clinic is a large institution, and through a coordinated effort we can efficiently serve patients involved in a mass casualty and ensure the best outcomes," Sohm says.

For more information

Disaster Management and Emergency Preparedness. American College of Surgeons.