You've Got This!

Theresa Demeter

Using Simulation to Prepare for a Mass Casualty Response

You can feel your heart pounding as you wait for the first ambulances to arrive. A large explosion at the mall has resulted in many casualties. You don’t know yet the number of casualties, or the cause of the explosion, however some type of terrorism is feared. You can feel your fight-or-flight response kicking in.

What is the first thing you should do? Take a deep breath and relax. You’ve got this!

Thankfully, this is a simulation training exercise, one of your hospital’s regular emergency-department drills, to prepare your entire team for mass casualty disasters. You are confident that simulating disaster response is moving you from a team of experts to an expert medical team. These team members not only have expert skills, but they also have a shared mental model of the workflow, they know where their emergency supplies are located, and they are committed to using their patient safety behaviors and tools so that even in a mass casualty incident, patients and staff are not unintentionally harmed through medical error.


Saving a life is difficult enough, but doing so during the chaos of a mass casualty incident can increase the stress and the potential for error. Through simulation, health-care teams can prepare for almost every situation they might encounter. While specific injuries may differ, the art of being prepared—knowing one’s role, being facile with the flow, and having a shared mental model of how the team works together—equips teams to be able to work calmly, confidently, and safely even in the midst of a disaster.

As we know from the Greek lyric poet Archilochus, “We don't rise to the level of our expectations; we fall to the level of our training.” That sentiment has been tweaked by a Navy SEAL as “Under pressure, you don't rise to the occasion, you sink to the level of your training.” What these two very different people had in common is an understanding of the importance of “practicing not just until you get it right, but until you can’t get it wrong.” Without the opportunity to regularly and thoroughly practice in the safe setting of simulation, health-care teams are more likely to feel stressed in the midst of a mass casualty event and revert to more familiar—but potentially chaotic—practices and behaviors, putting patientand caregiver-safety at risk.

One of the best routes to safe quality care during a mass casualty incident is to conduct in situ (in position or on site), multidisciplinary simulation drills on a regular basis to allow teams to work through processes until they “can’t get it wrong.”


In simulated clinical scenarios, using lifelike manikins increases the learning as caregivers practice both clinical procedures and processes at the same time. High-fidelity simulation manikins can replicate labor and birth, cardiac arrest, gunshot wounds, loss of limbs, and various symptoms such as vomiting, seizure, dilated pupils, and difficulty breathing.

But the manikins are really the least important component of a strong simulation program. To be prepared for a disaster requires all of the caregivers, in their actual roles and in their real place of work, simulating with the greatest attention to detail and accuracy. To conduct truly multidisciplinary simulations, everyone relevant to the scenario must be included— physicians, nurses, blood-bank transporters, pre-hospital personnel, nutrition services, code team, environmental-services staff, and others. This ensures that everyone caring for the patient is on the same page and has the same opportunity to provide thoughtful feedback, suggestions, questions, and concerns.

It is not unusual to hear one caregiver say to another during a simulation debrief, “Wow, I didn’t know that was your process. Had I known, I would have done things differently.”

Hospitals and caregivers must prepare for mass casualty disasters in as many ways as there are types of disasters. Mass casualty incidents can include natural disasters, train derailments, and population health crises, such as food contamination, pandemic flu or zika, terrorism, and mass shootings. The list is endless. To save lives, hospitals and emergency managers must prepare an external, community response as part of a bigger strategy to mitigate the effects of mass casualty events. Internal considerations include how to best care for a large surge in patients with potentially devastating injuries, and, in the case of a natural disaster such as an earthquake or a large storm, how the hospital can safely continue operations while potentially dealing with building damage, power and water outages, and stressed and distracted staff, patients, and visitors.

Committing to disaster preparedness is a daunting, time-consuming, expensive task. Simulation plays an essential role in that commitment.

A team from Northwestern University Feinberg School of Medicine used simulation to identify gaps in another type of disaster response—caring for a patient with Ebola. Associate professor of medicine Jeffrey H. Barsuk, MD, MS, noted, “At Northwestern Memorial Hospital, we have learned that preparing detailed guidance is not enough. We must conduct realistic drills and offer clinicians and administrators both practice and honest feedback on their performance.” The learning that occurred as a result of the simulation exercise reveals opportunities for organizations to address gaps and improve aspects of their preparedness efforts to respond successfully to real patients.1

While simulation is an important tool for communities, organizations, and hospitals to implement as part of their disaster preparedness strategy, it is also important to use simulation to support patient safety at the individual and departmental levels and in other outpatient clinical settings. When implementing a disaster preparedness simulation in the emergency department, operating room, or other area of the hospital, it is useful to conduct the simulation in situ—in the actual patient-care setting— allowing health-care teams to refine workflow, ensure that supplies and equipment are appropriate and in good working order, and that the teams understand age-old workarounds and how they may be a barrier to safe patient care. All this enables the teams to have the opportunity to standardize their processes and responses.


Researching, planning, and implementing a simulation scenario, such as a mass casualty event, allows health-care teams to have the opportunity to slow everything down and, through their combined experience, thoughtful reflection, and a tenacious desire to get it right, methodically inspect all the components that impact patient care. The customized macro-simulation process can be designed to meet the needs of the team members where they are at.

For example, in the emergency department it might be that a protocol doesn’t exist or hasn’t been revisited in years. Or the protocol might be so massive and detailed that it is too unwieldy to be useful. For this reason, a simulation will often start with the protocol. The simulation then lifts the protocol from the paper and gives teams the opportunity to refine it based on realworld needs, resources, and challenges. One hospital going through this macrosimulation process was able to simplify an outdated 15-page protocol down to one page with three clear job aids.

To implement a disaster response simulation, equip the participants for success by helping them understand the goals and by sending them advance information, such as a learning module, so they can prepare for participation. Each simulation session should be designed to be as realistic as possible and include only those individuals who would care for the patient at that particular moment in an actual situation. For instance, since it probably would not be realistic to have five nurses caring for a patient while two others leaned against a wall to observe, the simulation should not be designed that way.Participants should attend the simulation during a time when they will not be called away for other responsibilities, and they should show up dressed and prepared as if they were coming to work.

It is helpful to start each session by giving participants an opportunity to review pertinent information, such as protocols and roles, making sure they are familiar with any simulation equipment they will encounter. They should also understand the end point of the scenario. It is helpful to have a simulation facilitator who can start and end the exercise and call a time-out when a question arises that should be considered. Often simulation sessions are video-recorded for later analysis. So that participants can feel more comfortable during the simulation, they should be given the opportunity to sign consent forms prior to the session and understand all the ways the film may be used.

At the end of the session, simulation leaders guide the team through a debrief to understand what went well, in addition to barriers to quality care, supply and equipment issues, and gaps in safety behaviors, roles, communication tools, and leadership. If video recordings have been made, they are reviewed at this time. In a large emergency department these one-to two- hour simulation sessions may need to be repeated over the course of several days to insure that most of the caregivers can participate. This helps to create the shared mental model.


The debrief—information gleaned from the simulation process—is a goldmine of process-improvement action items.Some are easy wins that can be addressed even during the course of the simulation; others may need more discussion, research, resources, or to be re-simulated in a just-in-time training exercise. All information should be captured through an action-item list so that valuable nuggets are not lost. The multidisciplinary team of simulation planners should regularly refer to the action-item list to ensure completion. If simulation findings are not addressed, then the program’s quality and the improvements to disaster preparedness are at risk.

We all know the quote inspired by The Field of Dreams: “If you build it, he will come.” In simulation we say, “If you sim it, it will improve.” As director of a large, multidisciplinary simulation program conducting simulations across the country, I regularly hear the heartfelt comments of simulation participants. Here are a few:

  • “I’ve supported a large number of quality/safety initiatives, but none with such an impressive impact on patient safety as simulation.”
  • “I could have read about this a hundred times and not had the significant learning sink in, but now, six months after our simulation, I can still tell you how it’s done.”
  • “I realized through watching our simulation video that my deficit was in communicating to the rest of the team. I now know how to be a better communicator.”

The art of simulation is both simple and complex. Allowing teams the opportunity to slow down an event to thoughtfully practice, identify gaps, and improve team performance is the best way to prepare for that moment when you hear the call, “There has been a disaster.”

But this time, you’ve got it! 


1 Agency for Healthcare Research and Quality, “Healthcare Simulation to Advance Safety,” U.S. Department of Health and Human Services, February 2015, accessed August 17, 2016,

InSytu Advanced Healthcare Simulation has been conducting in situ, multidisciplinary macro-simulations since 2008, with more than 1,500 sessions successfully completed. For more information, call 206-215-5907 or e-mail