Mass Casualty Drill

"This Saturday morning was different from previous Saturday mornings."

Sarah blogs from Agok in South Sudan, where she's been working on the training needs of the local nursing team...

This Saturday morning was different from previous Saturday mornings.

The day before, we were told that this morning we would have a “mass casualty drill”. This is something that is conducted every few months or so to help prepare the team for a potential emergency situation, during which we would have an influx of critical patients brought to the ER. The team must be able to mobilize quickly, triage appropriately, and manage a large number of patients under significant stress.

Instead of heading to the kitchen to prepare my breakfast, I woke early to search the shelves of our storeroom in the hopes of finding some useful ingredients I could use to make a large batch of fake blood.

I thought I would have to rely on the natural dye from the local karkade tea, however, I was pleasantly surprised to find several small containers of food coloring powder. I found myself wondering which meal the cooks had dyed artificially red, then thought the better of thinking about this.

I grabbed a box of corn starch, some karkade remnants, instant coffee crystals (to give the blood a darker hue), and sugar, and set the water to boil. The color and consistency was not exactly as I had hoped, but it would suffice. We gathered 30 or so volunteer patients and another 20 caregivers into our crowded training room, and with the help of a couple translators, began assigning diagnoses.

There was playful banter and negotiating of diagnosis cards. Some wanted the severe, penetrating chest wound while others preferred more minor injuries. I then distributed used clothing to everyone, as most people had come wearing dresses or slacks. The last thing I wanted to do was destroy people’s only clothing with my batch of fake blood.

I then led the crew outside where I had everyone line up and present their card to me. Now for the fun part: painting on blood according to each patient’s injury. Once the team was good and bloody, I attempted to divide up the group according to severity of injury so as to be able to properly assign caregivers, as we had fewer caregivers than patients. By the time we were through, the team looked like the cast from “The Walking Dead”.

Once the blood was in place, the patients dove fully into their new characters. We had them load up into a line of waiting Land Rovers which would escort them outside the MSF gates in preparation for the beginning of the drill. I assumed they would walk to the waiting vehicles, but that is not what happened. Instead, people began to limp, fall on the ground, dragging themselves, yelling out in pain, asking to be carried, flailing their arms dramatically. It was crazy to say the least.

Once the drill was officially underway, we ran to our assigned places. My job was to supervise the nurses and nursing care in the yellow and blue zones. Yellow patients are those who are injured (broken leg, lacerations, wounds, etc.) but whose injuries can wait, i.e. they are not imminently life-threatening.

Yellow patients should be closely monitored, as they can quickly become red patients (those patients requiring immediate life-saving intervention). Blue patients are those whose injuries are too severe to justify spending hours of time and care to save; they will most likely not make it. However, once all of the other patients are treated, blue patients who are still living can then be taken to surgery if resources permit.

Although we had warned the patients in the ward that a drill would be taking place that morning, many of them still looked at us like we were crazy, while others wanted to help and began to volunteer to participate.  Crowd control was most certainly an issue as everyone wanted to see what was going on. 

As soon as the patients were carried in on stretchers, chaos ensued. I thought I had clearly explained to the nurses under my supervision where they should be working, however any direction given was quickly forgotten once the patients started pouring in. Communication was further hampered by language barriers and a lack of available translators. It was a struggle to keep staff away from the ‘red’ side, as emergency patients were much more exciting than ‘blue’ patients. Keeping a nurse in the blue tent was quite the challenge.

The most surprising part about the whole event was the degree of seriousness assumed by our fake patients. It was actually a bit out of control. Everyone wanted to pretend that they were dying! Patients laid on mats covering the floor, groaning, moaning, wailing, curled up in a fetal position. I would go look at their diagnosis/story card and it would read “Patient can walk and talk. They have a broken femur fracture but are stable.” Instead I would find this patient barely able to move, pretending that they were dead.

Transferring and lifting patients was a whole other ordeal as patients who should have been able to walk refused to move. It’s no wonder we didn’t all break our backs. One young girl became so wrapped up in her role that she actually started to hyperventilate and almost passed out! It was unbelievable how serious the patients took something meant to be a drill. Hollywood, if you need some fresh talent in your acting pool, I suggest you come to South Sudan for recruitment.

In addition to the onslaught of fake patients, we also had ‘armed’ soldiers, combative caregivers, and someone from the media. Our newswoman had a particularly lucky day as many of our patients gave her interviews before someone noticed what was going on and kicked her out.

And, just as I was wondering when it would all end, our surgeon was rushed in to the red tent on a stretcher carried by the entire scrubbed-up OT department. He had passed out and required resuscitating (again, mock drill, but quite believable).

Although an actual mass casualty situation would be much more intense, I was struck by the realistic nature of the drill. I came away with a good handle on what I should have done different and better. Of course, we all hope we will never have to initiate our mass casualty plan, however if the time comes, our staff will be ready.