Real Life Simulations: Mass Casualty Training in Med School

Medscape

11-06-2025

Anyone who watched television show The Pitt on Max knows how overwhelming a mass casualty event can be for a hospital. Preparation is key, and accredited hospitals are required to hold training exercises. But these incidents don't only affect physicians in the Emergency Department. The random nature of mass shootings, natural disasters, multi-car pileups, building collapses, and the like means an all-hands-on-deck situation could happen at any time.
An increasing number of medical schools see the value in preparing their students early.
'Unfortunately this is where the world is going. We need to rely on ourselves because help may not be coming,' said Jeffrey Pearl, MD, associate dean of professional health education at the University of Texas (UT) at Tyler School of Medicine. 'In the end, the first line is going to be one of us picking someone out of the rubble from a tornado and putting a tourniquet on.'
Unfortunately this is where the world is going. We need to rely on ourselves because help may not be coming.
More than 20 years ago, the Associations of American Medical Colleges and the CDC issued a joint report recommending disaster-related training for medical students. It's still a relatively rare offering — by 2021, only seven allopathic medical schools in the US mentioned disaster response training in their course catalogs. But just 2 years later, that number had more than doubled. Roughly 10% of allopathic medical schools now offer it, as do a number of osteopathic medical schools.
'I think the best part is, it gives you perspective as to what goes on out in the field,' said Joshua Goodman, a rising fourth-year medical student at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He's participated in the school's annual training day more than once. 'Even in non-MCI situations, you might wonder why the patient is being brought in in this condition. Why didn't they do this? Why didn't they do that? This gives you a better understanding of what it's really like out there, so you know what to expect and can act on it.'
Different Approaches to the Same Concept
In order to prepare their students for an unpredictable future, medical schools take a variety of tacks. At some schools, all students undergo this training. At others, it's voluntary. Scenarios include bus bombings, school shootings, landslides, and the like. Often, they're location-specific, like the New York City subway car used in Hofstra's training, done at the local fire training academy.
'They fill it with smoke, and have students come in to rescue patients,' said Thomas Kwiatkowski, MD, assistant dean for simulation and professor of emergency medicine and science education at Hofstra. 'Some victims speak a different language, which is typical for New York City. It really challenges the students.'
The variations don't stop there:
At both UT Tyler and Hofstra, all first-year medical students complete a full emergency medical technician course. It concludes with a mass casualty simulation, which provides the chance to really practice the skills they've just learned. 'We didn't just want them to ride along in an ambulance,' Kwiatkowski said. 'That's not going to provide anything more than observation. I wanted a true clinical experience.'
A presentation on FEMA's National Incident Management System kicks off the day at Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio. Students then move on to training with emergency equipment like cervical collars and backboards. But the bulk of the day is spent at the local fire department's training center for a hands-on simulation.
Training at Perelman School of Medicine, University of Pennsylvania, Philadelphia, is part of a popular 2-week elective in wilderness and disaster medicine. Medical students learn to handle scenarios including avalanches, dirty bombs, and chemical weapons.
At Idaho College of Osteopathic Medicine, Meridian, Idaho, training has included a simulated music festival gone awry as well as a multi-vehicle accident.
College of Osteopathic Medicine, University of New England, Portland, Maine, has held four annual mock events. Last year's program focused on the lessons learned in the 2023 mass shooting in nearby Lewiston.
Investing in Realism
Limited research has been done to show exactly how realistic simulations should be, but there is some that suggests the more accurately a scenario reflects real life, the more students can benefit from it. Depending on a medical school's budget, things can get quite realistic, indeed.
For many, it includes going off-site to a training ground, where students must triage realistic victims even as they experience the chaos of an actual event.
'When they walk into a burn tower knowing that there's been an explosion, and they hear people screaming out and they can't see much, it's an environment that probably causes their heart rate to go up a little bit, perhaps their respiratory rate to go up a little bit,' said William Burke, DO, dean of Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio. 'I think those types of situations help you better understand, as an individual, how you might respond in real life.'
William Burke, DO
For the simulations' victims, most schools use a combination of mannequins and volunteers — either locals or other medical students. Often, moulage artists are brought in to apply special-effects makeup.
At UT Tyler, a relatively new school, Pearl had a sizable budget to design the mass casualty training program. Faculty works with campus and local law enforcement, fire department and emergency medical services, and even the Federal Bureau of Investigation to make the event feel as real as possible for students. High-tech wound simulation includes three-dimensional printed shrapnel mounted on silicone patches that are easily applied to volunteers' bodies; bleeding systems that pump fake blood; two cut suits of repairable skin with organs that bleed — which can be operated on while actors wear them; and several mannequins with realistic injuries.
A significant amount of effort goes into creating thoughtful, plausible scenarios. A school shooting is part of the simulation at Hofstra.
'The way they set it up is hyper realistic, in that you have real police officers acting, there's a lot of yelling, it's dark, there's a lot of banging on doors. It's frankly a little bit scary,' Goodman, the medical student, said. 'You really do feel like you're in a school and you have to hide but you also have to triage: Who can we get out? How are we going to get them out? Is it safe to open the door?'
Decisions Under Pressure
Whatever the scenario, the goal in all these simulations is the same: To help medical students learn to make life-or-death decisions quickly, under extreme circumstances.
'The first minute or two, they're a little shell shocked. After that, it's like watching your children grow up,' Pearl said. 'These are first- and second-year med students, and they're rocking and rolling.'
Thomas Kwiatkowski, MD
During the exercises, they must triage victims into color-coded categories. Yes, just like in The Pitt : Green goes to the walking wounded, those who need minimal help. Yellow indicates a more serious injury, but not immediately life-threatening. Red means a victim has severe injuries, but with a high potential for survival. Victims designated with a black mark are either deceased or have injuries incompatible with life.
'It's very difficult when you have to make that decision,' Kwiatkowski said. 'There are a couple of maneuvers that people do before they can decide to make someone black, but sometimes you can have someone who's talking to you, and you know that you can't save them. That's an important experience for students.'
Other ethical considerations also play out. During some simulations, for instance, a school shooter is still active. Students must decide how to help children while staying safe themselves, or if and when it's worth it to risk their own lives.
At Ohio University, one situation involves a bombing. Unbeknownst to the students, the bomber is among the victims.
'Students are turning victims over and see the person playing the bomber has another bomb underneath them,' Burke said. 'It helps them understand the ethics of the situation: Do you treat them the same? The answer is yes, you take care of everybody. When you ask those questions, students are thinking about things in ways they've never had to before.'