Enhancing Mass Casualty Response in the U.S. Department of Defense: A Mixed-Methods Approach

Abstract Background Despite extensive recent warfare experience, the U.S. Department of Defense (DoD) lacks a comprehensive and systematic approach to Mass Casualty (MASCAL) response doctrine and training. Materials and Methods This project addressed this gap through a 3-phased approach: a doctrine inventory, a curriculum inventory, and a modified Delphi study involving 46 key stakeholders. Results The doctrine inventory of 7 identified relevant documents revealed a lack of standardization in MASCAL definitions, triage protocols, and guidance on ethical considerations and expectant casualty care. The curriculum inventory, analyzing 18 medic/corpsman training curricula (2012-2024), highlighted variability in instructional hours (3-18), learning objectives, and inconsistent integration of critical themes like moral injury and ethical decision-making. Although triage and patient flow were emphasized, a standardized pedagogical approach was absent. A modified Delphi study, conducted with 46 DoD stakeholders, achieved consensus on several key areas. Participants agreed on a definition of MASCAL emphasizing a shift from individual maximal care to the greatest good when resources are constrained. The “Move, Treat, Transport” paradigm and the critical role of time from point of injury in prioritizing interventions were endorsed. Extremity tourniquet application was identified as the highest priority first-pass action. Strong support emerged for developing and disseminating MASCAL plan templates and expectant casualty care guidelines. Finally, a scalable 5-domain training model (planning, patient movement, patient treatment, patient transport, regroup and recovery) with overarching themes of continuous triage, resource/mortuary management, and communication/accountability/security was proposed. Conclusions This project underscores the need for standardized doctrine and training to equip military responders with a unified and effective approach to MASCAL incidents, particularly at the far-forward levels of care. The findings provide a framework for future development of MASCAL response strategies within the DoD.