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Terror and disaster surgical care: training experienced trauma surgeons in decision making for a MASCAL situation with a tabletop simulation game



Mass-casualty incidents, especially in connection with a terrorist attack, can quickly overwhelm the capacities of receiving hospitals. After a mass-casualty terrorist incident, patients often arrive at hospitals in an uncoordinated manner on account of the chaotic situation. Many patients leave the incident site and refer themselves to hospitals independently. Hospital decision makers must, therefore, be able to make quick decisions on diagnostic procedures and treatment for every individual patient and, at the same time, take into consideration available resources. They require decision criteria and aids to properly manage such scenarios.

Materials and methods

As part of the preparation of the Terror and Disaster Surgical Care (TDSC®) course, we developed a tabletop simulation game based on a comprehensive and structured review of the literature, the opinions of renowned experts, and the results of specialised conferences. This tabletop simulation game is played four times during each TDSC® course.


Our analysis involved 264 of 465 course–participants from 2017 to 2019 and showed that the overall evaluation was very good and that participants grew more positive about the tabletop simulation game during the course. The tabletop simulation game received an average rating of 1.53 (1 = very good, 6 = insufficient). This rating remained consistently high over 19 courses.


Hospital decision makers must respond to mass-casualty terrorist situations in a defined tactical and strategic approach. Rapid decisions must be made that take into account the special situation and available capacities and resources to maximise the number of survivors even though individual patients may have a poorer functional outcome. As part of the TDSC® course, the tabletop simulation game teaches high-level decision-making algorithms and prepares key hospital personnel for such situations.

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Correspondence to Gerhard Achatz.

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Conflict of interest

Friemert B, Achatz G, Franke A and Bieler D are developers of the TDSC – Course and are active as Course-Directors or -Instructors in this Course. Pafrath T is Instructor in the TDSC – Course, Hofmann M is didactic advisor for the TDSC – Course, Blätzinger M and Hinz-Bauer S are members of AUC – Academy for Traume Surgery GmbH and organizer and operator of the TDSC – Course. Trentzsch H created, designed and conseptualized the simulation game in close cooperation with the developers of the TDSC – Course and the didactic advisor.

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For this study, there were no test or experiments to humans or animals.

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Achatz, G., Friemert, B., Trentzsch, H. et al. Terror and disaster surgical care: training experienced trauma surgeons in decision making for a MASCAL situation with a tabletop simulation game. Eur J Trauma Emerg Surg 46, 717–724 (2020).

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  • Terror
  • Disaster
  • Preparedness
  • Decision making
  • Table-top-Exercise
  • Simulation
  • Game