MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. -- Moulaged patients with mock injuries arrived at the doors of Madigan Army Medical Center's emergency room on April 24 to test the hospital's response to an exercise mass casualty scenario.Emergency management teams assessed the hospital's systems for triaging and tracking patients, standing up a labor pool, and running a command center in response to a disaster, said John Holwege, a Madigan emergency management specialist.In one of the largest exercises of its kind in recent years, the two-day joint MASCAL scenario evaluated the response from Madigan, the 62nd Airlift Wing, and Joint Base Lewis-McChord. It also brought in participants from Pierce County Emergency Management and MultiCare Health System, as well as the Northwest Healthcare Response Network (a regional healthcare coalition) which helped serve as evaluators."Really we should be having outside partners exercise with us every single time … because when disasters happen, they're never isolated events; we always work with our partners," said Holwege. In a situation like a mass casualty, not only do emergency responders share their expertise, but they also share their resources -- every available ambulance might be needed in an emergency.As one of 32 hospitals and supporting agencies with the Northwest Healthcare Response Network, Madigan also uses the WATrac system during emergencies to track in real time how many casualty victims supporting hospitals receive. Part of the preparation for the exercise, and real-life emergency responses, included training Patient Administration Division staff on the WATrac system as they interact with it from both the emergency operations center and triaging locations."Every single patient who comes to that ambulance bay, our PAD team needs to see them, needs to tag them, needs to provide a wristband to them, (and) needs to obtain the WATrac number because patients arrive with a WATrac tag (from first responders)," said Master Sgt. LeStiney Cray, the PAD noncommissioned officer in charge. She explained that PAD staff embedded at each of the triage locations are charged with keeping accountability of patients.One of their key locations is in the emergency room, where evaluators tested the infrastructure set up to receive patients, said Dr. David Misner, an emergency medicine physician and the emergency medical service director for JBLM. He also developed exercise scenarios to test blood banking and operating room triage capability.Standing up a labor pool helped to reduce congestion in the ER as available staff -- both clinical and nonclinical -- reported to Letterman Auditorium to wait for assignments to help with the exercise mass casualty response."This is the best turnout I've seen in a drill since 2003 that wasn't due to an actual MASCAL," said Misner, who's been in the emergency medicine field for more than 30 years to include as a responder to several mass casualty events in Mosul, Iraq in the early years of the war. "It was quite a success story as far as I'm concerned."While the after action review started the day after the exercise ended, the emergency management team is taking lessons learned to another level by developing working groups to address multidisciplinary topics."The AAR process tends to be focused on an exercise or an incident, and it tends to develop within enclaves like the Department of Surgery or the emergency room before being shared in a large forum. This is not well suited for large collaborative process improvement projects," said Lt. Col. (Dr.) Eric Roberge, chief of the Department of Radiology and the exercise's officer in charge here. "Developing operating procedures for complex care needs to be done in a small group format over several meetings."Outside of AARs and working groups, the emergency management team also encourages department-level exercises and drills in between hospital-wide exercises, said Holwege. Departments and divisions are asked to make plans to include staff on different shifts as well."Eighty-three percent of all emergencies happen after duty hours," said Bill Llewellyn, Madigan's senior emergency management coordinator.PAD embraced the preparedness mentality even before the recent exercise as they practiced mock alerts to activate their alert roster, mock mass casualties drills in their PAD hallway, and combed through their standard operating procedure once a week to understand their roles in emergency responses, said Cray."We just don't want to forget our skills and we want to make sure we improve on them," she said. While PAD earned kudos for their response to the exercise -- "I'm very, very proud of my PAD Soldiers, my PAD staff" -- they are taking with them the lessons learned of considering who else they need to communicate and coordinate with during such events, and ensuring they cross-train in different PAD emergency response roles.Misner shared universal advice for any staff involved in future emergency responses."Be prepared; just be a Boy Scout. Keep your communications lined up with your chain of command. If you keep those two basic things in mind, I think you'll get off the starting block."