**4. Mass casualty incidents (MCIs)**

MCIs are defined as events where the number of patients exceed the local resources (human or equipment). These events can occur remotely to the health facility or within the health facility. All the literature on mass casualties come from the trauma surgical discipline [13]. The questions we now need to ask is, **combined with COVID, do trauma protocols and triage principles need to change? Is there more that we can learn from this?** In an attempt to answer these questions, we revert to the literature. One must be cognizant of the fact that with the covid pandemic all patients essentially have a breathing problem, if one must consider ATLS principles, some of which may require invasive ventilation [1].

Tankel and Einov defined specific objectives that need to be planned for in a MCI, namely equipment and consumables, transport, hospital capacity, training, education, and debriefing, command and control and communication [13]. These are the same principles in disaster management, some of which will be highlighted in this text. These concepts are echoed by the WHO guidelines which involves a multisectoral planning which include national governments and healthcare personnel, starting at facility level to international level [14].

Data from the US stems from terrorism attacks and mass shooting events and have influenced MCI protocols [13]. The major difference between a MCI in a trauma setting and a pandemic is the length of the mass casualty. Most MCIs last 24–48 hours and thereafter there is a return to normal duties, which allows for a period of debriefing. But this MCI has lasted 2 years and there has been no return to 'normalcy' [15]. **So, can we truly extrapolate from MCI in the trauma setting to a pandemic? When do we return to pre pandemic triage/MCI principles when the MCI is prolonged?**

Planning ahead, stock piling of equipment and consumables are integral to a response to a MCI [13, 14]. However, consumables are a limiting factor in MCIs as well as in a pandemic as evidenced by the global oxygen supply shortage and ventilator shortage [16]. Tankel and Einov suggest that regional instead of local (individual hospital) stock piling is more cost effective, however maintenance of the consumables is questionable and therefore may not be functional when needed. One also needs to define MCI specific equipment for example during the pandemic this translated to

oxygen and ventilators but in a trauma, setting could be theater capacity, availability of trauma surgeons and blood and blood products [13].
