Volume 7 Number 1

Introduction

Disasters may be defined as events that cause significant disruption to the functioning of a community or society.¹ Mass casualty incidents (MCIs) are defined as a subset of disasters in which the medical needs of patients exceed locally available resources.² Fortunately, such incidents are rare. Schenk et al³ reviewed the 2010 US National EMS Database and found that approximately 0.1% of all EMS calls could be considered an MCI.Park et al⁴ reviewed the 2012 EMS data from South Korea and found crude incidence rates of MCIs involving six or more patients to be 0.6–5.0 events/100,000 population in that year.

Given the rarity of disasters and MCIs, many responders have no real-world experience responding to such situations and often lack crucial topic-specific education. Smith et al⁵ found that less than one-third of US medical schools included any formal curriculum related to disaster medicine. Only one-tenth had any training on triage principles. Studies have shown similar deficits in training for nurses⁶ and paramedics.⁷

Disaster medicine educators have sought to address this gap through different educational experiences. While national certification programs often center around lectures, multiple studies have shown the value of alternative training modalities, including tabletop exercises, drills, simulations, and virtual reality.^8,9 However, the availability of these types of modalities may be limited by financial and logistical constraints.

Other authors have investigated the potential utility of board games as a low resource means to facilitate disaster education. Drees et al¹⁰ showed that students found the AFTERSHOCK board game to be a useful component of learning disaster response.Chew¹¹ showed the tutorless SMARTriage board game to be non-inferior to tabletop exercises.

On review, it appears these types of board games are either publicly unavailable or commercially sold products. The authors of this paper would like to present our freely available triage-training board game called Incident Command System (ICS): The Game which is able to be printed and played from a digital PDF file.

Incident Command System (ICS): the game

Game overview

The objective of ICS: The Game is for players to save as many lives as possible by implementing the principles of disaster medicine. They will learn to form a cohesive response team, apply triage strategies efficiently, and manage different disaster scenarios with the available resources. Players must transport all victims to the hospital before they deteriorate or die. For full details on the game and instructions, see the digital PDF file provided in Appendix 1.

General game setup

The game can be played with two to five people. To start a game, one Scenario Card is drawn. The Scenario Card determines the specific disaster to be played. There are twenty possible game scenarios (Table 1) and each varies in complexity. Scenarios involve between four and 24 victims, have time limits between 10 to 45 minutes, and offer additional challenges through the Hazard Card system.

 

Table 1. Disaster scenarios

 

Once a scenario is chosen and assessed, players select which triage algorithm to use. Players will randomly draw victim cards from either the START (Simple Triage and Rapid Treatment) or SALT (Sort, Assess, Life-Saving Intervention, Treatment) Victim Decks.

Obstacles and victims are placed on the gameboard (12x12 grid) according to the template shown on the Scenario Card. Figure 1 shows an example game card for the scenario ‘Bombing’, as well as a photograph of the gameboard setup to begin play with this scenario. The Victim Cards selected are then randomly placed face down on the board. The randomisation of Victim Cards allows for high replay value.

 

Figure 1. Scenario card

 

To help players learn the importance of analysing their disaster environment, players (as a team) strategically choose where to place their one ICS Post. This combined piece serves two roles: it is where all Transport/Triage and Medic pieces start on the board; it is also where all victims need to be transported before going to the hospital (off scene).

The game is designed around the principles of triage, treatment, and transport. Each player is assigned a color and controls a set of color-coded pieces, including one Transport/Triage piece and one Medic piece. The Transport/Triage piece is deployed toward the victims on the board. Once it reaches a victim, the player applies a triage algorithm to label each one as either Blue (dead/unsalvageable), Red (critical), Yellow (urgent), or Green (stable/not urgent). Once triaged, a victim must be transported back to the Treatment Tent (same location as the ICS Post), and then to the hospital (off the board). All victims must be triaged before they can be transported. Red victims require a Medic piece and a Transport piece to accompany them to the Treatment Tent. 

Gameplay

To start, players take turns rolling a standard six-sided die to move their pieces. They must start at the ICS post and move the number of spaces rolled by the die. Players first prioritise moving their Triage pieces towards the victims. Once a Victim Card is reached with a Triage piece, the player may read the victim’s description from the instruction booklet. The player then attempts to triage the victim using their selected algorithm. For example, Victim Card 10 reads: “61-year-old woman. She is crouching on the floor and complaining of pain in her stomach. She has diaphoretic pale skin with regular breathing (RR 34). She has weak pulses with delayed capillary refill.” Players should triage this player as Red given her respiratory rate (RR) is over 30.

Once a determination is made, the Victim Card is flipped over which reveals the answer. If the player was correct in their triage designation, the player can continue their turn. If the player was incorrect, their turn ends immediately, and the next player rolls the die. This allows players to continuously practice SALT/START triage throughout the game and obtain immediate feedback on their performance.

The player then can choose to either begin to transport the victim towards the Treatment Tent or continue onward and triage other victims on the board. Players take turns rolling the die and moving their pieces to triage and transport victims to the Treatment Tent. Once a victim is transported to the Treatment Tent, at least one Medic piece must remain with the victims until they can be transported off the board to the hospital.

If a player rolls the Hazard Number (a number found on the Victim Card being transported by that player), the player must pick up a Hazard Card which asks a mass casualty question (Figure 2). Players work together to find the right answer. If the question is answered correctly, they roll again without adding to the roll counter, and if answered incorrectly, they must add an extra roll to the roll counter and end their turn. The purpose of Hazard Cards is to allow players to learn more advanced management of mass casualty patients.

 

Figure 2. Hazard card

 

To add pressure and a sense of urgency that occurs during mass casualties, players have a turn limit for each scenario. If all the victims have not been transported to the hospital by the turn limit, victims will deteriorate and ultimately die. The game ends once all victims are either transported to the hospital or deceased.

Discussion

Incident Command System (ICS): The Game aims to teach disaster response in an easy and engaging manner. In this board game, two to five players collaborate in real time to manage mass-casualty scenarios while making critical decisions under pressure.

A key educational benefit of ICS: The Game is its emphasis on teamwork and communication through a simplified ICS structure. During gameplay, participants must work together, share information, and negotiate on decisions using effective communication and leadership to save victims’ lives. This communication reflects real interprofessional dynamics in disaster response. Additionally, the immediate debrief or discussion after the game allows participants to reflect on their actions and solidify lessons learned. This educational structure aligns with the broader simulation literature, emphasising that simulation-based training provides better skill retention than traditional methods and boosts learner confidence for real high-stakes situations.^12,13

While traditional lecture-based instruction can efficiently deliver standardised content (such as outlining the steps of START triage or the structure of ICS) to large audiences, lectures are inherently a passive method of learning. This often results in lower engagement and may limit the learner’s ability to apply concepts under pressure. Studies in disaster education highlight that purely didactic teaching methods leave trainees underprepared for the realities of mass-casualty response.¹⁴ In contrast, a board game approach offers an experiential learning opportunity that translates theoretical knowledge into practice. Immediate feedback is inherent to the gameplay and requires more adaptability. If triage decisions are suboptimal, players see the in-game consequences (victims not saved in time), allowing participants to learn from mistakes in a safe setting. This kind of experiential learning helps bridge the gap between theory and practice—honing both technical knowledge (triage categories, ICS roles) and non-technical skills (situational awareness, teamwork). The board game functions as a microcosm of a disaster scene.

Full-scale disaster drills and high-fidelity simulations represent the gold standard for immersive training. However, these simulations come with considerable drawbacks: they are resource-intensive, costly, and logistically complex to organise. Conducting a mass-casualty drill might require dozens of personnel, special facilities or simulation centers, and interruption of normal operations. Such exercises are typically infrequent due to these challenges. ICS: The Game offers a low-cost, portable training alternative that can be played by as few as two people. It can be deployed in a simple classroom or meeting room without the need for technology, mannequins, or large numbers of facilitators. Because the game is self-contained and tutorless, even small hospitals or training programs with limited budgets can adopt it easily. The cost-effectiveness and ease of setup of ICS: The Game makes regular practice reasonable, ensuring that disaster preparedness training does not have to be a rare event.

Other board games have been developed to teach ICS (AFTERSHOCK, SMARTriage) and have proven to be effective at teaching ICS.^10,11 AFTERSHOCK teaches players humanitarian crisis management over a three-month period with less emphasis on medical triage (SALT/START). SMARTriage helps teach medical triage over a variety of scenarios, but with a different gameplay style than ICS: The Game. One of the unique aspects of ICS: The Game is that it is free and its materials can be printed and created at home. Additionally, it requires less than ten minutes to set up, and each scenario lasts between 10 to 45 minutes. With ICS: The Game, learners gain access to a free self-directed educational resource that can be easily incorporated into a busy schedule.

Limitations

One limitation of a board game is the reduced sensory immersion and realism; some aspects of disaster response (noise, chaos, physical exertion, and emotional stress) are inevitably abstracted. Trainees may not feel the same pressure as in a live drill, which is why ICS: The Game should be viewed as a complement, not a replacement, to high-fidelity simulations. Another limitation is that a board game requires gathering participants together with the appropriate materials along with an initial learning curve to understand the rules—whereas online training is undeniably convenient for dissemination at scale and for self-paced learning. Additionally, only START and SALT triage algorithms are used in this game, because they are commonly used in practice, relatively easy to learn, and free to use. Yet, both these methods have been found to be prone to over-triaging, and others have proposed different triage algorithms that have both high sensitivity and specificity.¹⁵ Furthermore, ICS: The Game is a simplified version of ICS to make the game accessible to all levels of trainees and allow for a small group (two to five people) to play. In doing so, it does not capture the full scale of ICS and should serve as a supplement to didactics and full-scale disaster drills. Future research will focus on comparing the degree of learning in trainees who learn ICS from didactics alone to trainees who learn ICS from didactics and ICS: The Game.

Conclusion

Overall, some of the advantages of teaching with ICS: The Game include increased learner engagement, opportunities for teamwork and leadership development, and the ability to repeatedly practice critical protocols like START and SALT triage. Importantly, the cost-effectiveness and portability of a board game make disaster training more accessible to a wide range of institutions, from large academic hospitals to smaller community programs.

While no single method can cover all aspects of disaster preparedness, ICS: The Game fills a niche by providing immersive learning without the high resource burden. When combined with other methods, such as supplementary lectures or online modules and following up with debriefings and occasional full-scale drills, ICS: The Game helps create a more well-rounded training program. By engaging medical professionals in active decision-making, teamwork, and real-time strategy application, ICS: The Game helps translate theoretical disaster plans into practiced skills—with the goal of preparing healthcare teams to respond effectively when real disasters strike.

Conflict of Interest

The authors declare no commercial or financial relationships that could be construed as a potential conflict of interest. ICS: The Game is open-access and designed to help trainees become better prepared for disaster response.

Acknowledgments

The authors acknowledge the Wilderness Medical Society and the Sidney Kimmel Medical College for the opportunity to test and optimise the game.

Appendix

Click here to download the complete article.

Author(s)

Sage P Rahm*¹, Gabrielle N Saifi², Kaitlin Payne³, Tamar Reich⁴, Ilana Porges⁵, Luis A Aguilar Montalvan⁶,
Michael Horrocks², Lara L Phillips⁷, Amit S Padaki^8
1Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
²Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
³Department of Medicine, Division of Gastroenterology and Hepatology, Tufts Medicine, Boston, MA, USA
⁴Northeast Emergency Medicine Specialists, Willimantic, CT, USA
⁵Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
⁶Department of Emergency Medicine, Jacobi/Montefiore Medical Centers, Albert Einstein School of Medicine, Bronx, NY, USA
⁷Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
⁸Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA

*Corresponding author email aspadaki@gmail.com

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