**5. Discussion**

The essential raise of knowledge among Thai EPs was registered in Command and control, Safety, Communication, and situation Assessment. At the same time, the understanding of the subject areas, Triage, Treatment, and Transport did not develop to the same extent. All changes were statistically significant. Since these physicians are working at both hospital and prehospital levels, it is not surprising that the grade of their knowledge in strict medical areas, e.g., Triage, Treatment, and Transport, is higher than other subjects within CSCATTT, which specifically deal with leadership characteristics.

Earlier studies have discussed the medical and nonmedical aspects of MID management, showing critical shortcomings in the latter [15]. Disaster and major incidents are rare, but they need to be mitigated and managed if they occur. In successful management, collaboration is one crucial factor that demands skilled leadership and reliable communication. In this group of EPs with no earlier experience of MID, the collaborative elements in a mutual task helped to reduce the organizational barriers, enlisted their abilities and limitations, and promoted interplay with no hierarchical authority, as well as the ability to switch between di fferent collaboration strategies as demanded by the specific situation and leadership styles. The groups grew up to be more stable, practiced transitions, overlaps, fearlessness, and improvised to create new ways of handling the unexpected situation by discovering di fferent communication alternatives. During training, their ability to try out the situation developed their confidence, increased their trust to each other, and reduced the internal fear of doing wrong. They could test a model, evaluate its e ffect in the next stage, create a new approach, test it, and develop their approach continuously [21,23,24,29]. All these elements are necessary for successful teamwork at the time of emergency. The ultimate requirement is to act in a flexible surge capacity (FSC) when hospitals and communities must activate their resources, respectively [10].

Choosing EPs as one of the major players in MID managemen<sup>t</sup> is a natural selection [17,19,20]. In countries such as Thailand, they work at both hospital and prehospital levels and thus have a logical connection to both entities [19,20]. In a changing world, when resources may not be enough to match the needs, there must be more material and personal options than what is o ffered by standard disaster plans. FSC aims to provide new innovative solutions to these shortcomings [10]. Other reports have high lightened the need for FSC and discussed the need for ACF [30]. This paper tried to examine the possibility of using a simulation model to increase the knowledge and understanding of a new set of professionals to lead MID management. Training EPs for the next MID will strengthen the whole chain of disaster managemen<sup>t</sup> and partly accommodate the WHO´s policy of proactivity and increase the strength and ability of communities to handle the first waves of MID impacts since EPs are one group, who will face upcoming incidents [17,19]. Other measures within the community, such as civilians' empowerment as immediate responders, and the necessity of creating new guidelines and systems have been reported elsewhere [31–33]. Altogether, they facilitate the concept of FSC (Flexible Surge Capacity). Using the elements of CSCATTT as a model enables a direct assessment of critical features that need to be in place during MID managemen<sup>t</sup> [18]. These elements are part of educational initiatives given to all healthcare sta ff, and are not only perceived abilities and knowledge but also what they practice in every-day missions, and emphasize the importance of medical and nonmedical aspects of MID management. In a future with limited resources and expanding needs, civilian help can be decisive in creating Resilience in each society [31–33]. The same method and elements can be used to educate other groups of people to act at di fferent levels of managemen<sup>t</sup> or maybe increase their awareness about any given event to mitigate the adverse outcomes of any incidents [15,30–34].

Moynihan [29] emphasizes the value of trying it out, i.e., to test a model to cope with an event, evaluate the e ffect of the model in the next stage, create a new approach, test it, and develop the method continuously. Through the 3LC-exercise, the EPs practiced their ability to make a concerted and coherent assessment of which collaboration form is applicable at a given time. The collaboration is not a static activity but subject to construction, deconstruction, and reconstruction, depending on what is appropriate for a specific time, place, or event. The 3LC exercise illustrates the primary goal of practicing the di fferent forms of collaboration and switching between them by including asymmetries in the scenarios [21–24]. For instance, the police can arrive first at the scene and begin caring for victims with serious injuries, or understa ffed emergency rescue services have to ge<sup>t</sup> help from the police and paramedics at a fire incident. The exercise also reveals the need for a joint assessment and the importance of knowing both prehospital and hospital fields. The latter o ffers a valuable opportunity to

increase the collaborative segmen<sup>t</sup> of MID management. At the same time, decisions can be made based on knowledge about the di fferent organizations' limitations and capabilities [15,16].
