Adaptive clinical command and operational resilience in maritime mass casualty incidents: A qualitative study.

INTRODUCTION: Maritime mass casualty incidents (MCIs) present significant operational challenges due to environmental instability, geographic isolation, and delayed sea-to-shore evacuation. Despite increasing maritime disaster risks, limited evidence exists on how emergency personnel experience and enact coordinated responses and operational resilience in island settings. METHODS: A qualitative descriptive study was conducted using individual semi-structured interviews with 12 emergency physicians and emergency nurses involved in maritime MCIs coordination in southern Thailand. Data were analysed using reflexive thematic analysis, with the incident command system (ICS) providing a structural lens and adaptive clinical command informing interpretation of adaptive coordination and decision making. FINDINGS: Three interrelated patterns relevant to operational resilience were identified: (1) operational volatility, characterised by environmental instability, delayed evacuation, and fluctuating patient surges; (2) adaptive clinical command, involving flexible triage, dynamic resource allocation, and cross-agency coordination; and (3) community-embedded interoperability, reflecting the contributions of local responders, shared training, and distributed response capacity. Together, these interrelated patterns illustrate how coordinated response is sustained under conditions of uncertainty. CONCLUSIONS: Operational resilience in maritime MCIs emerges from the interaction between structured command systems, adaptive frontline leadership, and distributed response capacity. Adaptive clinical command represents an important capability through which emergency physicians and nurses support situational awareness, coordination, and flexible decision-making during uncertain and resource-constrained maritime emergencies. Strengthening communication interoperability, adaptive leadership, and community-integrated preparedness may enhance disaster readiness in geographically isolated maritime settings.