Mass Casualty Triage Basics

Given the horrific events surrounding the Ariana Grande concert in Manchester, UK, we have come to realize that we may never be safe in today’s world. The bombing is new evidence, however, that no target is off limits to the terrorists in our midst. We can expect more episodes of terror in the western world in the future, and many will involve mass casualties.

The Mass Casualty Incident

The responsibilities of a caregiver is usually one-to-one; that is, the healthcare provider will be dealing with one ill or injured individual at a time.  This encounter usually falls within their expertise and resources.  There may be a day, however, when you find yourself confronted with a scenario in which multiple people are injured.  This is referred to as a Mass Casualty Incident (MCI).

A Mass Casualty Incident is any event in which your medical resources are inadequate for the number and severity of injuries incurred.  MCIs can be quite variable in their presentation.

Types of Mass Casualty Incidents

MCIs can be quite variable in their presentation:

• Doomsday scenario events, such as a nuclear weapon detonation
• Terrorist acts, such as occurred in Manchester
• Consequences of a storm, such as a tornado or hurricane
• Consequences of civil unrest or battlefield injuries
• Mass transit mishaps (train derailment, plane crash, etc.)
• A car accident with, say, four people injured (and only one ambulance)

 Responding to a Mass Casualty Incident

The effective medical management of any of the above events required rapid and accurate triage.  Triage comes from the French word for “to sort” (trier) and is the process by which medical personnel can rapidly assess and prioritize a number of injured individuals and do the most good for the most people. Note that I didn’t say: “Do the best possible care for each individual victim”.

Let’s assume that you were at the concert in Manchester, the Christmas market in Berlin, or the Boston Marathon when a bomb went off.  You are the first one to arrive at the scene, and you are alone.  There are twenty people on the ground, some moaning in pain.  There were probably more, but only twenty are, for the most part, in one piece.  The scene is horrific.  As the first to respond to the scene, you are “Incident Commander” until someone with more medical expertise arrives on the scene.  What do you do?

Your initial actions may determine the outcome of the emergency response in this situation.  This will involve what we refer to as the 5 S’s of evaluating a MCI scene:

• Safety
• Sizing up
• Sending for help
• Set-up of areas
• START – Simple Triage And Rapid Treatment

Safety Assessment:  An insidious strategy on the part of terrorists when they target crowds is to set off primary and secondary bombs.  The main bomb causes the most casualties, and the second bomb is timed to go off or is triggered just as the medical/security personnel arrive.  This may run counter to your instinct to help, but your primary goal is your own self-preservation. Keeping the medical personnel alive is likely to save more lives down the road.  Therefore, you do your family and community a disservice by becoming the next casualty.

As you arrive, be as certain as you can that there is no ongoing threat.  Do not rush in there until you’re sure that the damage has been done and you and your helpers are safe entering the area.  In the immediate aftermath of the 1995 Oklahoma City bombing, various medical personnel rushed in to aid the many victims.  One of them was a heroic 37-year-old Licensed Practical Nurse who, as she entered the area, was struck by a falling piece of concrete.  She sustained a head injury and died five 5 days later.

Sizing up the Scene:  Ask yourself the following questions:

• What’s the situation?   Is this a mass transit crash?  Did a building on fire collapse?  Was there a bomb?
• How many injuries and how severe?  Are there a few victims or dozens?  Are there “walking wounded” that could assist you?
• Are they all together or spread out over a wide area?
• What are possible nearby areas for treatment/transport purposes?
• Are there areas open enough for vehicles to come through to help transport victims?

Sending for Help:  If modern medical care is available, call 911 and say (for example):  “I am calling to report a mass casualty incident involving a multi-vehicle auto accident at the intersection of Hollywood and Vine (location).  At least 7 people are injured and will require medical attention.  There may be people trapped in their cars and one vehicle is on fire.”

In three sentences, you have informed the authorities that a mass casualty event has occurred, what type of event it was, where it occurred, an approximate number of patients that may need care, and the types of care (burns) or equipment that may be needed.

Set-Up:  Determine likely areas for various triage levels (see below) to be further evaluated and treated.  Also, determine the appropriate entry and exit points for victims that need immediate transport to medical facilities, if they exist.  If you are blessed with lots of help at the scene, assign triage, treatment, and transport team leadership roles.

S.T.A.R.T.:  Triage uses the acronym S.T.A.R.T., which stands for Simple Triage and Rapid Treatment.   The first round of triage, known as “primary triage”, should be fast (30 seconds per patient if possible) and does not involve extensive treatment of injuries.  It should be focused on identifying the triage level of each patient.  Evaluation in primary triage consists mostly of quick evaluation of respirations (or the lack thereof), perfusion (adequacy of circulation), and mental status.  These are known as “RPMs” and are a (very) basic indication of the level of injury.

Other than controlling massive bleeding and clearing airways, very little treatment is performed in primary triage. Controlling hemorrhage is best done with commercial tourniquets, for example, the SOF-T, CAT, or SWAT. It’s a sad sign of the times that I recommend carrying one of these if you have to go to areas where there are large crowds and little security. Tourniquets can be improvised with belts, bandannas, and other items, but are more difficult to apply effectively.

Although there is no international standard for this, triage levels in the U.S. are usually determined by color:

Immediate (Red tag): The victim needs immediate medical care and will not survive if not treated quickly.  (for example, a major hemorrhagic wound/internal bleeding) Top priority for treatment.

Delayed (Yellow tag): The victim needs significant medical care within 2-4 hours. Injuries may become life-threatening if ignored, but can wait until Red tags are treated. (for example, an open fracture of the femur without major hemorrhage)

Minimal (Green tag): Generally stable and ambulatory “walking wounded”, but may need some medical care. (for  example, broken fingers, superficial burns)

Expectant (Black tag): The victim is either deceased or is not expected to live.  (for example, a large open fracture of cranium with brain damage, multiple penetrating chest wounds

Patients may be identified with colored tape or triage casualty cards, but you’re unlikely to have these on hand. In that case, simply mark the victims’ foreheads with the numbers 1,2,3, and 4 indicating the priority for urgent care

Knowledge of this system allows a patient marking system that easily allows incoming medical personnel to understand the urgency of a patient’s situation.  It should go without saying that, in a power-down situation without modern medical care, a lot of red tags and even some yellow tags will become black tags.  It will be difficult to save someone with major internal bleeding without surgical intervention.

The surviving victims of the Manchester bombing were “fortunate”, if I may use the word, that emergency personnel were on the scene in minutes. Although the death count is currently at 22, many more of the 60 wounded would not have survived without their assistance and transport to modern medical facilities.

We live in a more dangerous world these days, something I call “The New Normal“. In the New Normal, increased vigilance and situational awareness will be needed if you want to stay safe in crowds. In future articles, we’ll explore further how to deal with mass casualty incidents as a medical asset, and also how to avoid becoming a victim of those who want to disrupt civilized society.

Joe Alton, MD

Learn more about mass casualties, active shooter, terror events, and 150 other medical topics in times of trouble in the 700 page Third Edition of the Survival Medicine Handbook: The Essential Guide for When Medical Help is Not on the Way.