Mass Casualty Incident Management: Part 6

There’s a three car MVA on the highway and you and your partner are first due. It doesn’t sound like the end of the world, but it does sound like it might involve more patients than your city has immediately available ambulances. You arrive and see a few people obviously hurt—some in their cars, some walking around and a bunch of people who could be bystanders or more patients. Your partner calls a mass (or multi) casualty incident (MCI) and assigns you to triage. What next?

Step 1—Take the job: The first thing you should do is coordinate with the EMS officer. Even if the EMS officer is your partner, or you’ve arrived at the same time and you know as much about the incident as they do, you’ll still want to coordinate with him or her to ensure you’re all on the same page.

Step 2—Dress for success: You know that you’re the triage officer, but does everyone else? Get your vest and any other system specific equipment, including triage kits and supplies, and get ready to go to work.

Step 3—Set up your workspace: Your workspace will ultimately be defined by the nature and scope of the incident.^1–3 Some areas are widespread while others are confined to a relatively small area. Whatever the size of your workspace, it will have four key components: the patient(s), the patient generator (the thing hurting people), and areas of ingress (where you want responders to enter the area to remove patients) and egress (how you want patients to leave the area).

Step 4—Go to work: The exact triage procedure you’ll use depends on local protocols and the MCI management system used by your service. Two of the most popular triage systems in the United States are Simple Triage and Rapid Treatment (START) for adults^{4, 5} and JumpSTART for pediatric patients.^{6, 7} Other systems used worldwide include the Sacco Triage Method (STM)⁸; Triage Sieve and Sort⁹; Homebush Triage Standard¹⁰; and most recently the Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) field triage system developed by the American College of Emergency Physicians.^11–13 Once all patients have been initially triaged it’s the responsibility of the triage officer to a) continue to check and re-triage patients as needed, and b) facilitate patient movement in coordination with the treatment officer—beginning with the priority patients. Remember, regardless of the triage system used, the focus is not hands-on treatment but moving patients in the order of greatest need out of the incident area.

Step 5—Communicate: The triage officer must communicate upstream with the EMS officer to request additional triage resources, as needed. You’ll also be providing regular updates on the severity and total number of patients involved in the incident, as well as the number remaining in the triage area. As mentioned, the triage officer must also coordinate downstream with the treatment officer to facilitate efficient patient movement. As fewer triage resources are needed they’re typically moved downstream to boost resources in the treatment area.

While the importance of preparation, training and practice of MCI management cannot be overemphasized, even relatively prepared EMS providers might find triage algorithms somewhat daunting. To overcome this, the first due crew may begin with the easy-as-pie Global Sorting triage method. Using Global Sorting, the first due crew can divide victims into four quick categories: watching, walking, waving and wounded in four easy steps.

1. Watching (Non-injured): Enter the triage (incident) area and separate people on scene into injured and non-injured groups. Law enforcement, fire service or other response personnel may be able to assist with this process.
2. Walking (Ambulatory): Next, direct any patients who can walk to move themselves to a designated area. These patients can be tagged as low-priority, as they’ve demonstrated they can both follow commands and move themselves.
3. Waving (Non-ambulatory, follows commands): Ask the remaining victims to raise their hand if they’re injured. Because these patients are mentating well enough to follow verbal commands but cannot move themselves they can be tagged as delayed priority.
4. Wounded (Most injured, deceased and expectant): The remaining patients will likely have the gravest injuries. This is where you will begin “detailed” or “secondary” triage to separate the deceased and expectant patients (lowest priority) from the patients who are most injured, but are breathing and have a pulse (highest priority).

These methods provide a fast, easy and efficient way to ensure that the right patients receive the right resources. While the system you use and the circumstances of your particular call will dictate exactly how you triage your patients, you can be assured that a standard and practiced approach to your job as triage officer will contribute to both the stability of the incident, and the health and well being of your patients.

Next month: Treatment.

References

1. AAOS. Emergency Care and Transportation of the Sick and Injured, 10th ed. Jones & Bartlett Publishers, 2010.

2. Limmer D, O'Keefe MF, Dickinson ET. Emergency Care. Prentice Hall, 2011.

3. Mistovich JJ, Hafen BQ, Karren KJ. Prehospital Emergency Care, 9th ed. Prentice Hall, 2009.

4. Simple Triage and Rapid Treatment (START).

5. Kahn CA, Schultz CH, Miller KT, Anderson CL. Does START triage work? An outcomes assessment after a disaster. Annals of Emergency Medicine, 54(3): 424–430, 2009.

6. The JumpSTART Pediatric MCI Triage Tool.

7. Sanddal TL, Loyacono T, Sanddal ND. Effect of JumpSTART training on immediate and short-term pediatric triage performance. Pediatric Emergency Care, 20(11): 749–753, 2004.

8. The Sacco Triage Method (STM).

9. Triage Sieve.

10. Nocera A, Garner A. An Australian mass casualty incident triage system for the future based upon triage mistakes of the past: the Homebush Triage Standard. Aust. N.Z. J. Surg., 69:603–608, 1999.

11. SALT Mass Casualty Triage Algorithm. 

12. Jenkins J, McCarthy M, Sauer L. Mass-casualty triage: time for an evidence-based approach. Prehospital and Disaster Medicine, 23(1): 3–8, 2008.

13. Lerner E, Cone D, Weinstein E, et al. Mass casualty triage: an evaluation of the science and refinement of a national guideline. Disaster Med Public Health Prep, 5(2): 129–137, 2011.

An emergency responder for more than 20 years with career and volunteer fire departments, public and private emergency medical services and hospital-based healthcare, Rom Duckworth is an internationally recognized subject matter expert, fire officer, paramedic and educator. He is currently a career fire lieutenant, EMS coordinator and an American Heart Association national faculty member.