In part 1 of this series on MASCALs (mass casualty incidents or MCIs), we discussed the classic “5 S’s” of mass casualty management and the S.T.A.R.T. system of primary triage. We also touched upon the newer S.A.L.T. system and even more recent suggestions.
This time, Let’s go further into an example of a mass casualty incident and discuss how you would perform primary triage on a victim using the classic protocol.
Here’s our hypothetical scenario: It’s market day at your village near the border with another (hostile) group. Suddenly, you hear an explosion. You’re the first to arrive at the scene. There are about twenty people down. What do you do?
Referring back to the 5 S’s of MCI management from the last article, let’s say that you have already determined the SAFETY of the current situation and SIZED UP the scene. It appears that a bomb has exploded. As far as you can tell, there are no hostiles nearby. You don’t see anything that you suspect might be a second device. Therefore, you believe that you aren’t currently in danger. The injuries are significant and the victims are all in an area no larger than, say, 20-30 yards.
The incident occurred on a main thoroughfare your people use, so there are ways in and out. You have SENT FOR HELP on your handheld radio and described the scene. Several survival group members have replied, including a former ICU nurse. The area is relatively open, so you can SET UP different areas for various triage categories. Now you can “START” (Simple Triage And Rapid Treatment).
In a loud voice, you shout “I’m _____ and I’m here to help. If you can walk and need medical attention, get up and move to the sound of my voice. If you are uninjured and can help, follow me.”
This first step is similar in SALT triage. In SALT, however, you then ask everyone not walking to wave. Those who stay still are then assessed first, as they are assumed to be the most in need of help; some of the still victims may, however, be deceased. S.A.L.T.’s criticism of the S.T.A.R.T. system is that someone might have a chest or abdominal wound and still be able to walk, thereby missing someone who needs immediate help. This, I think, is certainly possible, but would not be a very common occurrence.
This time, however, we’re using the S.T.A.R.T. system. You’re lucky, 13 of the 20 victims sit up, or at least try to. 10 can stand, and you direct the walking wounded to an area you designated. These people have cuts, burns, and scrapes. A couple are limping; one obviously has a broken arm. Two bruised but sturdy individuals volunteer to join you. By simply communicating, you have made your job as temporary Incident Commander easier by identifying the walking wounded (Green Tags) and getting some immediate help. You still have 10 victims down.
Your team then goes to the closest victim on the ground, evaluates them, and proceeds in an organized manner to the next nearest victim in turn. In this way, you will triage faster and more effectively than trying to figure out who needs help the most from a distance.
(In S.A.L.T., you would, instead, go directly to the first “still” victim)
Let’s cheat just a little and say that you happen to have SMART tags in your pack. SMART tags are handy tickets which allow you to mark a particular triage level on a patient. Once you identify a victim’s triage level, you remove a portion of the end of the tag until you reach the appropriate color and place it around the patient’s wrist.
It is important to remember that you’re triaging, not treating. The only treatments in START will be the control of heavy bleeding, opening airways, and elevating the legs in case of shock.
(In S.A.L.T., they add additional life-saving interventions like needle decompression. Off the grid, however, you might not have the materials needed.)
RPMs (Respirations, Perfusion, and Mental Status)
As you go from patient to patient, stay calm, identify who you are and that you’re here to help. Your goal is to find out who will need help most urgently (red tags) by checking “RPMs.” Any one failed RPM check tags the victim as red.
1.Respirations: Is your patient breathing? If not, restore the airway by tilting the head back and lifting the chin or, if you have them, insert an oral airway (Note: in MCI triage where time is of the essence, the rule against moving the neck of a victim due to risk of cervical spine injury is, for the time being, suspended).
If you have an open airway but no breathing, that victim is tagged black. If the victim begins to breathe once an airway is restored or has a respiration rate of more than 30 times a minute (or less than ten), tag red. If the victim is breathing normally, move on to perfusion.
2.Perfusion/Pulse: Perfusion involves evaluating the adequacy of blood flow and circulation. Check for the presence of a (wrist or neck) pulse, then press on a nail bed or finger pad firmly and quickly remove. The coloration will go from pale back to normal color in less than two seconds if circulation is good. This is referred to as the Capillary Refill Time (CRT). If you’re not feeling a pulse or it takes longer than 2 seconds for nail bed color to return, tag red. If you feel a pulse and CRT is normal, move to mental status.
3.Mental Status: Can the victim follow simple commands (“open your eyes,” “squeeze my hand”)? If the patient isn’t breathing excessively fast and has normal perfusion, but is unconscious or disoriented: Tag red. If they can understand you and follow commands, tag yellow if they can’t get up, or green if they can. Remember that, as a consequence of the explosion, some victims may not be able to hear you well.
It might be easier to remember all this by just thinking “30-2-Can Do”:
-30 (Is the respiration rate more than 30/minute or less than 10/minute?)
-2 (Is the CRT less than 2 seconds?)
-Can Do (Can the victim follow simple commands?)
If shock is suspected, elevate the legs above the level of the heart.
It should be noted that different regions may use other systems of primary triage or criteria. For example, normal CRT is considered by some to be 3 seconds. Also, children have higher respiratory rates than adults, so more than 45 respirations is used instead of 30.
If there is any doubt as to the category, always tag the highest priority triage level. Not sure between yellow and red? Tag red. Once you have identified someone’s triage level, tag them and move immediately to the next patient unless you have major bleeding to stop.
When there are multiple victims, spend only as much time as is needed to determine the triage level. The only actual treatment you’ll provide in the primary triage phase will be to stop heavy bleeding and clear airways with a chin-lift jaw thrust. In this way, you’ll do the most good for the most people in the shortest amount of time, if not the best for every individual.
It stands to reason that you would be more effective if you had help. If uninjured or minimally injured victims can help you apply pressure to a wound, you can move on to evaluate the next victim. A tourniquet or an airway in the medic’s pocket can be lifesavers.
Off the grid, the medic’s job is exponentially tougher, and some RED victims will assuredly end up tagged BLACK. You can only aim to achieve what Teddy Roosevelt once advised:
“Do what you can, with what you have, where you are.”
In the next part of this series, we’ll look at our ten victims one by one and decide how to class them using the START color system.
Joe Alton MD
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