Mass Casualty Incident Management: Part 6

While the importance of training and practice of MCI management cannot be overemphasized, even relatively prepared EMS providers might find triage algorithms daunting.


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 adults4, 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.

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