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Eagles Tackle MCI Triage

From resuscitation to trauma and terrorism to government advocacy, the first day of the 21st EMS State of the Science Conference—better known as the Gathering of Eagles—kicked off Friday in Dallas with big thoughts on big issues from big-name EMS physicians both American and European.

The show’s standard rapid-fire short presentations were clustered by theme. One of the most interesting dealt with various aspects of triage in mass-casualty incidents.

Asa Margolis, DO, deputy medical director for the U.S. Secret Service, opened the bundle with a look at the latest chemical threats that could be used by terrorists. Their attacks, including with chemicals, are growing in frequency and complexity, he said, and the Secret Service must respond immediately to any attack on a protectee, even before knowing the substance involved.

Those substances are getting scarier. In 2017 North Korean exile Kim Jong-nam, a critic of the regime of his brother Kim Jong-un, was assassinated in Malaysia with the chemical agent VX. Last year spy Sergei Skripal and his daughter were poisoned in Salisbury, England, using the even deadlier Novichok agent A-234, said to be 5 to 8 times more potent than VX. As far back as 2002, Russian authorities used an unknown chemical agent, thought to be a morphine derivative, to end the Dubrovka Theater siege, killing all 40 terrorists but also more than 200 hostages.

Secret Service agents are trained to the EMR level, Margolis said, and employ a toxidrome-based system of rapid triage for the most lethal agents, which include nerve agents, organophosphates, and asphyxiants.

Novichok agents, developed by Russia/the USSR in the 1970s and ’80s, are supposedly the deadliest nerve agents ever produced, some up to 10 times deadlier than soman. They are among the so-called fourth-generation agents, unique organophosphates that are more potent and persistent than other agents. They require more treatment, medications, and supportive care. However, Margolis said, the familiar mnemonics DUMB(B)EL(L)S and SLUDGEM can still be used to identify symptoms:

  • Diarrhea
  • Urination
  • Miosis
  • Bradycardia, bronchorrhea, bronchospasm
  • Emesis
  • Lacrimation
  • Salivations, secretions, sweating


  • Salivation
  • Lacrimation
  • Urination
  • Defecation
  • Gastro
  • Emesis
  • Miosis

Prehospital management of those exposed should focus on the ABCs and supportive care, decontamination, and drugs like anticholinergics and anticonvulsants.

Pierre Carli, MD, medical director for the EMS system in Paris, examined the ethical quandary of treating injured terrorists. How is it, he posed, that we can be intent on killing them one minute, then prioritize them for treatment the next?

In the classic approach to triage, the worst-injured are helped first, regardless of who they are. In the “just” approach, victims get priority over terrorists. While we should always treat terrorists humanely, the ethics of such situations can be flexible, Carli said. Society has both retributive and distributive (i.e., victims have more social value than terrorists) interests that might catalyze putting the innocent before the worse-injured guilty; a problem, of course, is that the groups can be difficult to distinguish in the mayhem of a terrorist incident.

After spending a decade in Israel, Colorado Springs’ EMS medical director, Stein Bronsky, MD, finds America’s traditional civilian MCI triage methods too complex and unrealistic—who can check capillary refill in an MCI situation? They also don’t work that well: In the 2007 Virginia Tech shooting, 69% of victims were overtriaged; at Fort Hood in 2009, 70% were triaged inaccurately. Both START and SALT are overly simplistic, Bronsky said, and don’t require the critical thinking desired of paramedics. RAMP—for Rapid Assessment of Mentation and Pulse—is a better alternative that asks patients to follow basic commands rather than requiring a GCS calculation. It is easily taught and remembered and needs no math.

After program host Paul Pepe, MD, previewed the forthcoming HHS/ASPR “road map” for MCI triage, Florida doc Peter Antevy—whose jurisdiction includes Parkland’s Marjory Stoneman Douglas High School—talked about ASPR’s TRACIE resource for disaster medicine, preparedness, and public health emergencies. TRACIE stands for Technical Resources, Assistance Center, and Information Exchange; it’s basically a repository for mass-casualty preparedness and response information.

The keys to an MCI response, Antevy noted, include early unified command, embrace of the principles of the Hartford Consensus, and an emphasis on strategies over tactics. At dynamic scenes, he urged, prioritize transport over structured triage. Unless transport is delayed, triage tags have little value, though tape can be used to ID survivors and prevent needless reassessments. Use reflective tape for dark conditions. Other tips include integrating law enforcement transport and emphasizing secondary triage at the hospital. Keep those hospital communications dynamic and ongoing, Pepe said, maintain preparedness, and be proactive about training others likely to be involved in mass-casualty situations.

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