Triage principles may need to be modified to include triage of multiple patient and mass casualty situations.
Triaging a single trauma victim is relatively straightforward. The prehospital care provider assesses the patient according to the defined triage criteria for that particular regionalized trauma system. If the patient meets the criteria of a major trauma victim, he or she is transported to the nearest designated trauma center.
In the situation of multiple patients, such as seen with multiple cars involved in the same accident, the same essential principles apply; however, decisions must be made in the field as to which patients have priority. A state of multiple casualties occurs when the numbers of patients and injury severity do not exceed the hospital resources. Those patients who are identified as major trauma victims by field triage criteria have priority over those who appear less injured. All major trauma patients should be transported to a trauma center as long as the trauma center has adequate resources to manage all the patients effectively. This type of situation can stress local resources, and possible diversion of the less critically injured to another trauma center should be considered. Monitoring transports with online computer assistance allows for contemporaneous determination if one trauma center is overwhelmed.
Triage in this situation is unique in that priorities are different from those in the single- or multiple-victim scenarios. In the instance of mass casualties, the resources of the designated trauma center, as well as the regional trauma system, are overwhelmed. When resources are inadequate to meet the needs of all the victims, priority shifts from providing care to those with the most urgent need to providing care to those with the highest probability of survival.
A severely injured patient, who would consume a large amount of medical resources, is now a lower triage priority. Despite the potential salvageability of this patient, the medical resources are focused on other patients who would benefit from advanced medical and surgical care. This method provides the greatest good for the greatest number of people. Field triage in this situation is probably the most difficult to perform as one has to make choices of quantity over quality with very limited amounts of information. These issues are further complicated when dealing with children.53
The most experienced and best-trained personnel available should make these field triage decisions. Physicians may be the best qualified to make these triage decisions; however, if they are the only receiving physicians available, direct patient care should take precedence and triage decisions would fall to other personnel. Patients are identified according to a triage code, based on the severity of injuries and likelihood of survival, and are treated accordingly. Occasionally, there may be an indication for a specialized surgical triage team with the capability to render acute lifesaving care of an injured trapped patient.54 In some disaster scenarios moving the intensive care into a disaster zone may be beneficial when evacuation of patients may be unrealistic due to logistical reasons.
In order to optimize patient care in these situations, it is important for regionalized systems to periodically have mock disaster drills. These drills allow for the proper training of all individuals who might be involved as well as the identification and correction of potential problems. With increasing terrorist activity, specific triage algorithms have been developed for specific scenarios such as biologic, chemical, radiologic, or blast attacks.55
Events surrounding the recent terrorist attacks of the Oklahoma Federal Building, World Trade Center, and the Pentagon, and natural disasters such as Katrina, should crystallize the resolve of all medical personnel to become educated and proficient in disaster management. The approach to disasters, whether natural or man-made, requires a coordinated relief effort of EMS, hospital, fire, police, and public works personnel. This multiorganizational operation can function in a crisis environment only if it is well directed and controlled. The ability to assess a disaster scene, call in appropriate personnel to provide damage control, fire and rescue operations, and crowd control is dependent on an organization structure that permits dynamic information processing and decision making of vital scene information.
The military uses the concept of command and control for its combat operations. Key personnel continually monitor and manage the battlefield situation. The Fire Service of the US Department of Forestry, in 1970, adapted command and control into an incident command structure. Within this framework, a centralized group of disaster personnel works to command and control all of resources at the disaster site. Dynamic disaster scene information is processed at the incident command and decisions as to how best to engage the rescue resources are implemented.
The incident command center structure is composed of seven key groups. If the disaster is small in scope, a single person may fill all seven areas. As the disaster increases in scope, more personnel are required to fulfill these functions. The incident commander is responsible for the entire rescue or recovery operation. Under the direction of the incident commander are the seven group commanders: operations, logistics, planning, finance, safety, information, and liaison. Each of these section commanders has well-defined areas of authority and responsibility. Continuous on-scene information will be communicated to the command center. This will enable the incident command center to plan and direct the rescue or recovery operation. Thus, limited resources and key personnel will be directed to produce the greatest benefit.
The disaster scene is typically divided into zones of operation. Ground zero is the inner hazard zone where the fire and rescue operations occur. EMS and other nonessential personnel are kept out of this area. Rescued victims are brought out of this area to the EMS staging area. This is the second zone, a primary casualty receiving area, and it is here that EMS personnel perform triage and initial care for the patient. Disposition directly to the hospital may occur or the patient may be sent to a distant receiving area for care and ultimate triage and transport.
The distant casualty receiving areas provide for additional safety in the environment. This downstream movement of injured patients prevents the primary triage sites from being overrun. Transportation of the wounded from the primary receiving site is reserved for the most seriously injured patients. Thus, a tiered triage approach is developed. A temporary morgue is also set up at a distant site.
Typically, groups of patients, the walking wounded, will migrate toward the nearest medical treatment facility. This process is called convergence. Medical facilities will often set up a triage area in front of the emergency department to handle these patients. Present-day medical teaching supports the treatment of any patient who arrives at an institution’s doorstep. Perhaps thought should be given to transporting groups of these patients to secondary medical facilities so that the closer hospitals do not become overburdened with an influx of patients. The use of outpatient operating facilities is being considered for this purpose.
The final operational zone of the disaster site is the outer perimeter. Police permit only essential personnel access into the disaster site. Crowd and traffic control ensure the safety and security of the disaster scene as well as to provide emergency vehicles rapid transit to and from the site.
Disasters may be of a small scale such as an intrafacility fire or explosion and may remain only a local or regional problem. As was seen at the World Trade Center, the magnitude of a local disaster was of such proportions that a national response was needed to address the rescue and recovery efforts. The standard appeal for this today is to activate the National Disaster Medical System.
Interestingly, in some of the more recent natural disasters, there have been approximately 10–15% of the survivors who were seriously injured. The remaining people either were dead or had mild to moderate trauma. It becomes a pivotal task to rapidly sort through the survivors and identify the level of care needed by each patient. In the World Trade Center, the New York Fire Department and EMS utilized the START system. The initial scene casualties were from the planes striking the building. Fire and rescue personnel could not reach these patients. With the collapse of the first tower, rescue operations were aborted and attempts to evacuate rescue personnel became paramount.52 Following the collapse, victims injured in the street or from the surrounding buildings required medical treatment. As rescue operations resumed, injured rescue workers began to arrive at medical treatment facilities. Unfortunately, there were only five survivors of the Twin Tower collapse with over 3,000 fatalities, which included civilians and rescue personnel.
The experience in Israel with terrorist attacks has demonstrated that rapid and accurate triage is critical to decrease or minimize mortality. Therefore, it has been suggested that the best triage officer, at least in bombings and shooting massacres, which are the most common form of terrorist violence, is the trauma surgeon. This is important to guarantee that those in real need of immediate surgical attention are seen and treated in a timely fashion without inundating the hospitals with patients who can be treated at a later time.
Critical concepts have been learned from the Israeli experience. These include rapid and abbreviated care, unidirectional flow of casualties, minimization of the use of diagnostic tests, and relief of medical teams ever so often to maintain quality and effectiveness in care delivery. The concepts of damage control should be liberally applied in the operating room (OR) to free up resources for the next “wave” of injured individuals.56–59
In mass casualties, hospitals become overwhelmed very easily. Therefore, communication between hospitals is critical to distribute the casualties in an evenly fashion.
Surgeons should be familiar with the basic principles of mass casualty management. Trauma surgeons should be the leaders in this field, as trauma systems serve as a template for the triage, evacuation, and treatment of mass casualty victims. The American College of Surgeons has emphasized on this critical role for surgeons.60