EMERGENCY MEDICAL RESPONSE
by Carl Crosswhite
Mass Casualty Triage*: Sorting and prioritizing injured victims for
treatment and transport
(*-TRIAGE: a French word meaning to "sort" by priority or
life-threatening nature of injury)
Many injured victims are present in the scenario. In order to expedite
treatment to those most seriously injured, and avoid wasting resources on less
seriously injured, a system of rapid "triage" or sorting has been
developed called "Special Triage and Rapid Transport" or START.
Victims can be quickly evaluated by emergency medical personnel. Initial
findings such as vital signs (pulse rate, blood pressure, respiration, level of
consciousness) are recorded on the triage tag, and then rechecked periodically
thereafter to monitor the victim's status and to RE-TRIAGE* if their conditions
becomes worse, or improves later. Responders are accountable for the
identity and security of all victims present in the area of the incident. Such
persons will not be allowed to leave the area until they are properly
identified, evaluated, treated, transported to a medical treatment facility
and/or medically cleared for release.
- Priority 1 (Red) Serious but salvageable life threatening injury/illness
- Victims with life-threatening injuries or illness (such as head injuries,
severe burns, severe bleeding, heart-attack, breathing-impaired, internal
injuries) are assigned a priority 1 or "Red" Triage tag code
(meaning first priority for treatment and transportation).
- Priority 2 (Yellow) Moderate to serious injury/illness (not immediately
- Victims with potentially serious (but not immediately life-threatening)
injuries (such as fractures) are assigned a priority 2 or "Yellow"
(meaning second priority for treatment and transportation) Triage tag code.
- Priority 3 (Green) "Walking-wounded"
- Victims who are not seriously injured, are quickly triaged and tagged as
"walking wounded", and a priority 3 or "green"
classification (meaning delayed treatment/transportation). Generally, the
walking wounded are escorted to a staging area out of the "hot
zone" to await delayed evaluation and transportation.
- Priority 4 (Blue)
- Those victims with critical and potentially fatal injuries or illness are
coded priority 4 or "Blue" indicating no treatment or
transportation. It is important to note that victims of mass casualty
incidents (MCI) who are still presenting some vital signs but may have
life-threatening or potentially fatal injuries, may be classified as
"unsalvageable" by the Triage officer. Although this is a very
difficult decision, it is necessary when many casualties require more
resources than may be available. It is axiomatic that committing resources
to save the life of a person who is most likely to live if cared for
promptly, outweighs committing resources to victims who probably will not
survive even if such resources are administered. In ordinary emergencies
where only a few victims are injured, it is possible for responders to
devote sufficient resources to critically injured patients, and to attempt
to save their lives by extraordinary medical support and rapid
transportation (when possible) to a level 1 or 2 Trauma Center. Such
patients often still succumb to their injuries, even after extensive care in
- Priority V (Black)
- Victims who are found to be clearly deceased at the scene with no vital
signs and/or obviously fatal injuries are classified as deceased or priority
5 (Black) in the triage coding system.
A Triage Officer coordinates the assignment of Triage
Teams of emergency medical first responders who quickly evaluate and tag
patients. Then as sorting continues, first responders are sent in to treat the
victims according to tag code.
* - RE-TRIAGE
Re-triage occurs when the status of a patient changes either to a worse
condition or if they improve to a less life-threatening level. The previous code
is crossed out after evaluation, and the new code and vital signs are listed on
the triage tag. Patients who have been initially moved to a specific
transportation area would then be moved to a greater or lesser priority
transportation area after re-triage has been concluded.
- Medical Treatment and Evacuation
- Medical Teams composed of emergency medical first responders enter the
area to initiate stabilization and care for victims by triage priority, and
to load and evacuate them to a Staging area according to priority
code. For example, all Reds will be moved to a staging and treatment
area for immediate transport. Yellows will treated and evacuated after all
Reds are properly treated and evacuated.
- Transportation of victims
- A Transportation Officer coordinates the arrival and assignment of
patients to appropriate ground or air transportation. Ambulances and medical
helicopters will transport most seriously injured patients (Reds) from the
red zone. The transportation officer coordinates with the Emergency
Medical Officer to assign hospital destinations for urgent cases. Medical
coordination with area hospitals is essential to route most seriously
injured patients to level I and II Trauma Centers within a "golden
hour" where the victim's survival probability is best if definitive
care is begun within an hour of the injury. Care must be taken to not
overload trauma centers, and to avoid sending less seriously injured
patients to such centers when they can be effectively treated at other area
- Non-priority victims: deceased or critical/fatally injured victims
- A Morgue Officer supervises fatally injured victims who cannot be moved or
transported until the Coroner investigates the scene and authorizes removal.
PERIMETERS: Controlling the access to and from the scene of the event
- Outer Perimeters: Controlling access to and from the scene
- Law enforcement officers are needed to set up a perimeter around the scene
to prevent pedestrians and vehicles from entering or driving through
hazardous areas. The perimeter may be as large as is necessary to keep
spectators away, and permit emergency vehicles to enter and leave without
being impaired by "looky-looks" who flock to the scene to see
"what's going on." Curiosity of on-lookers can greatly impede
rapid response of emergency vehicles by clogging roadways, parking in access
points, and failing to yield to emergency vehicles. Most of all, spectators
may enter an area which poses serious or fatal hazards due to fire, chemical
spill, downed power lines, explosions, etc.
- Double "Funnel" for victim transport
- Law Enforcement responders working with medical responders will establish
a "perimeter" around the scene of the Mass Casualty Incident,
often called a "HOT ZONE" An outbound funnel point will be
identified as a safe area through which to remove victims to a second
perimeter or zone where they are placed in their appropriate
"staging" area according to triage coding. No one is allowed
through the perimeter of the "HOT ZONE" to avoid misplacing or
unsafely moving victims without authorization. Other factors which may
affect the establishment of the "HOT ZONE" include hazardous
materials spills, fire, downed power lines, dangerous or unstable structures
- SCENE SAFETY: protecting the rescuers and victims
- The Safety Officer supervises the overall operation in terms of safe
conduct of rescue, fire suppression, evacuation, hazardous materials
control, etc. If a safety officer observes a potentially dangerous situation
which may kill or injure a rescuer or victim, he has authority to cease or
modify the operation to prevent further risk.
MASS CASUALTY INCIDENTS: exercise simulations save lives in real m.c.i.
Many first responders can quickly and effectively work together under a
unified command system which is universally used and understood, to save lives,
and minimize risk of injury and property damage. By exercising such responses in
realistic field simulations such as a "mass casualty incident"
rescuers become more proficient and capable in real situations.
Suffolk County R.A.C.E.S. Radio Officer is Bill Schiebel, N2NFI.
The Suffolk County
A.R.E.S. District Emergency Coordinator is Bill Schiebel, N2NFI.
have info for or need info on A.R.E.S./ R.A.C.E.S. e-mail Bill.
Send Email to N2NFI