Page 66 - JSOM Spring 2023

TABLE 6 Selected overtriage and undertriage rates (%) at MCIs, as scene safety, undertaking rapid triage and transport, providing
reported limited on-scene care, and optimizing LSI timing. 53–57
Incident Overtriage Undertriage
Beirut 1983 63 80 0 The data summarized above do not show a clear benefit of
Buenos Aires 1994 9,64,65 56 x using any algorithm. They are inaccurate and too complicated
9
Oklahoma City 1995 (START) 37 x to memorize from occasional training. In fact, some authors
suggest that the experience and judgment of EMS clinicians
New York City 2001 65,66 (START) 70 x play a substantial role during MCIs and may be as effective
Madrid 2004 65,68 89 0 as formalized algorithms. 13,54,58,59 Therefore, it may be prudent
London 2005 65 64 x to have the most experienced clinician on site act as the triage
Virginia Tech 2007 69,70 69 10 officer.
Amsterdam 2009 80 11
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(Triage Sieve tags in 12%) Longstanding efforts have sought to identify the ideal param-
eters on which to base triage decisions. The use of physiologic
parameters derived from retrospective analyses has shown the
Paris 2015 highest sensitivity among various triage algorithms. 60,61 How-
The 2015 attacks in Paris resulted in 130 deaths and 495 live ever, they are difficult to obtain on-scene, delay action, and are
casualties. Triage and management were systematic and led by potentially unreliable. All algorithms are variations on daily
13
tactical physicians. Similar to lessons learned at other events, practice: taking the radial pulse, ability to follow commands,
the Paris attacks demonstrated that a system to provide ade- and often, measurement of respirations. For now, they should
quate numbers of hemorrhage-control devices is necessary to be the basis for triage, but perhaps without a formal algorithm
improve MCI care. 2,13,46,47 to memorize. 62–64

San Bernardino 2015 Evidence on the optimal number of triage categories for MCIs
The 2015 San Bernardino shooting resulted in 36 casualties. remains limited. The most widely used algorithms assign pa-
Improvised extrication using blankets and chairs illustrated tients into four categories: Immediate, Delayed, Minor, and
the importance of training on casualty movement skills. Expectant/Deceased. The Las Vegas fire department used
Though trained to use START/JumpSTART, responders in- three categories: Walking wounded, Litter, and Expectant. 65,66
stead “reacted” using clinical judgement. Triage tags were not Whereas some authors recommend simplifying categories to as
widely used, but critical patients were transported within an few as two (i.e., “seriously injured” and “walking wounded”),
9
hour. Overall, this incident demonstrated an intuitive response, others recommend as many as five categories, suggesting that
but the number of injured was substantially more manageable an optimal number is unknown. We support the use of a
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than at other MCIs. 13,48–50 simplified, three-category system with geographic grouping:
transport now, transport later, deceased.
Las Vegas 2017
The outdoor festival shooting in 2017 on the Las Vegas strip LSIs should be used when indicated. Recent military and civilian
resulted in 58 dead and 527 injured. It is another example of experience supports not waiting until after triage to stop mas-
an overwhelming MCI. Bystanders transported casualties in sive bleeding, in agreement with prior algorithms. 13,48,55,56,62,68
personal vehicles. There was no substantive casualty collection
point or triaging until casualties reached hospitals, which were Efficient patient movement from the scene to a collection area
overwhelmed and unaware of the volume of incoming patients. or medical facilities is problematic and complicated by patient
There was a lack of coordination and communication among access, environmental factors, lack of stretchers, 13,46 and
13
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responders, law enforcement, and hospital personnel. 51,52 uncertainty over the role of non-EMS vehicles. 50,52 Recent an-
ecdotal reports have credited bystanders and law enforcement
Movement of Casualties at MCIs personnel for providing early LSIs and transport prior to EMS
52
arrival. The use of non-EMS personnel and vehicles should
Although no studies specifically address the movement of be included in MCI plans. 55
casualties during these incidents, it is mentioned in some
real-world events. 13,43–52 It was also observed by the senior au- Although there is not a uniform standard triage system, an at-
thors who ran these exercises that this part-task skill should tempt has been made by the US Department of Transportation
be emphasized in training. Moving casualties off the incident National Highway Safety Administration to use the Model
site generally requires improvised techniques. These should be Uniform Core Criteria for MCI triage, even though it, too,
14
codified and rehearsed. contains many of the issues identified in this review.

Discussion In general, we concur with the recommendations of Vayer et
al, who suggest simplifying triage as much as possible. They
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This literature review showed that triage systems are rela- advocate for using common daily practices as opposed to new
tively inaccurate and infrequently used. The events referenced systems with unique terminology. Finally, they support a more
demonstrate the variable use of triage algorithms. Their use intuitive triage system, grouping casualties together based on
is limited by chaos, mortal danger, and low adoption by EMS severity, without using tags or complex labeling systems.
providers. Overall, the results of this analysis, similar to the
conclusions of Vayer et al in 1986, suggest the need to fur- Limitations
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ther simplify the triage process. Other authors have identified Given the chaotic and dangerous nature of MCIs, data collec-
gaps in training and preparedness and recommend prioritizing tion to study these events is inherently limited by retrospective

64 | JSOM Volume 23, Edition 1 / Spring 2023