Page 64 - JSOM Fall 2024

Limitations of Triage in Military Mass Casualty Response

A Case Series

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Stephen Rush, MD ; Michael J. Lauria, MD *; Erik DeSoucy, DO ; Eric Koch, DO ;
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Jonathan Kamler, MD ; Michael A. Remley ; Nate Alway ; Fredrick Brodie ; Andrew Foudriat ;
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Paul Barendregt ; Michael Atkins ; Keary Miller ; Richard Hines ; Matthew Champagne ;
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Lorenzo Paladino, MD ; Stacy Shackelford, MD ; Ethan Miles, MD ; Joseph Obiajulu ;
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Warren Dorlac, MD ; Jennifer Gurney, MD ; Douglas Robb, DO ; Ricky Kue, MD, MPH 22
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ABSTRACT
Introduction: Mass casualty events (MASCALs) in the combat The top lessons learned were: 1) security and accountability
environment, which involve large numbers of casualties that are cornerstones of MASCAL management; 2) casualty move-
overwhelm immediately available resources, are fundamen- ment is a priority; 3) intuitive triage categories are the default;
tally chaotic and dynamic and inherently dangerous. Formal 4) life-saving interventions are performed as time and tactics
triage systems use diagnostic algorithms, colored markers, and permit. Conclusion: Formal triage systems requiring the use of
four or more named categories. We hypothesized that formal diagnostic algorithms, colored tags, and four or five catego-
triage systems are inadequately trained and practiced and too ries are seldom implemented in real-world military prehospital
complex to successfully implement in true MASCAL events. MASCAL management. The training of field triage should be
This retrospective analysis evaluates the real-world application simplified and pragmatic, as exemplified by these instances.
of triage systems in prehospital military MASCALs and other Keywords: mass casualty management; triage; MASCAL;
aspects of MASCAL management. Methods: We surveyed Spe- survey; SOF medics
cial Operations Forces (SOF) medics known to us who have
participated in military prehospital MASCALs and analyzed
them. Aggregated data describing the scope of the incidents, Introduction
the use of formal triage algorithms and colored markers, the
number of categories, and the interventions on scene were The role of first responders to perform triage during civilian
analyzed using descriptive statistics, and lessons learned were mass casualty events (MASCALs) is well described. 1–17 The ex-
consolidated. Results: From 1996 to 2022 we identified 29 istence of multiple formal triage systems that use diagnostic
MASCALs that were managed by military medics in the pre- algorithms, named categories, and colored markers indicates
hospital setting. There was a median of three providers (range there is no general consensus or ‘one size fits all’ process. 18–25
1–85) and 15 casualties (range 6–519) per event. Four or more Additionally, retrospective reviews of MASCALs demonstrate
formal triage categories were used in only one event. Colored that formal triage systems are infrequently used by medics
markers and formal algorithms were not used. Life-saving in- (16% of events), and when they are, lack accuracy (36%–52%
terventions were performed in 27 of 29 (93%) missions and accuracy). Numerous groups, including our authors, have
blood transfusions were performed in four (17%) MASCALs. published extensive civilian literature reviews summarizing
*Correspondence to mjlauria@uw.edu
1 Lt Col Stephen Rush is a member of the USAF Reserves, 308th Rescue Squadron, Patrick Space Force Base, FL, and Clinical Associate Pro-
fessor of Radiation Oncology and Neurosurgery, NYU Langone Medical Center, NY, NY. Capt Michael J. Lauria is a member of the USAF
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Reserves, Assistant Professor in the Department of Emergency Medicine Divisions of Critical Care and EMS at the University of Washington,
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and Associate Medical Director/Flight Physician for Airlift Northwest. Lt Col Erik DeSoucy is a member of the Trauma, Burn and Rehabilitative
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Medicine Team, Sheikh Shakhbout Medical City, Abu Dhabi, UAE. CDR Eric Koch is affiliated with the Department of Emergency Medicine,
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Navy Medicine Readiness and Training Command, Portsmouth, VA. Dr. Jonathan Kamler is affiliated with Weill Cornell Department of Emer-
gency Medicine, New York Presbyterian Hospital, New York, NY. 1SG Michael A. Remley is affiliated with the Army Medical Department.
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7 SFC (Ret) Nate Alway was affiliated with the U.S. Army. HMC (Ret) Fredrick Brodie was affiliated with the U.S. Marine Corps. SSgt Andrew
Foudriat is affiliated with 106th Rescue Wing, Westhampton Beach, NY. CMSgt (Ret) Paul Barendregt was affiliated with the Alaska Air Na-
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tional Guard. CMSgt (Ret) Michael Atkins was affiliated with the U.S. Air Force. MSgt (Ret) Keary Miller was affiliated with the Kentucky
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Air National Guard. MSG (Ret), Richard Hines was affiliated with the U.S. Army. SMSgt Matthew Champagne is affiliated with the 306th
Rescue Squadron, Tucson, AZ. Lt Col Lorenzo Paladino is affiliated with 106th Rescue Wing, Westhampton Beach, NY, and is Associate Pro-
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fessor, Department of Emergency Medicine State University New York Downstate and Kings County Hospital Medical Center, New York, NY.
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16 Col Stacy Shackelford is Trauma Medical Director, Defense Health Agency Colorado Market, Colorado Springs, CO. COL (Ret) Ethan Miles
was affiliated with the U.S. Army. 2LT Joseph Obiajulu is affiliated with 106th Rescue Wing, Westhampton Beach, NY. Department of Surgery,
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NYU Langone Medical Center, New York, NY. Col (Ret) Warren Dorlac is Medical Director, Pre-hospital Trauma Life Support and Associate
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Clinical Professor of Surgery, University of Colorado, Trauma and Acute Surgery, Medical Center of the Rockies, Loveland, CO. COL Jennifer
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Gurney is Chief, Joint Trauma System, San Antonio, TX. Lt Gen (Ret) Douglas Robb is affiliated with the Uniformed Services University for
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Health Sciences, Washington, DC. COL Ricky Kue is Brigade Surgeon, 86th IBCT (MTN), VTARNG, Medical Officer FEMA US&R MA-TF1,
and Deputy Medical Officer FEMA RED IST.
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