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Rapid Patient Movement and Common Terminology the references. AF assisted with data entry and compilation.
Two other overarching observations were made in this review of SR, ML, and ED were the primary authors of the manuscript.
military MASCALs. In line with the tenets of the Tactical Combat PB, MR, FB, NA, MA, KM, RH, and MC are the operators
Casualty Care (TCCC) “care under fire” phase, safety and security who provided the data. LP, SS, EM, WD, JG, and DR are senior
are prioritized over medical treatment through initial tactical re- physicians who provided significant subject matter expertise,
sponse and rapid movement of casualties from the point of injury. data analysis, and significant editorial contributions. SR, ML,
If the scene is not safe (e.g., environmental threat, smoke, fire) RK, and ED reviewed the technical elements and performed
or secure (enemy threat), the priority is to eliminate/suppress the final edits to the manuscript. RK served as the senior author.
threat, and/or extract the casualty to safety.
Disclosures
The importance of reducing time to definitive care (including None of the authors have any financial conflicts of interest or
blood transfusion and damage control surgery) is discussed in the pertinent disclosures.
report by Shackelford et al. This concept underpins the need for
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expert and rapid casualty movement. This includes movement by Disclaimer
military personnel manually as well as use of mechanized land, The views expressed in this article are those of the authors
sea, and air assets with good preplanning and execution. and do not necessarily reflect the official policy or position of
the Department of the Navy, Department of Defense, or the
Our review also identified the importance of using an intuitive United States Government. We are or were military service-
approach, previous experience, and common medical termi- members and employees of the U.S. government. This work
nology that is already known and used by medics. As shown was prepared as part of our official duties. Title 17 U.S.C.
above, medics used only two live categories in contrast to 105 provides that “Copyright protection under this title is not
the common triage systems, which use three groups for live available for any work of the United States Government.” Title
patients: immediate, delayed, and minimal; red, yellow, and 17 U.S.C. 101 defines a United States Government work as a
green; or urgent, priority, and routine. Expectant is a separate work prepared by a military servicemember or employee of the
category. NATO definitions for alive patient categories include United States Government as part of that person’s official du-
T1 Red, T2 Yellow, T3 Green, and T4 Blue/White. 42 ties. Survey data was derived from an approved Naval Medical
Center San Diego Institutional Review Board protocol number
We recommend that during the initial on-scene response by NMCSD.2021.0004.
medical personnel during a MASCAL, the two categories sta-
ble and unstable should be used as the initial triage categories Funding
for live patients because these terms are commonly known and No funding was provided for this project.
intuitive. They reflect the need to transport now or transport
later. Since it is necessary to re-triage casualties at every stage of References
movement, additional and more detailed triage categories can 1. Pepper M, Archer F, Moloney J. Triage in complex, coordinated
be added later at the CCP, movement platform, or MTF. The terrorist attacks. Prehosp Disaster Med. 2019;34(4):442–448.
use of two categories for live casualties during the initial scene doi:10.1017/S1049023X1900459X
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port terrorist bombing. Injury patterns and implications for di-
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Limitations mortality in urban mass casualty incidents: Analysis of triage,
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to determine actual military medic practices for managing 4. de Ceballos JPG, Turégano-Fuentes F, Perez-Diaz D, Sanz-Sanchez
a MASCALs, and not exact medical tactics, these methods M, Martin-Llorente C, Guerrero-Sanz JE. 11 March 2004: The
were consistent with the objective. This is not a comprehen- terrorist bomb explosions in Madrid, Spain--an analysis of the
sive survey of all MASCALs in the given timeframe, but rather logistics, injuries sustained and clinical management of casual-
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than three total categories are rarely employed in these mili- 7. American Academy of Pediatrics; American College of Emer-
tary MASCALs. This is consistent with findings in the civilian gency Physicians; American College of Surgeons – Committee on
MASCAL literature. Simplified approaches are more prag- Trauma; Model uniform core criteria for mass casualty triage. Di-
saster Med Public Health Prep. 2011;5(2):125–128. doi:10.1001/
matic and favored during the initial on-scene medical response dmp.2011.41
to a MASCAL. These findings will help refine current triage 8. Boston Trauma Center Chiefs’ Collaborative. Boston marathon
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Author Contributions 9. Biddinger PD, Baggish A, Harrington L, et al. Be prepared—
SR developed the idea for this investigation and manuscript, The Boston marathon and mass-casualty events. N Engl J Med.
2013;368(21):1958–1960. doi:10.1056/NEJMp1305480
collected and analyzed the data, and created the outline. JK, 10. King DR, Larentzakis A, Ramly EP; Boston Trauma Collabora-
EK, and JO performed the literature search and assisted with tive. Tourniquet use at the Boston Marathon bombing: Lost in

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