Page 129 - JSOM Fall 2025

Triage in Action

A Principles-Based Approach to Mass Casualty Management
in Tactical Combat Casualty Care

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Michael A. Remley, NRP *; Stacy Shackelford, MD ; Stephen Rush, MD ; Ricky Kue, MD MPH ;
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Jake Brown 18Z ; Andrew Schaffrinna MD ; Eric Koch, DO ; Jonathan Stringer, ATP ;
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Harold Montgomery, ATP ; Travis Deaton, MD 10
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ABSTRACT
Background: Current triage practices in military mass casualty into the 2025 TCCC guidelines to optimize outcomes across the
(MASCAL) events are frequently misaligned with real-world full spectrum of military operations.
operational needs, leading to delays, confusion, and suboptimal
outcomes. Despite the existence of formal triage systems, field he overall approach to mass casualty (MASCAL) man-
responders often default to simplified methods that emphasize agement (MCM) has changed little in the past 200 years.
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speed, clarity, and survivability. This review supports the Com- TAlthough texts often refer to this process as triage, we rec-
mittee on Tactical Combat Casualty Care (CoTCCC) recom- ommend using the term MCM to describe holistic management
mended transition to a principles-based, two-pass triage system of the event, which is not limited to sorting individual casu-
optimized for Role 1 prehospital environments. Methods: A alties. MCM guidelines must similarly be comprehensive and
multi-modal analysis incorporating retrospective case reviews, encompassing in their approach. In addition, despite efforts
field surveys, and doctrinal review was conducted to evaluate to standardize and improve triage methods, recent studies and
real-world triage practices across recent military MASCAL experience demonstrate that existing triage methods have lim-
incidents. Findings were synthesized to develop an updated ited accuracy and are infrequently used by responders during
triage methodology anchored in clinical judgment, tactical rele- MCM. As the United States military, international partners,
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vance, and operational simplicity. Results: In 93% of reviewed intergovernmental agencies, and other civilian organizations
MASCAL cases, formal triage tools involving color-coded tags prepare for the possibility of all-hazard MASCAL events, a prin-
and five-category algorithms were not used. Responders pre- ciples-based approach to prehospital MCM is needed to ensure
ferred a binary or simplified categorization (e.g., urgent vs. that all responders can perform the appropriate level of triage,
nonurgent) for rapid decision-making. The proposed two-pass initiate life-saving treatment, and ultimately optimize casualty
system includes an initial “first pass” to identify casualties re- care through effective management of the MASCAL event.
quiring immediate life-saving intervention and a more deliberate
“second pass” to sort casualties into urgent, priority, or routine In 2024, a survey of military medical personnel who have
categories aligned with established evacuation precedence. This managed MASCALs demonstrated that formal triage systems
model emphasizes rapid assessment via the Massive Hemor- requiring the use of diagnostic algorithms, colored tags, and
rhage, Airway, Respirations, Circulation, Hypothermia/Head four or five categories are seldom implemented in real-world
Injury (MARCH) framework, clear communication between military prehospital MASCAL incidents. This study shows
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medical and nonmedical personnel, and dynamic re-evaluation that the traditional delayed, immediate, minimal, and expect-
as conditions evolve. Conclusion: The principles-based two-pass ant (DIME) medical triage categories are not an effective or
triage model offers a practical and operationally aligned frame- intuitive means of making medical, logistical, and tactical
work for Role 1 casualty care. It improves decision-making, decisions at the scene of injury during dynamic and chaotic
communication, and casualty flow during complex MASCAL MASCAL events. Ninety-three percent of the MASCAL inci-
events while enhancing training, interoperability, and mission dents studied showed that prehospital providers preferred the
success. This approach is endorsed by CoTCCC and integrated use of binary or greatly simplified triage categories (urgent vs.
*Correspondence to mike_remley@outlook.com
1 SGM Michael A. Remley is affiliated with the US Army Medical Command. Col Stacy Shackelford is the Trauma Medical Director, Defense
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Health Agency Colorado Market, Colorado Springs, CO. LtCol Stephen Rush is a member of the USAF Reserves, 308th Rescue Squadron,
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Patrick Space Force Base, FL, and Clinical Associate Professor of Radiation Oncology and Neurosurgery, NYU Langone Medical Center, NY.
4 COL Ricky Kue the Brigade Surgeon, 86th IBCT (MTN), VTARNG, Beverly, MA, Medical Officer FEMA US&R MA-TF1, Jerico, VT, and Deputy
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Medical Officer FEMA RED IST. MSG Jake Brown is a Special Operations medic assigned to the United States Army Special Operations Command
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(USASOC) at Fort Bragg, NC. LTC Andrew Schaffrinna is an emergency medicine physician affiliated with Womack Army Medical Center, Fort
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Bragg, NC. CDR Eric Koch is affiliated with the Department of Emergency Medicine, Navy Medicine Readiness and Training Command, Ports-
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mouth, VA. HM1 Jonathan Stringer is a Special Operations Independent Duty Corpsman affiliated with Marine Corps Special Operations Command.
9 MSG (Ret.) Harold Montgomery is affiliated with the Joint Trauma System as Joint Program Manager and Vice Chair of the CoTCCC.
10 CAPT Travis Deaton is affiliated with the I Marine Expeditionary Force, Camp Pendleton, CA.
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