Combat Triage and Mass Casualty Management

Abstract

Although much of this book focuses on preparing for combat trauma care at the individual provider level, the most critical training for a unit to prepare to handle combat casualties is triage and mass casualty management. This chapter will share triage and mass casualty expedients from three combat perspectives representing different echelons of care. Every trauma patient triggers a triage or sorting to align available resources with needs. But when those needs surpass apparent resources, we declare a MASCAL or mass casualty and launch a series of rehearsed strategies to achieve the greatest benefit for most patients. Intensity, number of casualties, and environment all contribute to this overload calculation: a single complex injury patient can eliminate a unit’s ability to deliver additional casualty care, and two immediate surgical patients will max out many Level 2 facilities. Medical leaders can hone a unit’s trauma-ready posture to expand its ability, as “chance favors the prepared team.” This chapter reviews the “five Rs” to prepare a team for successful combat trauma response: resources, rehearsal, response, route, and reset.

Civilian Translation of Military Experience and Lessons Learned

• Alec C. Beekley 

Key Similarities

• The five Rs: resources, rehearse, respond, route, and reset are applicable in both civilian and military settings. The key to successful execution during a mass casualty event is advanced planning and rehearsal.

• Triage by highly experienced personnel, utilizing simple, hands-on/bedside techniques, are the best ways for quick and accurate triage in both military and civilian settings.

• Terrorist attacks with explosives or high-velocity weapons (e.g., Boston Marathon bombing, Orlando nightclub shooting) have blurred the lines between civilian and military mass casualty events.

Key Differences

• Civilian settings are more likely to have mass casualty events with blunt trauma mechanisms (e.g., train derailments, multiple vehicle pileups, and recently truck attacks into crowded areas).

• Civilian settings can often bring more resources to bear in mass casualty events, both in terms of personnel and hospital systems. Depending on the coordination and prior rehearsal of the locale’s medical system, this could be a benefit or a drawback.

• Hospitals in civilian mass casualty events are more likely to be inundated with walking wounded, families and friends searching for loved ones, and nonhospital personnel who are trying to help. The “crowd control” issues in civilian settings may therefore be even more challenging that in military ones.

• The demand from the media for initial information, constant updates, access to involved providers and patients, and comments from hospital leadership will be enormous and overwhelming. Plan for the PR piece well in advance.

The chapter on combat triage and mass casualty management by Dr. Aydelotte and colleagues provides a “top to bottom” primer on mass casualty management that is as relevant to any civilian hospital system as it is to a forward military unit. As we read about mass casualty events around the world (seemingly on a weekly basis), coverage of this topic in such an organized fashion could not be more timely. There are a handful of topics presented which are worth emphasizing, comparing, and contrasting to the civilian experience.

Security

The sorting and prioritization of casualties begins at the scene, not the hospital. However, the geographical and tactical situation at the scene may dictate which casualties are evaluated and evacuated first, and these are often not the worst injured. Depending on the mechanism of the event, casualties may be trapped in a hard to reach location, stuck in a damaged structure or vehicle, or trapped in a tactical situation where there is still active shooting. The result is a fluid and rapidly changing situation with both “known unknowns” and “unknown unknowns.” An example of a “known unknown” is, “we know there are more casualties, we just don’t know how many or what their status is yet.” An example of an “unknown unknown” would be the presence of a second attacker or secondary explosive device. In their description of the Orlando Regional Medical Center response to the Pulse nightclub shooting, the surgeons describe knowing about additional waves of casualties still coming and then having an alert about an active shooter actually at the hospital (the former which turned out to be true, the latter which turned out to be false). These experiences emphasize the need for both scene and hospital security. Known in combat settings as “the fog of war,” these events also illustrate the need for flexibility and ongoing communication. There should be a clear communication plan between EMS, local police and firefighters, incident command, and hospital personnel. The communication plan should have a backup if the first system fails. It should be rehearsed at least yearly.

Triage Is a Process, Not a Destination or Event

Triage is a process that may (or may not) begin at the scene, potentially allowing distribution of patients to near and far treatment facilities based on acuity. Triage continues en route to treatment facilities, with transporting providers often providing insight into casualties’ changing statuses. It occurs on arrival to the hospital and continues in order to prioritize existing and newly arriving patients for evaluation, ORs, and imaging studies. The authors’ admonition to put your most experienced and organized provider (usually a surgeon) in the role of triage officer is therefore correct. His clinical skills, while potentially valuable if applied to a single patient in the OR, will provide much more value to the entire process. Most importantly, although we normally worry about under-triage of trauma patients, in a MASCAL scenario, it is over-triage that should be a primary concern (Fig. 2.6). Clogging the trauma bay with minimal or nonurgent injuries means delays for patients with truly urgent/emergent problems.

Fig. 2.6

Graphic relation of over-triage rate to critical mortality rate, in ten terrorist bombing incidents from 1969 to 1995. Note the increases in the over-triage rate has a linear correlation to increased critical mortality (Reproduced from Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma 2002;53(2):201–212; with permission from Wolters Kluwer Health, Inc.)

One of the other most important lessons for surgeons assigned to an individual patient is STAY WITH THAT PATIENT until reassigned to another. There is a tendency for surgeons to “drift” toward gurneys with heavy activity – don’t. Be sure you have thoroughly assessed your patient, and be prepared to give a report on his status when the triage officer circles around again. If your patient is truly stable, he can be re-triaged to a Delayed or Minimal status, and you can be reassigned where needed. If you have drifted away to help on another patient, it is possible that (1) you did not completely assess your patient and (2) when the triage officer comes back, you will not be where you are expected to be.

Rehearse, Rinse, Repeat

One of the first lessons learned described in the after-action review of the Boston Marathon bombing was “resist complacency.” The authors of that comprehensive review cite superb city-wide planning and preparedness as key to the success of the response. It is critical that surgeons be engaged in the planning and rehearsal process; this should occur at least yearly. Expect to find issues with your system with each rehearsal, and expect that you still won’t identify them all. The military authors of this chapter identified problems from their experiences that mimic issues reported in some of the recent mass casualty events. For example, it is important that your hospital’s mass casualty has a plan for the placement and storage of the dead, preferably away from where living casualties are being treated. Establish a plan for dealing with the mental and emotional fallout of hospital personnel after the event. Establish a plan for dealing with anxious family and friends looking for their loved ones. Anticipate that something unanticipated will be a problem, and design a mechanism into your plan that can flex in response. Most civilian facilities (from my experience and discussions with colleagues) will NOT have performed realistic and wide-ranging MASCAL drills to test their system and their MASCAL plan. This should become a priority for the civilian trauma community.

Final Points

Recent mass and multiple casualty events, such as the Boston Marathon bombing, the Orlando Pulse nightclub attack, the coordinated Paris terror attacks in November 2015, the Philadelphia Amtrak train crash in 2016, and the recent truck attacks in Nice, France, Turkey, and Berlin, Germany illustrate the wide variety of mechanisms, both accidental and purposeful, that may cause mass casualties. The only thing that seems certain is there will be more. Trauma care practitioners must lead the way in designing robust, flexible, coordinated responses to these events, both at the hospital and community level. In addition, trauma leaders are key for designing resilience and responsiveness into communities themselves, with efforts like the Hartford Consensus I-IV and Stop the Bleed campaign.