Difficult Triage Decisions in the Combat or Austere Environment

Abstract

The past 13 years of sustained combat operations in Iraq and Afghanistan have provided a robust and high-volume experience to deployed providers in caring for severe multi-system traumatic injuries as well as managing mass casualty scenarios on a routine basis. With the rise of the use of improvised explosive devices (IED) in both combat and civilian arenas, all trauma providers and centers must now be prepared to handle these types of injuries and MASCAL scenarios. The purpose of this chapter is to discuss principles and priorities of triage and the management of MASCAL scenarios. These scenarios are characterized by the presentation of multiple patients whose numbers and/or severity of injuries exceeds the ability of the receiving facility in terms of personnel, training, resources, supplies, and equipment. Several cases of particularly challenging triage decisions will be presented to highlight important lessons regarding optimization of triage criteria and decisions, patient management strategies, team-building, and operating in a truly resource-constrained environment.