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Sort Victims, Save Lives

When you consider the possibility of a multiple casualty incident (MCI) in your jurisdiction, what sort of scenario do you envision? Traditional scenarios include such examples as the Force 3 tornado that struck an Iowa Boy Scout camp, killing four young Scouts and injuring 48; the Rhode Island nightclub fire that killed 100 people and injured more than 200 during evacuation; or the Minnesota school bus accident that killed four students and injured at least 14. Unfortunately, agencies must also consider the possibility of an MCI caused by an act of terrorism or mass shooting.

Depending on the type of event, EMS personnel may not be able to enter the scene initially because of ongoing or suspected hostile threats. EMS may also have a lengthy response time due to traffic, distance or road and weather conditions. What are you going to do while you wait for EMS to arrive? Some law enforcement functions may take priority, but you may also find yourself in a position to help the injured and speed up the treatment process to increase the likelihood of survival for those patients.

Regardless of the cause of the MCI, one thing is certain: Anytime you respond to a situation that involves more casualties than medically trained responders, someone has to sort the victims in a rapid, systematic manner.

Critical Considerations
So what is an MCI? It’s any incident in which the number of patients overwhelms your standard resources. Considering that a single ambulance can transport a maximum of two supine patients, it’s easy to see how quickly an MCI can occur, especially in rural jurisdictions. For many rural EMS providers, three or four patients may be enough to stress the system to its maximum load. If you imagine the possibility of an overturned school bus with 30–40 students in the same jurisdiction, you quickly realize the importance of a standardized and well-trained response that includes law enforcement officers.

Imagine you respond to a mass shooting at a local high school. SWAT teams and their tactical medics are en route. Contact teams have successfully contained or neutralized the bad guys, and you’re assigned to begin rescuing the numerous victims to waiting EMS units who can’t enter due to a fear of additional hidden shooters and explosive devices. You enter a room and find 10 victims. What do you do?

You could drag each body outside to EMS. By doing so, you may be wasting valuable time for both responders and patients—if you don’t first ask a few simple questions: Which patients need immediate medical attention and transport? Which patients can likely survive a delay in treatment? Which patients are likely to die regardless of treatment? How far do you have to move victims to reach EMS? Consider that anyone you attempt to rescue may have to be carried, dragged or shuttled by patrol cars for several hundred yards, as occurred at the Columbine massacre.

At an MCI, there probably won’t be enough EMS providers or tactical medics, at least initially, to perform all the patient care tasks required, including triage, treatment and transportation of the injured to hospitals. Sparsely populated rural areas with small volunteer EMS and fire agencies may be especially susceptible to being overwhelmed and under-equipped. Those EMTs and paramedics who are present will be best used for actual treatment of the injured, leaving the possibility that law enforcement officers may be needed to assist in performing initial triage duties. A basic understanding of the triage system used by your local EMS will allow you to provide valuable assistance and increase the odds of survival for those casualties.

Triage isn’t rocket science. It doesn’t require any medical training above a simple first-aid class. In fact, a 2003 study of British firearms officers who were cross trained in simple methods of patient triage concluded that officers have “great potential to provide accurate triage decisions in a mass-casualty scenario,” or an MCI. 

Cases in Point
Several cases exist in which 20/20 hindsight suggests that triage and rapid evacuation of patients by officers may have been very beneficial to the successful resolution of an MCI. In one example, officers at a mass shooting rescued several subjects found hiding from the shooters. A seriously wounded male was among those hiding. When the other victims were escorted to safety, this critically injured male was kept inside the building for approximately 40 minutes while officers waited for paramedics to enter the scene to provide treatment and evacuation. Sadly, the victim died alongside the rescuing officers, waiting for a traditional medical provider. 

In contrast, there have been two mass shootings in recent history where rapid entry tactics, combined with rapid triage and first aid by law enforcement officers, reportedly saved numerous lives. On April 16, 2007, a gunman killed 31 people in Norris Hall at Virginia Technical Institute, after murdering two other students earlier in the morning in a dormitory room. After forcing entry to Norris Hall, two teams of officers from Virginia Tech and Blacksburg police departments rapidly moved up the stairs toward the sound of gunfire. Upon arriving on the second floor, the officers found that the gunman had taken his own life but had left victims scattered throughout the classrooms. Two tactical medics, one each from Virginia Tech and Blacksburg SWAT teams, had accompanied the entry teams and immediately began triaging and treating the victims. One victim was bleeding profusely from a leg wound. Medics applied a tourniquet to the wound prior to evacuating the patient. Conventional EMS units weren’t allowed to enter the scene until approximately 20 minutes after law enforcement arrival on scene. A total of 27 patients were triaged and transported by EMS in a little over one hour. The tactical medics deserve a great deal of credit for their early lifesaving treatment and triage of the victims. There’s little doubt that their actions saved lives that day.

In another case, a gunman entered a lecture auditorium at Northern Illinois University (NIU) and shot 21 people before killing himself on Feb. 14, 2008. NIU police were nearby and entered the lecture hall within about two minutes of the first report of the shooting. After finding the gunman dead, the NIU officers, who are also certified EMTs, began triaging and treating the victims long before fire and EMS were on scene or allowed to enter. Out of 22 total casualties, 18 were transported to area hospitals after the officers’ effective triage. Six deaths occurred, including the gunman. He had been armed with a shotgun and two handguns and had plenty of ammunition remaining when he killed himself, indicating that the total casualties could have easily been much higher given the number of students in the lecture hall at the start of the rampage. Fortunately for the victims, NIU police had begun to prepare for such an incident even prior to the Virginia Tech shooting. Part of that preparation included training as EMTs, which was initiated in 2003 by Chief Donald Grady.

Getting STARTed
Since 9/11, attempts have been made to establish nationwide standards for many areas of emergency response, including triage. There are now several field triage systems in use throughout the U.S. and the world. Some military forces triage soldiers so that those with minor wounds are treated first in order to get them back into the fight as quickly as possible, but the goal of civilian EMS is to get seriously injured patients to definitive treatment within one hour. Rapid triage, lifesaving treatment and evacuation are essential to meet that goal. In addition, the ongoing threat of terrorism and secondary devices that target responders have increased the need to get as many patients and responders off the scene as soon as possible.

Although no existing triage tool is suitable for all incidents, and no triage system has been validated by outcome data, the most common and copied triage system is the Simple Triage and Rapid Treatment (START) system. Created in the 1970s by officials from the Newport Beach (Calif.) Fire Department and Hoag Hospital, START was adopted by numerous response agencies, first across California and then the rest of the U.S., in the 1980s. Today, it’s the most common triage system taught to EMS personnel across the U.S. because it is simple to learn and simple to put into practice. Designed to be conducted in 60 seconds or less per patient, START allows personnel with little first aid training to provide the greatest good for the greatest number of victims.

By basing triage decisions on observable vital signs, START allows responders to determine a patient’s stability and not get sidetracked by the shock of an ugly injury. START also removes some of the emotion associated with determining whether a patient is likely going to live or die and saves precious time. Sadly, sometimes we have to turn our backs on victims for whom we don’t have resources at the time. These decisions are not callous or heartless. They’re realistic, difficult decisions that must be made during an MCI. 

The START system divides MCI victims into four color-coded categories:

  • Minor (Green): The “walking wounded”: those with minor injuries, some of whom may require minimal first aid. These victims may help treat and move more seriously injured victims.
  • Delayed (Yellow): Victims who may have serious injuries and require aid but who are not at a high risk of death from those injuries.
  • Immediate (Red): Victims who require immediate medical assessment, intervention and transport for survival.
  • Deceased (Black): Victims who are already dead or those who are expected to die given the available resources. 

The following procedure is followed when triaging a patient using the START system: 

  1. Ask all victims who are able to do so to get up and move out of the area under their own power. These patients are initially classified as minor.
  2. Approach any remaining patients. Determine whether the patient is breathing. If not, open the airway using a head-tilt chin-lift. If the patient is still not breathing, they’re deceased. If they’re taking more than 30 respirations per minute then they should be classified as  immediate (Red) . If the patient’s respirations are less than 30 per minute, move on to the next step.
  3. Check the patient’s capillary refill by depressing the patient’s fingernail until the nail bed appears white. Count how many seconds pass before the nail bed turns red after you release the pressure on the nail. If capillary refill takes more than two seconds, classify the patient as  immediate (Red) . If the patient’s capillary refill takes less than two seconds, move on to the next step.
  4. Determine the patient’s mental status by speaking to him or her. If the patient can follow simple commands, classify them as delayed (Yellow). If the patient can’t follow simple commands, classify them as immediate (Red).

One great feature of most triage systems, including START, is the fact that very little equipment is required to be effective. Specially designed triage tags and colored tape may be used to identify a patient’s triage classification, and colored tarps or flags may be used to designate treatment areas for each triage designation. Triage training can be accomplished with written exercises, but the most effective method is to conduct a realistic MCI scenario using multiple moulaged role players exhibiting various observable injuries, signs and symptoms consistent with the scenario you’re replicating. Combine triage training with first-aid refreshers and training in patient moves, drags and carries.

Test Your Knowledge
Triage the patients described below using the START system:

  1. Adult male with an open leg fracture. Respirations under 30/minute. Capillary refill is less than two seconds. Patient can follow simple commands.
  2. Female child. No obvious injuries. No respirations. Pulse and capillary refill are absent. Patient is unresponsive.
  3. Adult female with an impaled object in the right upper abdomen. Respirations are over 30/minute. Capillary refill is less than two seconds. Patient can follow simple commands.
  4. Adult male with a gunshot wound to the right hand. Respirations are under 30/minute. Capillary refill is less than two seconds. Patient can follow simple commands.

Answers at end of article.

MCIs commonly result from motor vehicle accidents, structural collapses and natural disasters. However, terrorist organizations and angry individuals continue to try and increase body counts as they learn from the lessons of previous well-publicized attacks on schools and other soft targets. It may take time to secure such a scene of violence so that EMS can enter. It will also take time to get adequate EMS personnel on scene to triage, treat and transport all the injured. If the situation and manpower allow, the use of triage by law enforcement officers may save lives by helping officers effectively determine which patients need to be evacuated first to EMS units waiting outside the hot zone. These skills will be particularly useful in small agencies or jurisdictions where a low overall number of rescuers will be available. A patient’s condition may worsen or improve during the course of an incident, so triage should occur at multiple points.

Learn what triage system your local EMS uses so that you will all be on the same page. Triage systems bring a level of organization to otherwise chaotic situations. Understanding triage methods used by your local EMS will help avoid additional delays in patient care and prevent confusion and hostility between law enforcement and EMS over who should be treated and transported first.

The officers of the NIU and Virginia Tech who successfully triaged and treated the patients proved that properly trained officers can perform effective triage at an MCI, increase the survivability of patients and add a valuable component to any law enforcement MCI response.

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  1. Kilner T, HallFJ: “Triage decisions of United Kingdom police firearms officers using a multiple-casualty scenario paper exercise.”  Prehospital and Disaster Medicine. 20(1):40–46, January–February 2005.
  2. START Instructor’s Manual. Newport Beach (Calif.) Fire Department, 1994.


1. Delayed, 2. Deceased, 3. Immediate, 4. Minor

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