The Surgeon’s Role in Mass Casualty Incidents

History

The term “triage” was coined by Napoleon’s surgeon, Dr. Baron Larrey. Dr. Larrey poignantly describes the importance of addressing the most seriously injured patients first. The military’s earliest documented systems of triage date back to the eighteenth century, and triage is a principal component of battlefield care. MASCAL events are becoming increasingly common, and there are many lessons that can be learned from both the military and civilian systems in terms of triage and trauma systems in order to optimize care and outcomes for as many casualties as possible.

Triage is a term with its roots in military trauma, and the practice of triage arose from the demands of large amounts of battlefield casualties during war; the original triage concepts were primarily focused on MASCAL situations during battlefield trauma. Dr. Larrey was known for his surgical leadership and skill and is credited with the development of the concept of “sorting” patients to salvage the greatest number of casualties in a resource scarce battlefield environment. Dr. Larrey’s principals of sorting also included evacuating patients according to the severity of wounding and prioritizing their care based on both the severity of the injury and the likelihood of survival.

With each subsequent war since Napoleon’s time, the U.S. military and civilian medical communities have continued to advance the concepts of triage and MASCAL management. Simultaneously, developments in order to provide lifesaving care and procedures closer to the point of injury have evolved. Triage occurs along a continuum of tiered care in the military system with higher echelons of care having increasing capabilities. On the battlefield, appropriate triage of patients directs the patients to an appropriate level of care and helps manage a chaotic situation where large numbers of casualties receive appropriate and effective care. The tiered triage system used by the military has evolved and is still used in current wars with tiered levels of care from point of injury to advance care and rehabilitation in the United States. Other principals of current military triage, point of injury care, en route care, and the movement of advanced capabilities closer to the place and time of wounding have saved the lives of military patients and have the potential to do the same in civilian MASCAL situations. ^,

As the world becomes increasingly tumultuous with the higher frequency of MASCAL events, shootings, and natural disasters, the potential for surgeons to be involved in MASCAL situations is increasing. Surgeon leadership, hospital planning, and community preparation are the first steps to the successful management of these dreadful events. Surgeon involvement in every tier of MASCAL management is ideal. While the modern-day surgeon is rarely a prehospital provider, the comprehensive understanding of the system of trauma care, combined with intricate knowledge of the physiologic effects of injury, gives surgeons unique knowledge for oversight, leadership, and training to be involved with planning, leadership training for MASCAL events.

Key Definitions

In the normal, nonmass casualty trauma system functions, triage most frequently applies to the sorting of trauma or critically ill patients in order to direct them to the medical treatment facility with the appropriate level of capability. Accurate triage results in distributing patients to appropriate hospitals that can expertly manage their condition, whether it is traumatic injury, myocardial infarction, stroke, or sepsis. In terms of trauma, the standard civilian use of trauma triage refers to the day-to-day function of sending patients to the appropriate hospital/trauma center in order to avoid over- and undertriage. Basic triage (outside of MASCAL incidents) optimizes care delivery and resource allocation, and it is not the focus of this chapter. The chapter focuses on the surgeons’ role in MASCAL incidents, the trauma system, and triage. Optimizing triage in the face of multiple casualties and potentially limited resources requires leadership, planning, and an established trauma system. ^, Surgeon leadership in triage process and the trauma system helps establish a well-organized response to MASCAL incidents; surgeon involvement in the triage planning and process should occur at every level in a healthcare system: individual, local, regional, and national.

Triage is the process of sorting patients to provide the greatest amount of good for the highest number of patients. Triage is an essential component of any trauma system and is pivotal for optimizing survival in multiple casualty incidents (MCIs). Triage can occur in the absence of a MASCAL—but MASCALs always require triage. Success or failure is measured in lives saved or lives lost and resources wasted or appropriately utilized; success or failure depends on accurate and effective triage.

• Field triage

Done at or near the scene of the event. The process by which emergency medical service (EMS) providers decide which hospital to send patients injured by a disaster or traumatic event.

• Undertriage

Occurs when seriously injured patients are transported to nontrauma centers or centers that do not have the expertise or capability to manage the severity of the injury.

• Overtriage

Occurs when patients with minor or nonurgent injuries are transported to major trauma centers or triaged to an immediate care bed. In a MASCAL situation, this bogs down the system, results in significant bottlenecking, and can result in increased rates of adverse outcomes ( Fig. 24.2 ).

• Hospital triage

Sorting patients into predefined categories in order to determine their relative priority of treatment. Patients are separated into groups based on the local triage system that is used. Patients are sorted into categories: those not expected to survive even with treatment; those who will recover with minimal treatment; and the highest priority group, those who will not survive without treatment.

• Standard trauma incident

Typically involves one or several patients and there are an excess of available resources and expertise to manage these patients. These are the most common trauma incidents that occur in rural and urban trauma centers.

• MCI

Multiple injured patients present simultaneously, but adequate resources are present and the system is not significantly stressed. An MCI for a large trauma center could be routine, but an MCI may result in a MASCAL scenario for a small hospital.

• MASCAL incident

When the number of injured patients or the resources required to care for the patients exceed what is available and put a significant stress on the trauma system, hospital, and providers.

• Disaster incident

Large-scale natural or manmade MASCAL event that often results in overwhelming numbers of patients injured or ill, as well as frequent destruction or degradation of local infrastructure, which may include the healthcare facilities.

There is a critical distinction between an MCI and a true MASCAL event that must be understood and appreciated by the surgeon. While an MCI requires little to no change to the usual practices and the standard of care, a true MASCAL requires major alterations from the usual patient care protocols at that facility and a focus on optimizing group outcomes versus individual patient outcomes. The primary factor that distinguishes these two categories is the relationship between the presenting injuries and the available resources and expertise to care for them, and not purely the number of patients. This is commonly referred to as the surge capacity for a given facility or system. As shown in Fig. 24.3 , the standard level of care can be maintained for a finite number of patients, but once this number is exceeded, there is a precipitous decline in the level of care and associated outcomes. A well-resourced Level 1 trauma center may be easily able to handle 20 severely injured patients from one incident, whereas a smaller rural nontrauma center may be overwhelmed with more than two to three severely injured patients.

We have found that many of the events described as MASCALs are actually MCIs and should be labeled accordingly. A true MASCAL event rapidly exceeds the facility surge capacity and has the potential to quickly overwhelm an individual facility or the entire local/regional trauma system and evacuation processes. MASCAL events due to a local manmade or natural disaster (earthquake, flood, etc.) have the potential to result in the greatest number of injured and/or ill patients that can quickly overwhelm the local/regional facilities. In addition, these events can be particularly devastating when they are coupled with severe damage or destruction of critical local infrastructure, utilities, or even major damage to the healthcare facility itself. ^, Surgeon involvement in every level of training, education, and system refinement will help ensure a successful system when it is stressed with multiple casualties. The triage process is pivotal to the successful execution of any MASCAL plan, and surgeons must have both expertise in triage and be involved in system, regional, and hospital triage planning.

Mascal Key Principles

Multiple casualty and MASCAL events can occur via a wide variety of mechanisms or causes and will be highly heterogeneous in terms of the number and severity of presenting patients, the need for resources and specialty care, and the ultimate impact on the local healthcare facilities and system. Although it is impossible to develop a single inclusive protocol or set of detailed guidelines that will universally apply, there are a set of key principles and commonalities that have been observed across a wide variety of these events. The following is a list of the “top 10” MASCAL principles that have been reported across a broad range of events and experiences:

• 1.

  Triage is a dynamic process and should be happening at each level of care from the point of injury/scene to the final receiving hospital or other facility.

• 2.

  The MASCAL goal: do the best for the most, not everything for everyone.

• 3.

  Success of failure during an MCI or MASCAL depends on accurate and effective triage. The success of regional trauma systems depends on good Field Triage.

• 4.

  Triage starts with understanding and assessing the available system capabilities, resources, and personnel.

• 5.

  For in-hospital or single hospital triage, patients should be triaged through one entry point and with one-way only flow into the facility.

• 6.

  There must be redundancy of capability, not duplication of action, to avoid inefficiencies in an already stressed system.

• 7.

  Prearranged electronic or paper MASCAL chart and patient admission packets should be prepared and ready at the facility triage intake point.

• 8.

  There are multiple well-validated triage systems. Select and train with the optimal one for your system, and ensure all personnel know the system (DIME, START, SALT, etc.).

• 9.

  The triage officer should be one of the most experienced and organized personnel and should ideally have a deputy to facilitate communications and recording.

• 10.

  Scene security and safety is necessary for safe and effective care. Ensure scene safety prior to rushing into an unsecure scene; do not become a victim and put more stress on the system.

As emphasized in the list above, MASCAL preparation and effective triage are among the most important aspects associated with success and optimization of both patient and system outcomes. Although the first step of triage is often assumed to be the sorting of arriving patients into categories or a prioritized order for evaluation and interventions, this requires a clear understanding of the capabilities, capacity, and available resources before effective triage can be started. Thus, the first step of any experienced triage officer is to perform what we have termed the “zero survey.” This entails rapidly, assessing the current status and availability of critical resources at that facility and simultaneously activating the local MASCAL plan and the notification system for all hospital personnel. Although the natural focus in these scenarios tends to be on the emergency room (ER) bed status, it is important to also assess and optimize the availability of beds and staff in the operating room (OR), intensive care units (ICUs), and hospital wards. Key ancillary services including the blood bank, pharmacy, radiology, and laboratory must be notified to cease any nonurgent activities and prepare for the expected large influx of patients requiring their services. Two particularly critical nonclinical areas that also must be activated and in place prior to patient arrival (when possible) are patient administration (PAD) and security. Getting the incoming patients identified, registered, and entered into the hospital’s medical records system is a frequently overlooked issue that can create chaos and danger due to misidentification and medication or blood administration errors. ^,

Critical Mascal Lessons Learned

The past decade-plus of sustained combat operations by the U.S. military and the increased frequency of civilian terrorist and other intentional multiple casualty events has led to an increased level of knowledge and experience related to MASCAL operations and care. Among the most important principles for readiness and optimization of MASCAL outcomes is to optimize the learning from any and all of these events and to apply these “lessons learned” to improve the facility and local/regional healthcare system’s capabilities and response. A widely accepted “best practice” for achieving this goal is the performance of in-depth after-action reviews (AARs) as soon as possible after any multiple casualty or MASCAL event. ^, The purpose of these AARs, which should be held at every level from the individual hospital section/unit to the entire facility or system, is to review the sequence of events and identify key strengths, weaknesses, and opportunities for improvement with future events. These should be formally captured and compiled into a comprehensive action plan with adequate follow-up to ensure that changes are made and that the MASCAL plan is continually adjusted based on this feedback. Similar to the key principles listed previously, there have been a number of key common MASCAL “lessons learned” that have been reported across a wide variety of disparate events. Among the most important and widely applicable of these are the following:

• 1.

  No one is safe! MASCAL events can occur anywhere at any time and are likely to increase in frequency…be prepared.

• 2.

  Know your assets and capabilities at every level of care: prehospital, evacuation/transport, individual hospitals, and the system of care when there are multiple roles of care in the affected area.

• 3.

  Leadership and a chain of command are important especially when allocating trauma system and evacuation resources; reread #2.

• 4.

  Appropriate scene triage and point-of-injury care can turn a potential MASCAL into a more orderly MCI.

• 5.

  The most important job is that of the senior triage officer, who should be an experienced and trusted provider who is able to work well with others.

• 6.

  Scene control and scene safety are crucial. An organized security plan must be part of any MASCAL plan in order to prevent additional casualties, protect personnel, and limit entry points. MASCAL events create vulnerable situations, and secondary injury must be avoided. Hospitals are easy targets during MCIs or MASCALs. A good security plan is imperative.

• 7.

  Execution of a good MASCAL plan requires good patient flow and throughput with minimal congestion at the bottlenecks (ED, radiology). Establishment of one-way flow through the ED facilitates patients’ evaluation and disposition expeditiously to avoid congestion in the ED.

• 8.

  In true MASCAL events that exceed the capacity of the ED, establish a separate area for the minimally injured and the “walking wounded” that is outside of the ED and triage area. In hospitals, outpatient clinics are ideal for this and they should be staffed by providers who can examine and retriage patients if necessary.

• 9.

  Hemorrhage control, airway, and breathing issues are the initial priority for most MASCAL situations. Hemorrhage control can and should occur along the continuum of care.

• 10.

  Blood products are often a scarce resource in the initial phases of a MASCAL event. Have a plan to never run out of blood. Blood should be pushed far forward to triage sites if there is the potential for long transport times or extrications.

The initial triage and patient management/disposition schemes will set the precedent and the tone for the subsequent phases of any MASCAL event, starting with the prehospital/scene phase and continuing to the in-hospital phase. Triage at the scene is typically managed by the scene commander or their designated triage officer and should focus on the initial sorting into triage categories, performing needed immediate lifesaving interventions and then prioritizing and directing transport to the appropriate hospital facility. Tight control of this process at the scene and then appropriate and balanced distribution of patients from the scene to the available local facilities can convert what is a MASCAL event at the point of injury into multiple MCI events at the hospital level. The 2013 Boston Marathon bombing provides a ready example in which excellent scene care and triage were able to evenly distribute the seriously injured patients to multiple local hospitals rather than overwhelming the single closest center. ^,

Triage at the hospital level is arguably the most important of the key clinical leadership roles during the initial phases of any true MASCAL event. Historically, the importance of the role of the senior triage officer has been underappreciated and often assigned to the “least clinically useful” person on the medical team. This approach has now been widely recognized to be inappropriate and potentially disastrous, and the triage officer should be someone who is selected carefully for their advanced expertise in trauma management, leadership skills, and ability to communicate effectively. In our experience, this is usually best performed by an experienced trauma surgeon or emergency medicine provider. In scenarios in which there is a need to establish both an external (primary) and internal (secondary) triage area for the facility, then the senior triage office and assistant or secondary triage officer must work in a highly coordinated and consistent fashion.

Mascal Management and the Surgeon’s Role in Triage

Although there are numerous methods and reported systems for MASCAL management, no one approach has proven clearly superior or universally applicable. What has been clearly demonstrated is that complex and confusing systems that are not understood and well rehearsed by the frontline clinicians are doomed to failure. Arguably more important than which particular system is selected are the principles of simplicity, familiarity, and effective and realistic rehearsal drills as part of a comprehensive MASCAL/Disaster preparation program. ^, We propose the use of the mnemonic TRIAGE ( Box 24.1 ) as a memory aid and guide to the core principles of MASCAL management and the role of the surgeon in the preparation for and execution of these events.

Training

“Training is everything…” Mark Twain

Training for MASCAL events requires surgeon involvement at the local and regional levels. Effective leadership and training are foundational for a successful response to an MCI or MASCAL event; while surgeons are not involved with point-of-injury care or rarely with field triage, surgeon involvement with the planning and training is extremely important. Any trauma system, even the most established, can be burdened by large volumes of patients. Successful triage requires significant training and sorting and prioritizing of casualties according to their injuries while considering for the tactical situation and resources available; it is a skill that, in addition to training, requires education and leadership.

For both field and in-hospital triage, the choice of the triage officer should be determined as part of a MASCAL plan and the triage officer should be one of the most experienced and organized personnel; for in-hospital triage, the triage officer is frequently an experienced surgeon; and for field triage, either an ED physician or an experienced prehospital provider. It is essential that the triage officer be able to quickly recognize life-threatening injuries. The experience and expertise of the triage officer are crucial; the triage officer must be able to rapidly identify life-threatening injuries and injury patterns and place the patients in the correct triage category. The decision for who is going to be the triage officer should not be made at the time of the MASCAL event. Each hospital and field triage system should have redundancy in the personnel who can serve as the triage officer.

The triage officer must also have been informed and understand the tactical situation in order to appropriately manage resources and meet the goal of doing the best for the most, not everything for everyone. Awareness of the event, the situation, estimated number of casualties, risk for secondary event, effectiveness of field triage, etc., is important information to give the hospital triage officer perspective to facilitate optimization of resources. The triage officer should be one of the most experienced and organized personnel and should ideally have a deputy to facilitate communications and recording. While most triage officers are surgeons, experienced providers in emergency medicine can be excellent triage officers. MASCAL plans in the hospital should be trained and rehearsed. More than one potential triage officer should be identified and train for that role to provide redundancy in the available expertise and also to prepare for scenarios in which the primary triage officer is injured/ill, otherwise engaged, or in which multiple triage points need to be established.

The location for the triage point(s) should be predetermined and clearly spelled out in the written MASCAL plan and any rehearsal drills. One of the most common errors that we have observed in hospital MASCAL planning is the development of only one triage plan and location, which fails to appreciate the highly variable nature of these events. ^, We recommend the development of at least two flexible triage schemas that allow for the different triage requirements that will be seen in smaller-scale MASCAL events versus larger-scale or disaster-type events. In general, smaller-scale MASCAL events (relative to the available ED and hospital bed space) where all patients can be immediately brought inside the facility require only one primary triage point that is usually optimal to locate near the ED entrance. Larger-scale events that exceed the available bed space or providers necessitate the establishment of an external primary triage site where patients are categorized, prioritized, and held until they can be moved into the facility ( Fig. 24.4 ). ^, Secondary triage would then occur as patients are filtered into the facility and then directed to the appropriate location based on their needed level of care. The external triage location should have climate control, be well lit, and have prestocked supplies for immediate patient needs including hemorrhage control and airway/breathing interventions. All patients who arrive at the facility must be triaged and ideally enter the hospital through one tightly controlled entry point, with all other facility entrances protected by assigned security personnel.

Accompanying the triage officer during hospital triage should be a PAD officer, a nurse coordinator who acts as a “bed manager,” and a nurse or medic equipped with basic bleeding control supplies. The triage team organized in this fashion can sort, communicate, track, and treat casualties. As patients get sorted/prioritized by the triage officer, the PAD officer can tag the patient, keep accountability, and communicate the disposition to the centralized PAD center. The nurse coordinator is essential to help relay the plan for disposition of the patient and communicate this plan to the patient care areas in the hospital. If patients need to go straight to the OR for emergent surgery or into the ED for an urgent airway, the nurse coordinator can help communicate and facilitate the triage officer’s plans. Lastly, having a clinically experienced nurse, medic, or EMT on the triage team allows for immediate treatment of hemorrhage with tourniquet placement, wound packing, or the use of hemostatic adjuncts. Bringing a hemorrhage control capability to the triage team also helps patients move into lower-acuity triage categories; e.g., an immediate patient with a traumatic amputation can get triaged to a delayed category with tourniquet hemorrhage control. If advanced warning is received, these personnel and resources should be prepositioned in accordance with the (well-rehearsed) MASCAL plan. Triage starts with understanding the system capabilities, resources, and personnel; resource utilization and appropriation are the keys to effective triage. The plan, patient flow, and ancillary services (blood bank, pharmacy, PAD, incident command system, patient movement) all must be included in the training.

While there are many triage categorization schemes, each hospital and trauma system should choose one, keep it simple, and train with it regularly. ^{, ,} Training requires a significant time, energy, and resource investment; perfunctory training without stressing the weak areas in the process or involving the entire system will only lead to potential failures should the system be stressed with a MASCAL event. Surgeon leadership is necessary for MASCAL training; there is a tendency for triage and MASCAL training to involve prehospital providers and the initial hospital response, but the training does not get brought into the hospital beyond the ED phase of care. Not involving the ORs and the ICUs in the MASCAL training makes it less realistic and can portend a false sense of success when patients get rapidly moved out of the ED to go to the ORs without planning and training the times that it takes for multiple operations to occur. ^, While the details and nuances may be second nature to the triage officer, weak areas in the system will be amplified in the event of a MASCAL event. Realistic and typically resource-intensive training with surgeon involvement at all levels will improve the triage and initial response to a MASCAL situation.

Triage Systems

There are a number of useful and well-validated triage systems that are currently utilized for guiding the initial evaluation and then categorization of patients during a MASCAL event. However, many of these are primarily used and validated for initial evaluation and triage sorting at the point of injury or the scene triage point and may be less useful for performing triage at the hospital level. These typically combine a rapid assessment of clinical factors (mental status, ambulating, vital signs) and obvious injuries followed by categorization that prioritizes that patient for immediate interventions and for rapid transport to a trauma center. Several of the more commonly utilized include the following: Sort, assess, lifesaving interventions, and treatment/transport (SALT), Simple Treatment and Rapid Transport (START), JumpSTART (pediatric version of START), Care Flight Triage, the Sacco Triage Method, and Secondary Assessment of Victim Endpoint (SAVE). ^{, ,} Fig. 24.5 shows an example of the SALT triage system, which has been endorsed by the American College of Surgeons (ACS) and other professional organizations. Although there are strengths and weaknesses with each system, they can all be highly effective when used properly by a trained triage officer.

At the hospital level, similar rapid triage and categorization are again performed either as the patient is entering the facility or at an established external triage point. The above-mentioned prehospital triage systems are generally less useful at this level, where the primary focus now is to identify patients who require immediate intervention or surgery, those who require additional detailed workup, and those with negligible injuries who do not require urgent care or evaluation. In lower-volume MASCAL events at robust centers, the arriving patients can generally be triaged into only two categories: (1) the highest-acuity ED beds for patients with major or urgent injuries and (2) lower-acuity areas of the ED for less urgent or minimal injuries. However, in higher-volume events or at less robust facilities where the patient volume clearly outweighs the available ED staff and bed space, more traditional triage into multiple categories or priorities should be performed. In these instances, we recommend use of the North Atlantic Treaty Organization (NATO) triage categorization system based on the mnemonic DIME (also used by the SALT system shown in Fig. 24.5 ). This groups patients into categories of delayed, immediate, minimal, and expectant, as shown in Fig. 24.6 . In addition to these categories, it is also important to have a clear plan and identified location for those patients who are dead on arrival or who die shortly after presentation to the facility. Some key bullet points related to hospital level triage are listed below:

• ➢

  Retriage is a crucial component of the triage process. Triage is a fluid process at all levels; a change in the situation or resource availability may result in a change in the patient triage category at any time.

• ➢

  As the situation changes and resources become more or less available, retriage of delayed and expectant patients should occur.

• ➢

  Patients in the minimal category can undergo a secondary and tertiary survey and usually be discharged. Occasionally, they will have missed injuries discovered during the retriage process and should be immediately reassigned into the delayed or immediate category.

Patient inflow and movement into and out of the triage area are crucial to prevent bottlenecking and chaos. Not having a well-planned map of patient movement and patient triage category areas will lead to significant confusion and potentially have a negative impact on patient care. This attention to patient flow and throughput should be made clear to all personnel and should also be rehearsed regularly. In addition, there should be a diagrammatic map that is well displayed and accessible. Another frequently overlooked aspect of MASCAL execution is the need for a group of available personnel who are dedicated to assist with patient movement, running for supplies and equipment, and relaying messages. This “manpower pool” will be critical to the efficient and effective movement of patients between locations including the triage area, ED, ICU, OR, radiology, and wards. Patient flow must be in a logical fashion, and this movement should be practiced to ensure efficiency and understanding of the staff members.