Mass shootings revealed the old paradigm’s shortcomings – here’s how an upgrade would look.
The Aurora, Colo. police department made the first big paradigm shift in a penetrating mass casualty incident (MCI) on July 20, 2012, when they used police vehicles to scoop-and-run victims in police cruisers to the hospital.
For the first time in over 200 years, gray tag patients had a chance at life, instead of leaving them on the scene to succumb to their injuries. In a MCI, it is thought that we should save resources for those immediate cases that can be saved if given priority care.
Patients with severe injuries that would be labeled gray tags in a MCI are daily brought to trauma centers within the window to be stabilized first by resuscitation and saved by surgery. Afterwards, the team explains the severity of the injuries and how the patient was already inside death’s door as they congratulate themselves on saving that case while recounting the details to the incoming shift.
This level of heroic effort was deemed unfit for use in a MCI, where resources must be used judiciously. The other significant issue is finding gray tags within the surge in a MCI. If you don’t find them and resuscitate them immediately, they die. There has never been a proven way to triage a massive surge in an MCI on hospital grounds in an effort to save them; at least until the floors were cleaned and the trauma bays were restocked on Oct. 2, 2017.
I loved roller coasters as a child, especially when there was no line as I could get off, run through the empty line and ride again and again. The amusement park didn’t stretch out my ride due the lack of lines and did not speed up the rollercoaster to move the lines faster. The rollercoaster ride time was fixed. The line had to wait. Penetrating trauma is similar as the resuscitation, imaging and surgery cannot be sped up. Normally that line is empty and the rollercoaster can be ridden over and over again, just like a trauma bay under normal daily use. In a MCI, that line can be 5, 10, 20, 40 or more. This line represents the surge of patients arriving to the hospital in a MCI.
People who leave before waiting in line represent the green tags that don’t need resuscitation. Primary triage sorts out these patients in a MCI, which helps shorten the line if they are moved prior to joining the line. The key to handling the overwhelming surge, despite being outnumbered, is to stratify all of the potentially fatal injuries by estimated time-until-death.
An optimal triage method will predict the potential wounds to estimate the time-until-death. The Gray and Red tags will be actively decompensating on arrival, and all efforts should be directed at them first. Those who are predicted to decompensate after the red group are placed in the orange group, while those who are predicted to decompensate last are placed in the yellow group. This tiered system gives a small resuscitation team three different windows of opportunity to stabilize a life until surgery was available for definitive treatment. I hypothesized that this plan would handle a massive surge with limited initial manpower. This all hinged on the idea that it was possible for a triage system to predict the order in which patients would decompensate. However, none of the available and accepted triage systems estimated the time-until-death or had answers to the issues only brought on by a MCI.
In the previous article, we discussed the problems that are invisible in a single penetrating trauma, but are magnified in a MCI. This is how using a primary triage system that predicts the time-until-death can answer the issues brought on by a surge.
- Scale: A massive surge of patients can be organized if a predictive triage method is used.
- Disorganization: Separating potentially fatal from non-fatal wounds immediately shrinks the pool of the patients requiring resuscitation. This leads to efficiency, since there will be less movement required to travel from patient to patient within this smaller pool of patients.
- Surge: Refers to the tidal wave of approaching patients in a MCI. Primary triage first divides the potentially fatal from non-fatal injuries. By first picking out only the patients requiring resuscitation, the surge is converted into a miniature-surge. This miniature-surge is organized into smaller pools based on their potential injuries and their predicted time-until-death. Theoretically, these remaining pools of patients will decompensate in order, so the miniature-surge is further organized into micro-surges. If these micro-surges decompensate as predicted, there is a smaller number of patients actively requiring resuscitation and each micro-surge will be easier to handle than the entire tidal wave.
- Gray Tags: Apneic patients with a pulse. Modern day trauma centers attempt to save these dying patients on a daily basis, only if they present one at a time. In a MCI, conventional thought is that EMS does not even attempt to transport these patients. The same patient in a MCI today, is deemed unsalvageable, despite trying to save the exact same patient yesterday, solely because they presented one at a time. Scoop-and-Run will bring these viable patients to the hospital. Immediate identification of these gray tags will lead to a higher probability for successful resuscitation.
- Time-until-death: I noticed within the Golden Hour, patients would decompensate within three different 20-minute windows. These windows correspond with the tagging system of red, orange and yellow. There was a direct correlation between the severity of the injury and when a victim died. Only a triage system that sorts by estimated time-until-death based on potential injuries will be able to take advantage of the fact that patients with penetrating trauma do not simultaneously decompensate. If patients are sorted in this manner, a small team can work on those that are actively dying, while waiting for the next group to decompensate.
- Salvageability timeline: Only a triage system that prioritizes by estimated time-until-death, will allow a small team the opportunity to save red tags, while keeping a close eye on orange tags.
- Limited Manpower: To handle the surge with limited manpower, the solution is to resuscitate those whose time-until-death is near an end. A small team now has the optimal chance for successfully saving the decompensating while waiting for additional help to arrive.
- Limited Resources: Limited ventilators, chest tubes and supplies are some of these finite resources that we managed to work around. The most limited resource is time. By triaging patients by their estimated time-until-death, a small team can resuscitate patients in order and prevent wasting time.
- Bail-out: The innate protective instinct that everyone has for the victim that is a part of their life i.e. family members. They will bail-out of the car and rush towards an ER entrance carrying their loved one in their arms if the line for triage is too long or if the triage process is too slow. This visually looks like a zombie apocalypse all attempting to enter the ER at the same time. Bail-out inevitably leads to disorganization and loss of security. Triage systems that rapidly sort patients can prevent the bail-out phenomenon.
- Primary and Secondary Triage: Primary triage is done by the most experienced ER physician. This divides the patients that will die from those that will not die. Patients with potentially fatal wounds are further stratified into red, orange and yellow based on their presumed time-until-death. Red for actively dying, orange for those who will decompensate in the next 20-minute window and yellow for those who will decompensate in the last 20-minute window. Secondary triage is done by the trauma surgeon. It occurs after initial resuscitation and prioritizes resuscitated patients for surgery. Secondary triage is reserved for patients that require surgical intervention, such as those that required resuscitation.
In pre-planning, I realized how important triage would be to success. However, the available triage methods did not address certain issues brought about only in a MCI. A successful penetrating MCI primary triage method will need to:
- Quickly identify actively decompensating patients.
- Rapidly handle the surge and prevent bail-out.
- Sort by tiers to prevent disorganization.
- Address the issues related to limited manpower.
- Predict the time-until-death based on potential injuries, to prevent later disorganization.
The issues with the established methods are as followed.
SALT/START methods of triage cannot be used as primary triage of a surge from a penetrating MCI at the hospital. You cannot use the walking and waving method to sort in the ER during an MCI, since all the victims and family members want to enter the ER. Both of these methods sacrifice patients with pulses, but are not breathing (gray tags) for the good of the remaining patients.
The Army Method sorts patients based on vital signs and response to resuscitation. A standard set of vital signs is nearly impossible amidst a massive surge from a MCI. The time needed for a standard set of vitals slows the flow through primary triage and would ensure bail-out prior to primary triage. This method would be useable within the secondary triage position, after initial resuscitation.
Both the Abbreviated Injury System (AIS) and Injury Severity Score (ISS) are scoring systems used to predict the probability of death. These are used for stratifying victims based on probability for survival. However, scoring the three worst injuries, squaring those numbers and then adding them to calculate these scores would take too long in triage. The time needed to perform the calculation would make bail-out more likely. These triage systems would be most useful in the secondary triage position because the victim has been stabilized by resuscitation.
The Australian Triage Scale (ATS) can be used in the primary triage position, because the system does not use vital signs to identify Gray and Red tags, so it will prevent Bail-out. However, it has limitations. ATS triages patients based on initial presentation. It does nothing to predict decomposition, so this triage method does not address inevitable disorganization. Many victims with penetrating torso trauma can present within the three, four or five categories of the ATS. Without predicting time-until-death, the remainder of the golden hour will be disorganized as these patients begin to decompensate out of order, all over the entire footprint of the treatment space.
Canadian Emergency Department Triage and Acuity Scale (CTAS) can be used in the primary triage position because it prioritizes gray and red tags for resuscitation. CTAS uses vital signs to prioritize the non-resuscitation patients. Since the pool of patients is immediately reduced by recognizing gray and red tags, performing vital signs on the remaining pool of patients would cause less bail-out. However, disorganization will occur after the initial resuscitations because this triage method only evaluates patients at the time of presentation and does not predict time-until-death.
In the final triage article, we will cover the convoluted path I took from putting dowels through gunshot wounds at the coroner’s office in Detroit, to standing on a dimly lit driveway. Before me was a parade of police vehicles, limousines, taxis, pickup trucks, ambulances, hundreds of victims and family members that descended on a little known level 2 trauma center. All of our minds shared the same hope that we could pull off the impossible. It was on that driveway that convention was scrubbed and an idea that had been secretly tested for years, had its first chance at life.