ED triage systems fail in MCIs

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Why it’s important to take aim at out of the box strategies.

Triage is the most important step in increasing the survival rate in a Mass Casualty Incident (MCI). On the night of Oct. 1, 2017 in Las Vegas, triage was the key to organizing the largest surge of penetrating traumatic injuries that has ever presented to one U.S. hospital.


With hundreds of gunshot wounds presenting in under an hour, how do you find all of the needles in the haystack and then successfully resuscitate them all? I have been asked what triage system was used that fateful night.  In this three-part series, I will describe my unique triage system, which was built on the hypothesis there was no proven ED triage system that could successfully handle the 12-hour surge of large scale Penetrating MCI.


Dr. Dominique Jean Larrey is considered the innovator of triage during the Napoleonic Wars. He is credited with first stratifying patients into three categories:

  • Unlikely to live, regardless of what care they would receive
  • Likely to live, if they receive immediate care
  • Likely to live, even without care

In the 1980s, Hoag Hospital and Newport Beach Fire created START and the color coding tag system of black, red, yellow and green. SALT (Sort, Assess, Lifesaving Intervention, Transportation/Treat) added the sorting methods of walk, wave and still. SALT also added the pre-hospital interventions: major hemorrhage control, open airway, chest decompression and antidotes.


In response to increased active shooters and terrorist attacks, The Hartford Consensus II (THC II) laid out further guidelines to the public, law enforcement and fire/EMS on treatment and triage in a MCI. These are all pre-hospital strategies with some components of early hospital care. What’s missing is an exact template for what should you do at the hospital. More importantly, these methods continue the centuries old belief that gray tags do not have a chance at resuscitation in a MCI.

Existing PreHospital and ED Triage Systems

There are triage systems designed for the ER. There is the tried and true nursing ESI triage that sorts patients using vital signs and a brief history. But ESI is designed for normal ER operations, not a MCI.  SALT/START are pre-hospital triage methods that EMS uses to handle the surge of patients on scene. The Army Method (Mass Casualty and Triage Chapter) uses triage decision making on vital signs, pattern of injury and response to initial resuscitation. The Abbreviated Injury System (AIS) is a system that stratifies injuries into six categories while Injury Severity Score (ISS) is a scoring system used to predict the probability of death. The Australian Triage Scale (ATS) stratifies patients into five categories requiring care at different intervals from immediate to delayed at 120 minutes.

Similar in many regards to the ATS, the Canadian Emergency Department Triage and Acuity Scale (CTAS) separates patients into five groups from resuscitation to non-urgent. The system is designed for triaging medical and trauma patients that present to the ER. Resuscitations are identified by cardiac arrest, respiratory arrest, trauma with shock, respiratory distress and altered level of consciousness. The patients are grouped into the following categories: Resuscitation (see patient immediately), Emergency (see within 15 minutes), Urgency (see within 30 minutes), Less Urgency (see within 60 minutes) and Non-Urgency (see within 120 minutes). Vital signs are necessary to stratify these patients into the five groups. We will discuss how time needed to obtain vital signs will be problematic in a surge.

In a penetrating trauma scenario, one or a handful of patients present to the trauma center. EMS has performed anywhere from some to all of the initial stabilization procedures. The ABCs are re-addressed in the trauma center and if the patient is somewhat stable then imaging is done. If unstable, then the patient undergoes immediate damage control surgery. It is understood that it will not be business as usual in a MCI, so:


  1. What are the issues that arise from the surge of patients?
  2. How can they be addressed?
  3. Do any of the standard triage methods accommodate for this massive surge?
Triage System Shortcomings

To understand how ED triage systems will fail in a MCI, let’s begin by reviewing concepts that affect ED triage in the setting of an MCI.

  1. Scale. Since the definition of an MCI is overwhelming your available resources, the scale needed to constitute a MCI is different at each hospital. A critical access hospital with a single doctor and a handful of nurses might call a motor vehicle crash, with four critical injuries, an MCI. A fully staffed Level 1 Trauma Center could handle a few of these in a shift without feeling overwhelmed.
  2. Disorganization is the loss of order cause by the chaos of a MCI. As scale increases, disorganization increases. As critical patients are stabilized, the pool of critical un-resuscitated patients is reduced. As the scale of critical un-resuscitated patients decreases, disorganization is reduced.
  3. Surge. This occurs when hospitals experience a large volume of patients in a short period of time. Hidden within this surge of patients are the patients that are actively dying, those that will decompensate soon, those that will decompensate later and those that will never decompensate. This surge of patients is what primary triage must sort out to prevent disorganization.
  4. Gray Tags. Since the 1800s, the medical community has believed that in order to do the most good in a MCI, we must sacrifice those who are critically injured and deemed unsalvageable without even attempting resuscitation. A successfully saved gray tag patient will have a very long road to recovery and may never fully recover — yet the current belief is that such a patient shouldn’t even be given a chance.
  5. Time-until-death. After a gunshot wound occurs, every victim has a set amount of time until they will expire. This time-until-death is dependent on many factors including the severity of the injury, the patients underlying pre-injury health status and the number of injuries. If two different patients receive the same liver GSW, the patient with the underlying anemia and mild Congestive Heart Failure would have a shorter time-until-death than the young healthy 20-year-old with the exact same injury.
  6. Salvageability timeline. This window of time is the period that a victim is potentially salvageable. Injuries will be salvageable if resuscitated before the time-until-death runs out. Each victim’s time-until-death places them on this salvageability timeline.
  7. Limited Manpower. MCIs by definition are due to overwhelming resources. To be successful in any plan, the worst case scenario must be the primary consideration. Plans to handle the patient surge must be structured around the limited initial manpower.
  8. Limited resources. There are a number of resources that are limited in a MCI including equipment and blood. The most limited resource is time. With so many gray and red tag patients arriving in a surge, there may not be enough available time to resuscitate them all, unless primary triage can find these patients quickly and place them together such that movement of the resuscitating team is minimal.
  9. Bail-out: Scoop-and-run will create a line of vehicles filled with victims and family. If triage takes an extended period, a line will begin to form prior to primary triage. If the line continues to move at a snail’s pace, innate protective instincts will kick in and soon family members will bail-out of the car and start carrying their loved ones past the cars waiting ahead of them. When cars near the front of the line see this, their innate protective instincts will also kick in and they too will attempt to carry their family member to the front of the line. As all of these groups of patients converge on the ambulance bay entrance simultaneously, Disorganization will inherently occur.
  10. Primary and Secondary Triage: Primary triage 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 next and yellow for those who will decompensate last. Secondary triage is reserved for patients that require surgical intervention. Patients that need resuscitation will likely need surgical intervention. Primary triage is done by the most experienced ER physician. Secondary triage is done by the trauma surgeon. This occurs after initial resuscitation and it prioritizes resuscitated patients for surgery.

Achieving organization in the midst of chaos is one of the major challenges in navigating a triage situation in an MCI. Next month we will outline a plan to handle the surge of a MCI and discuss how the current triage methods will fail under the weight of a surge in a MCI.


Kevin Menes, MD is an emergency room physician who was working in Las Vegas the night of the Oct. 1 shooting. The team's non-standard approach to MCI was credited with saving hundreds of lives.  He is a former tactical physician with the Las Vegas Metropolitan Police Department SWAT team. Menes has taught various military special forces and other groups. He has traveled to numerous locations teaching Mass Casualty Preparedness. He credits his residency in Emergency Medicine at St. John Hospital, Detroit for his knowledge and experience.

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