Preventing an avoidable catastrophe

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ERs need focused approach for mass casualty incident management.

In 2002, terrorists took 900 people hostage in theater in Moscow. The terrorists were armed with AK-47s and wore suicide vests. Explosives were placed around the entire theater, waiting for the assault by Russian special forces. Just prior to assaulting the building, the military pumped an undisclosed gas (found later to be Carfentanil and Remifentanil) into the building to prevent the terrorists from detonating the vests and bombs.

Years later, on Bastille Day in 2016, a cargo truck drove down a crowded street in Nice, France. After the truck was disabled, the terrorist began shooting his firearm.


On October 2017 in Las Vegas, a gunman rained over 1,000 rounds into a crowd of concertgoers. Midway through the rampage, armor-piercing incendiary rounds were fired at two jet fuel tanks near the southeast side of the venue.

These real-life scenarios could have resulted in a mixture of injuries, a multiple mass casualty incident (MMCI). Luckily each resulted in a single predominant injury pattern of a mass casualty incident (MCI) template.

Imagine you’re on shift as the victims enter your ER as overdoses, blast victims and gunshot wounds (GSW) arrive in the same ambulance. Is your hospital ready to handle the influx of autopeds (auto vs. pedestrian) and GSWs. Who will you treat first, the burn victims or the GSWs?


Deficiencies of broad template

Most hospitals have a broad-based approach to mass casualty incident (MCI) management. Vital signs, triage tags and SALT or START triage are the pillars of these MCI plans. These pillars cannot handle a large-scale MCI and will not survive the mixed injuries from these incidents. The results could be catastrophic.

In most emergency departments, every Monday after a holiday is like a miniature MCI. Abdominal pain, chest pain, lacerations, ankle sprains and the occasional off-work-note comprise one’s active patient list. Studies, diagnosis and treatment for each complaint is different. Why then would we abandon this methodology in a MMCI where there are a variety of injuries?

There is no other specialty, like emergency medicine, that is best suited to handle this situation. Being Jack-of-all-trades, ER doctors have the knowledge base to stabilize critical victims in each of the different MCI templates:


  1. Penetrating
  2. Blunt
  3. Blast
  4. Burn
  5. Chemical
  6. Biological
  7. Nuclear

Although the acronym police will have to fight the urge to group the B’s together, there is a reason for this order. Time-until-death, the time one has after an injury to be saved, is the most time sensitive in the Top 5.

Who would you resuscitate first, the GSW to the chest or the autoped with a GCS of 3? The exsanguinating amputation or the burn to the face and torso? How would you approach the two patients with impaling shrapnel to the abdomen, bronchospasm and hypersecretions?

The Status Quo

  1. SALT or START are unable to make these fine distinctions between two critically ill patients. These systems were intended to triage patients on scene, not at the hospital.
  2. Vital signs — any combination of two patients would be circling the drain while waiting for a set of vital signs.
  3. Triage tags — how many times has an abdominal pain sat in the middle priority of your patient list until the CT returns as a ruptured AAA? Partitioning the emergency department into the color-coded sections (Red, Orange, Yellow and Green used during the Vegas shooting) is nimbler in a rapidly changing environment, than filling out paper tags.
  4. Trauma surgery is a helpful partner in the first four templates. Would they be your first call in a Chemical MCI?

Each of these MCIs have a distinct template, triage systems, supplies, specialist assistance, workarounds, pitfalls, optimal order of execution, etc.

One may say that it is too difficult to learn all of these templates and would prefer to continue the broad-based approach towards a mass casualty incident. The time to make the decision is not after notification of a multi-prong attack.

There’s too much to learn and understand to wait until then. For those who are interested in saving every life possible when the odds are completely stacked against you, you work when your partners are asleep with their phones on vibrate and you get a chill when you hear multiple sirens approaching, the multiple template approach is for you.


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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