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Understanding Triage Following a Mass Casualty Event

Avatar for Gaye Levy Gaye Levy  |  Updated: November 24, 2020
Understanding Triage Following a Mass Casualty Event

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If you read enough survival fiction, you will recognize that regardless of how well you prepare, there will be casualties.  Heck, you don’t even have to read fiction to know that casualties happen all of the time to innocent bystanders in real life.  This became an in-your-face reality a year ago during the Boston Marathon bombings.  More recently and much closer to home, the OSO mudslides occurred practically in my own backyard here in Washington State.

Whatever the cause, a mass casualty event is going to wreak chaos and burden first responders and medical personnel with the gruesome job of determining who is living and who is not and who is treatable and who, sadly, is too far gone to make an effort.

Understanding Triage Following a Mass Casualty Event | Backdoor Survival

This process – the process of evaluating victims and referring them to medical treatment is called triage.  Wikipedia defines triage as follows:

Triage is the process of determining the priority of patients’ treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately.

Today I share an article written by Contributing Author, Joe Alton. In it he describes what we, as non-medical professionals, need to know when faced with a worst-case scenario: a mass casualty event.  Here is what you need to know about understanding triage following a mass casualty event.

The Mass Casualty Incident

The responsibilities of a medic in times of trouble, will usually be one-to-one; that is, the healthcare provider will be dealing with one ill or injured individual at a time.  If you have dedicated yourself to medical preparedness, you will have accumulated significant stores of supplies and some knowledge.

Therefore, your encounter with any one person should be, with any luck, within your expertise and resources.  There may be a day, however, when you find yourself confronted with a scenario in which multiple people are injured.  This is referred to as a Mass Casualty Incident (MCI).

A Mass Casualty Incident is any event in which your medical resources are inadequate for the number and severity of injuries incurred.  Mass Casualty Incidents (we’ll call them “MCIs”) can be quite variable in their presentation.

Types of Mass Casualty Incidents

They might be:

  • Doomsday scenario events, such as nuclear weapon detonations
  • Terrorist acts, such as occurred on 9/11 or in Oklahoma City
  • Consequences of a storm, such as a tornado or hurricane
  • Consequences of civil unrest or battlefield injuries
  • Mass transit mishap (train derailment, plane crash, etc.)
  • A car accident with, say, three people significantly injured (and only one ambulance)
  • Many others

The effective medical management of any of the above events required rapid and accurate triage.

Triage comes from the French word “to sort” (“Trier”) and is the process by which medical personnel (like you, survival medic!) can rapidly assess and prioritize a number of injured individuals and do the most good for the most people. Note that I didn’t say: “Do the best possible care for each individual victim”.


Let’s assume that you are in a marketplace in the Middle East somewhere, or perhaps in your survival village near the border with another (hostile) group.  You hear an explosion.  You are the first one to arrive at the scene, and you are alone.  There are twenty people on the ground, some moaning in pain.  There were probably more, but only twenty are, for the most part, in one piece.  The scene is horrific.

As the first to respond to the scene, medic, you are Incident Commander until someone with more medical expertise arrives on the scene.  What do you do?

Your initial actions may determine the outcome of the emergency response in this situation.  This will involve what we refer to as the 5 S’s of evaluating a MCI scene:

Sizing up
Sending for help
Set-up of areas
START – Simple Triage And Rapid Treatment

1.  Safety Assessment:  Our friend Joshua Wander (the Jewish Prepper of BlogSpot fame)  relates to us an insidious strategy on the part of terrorists in Israel:  primary and secondary bombs.  The main bomb causes the most casualties, and the second bomb is timed to go off or is triggered just as the medical/security personnel arrive.  This may not sound right to you, but your primary goal as medic is your own self-preservation, because keeping the medical personnel alive is likely to save more lives down the road.  Therefore, you do your family and community a disservice by becoming the next casualty.

As you arrive, be as certain as you can that there is no ongoing threat.  Do not rush in there until you’re sure that the damage has been done and you and your helpers are safe entering the area.  In the immediate aftermath of the Oklahoma City bombing, various medical personnel rushed in to aid the many victims.  One of them was a heroic 37 year old Licensed Practical Nurse who, as she entered the area, was struck by a falling piece of concrete.  She sustained a head injury and died five 5 days later.

2. Sizing up the Scene:  Ask yourself the following questions:

What’s the situation?   Is this a mass transit crash?  Did a building on fire collapse?  Was there a car bomb?

  • How many injuries and how severe?  Are there a few victims or dozens? Are most victims dead or are there any uninjured that could assist you?
  • Are they all together or spread out over a wide area?
  • What are possible nearby areas for treatment/transport purposes?
  • Are there areas open enough for vehicles to come through to help transport victims?

3.  Sending for Help:  If modern medical care is available, call 911 and say (for example):  “I am calling to report a mass casualty incident involving a multi-vehicle auto accident at the intersection of Hollywood and Vine (location).  At least 7 people are injured and will require medical attention.  There may be people trapped in their cars and one vehicle is on fire.”

In three sentences, you have informed the authorities that a mass casualty event has occurred, what type of event it was, where it occurred, an approximate numbers of patients that may need care, and the types of care (burns) or equipment (jaws of life) that may be needed.  I’m sure you could do even better than I did above, but you want to inform the emergency medical services without much delay.

If the you-know-what has hit the fan and you are the medical resource, get your walkie-talkie or handie-talkie and notify base camp of whatever the situation is and what you’ll need in terms of personnel and supplies.  If you are not the medical resource, contact the person who is; the most experienced medical person who arrives then becomes Incident Commander.

4.  Set-Up:  Determine likely areas for various triage levels (see below) to be further evaluated and treated.  Also, determine the appropriate entry and exit points for victims that need immediate transport to medical facilities, if they exist.  If you are blessed with lots of help at the scene, determine triage, treatment, and transport team leaders.

5. S.T.A.R.T.:  Triage uses the acronym S.T.A.R.T., which stands for Simple Triage and Rapid Treatment.

The first round of triage, known as “primary triage”, should be fast (30 seconds per patient if possible) and does not involve extensive treatment of injuries.  It should be focused on identifying the triage level of each patient.  Evaluation in primary triage consists mostly of quick evaluation of respirations (or the lack thereof), perfusion (adequacy of circulation), and mental status.  Other than controlling massive bleeding and clearing airways, very little treatment is performed in  primary triage.

Know Your Colors

Although there is no international standard for this, triage levels are usually determined by color:

Triage Tape Amazon

Immediate (Red tag): The victim needs immediate medical care and will not survive if not treated quickly.  (for example, a major hemorrhagic wound/internal bleeding) Top priority for treatment.

Delayed (Yellow tag): The victim needs medical care within 2-4 hours. Injuries may become life-threatening if ignored, but can wait until Red tags are treated. (for example, open fracture of femur without major hemorrhage)

Minimal (Green tag): Generally stable and ambulatory (“walking wounded”) but may need some medical care. (for  example, 2 broken fingers, sprained wrist)

Expectant (Black tag): The victim is either deceased or is not expected to live.  (for example, open fracture of cranium with brain damage, multiple penetrating chest wounds)

Knowledge of this system allows a patient marking system that easily allows a caregiver to understand the urgency of a patient’s situation.

It should go without saying that, in a power-down situation without modern medical care, a lot of red tags and even some yellow tags will become black tags.  It will be difficult to save someone with a major internal bleeding episode without surgical intervention.

Dr. Bones

The Final Word

Even without medical training, having some basic knowledge of how triage works will allow us to lend a helping hand in identifying those victims who need the most urgent care. If things are really bad, that helping hand may be the only hand.

To be honest, it had never occurred to me to carry some colored triage tags or tape in my worst-case-scenario kit.  Following a severe disaster, help may be a long time coming and those of us still walking may have to determine on our own who will and will not survive.  As sobering as this may be, it is something to think about, be aware of, and yes, prepare for mentally.

Enjoy your next adventure through common sense and thoughtful preparation!

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Spotlight Item:  THE SURVIVAL MEDICINE HANDBOOK is a guide for those who want to be medically prepared for any disaster where help is NOT on the way.  It is written from the non-medical professional and assumes that no hospital or doctor is available in the aftermath of a catastrophic event.  It covers skills such as performing a physical exam, transporting the injured patient, and even how to suture a wound. This medical reference belongs in every survival library.

Bargain Bin: Survival is all about learning to fend for yourself. Here are some of the emergency medical reference books and supplies that belong in every household first aid kit.

Triage Tape Kit: Colorful and highly visible, Triage Ribbon is the most durable and easy to use Triage Ribbon available. Utilized in the emergency field or at mass casualty events by tying the appropriate color identification ribbon to the injured victim to inform the agencies on site which emergency station to utilize. Printed with designated S.T.A.R.T. legends. Kit contains 2 of each, minor, delayed, immediate, and deceased.

Quikclot Sport Brand Advanced Clotting Sponge: A must for any first aid or emergency kit, Quikclot Sport stops moderate to severe bleeding until further medical help is available.

Israeli Battle Dressing, 6-inch Compression Bandage: This is another inexpensive, yet critical item. Combat medics, trauma doctors, and emergency responders all recommend this Israeli Battle Dressing (IBD) for the treatment of gunshot wounds, puncture wounds, deep cuts, and other traumatic hemorrhagic injuries.

Living Ready Pocket Manual – First Aid: Fundamentals for Survival:  Whether you are miles from help or immersed in an urban disaster situation, every second counts during a medical emergency. This book will help you take quick, effective action to stabilize the situation. One of the best things about this book (other than the information, of course) is it’s size.  It is small enough to keep in your bug-out-bag and also in your first aid kit.

Where There Is No Doctor: Hesperian’s classic manual, Where There Is No Doctor, is perhaps the most widely-used health care manual in the world.

Vigilant Trails First Aid Kit: This kit is very popular with BDS readers. It contains 72 pieces of high quality first aid products and is equipped to help you manage minor cuts, abrasions, rashes, burns, insect bites, allergies, upset stomach, headaches, body aches, blisters, infections, mild dehydration, chapped skin and lips and exposure to poisonous plants containing Urushiol Oil (Poison Oak, Ivy and Sumac). Housed in a small crush proof plastic container, measuring just 5″ X 3.5 ” X 1 7/8″.

Emergency Mylar Thermal Blankets (Pack of 10):

Earloop Procedure Face Masks 50/Box:  Blue pleated ear loop procedure masks with glass-free filter. These 3-ply fluid resistant face masks are fiberglass free and designed to eliminate fogging. They offer bacteria filtration, with efficiency at 3.0 microns. Aluminum nose guard for extra comfort. Latex-free.

3M N95 Particulate & Respirator Mask: This is an inexpensive mask that can be used in a variety of emergency situations. They come in a box of 20 and are NIOSH-certified. The molded cone design is fluid and splash resistant and will greatly reduces your exposure to airborne particles.

Spark Naturals Essential Oils: The “Health and Wellness Kit” comes packaged in a tin and includes a brochure with suggested uses for each of the oils. It includes all of my favorites, including Lemon, Frankincense, Oregano, Melaleuca (Tea Tree), Rosemary, Lavender, Amend (Soothing Blend), Respire (Respiratory Blend), Shield (Protective Blend), and Peppermint.  Use the discount code  “BACKDOORSURVIVAL” to receive a 10% discount.



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5 Responses to “Understanding Triage Following a Mass Casualty Event”

  1. Hurricane Katrine victims who went to a county/locally funded hospital in New Orleans did better than those who ended in up in a large corporate run facility. The corporate mindset may not be to your advantage in a disaster. See the book “Five Days At Memorial.” You may want to be with medical professionals who are already used to solving their own problems, not those used to being micro-managed.

  2. This type of situation is one where I shine. Meaning, I’ve lived through enough hard situations, I moved into a mode until the job gets done, then I have time to allow the emotions to catch up. In such situations, each can find his/her place to help. While I couldn’t do the physical help, I can make decisions and instruct. This is part of my skills training which like so many others, will be needed for more than just the immediate aftermath. It’s something I pray I never have to do, just know I’m capable.

  3. The secondary bombs set up to take out first responders attributed to “insidious strategy on the part of terrorists in Israel” is also a method the United States has used in drone strikes in recent years.

    Great article. I really enjoyed reading it and found it to be very informative.

  4. I personally would have an extremely hard time doing triage on young children. I would feel that every effort should be made to save a child, even if it meant one or more adults, that could have been saved, die while working with the child.

    Off topic – gotta get outside and get these 7 baby chicks, that my niece ordered for me, set up where they are safe! Too many stray animals around to not try and make a safe place. I sure wish people wouldn’t dump their unwanted pets in the country!

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