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Who's Next?

Mass Casualty Triage

An emergency triage scene during a mass casualty incident.

This article is based on the Safety Member Certification training module "Mass Trauma Emergencies"[1].

From the Bible –

Who forgiveth all thine iniquities; who healeth all thy diseases (Psalm 103:3).

He healeth the broken in heart, and bindeth up their wounds (Psalm 147:3).

Introduction -

If you have more injuries in an incident than the number of medical responders, how do you decide who to treat first, then who to treat next? This kind of decision is called "triage" [tree-AZH].

Well, let's take a real-life illustration from a hospital emergency room. A restaurant cook comes in on a weekend night with a cut thumb. Persons seriously injured in a traffic accident are brought by ambulance several minutes after he arrives and are taken in immediately. It takes more than an hour before a physician treats the cook. About 45 years ago, I was that cook.

Those with lesser injuries or illnesses may become impatient when others are treated before them. It is easier to be patient as a patient when we understand that some cases may be more urgent than ours.

In the News -

Triage itself is seldom mentioned in news stories, but situations with several injuries requiring triage are reported.

Transportation Incidents:

Phoenix, Arizona, December 27, 2024 - An Alaska Airlines plane headed for Phoenix encountered extreme turbulence. Several persons were injured: crew members and a passenger. After landing in Phoenix, they were taken off the plane. The passenger's injury was very minor, but the flight attendants, who were not belted when the plane hit turbulence, were taken to a hospital [2].

Chino, California, April 9, 2017 - An elderly driver rapidly backed his SUV out of a stall in a church parking lot and into a crowd of people exiting from a reception, hitting six of them, then ran the vehicle forward into a wall. Two women were killed and four other persons in the crowd were injured. The driver and his passenger were also injured [3].

Severe Weather:

Goshen, Alabama, March 27, 1994 - The Palm Sunday service at Goshen United Methodist Church was interrupted when a tornado struck. No one was sheltered since those in the church had no warning. The death toll was 20, and 94 others were injured [4].

Fire:

Pittsburgh, Pennsylvania, March 13, 2004 - Pittsburgh firefighters thought they had a church fire under control, but then the steeple toppled and caused the roof to collapse, trapping several personnel inside. Two firefighters died, including a captain, while 29 others were injured [5].

Active Killer:

Sutherland Springs, Texas, November 5, 2017 - In an extreme overflow of domestic violence, a gunman invaded the First Baptist Church in Sutherland Springs, Texas. He killed 26 people and wounded 20 others. An attending physician at a San Antonio hospital shared with an HBO host how horrible the wounds were [6][7].

Different Scenes, Different Injuries -

In the news stories are five scenes with injuries caused in five different ways: being thrown around (falls), hit by a vehicle, pummeled by storm debris, a combination of blunt force, smoke, and fire, and by gunshots. Some incidents, particularly the Goshen tornado, had a larger variety of injury severity. In each case, some injuries needed quicker or more intensive treatment than others, and someone had to decide which.

Degrees of Injury: Minor to Extreme -

In the air turbulence incident, there was a notable difference between the one injured passenger and the flight attendants who had the more severe injuries. Among these, some injuries were worse than others, depending on their positions when the turbulence was encountered. Since the pilots had informed the tower that there were injuries on board, enough medical personnel could meet the plane at the terminal to treat every patient. This is exceptional. Usually, in a mass trauma event, injuries outnumber responders. Some injuries may require more than one person to treat, further limiting their availability for others. How does a response team decide who to treat first?

The Art of Triage -

"Triage" is based on the French word for "to sort." For medical emergencies, this is quickly sorting patients by urgency, namely who needs to be treated first, and so on. The primary criterion is saving lives. Therefore a finger cut or a broken arm can wait if another patient is having a heart attack or is bleeding profusely. The goal is to save the greatest number of lives.

The beginning of triage as a system is usually credited to a French army doctor sorting battlefield injuries, but battlefield sorting could be much older. Since the Roman army had doctors to treat the wounded, they had to decide who to treat first, but as far as we know, this was not described as a set procedure to be taught to others.

Category Color Coding:

Ideally, one of the responders checks all the injured and puts tags on them to indicate the triage category for each one. Just so everyone is on the same page, there is a color-coding system with four or five categories:

  1. Red: Severe injury, life-threatening - Treat immediately.
  2. Yellow: Moderate injury - Still serious, but treat after the most severe.
  3. Green: Minor injury - Can wait longer, hours or days.
  4. Blue or Gray: Expectant - not expected to live (a newly-separate category).
  5. Black or White: Deceased (formerly included expectant).

Indicators:

The responder doing the Triage considers signs such as the level of bleeding, respiration, heart rate, consciousness, cognition, and mobility. The American Training Association for CPR (ATAC) suggests that the first responder ask patients who can to walk to a marked area.

  1. This separates most of the minor injuries;
  2. It leaves more room for responders to treat others.

Code Red,

If the injured person cannot breathe or has no pulse, administer CPR. If severely bleeding, then Stop the Bleed. If the airway is blocked, free the airways. Severe head injuries require immediate transport to a hospital. A cognition test may indicate a probable concussion, meaning brain injury or stroke. Third degree burns, if over a large part of the body, classify as Code Red.

Some cases require immediate transportation. Treatment can begin on the way. A rule of thumb is to ask for one ambulance for every five injured. That way immediate transportation is available for some.

Code Yellow,

Broken bones, second-degree burns (not too extensive), and cuts not excessively bleeding can wait for Code Red injuries to be treated.

Code Green,

First-degree burns, bruises, minor cuts, and such can wait for several hours. However, if the person shows indications of a concussion, they should be upgraded to Red (maybe Yellow).

Code Blue (or Gray),

If the person cannot survive but has not yet expired, go on to treat others. If by some miracle they're still alive after others are cared for, then you may attempt to revive them if at all possible.

Code Black,

Raising the dead is beyond the capacity of most responders.

Online Resources -

Several online resources have advice on triage. There is general agreement among them, such as with the color coding. Some sites focus on mass casualty incidents, some others are geared for hospital care, and some cover both. Here are a few of these:

Training for Triage -

First of all, Safety Team members should be trained and certified through the Safety Member Certification course, which includes the training module "Mass Trauma Emergencies." Also, all members of a medical response team should take this training module, as well as anyone else in the church who is interested. Then these persons should study and drill for triage, all following the same procedures and guidelines. That way everyone is following the same pattern in an emergency, leading to better coordination and teamwork.

Conclusion -

Use triage to help those who need more immediate treatment with the goal of saving as many lives as possible.

References -

  1. Kris Moloney, "Mass Trauma Emergencies," Safety Member Certification, Sheepdog Church Security, © 2020 [https://sheepdog-church-security.thinkific.com/courses/safety-member-certification-2025].
  2. Ashley Gardner, "Crew members, passenger treated for injuries after extreme turbulence on flight to Phoenix," News 12 NBC (Phoenix), December 27, 2024, Updated December 28, 2024 [https://www.12news.com/article/news/local/valley/crew-members-passenger-treated-for-injuries-after-extreme-turbulence-on-flight-to-phoenix-sky-harbor-alaska-airlines/75-a125bff9-c13b-453b-bc06-39be881bfbc5].
  3. Whitney Irick, with Rick Montanez contributing, "Two people were killed when they were struck by a sport utility vehicle Sunday in a San Bernardino County church parking lot," NBC Los Angeles, April 9, 2017, Updated April 10, 2017 [https://www.nbclosangeles.com/news/vehicle-strikes-multiple-people-in-church-parking-lot-killing-2/12128/].
  4. Bill Murray, "March 27, 1994: The Goshen United Methodist Church Tornado," AlabamaWX Weather Blog, March 27, 2017 [https://www.alabamawx.com/?p=130100].
  5. David P. Novak, "Flare Up, Collapse at Church Blaze Kills Two Pittsburgh Firefighters, Injures 29," Firehouse, March 13, 2004 [https://www.firehouse.com/photo-story/article/10549546/flare-up-collapse-at-church-blaze-kills-two-pittsburgh-firefighters-injures-29].
  6. Joshua Barajas, "Everything we know about the south Texas church shooting," PBS News, November 6, 2017 [https://www.pbs.org/newshour/nation/watch-live-texas-officials-give-update-on-sundays-church-shooting].
  7. Jeanne Jakle, "S.A. surgeon releases horrific pics of Texas massacre victims' wounds on HBO," My San Antonio, Updated April 27, 2018 [https://www.mysanantonio.com/entertainment/movies-tv/article/S-A-surgeon-shares-horrific-pics-of-Texas-12870588.php].
  8. ATAC Team, "What Is Triage? Understanding Triage in Emergency Situations," American Training Association for CPR (ATAC), September 19, 2024 [https://www.uscpronline.com/first-aid/triage].
  9. Mayo Clinic Staff, "Mass casualty triage guidelines revised," Mayo Clinic, May 8, 2021 [https://www.mayoclinic.org/medical-professionals/trauma/news/mass-casualty-triage-guidelines-revised/mac-20512735].
  10. John Furst, "A guide to triage for first aiders and first responders," First Aid for Free, March 15, 2016 [https://www.firstaidforfree.com/a-guide-to-triage-for-first-aiders-and-first-responders/].
  11. Fire Engineering Staff, "First On Scene at the Mass Casualty Incident," Fire Engineering, February 19, 2007 [https://www.fireengineering.com/firefighting/first-on-scene-at-the-mass-casualty-incident/].
  12. Staff, "Guidelines for Field Triage of Injured Patients | Recommendations of the National Expert Panel on Field Triage, 2011," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention. January 13, 2012 [https://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf].
  13. Staff, "Topic Collection: On-Scene Mass Casualty Triage and Trauma Care," ASPR TRACIE: Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services, September 21, 2017 [https://files.asprtracie.hhs.gov/documents/trauma-care-and-triage.pdf].