Mass Casualty Incident Triage

Paramedics Jamal and Sherrie were posted in their ambulance in a parking lot outside of the high school football stadium when out of nowhere they heard several large cracks ring out in the night. Looking over towards the entrance they started to hear screams and yells from the crowd at the game. Guessing what was going on, Jamal radioed into dispatch, advising that there was a possible shooting in progress at his location. Dispatch radioed back that they had contacted police and a unit was sent in route. As a stampede of people flooded through the exit gate, Jamal stopped one of them and asked what was going on. A breathless teenager answered there was someone with a gun, and that multiple people had been shot. Hesitating only a second or two to weigh his options, Jamal looked at Sherrie and told her to wait for the police to show up, he grabbed his trauma kit and headed into the crowd to see if he could safely reach any of the injured victims to provide medical care before it was too late.

It’s every first responder’s worst nightmare scenario. An active shooter or mass casualty incident in which there are multiple victims needing lifesaving treatment, and either they are inaccessible because of safety issues, or there are too many victims at the scene to be treated with the limited personnel on hand. Sometimes equipment is needed that is not available, and often times the textbook goes out the window and judgment calls are made based on emotions.

Student’s that go through EMS school to become a Paramedic or EMT are given lessons on how to respond in these situations. But the events themselves can be so radically different in scope and nature that any type of standardized response protocols were extremely difficult to put together.

In 2008 due the rise in occurrences of mass casualty incidents, the CDC along with a panel of medical experts created SALT Triage with the goal of assessing multiple patients at one scene with both speed and accuracy. SALT stands for (Sort, Assess, Lifesaving Interventions, Treatment and/or Transport). It was designed to support MUCC (Model Uniform Core Criteria) for mass casualty incident triage.

SALT is designed to work with speed and prioritizes moving to patients who are able, to safer areas so that the scene is less congested, and the remaining patients are easier to assess. This is the first step, or Sort. By announcing with a loud voice or microphone to have everyone in the area who is able, walk to a designated spot. Next is to ask the remaining people to wave. Those who do wave, can be advised that they will be treated as soon as possible. The remaining individuals who did not wave are the first to be assessed. 

Assessment typically consists of only asking yes or no questions. There is simply not enough time to check blood pressure or heartrates. Once a life threat is detected, Lifesaving treatment is performed simultaneously. If it is a gunshot wound for example, the bleed is stopped with a goal of less than one minute. The patient is then tagged with color coded tape and the first responder moves on quickly to the next patient.

As more responders arrive tags are assessed and patients requiring additional Treatment or Transport are attended to and sent out as determined appropriate. SALT works efficiently and when done properly it can create order in an extremely chaotic environment.

Just like everything we do in EMS, it is the prior planning and preparation that will make the biggest difference in these nightmare scenarios. By heading onto the scene with a practical plan and purpose you will achieve a higher success rate. For more information on Trauma Incident training or to take the free SALT Triage course please visit https://www.ndlsf.org/salt

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