**Warning – this topic might be disturbing to some people.**

It’s time for a medical post (after all, I’m a doctor, and healthcare emergency planning is my first interest). I promise to make medical stuff understandable to all – not just those in healthcare. If I write anything you don’t understand, please question me. I always believe the more everyone understands healthcare,  the better patients will do.

Too Many Patients, Not Enough Resources

The concept of triage for injured or ill patients in a medical disaster is core to all healthcare emergency planning. The sad truth is that sometimes there are more patients than we can care for with available resources. How do we decide who gets treated?

A Mass Casualty Incident (MCI for short) simply means a situation where the number and severity of injured, dying, and dead overwhelm emergency medical services. Although large disasters such as earthquakes are obvious MCIs, MCIs are also isolated incidents. Classic examples include a plane crash, a bomb explosion, or a mass shooting. In a rural area with only a few first responders, even a multiple person car crash  could be an MCI.

1994 plane crash at Pope Air Force Base, with 24 fatalities.DoD photo by: MARCUS CASTRO

1994 plane crash at Pope Air Force Base, with 24 fatalities.

MCIs Are Medical Disasters

Like other disasters, in an MCI resources are not enough to meet needs. It’s a medical disaster!  On-site, the number of responders (firemen, EMTs, etc) can be an obvious limit. Two responders probably can’t stabilize three seriously injured patients at the same time. In a city,  twenty responders can’t simultaneously take care of sixty injured. Even with enough responders, supplies such as medications, intravenous fluids, and breathing equipment in the field may run out. Seriously injured patients need rapid transport to a hospital, so the number of ambulances is can be a problem.

U.S. Navy photo by Mass Communication Specialist 2nd Class Chad A. Bascom

Mass Casualty Drill, Naval Medical Center San Diego. Notice the crowds of people!

Hospitals also have potential problems. Emergency rooms may not have enough beds.  Ventilators, operating rooms, or scanners may not be adequate for the number of patients. Importantly, not all hospitals have physicians of the right type (neurosurgeons, trauma surgeons, orthopedists, etc) and number needed to treat a large volume of severe injuries. In reality, even the biggest hospitals have limits on the number of casualties they can receive. Hospitals agree to share or transfer patients, but this adds time before treatment is available.

Treat The One or Treat The Many?

What should emergency medical services do with too many patients? On a normal day in America, most people receive whatever treatment they need, but that is impossible in an MCI. Who to treat first? The closest patient? The patient making the most noise? The children?

In our country, emergency healthcare policy is to do the greatest good for the greatest number of survivors, given available resources. This means that both mildly injured and severely injured who are unlikely to survive may not get treatment initially.

Sample Triage Tag

Sample Triage Tag

Color Triage System

A red, yellow, green, and black triage system is taught to first responders, as well as trained volunteers. After spending only about 30 seconds per patient at the scene, each patient is literally tagged with a color.  Patient breathing,  level of consciousness (awake, unconscious, talking, confused), and circulation (heart, pulse, bleeding) primarily determine tag color.

Green means the patient is awake and can move under their own power – the “walking wounded”. Red is life threatening injury, treatable with urgent medical interventions. Yellow means serious injury, but not life-threatening if treatment delayed for several hours. Medical care on the scene and at the hospital focuses on reds, followed by yellows. Black means dead, or even worse, alive but with no meaningful chance of survival given available resources.

The Difficulties With Walking Wounded

Green patients are a troublesome group from a planning perspective. Often the largest group, they may need basic treatment such as stitches and splinting, they’re often uncomfortable, and usually very upset. From a medical perspective, however, there is no harm in delaying green treatment a few days (although greens rarely believe this).  If hospitals are barely coping with red and yellow influx,  the last thing they need is a deluge of green patients demanding emergency care. In some circumstances, hospitals even go on lock-down to prevent greens from entry.

First Aid Triangle Bandage for Broken Arm - classic Walking Wounded injury. By KMJPhotography (TillyDog)

First Aid Triangle Bandage for Broken Arm – classic Walking Wounded injury. By KMJPhotography (TillyDog)

How to handle greens? First and foremost, responders do their best to keep greens at the incident site under supervision while making plans. If they worsen (turn yellow), responders hopefully recognize this and increase care. Keeping greens at the incident site keeps them from driving themselves to the hospital.

On-site treatment or alternative treatment centers could provide green care, but only with advance planning, including medical staff and equipment. Unfortunately, most local planning has not gone this far. Some greens could go to their own physician or urgent care centers. We just don’t want them to go to the hospital unless instructed to do so.

The Ones We Can Not Help

Blacks are the other difficult group. A crime scene investigation can keep bodies from being moved. A temporary morgue may be set up on site. And what about the “not dead yet”? From my hospice background, this group upsets me the most. Some triage systems call these patients grey or blue to remind healthcare providers to give them comfort care if possible, and not just ignore them. My vision of on-call hospice physicians responding to MCIs to care for this group of patients is probably unrealistic, but I can dream, can’t I?

So there you have it – the basics of a tragic but necessary approach to mass casualty events. Even if you never help with triage (but watch future posts for ways you can volunteer), I think everyone should learn the triage concept. It is radically different from normal medical care in this country, and wrapping your mind around its necessity is unfortunately a part of emergency preparedness.

Please feel free to comment or contact me about this topic – I know it’s a big one.

Stay safe,


  1. Brett Popovich says:

    I hope that victims are reassessed and re-tagged by professionals following evacuation. In my CERT training experience, the initial tagging is done (in 30 seconds!) by non-medical S&R volunteer responders.
    Since we live in an isolated rural neighborhood and victims will have to wait a long time for medical evacuation, we have used “Map Your Neighborhood” to identify our neighbors with medical training, and plan to have them help staff our CERT triage/treatment areas.

    • disasterdoc says:

      Theoretically, victims are supposed to be frequently reassessed, both in treatment areas on the scene and at the hospital. It is quite easy for victims to shift up (or down) triage categories from a medical perspective. In a recent exercise where I was treating yellow patients at a hospital, I felt that one of them was really a red and increased the urgency of her interventions.

      The question is whether this actually happens in real disasters. I heard a recent tragic story by a chaplain in Hurricane Katrina who visited the morgue for black tagged patients, only to find that one of them was not only alive, but really was only suffering from advanced dementia!
      Sheila Sund, M.D.

  2. […] known as a mass casualty incident. If this is unfamiliar to you, you should first read my post on Triage – Who Gets Treated? One method of triage on the scene is called S.T.A.R.T. (Simple Triage And Rapid Treatment). In […]

  3. Tara says:

    Wow – that is very enlightening – the idea that people with no medical training would be going around mistakenly marking people is just crazy.

  4. […] quickly to decide who needs help first. To learn more about mass casualty triage, check out my post “Triage – Who Needs Treatment”?  I’ve included potential triage colors in the discussion below. Red means urgent medical […]

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