Unexpected Lessons from a Mass Casualty Simulation: Strategies for Management of the Minimally Injured Can Increase Efficiency and Decrease Chaos

Abstract

Introduction:The SALT Triage system has been advocated as an easy-to-use sorting and treatment system for mass casualty incidents (MCI). Minimally injured (GREEN) patients tend to be in the majority and may cause impediments to access and treatment of the most critically injured (RED). By identifying flaws in MCI communications that impair effective patient care, responders can be more effective.Aim:To discover strategies that effectively manage the minimally injured and leverage their help, increasing triage efficiency and treatment of the immediate casualties.Methods:Direct observation, after-action debriefing, and literature search.Results:The literature was vague regarding recommendations on a bystander and trained provider communication best practices. Feedback from standardized patients (actors) and participants during a structured debriefing following a 2018 American Society of Anesthesiology MCI exercise suggested that triaging providers under stress may communicate poorly, contributing to increased patient anxiety, disruptive behavior, and less effective team dynamics during a disaster. Strategies suggested include: eye contact; therapeutic touch (culturally appropriate); using slow, clear, reassuring speech; clearly explaining what is happening and why (sickest (RED and YELLOW) first priority, minimal (GREEN) next, expectant (BLACK) last); acknowledging their emotional state and their grief (not ignoring them); assigning nontechnical tasks to those capable of helping (putting pressure on a wound, moving casualties, or comforting the injured, dying, and the emotionally distraught).Discussion:Bystander engagement has been repeatedly identified as a means to increase the capacity of first responders to provide care to patients during an MCI. Utilization and management of the minimally injured and any uninjured bystanders and responders can become a force multiplier for the triage/treating responders. Developing a best practice dialogue to be used in training first responders could help improve many of these issues and augment current MCI training programs.