MASCAL/TRIAGE - PCC

Background

The foundation of effective PCC is accurate triage for both treatment in the PCC setting and for transportation to a higher level of care, as well as effective resource management across the entire trauma system. Resource management includes the appropriate utilization of medical and non-medical personnel, equipment and supplies, communications, and evacuation platforms. Like most Mass Casualty incidents (MASCAL), the purpose of triage in a PCC setting is to swiftly identify casualty needs for optimal resource allocation in order to improve patient outcomes. However, PCC presents unique and dynamic triage challenges while managing casualties over a prolonged period with a low likelihood of receiving additional medical supplies or personnel with enhanced medical capabilities apart from pre-established networks. MASCAL in a PCC environment will necessitate more conservative resource allocation than traditional MASCAL in mature theaters or fixed medical facilities where damage control surgery, intensive care, and medical logistical support are more readily available, and resupply is more likely. PCC dictates the need for implementing various triage and resource management techniques to ensure the greatest good for all. The objectives and basic strategies are the same for all MASCAL; however, tactics will vary depending on the available resources and situations.

MASCAL Decision Points

1. Determine if a PCC MASCAL is occurring – do the requirements for care exceed capabilities?

- What is the threat? Has it been neutralized or contained? If not, security takes priority.
- What is the total casualty estimate?
- Are there resource limitations that will affect survival?
- Can medical personnel arrive at the casualty location, or can the casualty move to them?
- Is evacuation possible?
- Communicate the situation to all available personnel conducting or enabling PCC.
- Assess requirements for which class of triage you are facing (see Appendix C) and scale medical action to maximize lethality then survivability.
- Remain agile and be ready to move based on the mission.

2. Determine if conditions require significant changes in the commonly understood and accepted standards of care (Crisis Standards of Care)3 or if personnel who are not ordinarily qualified for a particular medical skill will need to deliver care. MASCAL in PCC requires both medical and non-medical responders initially save lives and preserve survivable casualties. Both groups will need skills traditionally outside existing paradigms, such as non-medical personnel taking and record vital signs or Tier 3 TCCC medical personnel maintaining vent settings on a stable patient. The MASCAL standard of care will be driven by the volume of casualties, resources, and risk or mortality/morbidity due to degree of injury/illness; as such, remain agile throughout the MASCAL and trend in both directions based upon resources available.

3. MASCAL management is often intuitive and reactive (due to lack of full mission training opportunities) and should rely on familiar terminology and principles. Treatment and casualty movement should be rehearsed to create automatic responses.

4.. The tactical and strategic operational context will underpin every facet of MASCAL in a PCC environment, operational commanders MUST be involved in every stage of MASCAL response (The mere fact that a medical professional or team of medical professionals is forced to hold a casualty longer than doctrinal planning timelines means there is a failure in the operational/logistical evacuation chain. Battle lines, ground-to-air threat, etc. levels may have shifted.)

5. Logistical resupply may need to include non-standard means and involve personnel and departments not typically associated with Class VIII in other situations (i.e. aerial resupply, speedballs, caches, local national market procurement).

6. The most experienced person should establish MASCAL roles and responsibilities, as appropriate.

Key Considerations in MASCAL

- Usually, simpler is better.
- Focus on those that will preserve scarce resources, such as blood.
- Triage is a continuous process and should be repeated as often as is clinically and operationally practical.
- Avoid high resource and low yield interventions.
- Emergency airway interventions should prioritize REVERSIBLE pathology in salvageable patients.
- Decisions will depend on available resources and skillsets (i.e. penetrating traumatic brain injury [TBI] triaged differently if no neurosurgery is available in a timely manner or at all in theater).
- Conserve, ration, and redistribute additional scarce resources (i.e. blood, drug).