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Using the Model of Resource and Time-Based Triage (MORTT) to Guide Scarce Resource Allocation in the Aftermath of a Nuclear Detonation

  • Rocco Casagrande, Nick Wills, Elizabeth Kramer, Louise Sumner, Mark Mussante, Rachel Kurinsky, Patrick McGhee, Luba Katz, David M. Weinstock and C. Norman Coleman...

Conventional triage algorithms assume unlimited medical resource availability. After a nuclear detonation, medical resources are likely to be particularly limited, suggesting that conventional triage algorithms need to be rethought. To test various hypotheses related to the prioritization of victims in this setting, we developed the model of resource- and time-based triage (MORTT). This model uses information on time to death, probability of survival if treated and if untreated, and time to treat various types of traumatic injuries in an agent-based model in which the time of medical practitioners or materials can be limited. In this embodiment, MORTT focuses solely on triage for surgical procedures in the first 48 hours after a nuclear detonation. MORTT determines the impact on survival based on user-selected prioritization of victims by severity or type of injury. Using MORTT, we found that in poorly resourced settings, prioritizing victims with moderate life-threatening injuries over victims with severe life-threatening injuries saves more lives and reduces demand for intensive care, which is likely to outstrip local and national capacity. Furthermore, more lives would be saved if victims with combined injury (ie, trauma plus radiation >2 Gy) are prioritized after nonirradiated victims with similar trauma.

(Disaster Med Public Health Preparedness. 2011;5:S98-S110)

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      Using the Model of Resource and Time-Based Triage (MORTT) to Guide Scarce Resource Allocation in the Aftermath of a Nuclear Detonation
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Corresponding author
Correspondence: Address correspondence and reprint requests to Dr Rocco Casagrande, Gryphon Scientific, 6930 Carroll Ave, Suite 810, Takoma Park, MD 20912 (e-mail:
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1.Iserson, KV, Moskop, JC.Triage in medicine, part I: Concept, history, and types. Ann Emerg Med. 2007;49 (3):275281.
2.Albin, SL, Wassertheil-Smoller, S, Jacobson, S, Bell, B.Evaluation of emergency room triage performed by nurses. Am J Public Health. 1975;65 (10):10631068.
3.Agency for Healthcare Research and Quality. Mass Medical Care With Scarce Resources: A Community Planning Guide.AHRQ Publication No. 07-0001. Published February 2007. Accessed February 4, 2011.
4.Hick, JL, Weinstock, DM, Coleman, CN.Healthcare system planning for and response to a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S73S88.
5.Knebel, AR, Coleman, CN, Cliffer, KD.Allocation of scarce resources after a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5(Suppl 1)S20S31.
6.DiCarlo, AL, Maher, C, Hick, JL.Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S32S44.
7.Coleman, CN, Weinstock, DM, Casagrande, R.Triage and treatment tools for use in a scarce resources-crisis standards of care setting after a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S111S121.
8.Coleman, CN, Knebel, AR, Hick, JL.Scarce resources for nuclear detonation: project overview and challenges. Disaster Med Public Health Prep. 2011;5(Suppl 1)S13S19.
9.Benson, M, Koenig, KL, Schultz, CH.Disaster triage: START, then SAVE— a new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med. 1996;11 (2):117124.
10.Romig, LThe jumpSTART pediatric MCI triage tool and other pediatric disaster and emergency medicine resources. Accessed June 5, 2009.
11.Cook, L.The World Trade Center attack. The paramedic response: an insider's view. Crit Care. 2001;5 (6):301303.
12.Hines, S, Payne, A, Edmondson, J.Bombs under London. The EMS response plan that worked. JEMS.2005;30:58–60, 62, 64–57.
13.Tran, MD, Garner, AA, Morrison, I, Sharley, PH, Griggs, WM, Xavier, C.The Bali bombing: civilian aeromedical evacuation. Med J Aust. 2003;179 (7):353356.
14.Jenkins, JL, McCarthy, ML, Sauer, LM.Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med. 2008;23 (1):38.
15.Garner, A, Lee, A, Harrison, K, Schultz, CH.Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001;38 (5):541548.
16.Sacco, WJ, Navin, DM, Fiedler, KE, Waddell, RK II, Buckman, RF JrPrecise formulation and evidence-based application of resource-constrained triage. Acad Emerg Med. 2005;12 (8):759770.
17.Sacco, WJ, Navin, DM, Waddell, II, Fiedler, RK, Long, WB, Buckman, KE JrA new resource-constrained triage method applied to victims of penetrating injury. J Trauma. 2007;63 (2):316325.
18.Christian, MD, Hawryluck, L, Wax, RS.Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006;175 (11):13771381.
19.Berger, M, Leonard, R, Ricks, R, Wiley, AL, Lowry, PC, Flynn, DFHospital Triage in the First 24 Hours After a Nuclear or Radiological Disaster. Accessed February 4, 2011.
20.Kumar, P, Jagetia, GC.A review of triage and management of burns victims following a nuclear disaster. Burns. 1994;20 (5):397402.
21.Dacey, MJ.Tragedy and response- the Rhode Island nightclub fire. N Engl J Med. 2003;349 (21):19901992.
22.Defense Medical Standardization Board, US Department of Defense. The Defense Medical Materiel Program Office (DMMPO) Web site. Accessed May 15, 2009.
23.The Abbreviated Injury Scale—1990 Revision (AIS-90).Des Plains, IL: Association for the Advancement of Automotive Medicine, Committee on Injury Scaling; 1990.
24.Acosta, JA, Yang, JC, Winchell, RJ.Lethal injuries and time to death in a level I trauma center. J Am Coll Surg. 1998;186 (5):528533.
25.Demetriades, D, Kimbrell, B, Salim, A.Trauma deaths in a mature urban trauma system: is “trimodal” distribution a valid concept? J Am Coll Surg. 2005;201 (3):343348.
26.Demetriades, D, Murray, J, Charalambides, K.Trauma fatalities: time and location of hospital deaths. J Am Coll Surg. 2004;198 (1):2026.
27.Alam, HB, Shuja, F, Butt, MU.Surviving blood loss without blood transfusion in a swine poly-trauma model. Surgery. 2009;146 (2):325333.
28.Chambers, LW, Rhee, P, Baker, BC.Initial experience of US Marine Corps forward resuscitative surgical system during Operation Iraqi Freedom. Arch Surg. 2005;140 (1):2632.
29.Grau, LW, Jorgensen, WA.Handling the wounded in a counter-guerrilla war: the Soviet/Russian experience in Afghanistan and Chechnya. US Army Med Dept J. 1998;1/2:210.
30.Levitsky, S, James, PM, Anderson, RW, Hardaway, RM IIIVascular trauma in Vietnam battle casualties: an analysis of 55 consecutive cases. Ann Surg. 1968;168 (5):831836.
31.Burkle, C Jr, Newland, FM, Orebaugh, S, Blood, CG.Emergency medicine in the Persian Gulf War–Part 2. Triage methodology and lessons learned. Ann Emerg Med. 1994;23 (4):748754.
32.Jevtić, M, Petrović, M, Ignjatović, D.Treatment of wounded in the combat zone. J Trauma. 1996;40 3(Suppl)S173S176.
33.Brethauer, SA, Chao, A, Chambers, LW.Invasion vs insurgency: US Navy/Marine Corps forward surgical care during Operation Iraqi Freedom. Arch Surg. 2008;143 (6):564569.
34.Civil, ID, Schwab, CW.The Abbreviated Injury Scale, 1985 revision: a condensed chart for clinical use. J Trauma. 1988;28 (1):8790.
35.Gennarelli, TA, Wodzin, E.AIS 2005: a contemporary injury scale. Injury. 2006;37 (12):10831091.
36.Bogosian, D, Avanessian, HDBlunt trauma from blast-induced building debris.Paper presented at: 31st Explosives Safety Seminar; August 2004; San Antonio, TX.
37.Glasstone, S, Dolan, PJThe Effects of Nuclear Weapons.3rd ed. Washington, DC: Department of Defense; 1977:653.
38.Alexander, D.Death and injury in earthquakes. Disasters. 1985;9 (1):5760.
39.De Bruycker, M, Greco, D, Lechat, MF, Annino, I, De Ruggiero, N, Triassi, M.The 1980 earthquake in Southern Italy—morbidity and mortality. Int J Epidemiol. 1985;14 (1):113117.
40.Champion, HR, Copes, WS, Sacco, WJ.The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma. 1990;30 (11):13561365.
41.Coburn, AW, Spence, RJS, Pomonis, AFactors determining human casualty levels in earthquakes: mortality prediction in building collapse.Paper presented at: 10th World Conference Earthquake Engineering; 1992; Madrid, Spain.
42.Hare, SS, Goddard, I, Ward, P, Naraghi, A, Dick, EA.The radiological management of bomb blast injury. Clin Radiol. 2007;62 (1):19.
43.Jones, NP, Wagner, RM, Smith, GSInjuries and building data pertinent to the Loma Prieta earthquake: county of Santa Cruz.Monograph #5. Paper presented at: National Earthquake Conference; May 2–5, 1993; Memphis, TN.
44.Mahue-Giangreco, M, Mack, W, Seligson, H, Bourque, LB.Risk factors associated with moderate and serious injuries attributable to the 1994 Northridge Earthquake, Los Angeles, California. Ann Epidemiol. 2001;11 (5):347357.
45.Peek-Asa, C, Ramirez, M, Seligson, H, Shoaf, K.Seismic, structural, and individual factors associated with earthquake related injury. Inj Prev. 2003;9 (1):6266.
46.Ramirez, M, Peek-Asa, C.Epidemiology of traumatic injuries from earthquakes. Epidemiol Rev. 2005;27:4755.
47.Roces, MC, White, ME, Dayrit, MM, Durkin, ME.Risk factors for injuries due to the 1990 earthquake in Luzon, Philippines. Bull World Health Organ. 1992;70 (4):509514.
48.Seligson, H, Shoaf, K, Kano, MDevelopment of casualty models for non-ductile concrete frame structures for use in peer's performance-based earthquake engineering framework.Number 917. Paper presented at: 8th National Conference on Earthquake Engineering; 2006; San Francisco, CA.
49.Shoaf, KI, Sareen, HR, Nguyen, LH, Bourque, LB.Injuries as a result of California earthquakes in the past decade. Disasters. 1998;22 (3):218235.
50.Adedeji, OA, Driscoll, PA.The trauma team–a system of initial trauma care. Postgrad Med J. 1996;72 (852):587593.
51.Sugrue, M, Seger, M, Kerridge, R, Sloane, D, Deane, S.A prospective study of the performance of the trauma team leader. J Trauma. 1995;38 (1):7982.
52.Bergs, EA, Rutten, FL, Tadros, T, Krijnen, P, Schipper, IB.Communication during trauma resuscitation: do we know what is happening? Injury. 2005;36 (8):905911.
53.Cassera, MA, Zheng, B, Martinec, DV, Dunst, CM, Swanström, LL.Surgical time independently affected by surgical team size. Am J Surg. 2009;198 (2):216222.
54.Fung Kon Jin, PH, van Olffen, TB, Goslings, JC, Luitse, JS, Ponsen, KJ.In-hospital downgrading of the trauma team: Validation of the Academic Medical Center downgrading criteria. Injury. 2006;37 (1):3340.
55.Hoff, WS, Reilly, PM, Rotondo, MF, DiGiacomo, JC, Schwab, CW.The importance of the command-physician in trauma resuscitation. J Trauma. 1997;43 (5):772777.
56.Qazi, K, Kempf, JA, Christopher, NC, Gerson, LW.Paramedic judgment of the need for trauma team activation for pediatric patients. Acad Emerg Med. 1998;5 (10):10021007.
57.Murrain-Hill, P, Coleman, CN, Hick, JL.Medical response to a nuclear detonation: creating a playbook for state and local planners and responders. Disaster Med Public Health Prep. 2011;5(Suppl 1)xxxx.
58.van der Sluis, CK, ten Duis, HJ, Geertzen, JH.Multiple injuries: an overview of the outcome. J Trauma. 1995;38 (5):681686.
59.Gabbe, BJ, Cameron, PA, Wolfe, R, Simpson, P, Smith, KL, McNeil, JJ.Predictors of mortality, length of stay and discharge destination in blunt trauma. ANZ J Surg. 2005;75 (8):650656.
60.Holtslag, HR, Post, MW, van der Werken, C, Lindeman, E.Return to work after major trauma. Clin Rehabil. 2007;21 (4):373383.
61.Stineman, MG, Escarce, JJ, Goin, JE, Hamilton, BB, Granger, CV, Williams, SV.A case-mix classification system for medical rehabilitation. Med Care. 1994;32 (4):366379.
62.Stineman, MG, Escarce, JJ, Tassoni, CJ, Goin, JE, Granger, CV, Williams, SV.Diagnostic coding and medical rehabilitation length of stay: their relationship. Arch Phys Med Rehabil. 1998;79 (3):241248.
63.Cameron, CM, Purdie, DM, Kliewer, EV, McClure, RJ.Ten-year health service use outcomes in a population-based cohort of 21,000 injured adults: the Manitoba injury outcome study. Bull World Health Organ. 2006;84 (10):802810.
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