To the Editor:

During the last several decades, the incidence of large-scale multicasualty events has significantly increased. Therefore, modern health systems face the new challenge of successfully managing incidents that, on the one hand, involve an unprecedentedly large number of casualties with different types and severities of injury whereas, on the other hand, they are likely to have an unpredictable nature. Thus, I read with great interest the recent article by Lerner et al regarding the standardization of triage methodology across the United States at the time of disaster.Reference Lerner, Schwartz and Coule1 I utterly support the idea that a standard triage method could decrease uncertainty and confusion, by requiring health care delivery teams to follow strict guidelines. This unified approach could be enhanced, however, by the modification of the guideline according to the specific type of mass casualty incident (eg, explosion, shooting, natural disaster). Lessons learned from Israeli and other international experiences in the last few decades have demonstrated that certain types of information—pattern of injuries, number of casualties, and utilization of human medical resources—can be extrapolated to an extent from the information on previous incidents.Reference Arnold, Halpern and Tsai2

Thus, if first responders and other medical teams could get the preliminary information regarding the specific nature of a mass casualty incident, then they would be able to instantly implement a triage protocol tailored specifically to this particular setting. As a result, such compatibility could, presumably, reduce overtriage or undertriage issues, consequently improving patient outcomes. This would likewise help to allocate human medical resources more effectively. For example, according to the Israeli experience, explosions that occurred in buses had the highest rate of overall mortality (21.2%) and an unprecedentedly high incidence of head and neck injuries (61.8%) among survivors, whereas bombing attacks in open spaces resulted in substantially lower overall mortality rates and a high incidence of injuries to extremities (43.6%).3 Given this information, emergency medical services could more accurately plan and implement the prehospital triage protocols.

In conclusion, the physical setting in which mass casualty events occur dramatically affects the pattern of injuryin resulting casualties, their outcomes, and the associated impact on health services. Therefore, this information ought to be integrated with mass casualty triage guidelines.

Oleg Zaslavsky, RN, MHA

Doctoral student, University of Washington