In striving to ensure SALT kept triage teams focused on providing lifesaving intervention to those that theoretically need it most, the Working Group created what is potentially the most serious flaw in the system. Under SALT, the patient assessment process requires any patient that responds to the global sorting call to walk to be individually assessed last. Although this may seem logical in the mind’s eye in practice it would inevitably, and unavoidably, result in a degradation of patient care and negatively impact both resource requirement notification and hospital surge reduction.
A Beautiful Day in La La Land:
Research is a double-edge sword. It can tempt us into believing concepts on paper are valid. Unchecked, we see what we want to see and often this leads to the circumvention of testing our theories in the real world to ensure they are sound. In the case of SALT’s assessment prioritization criteria it is probable a mind’s eye concept was implemented before being validated. It would be nice to believe that SALT’s mandate of assessing walking patients last is a good idea. Maybe there is a place where it is. One thing is for certain, that place is not in the land of MCI mitigation.
In the 2012 Aurora Colorado shooting this was vividly apparent.
In reviewing the after action report it is clear that one of the primary factors delaying the triage teams from entering the theater was that they were overrun by the ‘walking wounded’ while staging in a parking lot. These moviegoers saw firefighters and instinctively headed toward them. Gunshot wounds, severe hemorrhaging and severed limbs were among the mix of how they presented.
Is it arguable the Triage Unit Leader should have divided his team and sent half downrange? Possibly. What is not arguable is that these people needed immediate medical care and off-scene resources. Care was given and lives were saved.
February 4th, 2013. A full tour bus crashes in San Bernardino, CA killing 8. A non-English speaker saw the ‘walking wounded’ moving toward an engine and decided to follow them. He took his arm with him. He and several others received immediate medical care.
These are just two of many examples of why deferring assessment priority away from those that can walk is simply a bad idea. START recognizes this by allowing for simultaneous assessments to occur - as it should be.
“...moviegoers walked or ran toward Century Division. Some were carried. Approximately 25 victims were treated, many of whom were severely injured”.
- Aurora Colorado After Action Report
In determining it’s sorting criteria, the Working Group determined there is no scientific evidence that one victim may carry another. Really?
Stating the Obvious:
It would be an understatement to say anyone with field experience would not know that buried within the walking are those that cannot. From the proverbial mother holding an injured child to good Samaritans assisting another. This is such a basic concept one has to wonder how a triage system could be conceived that did not account for it. To the Working Group’s credit they acknowledged they missed this tidbit stating “SALT is evolving”. Possibly that implies a future SALT 2.0 release will have the needed bug fix but it’s difficult to see how that would occur without reverting back to a more practical ‘START-like’ assessment process.
“I’m outta here”:
Patient care is not the only reason we allocate resources early on to those that walk. Even in incidents where it appears there are no seriously injured in the mix, having a dedicated resource is always a good idea.
An often overlooked, but well understood, advantage of providing resources to the walking early on is containment of patients to the scene. In keeping with the objective of not relocating the incident to hospitals from a transport destination perspective, the same holds true for reducing the tendency for walking patients to self-transport. If people feel they are not getting the attention they, or their loved ones need, they will self-transport surge to the closest hospital.
Even if only minor injuries are present, a single resource can be effective at voluntary containment. This reduces potential issues for the hospitals and, of least importance, will be appreciated by law enforcement.
Yet another advantage is the orderly release of patients not in need of, or refusing medical care. By having a simple medical release process not only is liability reduction achieved but, once again, law enforcement has involved party information available.
The Baseless Basis:
The concept of assessing the walking last is nothing new. Like everything in SALT, it is taken in fragmented or non-contextual form from other ideas that have either come and gone or have limited or no relevance to the objective of MCI triage.
This particular concept was derived by the Working Group from the poorly-devised MASS triage concept and reinforced from researching papers written on the subject of combat casualty care. If ever there was a time where apples and oranges have been compared, this is it.
The objectives of prioritizing assessment of casualties while under fire in a combat zone are completely different than those in an MCI.
In the interest of brevity, there is no reason to delve into the idiosyncrasies of what makes tactical hot-zone medicine different from civilian cold-zone MCI management. Those that see a parallel are encouraged to conduct their own research or contact a subject matter expert to derive an informed decision.
Did someone say active shooter? Well that is a warm zone and SALT’s assessment prioritization process won’t work there either. That subject is covered in this volume under a separate white paper.
The Last to Go
In START we call for the ambulatory. For that moment in time they are Greens and everyone else remaining is either Black, Red or Yellow.
This simplifies and speeds triage. Green ribbons in the casualty zone currently represent patients that have been triaged and have voluntarily stayed to assist a Yellow or Red. (We ribbon them so subsequent triage members know they have been assessed and counted as well as to provide a visual as to what patient care resources we have available). Under SALT, there are non-ambulatory Greens, or Minimals as SALT calls them. So based off a subjective determination as to if a non-ambulatory's injuries are serious or minor, that patient can be either a Delayed or a Minimal. In the SALT literature there is no real criteria as to what defines a minor injury but it suggests long bone fractures would be serious and short bone minor. (Although this is a bit confusing in that the official SALT training PowerPoint depicts a patient with a tib/fib fracture that is classified as a Delayed). In practice this subjective classification has shown to create confusion as demonstrated in a scientific study conducted in Connecticut. In it, 50% of the triage members misdiagnosed the SALT non-ambulatory Delayed as Minimals. As with any ‘scientific study’ with regard to triage, no clear opinion or conclusion should be derived from it either way until repeated and validated by separate studies. The point here is two-fold: No Greens in the casualty area seems to make sense and adding subjectivity to triage should be avoided whenever possible. The upside of the SALT process is that everyone will know who the last patient off-scene will be.
That Special Place
In fairness, there are instances where the SALT assessment prioritization process may be of more benefit to patient outcome than START’s simultaneous process. Take for instance the 2013 Boston bombing. (Not a great example because Boston was technically not an MCI due to the abundant resources available)
In this tight circumference type of incident involving blast and shrapnel injuries it becomes quickly apparent who needs assessment first (hence one reason it’s part of the military doctrine). But in the civilian sector these incident types are infrequent and we cannot base an entire process to fit the shoe of one hazard type, nor should we attempt to have multiple different systems that we deploy based on the hazard type we encounter. To ask any responder to memorize and apply completely different triage processes on demand is simply not a sound decision and reduces the muscle memory component of triage needed in a high-stress environment. If there is to be a deviation of what patient type gets assessed first, that determination should be logic driven by the IC or Triage Unit Leader, not algorithm driven based on untested research.
Having Your Cake...
Can’t we have it both ways? Yes and no. Under SALT such a deviation is not only disallowed but it would over tax the resources needed to fulfill its theoretical lifesaving intervention objectives and in doing so would negate the entire purpose of using SALT.
Under START the best of both worlds already exist. Resource allocation is incident driven allowing the Triage Unit Leader, via the Incident Commander, to dictate what resources go where. Before making that call, however, a competent IC will be cognizant that sizing up the true nature of the walkings’ injuries early on has a direct impact on the resources he will need.
A Tough Call? - Not So Much:
Experience clearly shows patients needing individual assessment and care first are often those that walk. Any decision to knowingly adopt a process that outright neglects this fact would border on reckless.
A Minor Dilemma:
Essentially two things can happen. We can either count and prepare to treat those that walk early on or we can ignore this group and watch as they start dropping or begin driving.
MCI standard of care:
Minor or Serious
The Walking Wounded The Walking Dead:
We are instinctive creatures. When motivated with the will to survive humans do amazing things. The public knows one thing when they see our lights. Help is near. When we call for those that can walk, they will. Don’t assume they will be fine, they won’t. Many come not out of obeying orderly commands, they come for help. Often the type of help they need would defy the fact they were capable of walking in the first place. Humans...go figure.