Re-post: Triage and Squeaky Wheel Medicine: Applying Order to Chaos

Re-post: Triage and Squeaky Wheel Medicine: Applying Order to Chaos

Just a few more days and I am back on track…Since I have not been able to regularly post here and since I am using this article for the final class that I have to ‘teach,’ the following is a re-post from almost a year ago…

Looking back, I don’t think I ran a single medical scenario where I would not have done something differently. It’s not that I made a lot of mistakes, it’s just that, I wish that I would have had more time, been more efficient at certain points. I don’t think I ever ran the perfect scenario.

The picture above is the look of a young operator that just realized that, no matter the training, we are not invincible. This is a picture of me coming to grips with what I could have done differently following the loss of my first battlefield patient and my decisions during a mass casualty incident outside Fallujah in April 2004.

I have been rolling this post over in my head for several months, ever since I started this project really. But with the lockdowns due to COVID19 and ‘homeschooling’ the youngens I could not organize my thoughts for this one. With classes finally over and all of the other events that are going on, this seemed like the right time.

I was involved in no less than six mass casualty incidents, not a lot by some medic / corpsmen standards but enough to be able to look back and wonder what could I have done differently? What worked and what didn’t? Were there small changes that I could have made that may have impacted a life or two here and there? For the most part, I think I performed fairly well but there is a part of me that will always wonder.

Today, we are going to talk about triage during a mass casualty incident or mascas for short. Here, according to the DelValle Institute Learning Center, is a really good description of what constitutes a mass casualty incident and a handy graphic:

Although many have attempted to put numbers to what constitutes a mass casualty incident (MCI), perhaps the best definition is any number of casualties that exceed the resources normally available from local resources. This is based upon available resources, number of injuries, and severity of injuries. For example, in your response system, 20 victims with minor injuries may not require instituting the MCI plan, while five victims with critical injuries may. 

Figure 1: What is a mass casualty incident? By the DelValle Institute Learning Center, obtained from:

So, for me, who spent the majority of my two deployments as the only medic on my Special Forces team and the purposes of this discussion, I will consider 4 or more patients, depending on the severity of their injuries as a mass casualty incident. Let me throw one great big ASTERISK in here just to be clear…I consider myself extremely lucky because I rarely worked on U.S. personnel. Unfortunately for our partner forces…they absorbed most of the casualties. Don’t get me wrong, we still grieved their loss, but it was just different.

Mass casualty incidents can be very chaotic and to manage them successfully, someone needs to take charge by setting priorities of treatment because, as you can see from the scale above, the number of victims can exceed the resources available. To accomplish this, you need to triage your patients.

Triage, according to Merriam-Webster, means:  

1a : the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors

b : the sorting of patients (as in an emergency room) according to the urgency of their need for care

2 : the assigning of priority order to projects on the basis of where funds and other resources can be best used, are most needed, or are most likely to achieve success

Simply put, triage means to sort or to apply order to chaos. The key to success is to immediately begin prioritizing and consider the conservation of resources. It may take some time to determine how many injuries there are, but if you can be methodical and can organize the incident, they are manageable. A bonus note: this can be applied to anything in life but today we are going to talk medicine. The key is making sure your hands ‘touch’ every patient or problem.

Before, we discuss how to triage patients, a quick note on initial contact and ‘care under fire.’ Care under fire is the aid that you can provide, which primarily consists of shooting back and self-aid, while the bullets are still flying or when the threat is level is still so high that you are not in a secure position. Care under fire has its own algorithm and class that we are not going to cover today. 

When do I begin to triage? Triage happens after the initial chaos of ‘care under fire’ when you are trying to reconsolidate and reorganize. During the initial stages of the reconsolidation phase is where a casualty collection point that has a single point of entry should be established to begin prioritizing treatment. There are a lot of different acronyms or methods used to sort patients and the medical buzzwords that we generally live by are immediate, delayed, expectant. One of the companies that I work for uses S.A.L.T. which stands for:


Can walk and follow commands, are responsive but can’t move well, unresponsive and not moving

Assess and Triage

Look for major hemorrhage, check airway, ensure adequate breathing

Put them in categories according to unit SOP; for example, immediate, delayed, expectant

Life Saving Interventions

Treat any immediate life threats: tourniquet, needle decompression, chest seal, etc.

Treatment and Transport            

Finally, reassess and continue treatment or transport them as soon as possible

And here is another that I found online:

Figure 2: START Triage algorithm for adult patient. Adapted from obtained from:

These are great resources for the medical field but in life and practice sometimes even those are hard to remember and most importantly, triage depends on your ability to manage the current events. When I did it, and what I like to teach non-medics, is to use four categories, like those above, that I think are simple and easy to remember:

  1. I need help (Immediate): I don’t think I can manage this by myself and I want this to be someone else’s problem as soon as possible.
  2. I got this…for a little while (Delayed): I have some training and I think I know what is going on and other people are hurt worse.
  3. Suck it up (minor): They are hurt but can manage and need to suck it up while I deal with more important things, ‘help each other, damnit’.
  4. Dead or soon to be (Expectant): in spite of my very best efforts I simply cannot save these people and I don’t want to waste resources on them.

It does not matter how ‘bad’ the injury is if you cannot manage it. For some, a penetrating chest injury can be manageable for a little while but for others it is simply beyond their scope. Again, the most important aspect of triage is being honest with yourself about your ability to manage the situation. Now that I’m done with that soapbox, lets discuss each category and an introduction to squeaky wheel medicine.

I need help.

The ‘I need help’ group can be composed of a wide range of injuries depending on your ability or can be driven by a lack of proper equipment. This group needs to contain all of the patients that A) require equipment that you do not have B) are unstable, or C) have so many issues you are overwhelmed and do not know how to treat them. For all intents and purposes, the latter (C) will signal your need to call for an expert.

In my experience, this was anyone that is unconscious and I didn’t know why, unconscious and I cannot fix it, requires equipment that I do not have, has penetrating head, chest or abdominal injuries or has uncontrolled bleeding that I cannot stop. It is a broad category that has a lot of room for interpretation and the severity of each injury can vary greatly. There are no hard rules here and medicine is thinking person’s game. As long as you can justify your decision, that is the best that you can do.

I got this…for a little while.

This group is made up of all of the patients that I understand what is going on and have a good idea of the treatment that they require and there is no immediate life threat. Again, this group can be pretty broad but it generally consists of individuals that are conscious, have non-complicated chest or abdominal injuries and their bleeding is controlled via packing or a tourniquet.

Suck it up.

This group consists of all of the people that are not severely injured and can pretty much be expected to help themselves or each other. These patients are alert, know what happened and understand how to fix themselves and are willing to help others despite the situation. These patients require monitoring for a change of status (they move to another group) but can watch each other.

Squeaky Wheel Medicine

Sometimes patients are difficult and require a disproportionate amount of your attention. This can be due to the severity of the injuries or to an altered mental status. I am not sure I can adequately explain how a disruptive an altered mental status can be.

In April of 2004 I was working a checkpoint outside of Fallujah and we were hit with mortars. This would be my first real mass casualty incident. We quickly scooped up all of the injured Iraqi soldiers, about five or six of them, and moved to a secure location. None of the injuries were particularly severe, regardless, my supplies were stretched a little thin. I thought I was doing pretty good on my triage and organization and honestly wouldn’t change a thing in that regard. We established a casualty collection point in a single room and I had two categories of patients. The I got this for a little while group and the you need to suck it up group. One patient in the suck it up group had a single piece of shrapnel about the size of a child’s fingernail stuck just under the surface of his skin on his neck…I could see it. Just to be sure, I put an occlusive dressing over the injury and told him via my interpreter to be calm, you are going to be alight and I have other people that are hurt worse that need my attention, but probably not in those exact words. However, the patient was unable to calm down and thought they were dying. No matter how many times I tried to reassure him, no matter how many times others tried to reassure him, he would not calm down and the disruption not only made things difficult for me but was agitating all of the other patients as well. So much so, that they were asking about his well-being and refusing treatment. I am not sure how long this went on but I could not separate the patients and finally, even though he did not really need it, I gave the patient 10mg of morphine just to shut him up. Was it the right call medically? Probably not, but it worked. Extremely squeaky wheel fixed.

I am not telling you that story as a way to treat patients, only to illustrate how disruptive certain patients can be and how important it is to address problems that are screaming for your attention. No matter how much you try to ignore them they simply need to be addressed.

Dead or soon to be.

This category sucks, but unfortunately is a reality. Quickly identifying whether a patient is alive or not is key to triaging patients. One of the biggest mistakes that I see when I teach classes is a failure to determine life and the subsequent wasting of time and resources on patients that have already expired.


We triage events in life all of the time and in medicine, like life, it is important to be honest with yourself about your abilities and too seek help when it is available. However, organization is key and will be critical to managing a seemingly overwhelming situation. To successfully triage patients or assign priorities in life you do not need fancy terminology or books, only an honest assessment of one’s own abilities. I hope this short article can provide some perspective on how to manage life’s chaos and the situations that we may face whether they involve medicine or not.    

6 thoughts on “Re-post: Triage and Squeaky Wheel Medicine: Applying Order to Chaos

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