disasterCase Writer:  Nikita Joshi, MD

Keywords: Mass casualty incident, building bombing, disaster, triage, ethics

Educational Objectives


  • Develop system of triage to optimize patient outcomes in prehospital disaster setting
  • Effectively utilize color coded tagging method to assist in categorizing patients
  • Develop treatment plans to address immediate emergency conditions per ATLS protocols


  • Maintain team and personnel safety precautions
  • Regularly provide updates to incident command center

Case Synopsis

A crowded 3-story commerce building within 4 blocks of the hospital was bombed from the lobby 10 minutes ago. An incident command center has opened and is directing the medical response. Police and fire volunteers have already rescued a few of the victims of the building and have laid them out on the sidewalk. The building is a commercial building with a daycare on the second floor for employees of the building. The victims range from toddlers to middle aged business workers. The medical team is responsible for triaging and formulating evacuation plan for victims. All pertinent information must be relayed to incident command center.


Prioritizes critical initial stabilization action and mobilizes hospital support services in the resuscitation of a critically ill or injured patient and reassesses after stabilizing intervention.
Milestone LevelMilestone to be AssessedSpecific Behavior
1Manages a single patient amidst distractions
  • Takes a brief history and physical from every victim
  • Examines and assigns a specific triage color level to all four victims
2Task switches between different patients
  • Reassesses patients who have change in physical exam
  • Verbalizes different procedures that each patient will require based on injury
5Employees task switching in an efficient and timely manner in order to manage multiple patients
  • Does not delegate a significant amount of time resuscitating victims triaged to Black nor to the walking wounded
8. ABEM Milestone: Multi-Tasking (Task-Switching) (PC8)


Prioritizes critical initial stabilization action and mobilizes hospital support services in the resuscitation of a critically ill or injured patient and reassesses after stabilizing intervention.
Milestone LevelMilestone to be AssessedSpecific Behavior
1Participates as a member of patient care team
  • Takes orders from team leader and executes orders
2Communicates pertinent information to emergency physicians and other healthcare colleagues
  • Obtains bombing history from police in order to understand the potential injury patterns
  • Contacts Incident Command Center upon arrival on the bomb scene to obtain information
  • Contacts Incident Command Center after triaging victims to communicate the order of evacuation
  • Communicates resources needed for patient such as advanced airway equipment for man with developing respiratory distress
3Ensures transition of care are accurately and efficiently communicated
  • Communicates with Incident Command Center each of the following: Four victims triage colors, resources needed to evacuate each victim, method of how victims need to be transported
  • Tells EMS the importance to obtain advanced airway on man with respiratory distress immediately upon arrival of EMS
4Recommends changes in team performance as necessary for optimal efficiency
  • Reassigns team tasks and roles when man with respiratory distress begins to deteriorate
5Communicates with out-of-hospital and nonmedical personnel such as police, media, hospital administrators
  • Communicates with police and obtains understanding of bombing
  • Communicates with EMS and gives sign out on all victims
  • Communicates with Incident Command Center
19. ABEM Milestone: Team Management (ICS2)

PDF of the case-specific ABEM Milestones (PC 8, ICS 2)
PDF of more detailed scenario description

Critical Actions

  1. Maintain team safety
  2. Perform triage based upon MASS and Color Coding system
  3. Perform lifesaving interventions on patients assigned a red color coding level
  4. Evacuation of victims based on triage


  • ED residents
  • EMS
  • EMS students
  • Nurses
  • Nursing students
  • Medical students


Sidewalk outside of bombed building


  • 3 yo girl
  • Mother
  • Man
  • Nonresponsive Man

Special Equipment

  • Triage Level Color Coding Cards

Standard Equipment

*Minimal emergency medical equipment will be made available given the pre-hospital location

  • Non-rebreather O2 mask
  • Oxygen tank
  • Back board – spinal immobilization
  • Cervical stabilizing collars
  • IV fluid
  • Scapels
  • Syringes


  • 3 yo girl (manikin or confederate)– soot and dirt on child
  • Woman (mother, confederate) – crush injury of lower extremity; using task trainer lower extremity
  • Man (confederate) – singed off eyebrows, coughing black material
  • Nonresponsive Man (manikin) – amputation of the upper extremity and structural material impaled through chest


  • Police Officer – gives history of finding mother and child; mentions how he helped the mother out of the building by assisting in the removal of heavy building material that trapped her lower extremity
  • 3 yo girl – crying
  • Mother – In extreme pain from the lower extremity
  • Man – Coughing, complaining of ringing in the ears, insists on immediate medical attention
  • Incident Command Center (voice) – asks team for regular updates, will bring resources if asked for by the team; asks the team to list the triage of the patients and discuss evacuation plan; informs team that there might be more bomb explosions
  • EMS – arrives to transport victims in order designated by team

Supporting Files / Media

  • None


BPBlood Pressure
HRHeart Rate
LOCLoss of Consciousness
RRRespiratory Rate
s/pstatus post
yoyear old

Additional References

  • ACEP Policy:  Health Care System Surge Capacity Recognition, Preparedness, and Response. 2011.
  • Asensio:  Current Therapy of Trauma and Surgical Critical Care, 1st ed. Chapter 9 Triage. 2008. Mosby, Inc. affiliate of Elsevier.
  • CDC Emergency Preparedness and Response:  Mass Casualty Event Preparedness and Response. 2013
  • DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med. 2005 Mar 31;352(13):1335-42. PMID: 15800229.
  • Kleber C, Cwojdzinski D, Strehl M, Poloczek S, Haas NP. Results of in-hospital triage in 17 mass casualty trainings: underestimation of life-threatening injuries and need for re-triage. Am J Disaster Med. 2013 Winter;8(1):5-11. PMID: 23716369.
  • Lee CH. Disaster and Mass Casualty Triage. Virtual Mentor. 2010. 12;6:466-470.

Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
Nikita Joshi, MD


Emergency Medicine Doctor Associate Editor of ALiEM Gun Sense Advocate #FOAMed #Docs4GunSense #MomsDemandAction Tweets represent my own views and opinions