Episode overview
About This Episode
Most of us were taught START, the sieve, RAMP, DIME, P1–P3. Andrew — EM physician on a small surgical team out of Fort Liberty — used none of it the night a helicopter went down with 22 people on board.
The rest of his medical team could not walk. Dust, firelight, yelling. Thirty-to-sixty seconds per patient on a linear algorithm is ten minutes before you reach number ten. People die of massive hemorrhage and lost airway in that window.
So he ran a binary pass: dying now or not. Blood sweep. “Take a deep breath.” Pulse. Ten to fifteen seconds. Keep a mental list of who leaves first. He got through about twelve before other medics arrived. He never reached the massive bleeder — a non-medic first responder did. That is the point.
Rick Hines puts the doctrine next to the wreckage. Triage is continuous, not a one-and-done sort. The most senior medical person is often the worst person to own the sort if they should be operating. Algorithms used after the first pass are training tools — studies put accuracy around or under 50 percent.
Training has to match that. Four casualties before twenty-two. Global endpoints, not a perfect score on every manikin. Delayed birds. Command decisions. Unit buy-in, not a tourniquet-and-check-the-block.
No perfect MASCAL. You were already behind when it started.
Listen: PFC Podcast · prolongedfieldcare.org · @prolonged_field_care
Top 5 takeaways
• First contact is binary. Dying now / not dying now. Blood sweep, air movement, pulse. 10–15 seconds. Do not spend a minute running START on patient one while patient ten bleeds out.
• Then deliberate triage. After LSIs and a move to the CCP: urgent / priority / routine (what TCCC/CoTCCC are leaning toward). Expectant exists when resources force it — not on the first pass.
• Move, treat, transport. Rush’s three verbs beat a four-color card at the wreck. Get off the X, stop hemorrhage and airway loss, get them to the next level.
• The senior clinician should not automatically own the sort. If they are the surgeon, someone else runs triage. Non-medic first responders are part of the system — Andrew never reached the massive hemorrhage; someone else did.
• Train the real constraints. Nail four before you role-play twenty-two. Score the lane on whether life threats were found, blood got to shock, accountability held, and evac was prioritized — not whether every individual critical-action list was perfect. Delay the bird. Make the commander choose.
Chapters
• 00:00 Disclaimer and welcome
• 00:20 Andrew Shafrina intro — EM, small surgical team, Fort Liberty
• 01:23 Why most of us never actually practiced triage
• 02:14 Categories: START, sieve, NATO — four bins plus expectant
• 04:10 Why linear algorithms are too slow at the point of injury
• 04:32 The crash: 22 onboard, medical team down, one provider
• 05:39 The 10–15 second pass — blood sweep, deep breath, pulse
• 06:09 Rush, Shackelford, Remley, Hines — binary is what people actually do
• 06:50 Move, treat, transport
• 08:07 What “stable” meant that night — not P1/P2/P3
• 08:51 Twelve patients in five minutes — and he still missed the bleeder
• 10:01 Triage is continuous, not one-and-done
• 10:36 Do not burn the surgeon on the sort
• 11:11 MASCAL means you are already overwhelmed
• 12:06 Put non-medics to work
• 12:43 Evac categories vs who actually needs an OR
• 13:45 First-pass binary, then UPR at the CCP
• 14:14 Algorithms as training tools — accuracy ~50% or worse
• 47:06 Train to global endpoints, not perfect individual checklists
• 48:08 Can you handle four? Then scale.
• 49:09 Rick: six dead, seventeen wounded, no bird, they drove them out
• 52:23 King for a day: two-phase triage + basics
• 53:50 There is no right way — only best with what you have
• 54:18 Put MASCAL inside unit drills, not isolated medic lanes
• 55:22 Scare the staff honestly — risk, delayed evac, command decisions
Mentioned on the show
Show Notes
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