Lessons From A War Zone: Mass Casualty Triage From Mosul Iraq In The Coalition Battle Against ISIS - Episode 1

Mass casualty triage at the ER Door. A what if scenario.

I was 16 when the bug bit me, the rear passenger in a motor vehicle struck in the side and knocked unconscious for a few minutes, a motor vehicle collision with 6 persons injured. I woke up, pulled a trapped friend with cerebral palsy from the smoking car and was met by a really kind lady who stopped and gave me a towel to stop the bleeding from my head and arm. She called an ambulance and I made my first trip to the ER on a spine board. The ER doctor asked me if I wanted to watch while he sutured me up, and I said "absolutely yes!" He spent time teaching me about the anatomy of the skull, arm, and skin. I vividly remember him sticking the needle driver down through the hole and touching the bone of my skull, pulling it back out and showing my the line of blood on the needle driver tips that exposed just how much soft tissue depth there is between the skull and the skin surface. I kept saying "this is the coolest thing that has ever happened to me." My parents weren't as excited.

Within a few months I joined the fire department and rescue squad. I became a firefighter, then I went to EMT school, then EMT-I, then nursing school. I eventually landed in the ER as a nurse. 8 years later I went to nurse practitioner school, and now, 12 more years later, I've recently returned from starting a war trauma hospital just outside of Mosul, Iraq. A place where all medical infrastructure had been destroyed and where I was one of the 2 triage officers sorting through hundreds of major trauma patients. Nearly every patient had a penetrating injury from an IED, rocket, mortar, bomb shrapnel, or varieties of bullets. Some injured days before presentation to the ER, but often trapped in the city by ISIS militants until they were freed by coalition forces.

I will never forget that beautiful little girl who was shot in the chest by an ISIS sniper while playing in the street. She was that day's target practice for a sniper. The projectile lacerated her diaphragm, penetrating her lung and causing massive blood loss. Her spleen herniated into the thorax. Her parents drug her inside the house where she was trapped for 4 hours while they struggled with what to do. The parents tried to leave to get help but ISIS refused to allow them to leave, unless...unless the parents agreed to turn over their other 5 children to be placed in a training program for young suicide bombers.

They traded the five to save the one, and waded across the river in the 20 degree cold after carrying her body for miles. She was handed to me by the mom, hypothermic, with a hemopneumothorax, and in hemorrhagic shock. Clinging to life, yearning for warm blood, a chest tube, and a trip to the OR. Her mom, looking into my eyes, said a phrase in Arabic that my translator spoke "I don't know if I did the right thing." She, being both relieved and terrified at the same time, wept at the bedside while we rushed to stabilize her daughter.

We saved her, and only a few days later, after many of my off hours sitting by her bed and singing songs to her, holding her hand and rubbing her head, we put her in some new clothes and her mom carried her back toward the fighting to find and hopefully rescue her siblings.

Not all of the moments were so sad. You may get a kick out of the story one ISIS militant told me about "accidentally" shooting himself in the thigh with a 50 cal truck mounted machine gun. Quite a nice fist sized hole he had, and such a nice shiny pulsing femoral artery just missed by the projectile. Apparently people get shot "cleaning their guns" in other countries also. Despite his mostly unbelievable, ok, ok, COMPLETELY, unbelievable story, we compassionately cared for him, and packed his wounds daily. Then, one day, he leaned up and kissed me on the forehead. Apparently, I'm told, a sign of true respect and thankfulness.

Over the years, I've triaged people in prehospital settings and in hospital settings. Triage, in the case of mass casualty incidents, is often consider a prehospital tool. It's a standard part of EMS training and something I've had to do too often in the past. The injured are sorted by the prehospital workers and brought to the emergency department in the order that they should be. The emergency department staff stands ready to receive them with at least some information, and usually a good idea of the resources needed to handle the incoming traffic.

Triage in the ER setting is somewhat different. A nurse or sometimes a medic is utilized to sort and order patients according to priority of medical or traumatic illness or injury. These more often than not are "walking wounded" and would most likely be tagged "green" in a prehospital setting during a mass casualty incident, yet possibly "urgent" in a hospital setting. This kidney stone goes before that arm laceration and so on. In the hospital setting, most of the "bad ones" come through the back door in an ambulance with some stabilizing measures already instituted.

My recent experience in a war zone was much different than any of the prehospital or hospital based triage situations I've experienced. When the back door of the ambulance opened, people were often stacked on top of each other and pulled out in the order they were stacked up. Usually the dead ones were on the bottom and the walking ones on top of the stack. Sometimes there were military vehicles with people piled inside or even laying on the hood. Complicating things, but utterly necessary, was the requirement to remove all clothing and screen them all for implanted IED's one at a time. Losing valuable moments of the golden hour. As bombs and gunfire rang out continuously outside of our blast walls, and the prehospital system continued to be overwhelmed to the point where all they could do was fill the truck with as many people as they could fit and just drive on, I thought for a moment, "what if this happened back home?" In this war zone hospital setting, I found myself relying more on my older prehospital skills rather than my hospital ER triage experience.

What if? When if? That big terrorist incident, or that stadium explosion, or that God forbid, war on our own soil, taxed the system so heavily that prehospital triage was no longer possible because there was not enough resources to meet the need. What if they all showed up at the same time in private vehicles, piled on top of each other, as many that will fit in a Chevy Tahoe or a Honda Accord, or the back of an F150. What if the number of tourniquets ON a patient outnumbered the number of IV's IN a patient, like they were in Mosul. Would the ER triage nurse then suddenly be out of his or her element? The doctor certainly couldn't step in when there are 4 that need chest tubes now, and 2 that have lost their airway.

As I lived though those moments sorting, and sifting, and rechecking those victims of war, and processing the feelings that come with deciding to black tag a living 10 day old septic baby or a 4 year old little girl with a gunshot wound to the head, and then having to red tag an ISIS militant who may have been the one who shot one or both of the precious little ones, a gap was exposed in how we do triage in the USA.

Very few ER triage staff have the full training or experience that is required to sift and sort patients who are typically sorted in the prehospital setting. I'm reminded of this again today as we watch the developing news from Manchester, England where one suicide vest resulted in over 80 patients. I think of what would happen at my local community hospital if suddenly the system fell into utter chaos like it was in Mosul. We are just one major storm, one radicalized terrorist, one major earthquake away from this happening in our home town.

I'm writing this to encourage ER directors, nurse managers, charge nurses, and hospital administrators to ensure that those who they assign to the role of triage in the hospital ER setting, be familiar with simple START prehospital triage protocols for mass casualty incidents and be prepared in case those moments come when kidney stones and lacerations become stacks of blasted bodies and critical injuries, and where ambulances become ferries instead of mini hospitals.

I pray my colleagues here never have to see the things I've seen, and never have to live with the decision to black tag a baby boy that would have been easily saved with the full resources we have at any moment in everyday America. The faces don't leave your mind. I think it's imperative that hospital ED's, whether big or small, prepare and train for the worst, and help educate our hospital triage personnel to handle mass casualties at the ER door. It's our duty, and it's becoming more of a possibility every day.