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.
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
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