What every nurse and doctor in Nepal needs to know about Triage of mass casualties Sept 7, 2015

The protests and response in Nepal are continuing and many people are worried they will get larger and more aggressive, provoking more violence as the Army tries to control things.

I am not here to take sides. The politics are too complicated. I am here to help the nurses and doctors save lives. Please share this, and prepare.


As many readers know, CCNEPal teaches critical care skills, and since 2011 we conducted 70 sessions of our two-day or three-day course, giving a total of 2,130 certificates. We have  been working to develop expertise of Nepali professionals to teach this at a universal level. By that I mean, senior-year of MBBS at all 21 medical schools in Nepal (as opposed to waiting for PG course) and final year of nursing school at all the hundreds of nursing schools, esp the B Sc programs. CCNEPal is suspended for now, while I am in USA.

Physical safety of hospitals

I recently published a blog about how hospital emergency rooms can stay safe, and preparatory steps to take in case violence spills into the inside of the hospital. Doctors and nurses need to remain neutral (treating everybody) and safe.

True Story

First, a true story about the April and May earthquakes. This took place at a major hospital in Kathmandu. I won’t say which one.

For the first earthquake, many casualties arrived. The senior doctor on duty had taken triage training and implemented a triage system right away. Things were chaotic but the triage system worked  about as well as it could.

For the May 12th earthquake, the senior doctor assumed that the junior doctors had now learned how to triage, so when casualties started arriving, he sent them out to assess the patients, piling up outside. The junior doctors on duty that day did not know how to triage, and did not sort anybody – the two of them just started by getting out their clipboards, walking over to the first in line, and taking a history. Just like they were trained – such things as family history, medications, allergies, etc.  When they went out, there were fifty victims waiting.

In the second case, the two young docs made things worse, not better. The people inside were waiting for the most serious cases, and the young docs did not identify and send them in.  It took an hour before the senior guys inside figured out that things were messed up and  they needed to get somebody else.  By the time they sent additional help, there were 250 victims in the courtyard. The people were adding up faster than the triage people could move them along.

It should be noted that in the MBBS system of medical education, the medical students get mostly bookwork for the first four years, and limited clinical. They do not get an ACLS class at this point, which is an important difference in their training (compared to USA where ACLS is required for every senior med student). I have said all along, that MBBS needs to include ACLS in senior year. Some medical schools are beginning to include this.

General rules of triage:

First, the goal is to do the most good for the greatest number of victims in the shortest possible time.

In triage, each victim gets examined for no more than thirty seconds before a decision is made what to do with them.

In triage, as in critical care skills I teach,  you look for immediate life threatening (and reversible) problems and take steps to fix those before you continue with the usual history-taking.

If they can walk, they are not as sick as those who cannot walk. start by asking everyone who can walk, to “walk over there” (wherever there is)

If they are not breathing and have no pulse, they are dead. An obvious dead person from the scene should not be brought to the hospital and the body should not be brought inside.

It’s the people in between who need to be sorted out to prevent further death.

If you have a large number of casualties, triage needs to take place outside the ER, or before the people even get there. You don’t want the ambulatory people taking up all the beds while the sick people are on the floor. If the person is dead on arrival, they don’t get moved inside either.

Specific to protests: I f tear gas has been used, you may need to decontaminate the victims before you treat them.

You never know when an incident will happen, and for that reason, everyone needs to be trained. I heard a story about one hospital that developed a triage system, and then didn’t use it because the people on the spot decided not to do it that way. The whole team needs to have a plan and stick to it.

I did a video search on triage on YouTube. First, there is a TV named “Healthcare triage” which has nothing to do with victims of mass casualty incidents. Next, there are some videos about day-to-day hospital triage in USA. These don’t apply either – they tell you how to sort out the out the people with chest pain from the ones who have a cold or earache. There was a movie titled “Triage” as well. So when you websearch, don’t let these distract you.

Recommended videos:

Here are three I thought were good. They teach how to use the S.T.A.R.T. triage system.

This one is 18-minutes long, and shows a simulated  incident with a bus accident in which the fire department responds and conducts triage at the scene.  They use S.T.A.R.T. https://youtu.be/n8pQGVvIInA

This one is 8-minutes long, and it’s from a school of nursing. It shows written slides, and the info is good but the voice of the narrator made me sleepy. https://youtu.be/9QHDs10e

This one is 5-minutes long, and it emphasizes the idea of not spending more than thirty seconds per victim in initial survey.  https://youtu.be/8-huujcjAWA


Here is a link to a five-page handout that you can use: http://www.emsconedonline.com/pdfs/starttriage.pdf


Here is a link to a flowchart http://citmt.org/Start/flowchart.htm


Here is a PowerPoint from South Alabama, USA. It’s 48 slides and I think it’s pretty good. arrtc.com/files/Rapid_Assessment_Triage_Methods%202010.ppt  The link goes straight to the download.


I don’t have links to specific textbooks. I will say one thing, which is that I have written two books about Nepal health care. The second is a novel, (fiction!) that takes place at a small hospital in rural Nepal, and in it, the doctors are caught in the middle while a battle takes place between the Maoists and the Nepal Army. The book describes what happened including how they did triage and what it felt like to be caught between two sides. Here is a review of the book in Nepali.

द साक्रामेन्ट अफ गोड्डेस्,,अथवा नेपाली मा भन्नु पर्दा देबी को प्रसाद,,एउटा यस्तो नोवेल जसमा माया,जिबन्,त्याग्,आत्मियता जस्ता आध्यात्मिक कुरहरु को मिठो बयान गरिएको छ, यसका लेखक जो निम्जुरा एउटा अमेरिकि नागरिक र पेसामा उनि नेपाल र अमेरिका दुबैमा राजइस्टर्ड नर्स हुन्,,बिगत ७ बर्ष देखी उनि नेपालमा स्वास्थ्य को क्षेत्रमा उल्लेख्हनिय काम गर्दै आइरहेका छन्,.यो किताब उन्कै मिहिनेत को फल हो,,यसमा नेपालमा दस बर्स सम्म चलेको जनयुद्द को बेलाको.. एउटा अमेरिकन सर्जन र नेपाल को बेनी भन्ने ठाउँमा बस्ने साधाराण नेपाली केटी बिचको प्रेम सम्ब्न्ध को बारेमा बयान गरिएको छ,,,,,, एउटा यस्तो पबित्र प्रेम सम्ब्न्ध जुनसाधारण,,अपरिपक्व,,र सारीरिक तर इन्टेन्स लभ बाट सुरु भएर,,धेरै त्याग र प्रतिक्षा बाट गुजृदै एउटा आत्मिय र परिपक्व्य प्रेम भएर फुल्छ,,यै प्रेम कथा लाई प्रमुख सेरोफेरो बनाएर लेखकले, ,,जिबन का धेरै तिता मिठा सत्य,,जिबन मा गरिने त्याग्,,तपस्या आदी को बारेमा अत्यन्तै सरल तर सत्य,मार्मिक र चित्त बुझ्दो तरिकबाट बयान गरेका छन्,,, नोवेलमा लेखकले नेपाल को गाउँ र शहर दुबै को सुन्दर्ता जती स्वच्छता का साथ बयान गरेका छन्,,,,एउटा बिदेशी नागरिक भएर पनि नेपाल लाई यती नजिक बाट नियालेका छन लेखक ले,,,जती नजिक बाट हामी नेपाली ले पनि नियाल्दैनौ होला माया,,प्रेम्,,,,तपस्या,,त्याग्,, पर्‍खाइ,,धैर्यता,,,, चोखो माया.. जस्तै भगवान प्रती को जस्तै सध्भाव्,,र सङ्सङ्गै मेडिकल ज्ञान ….लेखक का भाबुक्,,पबित्र शब्द बाट सजिएका मार्मिक पल हरु ले धेरै पटक आँखा रसाइदिन्छन एस्तै कुरा हरु को मिश्रड भएको नोवेल हो द साक्रामेन्ट अफ गोड्डेस्,,,, यो किताब को बारेमा थप जानकारिको लागि यसको फेसबुक पेज मा हेर्न सकिन्छ ( to read more go to the link)

You can buy the book in Thamel or on Amazon.

Further training by CCNEPal?

The funding I had for 2014-2015 has run out. I plan to return to Nepal if and when I get more funding. If the nurses and doctors of Nepal (especially those who have had the training, and also the medical schools) ask the Ministry of Health to add ACLS training of docs and nurses to the health plans, it will make it easier for me to apply for grants.  In the meantime,  Please share these resources.


About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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