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Objective: There are few data concerning the ability of prehospital providers to triage patients in a mass casualty incident (MCI). The authors evaluated the effectiveness of a brief educational intervention on MCI triage with a written scenario and test. The START method (simple triage and rapid treatment) was used., Methods: The authors enrolled and tested 109 prehospital providers consisting of 31 paramedics and prehospital registered nurses (PHRNs) and 78 emergency medical technicians (EMTs) and first responders. A written scenario of an MCI was used to test participants before, immediately after, and again at one month after a two-hour educational intervention consisting of a slide and video presentation utilizing START., Results: The 109 participants completed the pre-intervention and post-intervention test; 72 (66%) completed the one-month post-intervention as well. Mean work experience was 9 years (ranging from 1 to 27 years). The mean immediate post-test score (75% correct) was significantly improved compared with the mean pretest score (55% correct) for the 109 providers completing both tests (p < 0.001). Among advanced life support providers (EMT-Ps and PHRNs) completing all three surveys, the mean immediate post-test score (76% correct) and mean one-month post-test score (75% correct) were not significantly different. Among the basic life support providers completing all three surveys, a modest but statistically significant decay in mean scores from immediate post-test (74% correct) to one-month post-test (68% correct) was observed (p < 0.01). Prior training in MCI had no statistically significant effect on changes in mean test scores., Conclusion: The ability of prehospital providers of all levels of training and experience to triage patients in an MCI is less than optimal. However, this ability improved dramatically after a single didactic session, and improvement persisted one month later.

Emergency physicians often encounter patients in pain and may also have to cope with other problems (eg, alcohol intoxication, a patient's stubborn will to drive after the emergency department visit, narcotic "allergy"). Novel approaches can be used to treat these patients. Dr Heller discusses such approaches, including measures for treating patients with drug-seeking behavior (eg, use of nonnarcotic parenteral agents), and describes treatment options for patients with such specific conditions as hypotension, chest pain, and renal colic.

Open-chest cardiac massage was widely and successfully used for many decades before its virtual abandonment 25 years ago. Both experimental evidence and basic physiologic evidence indicate that it has many advantages over closed-chest massage (especially increased cardiac output). Both resuscitation techniques have specific and unique advantages and disadvantages: They are not mutually exclusive. However, significant increases in rates of survival after cardiac arrest cannot be expected with variations of closed-chest cardiac massage and standard advanced life support services. Therefore, physicians must be willing to support controlled human studies that can definitively determine the proper role of each in resuscitation after cardiac arrest.