TNCC Disaster Management 2 — Questions and Answers
Question 1: In the START triage system, a patient who is breathing but has a respiratory rate greater than 30, no radial pulse, and does not follow commands is classified as:
- Green (Minor)
- Yellow (Delayed)
- Red (Immediate) (Correct answer)
- Black (Expectant)
Correct answer: Red (Immediate)
In START triage, this patient fails the perfusion check (no radial pulse) and mental status check, classifying them as Red (Immediate) requiring urgent intervention.
The START (Simple Triage and Rapid Treatment) algorithm assesses patients in a stepwise manner: (1) Can they walk? If yes → Green. (2) Are they breathing? If no after repositioning → Black. (3) Respiratory rate? If >30 → Red. In this case, the patient is already Red at the respiratory rate check (>30/min). Even continuing the algorithm: no radial pulse suggests inadequate perfusion (another Red criterion), and inability to follow commands confirms altered mental status (also Red). Each checkpoint that fails leads to Red classification. The START system is designed for rapid triage of large numbers of casualties, spending approximately 30 seconds per patient, and aims to identify those who will benefit most from immediate medical intervention.
Question 2: During a mass casualty incident, the trauma nurse's FIRST priority upon arriving at the scene is:
- Beginning treatment of the most critically injured patient
- Establishing a triage area and beginning triage (Correct answer)
- Setting up a treatment area with IV supplies
- Calling for additional ambulances
Correct answer: Establishing a triage area and beginning triage
The first priority in an MCI is to establish a triage area and begin rapidly triaging patients to categorize the scope of injuries and direct limited resources appropriately.
Mass casualty incident (MCI) management fundamentally changes the approach from individual patient care to population-based care — the greatest good for the greatest number. The first priority is triage: rapidly categorizing all casualties to determine who needs immediate intervention, who can wait, who has minor injuries, and who is beyond help. Without triage, responders may spend all resources on the first critical patient encountered while others with survivable injuries die waiting. The Incident Command System (ICS) structure designates a triage officer who establishes the triage area, while other roles (treatment, transport, staging) are assigned as resources arrive. Treatment begins only after initial triage sweep is complete, directing resources to Red-tagged patients first.
Question 3: Which decontamination principle is most critical before treating victims of a chemical exposure incident?
- All patients must be decontaminated before entering the treatment area (Correct answer)
- Decontamination should occur after initial stabilization inside the hospital
- Only symptomatic patients require decontamination
- Decontamination is unnecessary if the chemical agent is unknown
Correct answer: All patients must be decontaminated before entering the treatment area
All potentially contaminated patients MUST be decontaminated before entering the treatment area to prevent secondary contamination of healthcare workers and the facility.
In hazardous materials (HAZMAT) incidents, the cardinal rule is that decontamination occurs BEFORE patients enter the treatment facility. This prevents secondary contamination — transferring the hazardous substance to healthcare workers, equipment, and other patients, which can incapacitate caregivers and shut down the entire treatment capacity. Decontamination typically involves removing all clothing (which removes approximately 80% of contamination) and thorough water irrigation. A decontamination corridor is established upwind of the treatment area. Even life-threatening conditions should ideally have gross decontamination before treatment, though some protocols allow simultaneous basic life support during decontamination for critical patients. Unknown agents are treated as dangerous until identified.
Question 4: In disaster triage, which patient would be classified as Black (Expectant)?
- A patient with a femur fracture and stable vital signs
- A patient with extensive burns over 90% of body surface area who is apneic after airway repositioning (Correct answer)
- A patient with a laceration to the scalp with controlled bleeding
- A patient with bilateral lower extremity fractures and a respiratory rate of 24
Correct answer: A patient with extensive burns over 90% of body surface area who is apneic after airway repositioning
A patient with 90% body surface area burns who is apneic even after airway repositioning is classified as Black (Expectant) as survival is unlikely even with full resources.
The Black/Expectant triage category is one of the most difficult decisions in disaster medicine. It designates patients whose injuries are so severe that survival is unlikely even with optimal care, or whose treatment would consume resources needed by multiple salvageable patients. A patient with 90% total body surface area burns who is apneic after airway repositioning meets these criteria — the burn injury alone has near-100% mortality, and apnea indicates probable severe inhalation injury or cardiopulmonary arrest. In a normal single-patient scenario, resuscitation might be attempted, but in an MCI, these resources must be allocated to patients with survivable injuries. This paradigm shift from individual to population-based care is a core TNCC disaster management concept.
Question 5: The Hospital Incident Command System (HICS) is activated during a disaster primarily to:
- Replace the hospital administrator's authority
- Provide a standardized organizational structure for managing the hospital's disaster response (Correct answer)
- Coordinate only with external agencies
- Assign clinical treatment protocols for specific injuries
Correct answer: Provide a standardized organizational structure for managing the hospital's disaster response
HICS provides a standardized, scalable command structure that organizes the hospital's disaster response, ensuring clear communication, defined roles, and efficient resource management.
The Hospital Incident Command System (HICS) adapts the National Incident Management System (NIMS) Incident Command System (ICS) for hospital use. It provides a standardized, scalable organizational structure with clearly defined roles, a chain of command, and communication pathways. Key positions include the Incident Commander (overall authority), and Section Chiefs for Operations (patient care), Planning (situation tracking), Logistics (supplies, staffing), and Finance/Administration (cost tracking, documentation). HICS does not replace clinical judgment or treatment protocols — it organizes the institutional response. Its standardized structure allows interoperability with external agencies (fire, EMS, public health) using common terminology and organizational concepts. HICS can be scaled up or down depending on incident scope.
Question 6: During a mass casualty event, a nurse must make triage decisions for 50 patients. Which ethical principle guides the shift from individual patient care to population-based care?
- Autonomy — respecting each patient's treatment preferences
- Beneficence — doing the greatest good for the greatest number (Correct answer)
- Nonmaleficence — avoiding harm to any single patient
- Justice — providing equal treatment time to every patient
Correct answer: Beneficence — doing the greatest good for the greatest number
The utilitarian principle of beneficence — maximizing benefit for the greatest number — guides MCI triage, requiring a shift from individual-focused to population-focused care.
Normal healthcare ethics prioritize the individual patient's welfare, autonomy, and right to treatment. Mass casualty incidents require a fundamental ethical shift to utilitarian principles — allocating limited resources to maximize survival across the entire affected population. This means that a critically injured patient who would normally receive full resuscitation efforts may be triaged as Expectant if treating them would consume resources needed to save multiple other patients. This is guided by the principle of beneficence applied at the population level — the greatest good for the greatest number. Nurses must be prepared for the moral distress this creates. Pre-incident training, institutional protocols, and post-event debriefing are essential supports for healthcare workers facing these decisions.
TNCC Disaster Management 2
In the START triage system, a patient who is breathing but has a respiratory rate greater than 30, no radial pulse, and does not follow commands is classified as: