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.

Listen: PFC Podcast · prolongedfieldcare.org · @prolonged_field_care

Top 5 takeaways

1. 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.
2. 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.
3. 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.
4. 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.
5. 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
• 55:22 Scare the staff honestly — risk, delayed evac, command decisions