Abstract: INTRODUCTION: Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005. METHODS: A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident. RESULTS: The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 “Immediate” patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 “Immediate” patients, two patients per center, while the 25 closest community hospitals offered to accept 75 “Immediate” patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients. CONCLUSIONS: The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for “Immediates”, and that they were distributed about equally between community hospitals and trauma centers.

Abstract: Each year nearly 5 million people worldwide die from injuries, approximately the number of deaths caused by HIV/AIDS, malaria, and tuberculosis combined. Ninety percent of these injuries occur in developing countries and that number is growing. Road traffic accidents account for 1.2 million of these 5 million deaths. For each death from trauma, three to eight more are permanently disabled. Orthopaedic surgeons should consider the victims of this epidemic by using their ability and capacity to treat these injuries. SIGN (Surgical Implant Generation Network, Richland, WA, USA) builds local surgical capability in developing countries by providing training and equipment to surgeons for use in treating the poor. It assists in treating long-bone fractures by using an intramedullary nail interlocking screw system. C-arm imaging, unavailable in many of these hospitals, is not necessary to accomplish interlocking. Surgery is performed primarily by local surgeons who record their cases on the SIGN surgical database. Discussion of these reports provides a means of communication and education among surgeons. This database demonstrates the capability of these surgeons. It also demonstrates that the SIGN intramedullary nail is safe for use in the developing world as it has been successful in treating 36,000 trauma patients.