Abstract
To the Editor:
We have critically engaged with the concept proposed by Valence and colleague in their significant work, “Time to Reconsider Analgesia in Mass Casualty Incidents.” 1 Their concept is commendable for bringing attention to the often inadequately addressed issue of pain management in mass casualty scenarios and for suggesting innovative analgesic approaches. Nonetheless, we propose that an enriched exploration and further clarification of certain points could serve to amplify the practical applicability of the suggested approaches. The article adeptly navigates the nuances of analgesia in disaster medicine, addressing the “why,” “how,” and “which” through a critical literature review and its nexus to patient care in mass casualty incidents (MCIs). In its assessment of disaster literature, the concept advances beyond the traditional maxim of “saving the most lives in the shortest time possible,” advocating for an elevated standard of care.
A distinguishing feature of an MCI, relative to other events, is the simultaneous occurrence of numerous casualties and the scarcity of available resources. The article contributes valuable insights to MCI literature, yet it stops short of addressing the prioritization of analgesia in injury management—a perspective that, we note, coalesces organically when this research is viewed in concert with existing studies. Triage, as the cornerstone of patient prioritization, dictates a structured progression of interventions in disaster response, typically commencing with an expedited protocol that merges triage and immediate intervention. For this very purpose, the Simple Triage and Rapid Treatment (START) was created in 1980 by the Newport Beach Fire Department and Hoag Hospital in California and has since become one of the most frequently used algorithms. 2 Scholarly discourse often highlights the triage component of the START protocol while neglecting its quintessential element: the seamless amalgamation of triage and emergent care. This synergy is pivotal to its status as the preeminent casualty management algorithm in MCIs. Despite this, the literature remains ambiguous in defining the subsequent steps post-triage and initial treatment within the START framework.
On February 6, 2023, twin earthquakes with magnitudes of 7.7 and 7.6 struck Kahramanmaraş, affecting 10 cities and resulting in 50,399 fatalities, 80,278 injuries, and 6444 collapsed buildings, with 13.5 million people impacted and 850 amputations in Turkey. 3 Immediately after the earthquake, Turkey issued a level 4 alert. A close scientific examination of the February 6 Kahramanmaraş earthquakes was undertaken, entailing numerous studies on early-stage field observations, patient transports, and emergency department patient management. 4 The studies specifically investigated the use of START and the subsequently proposed Secondary Assessment of Victim Endpoint (SAVE) algorithms in managing MCIs stemming from natural disasters such as earthquakes, with additional recommendations for these protocols being put forward. 5 Similarly, Benson and colleagues argued that MCIs could be successfully managed by sequentially using the START and SAVE algorithms. The sequential application of these algorithms during the devastating earthquake was observed to yield more favorable outcomes. Upon reviewing the research by Valence and colleagues, the placement of analgesia within MCI management algorithms was contemplated. The article underscores that medications beyond NSAIDs and paracetamol can be administered safely without the delay of establishing IV access, proposing that analgesia should ensue promptly post-START, emphasizing respiratory assessment in a streamlined sequence of simple triage, rapid treatment, and analgesia (START-A). The recent study by Muldowney et al demonstrated the positive impact of analgesia on the respiratory system in patients with chest trauma, suggesting that early and correct analgesia could positively affect many systems, including respiration. 6 Most MCI injuries encompass trauma patients, and providing sufficient prehospital analgesia for trauma patients is recognized as an important area for improvement. 7 As Valence et al emphasized, START-A can offer more comfortable injury management by providing early and effective analgesia, which contributes to patient management, procedural interventions, patient transport, and postincident anxiety management, alongside its humanitarian value.1,8 The Royal College of Emergency Medicine's latest guide on the management of pain in adults emphasizes that recognizing and alleviating pain in the treatment of patients and the injured should be a priority and that this process should start from triage. 9 Recent advancements in analgesic agents, characterized by ease of administration, rapid action, extensive therapeutic indices, minimal cognitive impact, and low incidence of respiratory adverse effects without necessitating constant monitoring, substantiate the integration of the START-A management algorithm in MCIs. 10
In the field of emergency medicine and MCIs, we believe that the START-A mnemonic could bring an innovative approach to triage and emergency intervention processes. This new mnemonic, built upon the traditional START system, considers not only the immediate medical needs of the patients but also their pain management. This holistic approach aims to improve patient comfort and the overall healing process. START-A could set a new standard in emergency medical education and practical applications. This mnemonic could stimulate emergency medical research and contribute to the development of more effective and comprehensive intervention methods. The potential increase in the quality of patient care indicates that this approach could lead to significant changes in health policies and disaster response protocols. Internationally, integrating START-A into emergency medicine and disaster management systems could significantly improve patient care. START-A holds the potential to transform practices and standards in both emergency situations and mass casualty event responses.
In conclusion, combining this research with guideline recommendations, other literature studies, and insights from the February 6 Kahramanmaraş earthquakes suggests that the START-A algorithm, with its sequence of simple triage, rapid treatment, and analgesia, can be successfully implemented in MCI management.
