A SHTF Guide to Mass Casualty Incidents, by W.G. Curry, NRP, TP-C

I’ve written this article with a hypothetical situation interspersed between
some factual text:

Your eyelids peel apart and allow dust to fall onto your eyes as you force them open and shut while rubbing them with filthy fists in an effort to washout some of the debris. The ringing noise is loud in your ears. “I wish it would stop,” you declare to yourself. A terrible ache forms in the depth of your skull. You ache all over. “What happened, where am I,” you ask? As your blurry vision begins to brighten and sharpen, you can see ash in the air,you can taste the metallic tinge of blood at your tongue as it parts your lips to feed your burning lungs with their much needed meal of fresh air. The ringing in your ear is fading in and out as you begin to make out different pitches of rings. Focusing even more, you begin to separate a new sound completely from the ringing. Screams. Those are screams. Everything rushes back to you now in one cinematic recollection. You were at the United States Holocaust Museum when a thunder of ear-shattering noise collapsed the roof of the exhibit…

That “thunder” that you recalled was the sound of an explosive device that was detonated a mere 100 feet away. Making your way to your feet, you see that the sharp pain in your back was large piece of concrete. Frustrated with it, you kick it away and it reveals a sign that had previously been on a wall.Through the dust you read “Hope is like peace. It is not a gift from God. It is a gift only we can give one another.” A quote by Elie Wiesel, a holocaust survivor. Reading this eases the brewing anxiety growing in your abdomen.Realizing that perhaps you are better off than some of your fellow Americans nearby, you decide to take action and help. You rush the ten feet to the first victim and curse the museum rules, realizing that your EDC bag is in your car;a 20 minute train ride away. It had bandages and a tourniquet. You drop to your knees and look down on a woman in her mid-twenties covered in ash and breathing hard, but she is unconscious. Her body is all grey except for the bright red blood spurting out from her smashed and mangled arm pinned beneath the concrete. As you think to yourself what to do first you are suddenly halted internally by a flash of adrenaline. Everything in the room gets a bit brighter, you notice you are breathing heavier and faster. Your fingers tremble. You don’t know what to do. Where do you start?


The Simple Acronym to Guide Your Aid: S-A-L-T

SALT is a form of systematic mass casualty triage that has been endorsed nationally by most medical associations and emergency organizations. My aim here, is to provide a simple way to understand and remember the importance of sorting and treating casualties in the event of horrible incident.

Although many emergency organizations are implementing new ways to coordinate and handle mass casualty incidents, the best first-line protection for the wounded may be the not-so-wounded.

The original and official acronym stands for Sort, Assess, Life-Saving Interventions, and Treatment/Transport.

For a mass casualty scenario before each person is assessed, we are only concerned with providing two types of aid:

1) Bleeding, and

2) Breathing.

SALT will help you determine how to start and stop your aid to others. Here is how SALT can be interpreted for those of you with no first responder training:

Sort – Sort out yourself and others by telling everyone to get up and starting helping others. What this does is immediately identify those that DON OT need immediate help.

Assess – Start vigilantly looking around to see if the environment is still unsafe. Check for hazards like fires, active shooters, or whatever is relevant and/or obviously dangerous. If you have concluded that the worst is over, begin to assess those in need of help.

Life Saving – The most important thing you can do is control severe bleeding. I am not referring to dark-red blood that oozes from an ear, but blood that is spurting each time the victim’s heart beats. We will discuss methods later. Next, if the patient is unconscious, open their airway and see if they begin breathing. If they are already breathing you need to lay them on their side, in the fetal position, and move on to the next victim. If they are not breathing after you have opened their airway, then move on to the next victim and realize that helping everyone is not always feasible. Bleeding or not, and breathing or not, it is very easy to allow yourself to become consumed and distracted by other injuries, which means less people get your help. As bad as a broken shin may look with bone sticking out and dried blood everywhere added to a victim screaming in pain, that patient doesn’t need you like the unconscious person 10 feet away who needs to have their airway opened.

Treat/Transport – The best things to do at this phase of SALT is to get people to safety or to places that first responders can more easily access.Once all of the people that can easily be moved have been, then begin treating what injuries you can on the patients that are still trapped, unable to easily move, or difficult to get to. Know and remember that a victim’s stability can change at any moment so each time they are moved, and periodically while stationary, you need to always continue to check for heavy bleeding and the presence of breathing.

Bleeding Control Techniques:

Plain and simple, if the bleeding is massive and coming out fast from a limb while spurting from the heart’s beat, then it needs a tourniquet.Commercially made tourniquets are produced and for sale, but typically aren’t available when citizens need them most and may present some legal issues when used by non-healthcare or non-trained personnel. One can fashion a tourniquet quite easily with common items. What is important is what not to use more so than what to use. Do not use anything that will cut into the skin when tightened. Examples would be: electrical wire or cordage, shoe strings, etc.Using things thin in width will not adequately cut off blood flow in an artery and will usually slice into the skin. Anything wide like a belt, a tee shirt,or a cutoff strap from a book bag should work so long as you can get it tight enough. The only two other things that are extremely important are how tight to tighten it and where to put it. You should already know, or should learn how,to check for a pulse at the wrist and at the ankle. This is crucial, because tourniquets need to be tightened tight enough to stop the pulse. This means finding and feeling a pulse as you are tightening it, or having someone else feel it. Most EMT and First Aid courses and textbooks recommend that you place a tourniquet two to three inches above the wound. However, what if the foot or hand is amputated? The shin and forearm are not the best places for tourniquet placement because the arteries run between the bones and require much more pressure on tightening them to actually stop blood flow, whereas the upper leg and arm has only one bone and the artery can be clamped against it. After all,the point isn’t to slow blood flow, but to stop blood flow. So, my recommendation is that regardless of where the wound is, place the tourniquet as high on the groin or armpit as possible. Always remember to continue to check tourniquets periodically, especially when using an improvised tourniquet as they could loosen, causing the victim to bleed out even faster than before.


…You drop to your knees and look down on a woman in her mid-twenties covered in ash and breathing hard, but she is unconscious. Her body is all grey except for the bright red blood spurting out from her smashed and mangled arm pinned beneath the concrete. Remembering the SALT acronym, you quickly remember to shout out for people to get up and help if they can and that next is the Life-Saving phase. “Bleeding first, then breathing, bleeding then breathing,” you think. You pull off your leather belt and wrap it around her upper arm near the shoulder and loop it through the buckle, pulling it backwards towards you to get it snug. You reach down to put two fingers on the wrist to feel a pulse but see that it is pinned beneath a massive piece of concrete. As you start cranking down on the belt to pull it as tight as you can, you notice the gaping hole no longer has blood spraying from it and is only dripping from being so saturated with blood. Securing the belt so that it tays tight, you begin to look around and see several other people rushing to the aid of others. You stand and move quickly to the next victim and point at two people standing, looking terrified at the scene in front of them. “You two, start trying to find us an exit, there is no way to bring stretchers inhere for these people and we need to get them outside!” They take off in a frantic hurry. Kneeling beside the next casualty, you see that his stomach and chest are both still, motionless and lifeless. As he lay lifeless on his back,you fight back the fear building inside of you as you lift his chin towards the sky, lifting his tongue off the back of his throat. Knowing that this would have allowed for him to take a breath if he was capable of doing so, and that he didn’t, you say a quiet “sorry” and promptly move on to the next person. The next person that no one is helping is an elderly woman who does not appear to be bleeding anywhere but has bruises all over her limbs. As you look to see if she is breathing, you see that she is, in fact she is breathing so hard that she is snoring, but she is unconscious. Unsure of how to proceed, you think of SALT again…


Breathing Assistance:

Most people are able to ascertain whether a person is breathing or not by looking at their stomach or chest. Following the SALT method, you either see that they are breathing and move on, or you notice they are not breathing and make an attempt to open their airway. Most of the time, the airway is shut off by the tongue falling back slightly and not allowing air to enter the lungs.The easiest way to help this is by turning someone on their side. This keeps the tongue out of the way and allows air to move freely, plus it allows fluids like vomit and blood to drain out rather than into the lungs. When turning someone on their side, lay their head against the inside of their upper arm and whatever leg is higher, bend it and lay it on the ground if it is uninjured.This will help stabilize them and prevent them from rolling back onto their back.


…The next person that no one is helping is an elderly woman who does not appear to be bleeding anywhere but has bruises all over her limbs. As you look to see if she is breathing, you see that she is, in fact she is breathing so hard that she is snoring, but she is unconscious. You roll her to her rights ide placing her head on her bicep and you move her left leg off of the right leg and on the ground. To your astonishment, her snoring stops and she lets outa hard cough that jettisons vomit onto her arm and the dust covered ground.Standing up, the two people that you instructed to find an exit come jogging up to you reporting that the main entrance is mostly open. Just as you shout to everyone to let them know, you are interrupted by the sound of not just one,but many sirens in the distance.


My purpose in writing this article is to empower the prepper community with some basic knowledge of how to help during a disaster as well as to advocate that if you have not sought out medical training, that you should. Learn the basics and practice them. Many areas have volunteer positions where you can practice skills like CPR and most companies can spare the money to put an employee through First Aid training.

Although I mentioned CPR, I do find it necessary to provide an opinion about its use in a SHTF scenario. Each day, thousands of people go into sudden cardiac arrest and desperately need Cardiopulmonary Resuscitation to survive.No one can deny that. However, in the prepping community, I see a lot of folks advocating CPR training, to my surprise. On one hand, CPR is a skill that I believe should at the beginning of any medical training, and is a course that I believe should be taught at every middle and high school in the nation, but CPR does not have much place in a SHTF or TEOTWAWAKI situation. Cardiac arrest victims who are successfully resuscitated by CPR typically had an underlying condition that caused it and often require several days to weeks in an Intensive Care Unit to make any level of recovery. Please do not think that I mean CPR has no place in a bad situation, it very well may. Rather, what I am saying is that there are many situations where it does not as well, and I hope that individuals consider this when faced with the situation. Start with a CPR class that includes First Aid and AED training. Then challenge yourself to attend alternative first aid courses like wilderness first aid, or even volunteer as an EMT at a rescue squad. Whatever you do, never stop preparing.

About The Author: I am W.G. Curry, a Nationally Registered Paramedic and EMT, a Certified Tactical Paramedic, Tactical Combat Casualty Care Provider, and CPR instructor that has seven years of Combat Arms experience from the U.S. Army as well as an advocate that we all be vigilant,prepared, and loyal to those that we cherish. Be safe!