Challenges of Triage in Mass Casualty Incidents from the Perspective of Emergency medical technicians: A Qualitative Content Analysis Study

When a disaster strikes—a bus crash, an earthquake, or a fire—the first few minutes are often the difference between life and death. In these chaotic moments, a specialized system called triage acts as the brain of the emergency response. Triage is the process of quickly sorting injured people based on how badly they need help, ensuring that limited medical resources go to those who will survive if treated immediately. This system relies heavily on emergency medical technicians, the skilled professionals who arrive first at the scene. Their job is not just to treat patients, but to make rapid, life-or-death decisions while surrounded by confusion, noise, and fear. If this sorting process breaks down, the entire chain of survival can collapse, leaving the most critical victims without care. Understanding how these professionals navigate such high-pressure environments is essential for improving how societies respond to tragedy.

A recent study conducted by researchers at Fasa University of Medical Sciences in southern Iran sought to understand exactly what gets in the way of this critical work. The team interviewed eighteen emergency medical technicians who had experience handling mass casualty incidents. These are events where the number of injured people overwhelms the available help. The researchers did not simply ask for statistics; they sat down with these workers for deep, hour-long conversations, asking them to describe their real-world experiences, the obstacles they faced, and the moments where the system failed them. By listening closely to these stories, the researchers uncovered a complex web of challenges that go far beyond simple medical training. They found that the ability to save lives is often held back not by a lack of courage, but by broken communication lines, missing equipment, and the overwhelming pressure of the crowd.

The most fundamental barrier identified was a breakdown in communication. The technicians described a system where the people answering the emergency calls often lacked the specific experience needed to understand the scale of a disaster. When a call comes in, the dispatcher is supposed to send the right amount of help, but if they do not know how many people are hurt or what kind of vehicles are involved, the response is delayed or mismatched. One technician recounted arriving at a scene only to find a massive number of injured people because the dispatcher had underestimated the situation. Beyond human error, the physical tools for communication were often missing. In remote areas or after earthquakes, mobile phone networks and radio signals frequently fail. Technicians described having to run kilometers away from the injured, leaving patients behind, just to find a spot with a signal to call for more ambulances. This simple act of trying to make a phone call can cost precious minutes that a patient does not have.

Even when communication works, the resources on the ground are often insufficient. The study highlighted a severe shortage of ambulances and medical supplies. In some cases, an ambulance would break down, forcing a neighboring team to cover a much larger area, which meant they arrived late or with only one vehicle for a huge number of victims. The human element was equally strained. The technicians spoke of the intense psychological pressure of facing a chaotic scene alone. Many admitted that despite their university training, the reality of a mass casualty event was terrifying. They described their hands shaking and their minds freezing when confronted with dozens of injured people and screaming families. The system often lacked enough trained specialists to manage the scene, leaving general staff to make impossible decisions without a clear leader to guide them.

The chaos at the scene was frequently made worse by a lack of coordinated leadership. When multiple emergency groups arrive—such as police, fire departments, and medical teams—they often operate without a single unified commander. The study found that different groups would give conflicting instructions, telling technicians to move patients in ways that contradicted medical priorities. One participant described a scene where everyone was shouting different orders, creating a disorder that made it impossible to sort the injured effectively. Without a clear chain of command, the most critical patients might be overlooked while less urgent cases are moved first, simply because no one was in charge of making the final call.

Perhaps the most unpredictable challenge came from the public itself. The researchers found that the behavior of bystanders and family members could severely disrupt the medical process. Curious onlookers often parked their cars in front of the scene, blocking the ambulances from reaching the injured. Family members, driven by panic and love, would sometimes physically grab technicians, demanding that their relative be treated first, regardless of how badly they were hurt. In the most extreme cases, this fear turned into violence. Technicians reported being threatened with weapons or physically assaulted by angry relatives. In these moments, the medical staff had to stop treating patients to protect their own safety, leaving the injured waiting in the dust. The study suggests that these sociocultural factors create a heavy psychological burden, forcing technicians to fight not just for their patients, but for their own right to work.

The researchers concluded that these challenges are deeply interconnected. A failure in communication leads to a lack of resources; a lack of resources increases the stress on the staff; and the stress, combined with a chaotic crowd, makes effective management nearly impossible. The study does not claim to have solved these problems, but it provides a clear map of where the system is failing. The authors suggest that to fix this, emergency managers need to look beyond just buying more equipment. They must invest in better training for dispatchers, build more reliable communication networks that work in remote areas, and establish clear leadership structures that all emergency groups can follow. Most importantly, they need to address the relationship between emergency workers and the public, finding ways to manage crowds and protect staff so that the sorting of the injured can happen without interruption. The path to saving more lives in future disasters lies in understanding that the medical team is only one part of a much larger, and often fragile, system.