Clostridium botulinum toxins, the most poisonous substance known to humankind, are considered to be a [US] Centers for Disease Control and Prevention Category A bioterrorist agent. Despite this concern, little has been published with regard to the tactical aspects of triaging a mass-casualty event involving botulism victims arriving at an emergency department. Because neuromuscular-ventilatory failure is a principal reason for botulism's early morbidity and mortality, using a quick and sensitive test to evaluate this possibility is imperative. The purpose of this article is to propose the adoption of the Single-Breath-Count Test (SBCT). The ease and validity of the use of the SBCT in evaluating complications associated with various neuromuscular disorders make it an attractive adjunct for triage during a mass-casualty incident due to botulism. While education, immune globulin, antitoxin, and invasive airway techniques are well-recognized steps in treating botulism, incorporating a time-honored technique such as the SBCT, will be an important addition to the triage process.

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Purpose: To describe the events that occurred on 1 July 1993 when a man entered a high-rise office tower in downtown San Francisco armed with semi-automatic handguns. Traveling through four floors of the 48-story building, the assailant shot 14 people before turning the gun on himself. Methods: Debriefings and interviews were performed with prehospital care providers, managers, dispatchers, trauma and emergency department physicians and staff, and police and fire personnel. Results: This multiple casualty incident (MCI) avoided the usual lack of central coordination that often impedes effective dispersal of victims to definitive care in a timely manner. However, communications problems secondary to radio reception voids as well as structural and logistical challenges related to the vertically oriented tactical situation were identified and reviewed. Conclusion: This event and its management provided a real-life test of the city's prehospital MCI plan as well as a test of the city's sole trauma center's and emergency department readiness to handle a MCI. The implications for prehospital disaster planning and trauma/emergency services was presented.

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