Transcript START
Simple Triage and Rapid Treatment
Immediate
Patients
Delayed
Deceased
John P. Frey, LP
Objectives
Define START and MCI
Identify the need for START
Learn the START Algorithm
Learn how to effectively use START
Immediate
Patients
Delayed
Deceased
What Problems Might We Find?
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What is an MCI
An event that produces more patients
than you have medics
Produces minimal casualties but has
unusual events surrounding the
incident
HazMat, Rail, Aircraft, Marine
Effects local hospitals ability to
adequately treat patients
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Elements of an Command System
Unified command
Limited span of control
Clear chain of command
Line and staff functions
Intelligence gathering
Flexibility
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Incident Command System (ICS)
ICS is a system of establishing command
and control of an emergency incident
Command
Treatment
Triage
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Transport
Staging
Qualities of a Great Commander
All knowing
Forceful, yet sensitive
Totally calm under fire
Likes dogs and small children
Free of impure thoughts
Brave, clean, honest, trustworthy
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So..Who’s In Charge?
First Responder
EMS
Supervisor
Line Officer
Chief
Governmental Official
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First Responders Responsibility
One member becomes
“Command”
Other members starts the
Triage process
Start calling for any additional
resources that you think you
will need
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Triage
French for “sorting” or “to sort”
A process for determining who to
treat and transport first in the case
of a multi casualty incident (MCI)
Refined during the Vietnam
conflict by military medics
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What is START?
START is an acronym for Simple Triage
And Rapid Treatment
It is a simple step-by-step triage and
treatment method to be used by the first
rescuers responding to a multi casualty
incident. It allows these rescuers to
identify victims at greatest risk for early
death and to provide basic stabilization
maneuvers
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Why START?
Medically responsible
Easily learned
Easily remembered
Clear-cut decision process
Relies only on BLS skills
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3rd Law of the House of God
In cases of cardiac arrest (or triage), the first
thing you do is check your own pulse!
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Your First Action
If you can walk, go stand over there!
All of Ya’ll, go over there! (Texas version )
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The Next Step
Take a DEEP breath
Ensure that your scene is safe
Start to triage all patients that
were unable to move
Spend about 60 seconds/patient
Put triage tag on and note group
Move to the next patient
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START Algorithm (Airway/Breathing)
RESPIRATIONS/VENTILATIONS
NONE
YES
REPOSITION AIRWAY
ASSESS RESPIRATIONS/VENTILATIONS
NONE
YES
> 30/MINUTE
DECEASED
IMMEDIATE
IMMEDIATE
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<30/MINUTE
ASSESS
PERFUSION
START Algorithm (Circulation)
PERFUSION
<2 SECONDS
ASSESS
MENTAL STATUS
> 2 SECONDS
CONTROL
BLEEDING
IMMEDIATE
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START Algorithm (Disability)
MENTAL STATUS
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FOLLOWS
SIMPLE
COMMANDS
FAILS TO FOLLOW
SIMPLE
COMMANDS
DELAYED
IMMEDIATE
Triage Tags (front)
TRANSPORTATION OFFICER
NAME______________________
AMBULANCE _______________
HOSPITAL __________________
PRIORITY-1
2
10945
NAME
AGE
MALE
FEMALE
MEDICATION/TIME:
________________________________
________________________________
________________________________
________________________________
________________________________
10945
Immediate
Patients
IMMEDIATE
10945
DELAY
10945
Delayed
Deceased
Triage Tag (back)
Immediate
IMMEDIATE
Patients
Delayed
DELAY
Deceased
Other Triage ID Methods
Different tags
Bracelets
Duct tape
Survey tape
Marker on forehead
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After Primary Triage
Move to secondary triage
Provide primary treatment
Complete triage tags
Call for necessary transport
Continue to reassess patients
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Field Triage
Primary Triage (Triage)
Implement START
Immediate, life saving care
Secondary Triage (Treatment)
Document information on triage tags
Provide medical treatment
Tertiary Triage (Transport)
Immediate
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Transport patients
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Example 1
57 year old female complaining of
chest pain. Respirations 24,
capillary refill 3 seconds,
responds to all verbal commands
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Triage Tags
TRANSPORTATION OFFICER
NAME______________________
AMBULANCE _______________
HOSPITAL __________________
PRIORITY-1
2
10945
NAME
AGE 57
MALE
FEMALE X
MEDICATION/TIME:
________________________________
________________________________
________________________________
________________________________
________________________________
10945
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IMMEDIATE
Patients
Delayed
Deceased
10945
Example 2
24 Year old male, with a 3’ pole
impaled through his abdomen,
respirations 28, capillary refill <2
seconds, responds to all
commands
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Example 2 Tag
TRANSPORTATION OFFICER
NAME______________________
AMBULANCE _______________
HOSPITAL __________________
PRIORITY-1
2
10945
NAME
AGE 24
MALE X
FEMALE
MEDICATION/TIME:
________________________________
________________________________
________________________________
________________________________
________________________________
10945
Immediate
Patients
IMMEDIATE
10945
DELAY
10945
Delayed
Deceased
Example 2 Tag (back)
Immediate
IMMEDIATE
Patients
Delayed
DELAY
Deceased
Example 3
3 year old child with no obvious
injury. No respirations, capillary
refill 6 seconds, unconscious
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Deceased
Example 3 Tag
TRANSPORTATION OFFICER
NAME______________________
AMBULANCE _______________
HOSPITAL __________________
PRIORITY-1
2
10945
NAME
AGE 3
MALE X
FEMALE
MEDICATION/TIME:
________________________________
________________________________
________________________________
________________________________
________________________________
10945
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Other MCI Concerns
What caused (or is causing) the
problem?
Medical Supplies
Communications
Transportation
Media Coverage
Crowd Control
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What’s Causing the Problem?
Was it an acute event?
Is it still occurring?
Are we in a safe area?
Is a chemical involved?
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Texas A&M Bonfire Collapse
November 18, 1999
2:30 AM bonfire stack collapsed
150 people believed to be on bonfire site
at time of collapse
As stack collapsed, all lighting was
pulled down leaving the area in total
darkness
First Responders reported hearing
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screaming in the darkness
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First Responder Actions
Immediate call for additional help
with description of bonfire collapse
Dispatch issued a MCI and paged all
personnel as well as CSFD and BFD
and Texas Fire Training Center
resources. MCHD ambulances
requested as well.
Fire Department and TxDot light
trucks were immediately called for
Triage started by flashlight
Triage Actions
START was used immediately
Separate Triage areas established
early to isolate patients needing triage
All site resources used the ICS system
for unified incident command.
Command was ultimately run by DPS.
Texas Task Force 1 (FEMA) was
mobilized for specialty rescue
Mobile morgue was sent to site
As the Sun Came Up
Final Outcome
All recoverable patients triaged and
transported in less than 1 hour
Last bodies recovered about 20 hours
after the collapse
27 patients injured, 12 killed
Investigative committees universally
credited first responders with saving
many lives
So....How does this apply to me?
Major incidents can occur
First responders are generally involved in
these incidents
Most responders face few large incidents
in their career
Preparation is the key to successful
handling of these incidents
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START Card
WALKING WOUNDED - Walks
and follows commands
IMMEDIATE - Respirations
greater than 30; capillary refill 2
sec's or longer; mental
confusion or no response
START Triage Steps:
1. “If you can get up and walk,
follow me”
2. Respiration
Perfusion
DELAYED - Cannot walk;
respirations less than 30; Cap
refill less than 2 sec's; responds
to questions
Mental Status
3. “Thirty and two, can do”
DECEASED - Patient with no
respirations after one attempt to
manually establish an airway
Front
Back
Additional Resources
The EMS Incident
Management System,
Christen/Maniscalco (Brady)
START Training Manual Texas
Department of Health
http://www.tdh.state.tx.us/hcqs/
ems/startman.exe
Questions