Terrorism & EMS
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Transcript Terrorism & EMS
So, How Did You Do?
NACCHO 02-2006
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MCI Triage:
2006 Advanced Practice Centers
for Preparedness
Training Conference
v. 01282006
NACCHO 02-2006
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Why Am I Here?
In a disaster, needs exceed resources
More patients than providers
Difficult choices must be made
Who receives care now?
Who does not?
How do I decide?
...TRIAGE
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Triage and Public Health
Competencies
CDC & CUSN-CHP (2002).
Bioterrorism & Emergency Readiness:
Competencies for All Public Health Workers, p. 12
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Objectives
Define “Triage”
Identify goals of MCI triage
Implement “MASS” Triage
Classify MCI victims by “ID-me”
categories
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In a Perfect World...
First responders respond to scene
Patients are triaged in the field
HazMat handles decon in the field
Sickest patients arrive with EMS:
►Already sorted and tagged
►Already decontaminated
►Already partially treated
All “we” have to do is take care of them!
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What REALLY Happens...
“Chaotic” phase: 15-25 min
No EMS, no scene leader
80% of minimally injured selftransport
They arrive at closest
hospitals:
► NO TRIAGE
► NO DECONTAMINATION
► NO MEDICAL
INTERVENTION
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Another Awful Thought...
Hospital as “Hot Zone”
Or....
It’s your “off “day
Or…
Flu Pandemic, Bioterrorism…
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Triage: Definition
Sorting of patients
by seriousness of
condition and
likelihood of
survival
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Triage: Goals
Primary Goal:
►Greatest good for the greatest
number of possible survivors
Secondary Goal:
►Relief of suffering
Depend on available resources
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Triage Systems
Multiple triage systems in use
Various methods using tags, categories,
colors, symbols
Familiarize yourself with your agency’s
system and PRACTICE it
IDEAL = one uniform system used by all
agencies in the field & at hospitals
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“M.A.S.S.” Triage
M – Move
A – Assess
S – Sort
S – Send
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“M.A.S.S.” Triage
Developed by the military
Tested & used by the military
Adapted for civilian disasters
It works!
►Fast
►Accurate (70%)
►Can handle large numbers of victims
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“M.A.S.S.” Triage
1. GROUP victims first...
then....
2. ...ASSESS individual victims
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Basis of
“M.A.S.S.” Triage
Ability to MOVE best predicts survival
►Head Injury patients
Glasgow Coma Scale (GCS)
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“M.A.S.S.” Triage
“MOVE”: STEP 1
Goal:
►Group - Victims who can WALK
Action:
►“Everyone who can hear me and
who can walk, please move to the
area with the green flag.”
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MINIMAL
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Why Bother With Them
FIRST?
MINIMAL group: major vital functions intact
►Assess last, after more critical groups
However, actively managing this group may:
► Facilitate scene management
► Conserve scene resources
► Reduce self-transports & overburdening of
nearest hospital ERs
Caveats:
► No individual assessment, yet
► Worsening conditions
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“M.A.S.S.” Triage
“MOVE”: STEP 2
Goal:
►Group – Victims who can’t walk, but
who can MOVE
Action:
►Ask the remaining victims
“Everyone who can hear me and
needs help, please raise an arm or
leg so we can come help you.”
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DELAYED
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“M.A.S.S.” Triage
“ASSESS”:
Goal:
►Group – Identify who is left, victims unable
to walk & unable to follow simple
commands to move
Action:
►Go immediately to these patients for life-
saving interventions (if medically trained)
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“M.A.S.S.” Triage
“ASSESS” IMMEDIATE patients:
Goal:
►Accurate count of IMMEDIATE patients
Action:
►Rapidly Assess ABCs
►If not EXPECTANT or already DEAD
►Correct immediate life threats…
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“M.A.S.S.” Triage
“ASSESS” IMMEDIATE patients:
www.rk19-bielefeld-mitte.de
►Open Airway
►Stop Bleeding
www.tpub.com
www.meridianmeds.com
►Give Chemical antidote
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“M.A.S.S.” Triage
“ASSESS” IMMEDIATE patients:
►Open Airway
►Stop Bleeding
►Give Chemical antidote
Pressure Points
Whatever it takes! Be creative!
Tourniquets
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“M.A.S.S.” Triage
“ASSESS” IMMEDIATE patients:
Question:
►Is transport available?
Move on!
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Victim Group Summary
Goal
Action
Group
ambulatory
patients
“Everyone who can
hear me and needs
medical attention,
move to the area with
the green flag”
Group awake,
can follow
commands
Identify who is
left
“Everyone who can
hear me, raise an arm
or leg so we can come
help you”
Delayed
Go immediately to
these patients for lifesaving interventions
Immediate
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ID-me
Group
Minimal
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ONLY NOW Do We Assess
Individuals
Having grouped victims according to
their ability to move...
...The next phase entails more detailed
individual assessment.
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“M.A.S.S.” Triage
“SORT”:
Goal:
►Sort patients based upon INDIVIDUAL
assessment
Actions:
►Assign to “ID-me” Categories:
IMMEDIATE, DELAYED, MINIMAL, EXPECTANT
►Continue treatment
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“M.A.S.S.” Triage
“SORT”:
Start with those who could MOVE
►Unless sufficient personnel for all
groups
Ideal: trained medical personnel
►May not be available
Tag immediately upon triage
►Including dead victims
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There Are Many Different
Patient Assessment Tools
www.usmc.mil/marinelink/mcn2000
CERT L.A. 2003
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START
Triage
“R”
“P”
“M”
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“ID-me” Categories
I - IMMEDIATE
D - DELAYED
M - MINIMAL
E - EXPECTANT
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EXPECTANT
LETHAL INJURY
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“M.A.S.S.” Triage
“SORT” – IMMEDIATE:
Life- or Limb-threatening injury
Airway, Breathing or Circulation Problem
Unconscious
Examples:
► Unresponsive, altered level of consciousness,
severe breathing difficulty, uncontrollable
bleeding, amputations above elbow or knee,
blue skin color, rapid or weak pulse, open
abdominal wounds, etc.
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“M.A.S.S.” Triage
“SORT” – DELAYED:
Need definitive medical care, but should
not worsen rapidly, if initial care is
delayed
Examples:
►Deep cuts or open fractures with
controlled bleeding and strong pulses,
finger amputations, abdominal injuries
with stable vital signs, closed head
injuries without altered LOC, etc.
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“M.A.S.S.” Triage
“SORT” – MINIMAL:
“Walking wounded”
Group, sort & facilitate transport from
scene
Volunteer help? Risk vs. Benefit
Examples:
►Scrapes, bruises, minor cuts, no
apparent injuries
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“M.A.S.S.” Triage
“SORT” – EXPECTANT :
Most severely injured with little chance of
survival
They are “expected” to die soon
In a perfect world, they would receive the
most care, even though chance of survival
is low
In an MCI....
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“M.A.S.S.” Triage
“SORT” – EXPECTANT :
Care resources NOT utilized initially
Comfort care as available
► Death could be hours or days away!
Reassessment & transport
► Transport those still alive after all
IMMEDIATE victims evacuated
► Resuscitate & treat as resources allow
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“M.A.S.S.” Triage
“SORT” – EXPECTANT :
Examples:
►Near 100 % burns
►Fatal radiation doses
►Absent pulse or breathing
Especially if multiple injuries
►Severe open brain injury
►Death “imminent”
“Judgment call”
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Triage Caveats
OVER-TRIAGE:
►Tendency to classify all victims as
IMMEDIATE
Defeats the purpose!
►Ruptured eardrums, chronic hearing loss,
language barrier, developmental handicaps,
etc.
Cannot respond to “MASS” commands
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Other Triage Caveats
UNDER-TRIAGE:
►Initial grouping ≠ individual assessment
►Worsening patient conditions:
Internal or external bleeding, shock
Closed head injury
Blast injury to lung, gut, brain
Airway swelling
Delayed chemical exposure symptom onset
Etc.
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“M.A.S.S.” Triage
“SORT” process is dynamic:
►Resources change
►Patient conditions change
Frequent reassessment
▲All categories
EXPECTANT may become IMMEDIATE
►“Most serious” injury present demands
“immediate” attention!
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Triage Tags
Tag immediately after sorting
►Tie triage tag directly to patient
►May need to improvise tags (tape, exam
gloves, cloth)
►May need to write on patient (lipstick, marker)
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Wrapping up the SORT...
When all patients have been triaged
and tagged:
►Count all IMMEDIATES
►Advise incident commander or
transport officer of number
Take all IMMEDIATES to collection
point for urgent transport
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“M.A.S.S.” Triage
“SEND”:
Objective:
►Transport or release ALL
living patients ASAP
Traditional sequence:
► IMMEDIATE
► DELAYED
► MINIMAL
►
EXPECTANT
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“M.A.S.S.” Triage
“SEND”:
Be mission-focused:
►Send MINIMALS or DELAYEDS with each
IMMEDIATE, if space allows
Be resourceful:
►Secondary treatment facilities for
MINIMALS
Be creative:
►Buses, taxis, trains, boats, etc.
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What About The DEAD?
Should NOT be moved or sent
►1 EXCEPTION?
Medical examiner / coroner:
►Identification of remains
►Disposition of remains
Crime scene investigation:
►Evidence must be preserved
►Apprehend perpetrators and prevent
future attacks
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The Need To Drill
Regardless of which triage
system your agency favors...
...Practice, practice, practice!
► “TRIAGE TAG TUESDAY”
Preparation will promote
more efficient triage in an
actual MCI
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When All Is Said and
Done...
MCI Triage is NOT “business as usual”
►Difficult decisions must be made
►Fatalities and suffering are likely
“Gut check” for healthcare providers
“Non-medical” people can participate
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Summary: Now you can
Define “Triage”
Identify goals of MCI triage
Implement “MASS” Triage
Classify MCI victims by “ID-me”
categories
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Thank You!
Questions?
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