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
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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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