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TX EMS 20081 MCI Triage: A Cure For A MASSive Headache Ronna G. Miller, MD EMS/Disaster Medicine/Homeland Security Section UT Southwestern Department of.

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Presentation on theme: "TX EMS 20081 MCI Triage: A Cure For A MASSive Headache Ronna G. Miller, MD EMS/Disaster Medicine/Homeland Security Section UT Southwestern Department of."— Presentation transcript:

1 TX EMS MCI Triage: A Cure For A MASSive Headache Ronna G. Miller, MD EMS/Disaster Medicine/Homeland Security Section UT Southwestern Department of Surgery Texas EMS Conference 2008

2 TX EMS The Fine Print Successful completion of this activity is based upon your attendance for the entire presentation. Successful completion of this activity is based upon your attendance for the entire presentation. The presenter has no commercial support, or other affiliations relating to a possible conflict of interest to disclose. The presenter has no commercial support, or other affiliations relating to a possible conflict of interest to disclose. There will be no discussion of off-label usage or product endorsement during this course. There will be no discussion of off-label usage or product endorsement during this course. The content of this presentation is designed for educational purposes only. The content of this presentation is designed for educational purposes only. The author has made every effort to verify the information presented, but neither the accuracy nor the completeness of this information can be guaranteed. The author has made every effort to verify the information presented, but neither the accuracy nor the completeness of this information can be guaranteed. The participant assumes all risks in using the information. The participant assumes all risks in using the information. The author shall not be held responsible for errors or omissions or held liable for any damages incurred as a result of use or reliance upon the material presented. The author shall not be held responsible for errors or omissions or held liable for any damages incurred as a result of use or reliance upon the material presented.

3 TX EMS Objectives Define MCI and Triage Define MCI and Triage Discuss goals of MCI triage Discuss goals of MCI triage Perform simulated MASS Triage Perform simulated MASS Triage Classify simulated MCI victims by ID-me categories Classify simulated MCI victims by ID-me categories Describe life-saving interventions during MCI victim triage Describe life-saving interventions during MCI victim triage Identify specific all-hazards triage concerns Identify specific all-hazards triage concerns

4 TX EMS Brief questionnaire Brief questionnaire Interactive mass cal simulation: Part 1 Interactive mass cal simulation: Part 1 Didactic presentation Didactic presentation Interactive mass cal simulation: Part 2 Interactive mass cal simulation: Part 2 The Plan

5 TX EMS Question 1 Which of the following best describes you? Which of the following best describes you? A.ECA B.EMT-B C.EMT-I D.EMT-P E.Physician F.RN G.Other

6 TX EMS Question 2 Which best describes the geographical area where you work? Which best describes the geographical area where you work? A.Rural B.Suburban C.Urban (city < 100,000) D.Urban (city 100,000) E.None of the above

7 TX EMS Question 3 Which one of the following is your primary type of EMS/healthcare service? Which one of the following is your primary type of EMS/healthcare service? A.Rural EMS (non-transporting) B.Rural EMS (transporting) C.Urban-Fire/EMS D.Urban-Third Service EMS E.Aeromedical F.Interfacility Transport Only G.Hospital-Based H.Student I.Retired J.Other

8 TX EMS Question 4 How long have you worked in EMS/healthcare? How long have you worked in EMS/healthcare? A.Less than 2 years B.2 to 5 years C.5 to 10 years D.10 to 15 years E.More than 15 years

9 TX EMS Question 5 Have you ever had formal classroom training in mass casualty triage? Have you ever had formal classroom training in mass casualty triage? A.Yes B.No

10 TX EMS Question 6 Have you ever participated in a hands- on mass casualty simulation or drill in which you triaged victims? Have you ever participated in a hands- on mass casualty simulation or drill in which you triaged victims? A.Yes B.No

11 TX EMS Question 7 Have you ever had to triage patients in an actual mass casualty incident? Have you ever had to triage patients in an actual mass casualty incident? A.Yes B.No

12 TX EMS Question 8 If yes, what triage method or system did you use during that incident? If yes, what triage method or system did you use during that incident? A.I answered No to Question 7 B.MASS C.START D.SAVE E.Sacco ® F.Military G.Other H.Dont Know

13 TX EMS Question 9 If yes, did you feel confident in your triage decisions during that incident? If yes, did you feel confident in your triage decisions during that incident? A.I answered No to Question 7 B.Yes C.No

14 TX EMS Question 10 Did you participate in relief efforts to provide medical care to evacuees after Hurricanes Katrina or Rita? Did you participate in relief efforts to provide medical care to evacuees after Hurricanes Katrina or Rita? A.Yes B.No

15 TX EMS Question 11 Is knowing how to perform mass casualty triage part of your professional responsibilities? Is knowing how to perform mass casualty triage part of your professional responsibilities? A.Yes B.No

16 TX EMS Question 12 What is the likelihood, in your opinion, that you would ever be called upon to perform mass casualty triage in the future? What is the likelihood, in your opinion, that you would ever be called upon to perform mass casualty triage in the future? A.Very likely B.Likely C.Neutral D.Unlikely E.Very unlikely

17 TX EMS Question 13 If there were an explosion at this location right now, how confident are you that you would be able to rapidly and accurately triage victims? If there were an explosion at this location right now, how confident are you that you would be able to rapidly and accurately triage victims? A.Very confident B.Somewhat confident C.Neutral D.Somewhat unsure E.Very unsure

18 TX EMS Lets Begin!

19 TX EMS

20 TX EMS Victim 1 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

21 TX EMS Victim 2 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

22 TX EMS Victim 3 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

23 TX EMS Victim 4 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

24 TX EMS Victim 5 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

25 TX EMS Victim 6 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

26 TX EMS Victim 7 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

27 TX EMS Victim 8 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

28 TX EMS Victim 9 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

29 TX EMS Victim 10 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

30 TX EMS Victim 11 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

31 TX EMS Victim 12 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

32 TX EMS MCI Triage: A Cure For A MASSive Headache Ronna G. Miller, MD EMS/Disaster Medicine/Homeland Security Section UT Southwestern Department of Surgery Texas EMS Conference 2008

33 TX EMS This is NOT a good thing!

34 TX EMS Why Am I Here? How do I decide who receives care now and who does not? In a disaster, needs exceed resources In a disaster, needs exceed resources More patients than providers More patients than providers Difficult choices must be made Difficult choices must be made

35 1942, Boston, MA 492 dead 2003, Warwick, RI 100 dead IS TRIAGE NEEDED HERE? Boston Globe AP Photo Boston Globe

36 TX EMS AP photo: Matt Slocum September 23, 2005 Wilmer, TX August 2, 1985 Dallas, TX Triage Typically Means Trauma

37 TX EMS Add Photos London? London? Madrid? Madrid? LA train? LA train? NYC crane? NYC crane?

38 TX EMS What About Medical Triage?

39 TX EMS Triage: Its not in my job description!

40 TX EMS Business As Usual Resources exceed demand Resources exceed demand

41 TX EMS The Perfect World of MCI Response First responders respond to scene First responders respond to scene Patients are triaged in the field Patients are triaged in the field HazMat handles decon in the field HazMat handles decon in the field Sickest patients arrive with EMS: Sickest patients arrive with EMS: Already sorted and tagged Already sorted and tagged Already decontaminated Already decontaminated Already partially treated Already partially treated Hospitals only need to care for them... Hospitals only need to care for them...

42 TX EMS What REALLY Happens... Chaotic phase: min Chaotic phase: min No EMS, no scene leader No EMS, no scene leader 80% of minimally injured self- transport 80% of minimally injured self- transport They arrive at closest hospitals: They arrive at closest hospitals: NO TRIAGE NO TRIAGE NO DECONTAMINATION NO DECONTAMINATION NO MEDICAL INTERVENTION NO MEDICAL INTERVENTION

43 TX EMS Mass Casualty Predictor

44 TX EMS Another Awful Thought... Hospital as Hot Zone Hospital as Hot ZoneOr.... Its your off day Its your off dayOr… Flu Pandemic, Bioterrorism… Flu Pandemic, Bioterrorism…

45 TX EMS Definitions

46 TX EMS MCI: Definition Mass Casualty Incident Mass Casualty Incident Major Casualty Incident Major Casualty Incident Multiple Casualty Incident Multiple Casualty Incident Healthcare needs exceed resources! Healthcare needs exceed resources! Resources must be rationed! Resources must be rationed!

47 Adapted from Heightman AJ (2006). JEMS 31(4):16.

48 TX EMS Your Own Safety Comes First! We all want to help We all want to help Triage is an important part Triage is an important part However, your first priority is to PROTECT YOURSELF! However, your first priority is to PROTECT YOURSELF! You dont need to die! You dont need to die!

49 TX EMS Before Any Casualty Care... Scene Size-Up – Scene Safety Scene Size-Up – Scene Safety Incident Survey BEFORE Casualty Survey Incident Survey BEFORE Casualty Survey

50 TX EMS RED Survey Rapid Evaluation of DisasterRapid Evaluation of Disaster Incident Survey Incident Survey BEFORE patient care! BEFORE patient care! Casualty Survey Casualty Survey Life-saving Interventions Life-saving Interventions

51 TX EMS All-Hazards: Definition Man-made or natural events with destructive capability for multiple casualties Man-made or natural events with destructive capability for multiple casualties Graniteville, SC – January 2005 La Conchita, CA – January 2005

52 TX EMS All-Hazards Examples Natural NaturalEarthquakes Landslides & Avalanches VolcanoesTornadoesHurricanes Floods & Flash Floods TsunamisWildfires Emerging Infectious Diseases Man-made Man-made Structure Fires Structure Collapses Explosive Devices Transportation Events: Air, Rail, Roadway, Water Air, Rail, Roadway, Water Industrial HazMat Events Terrorism Incidents: CBRNE events, Firearms CBRNE events, Firearms

53 TX EMS Triage: Definition Sorting of patients by seriousness of condition and likelihood of survival Sorting of patients by seriousness of condition and likelihood of survival

54 TX EMS Triage Levels Primary (scene & hospital) Primary (scene & hospital) Physiology: Physiology: Can patient use his own resources to deal w/injuries? Can patient use his own resources to deal w/injuries? Which conditions will benefit from use of scarce resources? Which conditions will benefit from use of scarce resources? Secondary (scene & hospital) Secondary (scene & hospital) Match patients current & anticipated needs with available resources Match patients current & anticipated needs with available resources Physiology, Physical Assessment, Initial Treatment & Reassessment, Knowledge of Resource Availability Physiology, Physical Assessment, Initial Treatment & Reassessment, Knowledge of Resource Availability Tertiary (hospital) Tertiary (hospital) Optimize individual outcome Optimize individual outcome Higher-level Treatment & Reassessment, Further Resource Assessment, Determination of Best Venue for Definitive Care Higher-level Treatment & Reassessment, Further Resource Assessment, Determination of Best Venue for Definitive Care

55 TX EMS Triage: History Trier: French for to sort Trier: French for to sort 18 th century European battlefields 18 th century European battlefields Original military goal: Original military goal: Return to combat as many soldiers as possible Return to combat as many soldiers as possible

56 TX EMS Triage: Goals Primary Goal: Primary Goal: Greatest good for the greatest number of possible survivors: maximize survival Greatest good for the greatest number of possible survivors: maximize survival Secondary Goals: Secondary Goals: Relief of suffering Relief of suffering Efficient resource allocation Efficient resource allocation Depend on available resources Depend on available resources

57 TX EMS Factors That Impact Resource Availability Volume and severity of patients Volume and severity of patients Limited numbers of providers Limited numbers of providers Infrastructure limitations Infrastructure limitations Inadequate hazard preparation (HAZMAT, etc.) Inadequate hazard preparation (HAZMAT, etc.) Limited transport capabilities Limited transport capabilities Multiple-jurisdictional response Multiple-jurisdictional response Lack of hospital surge capacity Lack of hospital surge capacity

58 TX EMS Triage Systems Multiple triage systems in use Multiple triage systems in use Various methods using tags, categories, colors, symbols Various methods using tags, categories, colors, symbols Familiarize yourself with your agencys system and PRACTICE it Familiarize yourself with your agencys system and PRACTICE it IDEAL = one uniform system used by all agencies in the field & at hospitals IDEAL = one uniform system used by all agencies in the field & at hospitals

59 TX EMS Why Triage? System tool to bring order from chaos System tool to bring order from chaos Get care for those who need it most and are most likely to benefit Get care for those who need it most and are most likely to benefit Aids resource allocation Aids resource allocation Objective framework for stressful & emotional decisions Objective framework for stressful & emotional decisions Increases provider efficiency & effectiveness Increases provider efficiency & effectiveness

60 TX EMS The Ideal Triage System? Simplicity Simplicity Easy to remember Easy to remember Easy to use Easy to use Objectivity Objectivity Accuracy Accuracy Ability to process large numbers of victims Ability to process large numbers of victims (Evidence-based) (Evidence-based)

61 TX EMS Underlying Parameters Life, limb or vision threat Life, limb or vision threat Level of medical intervention needed Level of medical intervention needed (Access to transportation) (Access to transportation)

62 TX EMS Triage Process GROUP GROUP SORT SORT TRANSPORT TRANSPORT

63 TX EMS M.A.S.S. Triage M – Move A – Assess S – Sort S – Send

64 TX EMS M.A.S.S. Triage M – Move A – Assess S – Sort S – Send

65 TX EMS ID-me Categories I - IMMEDIATE I - IMMEDIATE D - DELAYED D - DELAYED M - MINIMAL M - MINIMAL D - DEAD D - DEAD EXPECTANT LETHAL INJURY E - EXPECTANT

66 TX EMS M.A.S.S. Triage Tested & used by the military Tested & used by the military Adapted for civilian disasters Adapted for civilian disasters It works! It works! Fast Fast Accurate Accurate Large numbers of victims Large numbers of victims You neednt be an expert to help! You neednt be an expert to help!

67 TX EMS M.A.S.S. Triage 1. GROUP victims first... then SORT individual victims then TRANSPORT

68 TX EMS Basis of M.A.S.S. Triage Ability to move best predicts outcome Ability to move best predicts outcome Glasgow Coma Scale Glasgow Coma Scale Motor component Motor component

69 TX EMS M.A.S.S. TriageM.A.S.S. Triage MOVE: STEP 1MOVE: STEP 1 Goal: Goal: Group - Victims who can WALK Group - Victims who can WALK Action: Action: Everyone who can hear me and who can walk, please move to the area with the green flag. Everyone who can hear me and who can walk, please move to the area with the green flag. Identifies: Identifies: MINIMAL group MINIMAL group MINIMAL

70 TX EMS Why Bother with Them FIRST? MINIMAL group: major vital functions intact MINIMAL group: major vital functions intact Assess last, after more critical groups Assess last, after more critical groups However, actively managing this group may: However, actively managing this group may: Facilitate scene management Facilitate scene management Conserve scene resources Conserve scene resources Reduce self-transports & overburdening of nearest hospital ERs Reduce self-transports & overburdening of nearest hospital ERs

71 TX EMS M.A.S.S. TriageM.A.S.S. Triage MOVE: STEP 2MOVE: STEP 2 Goal: Goal: Group – Victims who cant walk, but who can MOVE Group – Victims who cant walk, but who can MOVE Action: 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. Ask the remaining victims Everyone who can hear me and needs help, please raise an arm or leg so we can come help you. Identifies: Identifies: DELAYED Group DELAYED Group DELAYED

72 TX EMS M.A.S.S. Triage ASSESS : ASSESS : Goal: Goal: Group – Identify who is left, victims unable to walk & unable to follow simple commands to move Action: Action: Go immediately to these patients for life- saving interventions (if medically trained)

73 TX EMS M.A.S.S. Triage ASSESS IMMEDIATE patients:ASSESS IMMEDIATE patients: Open Airway Open Airway Stop Bleeding Stop Bleeding Give Chemical antidote Give Chemical antidote Decompress TPtx Decompress TPtx

74 TX EMS M.A.S.S. Triage ASSESS IMMEDIATE patients:ASSESS IMMEDIATE patients: Open Airway Open Airway Stop Bleeding Stop Bleeding Give Chemical antidote Give Chemical antidote Pressure Points Tourniquets Whatever it takes! Be creative!

75 TX EMS M.A.S.S. Triage ASSESS IMMEDIATE patients:ASSESS IMMEDIATE patients: Question: Question: Is transport available? Move on! Move on!

76 TX EMS Victim Group Summary GoalAction ID-me Group Group ambulatory patients Everyone who can hear me and needs medical attention, move to the area with the green flag Minimal Group awake, can follow commands Everyone who can hear me, raise an arm or leg so we can come help you Delayed Identify who is left Go immediately to these patients for life- saving interventions Immediate

77 TX EMS In Other Words... GREEN: First Aid, DIY GREEN: First Aid, DIY YELLOW: Get thee to a doctor soon YELLOW: Get thee to a doctor soon RED: Gonna die without immediate care RED: Gonna die without immediate care

78 TX EMS ID-me and NATO Categories COLORID-me NATO Priority RED Immediat e 1 YELLOWDelayed2 GREENMinimal3 BLACKExpectantDEAD

79 Adapted from Heightman AJ (2006). JEMS 31(4):16.

80 TX EMS ONLY NOW Do We Assess Individuals Having grouped victims according to their ability to move... Having grouped victims according to their ability to move......The next phase entails more detailed individual assessment....The next phase entails more detailed individual assessment.

81 TX EMS M.A.S.S. Triage SORT:SORT: Goal: Goal: Sort patients via INDIVIDUAL assessment Sort patients via INDIVIDUAL assessment Actions: Actions: Assign to ID-me Categories: Assign to ID-me Categories: IMMEDIATE, DELAYED, MINIMAL, IMMEDIATE, DELAYED, MINIMAL, Continue treatment Continue treatment EXPECTANT

82 TX EMS M.A.S.S. Triage SORT:SORT: Ideally: trained medical personnel Ideally: trained medical personnel May not be available May not be available Begin with those who didnt move Begin with those who didnt move Tag immediately upon triage Tag immediately upon triage Including dead victims Including dead victims

83 TX EMS CERT L.A There Are Many Different Patient Assessment Tools

84 TX EMS R P M START Triage

85 TX EMS START Mnemonic R P M Can Do Can Do

86 TX EMS START Limitations? Do you have time to count RR for full minute? Do you have time to count RR for full minute? Can you measure CRT in the dark, in the cold, or in a contaminated patient? Can you measure CRT in the dark, in the cold, or in a contaminated patient?

87 TX EMS Sacco Triage Method (STM)

88 TX EMS Non-ambulatory Non-moving R Respirations Breathing? Position airway NO YES Too fast? Too slow? >6 & <30 P Pulse (radial) Palpable? NO YESNO M Mental Status Follows commands? MINIMAL (Already identified & grouped separately) YES NO DELAYED IMMEDIATE EXPECTANT Simplified Triage As needed: Bleeding control Chemical antidotes Decompress chest

89 TX EMS ATLS® Sift and Sieve Sift and Sieve Advanced Trauma Life Support for Doctors – Student Course Manual 7 th Edition American College of Surgeons, Chicago, IL, 2004

90 TX EMS BTLS/ITLS BTLS, 5 th Edition Campbell JE Brady – Prentice Hall, New Jersey, 2004

91 TX EMS M.A.S.S. Triage SORT:SORT: Goal: Goal: Sort patients based upon INDIVIDUAL assessment Sort patients based upon INDIVIDUAL assessment Actions: Actions: ID-me: ID-me: IMMEDIATE, DELAYED, MINIMAL,, DEAD IMMEDIATE, DELAYED, MINIMAL,, DEAD Continue treatment Continue treatment EXPECTANT

92 TX EMS M.A.S.S. Triage SORT:SORT: Ideally: trained medical personnel Ideally: trained medical personnel May not be available May not be available Begin with those who didnt move Begin with those who didnt move Tag immediately upon triage Tag immediately upon triage Including dead victims Including dead victims

93 TX EMS ID-me Categories I - IMMEDIATE I - IMMEDIATE D - DELAYED D - DELAYED M - MINIMAL M - MINIMAL EXPECTANT LETHAL INJURY E - EXPECTANT

94 TX EMS M.A.S.S. Triage SORT – IMMEDIATE:SORT – IMMEDIATE: Life- or Limb-threatening injury Life- or Limb-threatening injury Airway, Breathing or Circulation Problem Airway, Breathing or Circulation Problem Unconscious Unconscious Examples: Examples: Unresponsive, altered level of consciousness, severe breathing difficulty, uncontrollable bleeding, amputations above elbow or knee, cyanosis, rapid or weak pulse, open abdominal wounds, etc. Unresponsive, altered level of consciousness, severe breathing difficulty, uncontrollable bleeding, amputations above elbow or knee, cyanosis, rapid or weak pulse, open abdominal wounds, etc.

95 TX EMS M.A.S.S. Triage SORT – DELAYED:SORT – DELAYED: Need definitive medical care, but should not worsen rapidly, if initial care is delayed Need definitive medical care, but should not worsen rapidly, if initial care is delayed Examples: 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. 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.

96 TX EMS M.A.S.S. Triage SORT – MINIMAL: SORT – MINIMAL: Walking wounded Walking wounded Group, sort & facilitate transport from scene Group, sort & facilitate transport from scene Volunteer help? Risk vs. Benefit Volunteer help? Risk vs. Benefit Examples: Examples: Abrasions, contusions, minor lacerations, no apparent injuries Abrasions, contusions, minor lacerations, no apparent injuries

97 TX EMS M.A.S.S. Triage SORT – :SORT – : Most severely injured Most severely injured Little chance of survival Little chance of survival Expected to die soon Expected to die soon In a perfect world, they would receive the most care, even though chance of survival is low In a perfect world, they would receive the most care, even though chance of survival is low In an MCI.... In an MCI.... EXPECTANT

98 TX EMS M.A.S.S. Triage SORT – :SORT – : Care resources NOT utilized initially Care resources NOT utilized initially Comfort care as available Comfort care as available Death could be hours or days away! Death could be hours or days away! Reassessment & transport Reassessment & transport Transport those still alive after all IMMEDIATE victims evacuated Transport those still alive after all IMMEDIATE victims evacuated Resuscitate & treat as resources allow Resuscitate & treat as resources allow EXPECTANT

99 TX EMS M.A.S.S. Triage SORT – :SORT – : Examples: Examples: Near 100 % TBSA burns Near 100 % TBSA burns Fatal radiation doses Fatal radiation doses Apnea or pulselessness Apnea or pulselessness Especially if multiple injuries Especially if multiple injuries Severe open brain injury Severe open brain injury Death imminent Death imminent Judgment call Judgment call EXPECTANT

100 TX EMS Triage Category Summary RED: life-threatening but treatable RED: life-threatening but treatable YELLOW: potentially serious, but can wait a while YELLOW: potentially serious, but can wait a while GREEN: minor injuries can wait longer GREEN: minor injuries can wait longer BLACK: life signs present, but expected to die under disaster conditions BLACK: life signs present, but expected to die under disaster conditions

101 TX EMS Triage Caveats OVER-TRIAGE: OVER-TRIAGE: Urge to classify all victims as IMMEDIATE Urge to classify all victims as IMMEDIATE Defeats the purpose! Defeats the purpose! Ruptured eardrums, chronic hearing loss, language barrier, developmental handicaps, etc. Ruptured eardrums, chronic hearing loss, language barrier, developmental handicaps, etc. Cannot respond to MASS commands Cannot respond to MASS commands

102 TX EMS Other Triage Caveats UNDER-TRIAGE: UNDER-TRIAGE: Initial grouping individual assessment Initial grouping individual assessment Worsening patient conditions: Worsening patient conditions: Internal or external bleeding, shock Internal or external bleeding, shock Closed head injury Closed head injury Blast injury to lung, gut, brain Blast injury to lung, gut, brain Airway swelling Airway swelling Delayed chemical exposure symptom onset Delayed chemical exposure symptom onset Etc. Etc.

103 TX EMS M.A.S.S. Triage SORT process is dynamic:SORT process is dynamic: Resources change Resources change Patient conditions change Patient conditions change Frequent reassessment Frequent reassessment All categories All categories may become IMMEDIATE may become IMMEDIATE Most serious injury present demands immediate attention! Most serious injury present demands immediate attention! EXPECTANT

104 TX EMS Triage Tags Tag immediately after sorting Tag immediately after sorting Tie triage tag directly to patient Tie triage tag directly to patient May need to improvise tags (tape, latex gloves) May need to improvise tags (tape, latex gloves) May need to write on patient (lipstick, marker) May need to write on patient (lipstick, marker)

105 TX EMS Wrapping up the SORT... When all patients have been triaged and tagged: When all patients have been triaged and tagged: Count all IMMEDIATES Count all IMMEDIATES Advise incident commander or transport officer of number Advise incident commander or transport officer of number Take all IMMEDIATES to collection point for urgent transport Take all IMMEDIATES to collection point for urgent transport

106 TX EMS M.A.S.S. Triage SEND:SEND: Objective: Objective: Transport or release ALL living patients ASAP Transport or release ALL living patients ASAP Traditional sequence: Traditional sequence: IMMEDIATE IMMEDIATE DELAYED DELAYED MINIMAL MINIMAL EXPECTANT

107 TX EMS M.A.S.S. Triage SEND:SEND: Be mission-focused: Be mission-focused: Send MINIMALS or DELAYEDS with each IMMEDIATE, if space allows Send MINIMALS or DELAYEDS with each IMMEDIATE, if space allows Be resourceful: Be resourceful: Secondary treatment facilities for MINIMALS Secondary treatment facilities for MINIMALS Be creative: Be creative: Buses, taxis, trains, boats, etc. Buses, taxis, trains, boats, etc.

108 TX EMS The Need To Drill Regardless of which triage system your agency favors... Regardless of which triage system your agency favors......Practice, practice, practice!...Practice, practice, practice! TRIAGE TAG TUESDAY TRIAGE TAG TUESDAY Preparation will promote more efficient triage in an actual MCI Preparation will promote more efficient triage in an actual MCI

109 TX EMS What About The DEAD? Should NOT be moved or sent Should NOT be moved or sent 1 EXCEPTION? 1 EXCEPTION? Medical examiner / coroner: Medical examiner / coroner: Identification of remains Identification of remains Disposition of remains Disposition of remains Crime scene investigation: Crime scene investigation: Evidence must be preserved Evidence must be preserved Apprehend perpetrators and prevent future attacks Apprehend perpetrators and prevent future attacks

110 TX EMS Specific All-Hazards Considerations

111 TX EMS Chemical Incidents Issues: Issues: Minute quantities can be rapidly fatal Minute quantities can be rapidly fatal Risk of off-gassing and 2° contamination Risk of off-gassing and 2° contamination Delayed symptom onset for some Delayed symptom onset for some Implications: Implications: PPE for healthcare providers PPE for healthcare providers ~ Simultaneous decon, triage and treatment ~ Simultaneous decon, triage and treatment Dry decontamination removes 80-90% Dry decontamination removes 80-90% If you think it might be, safest bet is to decon If you think it might be, safest bet is to decon

112 TX EMS Capnography as Triage Tool... the only direct, non-invasive measure of ventilatory status available to EMS crews the only direct, non-invasive measure of ventilatory status available to EMS crews... Rapid (15 seconds) indication of: Rapid (15 seconds) indication of: Hypoventilation, respiratory depression or failure Hypoventilation, respiratory depression or failure Laryngospasm, upper airway obstruction Laryngospasm, upper airway obstruction Bronchospasm Bronchospasm Krauss B (2005) Pediatric Emerg Care 21(8): 493 Krauss B (2005) Pediatric Emerg Care 21(8): 493 Krauss B, Heightman AJ (2006) JEMS 31(6): Krauss B, Heightman AJ (2006) JEMS 31(6):

113 TX EMS Biological Incidents Issues: Issues: Person-to-person spread for some agents Person-to-person spread for some agents Non-specific flu-like symptoms Non-specific flu-like symptoms Lengthy incubation periods Lengthy incubation periods Implications: Implications: Delayed detection likely Delayed detection likely Triage only once outbreak underway Triage only once outbreak underway Healthcare providers may become victims Healthcare providers may become victims

114 TX EMS Radiological Incidents Issues: Issues: Covert release likely Covert release likely Detection requires special equipment Detection requires special equipment Symptom onset typically delayed Symptom onset typically delayed HOWEVER..... HOWEVER.....

115 TX EMS Radiation Risks for Healthcare Providers A living patient cannot be so radiologically contaminated as to present an acute hazard to medical personnel. A living patient cannot be so radiologically contaminated as to present an acute hazard to medical personnel. Medical Management of Radiological Casualties, 2 nd edition. AFRRI, Bethesda, 2003, p. 94. Download at:

116 TX EMS Patient Care Implications Limb- and life-saving medical attention should never be delayed because of the presence of radioactive material or contamination! Limb- and life-saving medical attention should never be delayed because of the presence of radioactive material or contamination! After 1 st 24 hours, radiation does matter After 1 st 24 hours, radiation does matter

117 TX EMS Nuclear Incidents Issues: Issues: Most immediate fatalities 2° trauma, burns Most immediate fatalities 2° trauma, burns Massive dose needed for early symptoms Massive dose needed for early symptoms Implications: Implications: Onset < 1-3 hr. post-exposure: Onset < 1-3 hr. post-exposure: Nausea/vomiting, altered LOC, CNS symptoms Nausea/vomiting, altered LOC, CNS symptoms EXPECTANT

118 TX EMS Natural Disasters Issues: Issues: More common than terrorism More common than terrorism Scene size may be enormous Scene size may be enormous Massive infrastructure destruction: hospitals Massive infrastructure destruction: hospitals Healthcare providers as victims Healthcare providers as victims Implications: Implications: Severely limited resources Severely limited resources Equipment, personnel, supplies, utilities Equipment, personnel, supplies, utilities

119 TX EMS Explosive & Bombing Incidents Issues: Issues: Still #1 terrorist modality Still #1 terrorist modality 4 Modes of Blast Injury 4 Modes of Blast Injury 1°blast injury (PBI): delayed onset 1°blast injury (PBI): delayed onset Ruptured TMs in blast survivors Ruptured TMs in blast survivors Implications: Implications: Basic ABCs Basic ABCs Frequent reassessment & re-triage Frequent reassessment & re-triage Lung, GI and brain Lung, GI and brain Otoscope as triage tool Otoscope as triage tool

120 TX EMS When All Is Said and Done... MCI Triage is NOT business as usual MCI Triage is NOT business as usual Standard of Care vs. Best Choices Standard of Care vs. Best Choices

121 TX EMS Gut Check for Healthcare Providers Difficult decisions must be made Difficult decisions must be made Fatalities and suffering are likely Fatalities and suffering are likely

122 TX EMS Its NOT Rocket Science, either! One need not be a specialist One need not be a specialist Identify, collect and control Identify, collect and control MINIMALS & DELAYEDS MINIMALS & DELAYEDS Focus first on those who most need care and are most likely to benefit from it! Focus first on those who most need care and are most likely to benefit from it! IMMEDIATES IMMEDIATES

123 TX EMS Adapted from Heightman AJ (2006). JEMS 31(4):16.

124 TX EMS More Work Is Needed National Standards National Standards WMD & All-Hazards Incidents WMD & All-Hazards Incidents Medical MCI Triage Medical MCI Triage Special Patients Special Patients Patient Tracking Systems Patient Tracking Systems More Effective Hands-on Training More Effective Hands-on Training

125 TX EMS Thank You! Questions?? Questions?? Lets try it again!! Lets try it again!! Copyright © 2007 by Ronna G. Miller, MD Copyright © 2007 by Ronna G. Miller, MD All rights reserved. No part may be modified or distributed in any format without written permission of the author. All rights reserved. No part may be modified or distributed in any format without written permission of the author.

126 TX EMS Victim 1 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

127 TX EMS Victim 2 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

128 TX EMS Victim 3 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

129 TX EMS Victim 4 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

130 TX EMS Victim 5 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

131 TX EMS Victim 6 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

132 TX EMS Victim 7 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

133 TX EMS Victim 8 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

134 TX EMS Victim 9 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

135 TX EMS Victim 10 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

136 TX EMS Victim 11 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

137 TX EMS Victim 12 Into which category would you triage this patient? Into which category would you triage this patient? A. IMMEDIATE B. DELAYED C. MINIMAL D. D. EXPECTANT

138 TX EMS Now what do you think?

139 TX EMS Question 14 Is knowing how to perform mass casualty triage part of your professional responsibilities? Is knowing how to perform mass casualty triage part of your professional responsibilities? A.Yes B.No

140 TX EMS Question 15 What is the likelihood, in your opinion, that you would ever be called upon to perform mass casualty triage in the future? What is the likelihood, in your opinion, that you would ever be called upon to perform mass casualty triage in the future? A.Very likely B.Likely C.Neutral D.Unlikely E.Very unlikely

141 TX EMS Question 16 If there were an explosion at this location right now, how confident are you that you would be able to rapidly and accurately triage victims? If there were an explosion at this location right now, how confident are you that you would be able to rapidly and accurately triage victims? A.Very confident B.Somewhat confident C.Neutral D.Somewhat unsure E.Very unsure

142 TX EMS The Newest Triage Method

143 TX EMS Contact Information Ronna G. Miller, MD Assistant Professor EMS/Disaster Medicine/Homeland Security Section Division of Emergency Medicine Department of Surgery UT Southwestern Medical Center at Dallas 5323 Harry Hines Blvd. Dallas, Texas Voic (214)

144 TX EMS

145 TX EMS

146 There must be a cookie here somewhere!

147 TX EMS Text References American College of Surgeons (2004). Advanced Trauma Life Support for Doctors – Student Course Manual, 7th Edition. American College of Surgeons, Chicago, IL. American College of Surgeons (2004). Advanced Trauma Life Support for Doctors – Student Course Manual, 7th Edition. American College of Surgeons, Chicago, IL. Campbell JE (2004). Basic Trauma Life Support for Paramedics and Other Advanced Providers, 5 th Edition. Brady/Prentice Hall. Campbell JE (2004). Basic Trauma Life Support for Paramedics and Other Advanced Providers, 5 th Edition. Brady/Prentice Hall. Ciottone GR et al (2006). Disaster Medicine, 3 rd Edition. Elsevier Mosby, Philadelphia. Ciottone GR et al (2006). Disaster Medicine, 3 rd Edition. Elsevier Mosby, Philadelphia. Hogan DE, Burstein JL (2002). Disaster Medicine, 2 nd Edition. Lippincott Williams & Wilkins, Philadelphia. Hogan DE, Burstein JL (2002). Disaster Medicine, 2 nd Edition. Lippincott Williams & Wilkins, Philadelphia.

148 TX EMS Text References – Contd. Keyes DC, Burstein JL, Schwartz RB, Swienton RE (2005). Medical Response to Terrorism – Preparedness and Clinical Practice. Lippincott Williams & Wilkins, Philadelphia. Keyes DC, Burstein JL, Schwartz RB, Swienton RE (2005). Medical Response to Terrorism – Preparedness and Clinical Practice. Lippincott Williams & Wilkins, Philadelphia. National Association of Emergency Medical Technicians (2003). PHTLS, 5 th Edition, Revised. Mosby, New York City. National Association of Emergency Medical Technicians (2003). PHTLS, 5 th Edition, Revised. Mosby, New York City. Smith, J.M., Spano M.A. (2003). Interim Guidelines for Hospital Response to Mass Casualties from a Radiological Incident. Washington, DC: Department of Health and Human Services. Smith, J.M., Spano M.A. (2003). Interim Guidelines for Hospital Response to Mass Casualties from a Radiological Incident. Washington, DC: Department of Health and Human Services.

149 TX EMS Text References – Contd. Weinstein RS, Alibek K (2003). Biological and Chemical Terrorism – A Guide for Healthcare Providers and First Responders. Thieme Medical Publishers, New York City. Weinstein RS, Alibek K (2003). Biological and Chemical Terrorism – A Guide for Healthcare Providers and First Responders. Thieme Medical Publishers, New York City.

150 TX EMS Journal References Armstrong JH et al (2008). Toward a National Standard in Primary Mass Casualty Triage. Disaster Med Public Health Prep 2 Suppl 1:S8. Armstrong JH et al (2008). Toward a National Standard in Primary Mass Casualty Triage. Disaster Med Public Health Prep 2 Suppl 1:S8. Briggs S (2007). Triage in Mass Casualty Incidents: Challenges and Controversies. Am J Disaster Med 2(2):57. Briggs S (2007). Triage in Mass Casualty Incidents: Challenges and Controversies. Am J Disaster Med 2(2):57. Donohue D (2008). Medical Triage for WMD Incidents. JEMS 33(5):60. Donohue D (2008). Medical Triage for WMD Incidents. JEMS 33(5):60. Goodloe JM, et al (2008). Big-Top Incident: Tulsa EMS responds to tent collapse. JEMS 33(9):42. Goodloe JM, et al (2008). Big-Top Incident: Tulsa EMS responds to tent collapse. JEMS 33(9):42. Heightman AJ (2006). Neutralize MCI Chaos. JEMS 31(4):16. Heightman AJ (2006). Neutralize MCI Chaos. JEMS 31(4):16. Kraus B (2005). Capnography as a Rapid Assessment and Triage Tool for Chemical Terrorism. Pediatric Emergency Care 21(8): Kraus B (2005). Capnography as a Rapid Assessment and Triage Tool for Chemical Terrorism. Pediatric Emergency Care 21(8):493-7.

151 TX EMS Journal References – Contd. Lerner EB et al (2008). Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline. Disaster Med Public Health Prep 2 Suppl 1:S25. Lerner EB et al (2008). Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline. Disaster Med Public Health Prep 2 Suppl 1:S25. McCarthy D, McClure R, Heightman AJ (2006). Orchestrating the Fast Moving MCI. JEMS 31(4):41-7. McCarthy D, McClure R, Heightman AJ (2006). Orchestrating the Fast Moving MCI. JEMS 31(4):41-7. Navin M, Waddell B (2005). Triage is Broken. EMS Magazine 34 (8 August 2005). Navin M, Waddell B (2005). Triage is Broken. EMS Magazine 34 (8 August 2005). Navin M, Waddell B (2005). A Disaster Doesnt Have to Be a Disaster. EMS Magazine (9 September 2005). Navin M, Waddell B (2005). A Disaster Doesnt Have to Be a Disaster. EMS Magazine (9 September 2005). Ressel R et al (2008). West Nickels Mines School Shooting. JEMS 33(5): 48. Ressel R et al (2008). West Nickels Mines School Shooting. JEMS 33(5): 48.

152 TX EMS Journal References – Contd. Robertson-Steel I (2006) Evolution of Triage Systems. Emerg Med J 23: doi: /emj Robertson-Steel I (2006) Evolution of Triage Systems. Emerg Med J 23: doi: /emj Sacco WJ, et al (2005) Precise Formulation and Evidence- Based Application of Resource-Constrained Triage. Academic Emergency Medicine 12: Sacco WJ, et al (2005) Precise Formulation and Evidence- Based Application of Resource-Constrained Triage. Academic Emergency Medicine 12: Zorster R (2006). Disaster Triage: Is It Time to Stop START? Am J Disaster Med 1(1):7. Zorster R (2006). Disaster Triage: Is It Time to Stop START? Am J Disaster Med 1(1):7.

153 TX EMS General Web Resources

154 TX EMS Specific Web Resources

155 TX EMS Specific Web Resources - 2 Military Medical Operations. (2003). Medical Management of Radiological Casualties, 2nd edition. Bethesda: Armed Forces Radiobiology Research Institute. Download at: Military Medical Operations. (2003). Medical Management of Radiological Casualties, 2nd edition. Bethesda: Armed Forces Radiobiology Research Institute. Download at: Gonzalez, M. S. (n. d.) The Impact of Mass Casualties on the Healthcare Delivery System – Conventional Injuries. Retrieved August 1, 2005 from: cal%20Aspect%20of%20Convenional%20injuries.ppt Gonzalez, M. S. (n. d.) The Impact of Mass Casualties on the Healthcare Delivery System – Conventional Injuries. Retrieved August 1, 2005 from: cal%20Aspect%20of%20Convenional%20injuries.ppt

156 TX EMS Specific Web Resources - 3 USAMRIID. USAMRIIDs Medical Management of Biological Casualties Handbook, 5 th edition. (2004). Download at: h ttp://www.usamriid.army.mil/education/bluebook.htm USAMRIID. USAMRIIDs Medical Management of Biological Casualties Handbook, 5 th edition. (2004). Download at: h ttp://www.usamriid.army.mil/education/bluebook.htm USAMRICD. Medical Management of Chemical Casualties Handbook, 3 rd edition. (2000). Download at: https://ccc.apgea.army.mil/sarea/products/handbooks/MMCC/ mmccthirdeditionjul2000.pdf USAMRICD. Medical Management of Chemical Casualties Handbook, 3 rd edition. (2000). Download at: https://ccc.apgea.army.mil/sarea/products/handbooks/MMCC/ mmccthirdeditionjul2000.pdf

157 TX EMS Bioterrorism & All-Hazards Disaster Medicine Training

158 TX EMS Hospital Preparedness GAO , August 2003 Report to Congressional Committees: fewer than half of hospitals have conducted drills or exercises simulating response to a bioterrorist incident. fewer than half of hospitals have conducted drills or exercises simulating response to a bioterrorist incident...must be balanced with the need to be prepared for all types of emergencies...must be balanced with the need to be prepared for all types of emergencies. August 2003, GAO August 2003, GAO Requires an All-Hazards approach Requires an All-Hazards approach

159 TX EMS ALL-HAZARDS Preparedness Chemical Chemical Biological Biological Radiological & Nuclear Radiological & Nuclear Natural & Accidental Natural & Accidental Explosive & Traumatic Explosive & Traumatic

160 TX EMS National Disaster Life Support Courses: ABCs, a foundation for national training: ABCs, a foundation for national training: Advanced Disaster Life Support (ADLS) Advanced Disaster Life Support (ADLS) Basic Disaster Life Support (BDLS) Basic Disaster Life Support (BDLS) Core Disaster Life Support (CDLS) Core Disaster Life Support (CDLS) NDLS-Decon NEW! NDLS-Decon NEW! Endorsements by: Endorsements by: AMA, CDC, ACEP, more than 30 other organizations AMA, CDC, ACEP, more than 30 other organizations Websites: Websites: and and

161 TX EMS For More Information NDLS / Texas BCE Contacts by Region (06-07) : NDLS / Texas BCE Contacts by Region (06-07) : University of Texas Health Center at Tyler (UTHCT): University of Texas Health Center at Tyler (UTHCT): Jill Howard University of Texas Medical Branch – Galveston (UTMB): University of Texas Medical Branch – Galveston (UTMB): Crystal Hobbs UT Southwestern Medical Center (UTSW): UT Southwestern Medical Center (UTSW): Song Lehman UNT Health Science Center at Fort Worth (UNTHSC): UNT Health Science Center at Fort Worth (UNTHSC): Christina Nelson UT Health Science Center San Antonio (UTHSC-SA): UT Health Science Center San Antonio (UTHSC-SA): Tina Fields UT Health Science Center Houston (UTHSC-H): UT Health Science Center Houston (UTHSC-H): C. Duplessis Texas A&M University System Health Science Center (TAMU): Texas A&M University System Health Science Center (TAMU): Kay Carpenter

162 TX EMS RED Survey Rapid Evaluation of DisasterRapid Evaluation of Disaster Incident Survey Incident Survey BEFORE patient care! BEFORE patient care! Casualty Survey Casualty Survey Life-saving Interventions Life-saving Interventions You dont need to die!

163 TX EMS RED Survey Rapid Evaluation of DisasterRapid Evaluation of Disaster Incident Survey Incident Survey BEFORE patient care! BEFORE patient care! Casualty Survey Casualty Survey Life-saving Interventions Life-saving Interventions

164 TX EMS RED Survey Rapid Evaluation of DisasterRapid Evaluation of Disaster Casualty Survey - Triage: Casualty Survey - Triage: 1. Rapid grouping by: Severity of injury AND Severity of injury AND Likelihood of survival, THEN Likelihood of survival, THEN 2. Individual assessment

165 TX EMS DISASTER Paradigm D – Detection D – Detection I – Incident Command I – Incident Command S – Scene Safety & Security S – Scene Safety & Security A – Assess Hazards A – Assess Hazards S – Support S – Support T – Triage & Treatment T – Triage & Treatment E – Evacuation E – Evacuation R - Recovery R - Recovery


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