SMART System & START Triage Bureau of Emergency Medical Services New York State Department of Health Jim Soto Associate Director
Objectives: Review Incident Management from EMS perspective What is an MCI ? Review Incident Management from EMS perspective Review Triage & Practice START
What is the Goal of MCI Management?
EMS GOAL: TO SAVE THE LARGEST NUMBER OF SURVIVORS FROM A MULTIPLE CASUALTY INCIDENT AIM To give a focus on the reason for this training. “To save the largest number of survivors from a multiple casualty incident” Teaching points This is what this presentation and training is ultimately concerned with. The aim should be referenced throughout the presentation. Note Throughout the training you must constantly assess if concepts and systems used will lead to producing maximum survivors.
What is an MCI Scene? AIM To explain the complexities of large multiple casualty scenes. Teaching Points The train wreck represents a complex multiple casualty scene. For us to produce maximum survivors we must ensure any system or equipment will work under numerous difficult challenges including; large multi-agency teams numerous casualties high stress working conditions scene hazard. This training will look at the problems posed by this type of incident and work with you to provide practical solutions.
What are some Common things affecting your MCI response? Typical staffing of your ambulance service? What does EMS routinely do daily? How do you handle the following? 4 victims in a two car “head-on” 17 victims in a “team” van 43 victims on a school bus 350 victims on a train Need Resources & Coordination
So what do you have to think about? TRIAGE STAGING COMMUNICATIONS COMMAND IMMODIUM SAFETY TREATMENT ASSESSMENT
THE INITIAL PROBLEM ON SCENE AIM To understand the importance of correct resources. Teaching points Rescue services normally work in a resource rich environment. The multiple casualty scene often presents a scenario where there are more casualties than initial resources On scenes where an initial assessment indicates heavier casualties than resources, clinical intervention is often not the first priority. Question to delegates What number of casualties would be required to out number one of your units ? Expected answer Normally one seriously injured person or two or three minor injuries. Teaching point from question Small incidents such as motor vehicle accidents can produce a resource poor scenario. Casualties Resources
THE OBJECTIVE Casualties Resources
THE OBJECTIVE Casualties Resources
THE OBJECTIVE Casualties Resources
THE OBJECTIVE Casualties Resources
THE OBJECTIVE Casualties Resources
THE OBJECTIVE Casualties Resources
THE OBJECTIVE Casualties Resources Achieve balance
How many patients are you taught to treat at one time? BUT - HOW IS EMS TRAINED? BLS, ALS CPR, ACLS, PALS PHTLS, BTLS CFR, EMT, EMT-I, EMT-CC, EMT-P How many patients are you taught to treat at one time?
WHAT CHANGES WHEN YOU HAVE AN MCI ? What are my resources? Who is a Patient? Which Patient do I treat first? Who can be salvaged? Who gets transported first? Who needs a Trauma/Specialty Center? Who can help care for others?
ARRIVAL OF REQUESTED RESOURCES TIME IS IMPORTANT ARRIVAL OF REQUESTED RESOURCES
TIME IS VERY IMPORTANT To the Victim THE GOLDEN HOUR “The critical trauma patient has only 60 minutes from the time of injury to reach definitive surgical care, or the odds of a successful recovery diminish dramatically”. Pre-Hospital Trauma Life Support, Second Edition, Patient Assessment and Management, page 42. 1990. To the Victim
Balancing Act Golden Hour Resources Arrive Time Management Casualties
Casualties Resources + = Maximum survivors
SCENE MANAGEMENT TIME H Command Safety Assessment Communication Triage Definitive Care H Command Safety Assessment Communication Triage Treatment Transport The Scene MANAGEMENT EMS OPERATIONS
Scene Management Command Safety Is there a hazard or threat? Who is in Charge? Who is in charge of what? Who is going to do what? Who else needs to be here? EMS is generally in Operations (Ops) Safety Is there a hazard or threat? Should I be here? Am I protected? What should I worry about?
Scene Management Assessment Communications What is going on? How big is this, how many people? What do I need? How does what I do affect others? What are they doing that can affect me? Communications Who needs to know? What do they need to know? Does Command & Ops know? Do the other players know?
Scene Management Triage Who is doing it? Where are they doing it? What are they finding? Treatment What the typical EMS provider comes “preloaded” with… How to organize? How much can we do?
Scene Management Transport Who is doing it? From where are they doing it? Where are the patients going? How many patients going where?
TRIAGE “Large scale triage is the hardest job anyone in pre-hospital care will ever do”. A.J Heightman, Mass Casualty Incident Management. A practical approach to solving complex operational dilemmas. AIM To educate students that triage is carried out in difficult circumstances and will be one of the most complex tasks they will face. Teaching points Although triage is a difficult job with the correct training and equipment we can make personnel effective in this skill.
Casualties exceed the number of skilled rescuers. TRIAGE WHEN ? Casualties exceed the number of skilled rescuers. AIM To discuss when we triage Key points We don’t just triage at large complex major incidents. Triage should be carried out every time you are out numbered. Remember earlier on we mentioned that one unit with two personnel could only cope with a very small number of injured people.
Types of Triage Primary Secondary On Scene prior to movement Incident dependant, probably prior to or during transport
TRIAGE CODING Immediate 1 Urgent 2 Delayed 3 Dead 0 Color Priority Treatment RED Yellow Green Black AIM To explain how triage decisions are communicated and introduce the Smart Tag. Teaching points A simple color coding system is used in triage to communicate a priority. The Smart Tag is designed to communicate this decision. Activity Hand one Smart Tag to each delegate and demonstrate how it is folded. Run a competition to see who can fold a Smart Tag the fastest to red and yellow labels Demonstrate Light stick Waterproof and tear proof material
TRIAGE TAGS What is the same ? What is improved ? What is different ? AIM To explain how triage decisions are communicated and introduce the Smart Tag. Teaching points A simple color coding system is used in triage to communicate a priority. The Smart Tag is designed to communicate this decision. Activity Hand one Smart Tag to each delegate and demonstrate how it is folded. Run a competition to see who can fold a Smart Tag the fastest to red and yellow labels Demonstrate Light stick Waterproof and tear proof material
Triage Protocol (START)
PRIMARY TRIAGE The Scene AIM To explain the need for effective primary triage Teaching points Primary triage must be ; Dynamic Safe Fast Reproducible Having effective primary triage allows you to allocate correct resources using minimal time. The Scene
The first attempt at balancing EMS resources and PRIMARY TRIAGE The first attempt at balancing EMS resources and casualties / injured What’s the first step, the first thing to do? See who’s dead? AIM - To teach a flow chart on primary triage Teaching points People who are walking have at that point in time; an airway adequate respiratory and circularity systems to maintain upright walking posture In a multiple casualty scene these people should be tagged as priority three . Remember priority three patients may have a wide range of injuries that could be potentially be life threatening. It is important we constantly re-assess these people. You may be able to use uninjured survivors who have first aid training to help you with these patients
Determining whether there is an PRIMARY TRIAGE …continued… AIM To teach the flow chart on primary triage Teaching points The airway is assessed by performing a simple opening manoeuvre (chin lift and jaw thrust). Those people who cannot breath despite this manoeuvre are dead. Those who can breathe are categorised as priority one. If an airway has to be maintained then a bystander can be quickly instructed how to maintain a jaw thrust and call for help if there are signs of danger. Determining whether there is an airway and breathing
If breathing, at what rate & is it good enough? PRIMARY TRIAGE …more details on the actual triage process… AIM To teach the flow chart on primary triage Teaching point Patients who can breath are now assessed for rate of respiration. If this is over thirty then we tag the patient as priority one. If breathing, at what rate & is it good enough?
PRIMARY TRIAGE They have an airway, and are breathing. There’s another step though, right? Not just whether they are breathing?? AIM To teach the flow chart on primary triage Teaching points Patients whose respiration is normal should be assessed for circulation. If the capillary refill is over two seconds we tag the patient as priority one. If capillary refill is difficult to record due to adverse field conditions the radial pulse should be checked. If this is absent the patient should be tagged as priority one. Any life threatening bleeding should be managed at this stage. They have an airway, and are breathing. Are they circulating blood sufficiently?
Circulatory Check… Maybe you should tell us more about the capillary refill time, what it measures, and so on.
PRIMARY TRIAGE A B C Mental Status And the final step, can they understand what’s going on, if you’re going to send them somewhere? AIM To teach the flow chart on primary triage Teaching points Patients whose circulation is normal should be assessed for level of consciousness. If they cannot obey simple commands we tag the patient as priority one. Summarize primary triage. Primary triage allows you to identify the most seriously injured patients so they can be treated / transported using time and resources effectively. C Mental Status
PEDIATRIC TRIAGE Children are involved in multiple casualty incidents. The over prioritizing of children will take valuable resources away from more seriously injured adults. Triage systems based on adult physiology will not provide accurate triage. AIM To understand criteria for Pediatric Triage. Teaching points Children are not small adults therefore adult systems will not be accurate if used on children A child’s length is proportional to their physiology A pediatric primary triage system must also have the same criteria as an adult system Dynamic Fast Safe Reproducible
SMART Pediatric Tape Developed by Pediatricians to use the existing START protocol but modified to reflect appropriate values for pediatric respirations and circulation.
START EXERCISE
Triage Protocol (START)
START EXERCISE Female, 30’s, walking Female, teens, walking, pale, complaining of severe abdominal pain Male, teens, walking, confused Male, teens, you open airway, does not breathe Male, 20’s, unconscious, breathing, RR 36, radial pulse absent Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructions AIM To familiarise students with the trauma score module. Teaching point Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module Explain the three elements 1. Glasgow Coma Scale 2. Respiratory rate 3. Systolic BP Explain how scoring is used to determine priority Run the practical on secondary triage (details are in the workbook). 1
START EXERCISE Female, 30’s, walking Female, teens, walking, pale, complaining of severe abdominal pain Male, teens, walking, confused Male, teens, you open airway, does not breathe Male, 20’s, unconscious, breathing, RR 36, radial pulse absent Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructions AIM To familiarise students with the trauma score module. Teaching point Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module Explain the three elements 1. Glasgow Coma Scale 2. Respiratory rate 3. Systolic BP Explain how scoring is used to determine priority Run the practical on secondary triage (details are in the workbook). 1 A
START EXERCISE Female, 60’s, fracture LL leg, cannot walk, RR 25, CRT 1, obeys commands Male, 30’s, you open airway, does not breathe Male, 30’s, lying on ground, breathing, gurgling sounds, RR 37, pulse absent, unresponsive Male, 50’s, you open airway, does not breathe Male, child, 75 cm, not alert, breathing, RR 30, CRT 2.5, pulse 100 Male, child, 130 cm, not walking, breathing, RR 24 CRT 1 AIM To familiarise students with the trauma score module. Teaching point Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module Explain the three elements 1. Glasgow Coma Scale 2. Respiratory rate 3. Systolic BP Explain how scoring is used to determine priority Run the practical on secondary triage (details are in the workbook). 2
START EXERCISE Female, 60’s, fracture LL leg, cannot walk, RR 25, CRT 1, obeys commands Male, 30’s, you open airway, does not breathe Male, 30’s, lying on ground, breathing, gurgling sounds, RR 37, pulse absent, unresponsive Male, 50’s, you open airway, does not breathe Male, child, 75 cm, not alert, breathing, RR 30, CRT 2.5, pulse 100 Male, child, 130 cm, not walking, breathing, RR 24 CRT 1 AIM To familiarise students with the trauma score module. Teaching point Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module Explain the three elements 1. Glasgow Coma Scale 2. Respiratory rate 3. Systolic BP Explain how scoring is used to determine priority Run the practical on secondary triage (details are in the workbook). 2 A
START EXERCISE Female, child, 145 cm, lying on ground holding chest, breathing with gurgling sounds, RR 37, CRT 3 Female, child, 47 cm, breathing, crying, pulse 160 AIM To familiarise students with the trauma score module. Teaching point Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module Explain the three elements 1. Glasgow Coma Scale 2. Respiratory rate 3. Systolic BP Explain how scoring is used to determine priority Run the practical on secondary triage (details are in the workbook). 3
START EXERCISE Female, child, 145 cm, lying on ground holding chest, breathing with gurgling sounds, RR 37, CRT 3 Female, child, 47 cm, breathing, crying, pulse 160 AIM To familiarise students with the trauma score module. Teaching point Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module Explain the three elements 1. Glasgow Coma Scale 2. Respiratory rate 3. Systolic BP Explain how scoring is used to determine priority Run the practical on secondary triage (details are in the workbook). 3 A
SECONDARY TRIAGE AIM To understand the role of secondary triage Teaching points Secondary triage is used to help get the right person to the right place in the right time. Primary triage segregates casualties into groups, which allow us to organise ourselves and resources. To refine our clinical picture of the individual patient we use secondary triage Secondary triage uses refined physiological scoring systems and anatomical examination. It is carried out as and when resources become available. This normally is at the casualty clearing station.
SECONDARY TRIAGE Purpose When does it happen? Determine among like priority category, higher priority patient When does it happen? Generally on extended duration events If treatment areas are established, there will likely be a need for Secondary Triage before transport AIM To familiarise students with the trauma score module. Teaching point Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module Explain the three elements 1. Glasgow Coma Scale 2. Respiratory rate 3. Systolic BP Explain how scoring is used to determine priority Run the practical on secondary triage (details are in the workbook).
SECONDARY TRIAGE AIM To familiarise students with the trauma score module. Teaching point Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module Explain the three elements 1. Glasgow Coma Scale 2. Respiratory rate 3. Systolic BP Explain how scoring is used to determine priority Run the practical on secondary triage (details are in the workbook).
SCENE MANAGEMENT TIME H Definitive Care Command Safety MANAGEMENT Assessment Communication Triage Treatment Transport The Scene MANAGEMENT EMS OPERATIONS
Tools to help manage Use of ICS FOGs and SOGs Command Boards Field Operations Guides Standard Operations Guides Command Boards Communications Radios / Cellular, etc Verbal Documentation Scribes/Runners
Tools to Organize
SMART COMMANDER ™ AIM To provide a practical demonstration on how the Smart Commander can help with multiple casualty management. Teaching points The Smart Commander is designed to assist the operational management personnel on scene Demonstrate How is it designed to fit your arm length Stored with ease in vehicles Command Boards Dispatch panels Holders for plans and maps Storage pouches for personalizing equipment
SMART COMMANDER ™ Organization for: Provides for: Command, Control, Coordination Provides for: Storage for extra supplies Storage sleeves for pre-plans Transport tracking sleeves Briefing information Operations & resource tracking
EMS INCIDENT MANAGEMENT AIM To explain the requirement for tracking and accounting for casualties Teaching points We need to account for where we are sending people once they are evacuated from the scene. We must have a system to store transport strips securely for future reference. Demonstrate The transport tag on the side of the Smart Tag and the Dispatch Panels in the Smart Commander.
SMART COMMANDER ™ Organization for: Provides: Command, Control, Coordination Provides: Overall Incident Management Team EMS Operations Specifics Incident Communications Weather Hazards Primary Triage Status Destination Capability & Patient Distribution
PATIENT ACCOUNTABILITY Use a system to track the patient condition Use a system to determine the priority for further treatment Use a system to determine transport to an appropriate hospital Use a system that tracks the patient throughout the transport process
SMART Commander - EMS
Incident Management Team
EMS Operations
ICS – 205 Communications Plan
Incident Weather Conditions
Incident Hazards
Triage Team & Casualty Status
Hospital Capability & Patient Distribution
SUMMARY MCI’s require: Change of EMS provider’s approach Single Pt. vs. Multiple Pts. Applying limited resources effectively & timely Incident & Time Management Organizing, Coordinating & Communicating in EMS Operations Accountability of resources & patients Who is doing what & how many patients do you have Appropriate distribution & destinations Where are they going & why? After Action Lessons Learned & Review of Existing plans
From Triage to Treatment Areas Incident Triage Treatment Immediate Search & Rescue Triage Team(s) Urgent Delayed Morgue
From Treatment to Definitive Care Treatment Transport Definitive Care Urgent Immediate Delayed Ambulances H Ambulances, Ambulettes, Buses, etc Appropriate Facility
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