The Mass Casualty Incident: Triage, by Amy Alton, A.R.N.P., and Joe Alton, M.D.

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The responsibilities of a medic in times of trouble will usually be one-to-one; that is, the healthcare provider will be dealing with one ill or injured individual at a time.  If you have dedicated yourself to medical preparedness, you will have accumulated significant stores of supplies and some knowledge. Therefore, your encounter with any one person should be, with any luck, within your expertise and resources.  There may be a day, however, when you find yourself confronted with a scenario in which multiple people are injured.  This is referred to as a Mass Casualty Incident (MCI).

A mass casualty incident is any event in which your medical resources are inadequate for the number and severity of injuries incurred.  Mass Casualty Incidents can be quite variable in their presentation.  They might be:

• ·         Doomsday scenario events, such as nuclear weapon detonations
• ·         Terrorist acts, such as occurred on 9/11 or in Oklahoma City
• ·         Consequences of a storm, such as a tornado or hurricane
• ·         Consequences of civil unrest
• ·         Mass transit mishap (train derailment, plane crash, etc.)
• ·         A car accident with, say, three people significantly injured (and only one ambulance)
• ·         Many others

The effective medical management of any of the above events required rapid and accurate triage.  Triage comes from the French word “to sort” (“Trier”) and is the process by which medical personnel (like you, survival medic!) can rapidly assess and prioritize a number of injured individuals and do the most good for the most people. Note that I didn’t say: “Do the best possible care for each individual victim”.

Let’s assume that you are in a marketplace in the Middle East somewhere, or perhaps in your survival village near the border with another (hostile) group.  You hear an explosion.  You are the first one to arrive at the scene, and you are alone.  There are twenty people on the ground, some moaning in pain.  There were probably more, but only twenty are, for the most part, in one piece.  The scene is horrific.  As the first to respond to the scene, medic, you are Incident Commander until someone with more medical expertise arrives on the scene.  What do you do?

Your initial actions may determine the outcome of the emergency response in this situation.  This will involve what we refer to as the 5 S’s of evaluating a MCI scene:

·         Safety
·         Sizing up
·         Sending for help
·         Set-up of areas
·         START – Simple Triage And Rapid Treatment

1.  Safety Assessment:  Our friend Joshua Wander (thejewishprepper.com) relates to us an insidious strategy on the part of terrorists in Israel:  primary and secondary bombs.  The main bomb causes the most casualties, and the second bomb is timed to go off or is triggered just as the medical/security personnel arrive.  This may not sound right to you, but your primary goal as medic is your own self-preservation, because keeping the medical personnel alive is likely to save more lives down the road.  Therefore, you do your family and community a disservice by becoming the next casualty.

As you arrive, be as certain as you can that there is no ongoing threat.  Do not rush in there until you’re sure that the damage has been done and you and your helpers are safe entering the area.  In the immediate aftermath of the Oklahoma City bombing, various medical personnel rushed in to aid the many victims.  One of them was a heroic 37 year old Licensed Practical Nurse who, as she entered the area, was struck by a falling piece of concrete.  She sustained a head injury and died five 5 days later.

2. Sizing up the Scene:  Ask yourself the following questions:

• ·         What’s the situation?   Is this a mass transit crash?  Did a building on fire collapse?  Was there a car bomb?  
• ·         How many injuries and how severe?  Are there a few victims or dozens? Are most victims dead or are there any uninjured that could assist you?
• ·         Are they all together or spread out over a wide area? 
• ·        What are possible nearby areas for treatment/transport purposes? 
• ·         Are there areas open enough for vehicles to come through to help transport victims?
3.  Sending for Help:  If modern medical care is available, call 911 and say (for example):  “I am calling to report a mass casualty incident involving a multi-vehicle auto accident at the intersection of Hollywood and Vine (location).  At least 7 people are injured and will require medical attention.  There may be people trapped in their cars and one vehicle is on fire.”

In three sentences, you have informed the authorities that a mass casualty event has occurred, what type of event it was, where it occurred, an approximate numbers of patients that may need care, and the types of care (burns) or equipment (jaws of life) that may be needed.  I’m sure you could do even better than I did above, but you want to inform the emergency medical services without much delay.

If the you-know-what has hit the fan and you are the medical resource, get your walkie-talkie or handie-talkie and notify base camp of whatever the situation is and what you’ll need in terms of personnel and supplies.  If you are not the medical resource, contact the person who is; the most experienced medical person who arrives then becomes Incident Commander.

4.  Set-Up:  Determine likely areas for various triage levels (see below) to be further evaluated and treated.  Also, determine the appropriate entry and exit points for victims that need immediate transport to medical facilities, if they exist.  If you are blessed with lots of help at the scene, determine triage, treatment, and transport team leaders.

5. S.T.A.R.T.:  Triage uses the acronym S.T.A.R.T., which stands for Simple Triage and Rapid Treatment.   The first round of triage, known as “primary triage”, should be fast (30 seconds per patient if possible) and does not involve extensive treatment of injuries.  It should be focused on identifying the triage level of each patient.  Evaluation in primary triage consists mostly of quick evaluation of respirations (or the lack thereof), perfusion (adequacy of circulation), and mental status.  Other than controlling massive bleeding and clearing airways, very little treatment is performed in  primary triage. 

Although there is no international standard for this, triage levels are usually determined by color:

Immediate (Red tag): The victim needs immediate medical care and will not survive if not treated quickly.  (for example, a major hemorrhagic wound/internal bleeding) Top priority for treatment.
 
Delayed (Yellow tag): The victim needs medical care within 2-4 hours. Injuries may become life-threatening if ignored, but can wait until Red tags are treated. (for example, open fracture of femur without major hemorrhage)
 
Minimal (Green tag): Generally stable and ambulatory (“walking wounded”) but may need some medical care. (for  example, 2 broken fingers, sprained wrist)
 
Expectant (Black tag): The victim is either deceased or is expected to die.  (for example, open fracture of cranium with brain damage, multiple penetrating chest wounds)

Knowledge of this system allows a patient marking system that easily allows a caregiver to understand the urgency of a patient’s situation.  It should go without saying that, in a power-down situation without modern medical care, a lot of red tags and even some yellow tags will become black tags.  It will be difficult to save someone with a major internal bleeding episode without surgical intervention.

In the next part of this series, we will go through a typical mass casualty incident with 20 victims, and show how to proceed so as to provide the most benefit for the most people.
 
 
Part 2

A mass casualty incident is any event in which your medical resources are inadequate for the number and severity of injuries incurred.  Mass Casualty Incidents (MCIs) can be quite variable in their presentation.  They might be:

• ·         Doomsday scenario events, such as nuclear weapon detonations
• ·         Terrorist acts, such as occurred on 9/11 or in Oklahoma City
• ·         Consequences of a storm, such as a tornado or hurricane
• ·         Consequences of civil unrest
• ·         Mass transit mishap (train derailment, plane crash, etc.)
• ·         A car accident with, say, three people significantly injured (and only one ambulance)
• ·         Many others
 
The effective medical management of any of the above events requires rapid and accurate triage.  Triage is the process of rapidly evaluating and sorting casualties by the severity of injury and the level of urgency for treatment. We will use the following categories:

Immediate (Red tag): The victim needs immediate medical care and will not survive if not treated quickly.  (for example, a major hemorrhagic wound/internal bleeding) Top priority for treatment.
 
Delayed (Yellow tag): The victim needs medical care within 2-4 hours. Injuries may become life-threatening if ignored, but can wait until Red tags are treated. (for example, open fracture of femur without major hemorrhage)
 
Minimal (Green tag): Generally stable and ambulatory (“walking wounded”) but may need some medical care. (for  example, 2 broken fingers, sprained wrist)
 
Expectant (Black tag): The victim is either deceased or is not expected to live.  (for example, open fracture of cranium with brain damage, multiple penetrating chest wounds)
 
If you don’t have triage tags, you can simply use a pen to mark the victim’s forehead with a 1 (Red), 2(Yellow), 3(Green), and 4(Black) to indicate the level of priority.
 
Here’s our hypothetical scenario:  you are in your village near the border with another (hostile) group.  You hear an explosion.  You are the first one to arrive at the scene, and you are alone.  There are about twenty people down, and there is blood everywhere.  What do you do?

In our last article, we discussed the 5 “S’s” of initial MCI scene evaluation.  From that, let’s say that you have already determined the SAFETY of the current situation and SIZED UP the scene.  There appears to have been a bomb that exploded.  There are no hostiles nearby, as far as you can tell, and there is no evidence of incoming ordinance.  Therefore, you believe that you and other responders are not in danger.  The injuries are significant (there are body parts) and the victims are all in an area no more than, say, 30 yards.  The incident occurred on a main thoroughfare in the village, so there are ways in and ways out. You have SENT a call for help on your handie-talkie and described the scene, and have received replies from several group members, including a former ICU nurse who is contacting everyone else with medical experience.  The area is relatively open, so you can SET UP different areas for different triage categories.  Now you can START (Simple Triage And Rapid Treatment).

You will call out as loudly as possible:  “I’m here to help, everyone who can get up and walk and needs medical attention, get up and move to ______ (pick an area). If you are uninjured and can help, follow me.”

You’re lucky, 13 of the 20, mostly from the periphery of the blast, sit up, or at least try to.  10 can stand, and 8 go to the area you designated.  These people have cuts and scrapes, and a couple are limping; one has obviously broken an arm. 2 beaten-up but sturdy individuals join you.  By communicating, you have made your job as temporary Incident Commander easier by identifying the walking wounded (Green) and getting some immediate help.  You still have 10 victims down.

You then go to the closest victim on the ground.  Start right where you are and go to the next nearest victim in turn.  In this way, you will triage faster and more effectively than trying to figure out who needs help the most from a distance or going in a haphazard pattern.

Let’s cheat just a little and say that you happen to have SMART tags in your pack.  SMART tags are handy tickets which allow you to make a particular triage level on a patient.  Once you identify a victim’s triage level, you remove a portion of the end of the tag until you reach the appropriate color and place it around the patient’s wrist.  You could, instead, use colored adhesive tape, colored markers, or numbers

(Priority 1 is immediate/red, 2 is delayed/yellow, 3 is minimal/green, 4 is dead/expectant/black; this is used in some other countries and is useful if you’re color blind).

It is important to remember that you are triaging, not treating.  The only treatments in START will be stopping massive bleeding, opening airways, and elevating the legs in case of shock. As you go from patient to patient, stay calm, identify who you are and that you’re here to help. Your goal is to identify who will need help most urgently (red tags).  You will be assessing RPMs  (Respirations, Perfusion, and Mental Status):

Respirations:  Is your patient breathing? If not, tilt the head back or, if you have them, insert an oral airway (Note: in a MCI triage situation, the rule against moving the neck of an injured person before ruling out cervical spine injury is, for the time being, suspended) If you have an open airway and no breathing, that victim is tagged black. If the victim breathes once an airway is restored or is breathing more than 30 times a minute, tag red.  If the victim is breathing normally, move to perfusion.

Perfusion:   Perfusion is an evaluation of how normal the blood flow or circulation is.  Check for a radial pulse and/or press on the nail bed (I sometimes use the pad of a finger) firmly and quickly remove.  It will go from white to pink in less than 2 seconds in a normal individual.  This is referred to as the Capillary Refill Time (CRT).  If no radial pulse or it takes longer than 2 seconds for nail bed color to return to pink, tag red.  If a pulse is present and CRT is normal, move to mental status.

Mental Status:  Can the victim follow simple commands (“open your eyes”, “what’s your name”)? If the patient is breathing and has normal perfusion but is unconscious or can’t follow your commands, tag red.  If they can follow commands, tag yellow if they can’t get up or green if they can.  Remember that, as a consequence of the explosion, some victims may not be able to hear you well. 

It might be easier to remember all this by just thinking:  30 (respirations) – 2 (CRT) – Can Do (Commands)

If there is any doubt as to the category, always tag the highest priority triage level.  Not sure between yellow and red?  Tag red.  Once you have identified someone as triage level red, tag them and move immediately to the next patient unless you have major bleeding to stop.  Any one RPM check that results in a red result tags the victim as red.  For example, if someone wasn’t breathing but began breathing once you repositioned the airway, tag red, stop further evaluation if not hemorrhaging and move to the next patient.  Elevate the legs if you suspect shock.

Finally, these are your 10 patients on the ground, in order.  Read the descriptions and decide the primary triage level; remember you have two unskilled helpers following you.  We’ll discuss how we triaged them in detail next article:

1.  Male in his 30s, complains of pain in his left leg (obviously fractured), Respirations 24, pulse strong, CRT 1 second, no excessive bleeding.
2.  Female in her 50s, bleeding from nose, ears, and mouth.  Trying to sit up but can’t, respirations 20, pulse present, CRT 1 second, not responding to your commands.
3.  Teenage girl bleeding heavily from her right thigh, respirations 32, pulse thready, CRT 2.5 seconds, follows commands
4.  Another teenage girl, small laceration on forehead, says she can’t move her legs.  Respirations 20, pulse strong, CRT 1 second.
5.  Male in his 20s, head wound, respirations absent.  Airway repositioned, still no breathing. 
6.  Male in his 40s, burns on face, chest, and arms.  Respirations 22, pulse 100, CRT 1.5 seconds, follows commands.
7.  Teenage boy, multiple cuts and abrasions but not hemorrhaging, says he can’t breathe, respirations 34, radial pulse present, CRT 2.5 seconds.
8.  Female in her 20s, burns on neck and face, respirations 22, pulse present, CRT 1 second, asks to get up and can walk, although with a limp.
9.  Elderly woman, bleeding profusely from an amputated right arm (level of forearm), respirations 36, pulse on other wrist absent, CRT 3 seconds, unresponsive.
10.  male child, multiple penetrating injuries, respirations absent.  Airway repositioned, starts breathing.  Radial pulse absent, CRT 2 seconds, unresponsive.
Next article, we’ll see how we used START to sort our victims, utilized our unskilled help, and proceeded once we completed primary triage.  We’ll also discuss how our evaluations would stand up in a SHTF scenario.
 
Part 3

In Part 2 we described a mass casualty incident scene with 20 victims and told you about initial considerations before beginning START (Simple Triage and Rapid Treatment).  You ended up with 10 victims on the ground, 8 walking wounded, and 2 uninjured but unskilled helpers.  You moved the walking wounded to a separate area and are now ready to quickly triage the remaining 10 victims.

To review the primary triage categories:

Immediate (Red tag): The victim needs immediate medical care and will not survive if not treated quickly.  (for example, a major hemorrhagic wound/internal bleeding) Top priority for treatment.

Delayed (Yellow tag): The victim needs medical care within 2-4 hours. Injuries may become life-threatening if ignored, but can wait until Red tags are treated. (for example, open fracture of femur without major hemorrhage)

Minimal (Green tag): Generally stable and ambulatory (“walking wounded”) but may need some medical care. (for  example, 2 broken fingers, sprained wrist)

Expectant (Black tag): The victim is either deceased or is not expected to live.  (for example, open fracture of cranium with brain damage, multiple penetrating chest wounds)

And here are your triage evaluation parameters (RPMs):

Respirations:  Is your patient breathing? If not, tilt the head back or, if you have them, insert an oral airway (Note: in a MCI triage situation, the rule against moving the neck of an injured person before ruling out cervical spine injury is, for the time being, suspended) If you have an open airway and no breathing, that victim is tagged black. If the victim breathes once an airway is restored or is breathing more than 30 times a minute, tag red.  If the victim is breathing normally, move to perfusion.

Perfusion: 
  Perfusion is an evaluation of how normal the blood flow or circulation is.  Check for a radial pulse and/or press on the nail bed (I sometimes use the pad of a finger) firmly and quickly remove.  It will go from white to pink in less than 2 seconds in a normal individual.  This is referred to as the Capillary Refill Time (CRT).  If no radial pulse or it takes longer than 2 seconds for nail bed color to return to pink, tag red.  If a pulse is present and CRT is normal, move to mental status.

Mental Status:  Can the victim follow simple commands (“open your eyes”, “what’s your name”)? If the patient is breathing and has normal perfusion but is unconscious or can’t follow your commands, tag red.  If they can follow commands, tag yellow if they can’t get up or green if they can.  Remember that, as a consequence of the explosion, some victims may not be able to hear you well.

Remember this:  30 (respirations) – 2 (CRT) – Can Do (follows commands)

Your 2 uninjured helpers are an able-bodied man and woman.  The woman knows how to take a pulse.  You have no medical equipment with you other than some oral airways and triage tags to work with.

Begin with the nearest victim (from our list in the last article):

1.  Male in his 30s, complains of pain in his left leg (obviously fractured), Respirations 24, pulse strong, CRT 1 second, no excessive bleeding.

Respirations are within acceptable range (less than 30), pulse and CRT normal.  Complains of pain, and is communicating where it hurts, so mental status probably normal.  This patient is tagged YELLOW: needs care but will not die if there is a reasonable (2-4 hour) delay.  Move on.

2.  Female in her 50s, bleeding from nose, ears, and mouth.  Trying to sit up but can’t, respirations 20, pulse present, CRT 1 second, not responding to your commands.

This victim has a significant head injury, but is stable from the standpoint of respirations and perfusion.  As her mental status is impaired, tag RED (immediate).  Move on.

3.  Teenage girl bleeding heavily from her right thigh, respirations 32, pulse thready, CRT 2.5 seconds, follows commands.

This victim is seriously hemorrhaging, one of the reasons to treat during triage.  Respirations elevated and perfusion impaired. You use your unskilled male helper to apply pressure by placing his hands on the bleeding and applying pressure, preferably using his shirt or bandanna as a “dressing”. Tag RED.  As the patient is already RED, you don’t really have to assess mental status. You and your female helper move on.

4.  Another teenage girl, small laceration on forehead, says she can’t move her legs.  Respirations 20, pulse strong, CRT 1 second.

Probable spinal injury but otherwise stable and can communicate.  Tag YELLOW.  Move on.

5.  Male in his 20s, head wound, respirations absent.  Airway repositioned, still no breathing. 

If not breathing, you will reposition his head and place an airway.  This fails to restart breathing.  This patient is deceased for all intents and purposes.  Tag BLACK, move on.

6.  Male in his 40s, burns on face, chest, and arms.  Respirations 22, pulse 100, CRT 1.5 seconds, follows commands.

This victim has significant burns on large areas, but is breathing well and has normal perfusion.  Mental status is unimpaired, so you tag YELLOW and move on.

7.  Teenage boy, multiple cuts and abrasions but not hemorrhaging, says he can’t breathe, respirations 34, radial pulse present, CRT 2.5 seconds.

This victim doesn’t look so bad but is having trouble breathing and has questionable perfusion.  Mental status is unimpaired, but he likely has other issues, perhaps internal bleeding.  You tag RED (respirations over 30, impaired perfusion) and move on.

8.  Female in her 20s, burns on neck and face, respirations 22, pulse present, CRT 1 second, asks to get up and can walk, although with a limp.

Obviously injured, this young woman is otherwise stable and communicating.  With assistance, she is able to stand up, and can walk by herself.  She becomes another of the walking wounded, tag GREEN.   Point her to the other GREEN victims and move on.

9.  Elderly woman, bleeding profusely from an amputated right arm (level of forearm), respirations 36, pulse on other wrist absent, CRT 3 seconds, unresponsive.

Obviously in dire straits, you use your shirt as a tourniquet and sacrifice your remaining helper to apply pressure on the bleeding area.  Tag Red, move on.

10.  Male child, multiple penetrating injuries, respirations absent.  Airway repositioned, starts breathing.  Radial pulse absent, CRT 2 seconds, unresponsive.
You initially think this child is deceased, but you follow protocol and reposition his airway by tilting his head back and lifting his jaw .  A Mass Casualty Incident is one of the few circumstances where you don’t worry as much about cervical spine injuries in making your assessment. He starts breathing even without an oral airway, to your surprise, so you tag him RED.  If he is bleeding heavily from his injuries, you apply pressure and wait for the additional help you requested on initial survey of the MCI to arrive.

You have just performed triage on 20 victims, including the walking wounded, in 10 minutes or less.  Help begins to arrive, including the ICU nurse that you contacted initially.  You are no longer the most experienced medical resource at the scene, and you are relieved of Incident Command.  The nurse begins the process of assigning areas for yellow, red and black areas where secondary triage and treatment can occur.

There is still much to do, but you have performed your duty to identify those victims who need the most urgent care.  In a normal situation, your modern medical facilities will already have ambulances and trained personnel with lots of equipment on the scene.  In a collapse situation, however, the prognosis for many of your victims is grave.  Go back ` over our list of victims and see who you think would survive if modern medical care was not available.  Many of the RED tags and even some of the YELLOW tags would be in serious danger of dying from their wounds.

In times of trouble, it is wise to carry some form of individual kit to deal with medical issues you may be confronted with. Nurse Amy and I constantly research, develop and tweak medical supplies to tailor them to collapse scenarios.  We are always learning and improvising, and it would serve you well to do the same.

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This page contains a single entry by Jim Rawles published on June 27, 2013 12:15 AM.

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