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

The Fine Print 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. 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 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 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. TX EMS 2008

Objectives Define “MCI” and “Triage” Discuss goals of MCI triage Perform simulated “MASS” Triage Classify simulated MCI victims by “ID-me” categories Describe life-saving interventions during MCI victim triage Identify specific all-hazards triage concerns TX EMS 2008

The Plan Brief questionnaire Interactive mass cal simulation: Part 1 Didactic presentation Interactive mass cal simulation: Part 2 TX EMS 2008

Question 1 Which of the following best describes you? ECA EMT-B EMT-I EMT-P Physician RN Other TX EMS 2008

Question 2 Which best describes the geographical area where you work? Rural Suburban Urban (city < 100,000) Urban (city ≥ 100,000) None of the above TX EMS 2008

Question 3 Which one of the following is your primary type of EMS/healthcare service? Rural EMS (non-transporting) Rural EMS (transporting) Urban-Fire/EMS Urban-”Third Service” EMS Aeromedical Interfacility Transport Only Hospital-Based Student Retired Other TX EMS 2008

Question 4 How long have you worked in EMS/healthcare? Less than 2 years 2 to 5 years 5 to 10 years 10 to 15 years More than 15 years TX EMS 2008

Question 5 Have you ever had formal classroom training in mass casualty triage? Yes No TX EMS 2008

Question 6 Have you ever participated in a hands-on mass casualty simulation or drill in which you triaged “victims”? Yes No TX EMS 2008

Question 7 Have you ever had to triage patients in an actual mass casualty incident? Yes No TX EMS 2008

Question 8 If yes, what triage method or system did you use during that incident? I answered “No” to Question 7 MASS START SAVE Sacco® Military Other Don’t Know TX EMS 2008

Question 9 If yes, did you feel confident in your triage decisions during that incident? I answered “No” to Question 7 Yes No TX EMS 2008

Question 10 Did you participate in relief efforts to provide medical care to evacuees after Hurricanes Katrina or Rita? Yes No TX EMS 2008

Question 11 Is knowing how to perform mass casualty triage part of your professional responsibilities? Yes No TX EMS 2008

Question 12 What is the likelihood, in your opinion, that you would ever be called upon to perform mass casualty triage in the future? Very likely Likely Neutral Unlikely Very unlikely TX EMS 2008

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? Very confident Somewhat confident Neutral Somewhat unsure Very unsure TX EMS 2008

Let’s Begin! TX EMS 2008

Now What???? TX EMS 2008

Victim 1 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL GREEN1 – GREEN GIRL EXPECTANT TX EMS 2008

Victim 2 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL RED1 – SAME WHITE LADY EXPECTANT TX EMS 2008

Victim 3 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL YELLOW1 – GAL BEING HELPED BY 2 GUYS EXPECTANT TX EMS 2008

Victim 4 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL BLACK1 – MANIKIN WITH EVISCERATION EXPECTANT TX EMS 2008

Victim 5 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL YELLOW2 – GAL IN WHITE SHIRT ON GROUND EXPECTANT TX EMS 2008

Victim 6 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL GREEN2 - HISPANIC GIRL IN WHITE SHIRT (EVEN THOUGH SHE’S REALLY WEARING A BLACK SHIRT) – I WAS TOO SUPERSTITIOUS TO CHANGE THE FILE NAME! EXPECTANT TX EMS 2008

Victim 7 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL BLACK2 – BLACK MAN IN GREEN SHIRT EXPECTANT TX EMS 2008

Victim 8 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL RED2 – MANIKIN WITH BKA EXPECTANT TX EMS 2008

Victim 9 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL RED3 - RED OR YELLOW FINGER AMP (ACTUALLY, IT’S A HAND AMP WITH OTHER INJURIES AND UNSTABLE VS) EXPECTANT TX EMS 2008

Victim 10 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL YELLOW3 – GIRL AND GUY WITH NO EYE EXPECTANT TX EMS 2008

Victim 11 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL BLACK3 – BURN RED SHIRT EXPECTANT TX EMS 2008

Victim 12 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL RED4 EXPECTANT TX EMS 2008

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

This is NOT a good thing! TX EMS 2008

“Why Am I Here?” How do I decide who receives care now and who does not? In a disaster, needs exceed resources More patients than providers Difficult choices must be made TX EMS 2008

IS TRIAGE NEEDED HERE? 2003, Warwick, RI 1942, Boston, MA 100 dead Boston Globe Although triage was developed more than 200 years ago on the battlefields of France, over the past century, mass casualty incidents have been all too common in the United States. These first photos are from the Cocoanut Grove nightclub fire in Boston in 1942, in which 492 people died and hundreds more were injured. But that was THEN and this is NOW, right? Wrong! These latter photos are from the Warwick, Rhode Island nightclub fire in February 2003. Although “ONLY” 100 people died, this, too, was a catastrophic man-made disaster, a true “mass casualty incident”. With so many victims and limited resources, how could anyone possibly assess and manage all the injured??? AP Photo AP Photo Boston Globe

“Triage Typically Means “Trauma”” AP photo: Matt Slocum www.masada2000.org September 23, 2005 Wilmer, TX “Triage Typically Means “Trauma”” August 2, 1985 Dallas, TX TX EMS 2008

Add Photos London? Madrid? LA train? NYC crane? TX EMS 2008

What About Medical Triage? Insert the CBN article here – instead or in addition to this one TX EMS 2008

Triage: “It’s not in my job description!” http://www.ahrq.gov/prep/cbrne/ TX EMS 2008

Business As Usual Use clip art for graphics Resources exceed demand Use clip art for graphics here -- lots of providers, few patients TX EMS 2008

The “Perfect World” of MCI Response First responders respond to scene Patients are triaged in the field HazMat handles decon in the field Sickest patients arrive with EMS: Already sorted and tagged Already decontaminated Already partially treated Hospitals “only” need to care for them... TX EMS 2008

What REALLY Happens... “Chaotic” phase: 15-25 min No EMS, no scene leader 80% of minimally injured self-transport They arrive at closest hospitals: NO TRIAGE NO DECONTAMINATION NO MEDICAL INTERVENTION TX EMS 2008

Mass Casualty Predictor http://www.bt.cdc.gov/masscasualties/predictor.asp TX EMS 2008

Another Awful Thought... Hospital as “Hot Zone” It’s your “off” day Or.... It’s your “off” day Or… Flu Pandemic, Bioterrorism… TX EMS 2008

Definitions TX EMS 2008

MCI: Definition Mass Casualty Incident Major Casualty Incident Multiple Casualty Incident Healthcare needs exceed resources! Resources must be rationed! TX EMS 2008

Adapted from Heightman AJ (2006). JEMS 31(4):16. How do I identify the sickest patients quickly? How do I remove ambulatory & least injured victims from the scene? Adapted from Heightman AJ (2006). JEMS 31(4):16.

Your Own Safety Comes First! We all want to help Triage is an important part However, your first priority is to PROTECT YOURSELF! You don’t need to die! TX EMS 2008

Before Any Casualty Care... “Scene Size-Up” – “Scene Safety” Incident Survey BEFORE Casualty Survey TX EMS 2008

“RED Survey” “Rapid Evaluation of Disaster” Incident Survey BEFORE patient care! Casualty Survey Life-saving Interventions TX EMS 2008

All-Hazards: Definition Man-made or natural events with destructive capability for multiple casualties Graniteville, SC – January 2005 La Conchita, CA – January 2005 TX EMS 2008

“All-Hazards” Examples Man-made Structure Fires Structure Collapses Explosive Devices Transportation Events: Air, Rail, Roadway, Water Industrial HazMat Events Terrorism Incidents: CBRNE events, Firearms Natural Earthquakes Landslides & Avalanches Volcanoes Tornadoes Hurricanes Floods & Flash Floods Tsunamis Wildfires Emerging Infectious Diseases Since 9/11, the public and media focus has been on terrorism and other man-made, intentional disasters. Yet NATURAL disasters are far more common and kill far more people every year. For example, in 2003: 50,000 people died worldwide in only *2* major disasters: 30,000+ in earthquake in Iran 20,000 in European heat wave (environmental emergencies such as this are not on the list, but ought to be!) Some of these disasters, whether “natural” or “man-made”, are frighteningly obvious when they occur. Others, however, may not be. [[Does anyone know which of these kills the most people in the US every year?]] TX EMS 2008

Triage: Definition Sorting of patients by seriousness of condition and likelihood of survival www.learnovation.com [Self-explanatory] TX EMS 2008

Triage Levels Primary (scene & hospital) Secondary (scene & hospital) Physiology: Can patient use his own resources to deal w/injuries? Which conditions will benefit from use of scarce resources? Secondary (scene & hospital) Match patients’ current & anticipated needs with available resources Physiology, Physical Assessment, Initial Treatment & Reassessment, Knowledge of Resource Availability Tertiary (hospital) Optimize individual outcome Higher-level Treatment & Reassessment, Further Resource Assessment, Determination of Best Venue for Definitive Care TX EMS 2008

Triage: History “Trier”: French for “to sort” 18th century European battlefields Original military goal: Return to combat as many soldiers as possible Just what is TRIAGE? The word triage is derived from the French word, trier, (pronounced Tree-ay), meaning “to sort”. It was originally developed on the battlefields of 18th century Europe. In that context, the goal was to treat and return to combat as many soldiers as possible. Although this remains even today an important focus, triage has also been applied to civilian events. http://nmhm.washingtondc.museum/ TX EMS 2008

Triage: Goals Primary Goal: Secondary Goals: Greatest good for the greatest number of possible survivors: maximize survival Secondary Goals: Relief of suffering Efficient resource allocation Depend on available resources TX EMS 2008

Factors That Impact Resource Availability Volume and severity of patients Limited numbers of providers Infrastructure limitations Inadequate hazard preparation (HAZMAT, etc.) Limited transport capabilities Multiple-jurisdictional response Lack of hospital surge capacity TX EMS 2008

Triage Systems Multiple triage systems in use Various methods using tags, categories, colors, symbols Familiarize yourself with your agency’s system and PRACTICE it IDEAL = one uniform system used by all agencies in the field & at hospitals There are several different modern triage systems in use, derived from both military and civilian sources. They employ different methods of classifying and tagging victims using symbols, colors, and other devices. Healthcare workers, first responders and EMS personnel among you might want to take the time to familiarize yourself with the system used by your agency. Ideally, everyone – both field personnel and hospital personnel – would use the same system. This would minimize confusion and maximize communication. ____________ TX EMS 2008

Why Triage? System tool to bring order from chaos Get care for those who need it most and are most likely to benefit Aids resource allocation Objective framework for stressful & emotional decisions Increases provider efficiency & effectiveness TX EMS 2008

The “Ideal” Triage System? Simplicity Easy to remember Easy to use Objectivity Accuracy Ability to process large numbers of victims (Evidence-based) TX EMS 2008

Underlying Parameters Life, limb or vision threat Level of medical intervention needed (Access to transportation) TX EMS 2008

Triage Process GROUP SORT TRANSPORT TX EMS 2008

“M.A.S.S.” Triage A – Assess S – Sort S – Send M – Move TX EMS 2008 Again, “MASS” is an easy-to-remember acronym that stands for “move, assess, sort and send”. The system has been tested and validated for handling large numbers of casualties in mass casualty incidents (MCIs). It utilizes U.S. military triage categories. One may also think of this system as it refers to “MASS” casualty incidents. Conducted in the “T” step of DISASTER MASS – Designed to quickly sort large numbers of victims that are in the same proximity. www.triagetags.com www.triagetags.com TX EMS 2008

“M.A.S.S.” Triage M – Move A – Assess S – Sort S – Send TX EMS 2008

“ID-me” Categories I - IMMEDIATE D - DELAYED M - MINIMAL D - DEAD EXPECTANT LETHAL INJURY E - EXPECTANT I – Needs IMMEDIATE care, but still potentially salvageable D – Needs definitive care, but not likely to die in next few minutes if care is DELAYED M – MINIMALLY injured “walking wounded” (& uninjured) E – EXPECTANT: “expected” to die soon because of the severity of injuries. Some systems use a BLUE tag for this category, to distinguish it from the BLACK used for those confirmed dead. D- Some agencies use a separate category/tag for victims that are already confirmed to be DEAD. TX EMS 2008

“M.A.S.S.” Triage Tested & used by the military Adapted for civilian disasters It works! Fast Accurate Large numbers of victims You needn’t be an “expert” to help! TX EMS 2008

“M.A.S.S.” Triage GROUP victims first... then.... SORT individual victims then... TRANSPORT TX EMS 2008

Basis of “M.A.S.S.” Triage Ability to move best predicts outcome Glasgow Coma Scale Motor component MASS Triage is based on research which shows that the motor component of the Glasgow Coma Scale is the best predictor of mortality for trauma patients. In other words, a patient’s ability to move strongly correlates with outcome. Let’s see how this works…. TX EMS 2008

“M.A.S.S.” Triage “MOVE”: STEP 1 Goal: Action: Identifies: Group - Victims who can WALK Action: “Everyone who can hear me and who can walk, please move to the area with the green flag.” Identifies: MINIMAL group MINIMAL The first step in the MOVE portion of MASS triage is to identify the minimally injured patients who require the least critical care. These patients are awake and ambulatory (and would have a normal score of 6 on the motor portion of the GCS). They are identified by asking “everyone who can hear me and who can walk, please move to the area with the green flag”. These victims then become the green, MINIMAL group. TX EMS 2008

Why Bother with Them FIRST? MINIMAL group: major vital functions intact Assess last, after more critical groups However, actively managing this group may: Facilitate scene management Conserve scene resources Reduce self-transports & overburdening of nearest hospital ERs Brief screening of this group will reveal the following: Airway, breathing, and circulation are intact. Mental status is also intact, at least to the extent that they can follow commands. These patients are NOT likely to have low blood pressure or breathing trouble. As such, this group should undergo formal assessment LAST, after that of the more critically injured victims. Why invest time to identify this group early? Active management of this group will conserve scene resources for those victims with the most dire need. And it may reduce self-transports and unnecessary overburdening of hospital emergency departments by minimally injured persons. Hence, limited hospital resources can be saved for the more critically ill, as well. Limitations: not based upon individual assessment yet. Some conditions may worsen over time, necessitating triage to a more urgent category. Ideally, trained personnel should monitor and frequently reassess these patients, re-triaging as needed. This gets them out of the way so that you may find the higher priority patients This also puts them in one area so they may be contained and assessed there when enough personnel become available ideally, assign someone to keep them in that area or else they will wander off. These patients must be assessed and reassessed as soon as possible as patients may deteriorate and change from their initial triage categories TX EMS 2008

“M.A.S.S.” Triage “MOVE”: STEP 2 Goal: Action: Identifies: Group – Victims who can’t walk, but who can MOVE Action: Ask the remaining victims “Everyone who can hear me and needs help, please raise an arm or leg so we can come help you.” Identifies: DELAYED Group DELAYED The next group to be identified during the “MOVE” Step of MASS Triage is the DELAYED group. These victims cannot walk, but are awake and able to follow commands to MOVE an arm or a leg. They are identified by asking the remaining victims, “everyone who can hear me please raise an arm or a leg so that we can come help you”. This becomes the yellow, DELAYED group. TX EMS 2008

“M.A.S.S.” Triage “ASSESS”: Goal: Action: Group – Identify who is left, victims unable to walk & unable to follow simple commands to move Action: Go immediately to these patients for life-saving interventions (if medically trained) Now that all the patients who can MOVE have been identified, MASS triage next focuses on ASSESSMENT of those victims who are left. Since they cannot either ambulate or follow simple commands to move (lower score on the motor scale of the GCS), it is assumed that they are more critically injured. Rescuers must proceed immediately to these patients to deliver critical life-saving interventions. This group of victims is now the red, IMMEDIATE group. Go to these patients first and deliver immediate life-saving interventions (bleeding control, airway opening, perhaps a MARK 1 kit), but that’s it for this moment. Whatever category the patient is in, tag him as such and move quickly to the next IMMEDIATE (failure to tag patient will result in another rescuer having to spend time triaging the same patient). Don’t forget that some of these patients may belong in other triage groups despite their initial grouping as immediate. For example, some may be dead or expectant. Expectant patients are those with likely fatal injuries. Dead patients should be tagged as such to prevent consumption of resources or wasting time by having other personnel attempting to triage the patient again. TX EMS 2008

“M.A.S.S.” Triage “ASSESS” IMMEDIATE patients: Open Airway Stop Bleeding Give Chemical antidote Decompress TPtx www.rk19-bielefeld-mitte.de www.tpub.com FIRST, Is the victim’s airway open? If not, open it manually with a jaw thrust or similar maneuver. NEXT, with the airway opened: Is the patient breathing? If not, he or she is assigned to the EXPECTANT group, and the rescuer proceeds to the next patient. NEXT, if the patient IS breathing: Is uncontrolled bleeding present? If so, apply direct pressure or a tourniquet. We will come back to this in a moment. (In contrast to what we were taught with boy scouts, basic first aid, basic life support or even advanced life support, one should not hesitate in THESE CRITICAL CIRCUMSTANCES to use a tourniquet, if necessary. The goal in this setting is to save a life, and it may be necessary to sacrifice a limb. Try to record on the patient the time the tourniquet was applied.) It may be necessary to assign someone else to do this, so that the rescuer can keep moving… FINALLY, In the setting of a nerve agent exposure, antidote kits, if available, may also be administered at this time. From a practical standpoint, this may be ALL the rescuer can do during this phase. Some authors include needle decompression of a tension pneumothorax with this list – assumes one has a large-bore angiocatheter handy! “D” for “decompression” or “dart” the chest! www.meridianmeds.com www.trauma.org TX EMS 2008

“M.A.S.S.” Triage “ASSESS” IMMEDIATE patients: Stop Bleeding Open Airway Stop Bleeding Give Chemical antidote Pressure Points Whatever it takes! Be creative! Delete In contrast to what we were taught with boy scouts, basic first aid, basic life support or even advanced life support, one should not hesitate in THESE CRITICAL CIRCUMSTANCES to use a tourniquet, if necessary. If an actual tourniquet is unavailable, alternative devices that can fill this need include: gauze bandages, belts, brassieres, disposable gloves or anything else that might be at hand. The goal in this setting is to save a life, and it may be necessary to sacrifice a limb. Try to record on the patient the time the tourniquet was applied. It may be necessary to assign someone else to do this, so that the rescuer can keep moving… FINALLY, In the setting of a nerve agent exposure, antidote kits, if available, may also be administered at this time. From a practical standpoint, this may be ALL the rescuer can do during this phase. Some authors include needle decompression of a tension pneumothorax with this list – assumes one has a large-bore angiocatheter handy! “D” for “decompression” or “dart” the chest! Tourniquets TX EMS 2008

Move on! “M.A.S.S.” Triage Is transport available? Question: “ASSESS” IMMEDIATE patients: Question: Is transport available? Move on! www.usmc.mil/marinelink/mcn2000 Delete While this assessment is underway, consider the availability of TRANSPORT means for these most severely injured victims. The incident commander or triage officer will contact receiving hospitals to advise them of the number of IMMEDIATE patients and to determine how many each facility can accept. Above all, keep moving. This assessment and intervention stage must be performed quickly, in order to identify as many salvageable patients as possible. Minimize the amount of time spent with each patient until all IMMEDIATES have been individually assessed. TX EMS 2008

Victim Group Summary Goal Action ID-me Group Minimal Delayed Immediate 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 TX EMS 2008

In Other Words... GREEN: “First Aid”, “DIY” YELLOW: Get thee to a doctor soon RED: Gonna’ die without immediate care TX EMS 2008

“ID-me” and NATO Categories COLOR “ID-me” NATO Priority RED Immediate 1 YELLOW Delayed 2 GREEN Minimal 3 BLACK Expectant DEAD TX EMS 2008

Adapted from Heightman AJ (2006). JEMS 31(4):16. Minimal - 3 Delayed - 2 Immediate - 1 Adapted from Heightman AJ (2006). JEMS 31(4):16.

ONLY NOW Do We Assess Individuals Having grouped victims according to their ability to move... ...The next phase entails more detailed individual assessment. Change assess to sort TX EMS 2008

“M.A.S.S.” Triage “SORT”: Goal: Actions: Sort patients via INDIVIDUAL assessment Actions: Assign to “ID-me” Categories: IMMEDIATE, DELAYED, MINIMAL, Continue treatment EXPECTANT Change assessment to sorting The next step, after moving groups of patients, is to SORT victims based on individual assessment. To a certain extent, this sorting process has already occurred during the MOVE and ASSESSMENT stages, using the “ID-me” mnemonic to classify patients into the RED (immediate), YELLOW (delayed), GREEN (minimal) and BLACK (expectant) groups. (In some systems, EXPECTANT patients are assigned a BLUE tag, with BLACK being reserved for DEAD patients.) We will return to a detailed explanation of this category in a moment. Treatment also continues during this phase, as preparations are made for evacuation and transport, the final step. TX EMS 2008

“M.A.S.S.” Triage “SORT”: Ideally: trained medical personnel May not be available Begin with those who didn’t move Tag immediately upon triage Including dead victims Now that the most immediately-needed life-saving interventions have been performed on the IMMEDIATE patients, all the rest of the patients are individually assessed and then sorted further in to the most appropriate triage category. (starting with the DELAYED group……..unless there are enough rescuers to start all groups simultaneously) The individual assessments would be best performed by trained medical personnel. However this of course may not be possible. TAG patients as they are triaged…….otherwise they will be triaged by multiple personnel, wasting time. Dead patients should also be tagged as such to prevent wasting resources to re-triage the patient. We will return to this in a moment…. TX EMS 2008

There Are Many Different Patient Assessment Tools A number of patient assessment tools may be used at this stage. www.usmc.mil/marinelink/mcn2000 CERT L.A. 2003 TX EMS 2008

START Triage “R” “P” “M” TX EMS 2008 Many of us are likely familiar with one such triage system, “START”, which stands for “Simple Triage and Rapid Treatment”. Originally developed by the Newport Beach, CA Fire and Marine Department, START is the current Department of Transportation standard triage system. Recall the 3 steps of START Triage, “R”, “P”, “M”, which stand for Respiration, Perfusion and Mental Status. This slide illustrates the algorithm. As you can see, it is somewhat complicated and includes parameters that might be impractical under dire MCI conditions. For example, the assessment of capillary refill (“blanch test”) might be nearly impossible or unreliable when the patient is cold or covered with debris (?contaminated) or blood, or in the dark. A somewhat simplified version of this algorithm has been developed.... “M” TX EMS 2008

START Mnemonic R P M 30 2 Can Do TX EMS 2008

START Limitations? 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? TX EMS 2008

Sacco Triage Method (STM) http://www.sharpthinkers.com/abc/ts_approach_triss.htm TX EMS 2008

Simplified Triage MINIMAL IMMEDIATE EXPECTANT DELAYED Non-ambulatory Non-moving Simplified Triage MINIMAL (Already identified & grouped separately) Respirations Breathing? As needed: Bleeding control Chemical antidotes Decompress chest YES NO Too fast? Too slow? Position airway >6 & <30 Pulse (radial) Palpable? YES NO IMMEDIATE EXPECTANT YES NO This is a modified, somewhat simpler triage algorithm that might be more practical under the most austere conditions. It still employs the “RPM” of START, but eliminates a few steps for simplicity. Recall that the “walking wounded” (minimally injured and uninjured) victims, the GREEN group, has already been identified and grouped separately during the initial “MOVE” stage of MASS triage. They *do* require formal individual assessment as soon as resources allow. Individual assessment begins with the remaining victims – those who neither walked to the “GREEN” triage area nor followed commands to “MOVE an arm or leg” during the “MOVE” phase of “MASS”. As with START, the first assessment parameter is RESPIRATIONS. If the victim is not breathing, a jaw thrust maneuver is performed. If the victim is still NOT breathing, he or she is tagged BLACK and one moves to the next victim. If the victim begins to breath after opening the airway, he/she is tagged IMMEDIATE. For a victim who is breathing, the next question is: is the respiratory rate too fast (>30) or too slow (<6). (These are somewhat arbitrary numbers, of course.) A victim with RR that is outside this range is tagged as IMMEDIATE. For a breathing victim with a RR between 6 and 30, the next step is PERFUSION/PULSE. (Capillary refill has been omitted for the reasons mentioned in the previous slide.) If the radial pulse is NOT palpable, the victim is tagged as IMMEDIATE. If the pulse is palpable, the next step is MENTAL STATUS. If the victim can follow commands, he/she is tagged as DELAYED (recall – this victim is breathing at a “normal” rate, has a BP high enough to generate a palpable radial pulse (~70 mmHg), and is awake enough to follow commands). If, on the other hand, the victim cannot follow commands, he/she is tagged IMMEDIATE. For all groups, Bleeding control, Chemical antidotes and Decompression of a tension pneumothorax are employed, as indicated. Mental Status Follows commands? NO DELAYED YES TX EMS 2008

ATLS® “Sift” and “Sieve” Advanced Trauma Life Support for Doctors – Student Course Manual 7th Edition American College of Surgeons, Chicago, IL, 2004 TX EMS 2008

BTLS/ITLS BTLS, 5th Edition Campbell JE Brady – Prentice Hall, New Jersey, 2004 TX EMS 2008

“M.A.S.S.” Triage “SORT”: Goal: Sort patients based upon INDIVIDUAL assessment Actions: “ID-me”: IMMEDIATE, DELAYED, MINIMAL, , DEAD Continue treatment The next step, after moving groups of patients, is to SORT victims based on individual assessment. To a certain extent, this sorting process has already occurred during the MOVE and ASSESSMENT stages, using the “ID-me” mnemonic to classify patients into the RED (immediate), YELLOW (delayed), GREEN (minimal) and BLACK (expectant) groups. (In some systems, EXPECTANT patients are assigned a BLUE tag, with BLACK being reserved for DEAD patients.) We will return to a detailed explanation of this category in a moment. Treatment also continues during this phase, as preparations are made for evacuation and transport, the final step. EXPECTANT TX EMS 2008

“M.A.S.S.” Triage “SORT”: Ideally: trained medical personnel May not be available Begin with those who didn’t move Tag immediately upon triage Including dead victims Now that the most immediately-needed life-saving interventions have been performed on the IMMEDIATE patients, all the rest of the patients are individually assessed and then sorted further in to the most appropriate triage category. (starting with the DELAYED group……..unless there are enough rescuers to start all groups simultaneously) The individual assessments would be best performed by trained medical personnel. However this of course may not be possible. TAG patients as they are triaged…….otherwise they will be triaged by multiple personnel, wasting time. Dead patients should also be tagged as such to prevent wasting resources to re-triage the patient. We will return to this in a moment…. TX EMS 2008

“ID-me” Categories I - IMMEDIATE D - DELAYED M - MINIMAL E - EXPECTANT LETHAL INJURY E - EXPECTANT No matter which patient assessment method is used, the goal is to classify patients into one of 4 color-coded categories that reflect the severity of their injuries and their likelihood of survival. These will be used to prioritize treatment and evacuation. I – Needs IMMEDIATE care, but still potentially salvageable D – Needs definitive care, but not likely to die in next few minutes if care is DELAYED M – MINIMALLY injured “walking wounded” (& uninjured) E – EXPECTANT: “expected” to die soon because of the severity of injuries. Some systems use a BLUE tag for this category, to distinguish it from the BLACK used for those confirmed dead. D- Some agencies use a separate category/tag for victims that are already confirmed to be DEAD. TX EMS 2008

“M.A.S.S.” Triage “SORT” – IMMEDIATE: Life- or Limb-threatening injury Airway, Breathing or Circulation Problem Unconscious Examples: Unresponsive, altered level of consciousness, severe breathing difficulty, uncontrollable bleeding, amputations above elbow or knee, cyanosis, rapid or weak pulse, open abdominal wounds, etc. If IMMEDIATE patients are found to be among the other triage groups, then immediately render life-saving interventions, TAG them, and move them to the IMMEDIATE area or the TRANSPORT area and advise the I.C./Triage Officer of the additional IMMEDIATE pt. Examples of this category are shown on this slide. TX EMS 2008

“M.A.S.S.” Triage “SORT” – DELAYED: Need definitive medical care, but should not worsen rapidly, if initial care is delayed Examples: Deep cuts or open fractures with controlled bleeding and strong pulses, finger amputations, abdominal injuries with stable vital signs, closed head injuries without altered LOC, etc. Human nature will likely compel rescue personnel to “over-triage” victims from the DELAYED category to the IMMEDIATE (RED) group. Such over-triage may complicate resource allocation, however. These patients should generally be OK to wait on transport until all the IMMEDIATEs have left the scene Ideally they will be physically grouped together into a DELAYED area, marked with YELLOW signs/flags/tarps/etc… Ideally a team of rescuers will be monitoring and treating them until they are transported If their condition changes, their triage category can be changed at any time and they can be moved to the other category’s physical collection area Examples of conditions triaged to the delayed group are listed here. TX EMS 2008

“M.A.S.S.” Triage “SORT” – MINIMAL: “Walking wounded” Group, sort & facilitate transport from scene Volunteer help? Risk vs. Benefit Examples: Abrasions, contusions, minor lacerations, no apparent injuries The next group to be individually sorted is the MINIMAL group. Ideally they will be physically grouped together into a MINIMAL area, marked with GREEN signs/flags/tarps/etc… Ideally a team of rescuers will monitor and treat them until they are transported, watching for deterioration due to “hidden” injuries missed during the initial triage. If their condition changes, their triage category can be changed at any time and they can be moved to the other category’s physical collection area If medical providers and equipment can be brought to the scene, then it may be possible to treat and release them AT THE SCENE (thus keeping the hospitals from being overwhelmed). Or they may be enlisted as volunteers to provide comfort to the dying, to hold pressure on exsanguinating wounds, and so on. On the other hand, their presence at the scene may contribute to confusion and disorganization. Similarly, one must consider the drain on resources they might create. TX EMS 2008

“M.A.S.S.” Triage “SORT” – : EXPECTANT Most severely injured Little chance of survival “Expected” to die soon In a perfect world, they would receive the most care, even though chance of survival is low In an MCI.... EXPECTANT Consolidate to one slide Who is left???? By this point, ideally, only EXPECTANT and DEAD victims will remain. Ideally, the expectant victims will be physically grouped together into an EXPECTANT area, marked with BLACK (sometimes BLUE) signs/flags/tarps/etc… Which patients are classified as EXPECTANT? They are the most critically injured, the most critically ill victims who still show some signs of life. They are the patients who, in an ideal world of a well-equipped and well-staffed ED, would receive the most intensive care and who might even survive. In an MCI setting, however, there are insufficient resources to render such intensive care for them; consequently, they are “expected” to die. As with the other groups, a team of rescuers should monitor and treat them until they are transported, if possible. If their condition changes, their triage category can be changed at any time and they can be moved to the other category’s physical collection area. As more resources become available and the IMMEDIATEs have been dealt with, more resources can be devoted to this group. Until then, one must recall that death might be hours or days away. Hence, any measure of comfort care possible should be provided. These patients should not be abandoned. TX EMS 2008

“M.A.S.S.” Triage “SORT” – : EXPECTANT Care resources NOT utilized initially Comfort care as available Death could be hours or days away! Reassessment & transport Transport those still alive after all IMMEDIATE victims evacuated Resuscitate & treat as resources allow Who is left???? By this point, ideally, only EXPECTANT and DEAD victims will remain. Ideally, the expectant victims will be physically grouped together into an EXPECTANT area, marked with BLACK (sometimes BLUE) signs/flags/tarps/etc… Which patients are classified as EXPECTANT? They are the most critically injured, the most critically ill victims who still show some signs of life. They are the patients who, in an ideal world of a well-equipped and well-staffed ED, would receive the most intensive care and who might even survive. In an MCI setting, however, there are insufficient resources to render such intensive care for them; consequently, they are “expected” to die. As with the other groups, a team of rescuers should monitor and treat them until they are transported, if possible. If their condition changes, their triage category can be changed at any time and they can be moved to the other category’s physical collection area. As more resources become available and the IMMEDIATEs have been dealt with, more resources can be devoted to this group. Until then, one must recall that death might be hours or days away. Hence, any measure of comfort care possible should be provided. These patients should not be abandoned. TX EMS 2008

“M.A.S.S.” Triage “SORT” – : EXPECTANT Examples: Near 100 % TBSA burns Fatal radiation doses Apnea or pulselessness Especially if multiple injuries Severe open brain injury Death “imminent” “Judgment call” EXPECTANT TX EMS 2008

Triage Category Summary RED: life-threatening but treatable YELLOW: potentially serious, but can wait a while GREEN: minor injuries can wait longer BLACK: life signs present, but “expected” to die under disaster conditions TX EMS 2008

Triage Caveats OVER-TRIAGE: Urge to classify all victims as IMMEDIATE Defeats the purpose! Ruptured eardrums, chronic hearing loss, language barrier, developmental handicaps, etc. Cannot respond to “MASS” commands Combine over and under triage slides TX EMS 2008

Other Triage Caveats UNDER-TRIAGE: Initial grouping ≠ individual assessment Worsening patient conditions: Internal or external bleeding, shock Closed head injury Blast injury to lung, gut, brain Airway swelling Delayed chemical exposure symptom onset Etc. TX EMS 2008

“M.A.S.S.” Triage “SORT” process is dynamic: Resources change Patient conditions change Frequent reassessment All categories may become IMMEDIATE “Most serious” injury present demands “immediate” attention! EXPECTANT It is critical to remember that the “SORT” process of “MASS” triage – or of ANY triage system – is DYNAMIC. This is true for ALL categories. Triage requires frequent reassessment. Once the IMMEDIATE (RED) group has been evacuated, the EXPECTANT (BLACK) group moves “up” to become the new IMMEDIATE (RED) group. In other words, the most “serious” injury present demands the immediate attention of on-scene personnel. Similarly, the LAST patient on the scene also moves “up” to become the most IMMEDIATE patient for attention and treatment, regardless of injury severity. TX EMS 2008

Triage Tags Tag immediately after sorting Tie triage tag directly to patient May need to improvise tags (tape, latex gloves) May need to write on patient (lipstick, marker) TAG each patient as he/she is categorized. Otherwise another rescuer will waste time re-tagging the same patient. The tag should be tied securely directly to the patient (not to clothing or shoes, which will be removed and perhaps lost). If formal triage kits are not available, improvise with tape or even by writing on the patient with a pen, lipstick, whatever is available. TX EMS 2008

Wrapping up the SORT... When all patients have been triaged and tagged: Count all IMMEDIATES Advise incident commander or transport officer of number Take all IMMEDIATES to collection point for urgent transport When all patients have been sorted and tagged, count all the IMMEDIATES and give the info to the Inc Command or Transport officer. All the IMMEDIATES must be moved to a collection point for urgent transport. The Transport Officer will have to control the flow of transport units into the scene and will have to ensure there are enough units en route he will also need to ensure that the most urgent patients are transported first It is essential that a clear route of egress be preserved for the transport units to leave the scene………it is not uncommon for incoming units to block EMS units in landing zones for helicopter transports may be needed and patients may need to be further prioritized for ground versus air transport TX EMS 2008

“M.A.S.S.” Triage “SEND”: Objective: Transport or release ALL living patients ASAP Traditional sequence: IMMEDIATE DELAYED MINIMAL The final step of MASS triage is to “SEND” - to evacuate, to transport or to release all living patients as soon as possible. Traditional sequence, not surprisingly, is Immediate > Delayed > Minimal > Expectant. EXPECTANT TX EMS 2008

“M.A.S.S.” Triage “SEND”: Be mission-focused: Be resourceful: Send MINIMALS or DELAYEDS with each IMMEDIATE, if space allows Be resourceful: Secondary treatment facilities for MINIMALS Be creative: Buses, taxis, trains, boats, etc. Hence, if vehicle space and resources allow, patients in the MINIMAL (GREEN) group can be sent with patients in the IMMEDIATE (RED) group. Once again, in the direst circumstances, the “GREEN” patients can assist in providing basic first aid or other tasks during the transport of the critically ill or injured. However, ambulance transport of IMMEDIATE victims should not be delayed while waiting to locate a MINIMAL patient to ride along. Moreover, as mentioned in previous sections, it is best not to tax resources by flooding hospitals that are receiving the most critical victims with a flood of “walking wounded”. Scene management and incident command will be facilitated by moving as many of these “MINIMAL” patients to secondary facilities, such as a makeshift clinic set up in a school gymnasium or other location. This process can be expedited by the use of non-conventional vehicles, such as buses, taxis, trains and boats. TX EMS 2008

The Need To Drill Regardless of which triage system your agency favors... ...Practice, practice, practice! “TRIAGE TAG TUESDAY” Preparation will promote more efficient triage in an actual MCI TX EMS 2008

What About The DEAD? Should NOT be moved or sent 1 EXCEPTION? Medical examiner / coroner: Identification of remains Disposition of remains Crime scene investigation: Evidence must be preserved Apprehend perpetrators and prevent future attacks What about the dead? First and foremost, the dead should NOT be moved or sent during the initial response. The highest level medical director should personally re-assess all black-tagged patients and affirm their designation as DEAD. If final determination has been made that patient is dead and no resuscitation is to be attempted, DO NOT DISTURB THE REMAINS OR THEIR IMMEDIATE SURROUNDINGS***. Why? evidence may be lost that could have lead to; proper identification of the remains cause of death time of death crucial information about the incident determination of whether this was an accident or an act of terrorism The person or persons responsible for the attack/crime PREVENTION of future attacks ***Exception- small soft-tissue fragments may rapidly degrade if exposed to high temperatures (thus DNA may be denatured). If these are the only remains found, it may be advisable to obtain permission from law enforcement personnel to quickly move the tissue out of sunlight and into a cool area to preserve the DNA. Law enforcement authorities will typically determine the deceased victim’s disposition (whether the body will be released to the family or if an autopsy/investigation is to be performed by the medical examiner/coroner/etc…). This may vary according to state law. Also: better not to strain on-scene resources caring for fatalities. Even for non-terrorism events, it is best to defer this care until additional specialized personnel and resources arrive, such as federal DMORT teams, to be discussed in a later presentation. TX EMS 2008

Specific All-Hazards Considerations TX EMS 2008

Chemical Incidents Issues: Implications: Minute quantities can be rapidly fatal Risk of “off-gassing” and 2° contamination Delayed symptom onset for some Implications: PPE for healthcare providers ~ Simultaneous decon, triage and treatment Dry decontamination removes 80-90% If you think it might be, safest bet is to decon TX EMS 2008

Capnography as Triage Tool “... the only direct, non-invasive measure of ventilatory status available to EMS crews...” Rapid (15 seconds) indication of: Hypoventilation, respiratory depression or failure Laryngospasm, upper airway obstruction Bronchospasm Krauss B (2005) Pediatric Emerg Care 21(8): 493 Krauss B, Heightman AJ (2006) JEMS 31(6): TX EMS 2008

Biological Incidents Issues: Implications: Person-to-person spread for some agents Non-specific “flu-like” symptoms Lengthy incubation periods Implications: Delayed detection likely “Triage” only once outbreak underway Healthcare providers may become victims TX EMS 2008

Radiological Incidents Issues: Covert release likely Detection requires special equipment Symptom onset typically delayed HOWEVER..... TX EMS 2008

Radiation Risks for Healthcare Providers “A living patient cannot be so radiologically contaminated as to present an acute hazard to medical personnel.” Medical Management of Radiological Casualties, 2nd edition. AFRRI, Bethesda, 2003, p. 94. Download at: http://www.afrri.usuhs.mil TX EMS 2008

Patient Care Implications Limb- and life-saving medical attention should never be delayed because of the presence of radioactive material or contamination! After 1st 24 hours, radiation does matter www.afrri.usuhs.mil AFRRI, page 94 TX EMS 2008

Nuclear Incidents Issues: Implications: Most immediate fatalities 2° trauma, burns Massive dose needed for early symptoms Implications: Onset < 1-3 hr. post-exposure: Nausea/vomiting, altered LOC, CNS symptoms EXPECTANT TX EMS 2008

Natural Disasters Issues: Implications: More common than terrorism Scene size may be enormous Massive infrastructure destruction: hospitals Healthcare providers as victims Implications: Severely limited resources Equipment, personnel, supplies, utilities TX EMS 2008

Explosive & Bombing Incidents Issues: Still #1 terrorist modality 4 Modes of Blast Injury 1°blast injury (PBI): delayed onset Ruptured TMs in blast survivors Implications: Basic ABCs Frequent reassessment & re-triage Lung, GI and brain Otoscope as triage tool TX EMS 2008

When All Is Said and Done... X MCI Triage is NOT “business as usual” “Standard of Care” vs. “Best Choices” TX EMS 2008

“Gut Check” for Healthcare Providers Difficult decisions must be made Fatalities and suffering are likely TX EMS 2008

It’s NOT “Rocket Science”, either! One need not be a “specialist” Identify, collect and control MINIMALS & DELAYEDS Focus first on those who most need care and are most likely to benefit from it! IMMEDIATES TX EMS 2008

Adapted from Heightman AJ (2006). JEMS 31(4):16. Immediate - 1 Delayed - 2 Minimal - 3 TX EMS 2008

More Work Is Needed National Standards WMD & “All-Hazards” Incidents “Medical” MCI Triage Special Patients Patient Tracking Systems More Effective Hands-on Training TX EMS 2008

Copyright © 2007 by Ronna G. Miller, MD Thank You! Questions?? Let’s try it again!! 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. TX EMS 2008

Victim 1 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT GREEN1 – GREEN GIRL TX EMS 2008

Victim 2 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT RED1 – SAME WHITE LADY TX EMS 2008

Victim 3 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT YELLOW1 – GAL BEING HELPED BY 2 GUYS TX EMS 2008

Victim 4 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT BLACK1 – MANIKIN WITH EVISCERATION TX EMS 2008

Victim 5 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT YELLOW2 – GAL IN WHITE SHIRT ON GROUND TX EMS 2008

Victim 6 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT GREEN2 - HISPANIC GIRL IN WHITE SHIRT (EVEN THOUGH SHE’S REALLY WEARING A BLACK SHIRT) – I WAS TOO SUPERSTITIOUS TO CHANGE THE FILE NAME! TX EMS 2008

Victim 7 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT BLACK2 – BLACK MAN IN GREEN SHIRT TX EMS 2008

Victim 8 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT RED2 – MANIKIN WITH BKA TX EMS 2008

Victim 9 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT RED3 - RED OR YELLOW FINGER AMP (ACTUALLY, IT’S A HAND AMP WITH OTHER INJURIES AND UNSTABLE VS) TX EMS 2008

Victim 10 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT YELLOW3 – GIRL AND GUY WITH NO EYE TX EMS 2008

Victim 11 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT BLACK3 – BURN RED SHIRT TX EMS 2008

Victim 12 Into which category would you triage this patient? IMMEDIATE DELAYED MINIMAL EXPECTANT RED4 TX EMS 2008

Now what do you think? TX EMS 2008

Question 14 Is knowing how to perform mass casualty triage part of your professional responsibilities? Yes No TX EMS 2008

Question 15 What is the likelihood, in your opinion, that you would ever be called upon to perform mass casualty triage in the future? Very likely Likely Neutral Unlikely Very unlikely TX EMS 2008

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? Very confident Somewhat confident Neutral Somewhat unsure Very unsure TX EMS 2008

The Newest Triage Method TX EMS 2008

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 75390-8890 Email: Ronna.Miller@UTSouthwestern.edu Voicemail: (214) 648-6881 TX EMS 2008

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TX EMS 2008

There must be a cookie here somewhere!

Text References 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, 5th Edition. Brady/Prentice Hall. Ciottone GR et al (2006). Disaster Medicine, 3rd Edition. Elsevier Mosby, Philadelphia. Hogan DE, Burstein JL (2002). Disaster Medicine, 2nd Edition. Lippincott Williams & Wilkins, Philadelphia. PHTLS 5E Revised by: National Association of Emergency Medical Technicians Published by: Mosby ©2003 TX EMS 2008

Text References – Cont’d. 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, 5th 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. TX EMS 2008

Text References – Cont’d. Weinstein RS, Alibek K (2003). Biological and Chemical Terrorism – A Guide for Healthcare Providers and First Responders. Thieme Medical Publishers, New York City. TX EMS 2008

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. 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. 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. Kraus B (2005). Capnography as a Rapid Assessment and Triage Tool for Chemical Terrorism. Pediatric Emergency Care 21(8):493-7. TX EMS 2008

Journal References – Cont’d. 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. Navin M, Waddell B (2005). Triage is Broken. EMS Magazine 34 (8 August 2005). Navin M, Waddell B (2005). A Disaster Doesn’t Have to Be a Disaster. EMS Magazine (9 September 2005). Ressel R et al (2008). West Nickels Mines School Shooting. JEMS 33(5): 48. TX EMS 2008

Journal References – Cont’d. Robertson-Steel I (2006) Evolution of Triage Systems. Emerg Med J 23:154-5. doi:10.1136/emj.2005.030270 Sacco WJ, et al (2005) Precise Formulation and Evidence-Based Application of Resource-Constrained Triage. Academic Emergency Medicine 12: 759-770. Zorster R (2006). Disaster Triage: Is It Time to Stop START? Am J Disaster Med 1(1):7. TX EMS 2008

General Web Resources http://www.emedicine.com http://www.ncemi.org http://emergency.cdc.gov http://www.emedicine.com http://www.ncemi.org http://www.OSHA.gov http://www.ready.gov http://www.usamriid.army.mil TX EMS 2008

Specific Web Resources http://www.ahrq.gov/prep/cbrne/ http://emergency.cdc.gov/masscasualties/ http://emergency.cdc.gov/masscasualties/ems.asp http://www2.cdc.gov/phtn/webcast/stress-05/ TX EMS 2008

Specific Web Resources - 2 Military Medical Operations. (2003). Medical Management of Radiological Casualties, 2nd edition. Bethesda: Armed Forces Radiobiology Research Institute. Download at: http://www.afrri.usuhs.mil Gonzalez, M. S. (n. d.) The Impact of Mass Casualties on the Healthcare Delivery System – Conventional Injuries. Retrieved August 1, 2005 from: www.vdh.state.va.us/.../Michael%20Secure%20Vrginia%20Medical%20Aspect%20of%20Convenional%20injuries.ppt TX EMS 2008

Specific Web Resources - 3 USAMRIID. USAMRIID’s Medical Management of Biological Casualties Handbook, 5th edition. (2004). Download at: http://www.usamriid.army.mil/education/bluebook.htm USAMRICD. Medical Management of Chemical Casualties Handbook, 3rd edition. (2000). Download at: https://ccc.apgea.army.mil/sarea/products/handbooks/MMCC/mmccthirdeditionjul2000.pdf TX EMS 2008

Bioterrorism & All-Hazards Disaster Medicine Training TX EMS 2008

Hospital Preparedness GAO-03-924, August 2003 Report to Congressional Committees: “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.” August 2003, GAO-03-373 Requires an “All-Hazards” approach TX EMS 2008

ALL-HAZARDS Preparedness Chemical Biological Radiological & Nuclear Natural & Accidental Explosive & Traumatic "CBRNE" TX EMS 2008

National Disaster Life Support Courses: ABCs, a foundation for national training: Advanced Disaster Life Support (ADLS) Basic Disaster Life Support (BDLS) Core Disaster Life Support (CDLS) NDLS-Decon NEW! Endorsements by: AMA, CDC, ACEP, more than 30 other organizations Websites: http://www.BDLS.com and http://www.NDLS.us http://www.texasBCE.org TX EMS 2008

For More Information http://www.TexasBCE.org NDLS / Texas BCE Contacts by Region (06-07) : University of Texas Health Center at Tyler (UTHCT): Jill Howard 903-877-7386 University of Texas Medical Branch – Galveston (UTMB): Crystal Hobbs 409-772-8220 UT Southwestern Medical Center (UTSW): Song Lehman 214-648-2594 UNT Health Science Center at Fort Worth (UNTHSC): Christina Nelson 817-735-0428 UT Health Science Center San Antonio (UTHSC-SA): Tina Fields 210-567-7813 UT Health Science Center Houston (UTHSC-H): C. Duplessis 713-500-2043 Texas A&M University System Health Science Center (TAMU): Kay Carpenter 979-845-2387 Need to check this! TX EMS 2008

“RED Survey” You don’t need to die! “Rapid Evaluation of Disaster” Incident Survey BEFORE patient care! Casualty Survey Life-saving Interventions Triage falls under the “casualty survey” portion of the response, ONLY after an incident survey has been performed. You don’t need to die! TX EMS 2008

“RED Survey” “Rapid Evaluation of Disaster” Incident Survey BEFORE patient care! Casualty Survey Life-saving Interventions Triage falls under the “casualty survey” portion of the response, ONLY after an incident survey has been performed. TX EMS 2008

“RED Survey” “Rapid Evaluation of Disaster” Casualty Survey - Triage: Rapid grouping by: Severity of injury AND Likelihood of survival, THEN Individual assessment Specifically, Triage first employs a rapid grouping of victims according to injury severity AND likelihood of survival. The second stage is individual patient assessment. TX EMS 2008

“DISASTER Paradigm” D – Detection I – Incident Command S – Scene Safety & Security A – Assess Hazards S – Support T – Triage & Treatment E – Evacuation R - Recovery In other words, Triage falls under the “T” of the “DISASTER Paradigm”, only after the other elements of the response have been dealt with. TX EMS 2008