1. Incorporation of Triage Skills into the Pharm D Curriculum Catherine A. White, Cham E. Dallas and Edward A. Rollor III University of Georgia Background Mass casualty Incident triage is taught in our disaster Training for Health Care Professionals, an elective course in the PharmD program and is also Open to other UGA students. Triage is taught by didactic and active learning techniques which include: Lecture IDME Scenarios Live Exercise In addition, students receive advanced first aid Training which is provided by the American Red Cross. The triage method we have incorporated into our course was developed by the CDC Specialty Center for Leadership in Education and Applied Research for Mass Destruction Defense at the University of Georgia and Medical College of Augusta and is endorsed by the American Medical Association. Triage is a series of assessments and not just an one initial pass. Patients can quickly move from one category to another based on their status. For example a minimal patient may become an immediate patient if he develops symptoms of a heart attack. The treatment phase of triage continues at the scene until all the victims are transported or no resources are available to continue. MASS TRIAGE Mass triage is a disaster triage system that uses US military triage categories with a proven means of handling large numbers of casualties in a mass casualty incident. M-Move A-Assess S-Sort S-Send IDME Is a phrase that is easy to remember for sorting patients during mass casualty incident triage. I-Immediate-RED D-Delayed-YELLOW M-Minimal_GREEN E-Expectant-BLACK Patients within each category must also be ranked for transport and treatment. MOVE The initial challenge in triage is to determine which patients need immediate and life-saving care vs those who are demanding immediate attention but are not in the same critical condition. First Step: Ask them to move to a given area. These are your minimal patients Second Step: Ask them to move an arm or leg. These are your delayed patients. Third Step: Patients who are not moving are the first priority. Proceed immediately to these patients and provide life-saving interventions. This group will also include the expectant patients ASSESS Victims initially placed in the immediate category are the first priority, those in the delayed category are the second priority, and those in the minimal category are the third priority. The anatomic and physiologic parameters of all victims are assessed to further define their appropriate triage category. IMMEDIATE GROUP Identify location of victims who are unable to ambulate and respond to commands Rapidly assess ABCs Is airway open? Open manually if possible If not, designate patient as Expectant and move on Is uncontrolled bleeding present? Apply direct pressure. Is it likely patient has incurred a fatal injury? If yes designate patient as Expectant and move on. Treat immediate life-threatening conditions if the victim is not in the Expectant group. Obtain an accurate count of immediate patients Is transport available? EXPECTANT GROUP If a quick initial survey of the victim reveals wounds that are likely to be fatal, the patient is considered Expectant. Most health care providers are uncomfortable with the concept of expectant care. It is important to remember the disaster axiom “doing the most good for the most victims” is important and must be adhered to. Lecture Material IDME Exercise Students are given a mass casualty incident scenario and are asked to assess 60 to 100 simulated patients. Students are given approximately 30-45 seconds to assess and classify each patient. Several patients are repeated in the exercise. An example of a scenario and several patients are shown below. Scenario: A highly publicized trial of a suspect with possible terrorist links is set to take place in your community. On the day of opening arguments the courtroom is packed. You are standing on the lawn in front of the courthouse waiting with others who also could not get seats for the local “Trial of the Century”. Suddenly an explosion is heard from the courthouse. Soon after, people begin pouring from the exits. Many are panicked, wounded, and in obvious distress. Putting all of your previous training into action, you immediately set up a triage area. In talking to the victims, you learn more about the events that have taken place. Not only did a bomb explode in the courtroom, but as people were exiting from a main hallway, a secondary device on a time delay, hidden in a trash can, released an unknown gas. A few of the victims noted a smell similar to bitter almonds. Results and Implications Ninety-eight students have completed the elective course over a 3-yr period. Overall evaluation of the triage computer exercises (mean score 4.3/5) and the live exercise (4.4/5) was positive. Students wanted additional class time and feedback for triage training. In the analysis of the computer simulated victims and live exercise, students had the greatest difficulties in differentiating which patients needed immediate care from those who should be placed in the delayed care category and in accepting that some patients will not be treated. Pharmacists will play a significant role in triage during natural and terrorist mass casualty incidents. It is essential that we provide PharmD students with the triage and first aid skills required for first receivers of patients after a mass casualty incident. The use of MASS triage model simplifies the process of triaging Large numbers of patients while maintaining a simple, common terminology. Objective To develop, implement and evaluate a program for teaching triage skills to PharmD students. Live Exercise Students participate in a live exercise which is conducted in the College of Pharmacy. Approximately 20 volunteers are recruited as victims and undergo moulage to simulate injuries. Victims are given a description of how to act and when to have symptoms appear. Complicating factors such as a secondary device, an interfering FBI agent, or the press, are included in the exercise. The following is a live exercise scenario and a description of some of the victims. Scenario: A bomb has exploded in the dispensing lab. Many people are injured and some reported smelling an odd odor after the device exploded Victim #1Victim #3Victim #4Victim #18 No apparent injuriesCannot hearsevere burns 60%Pain in Shoulder BSA Follows directionsNo apparent injuriesdifficulty breathingBruise on face After 10 min, chestSlightly confusedCut on forehead pains develop SweatingDevelops limpSevere pain Trouble Breathing Student Responses Patient 1Immediate-23 UnconsciousDelayed-0 Profuse bleeding from laceration on templeMinimal-1 Labored respirationsExpectant-2 Patient 2Immediate-2 AmbulatoryDelayed-1 Increased heart rateMinimal-22 Visibly agitatedExpectant-0 Alert & orientated Respirations 15 rpm Patient 4Immediate-0 UnconsciousDelayed-0 No respirations for >5 minMinimal-0 No pulse presentExpectant-26 Patient 7Immediate-13 UnconsciousDelayed-14 Irregular, rapid, shallow breathingMinimal-0 Red tint to skinExpectant-0 Capillary refill > 2seconds Patient 27Immediate-13 Non-ambulatoryDelayed-12 Severe abdominal painMinimal-0 Loss of hearingExpectant-0 Broken leg Patient 32Immediate-9 Major Burns >75% BSADelayed-1 DeliriumMinimal-1 Rapid, shallow respirationsExpectant-15 Multiple severe lacerations with little bleeding Patient 39Immediate-8 Blue tint to skinDelayed-0 Weak, intermittent heart beatMinimal-0 Shallow, gasping breathsExpectant-18 Convulsions Loss of consciousness Patient 54Immediate-6 AmbulatoryDelayed-17 Minor laceration on right legMinimal-3 N&VExpectant-0 Hyperventilation Headache Triage Categories Lecture Material SORT After the ASSESS phase and immediate life-threatening interventions have been completed, the next phase is to SORT patients into 1 of the 4 treatment categories: Immediate, Delayed, Minimal and Expectant. For each triage group, it is important to remember that the most serious injury present requires immediate attention and that triage is dynamic. For example, after treating immediate patients, the previously delayed group becomes the group of patients in need of immediate attention. On scene triage is in continuous flux until the last patient is transported from the scene. Immediate patients Obvious threat to life or limb Complication of ABCs First priority for evacuation Candidates for air evacuation Delayed patients Clearly need medical treatment’ Should not decompensate if care is initially delayed Have significant injuries that require hospitalization and surgery Should be transported after immediate patients Minimal patients Walking wounded Stable vital signs Abrasions, bruises, minor lacerations,etc Helped by non-physician medical personnel Will often transport themselves to treatment facilities May be used as on site volunteers Transport to secondary treatment facility away from hospitals Expectant patients Little to no chance of survival Will be treated as resources become available Comfort care is provided Will not necessarily die immediately Patients in this category will be reevaluated after immediate patients are evacuated Minimal patients can provide comfort for this group SEND Once SORT is operational, while treatment is ongoing, it is important to focus on SEND or the transport of patients away from the scene. Available options include: Treated and released at the scene Sent to hospitals and secondary treatment facilities Sent to morgue facilities Transport options include: Air transport Ambulance Buses Trains Cars Self-transport