1. Multiple Traumas: Where do I start?
Lee Faucher, MD FACS

2. Objectives: What is a Mass Casualty Incident ?
Review Incident Management from EMS perspective
Review Triage

3. Mass Casualty Incident (MCI)
Definition
An incident which produces multiple casualties such that emergency services, medical personnel and referral systems within the normal catchment area cannot provide adequate and timely response and care without unacceptable mortality and/or morbidity.

4. EMS Goal
To save the largest number of people of a multiple casualty incident

5. AIM
To explain the complexities of large multiple casualty scenes.
Teaching Points
The train wreck represents a complex multiple casualty scene. For us to produce maximum survivors we must ensure any system or equipment will work under numerous difficult challenges including;
large multi-agency teams
numerous casualties
high stress working conditions
scene hazard.
This training will look at the problems posed by this type of incident and work with you to provide practical solutions.

6. How do you start? Command Safety Triage Staging Communication
Treatment

7. Communication Obstacles Hospital Terrain Different Frequencies
Overloaded channels
Hospital
Medical Control
Patient Routing
Transportation Officer
Staging Officer

8. Things to Remember… Maintain strict radio procedures
Enroute communications must be limited to urgent matters only
Transport patients in adequate vehicles
Transport patients with adequate escort staff
Maintain a log of all Patients (PCR)

9. THE INITIAL PROBLEM ON SCENE
AIM
To understand the importance of correct resources.
Teaching points
Rescue services normally work in a resource rich environment.
The multiple casualty scene often presents a scenario where there are more casualties than initial resources
On scenes where an initial assessment indicates heavier casualties than resources, clinical intervention is often not the first priority.
Question to delegates
What number of casualties would be required to out number one of your units ?
Expected answer
Normally one seriously injured person or two or three minor injuries.
Teaching point from question
Small incidents such as motor vehicle accidents can produce a resource poor scenario.
Casualties
Resources

10. THE OBJECTIVE
Casualties
Resources

11. How many patients are you taught to treat at one time?
BUT - HOW IS EMS TRAINED?
BLS, ALS
CPR, ACLS, PALS
PHTLS, BTLS
CFR, EMT, EMT-I, EMT-CC, EMT-P
How many patients are you taught to treat at one time?

12. WHAT CHANGES WHEN YOU HAVE AN MCI ?
What are my resources?
Who is a Patient?
Which Patient do I treat first?
Who can be salvaged?
Who gets transported first?
Who needs a Trauma/Specialty Center?
Who can help care for others?

13. TIME IS VERY IMPORTANT THE GOLDEN HOUR
“The critical trauma patient has only 60
minutes from the time of injury to reach
definitive surgical care, or the odds of
a successful recovery diminish
dramatically”

14. Time management Arrival of resources Distribution of resources
Effective patient treatment

15. Scene Management Command Safety Is there a hazard or threat?
Who is in Charge?
Who is in charge of what?
Who is going to do what?
Who else needs to be here?
Safety
Is there a hazard or threat?
Should I be here?
Am I protected?
What should I worry about?

16. Scene Management Assessment Communications What is going on?
How big is this, how many people?
What do I need?
How does what I do affect others?
What are they doing that can affect me?
Communications
Who needs to know?
What do they need to know?
Does Command & Ops know?
Do the other players know?

17. Scene Management Triage Who is doing it? Where are they doing it?
What are they finding?
Treatment
What the typical EMS provider comes “preloaded” with…
How to organize?
How much can we do?

18. Scene Management Transport Who is doing it?
From where are they doing it?
Where are the patients going?
How many patients going where?

19. Triage
“Large scale triage is the hardest job anyone in pre-hospital care will ever do.” AJ Heightman

20. When do we triage
When casualties exceed the number of skilled rescuers

21. How often should you triage?
Primary
On scene
Secondary
Time of transport

22. Triage Protocol (START) Simple Triage And Rapid Treatment

23. Triage Tags

24. Primary Triage
Airway
Breathing

25. Primary Triage
Circulation

26. Primary Triage
Mental Status

27. Victims Female, 30’s, walking
Female, teens, walking, pale, complaining of severe abdominal pain
Male, teens, walking, confused
Male, teens, you open airway, does not breathe
Male, 20’s, unconscious, breathing, RR 36, radial pulse absent
Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructions

28. Victims Female, 30’s, walking
Female, teens, walking, pale, complaining of severe abdominal pain
Male, teens, walking, confused
Male, teens, you open airway, does not breathe
Male, 20’s, unconscious, breathing, RR 36, radial pulse absent
Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructions

29. Burn MCI Bali Nightclub 2002 Over 200 killed Additional 250 injured
All burn beds filled in Australia

30. Burn Resources in the U.S.
Just over 100 facilities listed in ABA directory
Only 200 open beds at any time
It only takes a few to make a burn disaster

32. Common in most burn MCI Up to 40% of casualties 50% discharged from ED
Mortality 5%

33. EMS Considerations Scene safety first Designate field commander
May require decontamination
Scene may be a crime scene
Designate field commander
Where to go may be different?

34. EMS considerations
Terrorism commonly has secondary devices targeting rescuers
Stage vehicles uphill and upwind

35. EMS supplies LR O2 Clean sheets/plastic wrap Narcotics
(hospitals need the same stockpile, might add burn ointment)

36. Disposition from scene
Severe: to burn center
Moderate: local care facilities
Minor: any care facility

37. Where to take them? International classification What this means in WI
Type A: resuscitation only
Type B: first 48 hours
Type C: everything
What this means in WI
Two Type C
Level 2 hospitals are Type B

38. What does this really mean?
If burn > 20% and/or inhalation injury, this is severe.
All others can be triaged again at hospital

39. Triage Decision Table Benefit-to-Resource Ratio
Based on Age & Total Burn Size

40. Summary MCIs require Change in EMS providers approach
Ability to apply limited resources effectively
Organization, coordination, communication
Appropriate distribution to definitive care
After action evaluation