1. Patient Assessment in the Wilderness

2. 6 Key Steps Scene Size Up (Are YOU Safe?)
Initial Assessment (ABC’s, AVPU)
Focused history (SAMPLE)
Physical Exam (Head to Toe)
Criticality and transport decision
Ongoing assessment (..cause you might be there for a while)

4. What injuries can we expect?

5. What time of day is this (and how will the temperature change?
Ongoing assessment. How will your care of the patient change?

6. Start at the Head!

7. The Head Look for obvious injuries Check the eyes
Feel top/back of head for instability (under their hair)
Check for any impacts to airway/breathing

9. Windows to the Brain

10. Problems?

11. Kids breath through their noses!

12. Airway problems?

13. Check the Neck!
Rope injury to the neck from an hanging attempt

14. Torso
Be sure to check chest, back, pelvis and for injuries and instability
Check abdomen for rigidity (sign of internal bleeding)
Take spinal precautions if history or assessment dictates

15. Chest Trauma
Gunshot wounds…make sure to check the back while checking the chest

16. What’s this from?
Bruising from an improperly worn seat belt. Note this bruise took over an hour to first show up…

17. Too Much Heat?
2nd and 3rd Degree burns (partial and full thickness)…..from propane tank leak and ignition

18. Extremities Feel down each arm and leg Look for injuries
Have patient wiggle fingers and toes
Have them squeeze your hands
Have them push their feet against your hands to check equal strength
Check capillary refill on finger (and toe if necessary)

19. Fleas on the left, Spider on the right

20. Sword Injury
Sword to the knee

21. Ouch!
Obvious ankle fracture…

22. This is why we require shoes

23. Ongoing Assessment Call for help early!
Determine response time and need to move patient to rescuers
Consider changes in temperature and weather
Continue to reassess to catch changes in patient’s condition or injuries that take longer to be apparent

24. How will movement affect your patient?

25. Exposure issues?

26. Triage French for “sorting” or “to sort”
A process for determining who to treat and transport first in the case of a multi casualty incident (MCI)
Used when you have more patients than you have responders
Patients
Immediate
Delayed
Deceased

27. First Responders Responsibility
One responder takes charge
Other members starts the Triage process
Start calling for additional resources (EMS, fire department) that you think you might need
Patients
Immediate
Delayed
Deceased

28. START is an acronym for Simple Triage And Rapid Treatment
What is START?
START is an acronym for Simple Triage And Rapid Treatment
Simple triage method used by first responders It allows you to identify victims at greatest risk for early death and to provide basic stabilization maneuvers
Patients
Immediate
Delayed
Deceased

29. Your First Action If you can walk, go stand over there!
All of Ya’ll, go over there! (Texas version )
It doesn’t matter where “there” is as long as it’s safe and not “here”
Patients
Immediate
Delayed
Deceased

30. The Next Step Take a DEEP breath Ensure that your scene is safe
Start to triage all patients that were unable to move
Spend 60 seconds/patient
Mark status (tag, mark, tape)
Move to the next patient
Patients
Immediate
Delayed
Deceased

31. Check Capillary refill
START Algorithm
BREATHING? NO
YES
REPOSITION AIRWAY
BREATHING NO
YES
> 30/MINUTE
IMMEDIATE
<30/MINUTE
Check Capillary refill
DECEASED
IMMEDIATE
Patients
Immediate
Delayed
Deceased

32. START Algorithm (Part 2)
CAPILLARY REFILL?
<2 SECONDS
ASSESS
MENTAL STATUS
> 2 SECONDS
CONTROL
BLEEDING
IMMEDIATE
Patients
Immediate
Delayed
Deceased

33. START Algorithm (Part 3)
MENTAL STATUS
FOLLOWS
SIMPLE
COMMANDS
FAILS TO FOLLOW
SIMPLE
COMMANDS
DELAYED
IMMEDIATE
Patients
Immediate
Delayed
Deceased

34. Mark Status IMMEDIATE DELAY 2 TRANSPORTATION OFFICER
NAME______________________
AMBULANCE _______________
HOSPITAL __________________
PRIORITY
NAME
AGE MALE FEMALE
MEDICATION/TIME:
________________________________
10945 2
Patients
Immediate
Delayed
Deceased

35. After Primary Triage Start treating “immediate” patients
Do full patient assessments on all patients
Fill out triage tags (if available)
Continue to reassess patients
Patients
Immediate
Delayed
Deceased

36. Example 1
57 year old female complaining of chest pain. Respirations 24, capillary refill 3 seconds, responds to all verbal commands
Patients
Immediate
Delayed
Deceased

37. 1 Triage Tags IMMEDIATE TRANSPORTATION OFFICER
NAME______________________
AMBULANCE _______________
HOSPITAL __________________
PRIORITY
NAME
AGE 57 MALE FEMALE X
MEDICATION/TIME:
________________________________
10945 1
Patients
Immediate
Delayed
Deceased

38. Example 2
24 Year old male, with a 3’ pole impaled through his abdomen, respirations 28, capillary refill <2 seconds, responds to all commands
Patients
Immediate
Delayed
Deceased

39. 2 Example 2 Tag IMMEDIATE DELAY TRANSPORTATION OFFICER
NAME______________________
AMBULANCE _______________
HOSPITAL __________________
PRIORITY
NAME
AGE 24 MALE X FEMALE
MEDICATION/TIME:
________________________________
10945 2
Patients
Immediate
Delayed
Deceased

40. Example 3
3 year old child with no obvious injury. No respirations, capillary refill 6 seconds, unconscious
Patients
Immediate
Delayed
Deceased

41. Example 3 Tag
TRANSPORTATION OFFICER
NAME______________________
AMBULANCE _______________
HOSPITAL __________________
PRIORITY
NAME
AGE 3 MALE X FEMALE
MEDICATION/TIME:
________________________________
10945 3
Patients
Immediate
Delayed
Deceased
But this would be a good candidate for a resuscitation attempt as soon as possible!

42. Texas A&M Bonfire Collapse
November 18, 1999
2:30 AM bonfire stack collapsed
150 people believed to be on bonfire site at time of collapse
As stack collapsed, all lighting was pulled down leaving the area in total darkness
First Responders reported hearing screaming in the darkness
Patients
Immediate
Delayed
Deceased

43. First Responder Actions
Immediate call for additional help
Dispatch declared a Mass Casualty Incident and paged all personnel as well as College Station and Brian Fire Departments; Texas Fire Training Center resources and Montgomery County EMS
Fire Department and TxDot light trucks were immediately called for
Triage started by flashlight

44. As the Sun Came Up

45. Final Outcome
All recoverable patients triaged and transported in less than 1 hour
Last bodies recovered about 20 hours after the collapse
27 patients injured, 12 killed
Investigative committees universally credited first responders with saving many lives

46. So....How does this apply to me?
Major incidents can occur
First responders are generally involved in these incidents
Most responders face few large incidents in their career
Preparation is the key to successful handling of these incidents
Patients
Immediate
Delayed
Deceased

47. Tools