1. TRIAGE OF MASS CASUALTIES MSF 11th Surgical Day Paris, 3 December 2011 Marco Baldan ICRC Head Surgeon

2. Al Hussein Hospital Karbala, Iraq 2 March 2004  First bomb attack in the city  Total victims = 277  Dead = 94  Wounded = 183

3. Hospital Situation  Beds in ER = 24  No place for cadavers  No communication with/among ambulances  Minimal hospital security system  No triage system / disaster plan  Medical supplies on 4th floor  Operating theatres on 1st and 2nd floors  Lifts not functioning

4. Clinical practice Normal clinical practice Multiple-casualty incident Mass casualties

5. Triage = Process by which priorities are set for the management of mass casualties.

6. The aim in a mass casualty situation is to do the best for the most, not everything for everyone.

8. JFK Memorial Hospital, Maternity Building Monrovia 2003

9. Triage Tent

10. Inside the Triage Tent

11. JFK Memorial Hospital, Main Building

12. Main Building, Triage Department

13. Triage Department, in use

14. Triage cannot be organised ad hoc. It requires planning:  Preparation before the crisis  Organisation of the personnel  Organisation of the space  Organisation of the infrastructure  Organisation of the equipment  Organisation of supplies  Training  Communication  Security  Convergence reaction = relatives, friends & the curious (especially the armed ones)

15. Triage involves a dynamic equilibrium between needs and resources. Needs = number of wounded and types of wounds Resources = infrastructure and equipment at hand & competent personnel present

16. The Triage Team  Triage team leader: co-ordinator  Clinical triage officer  Head nurse, matron: chief organiser  Nursing groups  Follow-up medical groups

17. Clinical Triage Officer No task in the medical services requires greater understanding, skill, and judgement than the sorting of casualties and the establishment of priorities for treatment.

18. Triage decisions must be respected. Discuss afterwards.

19. Triage is a dynamic process:  begins at the point of wounding,  occurs all along the chain of casualty care,  occurs at the hospital reception,  and continues inside the hospital wards:  continuous reassessment of patients.

20. Triage Documentation  Include basic information  Short-form  Clear  Concise  Complete

21. Triage Documentation Reality check What really happens! During post-triage evaluation: decided to use plastic sleeve to hold the documentation.

22. The triage process:  Sift  Place patients in main categories: priority  Sort  Priority amongst the priorities

23. Sift 1) Select those most severely injured and 2) identify and remove:  the dead  the slightly injured  the uninjured

24. Sort Categorise the most severely injured based on:  life-threatening conditions (ABC)  anatomic site of injury  Red Cross Wound Score  treatment available in terms of personnel and supplies

25. ICRC TRIAGE CATEGORIES Serious wounds: resuscitation and immediate surgery I.Serious wounds: resuscitation and immediate surgery Second priority: need surgery but can wait II.Second priority: need surgery but can wait Superficial wounds: ambulatory management III.Superficial wounds: ambulatory management Severe wounds: supportive treatment IV.Severe wounds: supportive treatment

26. Category I: Resuscitation and immediate surgery Patients who need urgent surgery – life-saving – and have a good chance of recovery. (E.g. Airway, Breathing, Circulation: tracheostomy, haemothorax, haemorrhaging abdominal injuries, peripheral blood vessels)

28. Distal pulse absent

29. Category II: Need surgery but can wait Patients who require surgery but not on an urgent basis. A large number of patients will fall into this group. (E.g. non-haemorrhaging abdominal injuries, wounds of limbs with fractures and/or major soft tissue wounds, penetrating head wounds GCS > 8.)

30. Category I for Airway; Category II for debridement

31. Femoral vessels intact

33. Category III: Superficial wounds (no surgery, ambulatory treatment) Patients with wounds requiring little or no surgery. In practice, this is a large group, including superficial wounds managed under local anaesthesia in the emergency room or with simple first aid measures.

34. Multiple superficial fragments

36. Category IV: Very severe wounds (no surgery, supportive treatment) Patients with such severe injuries that they are unlikely to survive or would have a poor quality of survival. The moribund or those with multiple major injuries whose management could be considered wasteful of scarce resources in a mass casualty situation.

38. War Wounded in the Field First Aid Dressing 30 - 40 % No surgery 12-15% Head 10% Chest 10% Abdomen 60-65% Limbs 90% Surgery Small wounds Paraplegia Quadriplegia Observation 10% NO Surgery 60 - 70 % Hospital care WW in the field (GSW, mine, blast) 100 wounded

39. Epidemiology of Triage: short evacuation time  Category I 5 - 10%  Category II25 – 30%  Category III50 - 60%  Category IV 5 - 7%

40. Triage in Monrovia 2003 3 June – 22 August  Total patients triaged = 2588  Total admitted = 1015 (40% of triaged)  War wounded = 88.5% of admissions  Operations = 1433  Admitted but not operated = 296  All category 1 patients triaged, admitted and operated within 24 hours

41. Patients triaged by date: three peaks

42. Summary of triage theory & philosophy: sorting by priority A simple emergency plan: personnel, space, infrastructure, equipment, supplies = system "Best for most" policy Priority patients are those with a good chance of good survival.