1. Triage CPT James R. Rice, PA-C Emergency Medicine Interservice Physician Assistant Program

2. Objectives Given casualties and no other medical assets, decide which casualty needs medical care first. Describe how to : –Prioritize injuries –Establish triage areas –Establish evacuation lanes Discuss establishing an LZ Discuss the use of the 9-Line MEDEVAC template

3. References Emergency War Surgery, OTSG, 1988 Textbook of Military Medicine, Part I, Vol 5 Conventional Warfare, OTSG, 1991 Gunshot Wounds, Swan & Swan, Yearbook Medical Publishers, 1989 Textbook of Surgery, Sabiston, editor W. B. Saunders, 1986 SESAP VI and SESAP ‘97-’98, American College of Surgeons, 1988, 1997 photos from other books and journals

4. What do I do? You might find yourself in this situation: There are casualties, and either –no other medical personnel available –or so many casualties that medical assets are over-whelmed. You will be expected to “do something.”

5. What do I do? You may find yourself with an overwhelming number of casualties.

6. Preparation Establish your triage area and your category holding areas. –“DIME” –Develop a marking system Establish your evacuation holding areas –Develop a marking system One-Way Traffic!! –Ensure a traffic control NCO Your triage NCO/Officer needs to be VERY experienced –Give them some basic class VIII

7. Preparation Where are the security assets? Be prepared to jump quickly –?establish the BAS vs Tailgate Medicine?

8. “DIME” D-Delayed I-Immediate M-Minimal E-Expectant

9. Evacuation Lanes Urgent Surgical –STAT to an FST Urgent –STAT to a CSH Priority –ASAP to FST or CSH Routine –Whenever…

10. CAPT HR Bohman FRSS / STP – Combat Casualties Results OIF-I: –338 -- Total casualties –90 (26%) Operative cases –21--Number Unstable Pt’s –45 min Mean Time to Arrival –All USMC survived OIF-II: –Total casualties – 300 –Operative cases – 125 (41%) –39--Number Unstable Pt’s –74 min Mean Time to Arrival –8/26 USMC were DOW

11. CAPT HR Bohman FRSS / STP – Critical Patients Results OIF-I –338 trauma cases 90 operative (26%) –Number Unstable Pt’s: USMC – 5 Iraqi – 16 –Mean Time to Arrival USMC – 30 min (15-45) Iraqi – 60 min –All USMC survived OIF-II –300 trauma cases 125 operative (41%) –Number Unstable Pt’s: USMC – 26 Iraqi – 13 –Mean Time to Arrival USMC – 63 min (20- 110) Iraqi – 85 min –8/26 USMC have DOW

12. Movement of Critical Patients OIF-II CAPT HR Bohman 23 km = distance from point of injury 20/39 (51%) of critical patients taken to BAS first 29 min = time to presentation at BAS 36 min = length of stay at BAS 8/20 (40%) had any ATLS intervention at BAS 74 min = time to arrival FRSS/STP

13. I D M E Triage Area Routine Priority Urgent Urgent Surgical Traffic Flow

14. Initial Approach Call out to the casualties, “If you can hear my voice, get up and come to me!” –If they get up and walk to you, they are Minimal –They may be helpful as litter bearers/buddy aid and security assets Call out, “All of you that can hear me, raise your hand or foot!” –If they raise a hand or foot, they are delayed If the casualties don’t get up, or raise a hand/foot, they are immediate or expectant….get busy!

15. Circulation Control the life threatening hemorrhage Check the radial pulse –If it is present=systolic pressure of 80mmHg –If it is strong Good sign –If it is bad Bad sign-may make your patient expectant

16. Breathing Put your hands on both sides of the chest and count his respiratory rate, effort, symmetry Ausculate if possible The patient is breathing and in no distress –Delayed vs minimal Is there respiratory distress? –Immediate No breathing=expectant

17. Airway and breathing Most casualties will NOT have an airway injury. If a casualty is talking or hollering, his airway is OK for the time being.

18. Airway This wound seems small, but it could cause bleeding or direct injury to the airway or spine. Don’t forget to continue to re-triage –It is a DYNAMIC process!!

19. Airway This man can breathe OK when sitting up. When you try to make him lie flat, he struggles and fights for air. Let him sit up! If there are medical personnel in the area, let them know about him first! And tell them that he can’t breathe when lying flat.

20. Airway In large flame burns, airway might start out OK, but within hours becomes narrowed by swelling. Get history while he can still talk. Then provide an airway before it becomes critical. Don’t be alarmed by the facial burn. Most of them heal well if not very deep.

21. No breathing or pulse In a mass casualty situation, with many truly injured people, –If you find a casualty who is not breathing and has no pulse, leave him and go on to the next. –Do not compel personnel to try to revive a dead casualty, when the living still need their help. Reminder - this goes for a mass casualty situation with many truly injured people.

22. But what about CPR? Trauma patients who are dead at the scene can rarely by revived, even under the best of circumstances. The few who might live will require skilled care and equipment that is not available to you. The living need your help more.

23. But what about CPR? CPR IS used in cases of: –drowning –hypothermia (freezing) –electrical shock –sudden cardiac death But not during mass casualties involving many truly injured people.

24. What can be done during triage? Stop bleeding Decompress a tension pneumothorax Insert a nasopharyngeal airway

26. Serious head injury In an over-whelming mass casualty situation, if a casualty does not open his eyes, talk, or move, leave him and go on to the next. In Vietnam, casualties with direct GSW to the head who were comatose either did not survive, or survived with serious impairment. Casualties who are comatose will require more care than you can give them in an over- whelming mass casualty situation.

27. Priorities in general Life has priority over limb or eye-sight Life threatening hemorrhage has priority over airway and breathing problems Airway and breathing problems have priority. Torso injuries might have priority over limbs. A limb with no pulse has priority over a limb with a pulse. Open fractures have priority over closed.

28. Helicopter Landing Zone  Clear all debris.  Mark obstacles (Panels/Chemlites/Glint Tape).  LZ should be generally level not >16 deg. And preferably < 8 deg.  Cleared diameter for UH-60 50m, CH-47 80m.  Aircraft will land facing into the wind.  UH-60s in particular may forward roll after landing 10- 50’ to avoid a “Brownout”. Anticipate it.  Avoid landing aircraft down slope  Ensure marking devices (Bean Bag/ Lights / Chemlites / VS17 Panels) are properly secured to avoid them being sucked up in the rotor wash.  Ground guides are NOT NEEDED to land.  Regardless of how the HLZ is marked, the pilot will determine where to land.

29. INVERTED “Y” LZ 7m 14m STEM LIGHT 14m RIGHT LEG LIGHT LEFT LEG LIGHT STEM LIGHT WIND DIRECTION

30. Helicopter Landing Zone  DAYLIGHT MARKING PROCEDURES  Determine method of marking (Smoke/Panels/Strobe/Star Cluster).  Do not pop smoke of fire star cluster until pilot requests it.  NIGHT MARKING PROCEDURES  Use light discipline as pilots will be on NODs (Only marking lights should be on as aircraft approaches.)  Determine the marking method  (Bean Bag Lights/Chemlites/Strobe).  May use an IR chemlite spun on a length of 550 cord to mark the HLZ or to indicate where the casualties/medics are located on the LZ.

31. Helicopter Landing Zone  MEDIC RULES  Package patient to withstand a rigorous evacuation in which no CASEVAC care may occur. All interventions should be secured/splinted/space or wool blanket on/litter straps on and snug.  Secure any loose items on or around the patient.  Remove weapons/pyro/sensitive items prior to evac and give them to 1SG/S4.  Ensure patient has an FMC or equivalent secured to their person.  Never approach the aircraft unless directed by a crewmember. Flight medics will normally disembark and come to you to evaluate your casualties.  Watch for, and obey immediately, any commands given by crewmembers.  Ensure that you have pertinent patient data recorded prior to them leaving.  Always have/wear a pair of goggles.

32. 9 – Line MEDEVAC  LINE 1 – LOCATION OF PICKUP SITE  LINE 2 – RADIO CALL SIGN & FREQUENCY  LINE 3 – NUMBER OF PATIENTS BY PRECEDENCE **A** Urgent **B** Urgent Surgical **C** Priority **D** Routine **E** Convenience  LINE 4 – SPECIAL EQUIPMENT NEEDED **A** None **B** Hoist **C** Extraction Equipment **D** Ventilator  LINE 5 – NUMBER OF PATIENTS BY TYPE **L** Number of Litter Patients **A** Number of Ambulatory Patients

33. 9 – Line MEDEVAC  LINE 6 – SECURITY OF PICK-UP SITE (WAR) **N** No Enemy Troops in the Area **P** Possible Enemy Troops in the Area (Approach with Caution) **E** Enemy Troops in the Area (Approach with Caution) **X** Enemy Troops in the Area (Armed Escort Required)  LINE 7 – METHOD OF MARKING HLZ **A** VS-17 Panel **B** Pyro, Type **C** Smoke, Color **D** None **E** Other  LINE 8 – PATIENT NATIONALITY AND STATUS **A** US Military **B** US Civilian **C** Military, Non-U.S. **D** Civilian, Non-U.S. **E** EPW  LINE 9 – DETAILS OF LANDING SITE

34. Questions??