1. CERT EMERGENCY MEDICAL OPERATIONS Part 1 Whatcom County Division of Emergency Management

2. OBJECTIVES 1.Identify “killers” 2.Apply techniques for opening airways, controlling serious bleeding, and treating shock 3.Conduct triage under simulated disaster conditions

3. DISASTER MEDICAL OPERATIONS Assumptions The number of victims will exceed local capacity for treatment Survivors will assist others

4. PHASES OF DEATH FROM TRAUMA Phase 1: Death within minutes Phase 2: Death within several hours Phase 3: Death after several days or weeks

5. 40%Experts agree that over 40% of disaster victims in the second and third phases of death could be saved by providing simple medical care CERT members aim to “Do the greatest good for the greatest number”

6. CERT REMINDER! CERT members MUST take care of themselves before caring for others Gloves Mask Goggles Pocket Mask

7. THE “KILLERS” Airway Obstruction Bleeding Shock

8. AIRWAY

9. OBSTRUCTED AIRWAY 4-6 minutes until brain death Heimlich –Conscious –Unconscious –Most common obstruction is the tongue

10. HEAD-TILT/CHIN-LIFT Step 1Can you hear me? Step 2One hand on forehead Other hand under chin Step 3Lift the jaw while tilting the head backwards slightly Step 4Look, Listen, Feel for signs of breathing (Chest Rise, Air Exchange, Abdominal Movement)

11. Pad under shoulders to maintain an open airway

12. WHAT IF... The person doesn’t breath after opening the airway? –Try one more time then move on. –Remember the CERT Mission. The person does start breathing but you need to move on to other patients? –Walking wounded. –Recovery position - consider neck injury.

13. PRACTICE TIME IC break class into teams. Medical Group Leader make victim and rescuer assignments. –Patient to breathe normally. –Rescuer to assess breathing. –Practice Head-Tilt/Chin-Lift. –Position patient in recovery position.

14. BLEEDING Uncontrolled Bleeding is a “Killer”! Three types –Arterialhigh pressure, spurts –Venouslow pressure, flows –Capillarylow pressure, oozes

15. BLEEDING CONTROL Direct Pressure –Brachial –Femoral Elevation –Local pressure combined with elevation will address 95% of bleeding. –Can take 5-7 minutes to work. –Get help from the patient, walking wounded, pressure bandage.

16. BLEEDING CONTROL Pressure Dressing Pressure Points May be combined. Not a tourniquet.

17. TOURNIQUET Rarely necessary except –Crushing injury –Partial amputation Use when willing to “sacrifice a limb to save a life” Leave it in plain sight - no bandage Time/Day written on patient’s forehead

18. CERT REMINDER! One CERT function is to collect and record information. Pencils, markers, and tape are important items for the disaster preparedness kit. The marker can be used for non-traditional purposes, such as marking a forehead.

19. PRACTICE TIME IC break class into teams –Medical Group Leader assign victims/rescuers –Practice making a pressure dressing –Practice slipping a square knot –Additional Skills Vital Signs (BP, HR, RR) EpiPens

20. SHOCK - THE SILENT KILLER Ineffective circulation of blood (which carries oxygen) Will lead to the death of cells, tissues and entire organs Adults compensate differently from children Early recognition is essential

21. Slightly increased rate of breathing - Breaths may be shallow Slightly increased pulse - pale and cool skin - Capillary refill of >2 seconds Restlessness, anxiety, irritability, apprehension, inability to follow simple commands Compensatory Stage Earliest Signs of Shock

22. Compensatory Stage CERT GOAL: Watch for subtle signs of early shock Slightly increased rate of breathing Slightly increased pulse - pale and cool skin Restlessness, anxiety, irritability, apprehension

23.  Increased, irregular, shallow breaths  Increased, irregular, weak pulse  Cool, moist, blue or pale skin  Dilated pupils  Listlessness, apathy Progressive Stage (uncompensated)

24.  This patient will die!  We must do what we can to prevent the condition from progressing to this point! Irreversible Stage

25. SHOCK ASSESSMENT R Rapid and shallow breathing - (Respirations/airway) P Capillary refill of greater than 2 seconds - (Pulse) M Follow simple commands, such as “Squeeze my hand” - (Mentation)

26. CERT TREATMENT Face Pale - Raise Tail Face Red - Raise Head Elevate feet 6-10 inches - Watch the airway Control bleeding Maintain body temperature Avoid rough or excess handling Give nothing to eat or drink - Expect the patient in shock to be nauseous or thirsty

27. DISASTER MEDICAL OPERATIONS Organization

28. TRIAGE French for “to sort” Evaluated and sorted by the immediacy of treatment needed Used when –Rescuer(s) are overwhelmed. –There are limited resources. –Time is critical.

29. TRIAGE PRIORITIZATION GREEN - Minor/Walking Wounded Patient may require professional care. Life not jeopardized by delay in treatment. RED - Immediate Life-threatening injuries demand immediate attention. Treatment may save a life. YELLOW - Delayed Needs care as soon as people and materials are available. Treatment is essential. BLACK - Dead Not breathing after two tries to open the airway. Massive trauma or major medical condition which exceeds available resources.

30. BEFORE CHARGING IN... 1ST - Stop, Look, Listen, Smell, Think –Dangers to CERT? –Where to set up staging/supply/treatment and morgue areas? Voice Triage - Identify “walking wounded” –Whistle. –“If you can walk, come to my voice.” –Label as GREEN - Reassess later. –Get information from them Stage them with a CERT member Use as needed.

31. PERFORMING TRIAGE R Respirations/Airway –Position. –Look, Listen, Feel. –Greater than 30 = Immediate/Red. –Treat for shock and move on. –Not breathing after 2 attempts = Dead/Black EXCEPTION: Give children 15 breaths and reassess before placing them in the Black category Begin with the first patient located

32. Step 1

33. PERFORMING TRIAGE P Pulse/Bleeding –Capillary refill greater than 2 sec. = Immediate/Red. –Control bleeding, treat for shock, and move on. Triage & quickly move to the next patient. Only immediate life-saving treatment is given during triage.

34. Step 2

35. PERFORMING TRIAGE M Mental Status –Ask the victim to follow a simple command, such as squeezing your hand. –No response or inappropriate response = Immediate/Red. –Treat for shock and move on.

36. Step 3

37. PRACTICE TIME Turn to your neighbor and perform a “shock assessment”. Look for normal RRespirations PPulse/Capillary Refill MMentation

38. TRIAGE - DETAILS Everyone gets a tag Keep a count of numbers in each color Triage is sorting - transportation does not start until triage is completed Time is critical in a disaster

39. AFTER TRIAGE - THEN TRANSPORT TO TREATMENT Immediate - RED Delayed- YELLOW –Most qualified rescuers. –Majority of medical equipment. Minor - GREEN –Walking wounded may already be in the treatment area. –May be able to help with Red and Yellow patients. –Record keepers. Dead - BLACK –A different location - morgue. –Consider sanitation/safety issues.

40. CERT REMINDER! Triage Pitfalls –Inadequate medical size-up. –No team plan, organization or goal. –Indecisive leadership. –Too much focus on one injury. –Treatment rather than triage.

41. PRACTICE TIME You are at the scene where a bus has been overturned as the result of an earthquake. No other emergency services will be able to reach your location for several hours, at least, and likely much longer. Use the worksheet to identify the category you will triage each of the following patients into. You will have 15 seconds to read the information and make a decision.

42. What’s your call?1 A young school aged boy is found lying on the roadway 10 ft from the vehicle. Respiratory Rate 10/min. Capillary Refill is 2 seconds. Groans to painful stimuli.

43. What’s your call?1 A young school aged boy is found lying on the roadway 10 ft from the vehicle. Respiratory Rate 10/min. Capillary Refill is 10 seconds. Groans to painful stimuli. R- Slow for a child P- OK M- Unable to follow command

44. What’s your call?2 An adult kneels at the side of the road, shaking his head. He says he’s too dizzy to walk. Respiratory Rate is 20. Capillary Refill is 2 sec. Obeys commands.

45. What’s your call?2 An adult kneels at the side of the road, shaking his head. Says he’s too dizzy to walk. Respiratory Rate is 20. Capillary Refill is 2 sec. Obeys commands. R - OK P - OK M - OK - but couldn’t walk

46. What’s your call?3 A school aged girl crawls out of the wreckage. She’s able to stand and walk toward you crying. Jacket and shirt torn. No obvious bleeding.

47. What’s your call?3 A school aged girl crawls out of the wreckage. She’s able to stand and walk toward you crying. Jacket and shirt are torn. No obvious bleeding. R - Crying P - No obvious bleeding M - Able to obey command

48. What’s your call?4 A toddler lies with his lower body trapped under the vehicle. Not breathing with modified jaw thrust and after 15 ventilations.

49. What’s your call?4 A toddler lies with his lower body trapped under the vehicle. Not breathing with modified jaw thrust and after 15 ventilations. R - no P - no M - no

50. What’s your call?5 Adult female driver, trapped by her lower legs under caved-in dash. Respiratory Rate 24. Capillary refill 4 sec. Moans with verbal stimulus.

51. What’s your call?5 Adult female driver, trapped by her lower legs under caved-in dash. Respiratory Rate 24. Capillary refill 4 sec. Moans with verbal stimulus. R - fast P - slow M - no

52. What’s your call?6 A toddler lies among the wreckage. Respiratory Rate 50. Capillary refill > 2 seconds. Withdraws when touched.

53. What’s your call?6 A toddler lies among the wreckage. Respiratory Rate 50. Capillary Refill > 2 seconds. Withdraws when touched. R - fast P - delayed M - inappropriate

54. What’s your call?7 A woman is carrying a crying infant. She is able to walk. Respiratory Rate 20. Capillary Refill 2 sec. Obeys commands.

55. What’s your call?7 A woman is carrying a crying infant. She is able to walk. Obeys commands. Respiratory Rate 20. Capillary Refill 2 sec. R - ok P - ok M - ok

56. What’s your call?8 An infant is carried by mother. He’s screaming but the woman quiets him. He focuses on mom. Respiratory Rate of 34. Capillary refill < 2 seconds. No obvious significant external injuries.

57. What’s your call?8 An infant is carried by mother. He’s screaming but the woman quiets him. He focuses on mom. Respiratory Rate of 34. Capillary refill < 2 seconds. No obvious significant external injuries. R - ok P - ok M - ok

58. What’s your call?9 School aged boy props himself up. Respiratory Rate 28. Capillary refill in hands and feet < 2 sec. Answers question and commands. Obvious deformity of both lower legs.

59. What’s your call?9 School aged boy props himself up. Respiratory Rate 28. Capillary refill in hands and feet < 2 sec. Answers question and commands. Obvious deformity of both lower legs. R - ok P - ok M - ok

60. What’s your call?10 A school aged girl lies among the wreckage. Respiratory Rate 40. Capillary Refill is 5 seconds. Pushes rescuers away.

61. What’s your call?10 A school aged girl lies among the wreckage. Pushes rescuers away. Respiratory Rate 40. Capillary Refill is 5 seconds. R - fast P - delayed M - questionable

62. What’s your call?11 A screaming infant is found among the bushes at the side of the road. Partial amputation of the foot without active bleeding. Reaches for you. Respiratory Rate 38. Capillary Refill < 2 seconds.

63. What’s your call?11 A screaming infant is found among the bushes at the side of the road. Partial amputation of the foot without active bleeding. Reaches for you. Respiratory Rate 38. Capillary Refill < 2 seconds. R - ok P - ok M - ok

64. What’s your call?12 An adult male lies at the water’s edge. No Breathing. Continues to not breath with jaw thrust.

65. What’s your call?12 An adult male lies at the water’s edge. No Breathing. Continues to not breath with jaw thrust. R - no P - no M - no

66. What’s your call?13 A youngster is up and walking around but is limping. Alert, crying hysterically for his mother. Capillary Refill is immediate.

67. What’s your call?13 A youngster is up and walking around but is limping. Alert, crying hysterically for his mother. Capillary Refill is immediate. R - Crying P - ok M - ok

68. What’s your call?14 A school aged boy lies close to the road. Respiratory Rate 36. Capillary refill is 2 seconds. Slowly looks at you when you talk to him.

69. What’s your call?14 A school aged boy lies close to the road. Respiratory Rate 36. Capillary refill is 2 seconds. Slowly looks at you when you talk to him. R - fast P - ok M - delayed

70. What’s your call?15 Teen girl lies next to vehicle, crying for someone to help her. A man with her says she needs her wheelchair. Minor cuts and bruises. Alert. Respiratory Rate 22. Capillary Refill is 1 second.

71. What’s your call?15 Teen girl lies next to vehicle, crying for someone to help her. A man with her says she needs her wheelchair. Minor cuts and bruises. Alert. Respiratory Rate 22. Capillary Refill is 1 second. R - ok P - ok M - ok

72. What’s your call?16 An adult male lies on the ground. Respiratory Rate 20. Capillary refill is 2 seconds. Obeys commands but cries that he can’t move his legs.

73. What’s your call?16 An adult male lies on the ground. Respiratory Rate 20. Capillary refill is 2 seconds. Obeys commands but cries that he can’t move his legs. R - ok P - ok M - ok OR

74. What’s your call?17 An older school aged child is found lying against a tree. Groggy, confused but slowly follows commands. Respiratory Rate 28. Capillary refill is 2 seconds.

75. What’s your call?17 An older school aged child is found lying against a tree. Groggy, confused but slowly follows commands. Respiratory Rate 28. Capillary refill is 2 seconds. R - ok P - ok M - slow

76. It can be confusing - but it’s ok to change your mind the second time through.

77. Next Class Search & Rescue

78. Next Class Public Health Considerations Disaster Medical Operations –Establishing Treatment Areas –More Indepth Patient Evaluations –Bandaging –Splinting