1. DPT 8.0 Special Hospital Considerations Part II Triage, Planning and Exercises

2. DPT 8.0 Hospital Triage Use a triage system in an MCI that parallels normal routine Practice regularly to ensure familiarity Triage is a continual process Re-triage all victims transported by EMS Set up triage area near the ED entrance – Shielded and secure – Readily accessible

3. DPT 8.0 Triage “Greatest good for the greatest number of casualties” Psychological impact Classification: RedYellowGreen Black Limitations: – Time consuming – User variability – Lack of familiarity

4. DPT 8.0 START Triage TRIAGE CRITERIA: Respiratory status Perfusion and pulse Neurological status TRIAGE CATEGORIES: Walking wounded - “Green” or minimal (relocate when told) Normal findings - “Yellow” or delayed (unable to relocated) Abnormal - “Red” or immediate Non-salvageable - “Black” or expectant

5. DPT 8.0 START - Respiratory Status Expectant No Respiratory Effort Immediate Respirations > 30 Go to Next Step Normal Respirations Respiratory Status

6. DPT 8.0 START - Perfusion Immediate Radial Pulse Absent Immediate Cyanotic Go to Next Step Radial Pulse Present Perfusion Status

7. DPT 8.0 START - Neurological Status Immediate Change in Mental Status Immediate Unconscious Move to Next Victim Normal Mental Status Neurologic Status

8. DPT 8.0 Nerve Agent Triage - “Immediate” Unconsciousness or convulsions Two or more body systems involved Rapid intervention should result in a good outcome

9. DPT 8.0 Nerve Agent Triage - “Delayed” Initial symptoms are improving (miosis still present) Recovering well from pre-hospital antidote therapy

10. DPT 8.0 Nerve Agent Triage - “Minimal” & “Expectant” Minimal Walking and talking which indicates intact breathing and circulation Expectant Apneic for more than 5 minutes No pulse or blood pressure

11. DPT 8.0 Mustard Triage Delayed 2 to 50% BSA burns by liquid Eye involvement Minimal < 2% BSA burns by liquid in non-critical areas Immediate Moderate to severe pulmonary symptoms Expectant > 50% BSA burns by liquid; apneic / pulseless

12. DPT 8.0 Triage of Biological Casualties Triage of biological agent casualties is different – Symptoms are delayed – Initial cases may go unrecognized – More difficult to detect Epidemiological information becomes critical

13. DPT 8.0 Radiological Triage Triage: – Stabilize the patient first and only when this is done does one consider irradiation and contamination. – Ensure ABCs

14. DPT 8.0 Triage - Psychological Casualties Disasters produce tremendous emotional and psychological stress, with large numbers of psychogenic casualties Presenting signs could be confused with organic disease Use of START triage system maintains focus on objective signs of disease & minimizes impact of subjective complaints on the triage process Psychological casualties are usually triaged as “minimal”

15. DPT 8.0 Triage - Hospital Arrivals Casualty arrival is uncoordinated Arrival times vary Closest hospital is typically overwhelmed Medical needs of unaffected community continue

16. DPT 8.0 Triage - Contaminated Human Remains Problems are agent-specific – Decontamination – Containment – Refrigeration until definitive disposal Follow local coroner and medical examiner protocols – Establish cooperative agreements for fatality management Secure personal effects – Not all can be decontaminated

17. DPT 8.0 Staff Preparedness Plan for the needs of the unaffected population Prepare to receive large numbers of casualties Prepare to receive large numbers of dead Rotate staff to avoid congestion and fatigue, especially personnel in PPE

18. DPT 8.0 Logistics / Supplies Highest priority: getting the right resources to the right place at the right time – Personal protective equipment and dosimetry – Medications / antidotes / vaccines – Mechanical ventilators – Isolation rooms remote from other patients Identify current inventory and augment as necessary Develop a procedure to access external assets

19. DPT 8.0 Maximal Utilization of Hospital Space Identify alternative medical treatment areas Planning for use of available space – Open areas – Isolated areas – Temporary morgue 1 2 3 5 6 7 8 9 10 11 12 13 14 15 16 19 18 17 20 4

20. DPT 8.0 Handling of Evidence Maintaining evidence is critical for an investigation – Clothing – Embedded foreign bodies – Decontamination runoff Chain of Evidence must be maintained EVIDENCE

21. DPT 8.0 Exercising the Plan Start small - few casualties Be realistic Coordinate with other agencies / hospitals Exercise frequently DON’T WAIT FOR A DISASTER TO HAPPEN

22. DPT 8.0 Scenario A football championship was what the city needed to boost its national reputation, and tonight was the night. Every hotel within 30 miles was booked with fans eagerly awaiting the game. After the national anthem was played the crowd began to loudly chant their team’s respective fight song. The sounds within the stadium were deafening.

23. DPT 8.0 Scenario Just as the game was ready to begin fans from section “A” started to run from their seats. Total chaos ensues. In a rampage fans were pushing and shoving trying to get out through the exit doors. Many were being trampled upon during the exodus. Most were coughing, rubbing their eyes, and many appeared to be choking. 911 was called and the closest hospital, two blocks away, was also notified.

24. DPT 8.0 Scenario Assume you are working in the emergency department, please answer the following: After notification, what would you do? Where would you set up triage? Who would function as the triage officer? Where would you set up & perform decon?

25. DPT 8.0 Scenario Within 15 minutes of the incident 100 victims arrive at your hospital without the assistance of EMS How will you control access into your hospital? What level of protective gear should be worn? Should these victims be decontaminated? How will you decontaminate these victims? Where will you treat the first wave of victims?

26. DPT 8.0 Scenario Victims are complaining of shortness of breath, cough, eye & throat irritation, and burning skin. What chemical were they exposed to? What clues would you look for to help you identify the agent? Lacking positive agent identification, how would you begin treatment? What medications/antidotes are necessary?

27. DPT 8.0 Teaching Points Hospitals must expand their emergency planning and scope of services to include NBC care Concentrate on the disaster planning process Develop policies & procedures Train frequently using realistic scenarios