Mass Casualty &
Disaster Triage
Amy Gutman MD
prehospitalmd@gmail.com
Overview
•
•
•
•
•
•
Disasters & MCIs
Triage
Pediatrics
WMD
Incident Command
Lessons Learned
Disasters Are Different
Defining a Disaster
What Is A Disaster?
• Any event, regardless of size or expanse, that overwhelms
available resources
• Any disaster can trigger a health crisis
• Initial disasters are often compounded by poor planning &
communications, costing time, resources, & lives
• Daily emergency care is not usually constrained by resource
availability
– In daily emergencies, you do the best for the individual
– In disasters, you do the greatest good for the greatest number
Murrah Federal Building
Oklahoma City, OK
168 dead, >800 injured
Van vs Train
New Zealand
2 dead, 6 critical, 2 stable patients
“A single death is a tragedy; a million
deaths is a statistic.” Josef Stalin
•
•
•
•
•
•
•
•
•
•
•
Air Force Base
Airports
Bridges
Chemical Plants
Hospitals
Ohio River
Skyscrapers
Sports Arenas
Train Depot
Universities
Weather
Any Disaster Requires a
Coordinated Response
Disaster “MCI” Categories
• I “Expanded Medical Incident”
– >10 critical, <50 patients
– Local resources available to treat injured
• II “Major Medical Incident”
– >50 critical, <200 patients
– Regional resources available to treat injured
• III “Disaster”
– >200 patients of any type
– Lack of regional resources available to treat injured
– State, Federal resources required
MCI Response: Brevard County
•
MCI LEVEL I
–
–
–
–
–
–
–
•
•
MCI LEVEL III
–
–
–
–
–
–
–
–
County Fire District Chief
5 ALS units
5 Fire companies
2 ALS helicopters
1 Logistics officer & supply trailer
Communications Chef
1 PIO
County FD Rescue Supervisors
15 ALS, 5 BLS units
10 Fire Companies
All available ALS helicopters
4 transit buses
3 Logistics Officers, 3 supply trailers
2 Communications Chiefs
1 PIO
MCI LEVEL II
–
–
–
–
–
–
–
–
County fire District Chief
10 ALS, 3 BLS units
7 Fire companies
3 ALS helicopters
2 Transit buses
2 Logistics Officers, 2 supply trailers
2 Communications Chiefs
1 PIO
•
MCI LEVEL IV
–
–
–
–
–
–
–
–
County FD Rescue Supervisors
20 ALS, 10 BLS units
15 Fire companies
All available helicopters
6 transit buses
4 Logistics officers, 4 supply trailers
2 Communications Chiefs
1 PIO
Disaster Emergency Codes
• Code Black
– Bomb Threat
• Code Gray
– Severe Weather
• Code Orange
– Haz Materials Incident
• Code Yellow
– Disaster
What is Triage?
•
“Triage” means “to sort”
•
A process in which victims are sorted into groups;
priorities of care established & resources allocated
•
Looks at medical needs & urgency of each individual
•
Sorting based on limited data acquisition & resource
availability to get care to those who need it and will
benefit from it the most
•
Provides an objective framework for stressful &
emotional decisions
Triage Organizes Priorities
• “Normal” Circumstances
– Use all available manpower & supplies to save a few lives
• Minor injuries receive immediate care
• Severe injuries receive immediate care
• Mortal injuries may or may not receive care
• “Disaster” Circumstances
– Number of injured > ability to treat in normal manner
– Resource use focuses on saving as many lives as possible
• Minor injuries wait for care
• Severe injuries receive immediate care
• Mortal injuries do not receive care
Disaster Ethical Considerations
•Alteration of standards of care
•“Utilitarian rule" governs medical care
•The greater good of the greater number rather than the
particular good of the individual
A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine, Univ.
of Washington School of Medicine
Triage is Dynamic
• Primary Triage is performed close to incident in a
“safe” area
• Secondary Triage is performed in a separate area by
a second set of medical personnel
• Tertiary Triage is performed either in the Secondary
Triage area, or at the destination facility
Primary Triage
• Sort patients based on need for immediate care
• Assumptions:
– Medical needs outstrip immediately available resources
– Additional resources will become available with time
• Triage based on physiology
– How well the patient is able to utilize their own resources
to deal with their injuries
– Which conditions will benefit the most from the
expenditure of limited resources
Secondary Triage
• Match patients’ current & anticipated needs with
available resources
•
Incorporates:
– A reassessment of physiology
– Initial treatment & assessment of patient response
– Further knowledge of resource availability
• Goal is to distinguish between:
– Victims needing life-saving treatment in a hospital setting
– Victims needing life-saving treatment initially available on
scene
– Victims with non-life-threatening injuries, at risk for delayed
complications
– Victims with minor injuries
NATO Secondary Triage Injury
Categories
•
Green
–Minor lacerations, contusions, sprains, superficial burns
•
Yellow
–Open abdominal wound, eye injury, pulseless limb, fractures,
significant burns other than face, neck or perineum
•
Red
–Airway obstruction, cardio-respiratory failure, external
hemorrhage, shock, open chest wound, burns of face or neck
•
Black
–GCS<8, burns >85% BSA, multisystem trauma, signs of
impending death
Tertiary Triage
•
Goal is to optimize individual outcome
•
Incorporates:
–
Sophisticated assessment & treatment
–
Further assessment of available medical
resources
–
Determination of best venue for definitive care
Triage Systems
Basic Disaster Life Support
• National Disaster Life Support Education Consortium, via
Medical College of Georgia’s Center of Operational
Medicine
– Disaster Medicine Online University (www.dmou.org)
• Endorsed by the AMA & NREMT
• MASS Triage
– Move
– Assess
– Sort
– Send
• ? Assessment guidelines or Pediatric considerations
START: Simple Triage & Rapid Treatment
• Prepares emergency personnel to quickly organize their
resources to handle multi-casualty emergencies by assuming
predetermined roles
• Based upon ambulatory status, respirations, pulse, & mentation
– Does not require any medical equipment
• Provides a rapid assessment of resource needs
• Developed jointly by Newport Beach (CA) Fire & Marine
Department & Hoag Hospital
• Gold standard for field adult multiple casualty (MCI) triage in the
US and numerous countries around the world
START Problems
• Does not take
resources into account
• Some are more “Red”
than others
• Uses a limited number
of physical parameters
(RPM)
• Not commonly used
during daily operations
Triage Categories
•
Green
•
Yellow
•
Red
•
Black
–Minor injuries that can wait for longer periods of time
for treatment
–Potentially serious injuries, but are stable enough to
wait a short while for medical treatment
–Life-threatening but treatable injuries requiring rapid
medical attention
–Dead or still with life signs but injuries are incompatible
with survival in austere conditions
START Patient Tags
Triage Flow Chart
RESPIRATIONS
Minor
NO
• Separate walking
wounded from
others
ALL WALKING
WOUNDED
YES
POSITION AIRWAY
Under
30/Min.
NO
YES
Morgue
Immediate
Over
30/Min.
Immediate
PERFUSION
Radial Pulse Absent
OR
• Use physiology
to assess:
– Breathing
– Blood flow
– Mental status
Capillary Refill
Nail Bed Press
Over
2 Seconds
Under
2 Seconds
Control
Bleeding
MENTAL STATUS
Immediate
Can’t Follow Simple
Commands
Can Follow Simple
Commands
Immediate
Delayed
All Walking Wounded Are “Green”
ALL WALKING
WOUNDED
RESPIRATIONS
NO
Minor
YES
POSITION AIRWAY
Under
30/Min.
Over
30/Min.
Immediate
NO
YES
PERFUSION
Morgue
Immediate
MENTAL STATUS
• If not walking & talking, begin assessing life functions
Breathing
ALL WALKING
WOUNDED
RESPIRATIONS
NO
Minor
YES
POSITION AIRWAY
NO
YES
Morgue
Immediate
Under
30/Min.
Over
30/Min.
PERFUSION
Immediate
• Cannot breathe on own after airway opened = BLACK
• Breathing rapidly = RED
• Breathing regularly = go to next step in flow chart
Perfusion
• If radial pulse =
go to “Mental
Status”
• If no radial pulse,
check capillary
refill
• If refill >2 secs =
RED
• If refill <3 secs =
go to “Mental
Status”
PERFUSION
Radial Pulse Absent
OR
Capillary Refill
Nail Bed Press
Over
2 Seconds
Control
Bleeding
Immediate
Under
2 Seconds
Mental Status
MENTAL STATUS
Can’t Follow Simple
Commands
Immediate
Can Follow Simple
Commands
Delayed
• Cannot follow simple command = RED
• Can follow simple command = YELLOW
• All victims have now completed primary triage
Pediatric Disaster Triage:
JUMPSTART
Walking Wounded = Green
• All green pediatric patients must be immediately reassessed in secondary triage
• May have been carried to the secondary triage area
& have not proven their physiologic stability
Breathing
• Position the upper airway of the apneic child
• If breathing = RED
Perfusion
• If the child doesn’t start breathing with upper airway
opening, feel for a pulse
• If no pulse is palpable = BLACK
Perfusion
•If the patient has a pulse, give 5 breaths to open the lower airways
•If no ventilations = BLACK
•If breathing = RED
Ventilation
•If respiratory rate is <15 or
>45 = RED
•If respirations are > 15 or <45,
move on to next step
Perfusion
• If no palpable pulse = RED
• If pulse is present, move to the next step
Mental Status
• If patient is inappropriately responsive to pain,
posturing, or unresponsive = RED
• If patient is alert, responds to voice or
appropriately responds to pain = YELLOW
Nonambulatory Children
• Patient can still be GREEN if no external signs of
trauma, breathing spontaneously, positive pulse &
normal vitals
• If patient has minor external trauma not involving
the head, but otherwise stable vitals, then tag as
YELLOW
• If patient meets any red criteria, then tag as RED
• If patient has no pulse, no spontaneous
respirations after 5 breaths, or significant external
trauma, then tag as BLACK
Triage in WMD Incidents
WMD Triage Challenges
•
Any triage model for WMD must consider decontamination
–
Patients with injuries from a conventional attack in addition
to a chemical, radiological, or nuclear exposure
•
Difficulty of conducting patient assessment & care with
responders in protective gear
•
Biological agents impact field triage & potentially the
destination facility
•
Patterns of EMS calls may assist in identification of a occult
biological agent attack or a natural epidemic
•
Example biosurveillance tool is the First Watch program
http://www.stoutsolutions.com/firstwatch
WMD Triage Challenges
• Some agents cause “toxindromes” that allow for
prediction of outcome based on presenting
symptoms and signs
• Agent-specific triage is dependent upon strong
suspicion of the agent’s use
• Very difficult to train & maintain readiness with
multiple agent-specific triage schemes
Nerve Agents Triage
• Red:
– Seizures, multisystem symptoms: GI,
neuromuscular, respiratory – excluding eyes &
nose
• Black:
– Pulseless or apneic, respiratory failure
Phosgene & Vesicants Triage
• Red:
– Moderate to severe respiratory distress, only
when intensive resources are immediately
available
• Black:
– Burns >50% BSA from liquid exposure, signs
of more than minimal pulmonary involvement,
when intensive resources are not available
Cyanide Triage
– Red:
• Active seizure or apnea with preserved
circulation
– Black:
• No palpable pulse
Key Points about MCI Triage
•
Anything that can organize the response to an MCI is useful,
including drills
•
MCI triage is different than daily triage, in both field & ED settings
•
Resource availability is the limiting factor in MCI triage
•
In order for MCI triage to work toward its goal, all victims must
have equal importance at the time of primary triage
– No patient group can receive special consideration other than that
dictated by their physiology
•
MCI triage will never be logistically, intellectually, or emotionally
easy, but we must be prepared to do it using the best of our
knowledge and abilities
Triage & Treatment Protocols
• Must develop protocols BEFORE they are needed
• Keep protocols and treatment plans up-to-date
• Practice triage method
• Practice getting organized to do triage
• Remember: Triage is a continuous process
Resource Allocation
Triage
Transportation
Scene Management
Resource Coordination
Scene Assessment & Triage
Priorities
•
Greatest good for the greatest number
•
Maintain universal blood & body fluid precautions
•
The initial response team assesses scene for potential hazards, safety
& number of victims to determine the appropriate level of response
•
Notify central dispatch to declare an MCI & need for interagency
support as defined by incident level
•
Identify and designate the following positions as qualified personnel
become available:
–
–
–
–
–
–
Incident Command Officer
Communications Officer
Extrication / Hazards Officer
Primary & Secondary Triage Officer
Treatment Officer
Loading/Transportation Officer
Scene Assessment & Triage
Priorities
• Identify & designate sector
areas of MCI
–
–
–
–
–
–
–
Incident Command
Communication Sector
Support & Supplies Sector
Staging Sector
Extrication / Hazards Sector
Primary & Secondary Triage
Primary & Secondary
Treatment Sectors
– Transportation Sector &
Landing Zone
– Post incident Plan
– Critical Incident Stress
Debriefing (CISD)
Disaster Transport Decisions
•
Separates those requiring rapid medical care to
salvage life or limb
•
By separating out minor injuries, triage reduces
urgent burden on medical facilities
–
–
–
•
<15% injured seriously enough to require hospital admission
<6% of hospitals suffered supply shortages
<2% of hospitals had personnel shortages
By providing equal & rational hospital distribution of
casualties, triage reduces burden on each to a
manageable level, often to "non-disaster" levels
Walking
Wounded
• “In an uncontrolled incident vast numbers of ‘walking
wounded’ (& non-patients) leads to a reverse triage
effect where patients with minor injuries present to
hospitals before the serious casualties arrive,
swamping emergency services to the detriment of the
severely wounded”
– Chaloner; BMJ 2005;331:119
“Delivery of Emergency Medical Services
in Disasters: Assumptions & Realities”
Quarantelli E.
Hospital Arrivals Post 10 Level I-III MCIs
– Ambulance
– Private Auto
– Police Vehicle
– Helicopter
– Bus or Taxi
– Ambulatory
54%
16%
16%
5%
5%
4%
Hospital Distribution of Disaster Casualties
(Quarantelli; Delivery of emergency services in disasters: Assumptions and realities)
Number of
Casualties
Number of Hospitals Number of Hospitals
Receiving Casualties
Capable of
Receiving Casualties
266
4
43
141
4
41
381
12
78
298
11
105
5 mins Air
25 mins Ground
15 mins Air
45 mins Ground
25 mins Air
100 mins Ground
20 mins Air
70 mins Ground
30 mins Air
45 mins Air
180 mins Ground
130 mins Ground
Scene Management
Making Sure the Right Players
Come to the Game
Don’t Come To The
Dance Unless Invited
• Responders from non-local agencies
often not in contact with the MCI
communications center
• Increased use & number of private HEMS agencies
contributes to this problem
• The KC Hyatt Skywalk Collapse post-disaster review
noted that at no point was communication established
with Incident Command, Triage or Transportation
Officers, The LZ Coordinator or Communications Center
by one HEMS crew for the 9 critical patients transported
(KC Health Dept, 1981:7)
Incident Command = Unified Command
• Based on commonality
– Many organizations work as “One”
– One system of integrative, standardized procedures for
rural, suburban, urban areas
• 5 synergistic characteristics:
–
–
–
–
–
1 Organizational Structure
1 Incident Command Post
1 Planning Process
1 Logistics Center
1 Communications Framework
IC Disaster Response
•
IC coordinates complex inter-relationships to deliver
quality, rapid, standardized care
•
Philosophy: “Whole is greater than the sum of its parts”
Incident
Command
Staging
Triage
Extrication
Treatment
Transportation
Incident Command
Operations
Medical
Hospital
Communications
Ground Transport
Coordinator
Transportation
Loading
Coordinator
Fire / Haz Mat
Air Operations
Air Transport &
Landing Zone
Coordinator
Patient Tracking
• Hospital Capabilities responsibility of the
Transportation Officer
• Patient Tracking responsibility of Ground &
Aeromedical Coordinators:
–
–
–
–
HAvBED
HEICS
HRSA
HERT
Scene
•
Patients rapidly counted & triaged (START)
–
IC determines resource requirements &
communicates needs to Coordinators
•
Ambulatory patients directed to supervised
area for secondary triage & treatment
•
Non-ambulatory patients moved from scene
to Treatment Areas
•
Patients decontaminated (as needed) prior to
leaving the incident scene
Treatment Area Diagram
Morgue
Medical
Supplies
SRC &
Rest Area
Immediate
Secondary
Triage
Delayed
Minor
Entrance From
Scene START
Triage
Transportation
Area
Rest Center
Police
Media Area
Outer
2
3
Inner
1
Triage
SRC
ICS
LZ
Ambulance Loading
Train Derailment;
Wales, 2001
14 Black
12 Red
30 Yellow
38 Green
Ambulance Parking Area
Morgue
Initial
Triage
Triage
Transport
LZ
IC
Four Errors That Cripple
Disaster Responses
• Panic
• Overestimating resource needs
• Limited communications
capabilities
• Poor planning or execution
Panic & Overestimating
Resource Needs
Resource Assessment:
You Make The Call
Taking “Don’t Panic” A Little Too Far
METHANE Method
• Major incident Declared
• Exact Location
• Type of incident
• Hazards
• Access & Egress
• Number of casualties / severity of injuries
• Emergency services required (personnel &
equipment)
Setting Up IC: “CSCAT3”
•
•
•
•
•
•
•
Command
Safety
Communication
Assessment
Triage
Treatment
Transport
Communication Failures
• Natural
– Either cause or effect of the disaster (i.e. earthquake)
• Human
– Often human error (i.e. radio set to wrong bandwidth)
• Technological
– Loss of infrastructure or system incompatibility
A Communications Failure
• A Chinese disaster plan included procedures preventing
overloading any single hospital. However, when an MCI
did occur:
– 125 / 140 patients taken to 1 hospital of 17
– Communications never notified any hospital of the
disaster
• No helicopter transports occurred despite repeated calls
from both ground crews and hospitals to redistribute
patients (Golec, 1977:172)
Frequency Incompatibility
• “Bands” are collections of neighboring frequencies
• Cannot communicate if different bands
–
–
–
–
–
–
Low (37-47 mHz)
High (250-255 mHz)
UHT (450-470 mHz)
UHF-TV (450-470 mHz)
800 mHz Band (806-902 mHz)
Military & Ham bands
• PDAs, pagers & Blackberries allow alerts & private
communications if tower intact
Regional Resources
• www.prepareohio.com
– Emergency preparedness
• www.cna.org/documents/mscc_aug2004.pdf
– Hospital & Health resource medical surge capacity
• www.training.fema.gov
– NIMS (National Incident Management Systems) training
• www.hcno.org/altered_care_standards_study.pdf
– Altered standards of care in mass casualty events
Summary
• Understanding basics
of Incident Command,
triage and resource
assessment &
allocation
• Failing to Plan is
Planning to Fail!
• A words about ABCs…
ABCDE-FGH
• “No one ever forgets the “ABCDEs” at the
scene, but they always forget the
“FGH”….
• “F—ing Get to the Hospital!
DSO Alan Payne
Thank You…Any Questions?
prehospitalmd@gmail.com
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Brady, Paramedic Emergency Care, Bledsoe, Porter, Shade
NIMS ICS Field Guide, 1st Edition – Infomed
Disaster Medicine, 2002 Lippincott Williams & Wilkins, Hogan and Burnstein
Emergency Medical Services at a Mass Casualty Incident, Joseph Cahill, Domestic
Preparedness Journal V. III, Issue 7, July 2007
Creating Order from Chaos: Part II: Tactical Planning for Mass Casualty and Disaster
Response a Definitive Care Facilities, Baker, Michael S., Article Military Medicine, Mar 2007
In a Moment’s Notice: Surge Capacity for Terrorist Bombings, Challenges and Proposed
Solutions, CDC, April 2007
International Nursing Coalition for Mass Casualty Education, Educational Competencies
for Registered Nurses Responding to Mass Casualty Incidents, August 2003
Mass Casualty Incident Program, Initial Triage Training, AEMS, courtesy of Pheonix FD.
Virginia Mass Casualty Incident Management, Secondary Triage
Improving health system preparedness for terrorism and mass casualty events,
Recommendations for action, July 2007, AMA/APHA Consensus report
Mass Medical Care with Scarce Resources, A Community Planning Guide, Health Systems
Research Inc., Feb. 2007
Nancy Caroline’s, Emergency Care in the Streets, Sixth Edition
National Incident Management System, Principles and Practice, Walsh, Christen, Miller,
Callsen and Maniscalco
LouRomig@jumpstarttriage.com