Mass Casualty & Disaster Triage

Amy Gutman MDprehospitalmd@gmail.com

Overview

• Disasters & MCIs• Triage • Pediatrics • WMD • Incident Command• Lessons Learned

Disasters Are DifferentDisasters Are Different

Defining a Disaster

What Is 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 BuildingOklahoma 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 A single death is a tragedy; a million deaths is a statistic.” deaths is a statistic.” Josef StalinJosef Stalin

• Air Force Base• Airports• Bridges• Chemical Plants• Hospitals• Ohio River• Skyscrapers• Sports Arenas• Train Depot• Universities• Weather

Any Disaster Requires a Any Disaster Requires a Coordinated ResponseCoordinated Response

Disaster “MCI” CategoriesDisaster “MCI” Categories

• I “Expanded Medical Incident”I “Expanded Medical Incident”– >10 critical, <50 patients– Local resources available to treat injured

• II “Major Medical Incident”II “Major Medical Incident”– >50 critical, <200 patients– Regional resources available to treat injured

• III “Disaster”III “Disaster”– >200 patients of any type– Lack of regional resources available to treat injured– State, Federal resources required

MCI Response: Brevard CountyMCI Response: Brevard County

• MCI LEVEL I– County Fire District Chief– 5 ALS units– 5 Fire companies– 2 ALS helicopters– 1 Logistics officer & supply trailer– Communications Chef– 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 III– 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 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 CodesDisaster 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: START: Simple Triage & Rapid TreatmentSimple 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–Minor injuries that can wait for longer periods of time for treatment

• Yellow–Potentially serious injuries, but are stable enough to wait a short while for medical treatment

• Red–Life-threatening but treatable injuries requiring rapid medical attention

• Black–Dead or still with life signs but injuries are incompatible with survival in austere conditions

START Patient Tags

Triage Flow Chart

• Separate walking wounded from others

• Use physiology to assess:– Breathing– Blood flow– Mental status

RESPIRATIONS

Morgue

POSITION AIRWAY

Minor

Under 30/Min.

Over 30/Min.

MENTAL STATUS

PERFUSIONImmediate

Delayed

Can’t Follow Simple Commands

Can Follow Simple Commands

ALL WALKING WOUNDED

Radial Pulse Absent

OR

Capillary RefillNail Bed Press

Over 2 Seconds

Under 2 Seconds

ControlBleeding

YESNO

NO YES

Immediate

Immediate

Immediate

Immediate

RESPIRATIONS

Morgue

POSITION AIRWAY

Minor

Under 30/Min.

Over 30/Min.

YESNO

MENTAL STATUS

PERFUSIONNO YES

Immediate

ALL WALKING WOUNDED

All Walking Wounded Are “Green”

• If not walking & talking, begin assessing life functions

Breathing

• Cannot breathe on own after airway opened = BLACK• Breathing rapidly = RED• Breathing regularly = go to next step in flow chart

Immediate

RESPIRATIONS

Morgue

POSITION AIRWAY

Minor

Under 30/Min.

Over 30/Min.

YESNO

PERFUSIONNO YES

Immediate

ALL WALKING WOUNDED

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 RefillNail Bed Press

Over 2 Seconds

Under 2 Seconds

ControlBleeding

Immediate

Mental Status

• Cannot follow simple command = RED• Can follow simple command = YELLOW• All victims have now completed primary triage

MENTAL STATUS

Delayed

Can’t Follow Simple Commands

Can Follow Simple Commands

Immediate

Pediatric Disaster Triage:JUMPSTART

Walking Wounded = Green

• All green pediatric patients must be immediately re-assessed in secondary triage

• May have been carried to the secondary triage area & have not proven their physiologic stability

• Position the upper airway of the apneic child• If breathing = RED

Breathing

• 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

Perfusion

Ventilation

•If respiratory rate is <15 or >45 = RED

•If respirations are > 15 or <45, move on to next step

• If no palpable pulse = RED

• If pulse is present, move to the next step

Perfusion

• If patient is inappropriately responsive to pain, posturing, or unresponsive = RED

• If patient is alert, responds to voice or appropriately responds to pain = YELLOW

Mental Status

• 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

Nonambulatory Children

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 AllocationResource Allocation

Triage

Transportation

Scene Management Resource Coordination

Scene Assessment & Triage Scene Assessment & Triage PrioritiesPriorities

• 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 Scene Assessment & Triage PrioritiesPriorities

• 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 DecisionsDisaster 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 Walking WoundedWounded

• “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 Delivery of Emergency Medical Services in Disasters: Assumptions & Realities” in Disasters: Assumptions & Realities”

Quarantelli E.

Hospital Arrivals Post 10 Level I-III MCIs

– Ambulance 54%– Private Auto 16%– Police Vehicle 16%– Helicopter 5%– Bus or Taxi 5%– Ambulatory 4%

Number of Casualties

Number of Hospitals Receiving Casualties

Number of Hospitals Capable of

Receiving Casualties

266 4 43

141 4 41

381 12 78

298 11 105

Hospital Distribution of Disaster Casualties (Quarantelli; Delivery of emergency services in disasters: Assumptions and realities)

30 mins Air

130 mins Ground

25 mins Air

100 mins Ground

45 mins Air

180 mins Ground

5 mins Air

25 mins Ground

15 mins Air

45 mins Ground

20 mins Air

70 mins Ground

Scene ManagementScene 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 CommandIncident 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 ResponseIC Disaster Response

• IC coordinates complex inter-relationships to deliver quality, rapid, standardized care

• Philosophy: “Whole is greater than the sum of its parts”

Triage TransportationTreatmentExtrication

Staging

IncidentCommand

Operations

Transportation

HospitalCommunications

Air OperationsLoading

Coordinator

Air Transport & Landing ZoneCoordinator

Medical Fire / Haz Mat

Ground TransportCoordinator

Incident Command

Patient TrackingPatient Tracking

• Hospital Capabilities responsibility of the Transportation Officer

• Patient Tracking responsibility of Ground & Aeromedical Coordinators:– HAvBED– HEICS– HRSA– HERT

SceneScene

• 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

Morgue MedicalSupplies

Immediate

Delayed

Minor

SecondaryTriage

TransportationArea

Entrance From Scene START

Triage

Treatment Area Diagram

SRC & Rest Area

Media Area

Ambulance Loading

LZ

InAmbulance Parking Area

Ou

t

Rest Center

Outer

Inner

Police

SRCTriage

ICS

132

Train Derailment; Wales, 2001 14 Black 12 Red 30 Yellow

38 Green

Morgue

InitialTriage

LZ

IC

Triage

Transport

Four Errors That Cripple Four Errors That Cripple Disaster ResponsesDisaster Responses

• Panic

• Overestimating resource needs

• Limited communications capabilities

• Poor planning or execution

Panic & Overestimating Panic & Overestimating Resource NeedsResource Needs

Resource Assessment: Resource Assessment: You Make The CallYou Make The Call

Taking “Don’t Panic” A Little Too FarTaking “Don’t Panic” A Little Too Far

METHANE MethodMETHANE Method

• MMajor incident Declared

• EExact Location

• TType of incident

• HHazards

• AAccess & Egress

• NNumber of casualties / severity of injuries

• EEmergency services required (personnel & equipment)

Setting Up IC: “CSCATSetting Up IC: “CSCAT33””

• Command

• Safety

• Communication

• Assessment

• Triage

• Treatment

• Transport

Communication FailuresCommunication 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 FailureA 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 IncompatibilityFrequency 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 ResourcesRegional 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-FGHABCDE-FGH

• “No one ever forgets the “ABCDEABCDEs” at the scene, but they always forget the “FGHFGH”….

• ““FF—ing —ing GGet to the et to the HHospital! ospital! DSO Alan Payne

Thank You…Any Questions?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