CERT EMERGENCY MEDICAL OPERATIONS

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CERTEMERGENCY MEDICAL OPERATIONS

• Part 1
• Whatcom County Division of Emergency Management

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OBJECTIVES

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

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DISASTER MEDICAL OPERATIONSAssumptions

• The number of victims will exceed local capacity
  for treatment
• Survivors will assist others

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PHASES OF DEATH FROM TRAUMA

• Phase 1 Death within minutes
• Phase 2 Death within several hours
• Phase 3 Death after several days or weeks

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• 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

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CERT REMINDER!

• CERT members MUST take care of themselves before
  caring for others
• Gloves
• Mask
• Goggles
• Pocket Mask

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THE KILLERS

• Airway Obstruction
• Bleeding
• Shock

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AIRWAY
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OBSTRUCTED AIRWAY

• 4-6 minutes until brain death
• Heimlich
• Conscious
• Unconscious
• Most common obstruction is the tongue

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HEAD-TILT/CHIN-LIFT

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

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Pad under shoulders to maintain an open airway
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WHAT IF. . .

• The person doesnt 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.

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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.

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BLEEDING

• Uncontrolled Bleeding is a Killer!
• Three types
• Arterial high pressure, spurts
• Venous low pressure, flows
• Capillary low pressure, oozes

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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.

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BLEEDING CONTROL

• Pressure Dressing
• Pressure Points
• May be combined.
• Not a tourniquet.

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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 patients forehead

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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.

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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

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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

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Earliest Signs of Shock

• Slightly increased rate of breathing - Breaths
  may be shallow
• Slightly increased pulse - pale and cool skin -
  Capillary refill of gt2 seconds
• Restlessness, anxiety, irritability,
  apprehension, inability to follow simple commands

Compensatory Stage
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CERT GOALWatch for subtle signs of early shock

• Slightly increased rate of breathing
• Slightly increased pulse - pale and cool skin
• Restlessness, anxiety, irritability, apprehension

Compensatory Stage
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• Increased, irregular, shallow breaths
• Increased, irregular, weak pulse
• Cool, moist, blue or pale skin
• Dilated pupils
• Listlessness, apathy

Progressive Stage (uncompensated)
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• This patient will die!
• We must do what we can to prevent the condition
  from progressing to this point!

Irreversible Stage
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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)

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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

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DISASTER MEDICAL OPERATIONSOrganization
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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.

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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.

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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.

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PERFORMING TRIAGE
Begin with the first patient located

• 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

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Step 1
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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.
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Step 2
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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.

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Step 3
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PRACTICE TIME

• Turn to your neighbor and perform a shock
  assessment. Look for normal
• R Respirations
• P Pulse/Capillary Refill
• M Mentation

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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

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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.

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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.

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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.

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Whats 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.

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Whats 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

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Whats your call? 2

• An adult kneels at the side of the road, shaking
  his head. He says hes too dizzy to walk.
• Respiratory Rate is 20.
• Capillary Refill is 2 sec.
• Obeys commands.

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Whats your call? 2

• An adult kneels at the side of the road, shaking
  his head. Says hes too dizzy to walk.
• Respiratory Rate is 20.
• Capillary Refill is 2 sec.
• Obeys commands.
• R - OK
• P - OK
• M - OK - but couldnt walk

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Whats your call? 3

• A school aged girl crawls out of the wreckage.
  Shes able to stand and walk toward you crying.
• Jacket and shirt torn.
• No obvious bleeding.

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Whats your call? 3

• A school aged girl crawls out of the wreckage.
  Shes 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

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Whats your call? 4

• A toddler lies with his lower body trapped under
  the vehicle.
• Not breathing with modified jaw thrust and after
  15 ventilations.

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Whats 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

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Whats 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.

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Whats 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

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Whats your call? 6

• A toddler lies among the wreckage.
• Respiratory Rate 50.
• Capillary refill gt 2 seconds.
• Withdraws when touched.

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Whats your call? 6

• A toddler lies among the wreckage.
• Respiratory Rate 50.
• Capillary Refill gt 2 seconds.
• Withdraws when touched.
• R - fast
• P - delayed
• M - inappropriate

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Whats your call? 7

• A woman is carrying a crying infant. She is able
  to walk.
• Respiratory Rate 20.
• Capillary Refill 2 sec.
• Obeys commands.

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Whats 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

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Whats your call? 8

• An infant is carried by mother.
• Hes screaming but the woman quiets him. He
  focuses on mom.
• Respiratory Rate of 34.
• Capillary refill lt 2 seconds.
• No obvious significant external injuries.

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Whats your call? 8

• An infant is carried by mother.
• Hes screaming but the woman quiets him. He
  focuses on mom. Respiratory Rate of 34.
• Capillary refill lt 2 seconds.
• No obvious significant external injuries.
• R - ok
• P - ok
• M - ok

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Whats your call? 9

• School aged boy props himself up.
• Respiratory Rate 28.
• Capillary refill in hands and feet lt 2 sec.
• Answers question and commands.
• Obvious deformity of both lower legs.

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Whats your call? 9

• School aged boy props himself up.
• Respiratory Rate 28.
• Capillary refill in hands and feet lt 2 sec.
• Answers question and commands.
• Obvious deformity of both lower legs.
• R - ok
• P - ok
• M - ok

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Whats your call? 10

• A school aged girl lies among the wreckage.
• Respiratory Rate 40.
• Capillary Refill is 5 seconds.
• Pushes rescuers away.

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Whats 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

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Whats 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 lt 2 seconds.

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Whats 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 lt 2 seconds.
• R - ok
• P - ok
• M - ok

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Whats your call? 12

• An adult male lies at the waters edge.
• No Breathing.
• Continues to not breath with jaw thrust.

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Whats your call? 12

• An adult male lies at the waters edge.
• No Breathing.
• Continues to not breath with jaw thrust.
• R - no
• P - no
• M - no

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Whats your call? 13

• A youngster is up and walking around but is
  limping.
• Alert, crying hysterically for his mother.
• Capillary Refill is immediate.

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Whats 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

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Whats 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.

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Whats 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

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Whats 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.

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Whats 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

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Whats your call? 16

• An adult male lies on the ground.
• Respiratory Rate 20.
• Capillary refill is 2 seconds.
• Obeys commands but cries that he cant move his
  legs.

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Whats your call? 16

• An adult male lies on the ground.
• Respiratory Rate 20.
• Capillary refill is 2 seconds.
• Obeys commands but cries that he cant move his
  legs.
• R - ok
• P - ok
• M - ok

OR
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Whats 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.

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Whats 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

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It can be confusing - but its ok to change your
mind the second time through.
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Next Class

• Search Rescue

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Next Class

• Public Health Considerations
• Disaster Medical Operations
• Establishing Treatment Areas
• More Indepth Patient Evaluations
• Bandaging
• Splinting