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Mass Casualty

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Title: Mass Casualty


1
Mass Casualty Disaster Triage
  • Amy Gutman MD
  • prehospitalmd_at_gmail.com

2
Overview
  • Disasters MCIs
  • Triage
  • Pediatrics
  • WMD
  • Incident Command
  • Lessons Learned

3
Disasters Are Different
  • Defining a Disaster

4
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

5
Murrah Federal Building Oklahoma City, OK 168
dead, gt800 injured
Van vs Train
New Zealand
2 dead, 6 critical, 2 stable patients
6
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

7
Any Disaster Requires a Coordinated Response
8
Disaster MCI Categories
  • I Expanded Medical Incident
  • gt10 critical, lt50 patients
  • Local resources available to treat injured
  • II Major Medical Incident
  • gt50 critical, lt200 patients
  • Regional resources available to treat injured
  • III Disaster
  • gt200 patients of any type
  • Lack of regional resources available to treat
    injured
  • State, Federal resources required

9
MCI 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

10
Disaster Emergency Codes
  • Code Black
  • Bomb Threat
  • Code Gray
  • Severe Weather
  • Code Orange
  • Haz Materials Incident
  • Code Yellow
  • Disaster

11
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

12
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 gt 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

13
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
14
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

15
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

16
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

17
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
  • GCSlt8, burns gt85 BSA, multisystem trauma, signs
    of impending death

18
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

19
Triage Systems
20
Basic Disaster Life Support
  • National Disaster Life Support Education
    Consortium, via Medical College of Georgias
    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

21
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

22
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

23
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

24
START Patient Tags
25
Triage Flow Chart
  • Separate walking wounded from others
  • Use physiology to assess
  • Breathing
  • Blood flow
  • Mental status

26
All Walking Wounded Are Green
  • If not walking talking, begin assessing life
    functions

27
Breathing
  • Cannot breathe on own after airway opened BLACK
  • Breathing rapidly RED
  • Breathing regularly go to next step in flow
    chart

28
Perfusion
  • If radial pulse go to Mental Status
  • If no radial pulse, check capillary refill
  • If refill gt2 secs RED
  • If refill lt3 secs go to Mental Status

29
Mental Status
  • Cannot follow simple command RED
  • Can follow simple command YELLOW
  • All victims have now completed primary triage

30
Pediatric Disaster TriageJUMPSTART
31
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32
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33
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

34
Breathing
  • Position the upper airway of the apneic child
  • If breathing RED

35
Perfusion
  • If the child doesnt start breathing with upper
    airway opening, feel for a pulse
  • If no pulse is palpable BLACK

36
Perfusion
  • If the patient has a pulse, give 5 breaths to
    open the lower airways
  • If no ventilations BLACK
  • If breathing RED

37
Ventilation
  • If respiratory rate is lt15 or gt45 RED
  • If respirations are gt 15 or lt45, move on to next
    step

38
Perfusion
  • If no palpable pulse RED
  • If pulse is present, move to the next step

39
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

40
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

41
Triage in WMD Incidents
42
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

43
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 agents use
  • Very difficult to train maintain readiness with
    multiple agent-specific triage schemes

44
Nerve Agents Triage
  • Red
  • Seizures, multisystem symptoms GI,
    neuromuscular, respiratory excluding eyes
    nose
  • Black
  • Pulseless or apneic, respiratory failure

45
Phosgene Vesicants Triage
  • Red
  • Moderate to severe respiratory distress, only
    when intensive resources are immediately
    available
  • Black
  • Burns gt50 BSA from liquid exposure, signs of
    more than minimal pulmonary involvement, when
    intensive resources are not available

46
Cyanide Triage
  • Red
  • Active seizure or apnea with preserved
    circulation
  • Black
  • No palpable pulse

47
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

48
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

49
Resource Allocation
  • Triage
  • Transportation
  • Scene Management
    Resource Coordination

50
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

51
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)

52
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
  • lt15 injured seriously enough to require hospital
    admission
  • lt6 of hospitals suffered supply shortages
  • lt2 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

53
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 2005331119

54
Delivery of Emergency Medical Services 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

55
Hospital Distribution of Disaster Casualties
(Quarantelli Delivery of emergency services in
disasters Assumptions and realities)
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
56
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 130 mins Ground
45 mins Air 180 mins Ground
57
Scene Management
  • Making Sure the Right Players Come to the Game

58
Dont 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,
    19817)

59
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

60
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
Transportation
Treatment
Extrication
61
Incident Command
Operations
Transportation
Medical
Fire / Haz Mat
Hospital Communications
Air Operations
Loading Coordinator
Air Transport Landing Zone Coordinator
Ground Transport Coordinator
62
Patient Tracking
  • Hospital Capabilities responsibility of the
    Transportation Officer
  • Patient Tracking responsibility of Ground
    Aeromedical Coordinators
  • HAvBED
  • HEICS
  • HRSA
  • HERT

63
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

64
Treatment Area Diagram
Morgue
Medical Supplies
SRC Rest Area
Immediate
Secondary Triage
Transportation Area
Delayed
Minor
Entrance From Scene START Triage
65
Rest Center
In
Outer
Police
Media Area
3
2
Inner
1
SRC
Triage
ICS
LZ
Ambulance Loading
Train Derailment Wales, 2001 14 Black
12 Red 30 Yellow
38 Green
Ambulance Parking Area
Out
66
Morgue
Initial Triage
Triage
Transport
LZ
IC
67
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68
Four Errors That Cripple Disaster Responses
  • Panic
  • Overestimating resource needs
  • Limited communications capabilities
  • Poor planning or execution

69
Panic Overestimating Resource Needs
70
Resource Assessment You Make The Call
71
Taking Dont Panic A Little Too Far
72
METHANE Method
  • Major incident Declared
  • Exact Location
  • Type of incident
  • Hazards
  • Access Egress
  • Number of casualties / severity of injuries
  • Emergency services required (personnel
    equipment)

73
Setting Up IC CSCAT3
  • Command
  • Safety
  • Communication
  • Assessment
  • Triage
  • Treatment
  • Transport

74
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

75
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,
    1977172)

76
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

77
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

78
Summary
  • Understanding basics of Incident Command, triage
    and resource assessment allocation
  • Failing to Plan is Planning to Fail!
  • A words about ABCs

79
ABCDE-FGH
  • No one ever forgets the ABCDEs at the scene,
    but they always forget the FGH.
  • Fing Get to the Hospital! DSO Alan Payne

80
Thank YouAny Questions?
  • prehospitalmd_at_gmail.com

81
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 Moments 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 Carolines, Emergency Care in the Streets,
    Sixth Edition
  • National Incident Management System, Principles
    and Practice, Walsh, Christen, Miller, Callsen
    and Maniscalco
  • LouRomig_at_jumpstarttriage.com
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