Triage

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Triage To Sort
Critical for Survival
Dr. Paul K. Carlton, Jr.
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June 22, 2005

• Dr. Paul K. Carlton Presentations
• Triage To Sort
• Current Threats
• Focus on Solutions to Current Threats
• The Pentagon The Rest of the Story
• Blueprints for Collaboration Between the
  Military, Communities, and Health Care Facilities
  in Response to National and Local Disasters

3
Iowa Master Center
Blueprint of the Future Other states to copy
Federal Blueprint
Self Sufficient after 1st round
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Overview

• MIDE
• Marine Barrack Attack October 83
• New Triage Recommendation

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M minimum I
immediate D delayed E
expectant
green
red
yellow
black
START Simple Triage and Rapid Transport
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Triage
Should not transfer disaster from one site to
another
Scene Hospital
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Management of Bombing Casualties
SOMA DEC 93
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Management of Bombing Casualties
Beirut Experience

• Case presentation
• Triage issues
• Management of mass casualty scenario
• Lessons learned, new directions

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Management of Bombing Casualties
Aeromedical Evacuation
USS Guam
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Management of Bombing Casualties
Points to Consider

• Communication with next echelon of care
• diagnosis
  therapy
  
  limited plan for care
• Resource allocation
  
  when and how to use resources
  
  limiting factorsmore physicians than patients
• When to delay and when to treat definitively
• Every provider needs to know perioperative care
  Semper Fi
  marine crashed between case 16 and 17!

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Management of Bombing Casualties
Chronology

• Beirut explosion
  Oct 83
• Investigations continued
  Dec 83
• FAST concept sold to USAFE Aug 84
• Lessons not applied in Desert Storm Feb 91
• 56th MDW fields POC teams
  Jun 94
• Improvements continue to date

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Management of Bombing Casualties
Lessons Learned

• Take care to patients
  dont require them to come to you
• Training is key
  first bloody body should be in training, not
  real world

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Management of Bombing Casualties
Surgical Summary

• 25 major cases in first 24 hours
• 16 take back operations during following 24
  hours
• No deaths
• No permanent disabilities
• No extremities lost

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Management of Bombing Casualties
General Surgeons

• Coordinated all 25 patients and made treatment
  priority decisions
• Operating room
  rotated 5 rooms
  tag team with general and orthopedic
  surgeons

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Management of Bombing Casualties
Orthopedic Surgeons

• Triaged with general surgeons
• Rotated as general surgeons did, in and out of
  operating rooms and preop area

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Management of Bombing Casualties
Operation Room Rotation
1
2
3
4
Preop Holding Area
5
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Management of Bombing Casualties

• Patient Care Specifics
• Every patient had his own physician
• Physician responsible for
• lab
  x-ray
  minor wound care
  his patient

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Management of Bombing Casualties
Pulmonary Blast Injuries

• Semper Fi marine
  ventilator dependent 5 days
• Four others required gt24 h ventilator support

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Management of Bombing Casualties
Regional Medical Assets
Weisbaden 250 beds
Frankfurt (97th GH) 300 beds
Landstuhl 300 beds
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Management of Bombing Casualties
Fog of War

• First airplane (C9)
  24 casualties
  1 died in route
  23 patients arrived
  Landstuhl thoracic
  trauma and head injuries (7)
  Weisbaden filled up with 16
  
• Second airplane (C141)
  expected gt100 casualties plan
  use Landstuhl and Frankfurt
  most dead

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Management of Bombing Casualties
Chronology, Sunday Morning
Beirut Marine barracks bombing

• 0610 Bomb explodes
• 1030 C9 launches for Beirut
• 1800 casualties arrive Rhein Main
• 1830 first load of 8 casualties to Weisbaden
• 1835 second load of 8 casualties to Weisbaden
• 2300 Larnican and Beirut Hospital casualties
  arrive

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Management of Bombing Casualties
Chronology (continued)

• Monday, 1600 All
  primary operations ended (25) Second look
  operations begin
• Tuesday, 1600 Second look operations completed

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Management of Bombing Casualties
Case Presentation
Semper Fi Marine

• 23 year old male
• Severe blast injury
• Multiple fractures (right UE, bilateral LE)
  compartment syndrome
• Depressed skull fracture
• Bilateral TM rupture
• Marked facial swelling

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Semper Fi Always Faithful

• Desperately ill 23 year old male
• 3 extremities crushed
• Face crushed globes not visible
• Pulmonary injury severe
• 16 in OR upgraded from expectant
• 1000 Monday am Commandant arrives to
  see troops

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Semper Fi

• Nurse yells Commandant here to see you
• First flicker of awareness
• Counts stars on shoulder with left hand
• Motions to write
• Semper Fi on back of IO sheet
• Commandant comes unglued!!

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Semper Fi
Black Yellow

• minimum resuscitation
• Pulmonary status addressed

• 16 in OR
• Compartments release
• Wounds debrided
• Back to ICU on vent at 0800 Monday

Engage
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Management of Bombing Casualties
Triage

• Situationally dependent 5 operating rooms
  5 operating room teams
  2 general surgeons 2 orthopedic
  surgeons
• Could engage and treat

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All To Us
M I D delayed E expectant
yellow
black
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Communication
Sempre Fi Marine

• Big Red 1 on IV Bag
• Taped CXR to chest under blanket
• Crush syndrome
• Extremus
• Not resuscitated
• Had to relieve compartment syndrome first then
  resuscitate 6 hour window extended by lack of
  resuscitation

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Communication

• Had not been resuscitated
• WHY?
• Lung injury
• Crush syndrome

• Mandates to proceed
• Relieve compartment syndrome
• Resuscitate
• Balance resuscitation in light of pulmonary injury

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TRIAGE

• Never static
• Always dynamic
• Always dependent on resources

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FIGHTS ON
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TRIAGE

• Different for us than at scene
• 5 operating rooms
• ICU
• Surgeons to proceed
• Sequence commenced and clearly communicated

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TRIAGE

• At scene all yellow or black
• At hospital upgrade to engage
• yellow red
• All compartment syndrome not resuscitated

Allowed luxury of transport
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TRIAGE

• So no swelling in extremities
• Why after more than 12 hours with no fascial
  release no extremities were lost or impaired
• No resuscitation
• As soon as released
• Resuscitated vigorously
• Tremendous swelling

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TRIAGE

• No renal failure
• Trade off with pulmonary dysfunction

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Yellow Red Black
Yellow Yellow
Red
As time and resources allow
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TRIAGE
RED recommended treatment
All went to Cyprus we received in the
middle of the night after stabilization for
transport
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Medical Game in Triage
Resource Allocation
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Semper Fi Always Faithful

• Desperately ill 21 year old male
• 3 extremities crushed
• Face crushed globes not visible
• Pulmonary injury severe
• 16 in OR upgraded from expectant
• 1000 Monday am Commandant arrives to
  see troops

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Semper Fi

• Nurse yells Commandant here to see you
• First flicker of awareness
• Counts stars on shoulder with left hand
• Motions to write
• Semper Fi on back of IO sheet
• Commandant comes unglued!!

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Semper Fi
Black Yellow

• minimum resuscitation
• Pulmonary status addressed

• 16 in OR
• Compartments release
• Wounds debrided
• Back to ICU on vent at 0800 Monday

Engage
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War Wound
Mix of blood and mud is tenacious
Diagnosis only after straight razor shave Very
Different
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Surge
During Surge routine does not stop

• 25 cases
• 23 marines
• 1 peri rectal abscess local area
• 1 appendectomy local area

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Management of Bombing Casualties
Lessons Learned

• Take care to patients
  dont require them to come to you
• Training is key
  first bloody body should be in training, not
  real world

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Lessons Learned

• Triage is situational dependent
• Communication is key whatever is required
• Management of all assets must be created over
  time and distance
• MIDE worked for small number

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Shortcomings of MIDE

• Not evidence based
• Not reproducible team to team
• Does not factor in survival nor deterioration
• Not scalable

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Need of Triage

• Evidence based
• Reliably reproducible
• Based on survival and deterioration rate
• Scalable

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Triage System

• Started addressing fixes in 83
• Dedicated resources and equipment in triage to
  redefine
• 98 Ben Taub in Houston
• Scalable
• Factors to measure
• Reproducible
• Uses computers

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Triage System

• 750 now in database
• Pulse ox not reliable indicator of survival
• Respiratory rate
• Motor responses
• Pulse
• Institute of Surgical Research
  is still accruing patients for
  database

still key
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November 2003

• Given SACCO brief
• Evidence based
• reproducible
• Factored in survival and deterioration
• Scalable

102,000 patients in Pennsylvania Trauma Registry
database
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Not Reproducible
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Evidence Based
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Resource Allocation
For Example
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10 Casualties-MVA RPM 4 -
10 2 8
2 - 6 2 - 3
Disaster
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Availability 1030 14 April
Total Casualties to Transport - 10
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Transport Available
Ambulances 4
(holds 2) Helicopters
1 (holds 2)
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Execute Order Local
When ? Where ? How ?
of Casualties RPM Score
Transport Destination 2
6
Helicopter (2) Ft. Walton 4
10
Ambulance (2) North Okaloosa
(2) Elgin AFB 2
8 Ambulance
(1) Twin Cities
(1) Elgin AFB 2
3 Helicopter
(2) Twin Cities
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Disaster
50 Casualties Multi-MVA RPM
16 10 5 9
3 8 7 7
6 6 4
5 3 4 3
3 3 2
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Regional

• Dothan

• Pensacola

• Panama City

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Availability Regional
10 Casualties
Local
Sacred Heart Baptist Hospital
Pensacola Center ICU Beds
Operating rooms Empty beds
3
3
2
40 Casualties
2
1
3
Regional
6
10
6
Surgeons
2
3
2
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Transport Available
Ambulances 10
(holds 2) Helicopters
3 (holds 2)
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Triage Execute Order
Dynamic Hospital and scene updates constantly
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Triage Execute Order
Dynamic Hospital and scene updates constantly
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Triage Execute Order
Dynamic Hospital and scene updates constantly
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Triage Execute Order
Dynamic Hospital and scene updates constantly
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Triage System

• Plan is logical
• Asset allocation
• Dynamic
• Is time and destination sensitive

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Scalable
This is scalable to optimize resources and
material to casualty numbers
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Disaster
150 Casualties Multi-MVA RPM
25 10 20 9
20 8 15 7
20 6 16 5
19 4 10 3
5 2
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ExtendedRegional

• Dothan

• Panama City

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Availability
Mobile Panama City
Dotham ICU Beds
Operating rooms Empty beds
10
15
8
150 Casualties
4
3
4
Extended Regional
15
18
12
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Transport Available
Ambulances 14
(holds 2) Helicopters
6 (holds 2)
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Extended Regional Area
After local and regional execution transport
to Tallahassee New Orleans Jacksonville Keesl
er
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Execute Order after Local and Regional
When ? Where ? How ?
More capabilities for transport More
capabilities for care All must be
coordinated and all areas need to be prepared for
repetition
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10 Casualties
Okaloosa 50 Casualties
Regional 150 Casualties
Extended Regional 1500 Casualties
Even Larger 15,000 Casualties
Much Larger
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The Probability of Survival and rate of
Deterioration drive triage decisions
How will victims deteriorate over time?
RPM Score 12 11 10 9
8 7 6 5
4 3 2 1 0
Survival Probability .98 .97
.94 .90 .84
.75 .63
.49 .35 .23
.15 .089 .052
Deterioration Rate SLOW

RAPID
Accelerated
minimum
delayed
Resources not stressed
Data 102,000 victims of
blunt and penetrating trauma Source Pennsylvania
Trauma Foundation
immediate
expectant
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The Probability of Survival and rate of
Deterioration drive triage decisions
How will victims deteriorate over time?
RPM Score 12 11 10 9
8 7 6 5
4 3 2 1 0
Survival Probability .94 .90
.84 .75 .63
.49 .35
.23 .15 .089
.052 ? ?
Deterioration Rate SLOW

RAPID
Accelerated
minimum
delayed
Stressed-Survival rates will decrease for the
same injury
Data 102,000 victims of
blunt and penetrating trauma Source Pennsylvania
Trauma Foundation
immediate
expectant
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The Probability of Survival and rate of
Deterioration drive triage decisions
How will victims deteriorate over time?
RPM Score 12 11 10 9
8 7 6 5
4 3 2 1 0
Survival Probability .84 .75
.63 .49 .35
.23 .15
.089 .052 .?
.? .? .?
Deterioration Rate SLOW

RAPID
Accelerated
minimum
Severely stressed-survival rates will decrease
further when casualty numbers are large
delayed
Data 102,000 victims of
blunt and penetrating trauma Source Pennsylvania
Trauma Foundation
immediate
expectant
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System Thinking
We are all in this together!
True Except in Chem/Bio Require different flow
chart
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Flow Chart
Could flow into scene and not away from scene
To Contain Contamination
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The Current Hospital Environment

• Key component of consequence management is timely
  medical care for victims of mass casualty
  incidents
• Incorrect assumptions made about existing
  medicalcapabilities to treat mass casualties
• Hospital surge capacity has never been more
  restricted
• Medical community struggling just to maintain
  everyday capacity
• Majority of preparedness issues are financially
  (revenue vs cost) based
• Without prompt action, the nation carries the
  risk thatvictims of a mass-casualty disaster
  might end up in ambulances to nowhere."

Source Barbera, Macintyre, and DeAtley , Mar
2002
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Ambulances to Nowhere

• Delivery of acute medical care evolved beyond
  ordinary business relationship to "trust" with
  patients
• Trust has extended to current threat
  environment
• Move from individual patient to community as a
  whole
• Financial support to hospitals by community
  create expectation hospitals will address
  community's health/medical needs, including
  disaster preparedness
• Reasonable cost for hospital preparedness for
  mass casualtieswas assumed to be necessary cost
  of doing business
• Financing costs
• Old Medicare and fee for service
• New Managed care payment system (capitation)
• Bottom line Disconnect between expectations and
  funding!

Source Barbera, Macintyre, and DeAtley , Mar
2002
89
Ambulances to Nowhere

• Funding shortfalls
• Decline in government support for public and
  privatehospitals
• Increasing number of expensive, unfunded, or
  under-funded regulatory mandates
• Continued expectation that hospitals will
  maintain highlevels of charity medical care
• National shortage of nurses for acute care
  hospitals, resulting in need for special
  compensation packages to attract personnel
• Results -- closure, downsizing, consolidation,
  reconfiguration, and partnering
• Abolition or downsizing of specialty services
  hurtsdisaster preparedness!

Source Barbera, Macintyre, and DeAtley , Mar
2002
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A Solution?

• Must have alternative funding options!
• Must recognize preparedness for mass casualty
  scenarios is public safety function (similar to
  fire, EMS)
• Economically unjust to expect cost to be borne by
  private-sector business or public medicine
  facilities
• Actual costs of preparedness should be assigned
• To public as a whole or
• To activities/organizations associated with
  increased risk of mass casualties
• Industries dealing in dangerous hazardous
  materials
• Organizations that present an attractive target
  for terrorists
• Organizations with historically higher than
  average risk for mass casualties

Source Barbera, Macintyre, and DeAtley , Mar
2002
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Military

• Medical war fighter
• Obligated to share with civilian colleagues
• Civilians not obligated to listen

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Mars - Venus
Medical war fighter does not speak same language
- MARS Public Health - VENUS Direct Care System -
VENUS New Normalcy We Must Communicate
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SACCO

• SHORTCOMINGS
• No prospective clinical trial
• Iowa could do that trial!!

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Focus on Options

• NERRTC
• DIMO
• TEXAS AM
• SACCO

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Iowa

• Money is in hand
• Responsible to Governor and Federal government
• What is the right sequence for courses,
  exercises, training and teamwork
• Model for Nation!!

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What do we mean by prepared?
the right place on the continuum between
mindless complacency and all consuming paranoia
You Must Define It!
Mindless Complacency
All Consuming Paranoia
Dr. Irwin Redlener, Associate Dean Director
The National Center for Disaster
Preparedness
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Education Training Disaster Life Support
?
Response to Radiological Terrorism
Education
More Specialized
Basic Disaster Life Support Course
Mayo course
?
DIMO
Core Disaster Life Support Course
NERRTC
NERRTC
DIMO
Training
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2 Year Plan Half
life of medical knowledge
2 year plan

• All measurable
• All toward common goal
• All agreed on in advance
• Reassessment occurs yearly -
  intelligent inquiry

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Iowa Master Center
Blueprint for the Future Other states to copy ?
Federal blueprint Self sufficient after 1st
round
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The Future
"The future is not some place we are going, but
one we are creating. The paths are not to be
found, but made, and the activity of making them
changes both the maker and the destination."
Author Unknown
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To obtain a copy of this presentation
www.tamushsc.edu/homeland/
Questions?
Dr Paul K. Carlton, Jr. Lt Gen, USAF, Ret
Director, Homeland
Security The Texas AM University System Health
Science Center