Mass Casualty

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Mass Casualty Disaster Triage

• Amy Gutman MD
• prehospitalmd_at_gmail.com

2
Overview

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

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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

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

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Any Disaster Requires a Coordinated Response
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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

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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

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Disaster Emergency Codes

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

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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

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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

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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
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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

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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

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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

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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

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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

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Triage Systems
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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

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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

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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

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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

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START Patient Tags
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Triage Flow Chart

• Separate walking wounded from others
• Use physiology to assess
• Breathing
• Blood flow
• Mental status

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All Walking Wounded Are Green

• If not walking talking, begin assessing life
  functions

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Breathing

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

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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

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Mental Status

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

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Pediatric Disaster TriageJUMPSTART
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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

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Breathing

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

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Perfusion

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

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Perfusion

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

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Ventilation

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

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Perfusion

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

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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

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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

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Triage in WMD Incidents
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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

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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

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Nerve Agents Triage

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

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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

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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

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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

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Resource Allocation

• Triage
• Transportation
• Scene Management
  Resource Coordination

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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

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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)

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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

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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

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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

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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
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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
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Scene Management

• Making Sure the Right Players Come to the Game

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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)

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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

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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
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Incident Command
Operations
Transportation
Medical
Fire / Haz Mat
Hospital Communications
Air Operations
Loading Coordinator
Air Transport Landing Zone Coordinator
Ground Transport Coordinator
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Patient Tracking

• Hospital Capabilities responsibility of the
  Transportation Officer
• Patient Tracking responsibility of Ground
  Aeromedical Coordinators
• HAvBED
• HEICS
• HRSA
• HERT

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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

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Treatment Area Diagram
Morgue
Medical Supplies
SRC Rest Area
Immediate
Secondary Triage
Transportation Area
Delayed
Minor
Entrance From Scene START Triage
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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
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Morgue
Initial Triage
Triage
Transport
LZ
IC
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Four Errors That Cripple Disaster Responses

• Panic
• Overestimating resource needs
• Limited communications capabilities
• Poor planning or execution

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Panic Overestimating Resource Needs
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Resource Assessment You Make The Call
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Taking Dont Panic A Little Too Far
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METHANE Method

• Major incident Declared
• Exact Location
• Type of incident
• Hazards
• Access Egress
• Number of casualties / severity of injuries
• Emergency services required (personnel
  equipment)

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Setting Up IC CSCAT3

• Command
• Safety
• Communication
• Assessment
• Triage
• Treatment
• Transport

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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

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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)

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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

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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

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Summary

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

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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

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Thank YouAny Questions?

• prehospitalmd_at_gmail.com

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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