smart system & start triage bureau of emergency medical services new york state department of...

SMART System & SMART System & START Triage START Triage

Bureau of Emergency Medical Services

New York State Department of Health Jim Soto

Associate Director

Objectives: Objectives:

• What is an MCI ?What is an MCI ?

• Review Incident Management Review Incident Management from EMS perspectivefrom EMS perspective

•Review Triage & Practice STARTReview Triage & Practice START

What is the Goal of MCI What is the Goal of MCI Management?Management?

EMS GOAL:

TO SAVE THE LARGEST NUMBER OF SURVIVORS

FROM A MULTIPLE CASUALTY INCIDENT

What is an MCI Scene?What is an MCI Scene?

What are some Common What are some Common things affecting your MCI things affecting your MCI

response?response?• Typical staffing of your ambulance Typical staffing of your ambulance

service?service?

• What does EMS routinely do daily? What does EMS routinely do daily?

• How do you handle the following?How do you handle the following?– 4 victims in a two car “head-on”4 victims in a two car “head-on”– 17 victims in a “team” van17 victims in a “team” van– 43 victims on a school bus43 victims on a school bus– 350 victims on a train350 victims on a train

So what do you have to think about? So what do you have to think about?

TREATMENT

IMMODIUM

COMMAND

TRIAGE STAGING

COMMUNICATIONS

SAFETY

ASSESSMENT

THE INITIAL PROBLEM ON SCENETHE INITIAL PROBLEM ON SCENE

Casualties Resources


THE OBJECTIVETHE OBJECTIVE

BUT - HOW IS EMS BUT - HOW IS EMS TRAINED?TRAINED?

• BLS, ALSBLS, ALS

• CPR, ACLS, PALSCPR, ACLS, PALS

• PHTLS, BTLSPHTLS, BTLS

• CFR, EMT, EMT-I, EMT-CC, EMT-PCFR, EMT, EMT-I, EMT-CC, EMT-P

How many patients are you taught How many patients are you taught to treat at one time? to treat at one time?

WHAT CHANGES WHEN YOU WHAT CHANGES WHEN YOU HAVE AN MCI ? HAVE AN MCI ?

• What are my resources? What are my resources?

• Who is a Patient? Who is a Patient?

• Which Patient do I treat first?Which Patient do I treat first?

• Who can be salvaged? Who can be salvaged?

• Who gets transported first?Who gets transported first?

• Who needs a Trauma/Specialty Center? Who needs a Trauma/Specialty Center?

• Who can help care for others? Who can help care for others?

ARRIVAL OF REQUESTED ARRIVAL OF REQUESTED RESOURCESRESOURCES

TIME IS IMPORTANTTIME IS IMPORTANT

THE GOLDEN HOURTHE GOLDEN HOUR““The critical trauma patient has only 60The critical trauma patient has only 60

minutes from theminutes from the time of injurytime of injury to reachto reach

definitive surgical care, or the odds ofdefinitive surgical care, or the odds of

a successful recovery diminisha successful recovery diminish

dramatically”.dramatically”.

Pre-Hospital Trauma Life Support, Second Edition,Pre-Hospital Trauma Life Support, Second Edition,

Patient Assessment and Management, page 42. 1990Patient Assessment and Management, page 42. 1990..

TIME IS VERY TIME IS VERY IMPORTANTIMPORTANT

Balancing ActBalancing Act


Time Management

Management

== Maximum survivorsMaximum survivors


++

SCENE MANAGEMENTSCENE MANAGEMENT

The Scene

TIMETIME

Command Command

Safety Safety

Assessment Assessment

Communication Communication

Triage Triage

TreatmentTreatment

TransportTransportDefinitive

Care

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MEN

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Scene ManagementScene Management

• CommandCommandWho is in Charge?Who is in Charge?

Who is in charge of Who is in charge of what?what?

Who is going to do Who is going to do what? what?

Who else needs to be Who else needs to be here?here?

EMS is generally in EMS is generally in Operations (Ops)Operations (Ops)

• SafetySafetyIs there a hazard or Is there a hazard or

threat?threat?

Should I be here? Should I be here?

Am I protected? Am I protected?

What should I worry What should I worry about? about?


• AssessmentAssessmentWhat is going on? What is going on? How big is this, how How big is this, how

many people?many people?What do I need?What do I need?How does what I do How does what I do

affect others? affect others? What are they doing What are they doing

that can affect me? that can affect me?

• CommunicationsCommunicationsWho needs to know? Who needs to know? What do they need What do they need

to know? to know? Does Command & Does Command &

Ops know? Ops know? Do the other players Do the other players

know? know?


• TriageTriage

Who is doing it?Who is doing it?

Where are they Where are they doing it?doing it?

What are they What are they finding?finding?

• TreatmentTreatment

What the typical EMS What the typical EMS provider comes provider comes “preloaded” with…“preloaded” with…

How to organize?How to organize?

How much can we How much can we do? do?


TransportTransport• Who is doing it?Who is doing it?

• From where are they doing From where are they doing it?it?

• Where are the patients Where are the patients going? going?

• How many patients going How many patients going where?where?

““Large scale triage is the hardest job anyone in Large scale triage is the hardest job anyone in pre-hospital care will ever do”.pre-hospital care will ever do”.

A.J Heightman, Mass Casualty Incident Management. A.J Heightman, Mass Casualty Incident Management.

A practical approach to solving complex operational dilemmas.A practical approach to solving complex operational dilemmas.

TRIAGETRIAGE

Casualties exceed the number Casualties exceed the number of skilled rescuers.of skilled rescuers.

TRIAGETRIAGE

WHEN ?WHEN ?

Types of TriageTypes of Triage

• PrimaryPrimary– On Scene prior to movementOn Scene prior to movement

• SecondarySecondary– Incident dependant, probably prior to or Incident dependant, probably prior to or

during transportduring transport

TRIAGE CODINGTRIAGE CODING

ImmediateImmediate 1 1

UrgentUrgent 2 2

DelayedDelayed 3 3

DeadDead 0 0

RED

Yellow

Green

Black

ColorColorPriority Priority TreatmentTreatment

TRIAGE TAGS TRIAGE TAGS

What is the What is the same ?same ?

What is What is improved ?improved ?

What is different ?What is different ?

Triage Protocol (START) Triage Protocol (START)

PRIMARY TRIAGEPRIMARY TRIAGE

The Scene


The first attempt at balancing EMS resources and

casualties / injured


Determining whether there is an

airway and breathing


If breathing, at what rate & is it good enough?


They have an airway, and are breathing.

Are they circulating blood sufficiently?

Circulatory Check…Circulatory Check…


A

B

C

Mental Status

PEDIATRIC TRIAGEPEDIATRIC TRIAGE

Children are involved in multiple casualty incidents.

The over prioritizing of children will take valuable resources away from more seriously injured adults.

Triage systems based on adult physiology will not provide accurate triage.

SMART Pediatric TapeSMART Pediatric Tape

• Developed by Pediatricians to Developed by Pediatricians to use the existing START protocol use the existing START protocol but modified to reflect but modified to reflect appropriate values for pediatric appropriate values for pediatric respirations and circulation. respirations and circulation.

START START

Triage Protocol (START)Triage Protocol (START)

STARTSTART EXERCISE EXERCISE

• Female, 30’s, walkingFemale, 30’s, walking

• Female, teens, walking, pale, complaining Female, teens, walking, pale, complaining of severe abdominal painof severe abdominal pain

• Male, teens, walking, confusedMale, teens, walking, confused

• Male, teens, you open airway, does not Male, teens, you open airway, does not breathebreathe

• Male, 20’s, unconscious, breathing, RR 36, Male, 20’s, unconscious, breathing, RR 36, radial pulse absent radial pulse absent

• Male, 20’s, holding left ankle, cannot walk, Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructionsRR 20, CRT 1, responds to instructions

1


• Female, 30’s, Female, 30’s, walkingwalking• Female, teens, Female, teens, walkingwalking, pale, complaining of , pale, complaining of

severe abdominal painsevere abdominal pain

• Male, teens, Male, teens, walkingwalking, confused, confused

• Male, teens, you Male, teens, you open airway, does not open airway, does not breathebreathe

• Male, 20’s, unconscious, breathing, Male, 20’s, unconscious, breathing, RR 36, RR 36, radial pulse absentradial pulse absent

• Male, 20’s, holding left ankle, Male, 20’s, holding left ankle, cannot walkcannot walk, , RR 20RR 20, , CRT 1CRT 1, , responds to instructionsresponds to instructions

1 A


• Female, 60’s, fracture LL leg, cannot walk, RR Female, 60’s, fracture LL leg, cannot walk, RR 25, CRT 1, obeys commands25, CRT 1, obeys commands

• Male, 30’s, you open airway, does not breatheMale, 30’s, you open airway, does not breathe• Male, 30’s, lying on ground, breathing, Male, 30’s, lying on ground, breathing,

gurgling sounds, RR 37, pulse absent, gurgling sounds, RR 37, pulse absent, unresponsiveunresponsive

• Male, 50’s, you open airway, does not breatheMale, 50’s, you open airway, does not breathe• Male, child, 75 cm, not alert, breathing, RR Male, child, 75 cm, not alert, breathing, RR

30, CRT 2.5, pulse 100 30, CRT 2.5, pulse 100 • Male, child, 130 cm, not walking, breathing, Male, child, 130 cm, not walking, breathing,

RR 24 CRT 1RR 24 CRT 12


• Female, 60’s, fracture LL leg, Female, 60’s, fracture LL leg, cannot walk,cannot walk, RR RR 25, CRT 1, obeys commands25, CRT 1, obeys commands

• Male, 30’s, you Male, 30’s, you open airway, does not open airway, does not breathebreathe

• Male, 30’s, lying on ground, breathing, gurgling Male, 30’s, lying on ground, breathing, gurgling sounds, sounds, RR 37RR 37, , pulse absentpulse absent, , unresponsiveunresponsive

• Male, 50’s, you Male, 50’s, you open airway, does not open airway, does not breathebreathe

• Male, child, Male, child, 75 cm75 cm, not alert, , not alert, breathingbreathing, , RR 30RR 30, , CRT 2.5, pulse 100CRT 2.5, pulse 100

• Male, child, Male, child, 130 cm130 cm, not walking, , not walking, breathing, breathing, RR 24 CRT 1RR 24 CRT 1

2 A


• Female, child, 145 cm, lying on ground Female, child, 145 cm, lying on ground holding chest, breathing with gurgling holding chest, breathing with gurgling sounds, RR 37, sounds, RR 37,

CRT 3CRT 3

• Female, child, 47 cm, breathing, Female, child, 47 cm, breathing, crying, pulse 160 crying, pulse 160

3


• Female, child, Female, child, 145 cm145 cm, lying on , lying on ground holding chest, breathing with ground holding chest, breathing with gurgling sounds, gurgling sounds, RR 37, CRT 3RR 37, CRT 3

• Female, child, Female, child, 47 cm47 cm, breathing, , breathing, crying, pulse 160 crying, pulse 160

3 A

SECONDARY SECONDARY TRIAGETRIAGE

SECONDARY TRIAGESECONDARY TRIAGE

• PurposePurpose– Determine among like priority category, Determine among like priority category,

higher priority patienthigher priority patient

• When does it happen? When does it happen? – Generally on extended duration eventsGenerally on extended duration events– If treatment areas are established, there If treatment areas are established, there

will likely be a need for Secondary will likely be a need for Secondary Triage before transportTriage before transport

SECONDARY TRIAGESECONDARY TRIAGE

SCENE MANAGEMENTSCENE MANAGEMENT

The Scene

TIMETIME

Command Command

Safety Safety

Assessment Assessment

Communication Communication

Triage Triage

TreatmentTreatment

TransportTransportDefinitive

Care

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Tools to help manageTools to help manage

• Use of ICSUse of ICS• FOGs and SOGsFOGs and SOGs

– Field Operations GuidesField Operations Guides– Standard Operations GuidesStandard Operations Guides

• Command BoardsCommand Boards• CommunicationsCommunications

– Radios / Cellular, etcRadios / Cellular, etc– VerbalVerbal– DocumentationDocumentation

• Scribes/RunnersScribes/Runners

Tools to Organize Tools to Organize

SMART COMMANDER SMART COMMANDER ™™

EMS INCIDENT EMS INCIDENT MANAGEMENT MANAGEMENT

SMART COMMANDER SMART COMMANDER ™™• Organization for:Organization for:

– Command, Control, CoordinationCommand, Control, Coordination• Provides:Provides:

– Overall Incident Management TeamOverall Incident Management Team– EMS Operations SpecificsEMS Operations Specifics– Incident CommunicationsIncident Communications– WeatherWeather– HazardsHazards– Primary Triage StatusPrimary Triage Status– Destination Capability & Patient Destination Capability & Patient

Distribution Distribution

SMART Commander - EMSSMART Commander - EMS

Incident Management

Team

EMS Operations

ICS – 205

Communications Plan

Incident Weather

Conditions

Incident Hazards

Triage Team & Casualty

Status

Hospital Capability &

Patient Distribution

SUMMARYSUMMARYMCI’s require:MCI’s require:• Change of EMS provider’s approachChange of EMS provider’s approach

– Single Pt. vs. Multiple Pts.Single Pt. vs. Multiple Pts.• Applying limited resources effectively & timelyApplying limited resources effectively & timely

– Incident & Time Management Incident & Time Management • Organizing, Coordinating & Communicating in Organizing, Coordinating & Communicating in

EMS OperationsEMS Operations• Accountability of resources & patientsAccountability of resources & patients

– Who is doing what & how many patients do you haveWho is doing what & how many patients do you have• Appropriate distribution & destinationsAppropriate distribution & destinations

– Where are they going & why? Where are they going & why? • After Action After Action

– Lessons Learned & Review of Existing plans Lessons Learned & Review of Existing plans

From Triage to Treatment From Triage to Treatment AreasAreas

Incident Triage Treatment

Search & Rescue

Triage Team(s)

Urgent

Immediate

Morgue

Delayed

From Treatment to Definitive From Treatment to Definitive Care Care

Treatment Transport Definitive Care

Urgent

Immediate

Delayed

Ambulances, Ambulettes, Buses, etc

Ambulances

Appropriate Facility

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smart system & start triage bureau of emergency medical services new york state department of...

Documents

objective slide

important slide

train slide

mci scene

goal of mci management

ems goal

patient assessment

time of injury