tx ems 20081 mci triage: a cure for a massive headache ronna g. miller, md ems/disaster...

TX EMS 2008 1

MCI Triage: A “Cure”

For A MASSive Headache

Ronna G. Miller, MDEMS/Disaster Medicine/Homeland Security Section

UT Southwestern Department of [email protected]

Texas EMS Conference 2008

TX EMS 2008 2

The Fine Print Successful completion of this activity is based upon

your attendance for the entire presentation. The presenter has no commercial support, or other

affiliations relating to a possible conflict of interest to disclose.

There will be no discussion of off-label usage or product endorsement during this course.

The content of this presentation is designed for educational purposes only.

The author has made every effort to verify the information presented, but neither the accuracy nor the completeness of this information can be guaranteed.

The participant assumes all risks in using the information.

The author shall not be held responsible for errors or omissions or held liable for any damages incurred as a result of use or reliance upon the material presented.

TX EMS 2008 3

ObjectivesDefine “MCI” and “Triage”Discuss goals of MCI triagePerform simulated “MASS” Triage Classify simulated MCI victims by

“ID-me” categoriesDescribe life-saving interventions

during MCI victim triageIdentify specific all-hazards triage

concerns

TX EMS 2008 4

Brief questionnaireInteractive mass cal simulation: Part

1Didactic presentationInteractive mass cal simulation: Part

2

The Plan

TX EMS 2008 5

Question 1

Which of the following best describes you?

A. ECAB. EMT-BC. EMT-ID. EMT-PE. PhysicianF. RNG. Other

TX EMS 2008 6

Question 2

Which best describes the geographical area where you work?

A. RuralB. SuburbanC. Urban (city < 100,000)D. Urban (city ≥ 100,000)E. None of the above

TX EMS 2008 7

Question 3

Which one of the following is your primary type of EMS/healthcare service?

A. Rural EMS (non-transporting)B. Rural EMS (transporting)C. Urban-Fire/EMSD. Urban-”Third Service” EMSE. AeromedicalF. Interfacility Transport OnlyG. Hospital-BasedH. StudentI. RetiredJ. Other

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Question 4

How long have you worked in EMS/healthcare?

A. Less than 2 yearsB. 2 to 5 yearsC. 5 to 10 yearsD. 10 to 15 yearsE. More than 15 years

TX EMS 2008 9

Question 5

Have you ever had formal classroom training in mass casualty triage?

A. YesB. No

TX EMS 2008 10

Question 6

Have you ever participated in a hands-on mass casualty simulation or drill in which you triaged “victims”?

A. YesB. No

TX EMS 2008 11

Question 7

Have you ever had to triage patients in an actual mass casualty incident?

A. YesB. No

TX EMS 2008 12

Question 8 If yes, what triage method or

system did you use during that incident?

A. I answered “No” to Question 7B. MASSC. STARTD. SAVEE. Sacco®

F. MilitaryG. Other H. Don’t Know

TX EMS 2008 13

Question 9

If yes, did you feel confident in your triage decisions during that incident?

A. I answered “No” to Question 7B. YesC. No

TX EMS 2008 14

Question 10

Did you participate in relief efforts to provide medical care to evacuees after Hurricanes Katrina or Rita?

A. YesB. No

TX EMS 2008 15

Question 11

Is knowing how to perform mass casualty triage part of your professional responsibilities?

A. YesB. No

TX EMS 2008 16

Question 12

What is the likelihood, in your opinion, that you would ever be called upon to perform mass casualty triage in the future?

A. Very likelyB. LikelyC. NeutralD. UnlikelyE. Very unlikely

TX EMS 2008 17

Question 13

If there were an explosion at this location right now, how confident are you that you would be able to rapidly and accurately triage victims?

A. Very confidentB. Somewhat confidentC. NeutralD. Somewhat unsureE. Very unsure

TX EMS 2008 18

Let’s Begin!

TX EMS 2008 19

TX EMS 2008 20

Victim 1

Into which category would you triage this patient?

A. IMMEDIATEB. DELAYEDC. MINIMALD. EXPECTANT

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Victim 2



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Victim 3



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Victim 4



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Victim 5



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Victim 6



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Victim 7



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Victim 8



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Victim 9



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Victim 10



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Victim 11



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Victim 12



TX EMS 2008 32

MCI Triage: A “Cure”

For A MASSive Headache

Ronna G. Miller, MDEMS/Disaster Medicine/Homeland Security Section

UT Southwestern Department of [email protected]

Texas EMS Conference 2008

TX EMS 2008 33

This is NOT a good thing!

TX EMS 2008 34

“Why Am I Here?”

How do I decide who receives care now and who does not?

In a disaster, needs exceed resources

More patients than providersDifficult choices must be made

1942, Boston, MA 492 dead

2003, Warwick, RI 100 dead

IS TRIAGE NEEDED HERE?

Boston Globe

AP Photo

AP Photo

Boston Globe

TX EMS 2008 36

www.masada2000.orgAP photo: Matt Slocum

September 23, 2005Wilmer, TX

August 2, 1985Dallas, TX

“Triage Typically Means “Trauma””

TX EMS 2008 37

Add Photos

London?Madrid?LA train?NYC crane?

TX EMS 2008 38

What About Medical Triage?

TX EMS 2008 39

Triage:“It’s not in my job

description!”

http://www.ahrq.gov/prep/cbrne/

TX EMS 2008 40

Business As Usual

Resources exceed demand

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The “Perfect World” of MCI Response

First responders respond to scenePatients are triaged in the fieldHazMat handles decon in the fieldSickest patients arrive with EMS:

Already sorted and tagged Already decontaminated Already partially treated

Hospitals “only” need to care for them...

TX EMS 2008 42

What REALLY Happens...

“Chaotic” phase: 15-25 min

No EMS, no scene leader 80% of minimally injured

self-transport They arrive at closest

hospitals: NO TRIAGE NO DECONTAMINATION NO MEDICAL

INTERVENTION

TX EMS 2008 43

Mass Casualty Predictor

http://www.bt.cdc.gov/masscasualties/predictor.asp

TX EMS 2008 44

Another Awful Thought...

Hospital as “Hot Zone”

Or....

It’s your “off” day

Or…

Flu Pandemic, Bioterrorism…

TX EMS 2008 45

Definitions

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MCI: Definition

Mass Casualty IncidentMajor Casualty IncidentMultiple Casualty Incident

Healthcare needs exceed resources!

Resources must be rationed!

Adapted from Heightman AJ (2006). JEMS 31(4):16.

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Your Own Safety Comes First!

We all want to helpTriage is an important partHowever, your first priority is to

PROTECT YOURSELF!You don’t need to die!

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Before Any Casualty Care...

“Scene Size-Up” – “Scene Safety”Incident Survey BEFORE Casualty

Survey

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“RED Survey”

“Rapid Evaluation of Disaster” Incident Survey

BEFORE patient care!Casualty SurveyLife-saving Interventions

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All-Hazards: DefinitionMan-made or natural events with

destructive capability for multiple casualties

Graniteville, SC – January 2005 La Conchita, CA – January 2005

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“All-Hazards” Examples

NaturalEarthquakesLandslides & AvalanchesVolcanoesTornadoesHurricanesFloods & Flash FloodsTsunamisWildfiresEmerging Infectious

Diseases

Man-madeStructure FiresStructure CollapsesExplosive DevicesTransportation Events: Air, Rail, Roadway, WaterIndustrial HazMat EventsTerrorism Incidents: CBRNE events, Firearms

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Triage: Definition

Sorting of patients by

seriousness of condition and likelihood of

survival

www.learnovation.com

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Triage Levels

Primary (scene & hospital) Physiology:

Can patient use his own resources to deal w/injuries? Which conditions will benefit from use of scarce

resources? Secondary (scene & hospital)

Match patients’ current & anticipated needs with available resources

Physiology, Physical Assessment, Initial Treatment & Reassessment, Knowledge of Resource Availability

Tertiary (hospital) Optimize individual outcome

Higher-level Treatment & Reassessment, Further Resource Assessment, Determination of Best Venue for Definitive Care

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Triage: History“Trier”: French for “to sort”18th century European battlefieldsOriginal military goal:

Return to combat as many soldiers as possible

http://nmhm.washingtondc.museum/

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Triage: Goals

Primary Goal: Greatest good for the greatest

number of possible survivors: maximize survival

Secondary Goals:Relief of sufferingEfficient resource allocation

Depend on available resources

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Factors That Impact Resource Availability

Volume and severity of patientsLimited numbers of providersInfrastructure limitationsInadequate hazard preparation

(HAZMAT, etc.)Limited transport capabilities Multiple-jurisdictional responseLack of hospital surge capacity

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Triage Systems

Multiple triage systems in useVarious methods using tags,

categories, colors, symbols Familiarize yourself with your

agency’s system and PRACTICE itIDEAL = one uniform system used by

all agencies in the field & at hospitals

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Why Triage?

System tool to bring order from chaos

Get care for those who need it most and are most likely to benefit

Aids resource allocationObjective framework for

stressful & emotional decisionsIncreases provider efficiency &

effectiveness

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The “Ideal” Triage System?

Simplicity Easy to remember Easy to use

ObjectivityAccuracyAbility to process large numbers

of victims(Evidence-based)

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Underlying Parameters

Life, limb or vision threatLevel of medical intervention

needed(Access to transportation)

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Triage Process

GROUPSORTTRANSPORT

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“M.A.S.S.” Triage

M – MoveA – AssessS – SortS – Send

www.triagetags.com www.triagetags.com

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M – MoveA – AssessS – SortS – Send

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“ID-me” Categories

I - IMMEDIATED - DELAYEDM - MINIMAL

D - DEAD

EXPECTANTLETHAL INJURY E - EXPECTANT

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Tested & used by the militaryAdapted for civilian disastersIt works!

Fast Accurate Large numbers of victims

You needn’t be an “expert” to help!

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1.GROUP victims first...then....

2.SORT individual victimsthen...

3.TRANSPORT

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Basis of “M.A.S.S.” Triage

Ability to move best predicts outcomeGlasgow Coma Scale

Motor component

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“MOVE”: STEP 1Goal:

Group - Victims who can WALKAction:

“Everyone who can hear me and who can walk, please move to the area with the green flag.”

Identifies: MINIMAL group

MINIMAL

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Why Bother with Them FIRST?

MINIMAL group: major vital functions intact Assess last, after more critical

groupsHowever, actively managing this

group may: Facilitate scene management Conserve scene resources Reduce self-transports & overburdening

of nearest hospital ERs

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“MOVE”: STEP 2Goal:

Group – Victims who can’t walk, but who can MOVE

Action: Ask the remaining victims “Everyone

who can hear me and needs help, please raise an arm or leg so we can come help you.”

Identifies: DELAYED Group

DELAYED

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“ASSESS”:Goal:

Group – Identify who is left, victims unable to walk & unable to follow simple commands to move

Action:Go immediately to these patients for life-saving interventions (if medically trained)

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“M.A.S.S.” Triage“ASSESS” IMMEDIATE

patients: Open Airway

Stop Bleeding

Give Chemical antidote

Decompress TPtx

www.rk19-bielefeld-mitte.de

www.tpub.com

www.meridianmeds.com

www.trauma.org

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“ASSESS” IMMEDIATE patients: Open AirwayStop Bleeding Give Chemical antidote Pressure Points

Tourniquets

Whatever it takes! Be creative!

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“M.A.S.S.” Triage“ASSESS” IMMEDIATE

patients:Question:

Is transport available?

Move on!

www.usmc.mil/marinelink/mcn2000

TX EMS 2008 76

Victim Group Summary

Goal Action ID-me Group

Group ambulatory patients

“Everyone who can hear me and needs medical attention, move to the area with the green flag”

Minimal

Group awake, can follow commands

“Everyone who can hear me, raise an arm or leg so we can come help you”

Delayed

Identify who is left

Go immediately to these patients for life-saving interventions

Immediate

TX EMS 2008 77

In Other Words...

GREEN: “First Aid”, “DIY”YELLOW: Get thee to a doctor

soonRED: Gonna’ die without

immediate care

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“ID-me” and NATO Categories

COLOR “ID-me” NATO Priority

RED Immediate 1

YELLOW Delayed 2

GREEN Minimal 3

BLACK Expectant DEAD

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ONLY NOW Do We Assess Individuals

Having grouped victims according to their ability to move...

...The next phase entails more detailed individual assessment.

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“M.A.S.S.” Triage“SORT”:Goal:

Sort patients via INDIVIDUAL assessment

Actions: Assign to “ID-me” Categories:

IMMEDIATE, DELAYED, MINIMAL, Continue treatment

EXPECTANT

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“SORT”:Ideally: trained medical

personnel May not be available

Begin with those who didn’t move

Tag immediately upon triage Including dead victims

TX EMS 2008 83

CERT L.A. 2003

There Are Many Different

Patient Assessment Tools

www.usmc.mil/marinelink/mcn2000

TX EMS 2008 84

“R”

“P”

“M”

STARTTriage

TX EMS 2008 85

START Mnemonic

RPM

302Can Do

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START Limitations?

Do you have time to count RR for full minute?

Can you measure CRT in the dark, in the cold, or in a contaminated patient?

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Sacco Triage Method (STM)

http://www.sharpthinkers.com/abc/ts_approach_triss.htm

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Non-ambulatoryNon-moving

RespirationsBreathing?

Position airway

NO

YES

YES

Too fast?Too slow?

>6 & <30

Pulse (radial)Palpable?

NO

YES NO

Mental StatusFollows commands?

MINIMAL(Already identified

&grouped separately)

YES

NO

DELAYED

IMMEDIATE EXPECTANT

SimplifiedTriage

As needed:Bleeding control

Chemical antidotesDecompress chest

TX EMS 2008 89

ATLS®

“Sift” and “Sieve”

Advanced Trauma Life Support for Doctors – Student Course Manual

7th Edition American College of Surgeons,

Chicago, IL, 2004

TX EMS 2008 90

BTLS/ITLS

BTLS, 5th EditionCampbell JE

Brady – Prentice Hall, New Jersey, 2004

TX EMS 2008 91

“M.A.S.S.” Triage“SORT”:Goal:

Sort patients based upon INDIVIDUAL assessment

Actions:“ID-me”:

IMMEDIATE, DELAYED, MINIMAL, , DEAD

Continue treatment

EXPECTANT

TX EMS 2008 92


“SORT”:Ideally: trained medical

personnel May not be available

Begin with those who didn’t move

Tag immediately upon triage Including dead victims

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“ID-me” Categories

I - IMMEDIATED - DELAYEDM - MINIMAL

EXPECTANTLETHAL INJURY

E - EXPECTANT

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“SORT” – IMMEDIATE: Life- or Limb-threatening injury Airway, Breathing or Circulation

Problem Unconscious Examples:

Unresponsive, altered level of consciousness, severe breathing difficulty, uncontrollable bleeding, amputations above elbow or knee, cyanosis, rapid or weak pulse, open abdominal wounds, etc.

TX EMS 2008 95


“SORT” – DELAYED:Need definitive medical care, but

should not worsen rapidly, if initial care is delayed

Examples: Deep cuts or open fractures with

controlled bleeding and strong pulses, finger amputations, abdominal injuries with stable vital signs, closed head injuries without altered LOC, etc.

TX EMS 2008 96


“SORT” – MINIMAL:“Walking wounded”Group, sort & facilitate transport

from sceneVolunteer help? Risk vs. BenefitExamples:

Abrasions, contusions, minor lacerations, no apparent injuries

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“SORT” – :Most severely injuredLittle chance of survival“Expected” to die soonIn a perfect world, they would receive

the most care, even though chance of survival is low

In an MCI....

EXPECTANT

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“SORT” – :Care resources NOT utilized

initiallyComfort care as available

Death could be hours or days away!

Reassessment & transport Transport those still alive after

all IMMEDIATE victims evacuated Resuscitate & treat as resources

allow

EXPECTANT

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“M.A.S.S.” Triage“SORT” – :Examples:

Near 100 % TBSA burns Fatal radiation doses Apnea or pulselessness

Especially if multiple injuries Severe open brain injury Death “imminent”

“Judgment call”

EXPECTANT

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Triage Category Summary

RED: life-threatening but treatable

YELLOW: potentially serious, but can wait a while

GREEN: minor injuries can wait longer

BLACK: life signs present, but “expected” to die under disaster conditions

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Triage Caveats

OVER-TRIAGE: Urge to classify all victims as

IMMEDIATEDefeats the purpose!

Ruptured eardrums, chronic hearing loss, language barrier, developmental handicaps, etc.Cannot respond to “MASS” commands

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Other Triage Caveats

UNDER-TRIAGE: Initial grouping ≠ individual

assessment Worsening patient conditions:

Internal or external bleeding, shock Closed head injury Blast injury to lung, gut, brain Airway swelling Delayed chemical exposure symptom

onset Etc.

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“M.A.S.S.” Triage“SORT” process is

dynamic: Resources change Patient conditions change

Frequent reassessment All categories

may become IMMEDIATE

“Most serious” injury present demands “immediate” attention!

EXPECTANT

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Triage TagsTag immediately after sorting

Tie triage tag directly to patient May need to improvise tags (tape,

latex gloves) May need to write on patient

(lipstick, marker)

TX EMS 2008 105

Wrapping up the SORT...

When all patients have been triaged and tagged: Count all IMMEDIATES Advise incident commander or

transport officer of numberTake all IMMEDIATES to

collection point for urgent transport

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“M.A.S.S.” Triage“SEND”:Objective:

Transport or release ALL living patients ASAP

Traditional sequence: IMMEDIATE DELAYED MINIMAL

EXPECTANT

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“SEND”:Be mission-focused:

Send MINIMALS or DELAYEDS with each IMMEDIATE, if space allows

Be resourceful: Secondary treatment facilities for

MINIMALSBe creative:

Buses, taxis, trains, boats, etc.

TX EMS 2008 108

The Need To Drill

Regardless of which triage system your agency favors...

...Practice, practice, practice! “TRIAGE TAG TUESDAY”

Preparation will promote more efficient triage in an actual MCI

TX EMS 2008 109

What About The DEAD?

Should NOT be moved or sent 1 EXCEPTION?

Medical examiner / coroner: Identification of remains Disposition of remains

Crime scene investigation: Evidence must be preserved Apprehend perpetrators and

prevent future attacks

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Specific All-Hazards Considerations

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Chemical IncidentsIssues:

Minute quantities can be rapidly fatal Risk of “off-gassing” and 2°

contamination Delayed symptom onset for some

Implications: PPE for healthcare providers ~ Simultaneous decon, triage and

treatment Dry decontamination removes 80-90%

If you think it might be, safest bet is to decon

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Capnography as Triage Tool

“... the only direct, non-invasive measure of ventilatory status available to EMS crews...”

Rapid (15 seconds) indication of: Hypoventilation, respiratory depression

or failure Laryngospasm, upper airway obstruction Bronchospasm

Krauss B (2005) Pediatric Emerg Care 21(8): 493 Krauss B, Heightman AJ (2006) JEMS 31(6):

TX EMS 2008 113

Biological Incidents

Issues: Person-to-person spread for some

agents Non-specific “flu-like” symptoms Lengthy incubation periods

Implications: Delayed detection likely “Triage” only once outbreak

underway Healthcare providers may become

victims

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Radiological Incidents

Issues:Covert release likelyDetection requires special

equipmentSymptom onset typically

delayed

HOWEVER.....

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Radiation Risks for Healthcare Providers

“A living patient cannot be so radiologically

contaminated as to present an acute hazard to medical

personnel.”

Medical Management of Radiological Casualties, 2nd edition. AFRRI, Bethesda,

2003, p. 94. Download at: http://www.afrri.usuhs.mil

TX EMS 2008 116

Patient Care Implications

Limb- and life-saving medical

attention should never be delayed

because of the presence of radioactive material or

contamination!After 1st 24 hours,

radiation does matter

www.afrri.usuhs.mil

TX EMS 2008 117

Nuclear Incidents

Issues: Most immediate fatalities 2°

trauma, burns Massive dose needed for early

symptomsImplications:

Onset < 1-3 hr. post-exposure: Nausea/vomiting, altered LOC, CNS

symptoms

EXPECTANT

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Natural Disasters

Issues: More common than terrorism Scene size may be enormous Massive infrastructure destruction:

hospitals Healthcare providers as victims

Implications: Severely limited resources

Equipment, personnel, supplies, utilities

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Explosive & Bombing Incidents

Issues: Still #1 terrorist modality 4 Modes of Blast Injury 1°blast injury (PBI): delayed onset Ruptured TMs in blast survivors

Implications: Basic ABCs Frequent reassessment & re-triage

Lung, GI and brain Otoscope as triage tool

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When All Is Said and Done...

MCI Triage is NOT “business as usual”

“Standard of Care” vs. “Best Choices”

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“Gut Check” for Healthcare Providers

Difficult decisions must be made

Fatalities and suffering are likely

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It’s NOT “Rocket Science”, either!

One need not be a “specialist”Identify, collect and control

MINIMALS & DELAYEDSFocus first on those who most need care and are most likely to benefit from it!IMMEDIATES

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More Work Is Needed

National StandardsWMD & “All-Hazards” Incidents“Medical” MCI TriageSpecial PatientsPatient Tracking SystemsMore Effective Hands-on Training

TX EMS 2008 125

Thank You!

Questions??Let’s try it again!!

Copyright © 2007 by Ronna G. Miller, MD All rights reserved. No part may be modified or distributed in any

format without written permission of the author.

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Victim 1


A. IMMEDIATEB. DELAYEDC. MINIMALD.

EXPECTANT

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Victim 2



EXPECTANT

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Victim 3



EXPECTANT

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Victim 4



EXPECTANT

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Victim 5



EXPECTANT

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Victim 6



EXPECTANT

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Victim 7



EXPECTANT

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Victim 8



EXPECTANT

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Victim 9



EXPECTANT

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Victim 10



EXPECTANT

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Victim 11



EXPECTANT

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Victim 12



EXPECTANT

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Now what do you think?

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Question 14

Is knowing how to perform mass casualty triage part of your professional responsibilities?

A. YesB. No

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Question 15

What is the likelihood, in your opinion, that you would ever be called upon to perform mass casualty triage in the future?

A. Very likelyB. LikelyC. NeutralD. UnlikelyE. Very unlikely

TX EMS 2008 141

Question 16

If there were an explosion at this location right now, how confident are you that you would be able to rapidly and accurately triage victims?

A. Very confidentB. Somewhat confidentC. NeutralD. Somewhat unsureE. Very unsure

TX EMS 2008 142

The Newest Triage Method

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Contact Information

Ronna G. Miller, MDAssistant ProfessorEMS/Disaster Medicine/Homeland Security SectionDivision of Emergency MedicineDepartment of SurgeryUT Southwestern Medical Center at Dallas5323 Harry Hines Blvd.Dallas, Texas 75390-8890

Email: [email protected]

Voicemail: (214) 648-6881

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TX EMS 2008 145

There must be a cookie here somewhere!

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Journal References Armstrong JH et al (2008). Toward a National

Standard in Primary Mass Casualty Triage. Disaster Med Public Health Prep 2 Suppl 1:S8.

Briggs S (2007). Triage in Mass Casualty Incidents: Challenges and Controversies. Am J Disaster Med 2(2):57.

Donohue D (2008). Medical Triage for WMD Incidents. JEMS 33(5):60.

Goodloe JM, et al (2008). Big-Top Incident: Tulsa EMS responds to tent collapse. JEMS 33(9):42.

Heightman AJ (2006). Neutralize MCI Chaos. JEMS 31(4):16.

Kraus B (2005). Capnography as a Rapid Assessment and Triage Tool for Chemical Terrorism. Pediatric Emergency Care 21(8):493-7.

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Journal References – Cont’d.

Robertson-Steel I (2006) Evolution of Triage Systems. Emerg Med J 23:154-5. doi:10.1136/emj.2005.030270

Sacco WJ, et al (2005) Precise Formulation and Evidence-Based Application of Resource-Constrained Triage. Academic Emergency Medicine 12: 759-770.

Zorster R (2006). Disaster Triage: Is It Time to Stop START? Am J Disaster Med 1(1):7.

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“RED Survey”


BEFORE patient care!Casualty SurveyLife-saving InterventionsYou don’t need to die!

TX EMS 2008 163

“RED Survey”


BEFORE patient care!Casualty SurveyLife-saving Interventions

TX EMS 2008 164

“RED Survey”

“Rapid Evaluation of Disaster”

Casualty Survey - Triage:1. Rapid grouping by:

Severity of injury AND Likelihood of survival, THEN

2. Individual assessment

tx ems 20081 mci triage: a cure for a massive headache ronna g. miller, md ems/disaster...

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