Multi-Casualty Incidents and Triage

Z03_CAMP7247_07_SE_A03.indd Page 1 8/23/11 9:22 PM user f-404 F-402 Multi-Casualty Incidents and Triage David Maatman, NREMT-P/IC Roy Alson, PhD, MD, FACEP Jere F. Baldwin, MD, FACEP, FAAFP John T. Stevens, NREMT-P Objectives Upon successful completion of this material, you should be able to: 1. Compare and contrast the definitions of the terms disaster and multi-casualty incident. 2. Define the term span of control. 3. List the responsibilities of the medical director, triage supervisor, transport supervisor, treatment supervisor, and staging supervisor. 4. Describe the ITLS POST (Primary On-Scene Triage) scheme. 5. Identify Priority 0, 1, 2, 3, and 4 patients. Disasters and Multi-Casualty Incidents DEFINITIONS Disaster (major). Any natural catastrophe that causes damage of sufficient severity and magnitude to warrant major disaster assistance. Incident command system (ICS). The combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure, designed to aid in the management of resources 1

Z03_CAMP7247_07_SE_A03.indd Page 2 8/23/11 9:22 PM user f-404 F-402 2 MULTI-CASUALTY INCIDENTS AND TRIAGE during emergency incidents. It is used for all kinds of emergencies and is applicable to small as well as large and complex incidents. Multi-casualty incident (MCI). An incident involving a large number of persons injured in which the EMS system is unable to manage the situation utilizing day-to-day procedures. An MCI may be classified as a disaster, but not all disasters are MCIs. Paper plan syndrome. Having a written MCI/disaster plan without training the individuals who would most likely activate and work it. Span of control. The number of individuals a supervisor is responsible for, usually expressed as the ratio of supervisors to individuals. (Under the NIMS, an appropriate span of control is between 1:3 and 1:7.) Triage. To prioritize or sort injuries or the injured, usually into five categories: Priority 0, 1, 2, 3 and 4 (Black, Red, Yellow, Green, Gray). THE ROLE OF EMS It is not uncommon for EMS to have more than one patient at a trauma scene. However, most day-to-day operational procedures are designed for the singlepatient incident. Safety, organization, and communication are paramount in all EMS activities. When faced with multiple patients, this need is even greater. It is essential that the components (safety, organization, and communication) be effective and that all entities of the emergency system work from the same plan. An effective and efficient way to obtain this unity is to have EMS operate as a branch of the incident command system (ICS). Primary functional components of the medical branch include the medical director, triage, treatment, transport, and staging. (Even with a single-patient incident, those five components exist, but one person usually is responsible for the functions of all components.) A medical director is in charge of the patient care (team leader), injuries are triaged (prioritized assessment), treatment is provided for the patient, a transport decision that includes destination and mode of transport is made, and deployment of on-scene vehicles is determined from a point of safety, ingress, and egress (staging). By having the medical branch function as part of the ICS, it provides EMS with dependable, reproducible results when faced with multi-casualty incidents. As with the other components of an ICS, the medical branch must be simple enough for new users but expandable enough to provide the necessary structure to manage large incidents. Incident Command System In the early 1970s the ICS was developed in southern California under FIRE- SCOPE (FIrefighting RESources of California Organized for Potential Emergencies). Though originally developed to assist in the response to wildland fires, it was quickly recognized as a system that could help public safety responders provide effective and coordinated incident management for a wide range of situations. Multiple variations of the FIRESCOPE ICS have been developed to include Fire Ground Command System (FGC) and National Fire Protection Association (NFPA) 1561, which was then called Standard on Fire Department Incident Management System.

Z03_CAMP7247_07_SE_A03.indd Page 3 8/23/11 9:22 PM user f-404 F-402 MULTI-CASUALTY INCIDENTS AND TRIAGE 3 Incident Command Fire Suppression Rescue/Extrication Law Enforcement Medical FIGURE 1 On-scene incident command structure. FIRESCOPE ICS and its variations served as the basis for the national incident management system s incident command system (NIMS ICS). The NIMS ICS was developed, under the Department of Homeland Security (DHS) Federal Emergency Management Agency (FEMA). Additional information about NIMS can be found online at www.fema.gov/nims The typical on-scene components of the operations section of an ICS are Command, Fire Suppression, Rescue/Extrication, Law Enforcement, and Medical ( Figure 1 ). The structured flexibility of an ICS enables it to be adapted to all types of emergency incidents: fire, rescue, law enforcement, and multi-casualty incidents. Because of its modular design, the structure of the ICS can be expanded or compressed, depending on the changing conditions of an incident. It must be staffed and operated by qualified personnel from an emergency service agency. If an on-scene incident command system is not immediately established, other rescuers will take independent actions, which will frequently be in conflict with each other. Those independent actions (freelancing) may be dangerous and disruptive in an environment that requires organization and accountability. Without organization and accountability, chaos will occur, and too many people will attempt to command the incident. If you do not control the situation, the situation will control you. MEDICAL (EMERGENCY SERVICES) BRANCH One branch of the operations sector of an on-scene ICS is the medical branch, which is broken down into manageable components (subfunctions or groups). The five primary positions of the medical branch are the medical director, triage group, treatment group, transport group, and staging group ( Figure 2 ). Each of the four groups answers to the medical director. It may not be necessary to have one person in each position, but it is necessary to ensure the function of each position is executed. At a scene with multiple patients, it may be necessary to have more than one person take on the function of those components. When considering the need to expand or condense the medical branch of the ICS, the best indicator is current or anticipated span of control. The general rule is to have one person oversee five subordinates (1:5). Some latitude may be given due to the complexity of the situation. A highly complex or difficult situation may require a span of control of 1:3, or a simple situation may allow up to 1:7. All participants of an ICS need to know their responsibilities. Following are ideas and suggestions used in determining the responsibilities of the medical branch of an ICS. Medical Director Establishes liaisons with on-scene Incident Command Establishes a working branch with appropriate groups

Z03_CAMP7247_07_SE_A03.indd Page 4 8/23/11 9:22 PM user f-404 F-402 4 MULTI-CASUALTY INCIDENTS AND TRIAGE Incident Command Fire Suppression Medical Law Enforcement Rescue/Extrication Medical Director Triage Group Treatment Group Transport Group Staging Group FIGURE 2 Medical branch of the ICS. Ensures that proper rescue/extrication services are activated Ensures law enforcement involvement as necessary Ensures that helicopter landing zone operations are coordinated Determines the amount and types of additional medical resources and supplies Ensures that area hospitals and medical control authorities (MCAs) are aware of the situation so they can prepare for casualties Designates assistance officers and their locations Maintains an appropriate span of control Works as a conduit of communications between subordinates and the Incident Commander EMS Staging Supervisor Maintains a log of available units and medical supplies Coordinates physical location of incoming resources (i.e., ambulances and helicopters) Coordinates incoming personnel who wish to aid at the scene Provides updates to the medical director as necessary Triage Supervisor Ensures proper use of the ITLS POST (Primary On-Scene Triage) scheme or other local protocol Ensures that triage tags or other visual identification techniques are properly completed and secured to the patient Makes requests for additional resources through the medical director Provides updates to the medical director as necessary Treatment Supervisor Establishes suitable treatment areas Communicates resource needs to the medical director

Z03_CAMP7247_07_SE_A03.indd Page 5 8/23/11 9:22 PM user f-404 F-402 MULTI-CASUALTY INCIDENTS AND TRIAGE 5 Assigns, supervises, and coordinates treatment of patients Provides updates to the medical director as necessary Transport Supervisor Ensures the organized transport of patients off-scene Ensures an appropriate distribution of patients to all local hospitals to prevent hospital overloading Completes a transportation log Contacts receiving hospitals to advise them of the number of patients and condition (may be delegated to a communications leader) Provides updates to the medical director as necessary TRIAGE As a triage person, you should spend less than 1 minute doing the ITLS POST to determine the priority of a patient. It cannot be overemphasized that the person doing the triage does not render any time-consuming treatment to a patient. Treatment is to be done by the treatment group of the medical branch of the ICS. A triage person that begins time-consuming treatment of victims is no longer doing triage, and the function of triage must be reassigned. Once the medical priority of a patient has been determined, using ITLS POST ( Figure 3 ), the triage person should affix an appropriately completed triage tag/band ( Figure 4 ) or other visual identification device to the victim and move on to the next victim to be assessed. After completing the ITLS POST, determine the priority. Use the following categories: Priority 0 Deceased. Black tagged; dead. All vital signs absent Priority 1 Immediate. Red tagged; critical condition, unstable but salvageable (load and go) Priority 2 Delayed. Yellow tagged; serious condition, potentially unstable Priority 3 Minimal. Green tagged; stable condition, minor injuries, walking wounded Priority 4 Expectant. Gray tagged; critical condition, unstable but unlikely to survive with existing resources Although there is a tendency to overtriage, one must refrain from this because of its impact on the resources available to the EMS system. You need to be as accurate in your triage assessment as possible. Three basic human systems need to be quickly evaluated to determine the patient s medical priority: respiratory system (breathing), circulatory (pulses), and neurological system (LOC). By using ITLS POST during the initial triage phase and the rapid trauma survey or the focused exam in the treatment phase, you will be accurate in your assessment and make the best use of resources by providing the greatest amount of good to the greatest number of patients. The general steps are as follows: General impression (patient overview, done as you are approaching the victim) Victim s approximate age? What position is the victim in?

Z03_CAMP7247_07_SE_A03.indd Page 6 01/09/11 10:38 PM user-s163 6 MULTI-CASUALTY INCIDENTS AND TRIAGE Global Sorting ITLS POST (Primary On-Scene Triage) An adaptation of SALT mass casualty triage Does not obey voice commands Still / Obvious Life Threat (assess 1st) Obeys voice commands Wave / Purposeful Movement (assess 2nd) Obeys voice commands Ambulatory (assess 3rd) Individual Assessment LSI Control major hemorrhage Open airway (if child consider 2 rescue breaths) Chest decompression Autoinjector antidotes Priority-0 Deceased No Yes Obeys commands or makes All Minor Injuries Yes Breathing? purposeful movements? Only? Has effective respirations? Yes Has adequate peripheral No perfusion? Major hemorrhage is controlled? Priority-2 Delayed No to any of the above Priority-3 Minimal Likely to survive given current resources? No Yes Priority-1 Immediate Priority-4 Expectant FIGURE 3 ITLS POST. This scheme reflects the steps of primary triage. Subsequent and more detailed assessments should occur throughout patient care. What is the victim s activity (aware of surroundings, anxious, in distress, purposeful movement)? Does the victim have adequate perfusion (skin color)? Are there any major injuries or major external bleeding? Major bleeding makes control of bleeding a higher priority than the airway (CABC rather than ABC). Level of consciousness Does the victim obey simple voice commands?

Z03_CAMP7247_07_SE_A03.indd Page 7 01/09/11 10:38 PM user-s163 MULTI-CASUALTY INCIDENTS AND TRIAGE FIGURE 4 Example of triage band (StatBand ). (Courtesy of David Maatman, NREMT-P/IC) Airway Is it open and self-maintained? Is it compromised? Breathing Is the victim breathing? If a pediatric patient (less than 8 years old), consider giving two breaths and reassess for breathing What is the approximate rate (fast, slow, normal), quality, and effort? Circulation Is there peripheral and central pulses? Is there adequate perfusion? What is the approximate rate (fast, slow, normal), quality, and regularity? Once the assessment has been completed and you have figured in a survivability factor based on existing resources, you have a good idea how to prioritize the patient. An example of applying the survivability factor would be if you were presented with a geriatric patient and a pediatric patient with similar critical injuries and you only have enough resources for one. Which one do you choose, and why? The decision should be based on objective evaluations rather than emotions. SPECIAL CONSIDERATIONS Injured Rescuers Many ICSs provide a separate medical component at the scene of the incident for the care and treatment of the rescuers. Structurally, this branch is part of the logistics section of a large ICS structure. In the event of illness or injury to one of your colleagues, you should ensure that they do not fall into the triage system of the victims of the incident. We are obligated to take care of our own. This will enable our sick or injured colleague to return to duty quicker and help the overall operation by providing the remaining rescuers the peace of mind of knowing that their fellow rescuer has not been forgotten. Standard of Care When reviewing the care of a patient at an MCI, we have to consider the adverse circumstances EMS was operating under at the time of the 7

Z03_CAMP7247_07_SE_A03.indd Page 8 29/08/11 6:05 PM user-s163 8 MULTI-CASUALTY INCIDENTS AND TRIAGE incident. During normal day-to-day operations, standard protocols treat all patients for the worst-case scenario, and thus many patients are overtreated. When manpower and resources are available, it is prudent to provide such care. However, when working in an MCI or disaster environment, the inefficient use of manpower and resources may be catastrophic. The guiding principle in triage and treatment of victims of an MCI is to do the greatest good for the greatest number of patients with the least depletion of available resources. Critique and Debriefing The management of all MCIs and disasters should be formally critiqued. Primary focus should be on what worked and what did not. An MCI/disaster plan is a dynamic document, modified when there is a problem. In addition to taking time to critique the incident, time also must be taken to provide critical incident stress debriefing (CISD) for the participants of an incident. The mental health of EMS professionals is as important as their physical health. Triage Schemes A variety of triage schemes are used around the world, most of which use similar principles of determining the priority of a patient. The primary principles used are assessment of respirations, perfusion, and level of consciousness (obeys commands). The START (Simple Triage and Rapid Treatment), JumpSTART (Pediatric version of START), Triage Sieve, Homebush, and STM (Sacco Triage Method) utilize a quantitative assessment (actual count) for respirations, pulses, and in some cases capillary refill time. Although there may be some value in quantifying assessment findings during the initial triage phase, it may be of more value to assess the effectiveness (qualitative) of respirations and pulses. The CareFlight Triage, SALT (Sort, Assess, Lifesaving interventions and Treatment/Transport) and the ITLS POST (Primary On- Scene Triage) schemes use a more qualitative approach. SALT (on which ITLS POST is based) was originally developed by the American College of Surgeons Committee on Trauma and was revised by an expert panel convened and supported by the Center for Disease Control (CDC) and the National Highway and Traffic Safety Administration (NHTSA). The panel had participants representing EMS, emergency medicine physicians, trauma surgeons and public health. This triage scheme is being proposed as the national standard field triage scheme. SALT and ITLS POST ( Figure 3 ) use five priority categories; Priority-0, Deceased (black tag); Priority-1, Immediate (red tag); Priority-2, Delayed (yellow tag); Priority-3, Minimal (green tag); and Priority-4, Expectant (gray tag). The patients categorized as Expectant have vital signs but are likely to die without assigning vast resources for care. The expectant category is intended to be flexible and dynamic, depending on the resources available, access to patients, time to treatment, and the provider s level of training. SALT and ITLS POST also have a formal process to provide lifesaving interventions (LSI) before assigning a triage category. LSI should be initiated rapidly and only if necessary supplies are readily available and the rescuer is trained and authorized to use. The LSI include control major hemorrhage, opening the airway, two rescue breaths for child casualties, decompression of tension pneumothorax, and use of autoinjector antidotes. The American College of Surgeons Committee on Trauma (ACS COT) and the National Highway Traffic Safety Administration (NHTSA) also developed a field triage decision scheme that is specific to trauma patients and aids in the determination of transport destinations to trauma centers. This algorithm assesses

Z03_CAMP7247_07_SE_A03.indd Page 9 8/23/11 9:22 PM user f-404 F-402 MULTI-CASUALTY INCIDENTS AND TRIAGE 9 vital signs and level of consciousness, anatomy of injury, mechanism of injury, and comorbid factors. Based on those findings, it recommends a transport destination. The triage scheme is detailed and is mainly directed at where the trauma patient should be taken and may not be applicable for the initial phases of on-scene triage to determine which patients should be treated and transported first. ITLS Recommendations The priorities of any incident, no matter how small or large, should be safety, organization, and then patient care. To provide the most effective and efficient patient care, one must approach it in a safe and organized fashion. To have an effective medical branch of the ICS requires its use in day-to-day operations, including the routine, small emergencies. The rehearsal of the standardized structure of an ICS on smaller situations will develop proficiency and allow for a smooth transition into the larger, more complex incidents. Activating the ICS only when an incident reaches a high level can result in a lack of familiarity with its use. Routine activation of the system develops confidence in its use for all levels of command and agencies involved. To avoid the paper plan syndrome, the regular implementation and review of an MCI/disaster plan is paramount to having successful operations. An ICS is not a magic wand that will save lives by itself, nor will it replace the common sense and good judgment required of experienced EMS professionals. It is necessary to have a plan, communicate it, and execute it. There is no single triage scheme that will provide effective triage in all situations. It may be necessary to blend multiple triage schemes to capitalize on the best outcome. Successful management of a situation still requires properly trained people who know what to do and how to do it. ICS properly utilized can increase the overall effectiveness of the participants by providing a proactive approach to management. If you do not manage the situation, the situation manages you. The key to effective performance in a leadership role is not necessarily rank, but the understanding of the duties of that position and the ability to properly function at that level. For large-scale incidents, an operation may last for days or even weeks and will require additional resources. As part of the disaster plan, an ICS provides the structure for the necessary administrative, planning, financial, and logistical support. 1. Cone, D., J. Serra, et al. 2009. Pilot test of the SALT mass casualty triage system. Prehospital Emergency Care 13(4): 536 540. 2. Introduction to ICS. Retrieved July 22, 2010, from http://training.fema.gov/emiweb/ IS/IS100A.asp 3. Centers for Disease Control and Prevention. Injury prevention and control: Field triage. Retrieved July 22, 2010, from http://www.cdc.gov/fieldtriage/ 4. Romig, L. E. The JumpSTART Pediatric MCI Triage Tool and other pediatric disaster and emergency medicine resources. Retrieved July 22, 2010, from http://www. jumpstarttriage.com Bibliography

Z03_CAMP7247_07_SE_A03.indd Page 10 8/23/11 9:22 PM user f-404 F-402 10 MULTI-CASUALTY INCIDENTS AND TRIAGE 5. START Support Services. START Triage: The race against time. Retrieved July 22, 2010, from http://www.start-triage.com/ 6. Think Sharp. Sacco triage method. Retrieved July 22, 2010, from http://www. sharpthinkers.com 7. Kahn, C., M. Schultz, et al. 2009. Does START triage work? An outcomes assessment after a disaster. Annals of Emergency Medicine 54(3): 424 431. 8. Lerner, E. B., et al. 2008. Mass casualty triage: An evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Preparedness 2(Suppl 1): S25 S34. 9. Maatman, D. V., S. A. Huisman. 2005. T-4, Triage treatment & transport training. Grand Rapids, MI: D&D Publications. 10. Nocera, A., A. Garner. 2000. An Australian mass casualty incident triage system for the future based on mistakes of the past: The Homebush Triage Standard. AJEM 15(2): 41 46.