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So, How Did You Do?

So, How Did You Do?. MCI Triage:. 2006 Advanced Practice Centers for Preparedness Training Conference. Why Am I Here?. In a disaster, needs exceed resources More patients than providers Difficult choices must be made Who receives care now? Who does not? How do I decide?

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So, How Did You Do?

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  1. So, How Did You Do? NACCHO 02-2006

  2. MCI Triage: 2006 Advanced Practice Centers for Preparedness Training Conference NACCHO 02-2006

  3. Why Am I Here? • In a disaster, needs exceed resources • More patients than providers • Difficult choices must be made • Who receives care now? • Who does not? • How do I decide? • ...TRIAGE NACCHO 02-2006

  4. Triage and Public Health Competencies CDC & CUSN-CHP (2002). Bioterrorism & Emergency Readiness: Competencies for All Public Health Workers, p. 12 NACCHO 02-2006

  5. Objectives • Define “Triage” • Identify goals of MCI triage • Implement “MASS” Triage • Classify MCI victims by “ID-me” categories NACCHO 02-2006

  6. In a Perfect World... • First responders respond to scene • Patients are triaged in the field • HazMat handles decon in the field • Sickest patients arrive with EMS: • Already sorted and tagged • Already decontaminated • Already partially treated • All “we” have to do is take care of them! NACCHO 02-2006

  7. 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 NACCHO 02-2006

  8. Another Awful Thought... • Hospital as “Hot Zone” • Or.... • It’s your “off “day • Or… • Flu Pandemic, Bioterrorism… NACCHO 02-2006

  9. Triage: Definition • Sorting of patients by seriousness of condition and likelihood of survival NACCHO 02-2006

  10. Triage: Goals • Primary Goal: • Greatest good for the greatest number of possible survivors • Secondary Goal: • Relief of suffering • Depend on available resources NACCHO 02-2006

  11. Triage Systems • Multiple triage systems in use • Various methods using tags, categories, colors,symbols • Familiarize yourself with your agency’s system and PRACTICE it • IDEAL = one uniform system used by all agencies in the field & at hospitals NACCHO 02-2006

  12. “M.A.S.S.”Triage M – Move A – Assess S – Sort S – Send NACCHO 02-2006

  13. “M.A.S.S.” Triage • Developed by the military • Tested & used by the military • Adapted for civilian disasters • It works! • Fast • Accurate (70%) • Can handle large numbers of victims NACCHO 02-2006

  14. “M.A.S.S.”Triage • GROUP victims first... then.... • ...ASSESS individual victims NACCHO 02-2006

  15. Basis of “M.A.S.S.”Triage • Ability to MOVE best predicts survival • Head Injury patients • Glasgow Coma Scale (GCS) NACCHO 02-2006

  16. “M.A.S.S.” Triage “MOVE”: STEP 1 • Goal: • Group - Victims who can WALK • Action: • “Everyone who can hear me and who can walk, please move to the area with the green flag.” MINIMAL NACCHO 02-2006

  17. Why Bother With Them FIRST? • MINIMAL group: major vital functions intact • Assess last, after more critical groups • However, actively managing this group may: • Facilitate scene management • Conserve scene resources • Reduce self-transports & overburdening of nearest hospital ERs • Caveats: • No individual assessment, yet • Worsening conditions NACCHO 02-2006

  18. “M.A.S.S.” Triage “MOVE”: STEP 2 • Goal: • 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.” DELAYED NACCHO 02-2006

  19. “M.A.S.S.” Triage “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) NACCHO 02-2006

  20. “M.A.S.S.” Triage “ASSESS” IMMEDIATE patients: • Goal: • Accurate count of IMMEDIATE patients • Action: • Rapidly Assess ABCs • If not or already DEAD • Correct immediate life threats… EXPECTANT NACCHO 02-2006

  21. “M.A.S.S.” Triage “ASSESS” IMMEDIATE patients: • Open Airway • Stop Bleeding • Give Chemical antidote www.rk19-bielefeld-mitte.de www.tpub.com www.meridianmeds.com NACCHO 02-2006

  22. “M.A.S.S.” Triage “ASSESS” IMMEDIATE patients: • Open Airway • Stop Bleeding • Give Chemical antidote Pressure Points Whatever it takes! Be creative! Tourniquets NACCHO 02-2006

  23. “M.A.S.S.” Triage “ASSESS” IMMEDIATE patients: • Question: • Is transport available? • Move on! NACCHO 02-2006

  24. Victim Group Summary NACCHO 02-2006

  25. ONLY NOW Do We Assess Individuals • Having grouped victims according to their ability to move... • ...The next phase entails more detailed individual assessment. NACCHO 02-2006

  26. “M.A.S.S.” Triage “SORT”: • Goal: • Sort patients based upon INDIVIDUAL assessment • Actions: • Assign to “ID-me” Categories: • IMMEDIATE, DELAYED, MINIMAL, • Continue treatment EXPECTANT NACCHO 02-2006

  27. “M.A.S.S.” Triage “SORT”: • Start with those who could MOVE • Unless sufficient personnel for all groups • Ideal: trained medical personnel • May not be available • Tag immediately upon triage • Including dead victims NACCHO 02-2006

  28. There Are Many Different Patient Assessment Tools www.usmc.mil/marinelink/mcn2000 CERT L.A. 2003 NACCHO 02-2006

  29. START Triage “R” “P” “M” NACCHO 02-2006

  30. “ID-me” Categories • I - IMMEDIATE • D - DELAYED • M - MINIMAL EXPECTANT LETHAL INJURY E - EXPECTANT NACCHO 02-2006

  31. “M.A.S.S.” Triage “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, blue skin color, rapid or weak pulse, open abdominal wounds, etc. NACCHO 02-2006

  32. “M.A.S.S.” Triage “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. NACCHO 02-2006

  33. “M.A.S.S.” Triage “SORT” – MINIMAL: • “Walking wounded” • Group, sort & facilitate transport from scene • Volunteer help? Risk vs. Benefit • Examples: • Scrapes, bruises, minor cuts, no apparent injuries NACCHO 02-2006

  34. “M.A.S.S.” Triage “SORT” – : • Most severely injured with little chance of survival • They are “expected” to die soon • In a perfect world, they would receive the most care, even though chance of survival is low • In an MCI.... EXPECTANT NACCHO 02-2006

  35. “M.A.S.S.” Triage “SORT” – : • Care resources NOT utilized initially • Comfort 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 NACCHO 02-2006

  36. “M.A.S.S.” Triage “SORT” – : • Examples: • Near 100 % burns • Fatal radiation doses • Absent pulse or breathing • Especially if multiple injuries • Severe open brain injury • Death “imminent” • “Judgment call” EXPECTANT NACCHO 02-2006

  37. Triage Caveats • OVER-TRIAGE: • Tendency to classify all victims as IMMEDIATE • Defeats the purpose! • Ruptured eardrums, chronic hearing loss, language barrier, developmental handicaps, etc. • Cannot respond to “MASS” commands NACCHO 02-2006

  38. 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. NACCHO 02-2006

  39. “M.A.S.S.” Triage • “SORT” process isdynamic: • Resources change • Patient conditions change • Frequent reassessment • All categories • may become IMMEDIATE • “Most serious” injury present demands “immediate” attention! EXPECTANT NACCHO 02-2006

  40. Triage Tags • Tag immediately after sorting • Tie triage tag directlyto patient • May need to improvise tags (tape, exam gloves, cloth) • May need to write on patient (lipstick, marker) NACCHO 02-2006

  41. Wrapping up the SORT... • When all patients have been triaged and tagged: • Count all IMMEDIATES • Advise incident commander or transport officer of number • Take all IMMEDIATES to collection point for urgent transport NACCHO 02-2006

  42. “M.A.S.S.” Triage “SEND”: • Objective: • Transport or release ALL livingpatients ASAP • Traditional sequence: • IMMEDIATE • DELAYED • MINIMAL EXPECTANT NACCHO 02-2006

  43. “M.A.S.S.” Triage “SEND”: • Be mission-focused: • Send MINIMALSor DELAYEDS with each IMMEDIATE, if space allows • Be resourceful: • Secondary treatment facilities for MINIMALS • Be creative: • Buses, taxis, trains, boats, etc. NACCHO 02-2006

  44. What About The DEAD? • Should NOTbe 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 NACCHO 02-2006

  45. 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 NACCHO 02-2006

  46. When All Is Said and Done... • MCI Triage is NOT “business as usual” • Difficult decisions must be made • Fatalities and suffering are likely • “Gut check” for healthcare providers • “Non-medical” people can participate NACCHO 02-2006

  47. Summary: Now you can • Define “Triage” • Identify goals of MCI triage • Implement “MASS” Triage • Classify MCI victims by “ID-me” categories NACCHO 02-2006

  48. Thank You!Questions? NACCHO 02-2006

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