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Simple Triage and Rapid Treatment

Immediate. Patients. Delayed. Deceased. Simple Triage and Rapid Treatment. John P. Frey, LP. Immediate. Patients. Delayed. Deceased. Objectives. Define START and MCI Identify the need for START Learn the START Algorithm Learn how to effectively use START. Immediate. Patients.

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Simple Triage and Rapid Treatment

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  1. Immediate Patients Delayed Deceased Simple Triage and Rapid Treatment John P. Frey, LP

  2. Immediate Patients Delayed Deceased Objectives • Define START and MCI • Identify the need for START • Learn the START Algorithm • Learn how to effectively use START

  3. Immediate Patients Delayed Deceased What Problems Might We Find?

  4. Immediate Patients Delayed Deceased What is an MCI • An event that produces more patients than you have medics • Produces minimal casualties but has unusual events surrounding the incident • HazMat, Rail, Aircraft, Marine • Effects local hospitals ability to adequately treat patients

  5. Immediate Patients Delayed Deceased Elements of an Command System • Unified command • Limited span of control • Clear chain of command • Line and staff functions • Intelligence gathering • Flexibility

  6. Immediate Patients Delayed Deceased Incident Command System (ICS) ICS is a system of establishing command and control of an emergency incident Command Treatment Transport Staging Triage

  7. Immediate Patients Delayed Deceased Qualities of a Great Commander • All knowing • Forceful, yet sensitive • Totally calm under fire • Likes dogs and small children • Free of impure thoughts • Brave, clean, honest, trustworthy

  8. Immediate Patients Delayed Deceased So..Who’s In Charge? • First Responder • EMS • Supervisor • Line Officer • Chief • Governmental Official

  9. Immediate Patients Delayed Deceased First Responders Responsibility • One member becomes “Command” • Other members starts the Triage process • Start calling for any additional resources that you think you will need

  10. Immediate Patients Delayed Deceased Triage • French for “sorting” or “to sort” • A process for determining who to treat and transport first in the case of a multi casualty incident (MCI) • Refined during the Vietnam conflict by military medics

  11. Immediate Patients Delayed Deceased What is START? START is an acronym for Simple Triage And Rapid Treatment It is a simple step-by-step triage and treatment method to be used by the first rescuers responding to a multi casualty incident. It allows these rescuers to identify victims at greatest risk for early death and to provide basic stabilization maneuvers

  12. Immediate Patients Delayed Deceased Why START? • Medically responsible • Easily learned • Easily remembered • Clear-cut decision process • Relies only on BLS skills

  13. Immediate Patients Delayed Deceased 3rd Law of the House of God In cases of cardiac arrest (or triage), the first thing you do is check your own pulse!

  14. Immediate Patients Delayed Deceased Your First Action If you can walk, go stand over there! All of Ya’ll, go over there! (Texas version )

  15. Immediate Patients Delayed Deceased The Next Step • Take a DEEP breath • Ensure that your scene is safe • Start to triage all patients that were unable to move • Spend about 60 seconds/patient • Put triage tag on and note group • Move to the next patient

  16. NONE YES REPOSITION AIRWAY ASSESS RESPIRATIONS/VENTILATIONS > 30/MINUTE YES NONE IMMEDIATE Immediate Patients Delayed Deceased START Algorithm (Airway/Breathing) RESPIRATIONS/VENTILATIONS <30/MINUTE ASSESS PERFUSION IMMEDIATE DECEASED

  17. Immediate Patients Delayed Deceased START Algorithm (Circulation) PERFUSION > 2 SECONDS CONTROL BLEEDING <2 SECONDS ASSESS MENTAL STATUS IMMEDIATE

  18. Immediate Patients Delayed Deceased START Algorithm (Disability) MENTAL STATUS FAILS TO FOLLOW SIMPLE COMMANDS FOLLOWS SIMPLE COMMANDS IMMEDIATE DELAYED

  19. TRANSPORTATION OFFICER NAME______________________ AMBULANCE _______________ HOSPITAL __________________ PRIORITY-1 2 10945 NAME AGE MALE FEMALE MEDICATION/TIME: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ 10945 Immediate IMMEDIATE 10945 Patients Delayed DELAY 10945 Deceased Triage Tags (front)

  20. Immediate IMMEDIATE Patients Delayed DELAY Deceased Triage Tag (back)

  21. Immediate Patients Delayed Deceased Other Triage ID Methods • Different tags • Bracelets • Duct tape • Survey tape • Marker on forehead

  22. Immediate Patients Delayed Deceased After Primary Triage • Move to secondary triage • Provide primary treatment • Complete triage tags • Call for necessary transport • Continue to reassess patients

  23. Immediate Patients Delayed Deceased Field Triage • Primary Triage (Triage) • Implement START • Immediate, life saving care • Secondary Triage (Treatment) • Document information on triage tags • Provide medical treatment • Tertiary Triage (Transport) • Transport patients

  24. Immediate Patients Delayed Deceased Example 1 • 57 year old female complaining of chest pain. Respirations 24, capillary refill 3 seconds, responds to all verbal commands

  25. Immediate Patients Delayed Deceased Triage Tags TRANSPORTATION OFFICER NAME______________________ AMBULANCE _______________ HOSPITAL __________________ PRIORITY-1 2 10945 NAME AGE 57 MALE FEMALE X MEDICATION/TIME: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ 10945 IMMEDIATE 10945

  26. Immediate Patients Delayed Deceased Example 2 • 24 Year old male, with a 3’ pole impaled through his abdomen, respirations 28, capillary refill <2 seconds, responds to all commands

  27. TRANSPORTATION OFFICER NAME______________________ AMBULANCE _______________ HOSPITAL __________________ PRIORITY-1 2 10945 NAME AGE 24 MALE X FEMALE MEDICATION/TIME: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ 10945 Immediate IMMEDIATE 10945 Patients Delayed DELAY 10945 Deceased Example 2 Tag

  28. Immediate IMMEDIATE Patients Delayed DELAY Deceased Example 2 Tag (back)

  29. Immediate Patients Delayed Deceased Example 3 • 3 year old child with no obvious injury. No respirations, capillary refill 6 seconds, unconscious

  30. Immediate Patients Delayed Deceased Example 3 Tag TRANSPORTATION OFFICER NAME______________________ AMBULANCE _______________ HOSPITAL __________________ PRIORITY-1 2 10945 NAME AGE 3 MALE X FEMALE MEDICATION/TIME: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ 10945

  31. Immediate Patients Delayed Deceased Other MCI Concerns • What caused (or is causing) the problem? • Medical Supplies • Communications • Transportation • Media Coverage • Crowd Control

  32. Immediate Patients Delayed Deceased What’s Causing the Problem? • Was it an acute event? • Is it still occurring? • Are we in a safe area? • Is a chemical involved?

  33. Immediate Patients Delayed Deceased Texas A&M Bonfire Collapse • November 18, 1999 • 2:30 AM bonfire stack collapsed • 150 people believed to be on bonfire site at time of collapse • As stack collapsed, all lighting was pulled down leaving the area in total darkness • First Responders reported hearing screaming in the darkness

  34. First Responder Actions • Immediate call for additional help with description of bonfire collapse • Dispatch issued a MCI and paged all personnel as well as CSFD and BFD and Texas Fire Training Center resources. MCHD ambulances requested as well. • Fire Department and TxDot light trucks were immediately called for • Triage started by flashlight

  35. Triage Actions • START was used immediately • Separate Triage areas established early to isolate patients needing triage • All site resources used the ICS system for unified incident command. Command was ultimately run by DPS. • Texas Task Force 1 (FEMA) was mobilized for specialty rescue • Mobile morgue was sent to site

  36. As the Sun Came Up

  37. Final Outcome • All recoverable patients triaged and transported in less than 1 hour • Last bodies recovered about 20 hours after the collapse • 27 patients injured, 12 killed • Investigative committees universally credited first responders with saving many lives

  38. Immediate Patients Delayed Deceased So....How does this apply to me? • Major incidents can occur • First responders are generally involved in these incidents • Most responders face few large incidents in their career • Preparation is the key to successful handling of these incidents

  39. START Card WALKING WOUNDED - Walks and follows commands IMMEDIATE - Respirations greater than 30; capillary refill 2 sec's or longer; mental confusion or no response DELAYED - Cannot walk; respirations less than 30; Cap refill less than 2 sec's; responds to questions DECEASED - Patient with no respirations after one attempt to manually establish an airway START Triage Steps: 1. “If you can get up and walk, follow me” 2. Respiration Perfusion Mental Status 3. “Thirty and two, can do” Front Back

  40. Additional Resources • The EMS Incident Management System, Christen/Maniscalco (Brady) • START Training Manual Texas Department of Health • http://www.tdh.state.tx.us/hcqs/ems/startman.exe

  41. Questions

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