Triage. Okay, let's talk about triage, or sorting patients so we can decide who's treated first, second, and so on. Alright, so some definitions first. Triage is simply sorting of patients or victims. With day-to-day triage in the ER, the sickest is treated first, no matter the cost or the possible outcome, whether they're going to live or not live. On the hospital floor, again, the sickest and most needy are cared for first. In a mass casualty incident, which can be different from a disaster, again, the sickest are treated first, and there is normal standards of care. We're going to talk more about standards of care in a bit. What we normally do for people who present to the hospital or clinic in this mass casualty incident could be bent a little bit, but the rules, the basic rules that we live by, are not broken. I should probably say here that I differentiate a mass casualty incident from a disaster. A mass casualty incident has large numbers of vixtom, victims, which stretch, but may not overwhelm the system. Disasters, by definition, overwhelm the system. Mass casualty incidents may be a disaster but may not be. Disasters may have or be mass casualty incidents, but again, may not All disasters overwhelm, but not all mass casualty incidents do. In disaster triage, all available resources are completely overwhelmed. There is not enough time, equipment, supplies, all the stuff we need to treat everyone the same way that we normally do. The goal changes to how we can save as many victims as possible with the available limited resources. So as I said, disasters come in all shapes and sizes. All disasters overwhelm the available resources, not all have significant numbers of wounded. The collapse of the World Trade towers did not produce large, overwhelming numbers of injured people. Not all disasters destroy infrastructure. For instance, a pandemic may be considered a disaster, and will sicken large numbers of people. This could impact services that would not necessarily destroy infrastructure. Same applies to chemical or biological terrorist events as well. They are designed to cause large number of victims and panic without damaging infrastructure. There are other events, such as the earthquake in Haiti in 2010, which destroyed the limited available resources the area had and produced large numbers of injured and dead. Disaster triage in the field will be different from disaster triage in the hospital or treatment center. There will need to be simple, rapid decisions, which divide the victims in categories. These categories, this is for the field, in general, these categories are minor, color-coded green, those who can wait, over forty-eight hours to be treated. They may never be transported and, and may be simply sent home or to a shelter to wait for treatment. Delayed, or yellow, is the next category, those who should be treated in 24 to 48 hours. These will be transported and treated second. Immediate, or red, are those who much be, must be treated in 12 to 24 hours. These will be transported and treated first. The dead or the dying, color-coded black. These are those who are too injured to save under the circumstances or who are deceased. Triage does not involve treatment. EMTs, paramedics, whoever's doing the triage, will classify the victim and move on. The START and JumpSTART systems are two triage systems that are commonly taught and used. There are many others. All right, so let's talk about a little triage basics here. We call this tagging the victim. The tag indicates by color and words the status of the victim. All documentation is done on the tag until the victim reaches definitive treatment facility. They become part of the victim's medical record. Tags are numbered, and may provide the only method of identify identification for the victims, who cannot provide their names or other information. Often these tags are doubled. There are two tags same number, but two tags. One tag is on the victim, while the other follows the victim's belongings such as in a decontamination system. This is an example of a common triage tag. Okay, let's talk about the Start Triage system which starts for simple triage and rapid treatment. This is one of several triage systems for adults. It should take less than 60 seconds per victim. First, all who can will be asked to stand up and walk to a specific spot. These are considered the walking wounded. They can follow orders, they can walk and they're classified as minor or green. Second, the triage person will go to each victim who has not gotten up and moved to that spot. They'll see if they are breathing. If they're are not breathing, they will open the airway. If they begin to breath, they will be tagged as red, immediate. If they do not begin to breath they will be tagged as black or deceased. They're will be no heroic efforts made to save them, such as CPR. Third, the triage person will check how fast the victim is breathing. If over 30 breaths per minute, and they may not need to count, if it's fast, they will know. They will tag the victim as red. If it's less than 30, they will check perfusion, or blood flow. To check perfusion or blood flow, they will check if they have a radial pulse, and they will look at what we call capillary refall, refill. Capillary refill is how fast the fingernail, or similar part of the body, pinks back up after we gently squeeze it. It should be less than the three seconds. If there is no radial pulse, and you can be alive and not have a radial pulse, or if the capillary refill is very slow, they are tagged as red. If their status is okay to this point, if they're perfusing okay, if they're breathing okay. The next step is to check their mental status. For mental status, they will ask the question, the person to do two things, such as squeeze their fingers and then let go. If they cannot follow two simple commands, they are tagged as red. If they can follow two simple commands, they have passed this stage as well as well as the others, and are tagged as yellow, or delayed. The JumpStart triage system is designed for children. It is similar to the Start system. They will begin the way, with the walking wounded. Second, is the child breathing? If not, they will open the airway and give two rescue breaths. Did they begin to breathe? If yes, they are tagged as red. If not, no other treatment will be done and they will be tagged as black, or deceased. Then they will walk away, which is one of the most difficult and horrible things responders will have to do in a disaster. Third, they will check the respiratory rate. Children breathe faster than adults, so a rate greater than 45, or less than 15, is tagged as Red. Then they will check for a palpable pulse, one that can be felt. If there isn't one, they are tagged as red. If there is one, they will check the mental status. The mental status is, for a child, is checked by responding to pain and other stimulus. If they respond only to pain, or if they are what we call posturing, holding their body in an unnatural position, caused by damage to the brain, then they are tagged as red. If they are alert, verbal, if they respond to verbal stimuli, they are tagged as yellow. With both systems, the triage officer tags and moves on. And other than simple treatment, such as stopping major blood flow, they do not treat. Other will-, others will come after and provide treatment or transportation. Triage is one of the most difficult tasks asked of a health care provider. After the initial triage, health care providers will conduct a secondary triage. They will start with children first, youngest to oldest. this may change the status of the victim. the status may move the victim to a more severe status if necessary. Now triage in the hospital setting is somewhat different Those who are tagged as immediate are treated first, but a more extensive process is enacted to determine who should be treated first of those marked immediate, who should receive the limited testing that's available. We test only if it will change the treatment options for the victim. Who should go straight to, to surgery? Possibly, who should be transported to a different facility, where they will receive care that's not available at that first facility. Those who are tagged as delayed are treated next. Until then, they are held in holding areas. They are reassessed often. Nurses will probably be providing all the care and hopefully based on established protocols, but it'll be nurses that'll be taking care of them. Minor, you may have to wait a long time or be sent home or to a shelter then come back over 48 hours later for treatment. Expected. These are the folks who are dead or those who cannot be saved with the available limited resources. Comfort measures only will be provided for these people. This will occur as far as those who we expect to die and we can't save, this will occur only in extremely difficult situations where resources are truly, truly overwhelmed. Victims in holding areas, either at the scene or in the treatment areas will be continually reassessed. There may be some initial treatment of injuries in this area, and there may be a status change, as I mentioned before, to a more severe level. This is a triage and urgent care area from a disaster response. Some of the initial injuries seen in the aftermath of a disaster may include acute care concerns such as large soft tissue injuries, such as crosh, crush injuries, particularly in the extremities. Fractures, particularly again in the extremities, but include, but could include areas like the pelvis, or chest, or head injuries. Traumatic amputations. these will often have bad outcomes unless there is immediate care for the victim. These three injuries, along with specific internal injuries are also common in explosions. Explosions are the most common terrorist act using a weapon of mass destruction. General illnesses are those who would be ill on a normal day will also need to be treated. They will still be ill and need to be treated in spite of the disaster. Births and deaths. People will be born and die as they normally do, regardless of a disaster. This is an example of a main treatment area of a temporary hospital. There are differences between non-disaster medicine and disaster medicine such as supplies and resupply. On a typical day in a typical hospital, resupply is readily available and providers Rarely run out of materials, pharmaceuticals, the drugs that they need to treat patients. In a disaster, there are logistics personnel who are dedicated to resupply the treatment area. Because of the disaster, there may be delays due to transportation concerns or other problems, which will limit this resupply. Pre- and post-disaster expectations will also be different. Under normal circumstances, we expect normal healthcare, and normal followup care for what is wrong. In a disaster, this is limited. Follow up may take place long after the disaster, and where referrals may be very, very limited. Additionally, the presence of free care in the aftermath of the disaster may eventually impede the return of normal health care. Why go to your regular hospital or provider when you can get free care from the temporary hospital or clinic that has been set up? So some final comments on triage. Triage is the most difficult position for any health care provider no matter what the setting. We do not like to walk away without treating or trying to save all of the victims.
