There is a historic collapse at the sports complex three blocks from your facility (structural, this time, not the on the field). Hundreds of people are rushing to your hospital for care.
What can you say generally about the first arriving victims and what can you do about them?
- Usually most of the initial victims will be the least injured – they were more mobile and able to get out of the building
- Keep walking patients out of the ED until you know that you have room and resources to treat them – put them at triage and in the lobby areas and get personnel out there to screen them
- Keep them busy – have them fill out the top paper section of their patient encounter (clipboards and forms are in the triage bins) or have them assist other patients – provide support, etc.
What is the main risk to the more severely injured patients?
- The higher the number of patients that are not severely injured (or tagged as ‘red’ or critical that are actually not) the worse the outcome for the critically injured (as resources are not available to them – this isn’t usually an overt thing, but lots of little distractions and issues that add up to sub-optimal outcomes) – this is known as ‘over-triage’ – in NYC on 9-11 the overtriage rates (not severe to severe casualties) were as high as 95%, and the mortality rate of the severely injured was 44% at that hospital vs. goal of 10% – there is a nearly linear correlation between the ratio of less-injured casualties : seriously injured and the mortality for these patients over many incidents in many countries
What are the key bottlenecks in triage?
- Front door/ambulance entrance – who waits, who gets a a bed, who’s critical
- US – everyone’s going to want them, but there’s only a few machines – make sure you get your FAST done FAST and make the machine available – consider making FAST part of the ambulance door triage for non-ambulatory patients
- CT – who needs one? And how can you avoid the ‘pan-scan’ and concentrate on heads and things that you MUST know right now
- OR – who needs it now (vs. who can wait – ortho and limb-related stuff can wait, most truncal and vascular cannot)
If things get really overwhelming, what are the priorities?
- Concentrate on the interventions that make the biggest difference with the least time and materials
- Control external hemorrhage (pack the wounds with gauze and use ACE wraps – works well, tourniquet if this doesn’t work)
- Decompress tension pneumothorax
- Manage airway obstructions
- If you have the option for OR send only those with shock, positive FAST and isolated abdominal injuries
What factors should you consider if you cannot take care of all the severely injured?
- Prognosis / odds of survival
- Resources required to treat them fully
- Underlying disease if it has an extremely poor short-term prognosis (cirrhosis, for example) – this is very limited
- Age is NOT a good triage indicator aside from older than 85 years (very few patients) and should not generally be used aside from advanced age in multi-system trauma or severe burns
- DON’T forget that even if you aren’t able to provide usual care (say you triage an 90% burn victim to expectant management) that you still have to provide symptom control / palliative care including analgesia, anti-emetics, anxiety control, etc. So just because you can’t do what you normally do doesn’t mean the patient doesn’t get care…
You find somebody to take over the Triage role and are assigned to three patients in the ED now what?
- Use your clinical skill – stop bleeding, splint fractures, etc.
- Don’t do definitive procedures until we know we can take the time to do it – (usually most of the victims arrive within the first 90 minutes after a mass casualty incident)
- Use US liberally for triage
- Only Xrays you should probably be ordering are chest and pelvis
- Work with your Team Center Leader to help prioritize access for procedures, CT, admission, OR, etc.
Congrats, your shift is now over – good luck facing the national media on the way out of the hospital!
Compiled by Dr. John Hick, Medical Director for the Office of Emergency Preparedness with the Minnesota Department of Health.