multi-casualty incidents and triage - pearson...

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.

1

Disasters and Multi-Casualty Incidents DEFINITIONS ■ Disaster (major). Any natural catastrophe that causes damage of suffi cient

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

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2 MULT I -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 classifi ed 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 fi ve 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 single-patient 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 effi cient way to obtain this unity is to have EMS operate as a branch of the incident command system (ICS). Primary functional compo-nents of the medical branch include the medical director, triage, treatment, transport, and staging. (Even with a single-patient incident, those fi ve compo-nents exist, but one person usually is responsible for the functions of all compo-nents.) 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 (FIrefi ghting RESources of California Organized for Potential Emergen-cies). Though originally developed to assist in the response to wildland fi res, 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 Man-agement System.


MULT I -CASUALTY INCIDENTS AND TRIAGE 3

FIRESCOPE ICS and its variations served as the basis for the national inci-dent management system’s incident command system (NIMS ICS). The NIMS ICS was developed, under the Department of Homeland Security (DHS) Fed-eral 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 fl exibility of an ICS enables it to be adapted to all types of emergency incidents: fi re, rescue, law enforcement, and multi-casualty inci-dents. 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 qualifi ed 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 confl ict 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 fi ve 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 fi ve subordinates (1:5). Some latitude may be given due to the complexity of the situation. A highly complex or diffi cult 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

Incident Command

Rescue/ExtricationBranch

Fire SuppressionBranch

Medical BranchLaw EnforcementBranch

FIGURE 1 On-scene incident command structure.



■ 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 offi cers 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 identifi cation 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

Incident Command

Medical BranchFire SuppressionBranch

Rescue/Extrication Branch

Medical Director

Law EnforcementBranch

TreatmentGroup

TriageGroup

StagingGroup

TransportGroup

FIGURE 2 Medical branch of the ICS.



■ 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 affi x an appropriately completed triage tag/band ( Figure 4 ) or other visual identifi cation 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?



■ 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?

Global Sorting

Obeys commands or makes purposeful movements?

Has effective respirations?Has adequate peripheral

perfusion? Major hemorrhage

is controlled?

Does not obey voicecommands

Still / Obvious Life Threat(assess 1st)

Priority-0Deceased Breathing?

Priority-2Delayed

Likely to survive givencurrent resources?

Priority-4Expectant

Priority-1Immediate

Priority-3Minimal

Individual Assessment

ITLS POST(Primary On-Scene Triage)

An adaptation of SALT mass casualty triage

Minor InjuriesOnly?

• Control major hemorrhage• Open airway (if child consider 2 rescue breaths)• Chest decompression• Autoinjector antidotes

LSI

No Yes YesAll

Yes

Yes

No

No

No to any ofthe above

Obeys voice commandsAmbulatory(assess 3rd)

Obeys voice commandsWave / Purposeful

Movement(assess 2nd)

FIGURE 3 ITLS POST. This scheme reflects the steps of primary triage. Subsequent and more detailed assessments should occur throughout patient care.

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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 fi gured in a “survivabil-ity 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 pre-sented 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 ill-ness 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

FIGURE 4 Example of triage band (StatBand ® ). (Courtesy of David Maatman, NREMT-P/IC)



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 ineffi cient 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 Debriefi ng 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, modifi ed when there is a problem. In addition to taking time to critique the incident, time also must be taken to provide critical incident stress debriefi ng (CISD) for the participants of an inci-dent. 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 pri-mary principles used are assessment of respirations, perfusion, and level of con-sciousness (obeys commands). The START (Simple Triage and Rapid Treatment), JumpSTART (Pediatric version of START), Triage Sieve, Home-bush, and STM (Sacco Triage Method) utilize a quantitative assessment (actual count) for respirations, pulses, and in some cases capillary refi ll time. Although there may be some value in quantifying assessment fi ndings 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 Traffi c 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 fi eld triage scheme.

SALT and ITLS POST ( Figure 3 ) use fi ve 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 fl exi-ble 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 autoinjec-tor antidotes.

The American College of Surgeons Committee on Trauma (ACS COT) and the National Highway Traffi c Safety Administration (NHTSA) also developed a “fi eld triage decision scheme” that is specifi c to trauma patients and aids in the determination of transport destinations to trauma centers. This algorithm assesses


Bibliography

vital signs and level of consciousness, anatomy of injury, mechanism of injury, and comorbid factors. Based on those fi ndings, 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 fi rst.

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 effi cient 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 stand-ardized structure of an ICS on smaller situations will develop profi ciency 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 famili-arity with its use. Routine activation of the system develops confi dence in its use for all levels of command and agencies involved. To avoid the paper plan syn-drome, the regular implementation and review of an MCI/disaster plan is para-mount 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 neces-sary to blend multiple triage schemes to capitalize on the best outcome. Success-ful 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 effec-tiveness 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 struc-ture for the necessary administrative, planning, fi nancial, and logistical support.

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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.

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Preparedness 2(Suppl 1): S25–S34.

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