EMERGENCY MEDICAL RESPONSE
Mass Casualty Triage*: Sorting and prioritizing injured victimsfor treatment and transport
(*-TRIAGE: a French word meaning to "sort" by priorityor life-threatening nature of injury)
Many injured victims are present in the scenario. In order toexpedite treatment to those most seriously injured, and avoidwasting resources on less seriously injured, a system of rapid"triage" or sorting has been developed called "SpecialTriage and Rapid Transport" or START. Victims can be quicklyevaluated by emergency medical personnel. Initial findings suchas vital signs (pulse rate, blood pressure, respiration, levelof consciousness) are recorded on the triage tag, and then recheckedperiodically thereafter to monitor the victim's status and toRETRIAGE* if their conditions becomes worse, or improves later. Responders are accountable for the identity and securityof all victims present in the area of the incident. Such personswill not be allowed to leave the area until they are properlyidentified, evaluated, treated, transported to a medical treatmentfacility and/or medically cleared for release.
- Priority 1 (Red) Serious but salvageable life threateninginjury/illness
- Victims with life-threatening injuries or illness (such ashead injuries, severe burns, severe bleeding, heart-attack, breathing-impaired,internal injuries) are assigned a priority 1 or "Red"Triage tag code (meaning first priority for treatment and transportation).
- Priority 2 (Yellow) Moderate to serious injury/illness (notimmediately life-threatening)
- Victims with potentially serious (but not immediately life-threatening)injuries (such as fractures) are assigned a priority 2 or "Yellow"(meaning second priority for treatment and transportation) Triagetag code.
- Priority 3 (Green) "Walking-wounded"
- Victims who are not seriously injured, are quickly triagedand tagged as "walking wounded", and a priority 3 or"green" classification (meaning delayed treatment/transportation).Generally, the walking wounded are escorted to a staging areaout of the "hot zone" to await delayed evaluation andtransportation.
NON-PRIORITY VICTIMS:
- Priority 4 (Blue)
- Those victims with critical and potentially fatal injuriesor illness are coded priority 4 or "Blue" indicatingno treatment or transportation. It is important to note thatvictims of mass casualty incidents (MCI) who are still presentingsome vital signs but may have life-threatening or potentiallyfatal injuries, may be classified as "unsalvageable"by the Triage officer. Although this is a very difficult decision,it is necessary when many casualties require more resources thanmay be available. It is axiomatic that committing resources tosave the life of a person who is most likely to live if caredfor promptly, outweighs committing resources to victims who probablywill not survive even if such resources are administered. In ordinaryemergencies where only a few victims are injured, it is possiblefor responders to devote sufficient resources to critically injuredpatients, and to attempt to save their lives by extraordinarymedical support and rapid transportation (when possible) to alevel 1 or 2 Trauma Center. Such patients often still succumbto their injuries, even after extensive care in hospitals.
- Priority V (Black)
- Victims who are found to be clearly deceased at the scenewith no vital signs and/or obviously fatal injuries are classifiedas deceased or priority 5 (Black) in the triage coding system.
MEDICAL COORDINATION
A Triage Officer coordinates the assignment of TriageTeams of emergency medical first responders who quicklyevaluate and tag patients. Then as sorting continues, first respondersare sent in to treat the victims according to tag code.
* -RETRIAGE
Retriage occurs when the status of a patient changes either toa worse condition or if they improve to a less life-threateninglevel. The previous code is crossed out after evaluation, andthe new code and vital signs are listed on the triage tag. Patientswho have been initially moved to a specific transportation areawould then be moved to a greater or lesser priority transportationarea after retriage has been concluded.
- Medical Treatment and Evacuation
- Medical Teams composed of emergency medical first respondersenter the area to initiate stabilization and care for victimsby triage priority, and to load and evacuate them to a Stagingarea according to priority code. For example, all Redswill be moved to a staging and treatment area for immediate transport.Yellows will treated and evacuated after all Reds are properlytreated and evacuated.
- Transportation of victims
- A Transportation Officer coordinates the arrival and assignmentof patients to appropriate ground or air transportation. Ambulancesand medical helicopters will transport most seriously injuredpatients (Reds) from the red zone. The transportation officercoordinates with the Emergency Medical Officer toassign hospital destinations for urgent cases. Medical coordinationwith area hospitals is essential to route most seriously injuredpatients to level I and II Trauma Centers within a "goldenhour" where the victim's survival probability is best ifdefinitive care is begun within an hour of the injury. Care mustbe taken to not overload trauma centers, and to avoid sendingless seriously injured patients to such centers when they canbe effectively treated at other area facilities.
- Non-priority victims: deceased or critical/fatally injuredvictims
- A Morgue Officer supervises fatally injured victims who cannotbe moved or transported until the Coroner investigates the sceneand authorizes removal.
PERIMETERS: Controlling the access to and from the scene ofthe event
- Outer Perimeters: Controlling access to and from the scene
- Law enforcement officers are needed to set up a perimeteraround the scene to prevent pedestrians and vehicles from enteringor driving through hazardous areas. The perimeter may be as largeas is necessary to keep spectators away, and permit emergencyvehicles to enter and leave without being impaired by "looky-loos"who flock to the scene to see "what's going on." Curiosityof on-lookers can greatly impede rapid response of emergency vehiclesby clogging roadways, parking in access points, and failing toyield to emergency vehicles. Most of all, spectators may enteran area which poses serious or fatal hazards due to fire, chemicalspill, downed power lines, explosions, etc.
- Double "Funnel" for victim transport
- Law Enforcement responders working with medical responderswill establish a "perimeter" around the scene of theMass Casualty Incident, often called a "HOT ZONE" Anoutbound funnel point will be identified as a safe area throughwhich to remove victims to a second perimeter or zone where theyare placed in their appropriate "staging" area accordingto triage coding. No one is allowed through the perimeter of the"HOT ZONE" to avoid misplacing or unsafely moving victimswithout authorization. Other factors which may affect the establishmentof the "HOT ZONE" include hazardous materials spills,fire, downed power lines, dangerous or unstable structures orvehicles.
- SCENE SAFETY: protecting the rescuers and victims
- The Safety Officer supervises the overall operation in termsof safe conduct of rescue, fire suppression, evacuation, hazardousmaterials control, etc. If a safety officer observes a potentiallydangerous situation which may kill or injure a rescuer or victim,he has authority to cease or modify the operation to prevent furtherrisk.
MASS CASUALTY INCIDENTS: exercise simulations save lives inreal m.c.i. events!
Conclusion:
Many first responders can quickly and effectively work togetherunder a unified command system which is universally used and understood,to save lives, and minimize risk of injury and property damage.By exercising such responses in realistic field simulations suchas a "mass casualty incident" rescuers become more proficientand capable in real situations.
