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TRIAGE TRAINING FOR LONG-TERM

CAREP R E S E N T E D B Y W E N D Y B O R E N , B S N , R N ,

U N I V E R S I T Y O F M I S S O U R I - C O L U M B I A S I N C L A I R S C H O O L O F N U R S I N G

F R E D G R O S S , E M T & C H R I S T I N A D E G E N H A R D T, E M T C A P E C O U N T Y A M B U L A N C E S E R V I C E

1 . D E F I N E A M A S S C A S U A LT Y I N C I D E N T ( M C I )

2 . D I S C U S S R E C E N T M C I ’ S A N D T H E I R I M PA C T O N C H A N G E S I N E M E R G E N C Y R E S P O N S E

3 . U N D E R S TA N D I N G I M M E D I AT E R E S O U R C E A L L O C AT I O N

4 . D E F I N E D I F F E R E N T T Y P E S O F T R I A G E

5 . L E A R N S I G N S / S Y M P TO M S O F H E A D T R A U M A

6 . D I S C U S S T H E P R I N C I P L E S O F “ S TO P T H E B L E E D ” A N D C E RT I F I C AT I O N

O B J E C T I V E S

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MASS CASUALTY INCIDENTS

MCI—MASS CASUALTY INCIDENT

• An incident which produces multiple casualties such that emergency services, medical personnel and referral systems within the normal catchment area cannot provide adequate and timely response and care without unacceptable mortality and/or morbidity.

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MAN-MADE MCI’S

NATURE-MADE MCI’S

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TRIAGE-DEFINED-TRADITIONAL VS RAMP-GETTING IT DONE

Reality-Testing: New Triage Tactics with Current Paradigms for MCIs

TRIAGE DEFINED

The process of sorting people based on their need for immediate medical treatment as compared to their chance of benefiting from such care.Triage is done in emergency rooms, disasters, and wars, when limited medical resources must be allocated to maximize the number of survivors.

Several systems of triage are available. There are pros and cons to each.

MAIN POINT—pick something easy to understand—even if you’re not a nurse—assess, make a decision, reassess.

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TRADITIONAL TRIAGE PRESENTSOVERLY-COMPLICATED ALGORITHMS

BOTH START & SALT: Utilize Complicated Algorithms

for Decisions Not User-Friendly Scene Confusion Neither Are Accurate Triage

START: Uses

Respirations Uses Numbers Uses Cap Refill

SALT: Global sorting EMS Critical Thinking of

Patient Survival

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REVIEWING RECENT MCI EVENTS:

VIRGINIA TECH SHOOTING (2017): Field triage was completed within

53 minutes of the second shooting event.

The under-triage rate at Virginia Tech was 10% (1 of 10), with a correspondingly higher over-triage rate of 69% (11 of 16).

Frykberg, ER.Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53:201–212. CrossRef | Google Scholar | PubMed

FORT HOOD MASSACRE (2009): 70% were triaged inaccurately Directly led to misuse of resources Increased fatality rate

From gathering of the EAGLES (2019): http://gatheringofeagles.us/2019/2019Presentations.htm

K. Sophia Dyer, MD E. Stein Bronsky, MDMedical Director, Boston EMS Chief Medical Director Colorado Springs FD, El Paso County AMR

WHY CURRENT TRIAGE MODELSARE SO INACCURATE:

“Fear Effect” In Responders Sympathetic response

Loss of critical thinking

Loss of fine motor skills

Reliance on basic muscle memory

Brad Keating, Rocky Mountain Fire Department Adapting New Triage Methods for the Modern Mass Casualty Event (RAMP) – (EMT/AEMT/EMT-I/PARAMEDIC

“Fear Effect” In Patients False assumptions of human behavior

All enhanced by overly-complicated triage algorithms

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WHY THE NEED FOR CHANGE?Checking the numbers:

Currently utilized methods (SALT & START) have only a 55-65% overall accuracy rate of appropriate triage.

Even newly trained and immediately tested: the accuracy of SALT was only around 70%.

Frequent training in simulations on triage can only expect accuracy improvements of at most 10% for EMS providers.

Neither SALT or START are sensitive or specific in identifying hospital outcomes in MCI patients.

Brad Keating, Rocky Mountain Fire Department Adapting New Triage Methods for the Modern Mass Casualty Event (RAMP) – (EMT/AEMT/EMT-I/PARAMEDIC

RAMP TRIAGE:(RAPID ASSESSMENT OF MENTATION AND

PULSE)

Rapid identification of most critically wounded patients

Easily remembered

Easy to use

Easily taught

No reliance on numbers or critical thinking

Uses scientific evidence

Multi patient use

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HOW RAMP TRIAGE WORKS:Three simple Steps: Obvious Death Follow Commands Radial Pulse Present or Absent

SCIENCE BEHIND RAMP TRIAGE

GCS directly correlates with hospital discharge in trauma

Following basic commands as substitute for GCS

Best overall indicator of survival from trauma

No radial pulse and not following commands

92% mortality rate

Yellow triage category is most inaccurate by EMSBrad Keating, Rocky Mountain Fire Department Adapting New Triage Methods for the Modern Mass Casualty Event (RAMP) – (EMT/AEMT/EMT-I/PARAMEDIC

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START V S . RAMP( A19 PATIENT SCENARIO)

START

Time at Patient 59.53 seconds

Triage Accuracy 58%

Time until all Reds Off Scene 29.31 Minutes

RAMP

Time at Patient 45.36 Seconds

Triage Accuracy 84%

Time until all Reds Off Scene 20.17 Minutes

* SECONDS SAVE LIVES *Brad Keating, Rocky Mountain Fire Department Adapting New Triage Methods for the Modern Mass Casualty Event (RAMP) – (EMT/AEMT/EMT-I/PARAMEDIC

DIFFERENCE

Time at Patient 14.17 Seconds

Triage Accuracy 26%

Time until all Reds off Scene 9.14 Minutes

CONCLUSION: RAMP IS BETTER & FASTER

RAPID IDENTIFICATION OF MOST SEVERLY WOUNDED

EASIER TO USE

EASILY TAUGHT

NO NUMBERS OR CRITICAL THINKING INVOLVED

USES SCIENTIFIC EVIDENCE

RAMP REALLY DOES THE MOST GOOD FOR THE MOST PATIENTS WHICH IS THE DEFFINITION OF TRIAGE

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MANAGING HEAD TRAUMA

MANAGING HEAD TRAUMA—THE BASICSHead injuries occur most commonly in two ways—coup, when the head hits forward onto the frontal lobe area of the brain (forehead) or countercoup, when the head falls backward and hits the occipital area of the brain. BOTH can occur with the same incidence.

Some symptoms may appear immediately but others can take over 24 hours to develop.

Things to Look for Immediately: Dilated pupils Trouble walking or speaking Vomiting Seizures Weakness or numbness in extremities Blood or clear fluid draining from ears or nose

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MANAGING HEAD TRAUMA, CONT’D.HALO Test—use this test to determine if there is cerebrospinal fluid leaking from the brain

1. Using a clean piece of napkin, gauze, or even a paper towel will work in a pinch.

2. Dip it in the blood coming from a patients head wound. This may be from the ear, nose or open head wound. T

3. Cerebral spinal fluid is less viscous than ordinary blood. The cerebral spinal fluid will wick into the gauze faster than the blood will. This causes a "halo" or yellowish ring around the blood spot on your gauze.

Halo of CSFRed blood cells

MANAGING HEAD TRAUMA, CONT’D.

Things to Look for Post-Acute Raccoon eyes Seizures Balance problems Posturing Changes in respiration (Cheyne-Stokes, agonal) Changes in personality, mood

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STOP THE BLEED

www.stopthebleed.org

PRINCIPLES OF STOP THE BLEEDWas born after the Sandy Hook school shooting.

GOAL—as many people trained as possible—all ages, all capabilities

1. Ensure your own safety.

2. Follow the ABC’s—1. Alert 9-11

2. Bleeding—find the bleed and assess

3. Compress—apply pressure to stop the bleeding by covering the wound and apply direct pressure; using a tourniquet; or, packing the wound with gauze and applying pressure.

TIPS:

Use whatever you have on hand. Be quick, calm, and efficient. Apply pressure until help arrives.

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REFERENCES Frykberg, ER.Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma.

2002;53:201–212. CrossRef | Google Scholar | PubMed

Brad Keating, Rocky Mountain Fire Department Adapting New Triage Methods for the Modern Mass Casualty Event (RAMP) – (EMT/AEMT/EMT-I/PARAMEDIC

From gathering of the EAGLES (2019): http://gatheringofeagles.us/2019/2019Presentations.htm

K. Sophia Dyer, MD Medical Director, Boston EMS E. Stein Bronsky, Chief Medical Director Colorado Springs FD, El Paso County AMR

https://www.stopthebleed.org/