The difference between strategies and tactics is an important concept to understand. Strategies are the overall goals you are trying to accomplish, while the tactics are the methods to obtain the goals. In a mass casualty incident Basic MCI strategies may be to move all immediate patients off-site first. One tactic to achieve this may be to identify immediate patients with triage tags so they can be quickly sorted and transported.
Normally there are many tactics to achieve a strategic goal. But, the overall strategic priorities that need to be accomplished for a MCI are the three Ts:
- Transporting patients
If done in this order, you will hopefully be ahead of the curve for the MCI. This series of articles will discuss tactics to help you succeed in each of these areas and manage a MCI. If we do not manage the MCI in the field, things will only get worse by moving it to somewhere else such as a hospital ER.
One of the first areas that one needs to focus on is the management and control of the MCI, which are amongst the most chaotic and confusing situations that can be encountered. In addition, there may be many several organizations involved, with many never having worked together. Regardless of incident size, the initial crews will play a critical role in the success of dealing with it by following the three Ts.
The first units to arrive are almost the first troops to hit the beach. They will find themselves overwhelmed and under equipped to gain the upper hand in the incident. Just like during wartime where the sergeants play the critical role, the fire company officer will likely be in command prior to the arrival of a command staff. With no luxuries other than the equipment than is carried on their apparatus, the first arriving units have a daunting task.
Tip: Put together a triage fanny pack that is just for such an emergency as an MCI. Rather than digging through trauma bags for those elusive triage tags when you pull up to a MCI, a fanny pack can be deployed quickly with all the needed items such as tags, markers and PPE. Put these in the jump seat areas where they can be quickly deployed and start triaging patients.
Assuming there are no other life hazards, a four-person fire crew and an ambulance unit can start an effective “beachfront attack” on a MCI. Assigning personnel to initially do triage ensures the first stages of sorting patients into severity groups (red, yellow, green and black) can be carried out. Remember, not much else can happen until patients are triaged and tagged appropriately.
A well-trained responder should be able to triage a patient in one minute; by this measure, two responders should be able to triage 20 patients in 10 minutes, a figure that would amount to an MCI in almost any city. Triage should be done quickly and halted only to provide a lifesaving intervention, such as opening an airway.
All responders need to be trained in how to triage a patient. One of the easiest methods to use for triaging patients is the START method, which stands for Simple Triage And Rapid Treatment. This was developed by the Hoag Hospital and the Newport Beach, Calif., Fire Department. It can be taught to responders quickly and should be part of your training program. The START method allows a patient to be triaged in under a minute by checking three key patient indicators — respiration, pulse and mental status. Training for this can be found in almost any EMT manual, but if you need help please contact me.
Tip: Triage training can be easy and even fun. One simple method is to make paper patients on recipe cards. On the recipe cards, list a patient’s injuries and vital signs. Scatter the cards and have crews evaluate, triage, tag and move the “patients” to treatment areas. The treatment areas can be red, yellow, green and black pieces of paper signifying the colors in the START system. This training can be made to include hospitals as part of a larger tabletop drill.
Most triage tags are designed to be used with the START system by classifying patients into four areas: Red (Immediate), Yellow (Delayed), Green (Minor) and Black (Dead). Your priority — or tactical benchmark — for a MCI should be to identify and move the most immediate patients first. These patients would be identified as Red under the START system, making them easy and quick to identify.
Tip: Ensure that everyone in your system is using the same triage tags. Although there may only be subtle differences between makers of tags, keeping everything the same decreases the potential for mistakes in a high-stress environment. Some states, South Dakota for one, have adopted the same triage tag for all agencies. Grant funding can help purchase tags for organizations that lack funds to purchase them on their own.
Identifying Contaminated Patients
Your department, or better yet your system, should have a predetermined method to identify if a patient is contaminated. Some triage tags incorporate a method to determine if a patient has been decontaminated in the event of a WMD incident or hazmat spill. Identification of contaminated patients needs to be determined on a system-wide basis before a MCI. Patients should be triaged after moving through decontamination.
I was on an incident once when one person decided to identify decontaminated patients with ribbons; but other agencies did not know if this meant the patient was or was not contaminated. At another incident, the crews used colored clothes pins to identify decontaminated patients; but the pins fell off and were not effective.
Tip: Make sure your tags have the START system printed on the tag as your MCI may be at 3 in the morning, when recalling START may be a little fuzzy. Having the START system on the tag helps with recall and ensures patients are properly and consistently evaluated.
Remember that a ribbon or other type of marking may be clear to you or your agency, but may mean the opposite or something totally different to someone at the receiving hospital. Just take a look at the variety of things around the wrists of people at any school, workplace or concert. Now put yourself in a chaotic hospital or MCI: “Hey, what’s a yellow ribbon mean again?” Communications will be limited, or non-existent, between every single provider, so have a plan in place before your incident.
Who Should Do Triage?
One of the most common questions is who should do the triage? Personally, I prefer an EMT or first responder who is trained in the START method being put in the role of triage. The START method is an easy, consistent and a simple way to triage patients and does not require a great deal of training or equipment.
I prefer to keep the highly trained paramedics in the treatment areas, where their skills and advanced interventions can save lives. Paramedics play a critical role and should be viewed as “force multipliers” since they bring a unique skill set to the incident. There will not be enough paramedics to go around, so deploy them wisely. Put them in roles where they will have the biggest impact on patient outcomes, and that is in the treatment and transport areas.
Tip: Make, or purchase, some red reflective bumper stickers that say “IMMEDIATE” in big letters. Place these with triage tags in your triage fanny pack. Put those bumper stickers on your Red patients in addition to their triage tag, which will make them easier for litter bearers to find. At night, the reflective sticker will stand out as well, making it easier to locate these critical patients. Another use for the bumper stickers is on a MCI involving many vehicles with trapped patients. Putting the stickers on the doors of vehicles with “Immediate” patients will allow incoming units to treat or extricate those patients first.
Each MCI will be different and bring its own unique challenges. This article hopefully gave you some ideas and tips to better conduct triage on your next MCI. More in this series will follow, but please feel free to contact me if I can be of any help or offer any input.
About the Author
Jim Sideras is a division chief for Sioux Falls, S.D., Fire Rescue. He is a 23-year veteran of SFFR and a registered nurse with a masters of science degree in nursing as a clinical nurse specialist. Jim received the Harvard University Fire Executive Fellowship, and has also completed a human resources program at Cornell University. He is currently in the National Fire Academy’s Executive Fire Officer program, and has spoken at several national conferences on emergency medical topics. In addition, Jim is a former intensive care burn nurse and a member of the National Association of EMS Physicians, Sigma Theta Tau International Honor Society of Nursing, the South Dakota Nurses Association and the South Dakota EMT Association. In summer 2007, he received his national Chief Fire Officer designation. To contact Jim, e-mail sideras[at]post.harvard.edu.