SMART System & START Triage

1. SMART System & START Triage Bureau of Emergency Medical Services New York State Department of Health Jim Soto Associate Director

2. Objectives: • What is an MCI ? • Review Incident Management from EMS perspective • Review Triage & Practice START

3. What is the Goal of MCI Management?

4. EMS GOAL: TO SAVE THE LARGEST NUMBER OF SURVIVORS FROM A MULTIPLE CASUALTY INCIDENT

5. What is an MCI Scene?

6. What are some Common things affecting your MCI response? • Typical staffing of your ambulance service? • What does EMS routinely do daily? • How do you handle the following? • 4 victims in a two car “head-on” • 17 victims in a “team” van • 43 victims on a school bus • 350 victims on a train Need Resources & Coordination

7. TRIAGE STAGING COMMUNICATIONS COMMAND IMMODIUM SAFETY TREATMENT ASSESSMENT So what do you have to think about?

8. THE INITIAL PROBLEM ON SCENE Casualties Resources

9. THE OBJECTIVE Casualties Resources

10. THE OBJECTIVE Casualties Resources

11. THE OBJECTIVE Casualties Resources

12. THE OBJECTIVE Casualties Resources

13. THE OBJECTIVE Casualties Resources

14. THE OBJECTIVE Casualties Resources

15. THE OBJECTIVE Casualties Resources Achieve balance

16. BUT - HOW IS EMS TRAINED? • BLS, ALS • CPR, ACLS, PALS • PHTLS, BTLS • CFR, EMT, EMT-I, EMT-CC, EMT-P How many patients are you taught to treat at one time?

17. WHAT CHANGES WHEN YOU HAVE AN MCI ? • What are my resources? • Who is a Patient? • Which Patient do I treat first? • Who can be salvaged? • Who gets transported first? • Who needs a Trauma/Specialty Center? • Who can help care for others?

18. TIME IS IMPORTANT ARRIVAL OF REQUESTED RESOURCES

19. TIME IS VERY IMPORTANT THE GOLDEN HOUR “The critical trauma patient has only 60 minutes from thetime of injuryto reach definitive surgical care, or the odds of a successful recovery diminish dramatically”. Pre-Hospital Trauma Life Support, Second Edition, Patient Assessment and Management, page 42. 1990. To the Victim

20. Casualties Resources Balancing Act Management Golden Hour Resources Arrive Time Management

21. Casualties Resources + = Maximum survivors

22. TIME H The Scene H H Definitive Care SCENE MANAGEMENT Command Safety Assessment Communication Triage Treatment Transport MANAGEMENT EMS OPERATIONS

23. Command Who is in Charge? Who is in charge of what? Who is going to do what? Who else needs to be here? EMS is generally in Operations (Ops) Safety Is there a hazard or threat? Should I be here? Am I protected? What should I worry about? Scene Management

24. Assessment What is going on? How big is this, how many people? What do I need? How does what I do affect others? What are they doing that can affect me? Communications Who needs to know? What do they need to know? Does Command & Ops know? Do the other players know? Scene Management

25. Triage Who is doing it? Where are they doing it? What are they finding? Treatment What the typical EMS provider comes “preloaded” with… How to organize? How much can we do? Scene Management

26. Transport Who is doing it? From where are they doing it? Where are the patients going? How many patients going where? Scene Management

27. TRIAGE “Large scale triage is the hardest job anyone in pre-hospital care will ever do”. A.J Heightman, Mass Casualty Incident Management. A practical approach to solving complex operational dilemmas.

28. TRIAGE WHEN ? Casualties exceed the number of skilled rescuers.

29. Types of Triage • Primary • On Scene prior to movement • Secondary • Incident dependant, probably prior to or during transport

30. Priority Treatment Color RED Yellow Green Black TRIAGE CODING Immediate 1 Urgent 2 Delayed 3 Dead 0

31. TRIAGE TAGS What is the same ? What is improved ? What is different ?

32. Triage Protocol (START)

33. PRIMARY TRIAGE The Scene

34. PRIMARY TRIAGE The first attempt at balancing EMS resources and casualties / injured

35. PRIMARY TRIAGE Determining whether there is an airway and breathing

36. PRIMARY TRIAGE If breathing, at what rate & is it good enough?

37. PRIMARY TRIAGE They have an airway, and are breathing. Are they circulating blood sufficiently?

38. Circulatory Check…

39. PRIMARY TRIAGE A B C Mental Status

40. PEDIATRIC TRIAGE Children are involved in multiple casualty incidents. The over prioritizing of children will take valuable resources away from more seriously injured adults. Triage systems based on adult physiology will not provide accurate triage.

41. SMART Pediatric Tape • Developed by Pediatricians to use the existing START protocol but modified to reflect appropriate values for pediatric respirations and circulation.

42. START EXERCISE

43. Triage Protocol (START)

44. START EXERCISE • Female, 30’s, walking • Female, teens, walking, pale, complaining of severe abdominal pain • Male, teens, walking, confused • Male, teens, you open airway, does not breathe • Male, 20’s, unconscious, breathing, RR 36, radial pulse absent • Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructions 1

45. START EXERCISE • Female, 30’s, walking • Female, teens, walking, pale, complaining of severe abdominal pain • Male, teens, walking, confused • Male, teens, you open airway, does not breathe • Male, 20’s, unconscious, breathing, RR 36, radial pulse absent • Male, 20’s, holding left ankle, cannot walk, RR 20, CRT 1, responds to instructions 1 A

46. START EXERCISE • Female, 60’s, fracture LL leg, cannot walk, RR 25, CRT 1, obeys commands • Male, 30’s, you open airway, does not breathe • Male, 30’s, lying on ground, breathing, gurgling sounds, RR 37, pulse absent, unresponsive • Male, 50’s, you open airway, does not breathe • Male, child, 75 cm, not alert, breathing, RR 30, CRT 2.5, pulse 100 • Male, child, 130 cm, not walking, breathing, RR 24 CRT 1 2

47. START EXERCISE • Female, 60’s, fracture LL leg, cannot walk,RR 25, CRT 1, obeys commands • Male, 30’s, you open airway, does not breathe • Male, 30’s, lying on ground, breathing, gurgling sounds, RR 37, pulse absent, unresponsive • Male, 50’s, you open airway, does not breathe • Male, child, 75 cm, not alert, breathing, RR 30, CRT 2.5, pulse 100 • Male, child, 130 cm, not walking, breathing, RR 24 CRT 1 2 A

48. START EXERCISE • Female, child, 145 cm, lying on ground holding chest, breathing with gurgling sounds, RR 37, CRT 3 • Female, child, 47 cm, breathing, crying, pulse 160 3

49. START EXERCISE • Female, child, 145 cm, lying on ground holding chest, breathing with gurgling sounds, RR 37, CRT 3 • Female, child, 47 cm, breathing, crying, pulse 160 3 A

50. SECONDARY TRIAGE